Research Activities, January 2009, No. 341
Castel, L.D., Williams, K.A., Bosworth, H.B., and others (2008). "Content validity in the PROMIS social-health domain: A qualitative analysis of focus-group data." (AHRQ grant T32 HS00032). Quality of Life Research 17, pp. 737-749.
In order to contribute to the process of improving health-related quality-of-life measures, the researchers assessed the content validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) by comparing a prespecified conceptual model with concepts that focus on what group participants identified as important social-health-related outcomes. The researchers convened a panel of experts on patient-reported outcomes to achieve a consensus on social health constructs to measure. They then conducted 4 focus groups consisting of 25 persons with chronic health conditions to examine whether the focus group discussions would provide qualitative information that would either support or refute the concepts of the social-health domain as it was defined. This included performance and satisfaction with social roles in the context of family/friends, work/school, and leisure activities. Fulfilling family and work responsibilities was important, with performance and satisfaction overlapping. However, volunteerism and pets, which were not included in the researchers' original definition of social health, were also found to be important.
Clancy, C. (2008). "New patient safety organizations lower roadblocks to medical error reporting." American Journal of Medical Quality 23, pp. 318-321.
The most notable roadblock to sustained quality improvement is the lack of uniform Federal standards for confidentiality of information about events that jeopardize patient safety. Patient safety organizations (PSOs) authorized by Federal legislation in 2005 will diminish the fear of legal liability and sanctions among physicians and health care organizations, according to Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ). For the first time, clinicians and health care organizations throughout the United States will be able to share information about medical errors and near misses within a protected legal environment, without the threat of the information being used against them. Health care providers will decide whether to work with PSOs, and if so, which PSO can best meet their needs. The information developed by the PSOs can help providers more effectively target their patient safety and error prevention strategies. Working together, PSOs and health providers have a new opportunity to translate our aspiration for a safer medical system into reality.
Reprints (AHRQ Publication No. 09-R002) are available from the AHRQ Publications Clearinghouse.
Deshefy-Longhi, T., Schwartz, M.K., and Grey, M. (2008, May). "Characterizing nurse practitioner practice by sampling patient encounters: An APRNet study." (AHRQ grant HS11196). Journal of the American Academy of Nurse Practitioners 20, pp. 281-287.
Patients seen by nurse practitioners (NPs) are more likely to receive health counseling as part of a primary care visit than those seen by physicians, according to this study. Researchers analyzed information collected on both NP and physician practices by a group of Practice-based Research Networks (PBRNs). A southern New England-based network of NPs, the Advanced Practice Registered Nurse Network (APRNet), and 19 PBRNs of physician-led primary care practices provided demographic and practice information, as well as data on 30 patient encounters during a 2-4 week period as part of a survey. Acute health problems accounted for 45 percent of the visits, followed by chronic illness (30 percent), or nonillness care (24 percent), including health promotion and annual exams. Prescription of contraceptive medication was among the top 20 reasons for a primary care visit to an NP, but ranked much lower among reasons for visits to a physician-led practice. Both APRNet and the combined networks were comparable in providing diagnostic or screening services and prescribing medication. However, NPs reported providing therapeutic and preventive services (nutrition, physical exercise, family planning, prenatal instructions, tobacco cessation, and growth and development counseling) in 84 percent of patient visits in contrast to 61 percent of visits for all networks combined.
Dilworth-Anderson, P., Hendrie, H.C., Manly, J.J., et al. (2008). "Diagnosis and assessment of Alzheimer's disease in diverse populations." (AHRQ grant HS10884). Alzheimer's and Dementia 4, pp. 305-309.
The Alzheimer's Association convened a think tank meeting on the "Diagnosis and Assessment of Alzheimer's Disease in Diverse Populations" in 2007 in Chicago. Thirty clinicians and researchers met to discuss how Alzheimer's disease (AD) affects various communities differently and how its diagnosis and treatment present challenges specific to certain population groups. A number of major points emerged from the meeting. Researchers need to deconstruct racial and ethnic variables into more meaningful variables, given that the acknowledged research shows that black and Hispanic communities suffer a greater incidence of AD than do white Americans. Better ways must be developed to get at-risk adults, especially those from ethnic minorities, to participate in memory screenings. Clinics need to provide comfortable, culturally sensitive environments for the families they serve in order to keep patients in the screening program. Finally, investigators must learn more about how chronic diseases such as hypertension and diabetes interact with AD pathology, especially among ethnic minorities, who suffer disproportionately from these conditions.
Duterte, E.E., Bonomi, A.E., Kernic, M.A., and others (2008, January). "Correlates of medical and legal help seeking among women reporting intimate partner violence." (AHRQ grant HS10909). Journal of Women's Health 17(1), pp. 85-95.
