Research Activities, April 2009
Chien, A. T., and Chin, M. H. (2009, January). "Incorporating disparity reduction into pay-for-performance." (AHRQ grant HS17146). Journal of General Internal Medicine 24(1), pp. 135-136.
One concern about pay-for-performance (P4P) strategies is their potentially negative impact on racial/ethnic disparities in care. The authors of this paper suggest four ways that payors and policymakers can incorporate disparity reduction goals into existing P4P programs. P4P strategies should take into account whether existing disparities are driven by differential treatment of minority patients by health care providers within the same institution, or by minority patients tending to be cared for by lower quality providers. These strategies should employ performance measures that target disparity reduction, such as treatment gaps in breast cancer screening and treatment. P4P programs should reward performance improvement in addition to achievement. Finally, payors and health care organizations should tie P4P incentives to disparity reduction by stratifying quality of care data by racial/ethnic groups.
Chou, R., Aronson, N., Atkins, D., and others (2008, September). "Assessing harms when comparing medical interventions: AHRQ and the effective health-care program." Journal of Clinical Epidemiology
Comparative effectiveness reviews (CERs) systematically review and evaluate the evidence on alternative interventions to help clinicians, policymakers, and patients make informed treatment choices. The authors of this paper caution that CERs should assess harms and benefits to provide balanced assessments of alternative interventions. They provide guidance for evaluating harms when conducting and reporting CERs. They suggest prioritizing harms to be evaluated, use of consistent and precise terminology related to reporting of harms, and selection of a broad array of evidence sources on harms. They also discuss assessment of risk of bias in harms reporting, and the synthesis and reporting of evidence on harms. Finally, they suggest caution when drawing conclusions on harms when events are rare and risk estimates are imprecise.
Cohen, S. B., and Yu, W. W. (2009, January). "The utility of prediction models to oversample the long-term uninsured." Medical Care 47(1), pp. 80-87.
It is important to distinguish between persons who are uninsured for short periods of time and those who are uninsured for several years, who face high out-of-pocket costs. Prediction models to oversample the long-term uninsured are viable sampling methodologies for adoption in national health care surveys, conclude the authors of this paper. They used nationally representative data from the Medical Expenditure Panel Survey (MEPS) to examine national estimates of nonelderly adults without health insurance coverage for 2 consecutive years. They also used the MEPS data to develop prediction models to identify individuals most likely to experience long-term spells without coverage. Use of their models for oversampling allowed the cost-effective selection of the targeted sample of individuals who are continuously uninsured for 2 consecutive years.
Reprints (AHRQ Publication No. 09-R029) are available from the AHRQ Publications Clearinghouse.
Frick, K., Clark, M., Steinwachs, D., and others (2009, January-February). "Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment." (AHRQ grant HS09506). Women's Health Issues 19(1), pp. 70-78.
Women who suffer from abnormally heavy uterine bleeding experience decreased quality of life as well as financial burdens. The cramps and pain they experience can lead to fatigue and limited physical activity, and the costs of medication, tampons, and pads also add up over time. A new study finds that lost productivity costs from missed work or not being able to manage their homes averaged $2,625 a year for these women, and out-of-pocket costs for drugs and sanitary products averaged $333 a year. Although hysterectomy is the only surgery that eliminates the dysfunctional uterine bleeding, it is a costly procedure that requires significant recovery time. However, considering the costs, both financial and to the women's quality of life, the researchers conclude that a surgical treatment that costs $40,000 or more would be cost effective in lieu of unsuccessful medical treatment. They studied 237 women who had surgery for their dysfunctional uterine bleeding from 1997 to 2001.
Harrison, M. I., and Kimani, J. (2009, January-March). "Building capacity for a transformation initiative: System redesign at Denver health." Health Care Management Review 34(1), pp. 42-53.
This article examines prior factors that led to successful care system redesign at Denver Health (DH), a large, integrated, urban, safety-net system. For example, clinical reengineering projects to preserve DH's safety-net services during the 1990s paved the way for introduction of lean design in 2004. DH leaders' personal ties, status, knowledge, and past experience in improvement efforts also helped, including facilitating political and financial support by the city of Denver. DH's preexisting organizational structure and expanded human resource capacities (for example, upgrading the skills of DH's nurses, physicians, and middle managers) during the prior decade also contributed to the launch and implementation of system redesign. Finally, in the 1990s DH had built a sophisticated health information technology infrastructure and had modernized and expanded its physical infrastructure.
Reprints (AHRQ Publication No. 09-R017) are available from the AHRQ Publications Clearinghouse.
