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Aragon, S.J., and Gesell, S.B. (2003, November). "A patient satisfaction theory and its robustness across gender in emergency departments: A multigroup structural equation modeling investigation." (AHRQ training grant T32 HS00032). American Journal of Medical Quality 18(6), pp. 225-228.

This study offers an alternative paradigm for measuring and achieving emergency department satisfaction that is based on a hierarchy of patient expectations, with physician service, waiting time, and nursing service being most important to satisfaction. The investigators studied the Primary Provider Theory, which holds that patient satisfaction occurs at the nexus of provider power and patient expectations, in national random samples of emergency patients. Physician service, waiting time, and nursing satisfaction explained 48 percent, 41 percent, and 11 percent, respectively, of overall satisfaction plus 92 percent and 93 percent of female and male satisfaction, respectively.

Ballard, D.J. (2003). "Indicators to improve clinical quality across an integrated health care system." (AHRQ grant HS10970). International Journal for Quality in Health Care 15, Suppl.1, pp. i13-i23.

Using clinical indicators to establish baseline performance and to assess the effectiveness of proposed quality improvements provides quantitative and qualitative means to identify and disseminate best care practices, conclude these authors. To develop a health care quality improvement strategic plan, their integrated health care delivery organization in Texas, which includes 11 hospitals and 47 primary care and senior centers, undertook a system-wide effort to improve care. The effort was supported by the use of clinical quality indicators focused on measures of health care underuse, overuse, and misuse. These indicators demonstrated the accomplishments of specific process of care improvements throughout the system. However, its indicators of medication misuse remain in a formative stage.

Bender, R.H., Lance, T.X., and Guess, L.L. (2003, Fall). "Including disenrollees in CAHPS® managed care health plan assessment reporting."(AHRQ grant HS09218). Health Care Financing Review 25(1), pp. 67-79.

Initially, the Consumer Assessment of Health Plans Study (CAHPS®) survey was completed by a sample of current plan enrollees. Concern arose that evaluating health plans by surveying only their enrolled membership would not be accurate because the members who are most dissatisfied with the plan have disenrolled and are no longer eligible for the survey. Indeed, the evidence suggests that including disenrollee feedback improves accuracy of health plan assessment, according to these researchers. They found that including disenrollee data when calculating the CAHPS® scores reported in health plan assessments significantly decreased the scores.

Borders, T.F., Rohrer, J.E., Xu, K.T., and Smith, D.R. (2004, February). "Older persons' evaluations of health care: The effects of medical skepticism and worry about health." (AHRQ grant HS11606). Health Services Research 39(1), pp. 35-52.

Consumers who are skeptical of medical care tend to give lower ratings to the care they receive, according to this study. The researchers surveyed about 5,000 elderly residents in one region about their views on health care. They measured the subjects' evaluation of health care using the Consumer Assessment of Health Plans Study (CAHPS®) survey, an overall care rating, and a personal doctor rating and examined the association of medical skepticism and other factors with the ratings. Consumers who were skeptical of prescription drugs relative to home remedies, those who believed they understood their health better than most doctors, and those who worried about their health had worse ratings of overall care and personal doctors.

Burke, L.E., Dunbar-Jacob, J., Sereika, S., and Ewart, C.K. (2003). "Development and testing of the cholesterol-lowering diet self-efficacy scale." (AHRQ grant HS08891). European Journal of Cardiovascular Nursing 2, pp. 265-273.

The cornerstone of treatment for high cholesterol is dietary therapy. However, most patients find it difficult to adhere to the therapeutic diet. This study reports on the development and initial psychometric evaluation of the Cholesterol-Lowering Diet Self-Efficacy Scale in a sample of 44 cardiac rehabilitation patients. It also describes the establishment of the scale's psychometric properties using a sample of 228 patients being treated for high cholesterol. The scale showed good reliability and validity. Reported self-efficacy was related to prior persistence and past success in modifying and maintaining dietary changes and also to concurrent measures of dietary adherence behaviors. The scale seemed adequate in identifying success in achieving and maintaining a cholesterol-lowering eating plan.

