Research Activities, August 2009, No. 348
AcademyHealth Roundtable Panels. (2009, April). "Roundtable on expanding capacity for comparative effectiveness research in the United States." HSR:Health Services Research 44(2), pp. 327-342.
This discussion took place on June 2, 2007, at the AcademyHealth Annual Research Meeting in Orlando, FL. The facilitator was Sean Tunis, M.D., director of the Center for Medical Technology. The panelists were Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, W. David Helms, Ph.D., president of AcademyHealth, J. Michael McGinness, M.D., senior vice president at the Robert Wood Johnson Foundation, and Steven D. Pearson, M.D., president of the Institute for Clinical and Economic Review at Harvard Medical School. The discussion focused on clarifying what falls under the umbrella of clinical effectiveness. It began with an effort to define "comparative effectiveness." This, in turn, led to a discussion about what is being compared: Are comparisons only about drugs, devices, and surgical procedures, or the many different and sequential options embedded in the choices that clinicians have to make? The extent to which cost and cost effectiveness should be considered in comparisons was also discussed. In addition, attention was given to the methods to be used in comparative effectiveness research.
Brown, J. S., Kulldorff, M., Petronis, K. R., and others (2009). "Early adverse drug event signal detection within population-based health networks using sequential methods: Key methodologic considerations." (AHRQ grant HS10391). Pharmaco-epidemiology and Drug Safety 18, pp. 226-234.
The authors report on the use of active surveillance of HMO patient records to detect patterns of adverse drug events (ADEs) associated with specific drugs, and how changes in the study specifications change the ability to prospectively detect signals of such patterns. The study drew on patient records from nine geographically diverse health plans involved in the Agency for Healthcare Research and Quality-funded HMO Research Network's Center for Education and Research on Therapeutics from the beginning of 2000 to the end of 2005. The authors found that relaxing the exclusion criteria for ADEs resulted in earlier detection of an ADE signal by 10-16 months. They did this by either including HMO members with prior outpatient diagnoses used as ADE signals for a drug of interest or reducing to 90 days the time before a patient was started on a drug of interest.
Clancy, C. M. (2009). "CMS's hospital-acquired condition lists link hospital payment, patient safety." American Journal of Medical Quality 24(2), pp. 166-168. Reprints (AHRQ Publication No. 09-R054) are available from the AHRQ Publications Clearinghouse.
A change in policy by the Center for Medicare & Medicaid Services means that hospitals are no longer paid the additional costs incurred when patients develop certain "hospital-acquired conditions," such as treatment-related infections, pressure ulcers, and falls. In this commentary, Agency for Healthcare Research and Quality (AHRQ) Director Carolyn M. Clancy, M.D., discusses the history and rationale for the new policy. She notes that the excluded conditions are also related to the list of "never events" developed by the nonprofit National Quality Forum. The commentary notes the possibility of negative impacts of this policy, especially on the treatment of the elderly. It also highlights the recent AHRQ-funded study on reducing catheter-related infections that saw a 66 percent decrease in the rate of such infections because of the use of safer procedures during an 18-month study period. Dr. Clancy concludes that the momentum for linking hospital payments with prevention of adverse events will only increase over time.
Clarke, J. L. (2009). "The accountability conundrum: Staying focused, delivering results. A report on the UHC 2008 Quality and Safety Fall Forum." American Journal of Medical Quality 24(Suppl.), pp. 5S-43S. (AHRQ Director Carolyn M. Clancy participated, pp. 8S-10S). Reprints (AHRQ Publication No. 09-R055) are available from the AHRQ Publications Clearinghouse.
Dr. Clancy spoke at the University HealthSystem Consortium's 2008 Quality and Safety Fall Forum on "Partnering with External Regulators to Advance Quality and Safety." She described the Agency's efforts in knowledge creation, including initiatives in reducing methicillin-resistant Staphylococcus aureus (MRSA) and the Effective Health Care Program. Synthesis and dissemination activities include the actions of the U.S. Preventive Services Task Force, which is revisiting its recommendations to address not just "Does the test work?" but also "Does it detect the disease early enough to make a difference?" To foster implementation and use of knowledge funded by the Agency, AHRQ is encouraging collaboration between multiple stakeholders at the local community level across organizations and aligning metrics across settings. Dr. Clancy noted that ideally we should have a health care system we can count on wherever we go-"like tap water."
