Research Activities, July 2009, No. 347
An, P. G., Rabatin, J. S., Manwell, L. B., and others (2009, February). "Burden of difficult encounters in primary care: Data from the Minimizing Error, Maximizing Outcomes study." (AHRQ grant HS11955). Archives of Internal Medicine, 169(4), pp. 410-414.
Difficult encounters between patient and physician are a readily recognized challenge in primary care, and the shared responsibility and contributions to such interactions have been increasingly acknowledged. Using a survey derived from the Physician Worklife Survey, the researchers asked general internists and family physicians associated with ambulatory clinics in three States about such interactions. These included encounters in which the patient insisted on an unnecessary drug or procedure, was verbally abusive, not respectful, or persistently complained about care. They found that insisting on an unnecessary drug was the most frequently cited challenge (36 percent). A Latent Cluster Analysis was used to classify physicians based on their responses of the Burden of Difficult Encounters measure. Physicians were divided into clusters of low, medium, or high difficulty, based on perceived difficulty. Physicians were also measured on job satisfaction, stress, and burnout. High difficulty cluster physicians were significantly younger on average (41 years), compared with those in medium (43 years), and low (46 years) clusters. They were also 2.2 times more likely than medium difficulty cluster physicians to report burnout and 12.2 times more likely to be burned out than low difficulty cluster physicians.
Battles, J. B., and Stevens, D. P. (2009, February). "Adverse event reporting systems and safer healthcare." Quality and Safety of Health Care, 18(1), p.2. Reprints (AHRQ Publication No. 09-R043) are available from the AHRQ Publications Clearinghouse.
Although event-reporting systems are now central elements in effective patient safety systems, their growth and implementation have been slow, and their effective use for implementing strategies for safer care has been even slower. Large-scale reporting systems have been developed in the U.S. Veteran's Administration, national systems in Denmark and the UK, and State-based systems in the United States and Australia. However, regulations to allow an effective national approach in the United States did not become effective until January 2009. The UK established its National Reporting and Learning System in England and Wales in 2003, and by 2007, had over one million reports. Reporting must be accompanied by real change and improvement that uses what we know to address what we find by such measurement systems. The authors conclude that the most compelling challenge to operators of existing reporting systems is to mine their data and publish findings from their systems.
Clancy, C. M. "New patient safety organizations can help health providers learn from and reduce patient safety events." (2009, March). Journal of Patient Safety 5(1), pp 1-2. Reprints (AHRQ Publication No. 09-R049) are available from the AHRQ Publications Clearinghouse.
In this commentary, AHRQ Director Carolyn M. Clancy, M.D., discusses the creation of patient safety organizations (PSOs) by the Patient Safety and Quality Improvement Act of 2005. She explains that PSOs are intended to address the need for privilege and confidentiality of information about patient safety events so that this information can be collected for analysis without fear of such data being used in lawsuits. She explains how PSOs will serve the function of providing a national, uniform set of privilege and confidentiality protections on submitted data and technical support to health care providers who want a patient safety event or set of events analyzed. To facilitate the collection and reporting of patient safety information, AHRQ released Common Formats for event reporting last fall. Because of the value of large-scale data aggregation to identify the underlying causes of the risks and hazards of patient care, The Department of Health and Human Services has been authorized to create a network of patient safety databases to encourage learning from pooled event data and dissemination of lessons learned.
Clancy, C. M., Anderson, K. M., and White, P. J. (2009, March/April). "Investing in health information infrastructure: Can it help achieve health reform?" Health Affairs 28(2), pp. 478-482. Reprints (AHRQ Publication No. 09-R045) are available from the AHRQ Publications Clearinghouse.
This paper examines the current status of health information technology (health IT) in supporting quality measurement efforts in health care, describes near-term steps to link health IT and quality improvement, and suggests future directions for using health IT to support quality health care. The authors note that current commercial health IT systems only have a rudimentary capacity for quality measurement without additional programming by the user facility. They list a series of near-term initiatives to improve this situation recommended by the Health IT Expert Panel convened by the National Quality Forum. The initiatives are: emphasize and provide incentives for data sharing as a first step toward care coordination; launch focused multipayer pilot projects; create policy interoperability, such as for State and Federal privacy protections; and tailor resources to a region's readiness for health IT adoption. The authors note that, for the future, sizable long-term investments are needed to create and manage a strategic plan to achieve a high-value health care system that takes full benefit of health IT.
Conway, P. H., and Clancy, C. M. (2009). "Transformation of health care at the front line." Journal of the American Medical Association 301(7), pp. 763-765. Reprints (AHRQ Publication No. 09-R026) are available from the AHRQ Publications Clearinghouse.
