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Bito, S., Matsumura, S., Singer, M., and others. (2007). "Acculturation and end-of-life decisionmaking: Comparison of Japanese and Japanese-American focus groups." (AHRQ grant HS07370). Bioethics 21(5), pp. 251-262.
End-of-life decisionmaking varies among ethnic groups and may also vary within ethnic groups, depending on their acculturation. The researchers conducted separate focus groups among Japanese, Japanese-speaking Japanese-Americans, and English-speaking Japanese Americans to assess possible differences. They found that disclosure of a terminal diagnosis became more acceptable with acculturation; however, Japanese Americans still preferred that the diagnosis be disclosed first to the family, who would then decide in what form to communicate it to the patient. Japanese-Americans also trusted their physician more than the Japanese, because there is a less hierarchical physician-patient relationship in the United States than in Japan.
All three groups accepted the concept of advance care planning, but the Japanese participants rejected formal advance directives, consistent with the less frequent personal use of lawyers in Japan compared with the United States. In addition, the three groups preferred a family-oriented decisionmaking model to one based on the autonomous individual, which would not conform to the cultural norms of many Japanese-Americans.
Bracken, M.E., Medzon, R., Rathleve, N.K., and others. (2007, January). "Effect of intoxication among blunt trauma patients selected for head computed tomography scanning." (AHRQ grant HS09699) Annals of
Emergency Medicine 49(1), pp. 45-51.
A new study found that the prevalence of intracranial injury among intoxicated blunt trauma patients selected for computed tomography (CT) scanning was lower than nonintoxicated patients. This is not due to the protective nature of intoxication in blunt trauma, but rather, it is probably due to emergency physicians' heightened concern about cranial injury in intoxicated patients.
The researchers analyzed data from the National Emergency X-Radiography Utilization Study II (NEXUS II) head injury database. Physicians detected intracranial injury in 1,193 of the 13,728 enrolled patients (8.7 percent) at 21 emergency departments. About one-fourth (24.4 percent) of enrolled patients were intoxicated.
Overall, 6.9 percent of intoxicated patients and 8.1 percent of nonintoxicated patients suffered intracranial injury. The NEXUS II decision instrument considers patients at low risk based on the absence of all of the following criteria: older than 65 years, evidence of significant skull fracture, scalp hematoma, neurologic deficit, abnormal level of alertness, abnormal behavior, coagulopathy (abnormal blood clotting), and persistent vomiting.
Farquhar, M., Collins Sharp, B.A., and Clancy, C. (2007). "Patient safety in nursing practice." AORN Journal 86(3), pp. 455-457.
Patient safety, and in particular, the reduction of preventable medical errors, have become central public concerns. Nurses, as the largest group of direct health care providers, are vital to the effort to prevent errors, note the authors of this commentary. The Agency for Healthcare Research and Quality is a partner in this effort as it seeks to make sure that the findings, knowledge, and tools that result from research are broadly applied to improve health care.
For example, AHRQ-funded research has shown that nurse managers can help patients with congestive heart failure achieve better results. Our knowledge that patient safety problems are usually the result of structural design flaws will help lead to system transformation. Research has shown that the long hours demanded of nurses and low nurse staffing levels can lead to errors in administering medications and poor outcomes for patients.
The authors suggest that the ultimate goal must be the creation of a culture of patient safety in which errors, near misses, and adverse events can be reported and discussed in an atmosphere of trust and respect without fear of retribution.
Reprints (AHRQ Publication No. 08-R019) are available from AHRQ.
Friedman, A.L., Geoghehan, S.R., Sowers, N.M., and others. (2007, March). "Medication errors in the outpatient setting." (AHRQ grant HS15038). Archives of Surgery 142, pp. 278-283.