Dhaliwal, G., Schmidt, K.E., Gilden, D.J., and Saint, S. (2004, January). "True, true, and related." (AHRQ HS11540). New England Journal of Medicine 349, pp. 2253-2257.

This article recounts the diagnostic journey of a clinician treating a 51-year-old woman admitted to a community hospital with a 6-week history of progressive shortness of breath. She had initially noted shortness of breath when climbing stairs at work, and by the time of admission, it prevented her from walking more than 15 feet. The patient reported no fever, chills, weight loss, or night sweats, and she had no cough, chest pain, dizziness, or lower-extremity edema. Although she took no prescription medications, she did take five types of herbs. On the basis of the patient's chief symptom of labored breathing, the doctor anticipated a cardiac or pulmonary disorder. However, there was no history of cardiac or respiratory problems. The blood work (no reticulocyte count) and a lung x-ray showing mild hyperinflation and possible fullness in the anterior mediastinum, suggested thymoma, but getting to the diagnosis was not clearcut in this case.

Gould, C.V., Fishman, N.O., Nachamkin, I., and Lautenbach, E. (2004, February). "Chloramphenicol resistance in vancomycin-resistant enterococcal bacteremia: Impact of prior fluoroquinolone use?" (AHRQ grant HS10399). Infection Control and Hospital Epidemiology 25, pp. 138-145.

From 1989 to 1997, the percentage of hospital-acquired enterococci resistant to vancomycin, a broad-spectrum antibiotic, increased from 0.3 to 15.4 percent among hospitalized patients in the United states. Chloramphenicol is one of the few effective treatment options for vancomycin-resistant enterococci (VRE) infections. However, significant increases in the prevalence of chloramphenicol-resistant VRE may limit the future utility of chloramphenicol in the treatment of VRE infections, warns this study. The investigators examined trends in the prevalence of chloramphenicol resistance in VRE blood isolates of patients at two hospitals from 1991 through 2002. During this period, the annual prevalence of chloramphenicol-resistant VRE increased from 0 to 12 percent. Independent risk factors for chloramphenicol-resistant VRE were prior chloramphenicol use and prior fluoroquinolone use.

Lee, S.D., Arozullah, A.M., and Cho, Y.I. (2004). "Health literacy, social support, and health: A research agenda." (AHRQ grant HS13004). Social Science & Medicine 58, pp. 1309-1321.

Research is needed to determine the impact of social support that people can draw on when problems arise due to their health literacy limitations, according to these authors. They propose a research agenda to accomplish this. First, they cite the need to gain a better understanding of the causal effects of health literacy and identify missing links in the delivery of care for patients with low health literacy. Second, if social support buffers the adverse effects of low health literacy, more effective interventions can be designed to address differences in individuals' social support systems in addition to individual differences in reading and comprehension.

Lohr, K.N. (2004). "Rating the strength of scientific evidence: Relevance for quality improvement programs." (AHRQ contract 290-97-0011). International Journal for Quality in Health Care 16(1), pp. 9-18.

Drawing on an extensive review of checklists, questionnaires, and other tools in the field of evidence-based practice, this author discusses clinical, management, and policy rationales for rating strength of evidence in a quality improvement (QI) context. After a review of 121 systems for grading the quality of articles, 19 systems, mostly study-design specific, met a priori scientific standards for grading systematic reviews, randomized controlled trials, observational studies, and diagnostic tests. Eight systems out of 40 that were reviewed met similar standards for rating the overall strength of evidence. The author concludes that formally grading study quality and rating overall strength of evidence, using sound instruments and procedures, can produce reasonable levels of confidence about the scientific base of QI programs.