Coleman, L. A., Kottke, T. E., Rank, B., and others (2008). "Partnering care delivery and research to optimize health." (AHRQ grant HS17518). Clinical Medicine & Research 6(3/4), pp. 113-118.
In this paper, a report on a clinical leadership panel held at the 14th Annual Health Maintenance Organization Research Network Conference, speakers discuss five principles that have been proposed to optimize care through research. Key among these is that the needs of patients and populations should determine the research agenda and that the research agenda must determine the research methods (rather than vice versa). The research agenda must also address context and implementation issues, such as development of care delivery and accountability systems. While generally in agreement, the speakers-who came from large integrated health care systems that conduct research-differed on how to achieve the goals.
Dalal, P. G., Murray, D., Messner, A. H., and others (2009). "Pediatric laryngeal dimensions: An age-based analysis." (AHRQ grant HS16652) Pediatric Anesthesiology 108(5), pp. 1475-1479.
Decisions on airway management in children have relied on the belief that the pediatric larynx is funnel-shaped, with the widest part near the glottis and the narrowest part at the level of the cricoid cartilage. This belief is based on a limited number of autopsy measurements. However, the authors of this paper used video bronchoscopy to measure the dimensions of the larynx in 135 anesthetized children, aged 6 months to 13 years. As part of the study, the children were placed on ventilation while their upper airway muscles were temporarily paralyzed. In contrast to the postmortem findings, the current study found that the airway shape was more cylindrical than funnel-shaped, as is typical of the adult larynx. The authors suggest that future studies should investigate the dynamics of the larynx in vivo, with and without an endotracheal tube.
Dintzis, S. M. and Gallagher, T. H. (2009). "[Editorial] Disclosing harmful pathology errors to patients." (AHRQ grant HS16506) American Journal of Clinical Pathology 131, pp. 463-465.
In this editorial, the authors set out the problems in disclosing harmful errors in diagnostic pathology. In particular, they present a problem in which the pathologist recognizes a previous mistake in pathology and communicates it to the patient's primary physician, but the physician decides not to inform the patient. In this case, what is the responsibility of the pathologist to the patient? The authors discuss this issue in light of recent movements by the Joint Commission on Accreditation of Healthcare Organizations and the National Quality Forum toward requiring greater transparency of health care organizations and the increase in patient safety event reporting systems.
Greenlee, R. T., Coleman, L. A., Nelson, A. F., and Selby, J. V. (2008). "Partnerships in translation: Advancing research and clinical care. The 14th Annual HMO Research Network Conference, April 13-16, 2008, Minneapolis, Minnesota." (AHRQ grant HS 17518) Clinical Medicine & Research 6(3/4), pp. 109-112.
In this paper, the authors provide an overview of the 14th Annual Health Maintenance Organization (HMO) Research Network Conference. They outline the background of the HMO Research Network, which has grown to 15 organizations in locations from Hawaii to Massachusetts, and describe the topics discussed at the conference's plenary and scientific sessions. In a table, the authors list the nine large, federally funded research collaborations that use the HMO Research Network, including three with the Agency for Healthcare Research and Quality: the Centers for Education and Research in Therapeutics; the Developing Evidence to Improve Decisions about Effectiveness Network; and the Integrated Delivery Systems Research Network. These collaborations allow specific research questions in health care delivery to be investigated in real-world patient populations.
Kelly, C. Y., and Clancy, C. M. (2009). "Pharmacists emerge as key stakeholders in quality, patient safety efforts." Journal of the American Pharmacists Association 49(2), pp. 146-150. Reprints (AHRQ Publication No. 09-R057) are available from the AHRQ Publications Clearinghouse.