Given an underperforming health care system and untenable rising costs, it is important for health care to take the path that aligns quality and value efforts with care where it matters, at the front line with clinicians and patients. The Agency for Healthcare Research and Quality has a role to play in developing the science of measurement, research on quality improvement, and informing how to transform the system successfully, but leadership and collaboration from all stakeholders and a clear vision are needed. In this process, the five key drivers are quality measurement and payment, health information technology, comparative effectiveness, quality improvement collaboratives and learning networks, and clinician training. There must be an investment in these key drivers, which are fundamental building blocks in the transformation of care. Also, clinicians need to actively engage in the process of developing solutions to improve care at the front line. In addition, the health care payment system should increase its focus on payment for high-quality efficient care.
Diamond, C. C., Mostashari, F., and Shirky, C. (2009). "Collecting and sharing data for population health: A new paradigm," (AHRQ grant HS17059). Health Affairs 28(2), pp. 454-466.
The dominant approach to handling population health data over the past 30 years has been to gather copies of the needed information into a data storehouse, make data from different sources comparable (normalize the data), and run queries against the collected data. This centralized databank model can create difficulties because of incomplete participation by institutions that gather the data, the likelihood of errors in the data, and time lags between gathering and analysis of the data. These problems can be avoided by use of a networked technical architecture and a federated governance model, suggest the authors of this paper. The advantages of a networked model for analyzing population health information are that the original sources retain strong control of their data and little raw data is moved around. Instead, using shared standards, queries are sent to each of the data sources and normalized and question-specific data are shared with the researchers. Such networked architectures can reduce costs and make better use of existing technical infrastructure, the authors suggest. Examples of successful distributed data networks, such as the Distributed Surveillance Taskforce for Real-time Influence Burden Tracking, are discussed in the paper.
Dimitropoulos, L., and Rizk, S. (2009). "A State-based approach to privacy and security for interoperable health information exchange." (AHRQ Contract No. 290-05-0015). Health Affairs 28(2), pp. 428-434.
The design of systems that allow for exchange of information from electronic health records is made more difficult by variations in State laws and organizational policies on privacy and authorization. This article describes the formation of the Privacy and Security Solutions for Interoperable Health Information Exchange project, and its creation of the Health Information Security and Privacy Collaboration (HISPC) that currently involves 42 States and territories. The key activities have been assessment of variation in: consent and permission, privacy and security, authentication and authorization, and linking data to one person. A multi-State collaboration is working to develop common solutions for: patient consent for disclosure, harmonizing State privacy laws, standard authentication and audit policies, model interorganizational agreements, consumer education and engagement, and provider education. The authors note that the challenge ahead is to gain widespread adoption of the solutions developed by the HISPC.
Grossman, J. M., Zayas-Caban, T., and Kemper, N. (2009). "Information gap: Can health insurer personal health records meet patients' and physicians' needs?" Health Affairs 28(2), pp. 377-389. Reprints (AHRQ Publication No. 09-R044) are available from the AHRQ Publications Clearinghouse.
The authors report the findings of a qualitative study of personal health records (PHRs)-centralized electronic places for people to store and organize their health information-created by insurers, which contain a combination of insurer claims data and data from enrollees. They note that PHRs can benefit both patients and doctors. Unlike so-called "tethered PHRs," limited to a single health care system or HMO, newer PHRs offered by insurers or third-party sources provide access to information for care across many providers (and in the case of third-party sources, across multiple insurers). Drawing on telephone interviews conducted during summer 2008 in 12 nationally representative markets, the authors collected qualitative information on the PHRs offered by a leading insurer in each market. All offered the ability for enrollees to enter data, and 7 of 12 offered autofilling of data from claims at the time of the study. Enrollees were able to print out summaries to share with physicians in all cases, but varied in offering physicians electronic access to the PHR or the claims-based data. The authors note that the PHRs are not portable in their current form if the enrollee changes insurer, nor do they contain data on services not resulting in claims to the insurer. The authors suggest several ways that insurers can reduce barriers to participation by enrollees.
Halm, E. A., Tuhrim, S., Wang, J. J., and others (2009). "Risk factors for perioperative death and stroke after carotid endarterectomy: Results of the New York Carotid Artery Surgery Study." (AHRQ grant HS09754). Journal of the American Heart Association 40, pp. 221-229.