Hughes, R. G., and Clancy, C. M. (2009, January-March). "Nurses' role in patient safety." Journal of Nursing Care Quality 24(1), pp. 1-4.
Nurses, who work at the frontline of care delivery, play a critical role in improving patient safety, assert the authors of this commentary. They note that improving the quality and safety of health care will require purposeful redesign of health care organizations and processes. Organizations committed to high quality and safe care will not blame nurses for mistakes at the "sharp end" of care, but will focus instead on system improvements. The Agency for Healthcare Research and Quality (AHRQ) has long been a partner in the national endeavor to improve health care quality. The handbook, Patient Safety and Quality: An Evidence-Based Handbook for Nurses, provides nurses with proven techniques and interventions they can use to enhance patient and organizational outcomes. The handbook (http://www.ahrq.gov/qual/nurseshdbk) was developed by AHRQ with support from the Robert Wood Johnson Foundation.
Liang, H., Tomey, K., Chen, D., and others (2008, August). "Objective measures of neighborhood environment and self-reported physical activity in spinal cord injured men." (AHRQ grant HS11277). Archives of Physical Medicine and Rehabilitation 89, pp. 1468-1473.
Obesity-related risk factors are associated with lower levels of physical activity in men with spinal cord injuries, according to a new study. The researchers gathered medical and address information for 131 young to middle-aged men with spinal cord injuries living in Chicago who used a wheelchair for mobility. A lower level of physical activity was associated with the following obesity-related risk factors: elevated triglycerides in the blood, metabolic syndrome (having at least three of the following: abdominal obesity, elevated triglycerides, reduced high-density lipoprotein levels, elevated blood pressure, and elevated fasting blood glucose), and high blood levels of C-reactive protein (an indication of inflammation). Men in the highest third of the group in terms of physical activity had 81 to 85 percent lower risk of these risk factors compared with men in the lowest third. Although lower physical activity was associated with neighborhood environmental characteristics, only the total neighborhood crime rate was significantly associated with lower physical activity, after accounting for multiple factors.
Liu, S. Y. (2009, January-February). "Hospital readmissions for childhood asthma: The role of individual and neighborhood factors."(AHRQ cooperative agreement with the Centers for Disease Control and Prevention). Public Health Reports 124, pp. 65-78.
Differences in health care coverage are linked to higher readmission rates for pediatric asthma. However, the relationship between neighborhood inequality and children's repeat hospitalizations for asthma require further research, conclude the authors of this study. They analyzed Rhode Island hospital discharge data from 2001 to 2005 to identify 2,919 children at the time of their first asthma hospitalization. During the study period, 15 percent of those children were readmitted to the hospital for asthma. After adjusting for several factors, the crowded housing conditions, proportion of racial/ethnic minority residents, or poverty of disadvantaged neighborhoods did not affect rehospitalization rates. However, children insured by Medicaid at the time of their initial admission had readmission rates that were 33 percent higher than children who were privately insured. The authors suggest further study of the link between neighborhood markers of economic disadvantage and asthma disparities.
Platt, R., Madre, L., Reynolds, R., and Tilson, H. (2008). "Active drug safety surveillance: A tool to improve public health." (AHRQ grant HS13474). Pharmacoepidemiology and Drug Safety 17, pp. 1175-1182.
The Centers for Education and Research on Therapeutics recently convened experts from academia, government, and industry to assess strategies to improve the U.S. system for identifying and evaluating potential drug safety signals. They concluded that a public-private partnership to create a network of government and private data to enable evaluation of routine and priority safety questions is in the public interest. However, better methods are needed to address the limitations of pharmacoepidemiology, and a knowledgeable workforce is needed to conduct the studies and to understand how to interpret the results. The experts also suggested developing guidelines on when and how to communicate to stakeholders, particularly physicians and patients, that a drug safety signal exists and is being evaluated, as well as the outcome of that evaluation.
Rhee, M.K., Musselman, D., Ziemer, D.C., and others (2008). "Unrecognized glucose intolerance is not associated with depression. Screening for Impaired Glucose Tolerance study 3 (SIGT 3)." (AHRQ grant HS07922). Diabetic Medicine 25, pp. 1361-1365.
Diabetes is compounded by concomitant depression in 11-32 percent of patients with diagnosed diabetes, a twofold higher prevalence than that in unaffected populations. Although the evidence of the relationship between depression and diabetes is strong, the mechanism of the association remains unclear: depression may lead to diabetes or diabetes may lead to depression. To learn whether depression is linked to the metabolic abnormality per se, the researchers determined the prevalence of depressive symptoms along the continuum of glucose tolerance in individuals without previously known diabetes. They used the oral glucose tolerance test to screen for diabetes or pre-diabetes and the Patient Health Questionnaire to screen for depression in a study population of 1,047 subjects without known diabetes. No association was observed between glucose tolerance and depressive symptoms or history of depression treatment.
