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Barr, D. and Vergun, P. (2000, December). "Using a new method of gathering patient satisfaction data to assess the effects of organizational factors on primary care quality." (AHRQ grant HS09350). Joint Commission Journal on Quality Improvement 26, pp. 713-723.

A common measure of quality of care is patient satisfaction with the care process. These researchers evaluated a quality assessment tool they developed that measures both patient satisfaction with care and how organizational factors within practice organizations affect satisfaction. They evaluated the tool in a random sample of patients visiting a large, multispecialty group practice in California. The patients arrived for an office visit accompanied by a survey worker who recorded objective characteristics of the visit (for example, waiting time), surveyed patients about their impressions of certain aspects of the visit related to satisfaction, and administered a standardized visit satisfaction survey. Control patients who visited the same doctor on the same day were contacted by phone and given the satisfaction survey, a traditional survey method. The new concurrent method provided significant information about organizational factors that influenced patient satisfaction.

Barry, M.J., Williford, W.O., Fowler, Jr., F.J., and others (2000, November). "Filling and voiding symptoms in the American Urological Association symptom index: The value of their distinction in a Veterans Affairs randomized trial of medical therapy in men with a clinical diagnosis of benign prostatic hyperplasia." (AHRQ grant HS08397). Journal of Urology 164, pp. 1559-1564.

Lower urinary tract symptoms in older men that may be associated with benign prostatic hyperplasia (BPH) traditionally have been separated into obstructive and irritative categories. It has been proposed that these symptom categories should be calculated as separate filling and voiding subscores on the American Urological Association symptom index to reflect more accurately the association of each symptom with a different phase of the process of storing urine and emptying the bladder. While these subscores are psychometrically valid, they are not clinically useful, conclude these authors. They used data from a large Veterans Affairs trial of medical therapy for men with BPH to evaluate calculating these separate filling and voiding subscores. The subscores did not result in differential correlations with measures of disease interference or severity, nor did they enable the researchers to predict a better symptomatic or uroflowmetry response to medical therapy.

Cagney, K.A., Wu, A.W., Fink, N.E., and others (2000). "Formal literature review of quality-of-life instruments used in end-stage renal disease." (AHRQ grant HS08365). American Journal of Kidney Diseases 36(2), pp. 327-336.

These authors conducted a formal literature review to determine how quality of life has been conceptualized, measured, and evaluated for patients with end-stage renal disease (ESRD). Of 78 articles they reviewed, only 32 percent defined quality of life. Few articles defined quality-of-life domains or adequately described instrument development and testing. The most frequently assessed quality-of-life domains were depression (41 percent), social functioning (32 percent), positive affect (30 percent), and role functioning (27 percent). Quality-of-life testing was completed for test-retest reliability in 20 percent of studies; interrater reliability, 13 percent; internal consistency, 22 percent; content validity, 24 percent; construct validity, 41 percent; criterion validity, 55 percent; and responsiveness, 59 percent.

Chapman, R.H., Stone, P.W., Sandberg, E.A., and others (2000). "A comprehensive league table of cost-utility ratios and a sub-table of 'panel-worthy' studies." (National Research Service Award training grant T32 HS00020). Medical Decision Making 20, pp. 451-467.

Ranked listings of the cost-effectiveness ratios of various health and medical interventions, often called "league tables," have been used to facilitate comparisons across cost-effectiveness analyses. These comparisons of ratios are needed because it is not possible to determine whether a program is a good value until it is compared with the benefits derived from resources expended in other programs. One criticism is that many utility analyses vary widely in the methods used for estimating and reporting costs, effectiveness, and preference weights. These authors compiled a comprehensive league table of cost/quality-adjusted-life-year (QALY) ratios (available on the Web) and a standardized table of analyses satisfying selected reference case criteria from the U.S. Public Health Service Panel on Cost-Effectiveness in Health and Medicine. They identified 228 cost-utility analyses through literature searches and abstracted data on methods and cost-utility ratios.

Downs, S.M., and Wallace, M.Y. (2000). "Mining association rules from a pediatric primary care decision support system." (AHRQ grant HS09507). Journal of the American Medical Informatics Association, Symposium Supplement, pp. 200-204, 2000.

One goal of clinical computing is to capture clinical data that can provide decision support at the point of care. The process of identifying novel and potentially useful patterns in data, "data mining" or "knowledge discovery," facilitates the conversion of clinical data into evidence for future decision support. The purpose of this study was to apply an unsupervised data mining algorithm to a database containing data collected at the point of care for clinical decision support. The authors applied a pattern discovery algorithm to data from the Child Health Improvement Program, a preventive service tracking and reminder system in use at the University of North Carolina. The program has data on over 30,000 visits. The algorithm discovered 16 2nd-order associations and 103 3rd-order associations, revealing that both tobacco smoke exposure and chronic cardiopulmonary disease were associated with failure on developmental screens.

Editor's Note: Select "Travers and Downs" for more information on this project.

Ioannidis, J.P., Schmid, C.H., and Lau, J. (2000). "Meta-analysis in hematology and oncology." (AHRQ grant HS10064). Hematology/Oncology Clinics of North America 14(4), p. 973-989.