Muntner, P., Coresh, J., Klag, M.J., and others (2003, December). "Exposure to radiologic contrast media and an increased risk of treated end-stage renal disease." (AHRQ grant HS06978). American Journal of the Medical Sciences 326(6), pp. 353-359.

Repeated use of radiologic contrast media may accelerate progression of chronic kidney disease to end-stage renal disease (ESRD), that is, kidney failure, suggests this study. The investigators compared 716 treated ESRD patients with 361 age-matched control subjects drawn from the general population. They interviewed participants by telephone about previous exposure to various imaging procedures. After adjusting for ultrasound exams and several possible confounders, those who had a history of one, two or three, or four or more radiocontrast exams were at progressively higher risk of treated ESRD than people who had no such procedures. However, these findings must be confirmed in future prospective studies.

Murray, M.E., Brennan, P.F., and Moore, S.M. (2003, November). "A model for economic analysis." (AHRQ grant HS10667). Nursing Economics 21(6), pp. 280-287.

Using a production process model, these authors provide an approach to performing an economic assessment of innovative patient care initiatives involving technology. They examine the "cost per unit" of innovation within the context of a clinical trial involving the use of a computer-based home care program for postsurgical cardiac patients. The production process model involves the examination of variables such as economic efficiency, economics of scale, marginal productivity, and the influence of time on short- and long-term production costs. The authors suggest that when defining initial cost variables, consideration should be given to less-obvious costs such as fringe benefits, consultation fees, printing costs, secretarial support, and training time for staff during implementation.

Patient Safety Supplement. A special supplement to the journal Quality and Safety in Health Care (12, suppl. II, December 2003) is devoted to issues related to the most appropriate methods for conducting patient safety research. Four articles and an overview from the supplement were authored by AHRQ staff or AHRQ-funded researchers. The papers were prepared initially for presentation at the first United States/United Kingdom Patient Safety Research Methodology Workshop, which was held in September 2002, in Iceland. The workshop was jointly sponsored by AHRQ and the Patient Safety Research Program of the United Kingdom's Department of Health.

Staff-authored articles are as follows:

Battles, J.B. (2003). "Patient safety: Research methods for a new field," pp. ii.

This overview describes the supplement and an international workshop on the topic.

Battles, J.B., and Lilford, R.J., "Organizing patient safety research to identify risks and hazards," pp. ii2-ii7.

The authors suggest that patient safety research initiatives can be considered in three different stages: identification of the risks and hazards; design, implementation, and evaluation of patient safety practices; and maintaining vigilance to ensure that a safe environment continues and patient safety cultures remain in place. No single method (for example, use of medical records, focus groups, or safety culture assessment) can be universally applied to identify risks and hazards.

Reprints (AHRQ Publication No. 04-R034) including the overview are available from the AHRQ Publications Clearinghouse.

Henriksen, K., and Kaplan, H., "Hindsight bias, outcome knowledge and adaptive learning," pp. ii46-ii50.

A major challenge of individuals who investigate adverse events is understanding how knowledge of the outcome of the event influences their thinking and assessment of the event. This paper examines the influence of outcome knowledge in relation to reconstructive memory and legal testimony, ways for reducing the impact of outcome knowledge, and an adaptive learning framework that places hindsight bias in a broader context of rapid updating of knowledge.

Reprints (AHRQ Publication No. 04-R036) are available from the AHRQ Publications Clearinghouse.

Zhan, C., and Miller, M.R., "Administrative data based patient safety research: A critical review," pp. ii58-ii63.

Despite coding irregularities and limited clinical details, administrative data—supplemented by tools such as AHRQ's patient safety indicators—could serve as a screen for potential patient safety problems that merit further investigation. These data also offer valuable insights into adverse impacts and risks of medical errors and, to some extent, provide benchmarks for tracking progress in patient safety efforts at local, State, and national levels.

Reprints (AHRQ Publication No. 04-R035) are available from the AHRQ Publications Clearinghouse.

Mackenzie, C.F., and Xiao, Y. "Video techniques and data compared with observation in emergency trauma care," pp. ii51-ii57.