In this commentary, Agency for Healthcare Research and Quality (AHRQ) Director Carolyn M. Clancy, M.D., and AHRQ colleague Carmen Y. Kelly, Pharm.D., discuss the emerging role of pharmacists in ensuring quality and safety of patient care. They note that medication errors represent nearly 20 percent of adverse events, affecting 4 percent of all hospital stays. A 2006 Institute of Medicine study put the number of preventable medication adverse events in emergency departments at 3.6 million annually. The authors focus in their article on the role of pharmacists in medication therapy management for patients with chronic illnesses, the role of emergency pharmacists in reducing ED drug-related errors, and the importance of raising awareness among pharmacy staff about patient health literacy problems. They suggest that pharmacists and pharmacy staff work with other stakeholders to address quality and safety problems.
Lorch, S. A., Silber, J. H., Even-Shoshan, O., and Millman, A. (2009, April). "Use of prolonged travel to improve pediatric risk-adjustment models." (AHRQ grant HS09983). HSR: Health Services Research 44:2 (Part I), pp. 519-541.
The researchers sought to determine whether the time and distance sick children travel to get to the hospital could explain previously reported differences in length of stay (LOS), readmission, or death at children's hospitals versus other hospital types. They used claims data on children aged 1-17 years admitted to acute care hospitals in Pennsylvania between 1996 and 1998. They identified 19 common, unscheduled medical conditions from the ICD-9-CM codes. Prior work had suggested that children's hospitals have longer LOS, higher readmission rates, and higher mortality rates compared with other types of hospitals. The researchers found that the addition of a travel variable to a traditional risk-adjustment model-whether geocoded travel times or nongeocoded travel distances-reduced these systemic differences. Their analysis suggests that the severity adjustment of the models improves when these travel variables are factored in, because patients who travel further to receive care are sicker by all available measures.
Parente, S. T., and McCullough, J. S. (2009). "Health information technology and patient safety: Evidence from panel data." (AHRQ grant HS15001). Health Affairs 28(2), pp. 357-360.
Extensive literature shows the value of health information technology (IT) at leading academic institutions; however, its broader value remains unknown. Using a large, nationally representative sample of Medicare patient data, the researchers sought to determine the impact of three health IT applications-electronic medical records (EMR), nurse charts, and picture archiving and communications systems (PACS)- on patient safety indicators. The indicators were infections due to medical care, postoperative hemorrhage or hematoma, and postoperative pulmonary embolism or deep vein thrombosis. The study found that EMRs were the only health IT application to have a clear and statistically significant effect on patient safety. The use of EMRs resulted in about two averted infections per year at an average hospital. However, the authors conclude that the evidence base is not yet sufficient to draw definite conclusions about the value of health IT. A major reason is that the nationally available patient safety metrics are less than comprehensive.
Pincus, H. A. (2009, April). "Challenges and pathways for clinical and translational research: Why is this research different from all other research?" (AHRQ grant HS16097). Academic Medicine 84(4), pp. 411-412.
The author's commentary on three articles in the same issue addresses four questions about clinical and translational research that should be considered by policymakers at a national level, by academic institutions, and by individual scientists: what, who, how, and why. Most of his comments are directed at the first two questions. The author perceives ambiguity in the differing definitions of clinical and translational research (C/T research) offered by the groups discussed in the articles. This ambiguity means that policymakers are not providing a clear target for institutions and researchers. Future C/T researchers will be determined by issues of recruitment, training, mentoring, social supports, the institutional reward system, and the impact of Federal and other programs. Given the rapid evolution of new tools and methodologies in C/T research, the author believes that it is important to consider each of these issues across the full developmental pathway of a C/T researcher. He also provides a list of the roles and tasks of the C/T researcher.
Politi, M. C., Schleinitz, M. D., and Col, N. F. (2008, June). "Revisiting the duration of vasomotor symptoms of menopause: A meta-analysis." (AHRQ grant HS13329). Journal of General Internal Medicine, 23(9), pp. 1507-1513.
Researchers conducted an extensive literature review of 410 studies to determine how long hot flashes and night sweats, called "vasomotor symptoms," are thought to occur during menopause. The studies showed that these symptoms peak 1 year after the final menstrual period, with 50 percent of women experiencing symptoms 4 years after their last periods. If these durations are accurate, the researchers suggest they should affect clinical guidelines so that the risks of hormone therapy are balanced with the woman's quality of life. Further, more studies need to be conducted that address the duration of hot flashes and night sweats so true timelines can be determined and treatments developed. Finally, risk factors for vasomotor symptoms should also be researched.