The benefits of carotid artery surgery must be weighed against the risk of perioperative death or stroke. To identify independent patient risk factors for death and stroke within 30 days of carotid endarterectomies (CEAs), the researchers used data from the statewide New York Carotid Artery Surgery Study of 9,308 CEAs performed by 482 surgeons in 167 hospitals. The 30-day rate of death or stroke among asymptomatic patients with no history of stroke/transient ischemic attack (TIA) was 2.71 percent. Patients with a higher rate of death or stroke included asymptomatic ones with a distant history of stroke/TIA (4.06 percent), those operated on for carotid TIA (5.62 percent), those with a stroke (7.9 percent), and those with crescendo TIA/stroke-in-evolution (13.33 percent). Significant factors predictive of a greater risk of death or stroke, in addition to those just mentioned, included: age greater than 80, nonwhite race, admission from the emergency department, contra-lateral carotid stenosis, severe disability, and having diabetes treated with insulin. The finding that black and Hispanic patients had worse outcomes was unexpected and requires further investigation.
Horvath, M. M., Cozart, C., Ahmad, A., and others (2009). "Sharing adverse drug event data using business intelligence technology." (AHRQ grant HS14882). Journal of Patient Safety 5(1), pp. 35-41.
This paper describes the software strategy used by the three hospitals of the Duke University Health System (DUHS) to automate adverse drug event (ADE) surveillance data and to make reports accessible to patient safety leadership. In many health care organizations, aggregate reports of ADEs are created by hand in Microsoft® Excel by a dedicated research analyst. Merging many data extracts (ADE surveillance, patient census, hospital encounter details, and demographics) is very time-consuming, preventing the research analyst from designing queries that patient safety leaders can use by themselves. Using business intelligence software to extract, transform, and load the desired ADE and other relevant information from the DUHS data warehouse, the Duke patient safety leaders can use a set of prewritten reports, available through a Web interface. Emphasis is on reports concerning ADEs caused by three drug categories (anticoagulants, hypoglycemia medication, and narcotics/benzodiazepines). The major classes of reports are a list of ADEs with event details, ADE rates by month by drug category, and ADE rates per month by nursing station.
Hsieh, Y., Rothman, R. E., Bartlett, J. G., and others (2008). "HIV seropositivity predicts longer duration of stay and rehospitalization among nonbacteremic febrile injection drug users with skin and soft tissue infections." (AHRQ grant HS09555). Journal of Acquired Immune Deficiency Syndrome 49(4), pp. 398-405.
Among injection drug users (IDUs), skin and soft tissue infections (i.e., cellulitis and abscesses) are a leading cause of emergency department and hospital admissions. The researchers retrospectively studied the epidemiology of skin and soft tissue infections (SSTIs) in 295 IDUs with fever. For these patients, increased length-of-stay (LOS), a proxy for increased health care use, was associated with positive culture results (either blood or SST) and being older. For those without bacteremia, positive SST culture results and being HIV positive predicted increased LOS. Furthermore, having HIV infection was associated with an increased rate of hospital readmission (another proxy for health care resource utilization). Among injection drug users with SSTIs, bacteremia was the strongest predictor for longer LOS. In those who were nonbacteremic, HIV infection was associated with increased LOS and approximately tripled the risk for rehospitalization within 90 days. This study provides pilot data for further examination of risk factors associated with adverse outcomes of IDUs with fever and SSTIs.
Jerant, A., Chapman, B. P., Duberstein, P., and Franks, P. (2009). "Is personality a key predictor of missing study data? An analysis from a randomized controlled trial." (AHRQ grant HS13603). Annals of Family Medicine 7(2), pp. 148-156.
Missing data can affect validity of the results of a randomized controlled trial (RCT). This paper sought to investigate whether personality factors are a predictor of missing study data. The researchers chose to use the well-studied Five Factor Model of personality factors (neuroticism, extroversion, openness, agree-ableness, and conscientiousness) to predict missing data in an RCT of an intervention to help patients with chronic illnesses take better care of themselves. A total of 381 patients with chronic illnesses were deemed eligible for the study and randomly assigned to either participate in a weekly home-visit intervention, a weekly telephone call intervention, or usual care with their regular physician (the control group). The researchers found that missing data were significantly less likely for participants with higher levels of openness, conscientiousness, and agreeableness. Greater efforts to gain full participation by subjects identified as being at-risk for missing data collection on the basis of their psychological characteristics may be an important step in improving the conduct of research studies, the researchers suggest.
Kahn, J. S., Aulakh, V., and Bosworth, A. (2009). "What it takes: Characteristics of the ideal personal health record." (AHRQ grant HS17784). Health Affairs 28(2), pp. 369-376.