Video records are a rich source of data for documenting clinician performance and revealing safety and systems issues not identified by observation. These authors report their experiences with using video recording techniques in a trauma center, including how to gain cooperation of clinicians for video recording of their workplace performance, identify strengths of video compared with observation, and suggest processes for consent and maintenance of confidentiality of video records. Using video recording, they were able to identify patient safety, clinical, quality assurance, and ergonomic issues, as well as systems failures.

Editor's Note: See the supplement for more details on these articles as well as other ones that deal with various aspects of conducting patient safety research.

Meyer, G.S., Battles, J., Hart, J.C., and Tang, N. (2003). "The U.S. Agency for Healthcare Research and Quality's activities in patient safety research." International Journal for Quality in Health Care 2003 15(S1), pp. i25-i30.

The purpose of this paper is to update the international community on AHRQ's recent and current activities in improving patient safety by presenting a representative sample of patient safety studies from those recently funded by AHRQ. In fiscal year 2002, the Agency spent $55 million on patient safety research in six research areas: health systems error reporting, analysis, and safety improvement research demonstrations; clinical informatics to promote patient safety; centers of excellence for patient safety research and practice; developmental centers for evaluation and research in patient safety; the effect of health care working conditions on quality of care; partnerships for quality; and patient safety research dissemination and education.

Reprints (AHRQ Publication No. 04-R032) are available from the AHRQ Publications Clearinghouse.

Peleg, M., Boxwala, A.A., and Tu, S. (2004, January). "The InterMed approach to shareable computer-interpretable guidelines: A review." (Cofunded by AHRQ and the National Library of Medicine).  Journal of the American Medical Informatics Association 11(1), pp. 1-10.

These authors discuss lessons learned from InterMed, a collaboration among research groups from Stanford, Harvard, and Columbia Universities to develop a shareable language that could serve as a standard for modeling computer-interpretable guidelines (CIGs). They describe six lessons: a work process for multi-institutional research and development that considers different viewpoints; an evolutionary life cycle process for developing medical knowledge representation formats; the role of cognitive methodology to evaluate and assist in the evolutionary development process; development of an architecture; design principles for shareable medical knowledge representation formats; and a process for standardization of a CIG modeling language.

Pronovost, P.J., Weast, B., Holzmueller, C.G., and others (2003). "Evaluation of the culture of safety: Survey of clinicians and managers in an academic medical center." (AHRQ grant HS11902). Quality and Safety in Health Care 12, pp. 405-410; and Pronovost, P.J., Weast, B., Bishop, K., and others (2004, February). "Senior executive adopt-a-work unit: A model for safety improvement." (AHRQ grant HS11902). Joint Commission Journal on Quality and Safety 30(2), pp. 59-68.

The first study included two surveys. One survey asked physicians, nurses, pharmacists, and other intensive care unit (ICU) staff at one hospital about their perceptions of a strong organizational commitment to patient safety. The other survey asked clinical and administrative leaders to evaluate the extent to which safety was a strategic priority for the organization. Staff perceived that supervisors had a greater commitment to safety than senior leaders. Management perceived safety efforts to be further developed than members of the Patient Safety Committee. Both groups gave strategic planning for safety the lowest scores, suggesting that this area needs improvement. Based on these results, the Johns Hopkins Hospital patient safety committee created a program to encourage staff to identify and eliminate potential errors in the patient care environment, which is described in the second article. As part of this program, senior hospital executives each adopted an ICU and worked with the staff to identify issues and empower them to address safety issues. This approach was successful in identifying and eliminating hazards to patient safety and in creating a culture of safety.

Quality Improvement Research. Nelson, E.C., Splaine, M.E., Plume, S.K., and Batalden, "Good measurement for good improvement work;" Speroff, T., and O'Connor, G.T., "Study designs for PDSA quality improvement research;" and Speroff, T., James, B.C., Nelson, E.C., and others, "Guidelines for appraisal and publication of PDSA quality improvement." (2004, January). (AHRQ grant HS10086). Quality Management in Health Care 13(1), pp. 1-16, 17-32, 33-39.