Rothman, A. A., Park, H., Hays, R. D., and others (2008, December). "Can additional patient experience items improve the reliability of and add new domains to the CAHPS hospital survey?" (AHRQ cooperative agreement with the National Institute on Aging). HSR: Health Services Research 43(6), pp. 2201-2222.
Adding new questions on hospital discharge and coordination of care can significantly improve the psychometric properties of the CAHPS® Hospital Survey, concludes this study. The CAHPS® contains 18 questions about hospital care. To determine whether adding questions would increase the reliability and validity of the survey, the authors analyzed survey responses of patients at 181 hospitals participating in the California Hospitals Assessment and Reporting Taskforce (CHART), which added nine questions to CAHPS®. Of the 40,172 surveys analyzed, adding two new discharge information questions improved the internal consistency reliability from 0.45 to 0.72 and the hospital-level reliability from 0.75 to 0.81. Adding five new coordination-of-care questions had good internal consistency reliabilities ranging from 0.58 to 0.70 and hospital-level reliabilities ranging from 0.84 to 0.87.
Rubenstein, L.V., Hempel, S., Farmer, M.M., and others (2008). "Finding order in heterogeneity: Types of quality-improvement intervention publications." Quality and Safety in Health Care 17, pp. 403-408.
An important challenge confronting stakeholders in promoting quality-improvement intervention (QII) publication and synthesis has been the lack of agreed-upon standards for evaluating QII research. The authors report on the development and preliminary testing of a classification framework for QII articles. Their aim was to create categories homogeneous enough to support coherent scientific discussion on QII reporting standards and facilitate systematic review. The final framework screened articles into the following categories: empirical literature on development and testing of QIIs, QII stories, theories, and frameworks, QII literature syntheses and meta-analyses, and development and testing of QII-related tools. The first category (empirical literature on development and testing of QIIs) was subdivided into development of QIIs, history, documentation, or description of QIIs, and success, effectiveness, or impact of QIIs. The article contains detailed descriptions of each of these categories, as well as the process by which the participating experts reached agreement on how to properly categorize the 80 articles that were selected to test the framework.
Schuber, P. A. (2008). "Measuring attitudes toward participation in cancer treatment and cancer prevention trials: The Attitudes toward Cancer Trials Scales (ACTS)." (AHRQ grant HS10583). Journal of Nursing Measurement 16(2), pp. 136-152.
This paper describes the development of a questionnaire to measure attitudes toward participation in cancer treatment and cancer prevention trials, the Attitudes toward Cancer Trials Scales (ACTS). The researchers collected survey data within multiple settings, targeting an ethnically diverse sample of 312 individuals. Item and principal component analyses empirically supported the ACTS, a two-dimensional survey containing an 18-item cancer treatment (CT) scale and a 16-item cancer prevention trial (CPT) scale. Four components comprised the CT scale: personal benefits, personal barriers and safety, personal and social value, and trust in the research process. Three components comprised the CPT scale: personal barriers and safety, altruism, and personal value. Study results provided evidence that the ACTS has sufficient reliability and validity for use in adult populations.
Schultz, D., Seid, M., Stoto, M. A., and Bustain, J. M. (2008, November). "The Agency for Healthcare Research and Quality's children's health research portfolio." (AHRQ Contract No. 282-00-0005). Maternal and Child Health Journal
This article describes and assesses the potential impact of the Agency for Healthcare Research and Quality's (AHRQ) children's health activities. The authors used AHRQ databases and publication lists and generic search engines to develop a comprehensive list of the Agency's funded children's health activities from 1990 through 2005 and related publications (1996-2002). They found that the child health portfolio has changed over time, with a growing number of activities related to patient safety and health information technology. The Agency has contributed a substantial body of new knowledge as a result of its funding for children's health activities. Most of these new findings can be building blocks early in the translation continuum rather than findings that directly inform policy or change clinical practice, suggest the authors. They conclude that, while AHRQ has successfully engaged the child health services research community, efforts to broaden into policy, practice, and patient arenas have been less successful.
Slutsky, J. R., and Clancy, C. M. (2009, January-February). "AHRQ's Effective Health Care Program: Why comparative effectiveness matters." American Journal of Medical Quality 24(1), pp. 67-70.