The duration and severity of domestic abuse that women endure serve as a predictor of whether they will seek medical and legal help, a new study finds. Researchers in Seattle conducted telephone interviews with 1,509 women who participated in a health plan covering Washington and Northern Idaho and said they had experienced physical, sexual, or psychological abuse since reaching the age of 18. Women who were sexually or physically abused were more likely to seek medical care and legal assistance than women who reported only psychological abuse. For example, sexually abused women were 1.3 times as likely to seek medical care as women who were psychologically abused. The longer the abuse continued, the more likely the woman was to obtain legal help. For example, compared with women who were abused for 0 to 2 years, women who were physically abused for 3 to 10 years were 1.4 times more likely to seek legal services. Those who suffered physical abuse for more than 10 years were 1.9 times as likely to get legal help. Women who were psychologically abused were more inclined to obtain legal than medical services.
Edwards, P.J., Scott, T., Richardson, P., and others (2008, June). "Using staff perceptions on patient safety as a tool for improving safety culture in a pediatric hospital system." (AHRQ grant HS15326). Journal of Patient Safety 4(2), pp. 113-118.
Researchers used the Hospital Survey on Patient Safety developed by the Agency for Healthcare Research and Quality (AHRQ) to examine safety culture perceptions of clinical staff at two hospitals (one academic, one community-based) that are part of Children's Healthcare of Atlanta. Overall, 394 staff members at the system's 2 hospitals completed the baseline survey and 428 completed the followup survey 18 months later. Results from the baseline survey showed three low-scoring areas needing improvement: nonpunitive response to error, patient handoffs and transitions, and teamwork across hospital units. These findings were in the same range as those reported in AHRQ's benchmark national survey of 382 hospitals. Following the baseline survey, several patient safety initiatives were implemented to address nonpunitive responses to error and handoffs and transitions. The followup survey indicated a 5 percent improvement in the nonpunitive response to error following the implementation of monthly and ad hoc safety rounds and the release of an enhanced self-reporting system. The significant improvements in feedback and communication regarding error, frequency of event reporting, and supervisor/manager expectations resulted in scores that were on par with the national benchmarks. However, there was a decline in safety scores related to handoffs and transitions possibly due to workflow changes related to implementing an electronic medical record.
Fields, W., Tedeschi, C., Foltz, J., and others (2008, March/April). "Reducing preventable medication safety events by recognizing renal risk." (AHRQ grant HS13131). Clinical Nurse Specialist 22(2), pp. 73-78.
Researchers collected information on 1,052 medication safety events (both actual and potential adverse drug events) including 318 medication errors reported on 17 clinical units at 2 urban, nonteaching community hospitals before the implementation of a commercial computerized physician order entry (CPOE) system. The researchers estimated creatinine clearance and used laboratory measurement of serum creatinine to classify each patient as being at high (144 patients), hidden (81 patients), or low (93 patients) risk of kidney-related medication events. High-risk patients had high levels of serum creatinine and low clearance rates, low-risk patients had low serum creatinine and high clearance rates, while hidden-risk patients had a combination of low serum creatinine and low clearance rates. Age and sex were each significantly associated with renal risk groups: patients over 80 years old formed the largest group for hidden risk, while men were the largest group at high risk and more women than men had hidden risk. Medication errors among patients with high or hidden risk of renal insufficiency primarily occurred during ordering or transcription of the order, and most often involved a wrong dose rather than wrong drug choice or frequency of administration. The researchers found that antibiotics accounted for a fourth and diabetes drugs accounted for a sixth of medication errors. Antibiotics accounted for more than a third of the errors in the high-risk group and less than a fifth of errors for the hidden-risk and normal-risk groups.
Gessert, C.E., and Haller, I.V. (2008, Spring). "Medicare hospital charges in the last year of life: Distribution by quarter for rural and urban nursing home decedents with cognitive impairment." (AHRQ grant HS13022). Journal of Rural Health 24(2), pp. 154-160.
Medicare hospital charges in the last year of life for urban nursing home residents with cognitive impairment are higher than those of their rural counterparts. These charges tend to be concentrated in the last 90 days of life for urban residents. Researchers analyzed rural-urban differences in Medicare hospital charges in the last year of life for 3,703 nursing home residents with severe cognitive impairment in Minnesota and Texas who died in 2000-2001. During the last year of life, unadjusted charges averaged $31,780 for urban residents and $12,448 for rural residents. Overall, 15 to 20 percent of these charges were incurred in each of the first three quarters, and 47 percent (rural) and 52 percent (urban) in the last quarter of life. A larger proportion of urban (43 percent) than rural (37 percent) residents were hospitalized in the last 3 months of life.