Three papers from the same journal focus on quality improvement (QI) research methods. The first paper provides guidance on using measurement to support the conduct of local QI projects in order to strengthen the evaluation of results and increase their potential for publication. The authors offer eleven procedures to promote intelligent measurement in QI studies that may become publishable. The second paper discusses the strengths and weaknesses of quasiexperimental designs used in health care QI research. It is directed at investigators in plan-do-study-act (PDSA) QI initiatives who want to improve the rigor of their methodology and publish their work and at reviewers who evaluate the quality of research proposals or published work. A primary purpose of PDSA QI research is to establish a functional relationship between process changes in systems of health care and variation in outcomes. The third paper provides guidelines for appraisal and publication of PDSA QI findings. The authors address four questions to determine the value of a QI study and provide a set of guidelines to help answer them.

Tang, N., Eisenberg, J.M., and Meyer, G.S. (2004, January). "The roles of government in improving health care quality and safety." Joint Commission Journal on Quality and Safety 30(1), pp. 47-55.

In this article, the authors provide a framework for understanding the 10 roles that government plays in improving health care quality and safety in the United States. They present examples of proposed Federal actions to reduce medical errors and enhance patient safety to illustrate the 10 roles. They note that achieving the ultimate goal of high quality health care will require strong partnerships among Federal, State, and local governments and the private sector. Translating general principles regarding the appropriate role of government into specific actions within a rapidly changing, decentralized delivery system will require the combined efforts of the public and private sectors.

Reprints (AHRQ Publication No. 04-R029) are available from the AHRQ Publications Clearinghouse.

Sawalha, A.H., Bronze, M.S., and Saint, S. (2003, December). "Step by step." (AHRQ grant HS11540). New England Journal of Medicine 349(23), pp. 2253-2257.

These authors describe the diagnosis and treatment in a difficult case involving a 63-year-old man who arrived at the ER for evaluation of acute, mild rectal bleeding. He reported a 2-week history of shortness of breath on exertion and generalized weakness, as well as mild pain and fullness in the abdomen and weight loss of 30 pounds over a 1-year period. Rectal bleeding in patients in this age group is usually due to diverticulosis, benign anorectal disease, colorectal cancer, or angiodysplasia of the bowel. Despite the presentation with hepatosplenomegaly, the absence of classic symptoms typically ascribed to mastocytosis made its diagnosis particularly difficult in this patient. A bone marrow biopsy, which showed focal infiltration of mast cells, finally led to the diagnosis.

Small, S.D. (2004, January). "Medical device-associated safety and risk: Surveillance and stratagems." (AHRQ grants HS11905 and HS11553). Journal of the American Medical Association 291(3), pp. 367-370.

The author of this editorial comments on a study of various ways to identify medical-device-related harms such as computer-based flags and clinical engineering logs. He points out that the taxonomy used by computer-based flags may be too broad to provide useful information. For example, the loosening of a hip prosthesis might be due to a choice of the patient to engage in an ill-advised activity following surgery or to the design of the device. A classification system that considers usability issues, costs, and the potential for harm is preferred. Clinical engineering logs are an underused, rich resource for capturing and understanding device usability and safety issues. Determining whether equipment actually malfunctioned or its operation was not understood by the user would facilitate specific interventions to enhance device usefulness and safety.

Strauss, R., Mofidi, M., Sandler, E.S., and others (2003, November). "Reflective learning in community-based dental education." (AHRQ training grant T32 HS00032). Journal of Dental Education 67(11), pp. 1234-1242.