This article describes the Agency for Healthcare Research and Quality's (AHRQ) Effective Health Care Program, which was launched 3 years ago. The core question of comparative effectiveness research-which treatment works best, for whom, and under what circumstances-is a fundamental concern for patients and clinicians confronting a health problem. The Effective Health Care Program focuses on 14 priority conditions that include arthritis, cancer, cardiovascular disease, dementia, autism, diabetes, infectious disease, obesity, and substance abuse. The program publishes the following four types of products: comparative effectiveness reviews of studies that make head-to-head comparisons of treatments; technical briefs on emerging clinical interventions; DEcIDE reports, which draw on existing health care databases to evaluate health care interventions; and summary guides, tailored to a variety of audiences (including clinicians), which summarize report findings.
Reprints (AHRQ Publication No. 09-R028) are available from the AHRQ Publications Clearinghouse.
Soumerai, S., Zhang, F., Ross-Degnan, D., and others (2008, May-June). "Use of atypical antipsychotic drugs for schizophrenia in Maine Medicaid following a policy change." (AHRQ grant HS10391). Health Affairs 27(3), pp. w185-w195.
In July 2003, Maine implemented a Medicaid policy requiring a prior authorization for new users of atypical antipsychotics, which are commonly prescribed for conditions such as schizophrenia or bipolar disorder. When individuals with schizophrenia experience disruptions in their medication, this can lead to psychotic episodes and hospitalizations. As a result of the Maine policy, patients experienced a 29 percent greater risk of treatment discontinuity than patients who were able to receive atypical antipsychotics before the preauthorization policy was effected. There was a 3 percent increase in preferred atypical antipsychotic use and a 5.6 percent decrease in nonpreferred atypical antipsychotic use, which led to an overall decrease in spending for atypical antipsychotics. However, Maine suspended the prior authorization policy in March 2004 after many reports of adverse effects. The researchers suggest that these sorts of restrictions on prescribing atypical antipsychotics should not apply to patients with severe mental illnesses.
Sterling, R. (2008, November). "The on-line promotion and sale of nutrigenomic services." (AHRQ grant T32-HS00034). Genetic Medicine 10(11), pp. 784-796.
Nutrigenomics (NG) examines relationships among genes, diet, and health. Despite the methodological challenges confronting NG research that have contributed to inconsistent findings across genetic association studies, biotechnology companies and laboratories are offering genetic services based on findings from NG research. The researcher performed a systematic search and analysis of Web sites promoting nutrigenomic services in order to evaluate the promotion and sales practices of the host organizations. There were 82 identified Web sites hosted by 64 organizations, one of which was not-for-profit. At-home testing was offered by 24 organizations. Twenty-six organizations either sold services online or provided a direct link to online sales. Few organizations provided information about laboratory certifications, nutrigenomic test or research limitations, test validity or utility, or genetic counseling. Evidence suggests that current findings in NG research do not support the use of genetic information to improve individual health. However, service provider Web sites described NG tests as a useful tool for understanding and improving the health of patients.
Stout, N.K., and Goldie, S.J. (2008). "Keeping the noise down: common random numbers for disease simulation modeling." (AHRQ grant HS00083). Health Care Management Science 11, pp. 399-406.
Disease simulation models are used to conduct decision analyses of the comparative benefits and risks associated with preventive and treatment strategies. Applied to disease simulation modeling, common random numbers (CRN) reduces stochastic noise between model runs and has the additional benefit of enabling modelers to conduct direct "counterfactual- like" analyses at the individual level. This technique uses synchronized random numbers across model runs to induce correlation in model output thereby making differences easier to distinguish as well as simulating identical individuals across model runs. The CRN technique allows statistics such as the change in life expectancy from a treatment or the lead-time due to screening to be estimated by comparing individual level data between simulation runs. The researchers provide a tutorial introduction and demonstrate the application of common random numbers in an individual-level simulation model of the epidemiology of breast cancer.
Tang, L., Duan, N., Klap, R., and others (2009). "Applying permutation tests with adjustment for covariates and attrition weights to randomized trials of health-services interventions." (AHRQ grant HS09908). Statistics in Medicine 28, pp. 65-74.
The authors of this paper describe their development of a permutation test. Their method first permutes treatment status according to the original study randomization design, and then reconstructs study attrition weights using the permuted data. The researchers then rerun weighted regressions using the reconstructed weights. They illustrate their proposed permutation test using data from a randomized controlled trial, the Youth Partners-in-Care (YPIC) study, which was aimed at evaluating a quality improvement intervention for adolescent depression in primary care clinics. Their goal was to demonstrate the viability of permutation tests based on permuting treatment indicators in the context of complex randomization protocols, the availability of covariates, the use of logistic regression or other nonlinear procedures, and the application of attrition weighting.