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Amin, M.G., Tighiouart, H., Weiner, D.E., and others (2004, April). "Hematocrit and left ventricular mass: The Framingham Heart Study." (AHRQ training grant T32 HS00060). Journal of the American College of Cardiology 43(7), pp. 1276-1282.
Anemia may be an independent risk factor for cardiovascular disease in the general population. One potential explanation for this finding could be an association between hematocrit and left ventricular mass index or left ventricular hypertrophy. To assess this association, the researchers analyzed data on participants in the 16th biennial examination of the original Framingham Heart Study, which began enrolling subjects in 1971, and the second biennial examination of the offspring cohort. The study involved data on 1,376 men, 760 postmenopausal women, and 1,000 premenopausal women. They found that a lower hematocrit (in the low-normal range of anemia) is associated with a small increase in left ventricular mass index in men and postmenopausal women without known hypertension or cardiovascular disease. The clinical importance of these findings remains unknown.
Fuhlbrigge, A., Carey, V.J., Adams, R.J., and others (2004, May). "Evaluation of asthma prescription measures and health system performance based on emergency department utilization." (AHRQ grant HS08368). Medical Care 42(5), pp. 465-471.
Measures based on the use of either antiinflammatory medications (such as steroid inhalers) and/or reliever medications (such as inhaled beta-agonists) have been used to evaluate clinical performance in asthma care. This study found that among children with persistent asthma, the dispensing of a controller medication was associated with a significantly lower risk of an emergency department (ED) visit compared with children not dispensed a controller. Also, the controller to reliever ratio was associated with the risk of a subsequent ED visit. However, the association between the ratio measure and risk for an ED visit was modified by the underlying level of reliever dispensing.
Hu, K.K., Lipsky, B.A., Veenstra, D.L., and Saint, S. (2004, May). "Using maximal sterile barriers to prevent central venous catheter-related infection: A systematic evidence-based review." (AHRQ grant HS11540). American Journal of Infection Control 32, pp. 142-146.
Central venous catheters (CVCs) are often required to provide patients with total parenteral nutrition, long-term intravenous medications, or frequent blood sampling. A recent systematic review of research studies compared infectious outcomes using maximal sterile barriers (MSB) versus using less sterile barrier techniques during central venous catheter insertion. MSB requires that the person inserting the CVC wear a head cap, face mask, sterile body gown, and sterile gloves and use a full-size sterile drape. Less stringent measures usually require only sterile gloves and a small regional sterile drape. While the available evidence supports the use of MSB during routine insertion of CVCs, prospective studies and economic analyses would better clarify its value.
Jha, A.K., Shojania, K.G., and Saint, S. (2004, June). "Forgotten but not gone." (AHRQ grant HS11540 and T32 HS00020). New England Journal of Medicine 350(23), pp. 2399-2404.
This article recounts the step-by-step diagnosis of a 74-year-old man
who was brought to the emergency department confused after a fall and with a cough for 4 days. The doctor treated him for possible pneumonia and dehydration. The patient improved and then quickly declined. This lead to exploration of the possibility of pulmonary edema and possible acute respiratory distress due to worsening sepsis and treatment with a broad-spectrum antibiotic. Concern began to shift to resistant organisms. The autopsy revealed systemic tuberculosis infection, with extensive involvement of the adrenal glands. In retrospect, the diagnosis of tuberculosis warranted consideration in a marginally housed, elderly man with probable chronic liver disease. Also, lack of response to initial antibiotic therapy indicated the need to further consider atypical infections, including tuberculosis.
Kasal, J., Jovanovic, Z., Clermont, G., and others (2004). "Comparison of Cox and Gray's survival models in severe sepsis." (AHRQ grant HS/HL11620). Critical Care Medicine 32(3), pp. 700-707.
This study compared Gray's survival model with two different Cox models to predict survival in 1,090 adults at 136 medical centers who had signs and symptoms of severe sepsis or probable gram-negative infection. The investigators considered 27 potential baseline risk factors and modeled survival over the 28 days after the onset of sepsis. In single-variable analyses, 20 of the 27 potential factors were significantly associated with mortality, and 10 of 20 had nonproportional hazards. Of the three models, Gray's model best captured the changing hazard ratios over time. The researchers conclude that many important predictors of death in severe sepsis are nonproportional, and Gray's model seems best suited for modeling survival in this condition.
Lubomski, L.H., Pronovost, P.J., Thompson, D.A., and others (2004, May). "Building a better incident reporting system: Perspectives from a multisite project." (AHRQ grant HS11902). Journal of Clinical Outcomes Management 11(5), pp. 275-280.
Each intensive care unit (ICU) patient is estimated be at risk for exposure to 1.7 errors per day spent in the ICU. A Web-based incident reporting system was developed as part of the Intensive Care Unit Safety Reporting System project to understand system factors associated with the occurrence of ICU adverse events resulting in actual patient harm or "near misses." Implementation of the system at 23 ICUs in the United States suggests that four areas should be targeted to maximize the success of incident reporting systems. These include integration with existing reporting structures, promoting incident reporting by staff, coding and analysis of event reports, and use of incident reports to improve patient safety.