Between 5 and 10 percent of clinical trials published each year deal with cancer or cancer-related conditions, easily taxing the ability of any clinician to keep current. Indeed, a recent survey found that about 70 percent of clinicians rely on review articles written by experts to guide their clinical decisionmaking. These authors point out the many deficiencies of what they describe as mostly unsystematic, narrative reviews, ranging from lack of critical appraisal of study methods to lack of a formal, quantitative synthesis of the reported treatment benefits. They provide guidelines for conducting a meta-analysis of cancer studies that may vary in the patient populations studied and stage or severity of disease studied. The authors contend that proper meta-analysis of cancer studies can point out deficiencies in the study design of past and current studies, suggest the need for new studies, and inform researchers about the size and design of these studies.

Lobach, D.F., and Kerner, N. (2000). "A systematic process for converting text-based guidelines into a linear algorithm for electronic implementation." (AHRQ grant HS09436). Journal of the American Medical Informatics Association, Symposium Supplement, pp. 507-511.

Clinical practice guidelines (CPGs) have gained importance as a tool to standardize practice patterns and improve the quality and efficiency of health care delivery. Unfortunately, most of the available CPGs exist only in a text-based format, which is difficult to integrate into the patient care process. This paper describes a systematic process to convert text-based CPGs into a linear algorithm with structured content as an intermediate step to electronic implementation. The process has been used successfully to prepare more than two dozen guidelines for computerization. It has been tested by several physicians and informatics experts and shown to be transferable to various user groups.

Malone, R.E. (2000, September). "Dimensions of vulnerability in emergency nurses' narratives." (AHRQ grant HS08412). Advances in Nursing Science 23(1), pp. 1-11.

The saving of strangers is the essence of emergency nursing, and nurses are constantly confronted with the existential, physical, emotional, economic, and social vulnerability of their patients. In turn, emergency department (ED) nurses are vulnerable. In this commentary, the author uses data from an ethnographic study conducted in two hospital EDs to illustrate tensions between two types of vulnerability as they are reflected in emergency nurses' narratives. One type of vulnerability is equated with susceptibility to particular harmful agents, conditions, or events at particular times and is considered something to be avoided or resisted. Another type of vulnerability is the ever-present, common condition of all sentient beings and a condition of nurses' access to understanding patients' experiences.

Rodenberg, C., and Zhou, X-H. (2000, December). "ROC curves estimation when covariates affect the verification process." (AHRQ grant HS08559). Biometrics 56, pp. 1256-1262.

An ROC curve is commonly used to measure the accuracy of a medical test. It is a plot of the true positive fraction (sensitivity) against the false positive fraction (1-specificity) for increasingly stringent positivity criteria. Bias can occur when estimating an ROC curve if, for example, only some of the tested patients are selected for disease verification and if analysis is restricted only to the verified cases. This is known as verification bias. The authors address the problem of correction for verification bias in estimation of an ROC curve when the verification process and efficacy of the diagnostic test depend on covariates. The authors also address the issues associated with selecting and checking the research model.

Sanders, G.D., Nease, Jr., R.F., and Owens, D.K. (2000). "Publishing Web-based guidelines using interactive decision models." (AHRQ grant HS08362). Medical Decision Making 20(2), pp. 145-159.

These authors developed a Web-based system, ALCHEMIST, which takes previously developed decision models and automatically creates evidence-based global guidelines that can be disseminated over the Web. To demonstrate the ability of a user to tailor and update global guidelines using the ALCHEMIST system, they chose three clinical problems: chlamydia screening for adolescent women, antiarrhythmic therapy for the prevention of sudden cardiac death, and genetic testing of women for the BRCA breast cancer mutation. For example, they show how a clinician could use ALCHEMIST to incorporate a woman's preferences for relevant health states and thereby develop patient-specific recommendations for BRCA testing. In this case, the patient-specific recommendation improved quality-adjusted life expectancy by 37 days.

Sim, I., Owens, D.K., Lavoir, P.W., and Rennels, G.D. (2000). "Electronic trial banks: A complementary method for reporting randomized trials." (AHRQ grant HS08362). Medical Decision Making 20, pp. 440-450.

Decision-support systems that access shared, up-to-date trial banks could help clinicians manage, synthesize, and apply evidence from randomized clinical trials (RCTs) more effectively, assert these authors. They propose that RCTs be reported into electronic knowledge bases—trial banks—in addition to being reported in the literature. Using the competency decomposition method, they specified the ideal trial-bank contents as the information necessary and sufficient for completing the task of systematic reviewing. They decomposed the systematic reviewing tasks into 4 top-level tasks and 62 subtasks; 162 types of trial information (related to the trial's design, execution, administration, and results) were necessary and sufficient for completing these subtasks. They found that trial-bank publishing of these 162 items would capture into computer-understandable form all the information needed for critically appraising and synthesizing trial results.

Travers, D.A., and Downs, S.M. (2000). "Comparing user acceptance of a computer system in two pediatric offices: A qualitative study." (AHRQ grant HS09507). Journal of the American Medical Informatics Association, Symposium Supplement, pp. 853-857.

This paper presents a qualitative study of user acceptance of a computer system, the Child Health Improvement Program, which was implemented in two pediatric offices in the Southeast. The researchers gathered data through staff interviews, observations in the clinical area, and a review of system implementation records. One practice was still using the program 5 months later, but the other practice had discontinued its use. Differences in user acceptance at the two practices were related to benefits versus costs, organizational cultures, relationship of the information system with the clinical staff in the practices, experiences in the two practices after implementation, and difficulty with transfer of technology from the academic center to private practice. These findings indicate a need to develop and validate tools to measure health care organizational climate and readiness for change.

Editor's Note: Select "Downs and Wallace" for more information on this study.

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Current as of January 2001
AHRQ Publication No. 01-0015

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