Ghods, B.K., Roter, D.L., Ford, D.E., and others (2008, May). "Patient-physician communication in the primary care visits of African Americans and whites with depression." (AHRQ grant HS13645). Journal of General Internal Medicine 23(5), pp. 600-606.
Researchers studied primary care visits of 46 white and 62 black, nonelderly adults with depressive symptoms, who were receiving care from 1 of 54 physicians in urban community-based practices. Communication about depression only occurred in one-third (34 percent) of visits (43 percent of white vs. 27 percent of black patient visits). Black patients were less likely to express their depression than white patients (10.8 vs. 38.4 statements). Also, physicians uttered fewer rapport-building statements during visits with black patients than white patients (20.7 vs. 29.7 statements), and made fewer depression-related statements during visits with black patients (4.3 vs. 13.4 statements). Yet, even in visits where communication about depression occurred, physicians considered fewer black than white patients as suffering significant emotional distress (67 vs. 93 percent). There were no differences in depression communication by concordance of physician-patient race or gender. The exceptions were rapport-building exchanges, which were higher in race-concordant visits, and more biomedical information exchanges in gender-concordant visits.
Graham, D.G., Harris, D.M., Elder, N.C., and others (2008, June). "Mitigation of patient harm from testing errors in family medicine offices: A report from the American Academy of Family Physicians National Research Network." (AHRQ grant HS13554). Quality and Safety in Health Care 17, pp. 201-208.
Nearly one-fourth of diagnostic testing errors from eight practice groups reported by clinicians and their staff were mitigated-that is, action was taken to prevent or reduce harm to patients from these errors, according to this study. Also, mitigated events were significantly less likely to be associated with patient harm and negative consequences (time or financial loss, delay in care, pain/suffering, or impact on clinical outcome). The researchers determined how often reported errors were mitigated, what conditions were associated with greater or lesser chance of error mitigation, and the impact of mitigation on patient outcomes. Mitigation occurred in 123 (21 percent) of 597 testing process events that were reported. Most of the persons identified as mitigators of harm (79 percent) were part of the practice that reported the error, 13 percent were laboratory or pharmacy staff, and 7 percent were patients or their family members. Patients aged 65 years or older were significantly more likely than 18 to 44-year-olds to have a testing error mitigated. Events involving test implementation were less likely to be mitigated than events containing reporting or ordering errors. The greater the number of errors in a reported event, the less likely the event would be mitigated.
Hickner, J., Graham, D.G., Elder, N.C., and others (2008, June). "Testing process errors and their harms and consequences reported from family medicine practices: A study of the American Academy of Family Physicians National Research Network." (AHRQ grants HS13554 and HS11584). Quality and Safety in Health Care 17, pp. 194-200.
A new study of testing process errors in a group of family practice offices classifies the errors, their potential harm to the patient, and consequences of the errors. The study involved 243 clinicians and office staff at 8 family practice offices in 7 States across the United States (4 private practices and 4 family medicine residency clinics). Errors in testing most often involve the implementation of the tests (18 percent) and reporting of the results to physicians (25 percent). Charting or filing errors account for more than 14 percent of the errors, while notifying patients of results and response of clinicians to results each accounted for close to 7 percent of the errors. There was a significant association between the type of error and type of person reporting it (clinician or office staff), the number of labs used by the practice, absence of a results followup system, and patient race or ethnicity. Significant physical harm was rare as a result of a testing error, but patients often suffered adverse consequences. Negative consequences included time lost by the patient and other financial impacts (22 percent), delays in care (24 percent), pain and suffering (11 percent), and clinical consequences (2 percent). No harm occurred to patients in 54 percent of the testing errors, some harm resulted from 18 percent of the errors, and whether harm occurred was unknown in 28 percent. Adverse consequences were more common for errors reported by clinicians, involved middle-aged patients (ages 45-64 years), and were associated with test implementation errors.
Hlatky, M.A., and Bravata, D.M. (2008). "Stents or surgery? New data on the comparative outcomes of percutaneous coronary intervention and coronary artery bypass graft surgery [Editorial]." (AHRQ contract 290-02-0017). Circulation 118, pp. 325-327.
Patients with several blocked coronary arteries survive equally well with angioplasty or coronary artery bypass graft surgery (CABG) according to combined findings from the 6-year followup report from the Stent or Surgery (SoS) trial and the findings of nine other randomized clinical trials that followed patients receiving treatment with either angioplasty with stents or CABG for 5 or more years. The new report from the SoS trial reported significantly more deaths among angioplasty patients than CABG patients at a median of 6 years followup (53 deaths vs. 34 deaths). However, combining the findings with those from the other long-term followup trials, the researchers found no significant difference in deaths. The researchers noted that the risk of failure associated with CABG was higher than that of angioplasty, but CABG patients were more likely to have greater and longer-lasting relief of chest pain (angina).