McNicol, E., Strassels, S., Goudas, L., and others (2004, May). "Nonsteroidal anti-inflammatory drugs, alone or combined with opioids, for cancer pain: A systematic review." (AHRQ contract 290-97-0019). Journal of Clinical Oncology 22(10), pp. 1975-1992.
The World Health Organization recommends the use of nonsteroidal antiinflammatory drugs (NSAIDs, for example, aspirin or ibuprofen) or acetaminophen for mild pain and the addition of a weak opioid for mild to moderate pain. The purpose of this study was to assess the safety and efficacy of NSAIDs alone or combined with opioids for the treatment of cancer pain. The researchers examined 42 published controlled trials with a total of 3,084 patients and 16 NSAIDs. Eight of the trials compared NSAID with placebo; 13 compared one NSAID with another; 23 compared NSAID with opioid or NSAID or opioid versus various combinations of NSAIDs, and 9 studies assessed the effect of increasing NSAID dose. They found that although NSAIDs appeared to be more effective than placebo for mild cancer pain, there was insufficient evidence to support superior safety or efficacy of one NSAID compared with another. Trials of combinations of an NSAID with an opioid (usually recommended for mild to moderate or moderate to severe pain) found either no significant difference, or at most a slight but significant advantage, compared with either single medication. NSAID side effects, although not consistently reported, tended to be minor and occur infrequently. However, many adverse effects, such as development of an ulcer or renal toxicity, might not be apparent with short-term dosing. More high-quality trials of the safety and efficacy of NSAIDs with or without opioids for cancer patients are needed.
Patel, U.D., Hollander, H., and Saint, S. (2004, May). "Index of suspicion." (AHRQ grant HS11540). New England Journal of Medicine 350(19), pp. 1990-1995.
This article traces step-by-step the diagnosis of a 26-year-old woman with end-stage renal disease after she presented with a 2-week history of fever and 11 months after having received her second renal transplant. She also
had generalized malaise, anorexia, and 3 pound weight loss since the onset of fever, as well as swelling of her left index finger. Due to the immunosuppressive drugs given for her transplant, many of the blood tests were negative, including the one for bartonella, a bacterial infection responsible for cat-scratch disease. Although cat scratch disease most often affects healthy people, it has also been found in people with HIV and in organ transplant recipients, and it was the ultimate diagnosis in this case. The woman worked for a veterinarian and had contact with cats and dogs. This case highlights the potential limitations of some diagnostic tests for opportunistic infections, particularly in immunosuppressed patients. The doctor finally ordered tests involving lymph nodes to detect the involvement with bartonella.
Romano, P.S., and Mutter, R. (2004, May). "The evolving science of quality measurement for hospitals: Implications for studies of competition and consolidation." (AHRQ contract 290-02-0007). International Journal of Healthcare Finance and Economics 4, pp. 131-157.
The literature on the relationship between hospital competition and quality is young. Most empirical studies have focused on few conditions and outcomes. Measures of in-hospital mortality and complications are susceptible to bias from unmeasured patient illness severity and transfer/discharge practices. Only one research team has evaluated related process and outcome measures, and none has exploited chart-review or patient survey-based data. Prior studies have generated inconsistent findings, suggesting the need for additional research. In this paper, the authors describe the strengths and limitations of various approaches to quality measurement, summarize how quality has been operationalized in studies of hospital competition, outline three mechanisms by which competition may affect hospital quality, and propose measures appropriate for testing each mechanism.
Schneeweiss, S., Wang, P.S., Avorn, J., and others (2004). "Consistency of performance ranking of comorbidity adjustment scores in Canadian and U.S. utilization data." (AHRQ grant HS10881). Journal of General Internal Medicine 19, pp. 444-450.
The performance of standard comorbidity scores (that reflect a person's coexisting medical conditions) to control confounding is poorly defined in health care use data across elderly populations. These investigators evaluated and ranked the performance of six frequently used comorbidity scores across four U.S. and Canadian elderly populations represented in health care use databases. They calculated the six scores for all participants during the baseline year to examine mortality within a year. Performance ranking of the comorbidity scores in predicting 1-year mortality was consistent across the selected elderly populations, after including age and sex. Performance was improved by an average of 6 percent by adding the number of different prescription drugs received during the previous year.
Scholle, S.H., Weisman, C.S., Anderson, R.T., and Camacho, F. (2004). "The development and validation of the primary care satisfaction survey for women." (AHRQ grant HS10237). Women's Health Issues 14, pp. 35-50.
This paper reports the development and psychometric properties of a new survey instrument to measure women's satisfaction with their primary care. The investigators conducted a multisite, cross-sectional validation survey of 1,202 women receiving primary care in three States. They used item response theory and factor analysis methods to identify three scales in the Primary Care Satisfaction Survey for Women (PCSSW): communication, administration and office procedures, and care coordination and comprehensiveness. The PCSSW showed internal consistency reliability, as well as convergent validity in relation to two generic measures, the Medical Outcomes Study Visit Satisfaction and the Consumer Assessment of Health Plans Study (CAHPS®).
Current as of August 2004
AHRQ Publication No. 04-0068