These authors describe how structured reflection assignments and methods are incorporated in the University of North Carolina School of Dentistry's Community-based Dentistry in Service to Communities Program. They discuss several strategies to enrich community-based learning experiences for dental students: photographic documentation; written narratives; critical incident reports; and mentored, postexperiential small group discussions. Fieldwork and course-related examples are drawn from community-based dental experiences to illustrate how reflective teaching approaches can enhance student learning.

Tsai, A.C. (2003). "Conflicts between commercial and scientific interests in pharmaceutical advertising for medical journals." (NRSA training grant T32 HS00059). International Journal of Health Services 33(4), pp. 751-768.

Medical journals and their parent societies rely to a substantial degree on advertising sales for financial support. This can be substantial, given the over $4,000 base annual rate for a black-and-white full-page advertisement in the early 1990s. For many years, opinionated readers have been writing letters of complaint about the quality of pharmaceutical advertisements circulated in U.S.-based medical journals. The author cites examples of increasingly diverging interests between medical journal editors and publishers. In the decade since this issue first gained prominence, observers have continued to cite deficiencies in medical journal pharmaceutical advertisements. For example, a recent study documented a 36 percent rate of numeric distortion in the graphs of a sample of 484 pharmaceutical advertisements. A 1995 survey of North American journal editors revealed that of the journals that sold pharmaceutical advertisements, two-fifths of the editors reported having a great deal of control, while one-fifth reported having no control over advertising content. About one-third of the editors had staff who regularly screened pharmaceutical advertisements for accuracy and truthfulness.

Tye, S., Phillips, K.S., Liang, S., and Haas, J.S. (2004, February). "Moving beyond the typologies of managed care: The example of health plan predictors of screening mammography." (AHRQ grants HS10771 and HS10856). Health Services Research 39(1), pp. 179-206.

It is important to examine the effect of individual health plan components on the use of health care, rather than use the traditional broader categorizations of managed vs. nonmanaged care or simple health plan typologies, conclude these authors. They analyzed plan characteristics that predicted screening mammography using data from the 1996 Medical Expenditure Panel Survey (MEPS). Women ages 40 years and over with private insurance and no history of breast cancer were included in the study. The researchers found no significant differences in reported mammography use when they compared women enrolled in managed care with those in indemnity plans. However, women in health plans with a defined provider network were more likely to report having received a mammogram in the previous 2 years than those without networks, as were women in gatekeeper plans compared with those in plans without gatekeepers.

Watt, A., Williams, S., Lee, K., and others (2003, November). "Keen eye on core measures." (AHRQ grant HS13728). Journal of the American Health Information Management Association 74(1), pp. 20-28.

In July 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required that accredited U.S. hospitals collect and report data on evidence-based, standardized performance measures in certain areas: acute myocardial infarction, heart failure, community-acquired pneumonia, and pregnancy and related conditions. Beginning in January 2004, the majority of JCAHO-accredited hospitals will be required to report on three of these core measures based on the services they provide. The JCAHO is conducting a research project to assess the completeness and accuracy of the data flowing into the national comparative core measures database and to evaluate improvement actions taken by health care organizations. The authors of this article summarize results to date.

Whitney, S.N., McGuire, A.L., and McCullough, L.B. (2003). "A typology of shared decision making, informed consent, and simple consent." (AHRQ grant HS11289). Annals of Internal Medicine 140, pp. 54-59.

Enhancing patient choice is a central theme of medical ethics and law. Informed consent is the legal process used to promote patient autonomy, and shared decisionmaking is a widely promoted ethical approach. The approach outlined in this article uses a model that arrays all medical decisions along two axes—risk and certainty—at the extremes of which four decision types are produced. Shared decisionmaking is most appropriate in situations of uncertainty in which two or more clinically reasonable alternatives exist. When there is only one realistic choice, patient and physician may gather and exchange information; however, the patient cannot be empowered to make choices that do not exist. When a clinical decision contains both risk and uncertainty, shared decisionmaking and informed consent are both appropriate. For decisions of lower risk, consent should still be present, but it can be simple rather than informed.

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