To identify and prevent medication errors in organ transplant patients, researchers examined outpatient medication errors among its liver, kidney, and/or pancreas transplant patients during a 1-year period in 2004 and 2005. The researchers identified 149 medication errors (and 5 major types) in 93 transplant patients who were prescribed a mean of 11 medications each. Patient harm or adverse events were associated with 32 percent of errors, including hospitalizations or outpatient invasive procedures in 13 percent of cases. Nine episodes of rejection and 6 failed transplants were also identified. The most common type of medication error was patient error (incorrect use of an available prescribed medication, 56 percent), followed by prescription errors (13 percent), delivery errors (13 percent), availability errors (patient did not have enough medicine for 24 hours or more, 10 percent), and reporting errors (8 percent). Root cause analysis identified the patient as the cause of 68 percent of errors and the health care system as the cause of 27 percent of errors. Finances were linked to 5 percent of errors.
Jodlowski, D., Sharf, B.F., Nguyen, L.C., and others. (2007). "Screwed for life: Examining identification and division in addiction narratives." (AHRQ grant HS10876). Communication & Medicine 4(1), pp. 15-26.
Online support groups have evolved as a way for opiate addicts to share their experiences and assist each other in recovering from addiction. The researchers examined the contents of a specific online Web site to determine both the attributes of communication that enhance supportive communication and those that contribute to divisiveness. More specifically, they used the theories of Kenneth Burke to question how the motives of suffering and the attempt to strive for perfection led to bringing participants closer together (identification) or estranging them from one another (division). Suffering is discussed from the standpoint of what it feels like to recover from drug addiction. The drive for perfection is related to a debate over what it means to be "clean" with respect to drug usage. Much of the article consists of quotations from and analysis of participant narratives. The
researchers conclude that the narrative of suffering brings participants closer together while the narrative of seeking perfection (that is, how to stay "clean") tends to be divisive.
Landon, B.E., Hicks, L.S., O'Malley, A.J., and others. (2007, March). "Improving the management of chronic disease at community health centers." (AHRQ grant HS13653) New England Journal of Medicine 356, pp. 921-934.
This study examined the impact of the Health Disparities Collaboratives on improved quality of care for patients with asthma, diabetes, and hypertension who received care at community health centers. The researchers compared quality of care among 9,658 patients at 44 collaborative community health centers and 20 non-collaborative community health centers. Overall, the collaborative centers improved the quality of care for asthma and diabetes (but not hypertension) considerably more than the control centers. For example, compared with control centers, the collaborative centers had significant improvements in prevention and screening measures. These included a 16-percent increase in the assessment of glycated hemoglobin levels and a 21-percent increase in foot exams for patients with diabetes as well as a 14-percent increase in the use of anti-inflammatory medications for patients with asthma.
Levine, S.R. and McConnochie, K.M. (2007). "Telemedicine for acute stroke. When virtual is as good as reality." (AHRQ grant HS15165). Neurology 69, pp. 819-820.
The primary barrier to ideal care for stroke in a small hospital is the lack of an experienced stroke neurologist. A study on telemedicine for patients with acute ischemic stroke (AIS) published in the same issue of this journal reported that community hospitals employing telemedicine access to stroke neurologists had results (mortality rates and functional outcomes) similar to those obtained by stroke experts in their own centers. The hospitals combined telemedicine (video/audio conferencing and transmission of computerized tomography images) and the use of recombinant tissue plasminogen activator (rt-PA) in the care of AIS patients. When rt-PA is initiated within 60 minutes of initial stroke symptoms, rather than 3 or more hours later, the chances of recovery without disability are quadrupled.
The authors of this editorial note that rt-PA is not given in over 95 percent of cases and that success with telemedicine systems is "much more about politics than technology." As such, use of telemedicine for acute stroke requires new organizational and personal relationships which are established and maintained through interactions serving organizational and professional values.
Nutting, P.A., Dickinson, W.P., Dickinson, L.M., and others. (2007, January). "Use of chronic care model elements is associated with higher-quality care for diabetes." (AHRQ grant HS10123). Annals of Family Medicine 5(1), pp. 14-20.