Personal health records (PHRs) have been suggested as tools to allow patients to manage their health care information. However, existing PHRs do not meet all of the patients' needs, leaving a gap that inhibits their widespread use. The authors of this paper review the technical and policy challenges that contribute to slow adoption of PHRs. Among the factors the authors focus on are the combination of computer competency, Internet access, and health literacy; the variety of functions that PHRs are expected to address; and interoperability, data security, consumer control of their health information, and fair access (by underserved populations). Despite the array of problems, the authors are optimistic that new entries, such as the Web-based tools launched by Google™ and Microsoft®, will help push the spread of PHRs. They believe that PHRs will likely prove to be invaluable.
Liu, L. (2009). "Joint modeling longitudinal semi-continuous data and survival, with application to longitudinal medical cost data." (AHRQ grant HS16543). Statistics in Medicine 28(6), pp. 972-986.
Analyzing accumulated medical costs over a period of time (longitudinal medical cost) can be important for budgeting and decisionmaking purposes. This approach allows prediction of future medical costs and identification of population groups with the greatest financial need, improving analysis of cost-effectiveness. The author of this paper reports a method for joint analysis of longitudinal medical cost data and survival that takes into account the semicontinuous nature of medical costs. The model includes the author's conjecture that sicker patients, who are at greater risk of death, tend to seek medical treatment more often (have higher odds of positive monthly cost) and receive more intensive care when treated (resulting in a higher monthly expenditure). In addition to presenting the mathematics of the joint model, the author applies the model to analyze medical costs and survival for 1,455 chronic heart failure patients.
Lu, C., Frank, R. G., and McGuire, T. G. (2009, January). "Demand response to cost sharing under managed health care." (AHRQ grant HS10803). Contemporary Economic Policy 27(1), pp. 1-15.
The researchers sought to estimate demand response to cost-sharing arrangements used by managed health care. They used data from the 1996 Medical Expenditure Panel Survey, since it provides information on insurance coverage policy. The focus was on employees who are privately insured and have no choice of health plan. The principal findings were that the level of a deductible has no significant impact on the use of ambulatory services in the ranges observed; demand response to the coinsurance rate under managed care is less than in traditional indemnity plans; and in particular, raising the coinsurance rate has smaller effects on the level of expenditures in managed care. The researchers conclude that policies that encourage the supply of "high-deductible" health plans will reduce health insurance costs mainly by shifting costs to consumers. They add that a move to higher consumer cost sharing in managed care goes against the tenets of optimal insurance. A low demand response should be tied to lower, not higher, cost sharing.
Meyers, D. S., and Clancy, C. M. (2009). "Primary care: Too important to fail." Annals of Internal Medicine 150(4), pp. 272-273. Reprints (AHRQ Publication No. 09-R037) are available from the AHRQ Publications Clearinghouse.
A recent study found that over the course of a year, a typical primary care clinician must coordinate the care of their Medicare patients with 229 other physicians working in 117 practices. The functions of primary care, including care coordination, cannot be accomplished by the lone physician. Primary care teams are a central tenet of the patient-centered medical home, a comprehensive model for delivering primary care. A community-based health care extension service utilizing primary care teams may play an important enabling role in transforming and sustaining primary care. Its functions would be to: provide primary care practices with care managers, social workers, and health educators; serve as connectors linking practices to existing community resources; offer quality improvement technical assistance; and partner with academic centers and research networks to coordinate practical clinical trials. This model has already been demonstrated by the Community of North Carolina initiative, which has shown improved quality of care, cost savings, physician satisfaction, and scalability.
Newman-Toker, D. E., and Pronovost, P. J. (2009, March). "Diagnostic errors-the next frontier for patient safety." (AHRQ grant HS17755). Journal of the American Medical Association 301(10), pp. 1060-1062.
An estimated 40,000 to 80,000 U.S. hospital deaths result from misdiagnosis annually. There has been little systematic study of diagnostic errors. Most organizations such as the Institute of Medicine and the National Quality Forum have placed their emphasis on treatment errors. Practical solutions to reduce diagnostic errors have lagged behind those in other areas of patient safety. The authors offer suggestions to help safety researchers work toward reducing misdiagnosis-related harm. They urge developing systems solutions to cognitive problems. Diagnostic errors are often seen as cognitive errors rather than system errors, thus perpetuating the view that individual physicians are to blame. To achieve this, they advise the creation of actionable categories of errors based on context rather than cause. They further recommend emphasizing misdiagnosis-related harm rather than diagnostic error, building workflow-sensitive solutions, and focusing on comparative and cost-effectiveness. Finally, they call for tort reform to reduce excessive testing associated with the practice of "defensive medicine" and ask for a defining of acceptable error.