Ross, L. E., Hall, I. J., Fairley, T. L., and others (2008, October). "Prayer and self-reported health among cancer survivors in the United States National Health Interview Survey, 2002." (AHRQ grant HS13353). Journal of Alternative and Complementary Medicine 14(8), pp. 931-938.
Many cancer patients seem to find solace in prayer, according to a new study. Using data from the 2002 National Health Interview Survey, researchers from Shaw University in North Carolina found that almost 70 percent of 2,262 cancer patients prayed for their own health and 72 percent reported their health as good. Groups who most often used prayer for health included individuals who were 35 and older, women, married, or who reported having never served in the military. Conversely, individuals who were age 18 to 34, men, unmarried, or veterans did not report using prayer for health often. Blacks (80.5 percent) and Hispanics (72.9 percent) used prayer for health more than non-Hispanic whites (68.2 percent). However, whites (72.9 percent) were more likely to report better health than blacks (55.1 percent) and Hispanics (59.3 percent). The authors found no link between socioeconomic status and prayer. Patients with breast, colorectal, prostate, and short-survival cancers (lung, liver, esophagus, pancreas, and stomach) were more likely to use prayer than patients with skin cancer.
Schadow, G. (2009, March/April). "Structured product labeling improves detection of drug-intolerance issues." (AHRQ grant HS13577). Journal of the American Medical Informatics Association 16(2), pp. 211-219.
The researcher compared the performance of drug-intolerance issues detection by a new method using structured product labeling (SPL) and its public knowledge sources with an older method (the Regenstrief Institute's Gopher computerized provider order entry system). Both methods were applied to a large set of drug-intolerance (allergy) records, drug orders, and medication dispensing records covering more than 50,000 patients between 1977 and 2008. The new approach detected four times as many drug-intolerance issues on twice as many patients. The SPL method outperformed the Gopher method because it is more systematic and complete. For example, it is capable of resolving a substance class to all drugs that include any ingredient of that class. Another reason SPL outperformed Gopher is the deeper structure of the systematic chemical class terminology that is used together with the SPL method.
Scholle, S. H., Roski, J., Dunn, D. L., and others (2009, January). "Availability of data for measuring physician quality performance." (AHRQ grant HS16277). The American Journal of Managed Care 15(1), pp. 67-72.
Administrative data for single health plan may not provide enough information for benchmarking performance of individual physicians, conclude the authors of this paper. They report that most primary care physicians do not have enough patients experiencing quality measure events to give accurate measures of their quality of care. The researchers estimated 30 eligible patients as the minimum number of patients needed to allow comparisons on an individual measure. In fact, using claims data from 9 health plans (a total of 170,168 primary care physicians) over 2 years, the authors found that the proportion of physicians who had at least 30 patients eligible for any of 27 quality measures ranged from near 0 to 18 percent. For example, only 6 percent of the physicians had seen at least 30 patients who were eligible for glaucoma screening one or more times. The authors also found that requiring the physician to have provided at least 50 percent of the patient's care visits reduced the mean number of quality measure events per physician by a third (from 8.9 to 5.9 events).
Setoguchi, S., Wang, P. S., Brookhart, M. A., and others (2008, September). "Potential causes of higher mortality in elderly users of conventional and atypical antipsychotic medications." (AHRQ Contract no. 290-05-0016). Journal of the American Geriatrics Society 56(9), pp. 1644-1650.
Researchers analyzed data of 37,241 elderly patients in British Columbia who were prescribed conventional or atypical antipsychotic medications (APMs) from 1996 to 2004. Almost 13 percent of patients who received conventional APMs died from non-cancer causes within 180 days after they began taking the drugs compared with 9 percent of patients who were prescribed atypical APMs. Forty-nine percent (3,821) of the patients who died within 6 months of starting conventional APMs died from cardiovascular (CV) causes. The most frequently used conventional APM was loxapine (69 percent), followed by haloperidol (11 percent) and chlorpromazine (7 percent). The most frequently used atypical APM was risperidone (75 percent) followed by quetiapine fumarate (15 percent) and olanzapine (10 percent).