This study surveyed primary care practices to assess the extent to which they used the chronic care model (CCM) in routine care of patients with diabetes. The researchers surveyed 90 clinicians from 30 small independent primary care practices about their use of elements of the CCM. Analysis included a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin (a protein in urine that indicates kidney functioning), and glycated hemoglobin (HbA1c); foot examinations; and dilated retinal examinations.
Researchers also computed a behavioral care composite score for support from the clinician in setting self-management goals, provision of nutrition education or therapy, and encouragement to self-monitor blood-glucose levels. For every unit increase in clinician-reported CCM use (for example, from rarely to occasionally), there was an associated 0.30 percent reduction in HbA1c value and 0.17 reduction in the ratio of total cholesterol to high-density lipoprotein cholesterol. Clinician use of the CCM elements was significantly associated with the behavioral composite score and marginally associated with the clinical care composite score.
Plantinga, L.C., Fink, N.E., Jaar, B.G., and others. (2007). "Relation between level or change of hemoglobin and generic and disease-specific quality of life measures in hemodialysis." (AHRQ grant HS08365). Quality of Life Research 16, pp. 755-765.
One consequence of chronic kidney disease is anemia, as reflected by low hemoglobin and hematocrit levels. Effective treatment of anemia has been shown to improve quality of life (QOL). The authors of this study examined the impact on various aspects of QOL of raising hemoglobin levels to 11 g/dl (the minimum guideline established by the Kidney Disease Outcomes Quality Initiative) among 438
hemodialysis patients with kidney failure. These aspects included such QOL domains as physical, social, and cognitive functioning, and domains related to fatigue levels such as sexual functioning, work, and recreation.
After one year, patients who had achieved 11 g/dl for at least 6 months, had significantly higher QOL for physical functioning, bodily pain, mental health, social functioning, cognitive functioning, as well as diet restriction and dialysis access domains. In addition, even incremental increases of 1 g/dl over initial hemoglobin levels were correlated with higher QOL scores for most domains.
Reyes Ortiz, C.A., Freeman, J.L., Koop, Y., and others. (2007). "The influence of marital status on stage at diagnosis and survival of older persons with melanoma." (AHRQ grant HS11618). Journal of Gerontology: Medical Science 62A (8), pp. 892-898.
Skin-screening programs should target unmarried older persons, especially widowed older patients, recommend the authors of this study. To determine the association between marital status, stage at diagnosis, and survival of older persons with melanoma, they analyzed data on 14,630 elderly men and women from the Surveillance, Epidemiology, and End Results (SEER) registries—Medicare-linked database (1991-1999). Older married persons were diagnosed with melanoma at earlier stages and survived longer than those were widowed. These results persisted even after adjusting for age, gender, income, ethnicity, and tumor characteristics. Some possible explanations include high emotional stress (for example, grief), loss of social support, decreased income, less adherence to treatment or lower quality hospitals, and weakened immunity.
An additional finding was that married women were less likely than married men be diagnosed with melanoma at late stage. Neither of these differences was found to exist between unmarried women and unmarried men.
Rosenberg, M.A., Frees, E.W., Sun, J., and others. (2007). "Predictive modeling with longitudinal data: A case study of Wisconsin nursing homes." (AHRQ grant HS16519). North American Actuarial Journal 11(3), pp. 54-69.
The article is intended as a tutorial for analysts, who may be interested in using this type of predictive model with longitudinal data. Predictive modeling is a process that involves problem identification, data analysis, and candidate model development, estimation, and validation. Predictive modeling with the use of longitudinal data allows for more accurate predictions than regression modeling since it takes into account historical trends. Its prior health care applications have included provider profiling, provider reimbursement, and identification of high-cost users. To illustrate how the model works in practice, the authors use cost reports for 400 Wisconsin nursing homes to make forecasts of total patient days. The article demonstrates many of the common difficulties that analysts face in analyzing longitudinal health care data, as well as techniques for addressing these difficulties.
Rumptz, M.H., Tobias, C., Rajabiun, S. and others. (2007). "Factors associated with engaging socially marginalized HIV-positive persons in primary care." (AHRQ grant HS10858). AIDS Patient Care and STDs 21(Suppl.1), pp. S30-S39.