Huey, S.J., and Polo, A.J. (2008, January). "Evidence-based psychosocial treatments for ethnic minority youth." (AHRQ grant HS10870). Journal of Clinical Child and Adolescent Psychology 37(1), pp. 262-301.
A review of studies found that psychotherapy is moderately effective for many mental health problems experienced by minority youth, although the researchers uncovered no well-established treatments for this group. Cognitive behavioral therapy (CBT) or individual psychotherapy (IPT) may be preferable to untested alternative therapies when treating depressed Latino adolescents. CBT uses self-control training, contingency management and contracting, peer modeling, feedback, and other strategies. CBTs are generally superior to insight-oriented treatments for youth and ethnic minority youth respond best to treatments that are highly structured, time-limited, pragmatic, and goal-oriented. IPT is possibly efficacious for clinically depressed Puerto Rican youth and may also work with U.S. Latino adolescents. Also, the studies supported the efficacy of family systems treatments, such as brief strategic family therapy (BSFT), for minority youth with conduct problems and drug-related disorders. BSFT adopts strategies such as joining, reframing, and boundary shifting to restructure problematic family interactions of these youth and their parents. MST (multisystemic therapy) is perhaps the only treatment shown to reduce criminal offending among black delinquent youth. MST is delivered in the youth's home or school by therapists trained in techniques such as contingency contracting, behavioral parent training, and communication training.
Kroll, T. (2008, February). "Rehabilitative needs of individuals with spinal cord injury resulting from gun violence: The perspective of nursing and rehabilitation professionals." (AHRQ grant HS13039). Applied Nursing Research 21, pp. 45-49.
Young urban, mostly minority, men who have suffered violence-associated spinal cord injury (VASCI) due to a gunshot wound (the third leading cause of SCI in the U.S.) have more barriers to rehabilitation and social integration than other victims of SCI, according to this study. As a result, these individuals are more likely than those with non-violence-associated SCI (NVASCI due, for example, to motor vehicle accident or fall) to end up in a nursing home. Thilo Kroll, Ph.D., of the National Rehabilitation Center for Health and Disability Research in Washington, D.C., interviewed 11 rehabilitation professionals at the Center about barriers to rehabilitation of this vulnerable group. The professionals saw no difference in treatment between the VASCI and NVASCI group. However, a complex interplay of physical, social, and economic barriers after hospital discharge-which include housing, transportation, insurance, and family and social support-limits the social participation of VASCI survivors. Many VASCI survivors and their families do not have the financial resources to make their homes wheelchair-accessible or to pay for attendant care, or they live in public housing that is not wheelchair-accessible. Thus, many individuals with VASCI are discharged to or moved into nursing homes ill-equipped to meet the needs of these young people.
Mauksch, L.B., Dugdale, D.C., Dodson, S., and Epstein, R. (2008, July). "Relationship, communication, and efficiency in the medical encounter." (AHRQ grant HS13172). Archives of Internal Medicine 168(13), pp. 1387-1395.
Little is known about how physicians can combine effective relationship development and communications skills with time management to maximize efficiency in the medical encounter with the patient. The authors conducted a literature search to find studies reporting original data on the use of communication or relationship skills and their effects on time use or visit length. Based on their findings from nine studies, they created a clinical model to better understand how to assist physicians in communicating effectively without lengthening the visit. They singled out four skill sets providing ongoing influence: relationship development and maintenance, mindful practice, topic tracking, and acknowledg-ment of patient clues. Also, they identified three skill sets occurring in sequence: upfront collaborative agenda setting, understanding the patient perspective, and reaching mutual agreement on a plan. The main part of the article defines each of these skills, offers examples, shows pitfalls, and discusses how to avoid them.
Orzano, A. J., Ohman-Strickland, P.A., and Patel, M. (2008, July-September). "What can family medicine practices do to facilitate knowledge management?" (AHRQ grant HS14018). Health Care Management Review 33(3), pp. 216-224.
Creating an environment that allows members of a family practice to find, share, and develop information and knowledge across the practice may offer a framework to improve workplace satisfaction, productivity, and the quality of care, concludes this study. As a practitioner- and organizational-management-derived framework, knowledge management (KM) can enhance an organization's performance by improving workplace relationships. After developing a preliminary social-technical model of KM, the researchers had clinical and nonclinical staff of 13 practices fill out a Practice Staff Questionnaire that asked questions about KM and the extent to which it is facilitated by leadership promoting participatory decisionmaking, effective communications, and human resource processes. Practices that had greater participatory decisionmaking, human resource processes, and effective communications had greater odds of reporting satisfactory KM, even when practice members perceived their practice environment as being more chaotic. Efforts to improve these facilitators of KM should not require an infusion of additional or sophisticated resources into family practices.