Shea, J. A., Guerra, C. E., Weiner, J., and others (2008, October 2008). "Adapting a patient satisfaction instrument for low literate and Spanish-speaking populations: Comparison of three formats." (AHRQ grant HS10299). Patient Education and Counseling 73, pp. 132-140.
A study comparing an interactive voice format for the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS®) with illustrated and print formats found that the voice format was no more effective for soliciting responses from low literacy consumers than the other two formats. Researchers asked 2,015 primary care adult patients to complete demographic information, a test of functional health literacy, and 1 of 3 CAHPS formats. A second sample of 4,800 patients was randomized to receive the illustrated or interactive voice formats. Independent of survey format, low literacy predicted worse CAHPS satisfaction scores. Response rates for the illustrated (31.3 percent) and print (30.4 percent) formats were significantly higher than for the interactive voice format (18.1 percent). Results of the illustrated format were comparable to the traditional text version, but required about 2 minutes more to complete by both low and high literacy groups. There were almost no invalid responses for the interactive voice format, but the format was associated with lower CAHPS satisfaction scores.
Thrasher, A. D., Earp, J. L., Golin, G. E., and Zimmer, C. R. (2008, September). "Discrimination, distrust, and racial/ethnic disparities in antiretroviral therapy adherence among a national sample of HIV-infected patients." (AHRQ grant HS00032). Journal of Acquired Immune Deficiency Syndrome 49(1), pp. 84-92.
This study found that minorities with HIV have poorer adherence to antiretroviral therapy than whites (40 versus 50 percent); however, discriminatory health care experiences and related provider distrust did not seem to be the underlying link to poorer adherence. More than 40 percent of the 1,886 patients surveyed reported they had experienced discrimination in a health care setting since they were diagnosed with HIV. Yet, minority patients were less likely than whites to report discrimination. Although minorities' experience with discrimination led to distrust of their providers and their belief that drug therapy was not worthwhile, it did not affect their medication adherence. Both white and minority patients with HIV tended to trust their care providers. Patients who reported distrust of their medical provider nevertheless tended to adhere to antiretroviral therapy. The authors suggest that distrust may actually fuel patients' vigilance in taking their drugs because these patients believe they are solely responsible for their health.
Unruh, L., Russo, C. A., Jiang, H. J., and Stocks, C. (2009). "Can state databases be used to develop a national, standardized hospital nurse staffing database?" Western Journal of Nursing Research 31(1), pp. 66-88. Reprints (AHRQ Publication No. 09-R040) are available from the AHRQ Publications Clearinghouse.
The authors survey the usefulness of existing State nursing databases for studies of nurse staffing. They find that 25 States collect some form of nurse staffing data, but only 12 of these make complete, usable data available. Because of the differences in data collection among the States, especially for measures of registered nurses (RNs), they propose continued improvement of State-level nurse staffing databases. They also propose the creation of a standardized, multistate database with uniform data elements. Another issue that makes staffing research difficult is that the State databases typically collect data at the hospital level, making it difficult to do comparisons or analyses for different types of hospital units, the authors note.
Zaydfudim V., Wruight, J. K., and Pinson, C. W. (2009, April). "Liver transplantation for iatrogenic porta hepatic transaction." (AHRQ grant T32 HS13833). The American Surgeon 75(4), pp. 313-316.
The authors describe two cases in which damage during surgery to the main vein, artery, and bile duct in the liver (iatrogenic porta hepatis injury) was successfully treated by liver transplant. This serious problem can occur during minimally invasive removal of the gallbladder (laproscopic cholecystectomy). Attempts to reconstruct the bile duct or manage arterial injuries without transplantation rarely result in return to a normal health-related quality of life. The authors report on 2- and 6-year follow-ups of two patients treated by liver transplantation. Both patients were alive and well at the time of writing. The authors suggest that two-state total liver removal with portocaval shunting followed by liver transplantation be considered for patients suffering this surgery-related injury.