Engagement in medical care is essential, if people living with HIV disease are going to benefit from life-prolonging HIV care and treatment. This study examined factors related to HIV-positive persons who were only somewhat engaged in care or not at all engaged in care. Of the 984 socially marginalized patients initially surveyed, 40 percent were somewhat engaged and 12 percent were not at all engaged in HIV primary care. Twelve months later, according to a followup survey, 58 percent of those not initially engaged in care had become more fully engaged in HIV primary care. The use of HIV primary care had increased as the major barriers to care (drug use, structural barriers, belief barriers, and unmet needs) were discontinued or reduced. These patients were part of a multisite demonstration study in which the barriers to care were addressed by one or more of 10 types of outreach intervention.
Tobias, C., Cunningham, W.E., Cunningham, C. O., and others. (2007). "Making the connection: The importance of engagement and retention in HIV medical care." (AHRQ grant HS10858). AIDS Patient Care and STDs 21(Suppl.1), pp. S3-S8.
This paper is an introduction to a supplemental journal issue reporting on the results of a 5-year multisite outreach initiative to engage and retain patients in HIV care. It focuses on HIV patients not receiving ongoing HIV care and the barriers to care that they face. It also discusses intervention options and the public policy implications of this issue. Barriers to care may be structural, financial, or personal/cultural, according to a framework developed by the
Institute of Medicine. Structural barriers include unavailable or inconveniently located services, as well as subsistence needs competing with health care priorities. Financial barriers include lack of insurance, underinsurance, or the cost of services. Personal/cultural barriers include individual attitudes and beliefs as well as racism, sexism, and homophobia. To counteract these different barriers, the researchers used relationship building, service linking, and advocacy as part of the outreach initiative. The journal supplement provides new evidence about outreach and related strategies that promote sustained participation in HIV care by underserved populations.
Van der Steen, J.T., Mitchell, S.L., Fritjers, D.H.M., and others. (2007, September). "Prediction of 6-month mortality in nursing home residents with advanced dementia: validity of a risk score." (AHRQ grant HS08551). Journal of the American Medical Directors Association 8, pp. 464-468.
Seventy percent of U.S. patients with dementia die in nursing homes. Families and physicians of these patients can make use of prognostic information to make decisions about palliative care. The authors developed a risk score based on variables from the Minimum Data Set (MDS) to predict 6-month mortality in 269 Dutch nursing home patients with advanced dementia and 270 Missouri nursing home patients with both advanced dementia and lower respiratory infections. The risk score identified residents at low and moderate risk of 6-month mortality (up to 40 percent) with reasonable accuracy. As mortality rates rose incrementally in each group, the risk score increased. It performed less well for residents with a higher risk of mortality; however, very few residents were estimated to have a mortality risk of well over 50 percent. Well-derived risk scores, while not suitable as a sole guide, can add important information for those making palliative care decisions.
Whitney, S.N. and McCullough, L.B. (2007). "Physicians' silent decisions: Because patient autonomy does not always come first." (AHRQ grant HS11289). The American Journal of Bioethics 7(7), pp. 33-38.
Although patients today are increasingly participating in medical decisionmaking about their care, there remains a context in which physicians may justifiably make silent decisions about patient care, i.e., they may consider and reject decisions without informing the patient. Silent decisions may represent the physician's choice to follow a widely recognized guideline, to invoke an accepted exception to the guideline, or to take some other action that is justified by an individual patient's circumstance. Such decisions are frequent, inevitable, and entirely appropriate, according to these authors. For example, the physician, by the exercise of his professional clinical judgment, may determine that a procedure offers no net benefit to the patient and therefore does not mention it to the patient. The authors discuss several examples of silent decisions. In the process, they make an ethical case for a limited set of clinically significant, ethically valid silent decisions.
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AHRQ Publication No. 08-0015
Current as of January 2008
Research Activities Newsletter. January 2008, No. 329. AHRQ Publication No. 08-0015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/jan08/