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Arbogast, P.G., Kaltenbach, L., Ding, H., and Ray, W.A. (2008, January). "Adjustment for multiple cardiovascular risk factors using a summary risk score." (AHRQ grant HS10384). Epidemiology 19(1), pp. 30-37.

Studies that use large databases on medical care encounters for cardiovascular disease often include confounding patient risk factors such as cardiovascular medications and coexisting illnesses. The standard method of controlling for such confounding is to fit multiple-regression models that include each of the potential confounders. However, using a summary risk score can be a reasonable approach for summarizing many risk factors in large cohort studies, concludes this study. The authors conducted simulation studies comparing regression models adjusting for all risk factors with models using a summary risk score (created from regression models relating these risk factors to outcome) to adjust for multiple cardiovascular risk factors for large cohort studies. The standard errors from the regression models using the summary risk score were similar to the standard errors from regression models directly adjusting for all risk factors.

Austin, E.L., Andersen, R., and Gelberg, L. (2008). "Ethnic differences in the correlates of mental distress among homeless women." (AHRQ grant HS08323). Women's Health Issues 18, pp. 26-34.

To study ethnic differences in the correlates of mental distress among homeless women, the authors conducted face-to-face interviews with 821 homeless women in the Los Angeles area, of whom 67 percent were black, 17 percent Hispanic, and 16 percent white. Almost half of the women studied had a mental distress score suggesting the need for further evaluation and possible clinical intervention. Black women reported the lowest overall mental distress scores (43 percent compared with 51 percent for both white and Hispanics), as measured by the Mental Health Index (MHI-5). Nearly twice as many white women as Hispanic or black women reported childhood or recent physical or sexual assault. More than one-third of these homeless women had been physically or sexually abused during childhood or physically assaulted in the past year. One striking finding is the high level of mental distress associated with being partnered for black women without children and among white women, regardless of parenting status. These and other differences should be considered in the development of culturally appropriate services for the homeless population.

Clancy, C.M. (2008, February). "Bariatric surgery: What women need to know." Nursing for Women's Health 12(1), pp. 21-24.

Bariatric surgery, such as gastric bypass, can lead to dramatic weight loss of 57 to 66 percent. This much weight loss has led to resolving diabetes in 77 percent of patients. Clearly, bariatric surgery can be a lifesaver in many cases, notes Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality, in this commentary. Bariatric surgery is recommended for patients with a body mass index (BMI) of at least 40 or with a BMI of at least 35 plus serious medical conditions such as severe sleep apnea and diabetes. Although the safety of bariatric surgery has improved (death rates of 0.19 percent in 2004), it still remains a high-risk procedure with 4 in 10 patients developing a complication within 6 months. Given the necessary lifestyle changes that must accompany bariatric surgery, the role of nurses really can "make or break" the surgery's success for women, notes Dr. Clancy.

Reprints (AHRQ Publication No. 08-R061) are available from the AHRQ Publications Clearinghouse.

Clancy, C.M. (2008). "Clinical research training: Scientific literacy for the twenty-first century." Journal of General Internal Medicine 23(2), pp. 219-220.

Health information technology holds great promise for delivering evidence-based information to the point of care and shortening the oft-discussed delay in incorporating scientific advances into routine practice. Use of this evidence demands clinicians with strong skills in information management, interpretation, and application, notes Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality. She contends that the capacity to understand how evidence is generated, synthesized, and applied to the care of an individual patient with unique characteristics and preferences can no longer be considered a special interest. Rather, for clinicians, who need to understand clinical research methods and clinical methods, it is becoming a required skill set. Programs that incorporate these skills into clinical training time increase the potential for that training to influence how residents consider the strength of clinical evidence in their daily work.

Cook, R.I., Wreathall, J., and Smith, A., and others (2007, December) "Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003." (AHRQ grant HS12461). Transplantation, 84(12), pp. 1602-1609.

Following an accidental ABO-incompatible thoracic organ transplantation in 2003, the authors of this study undertook a probabilistic risk assessment (PRA) of the donor-recipient matching processes for thoracic organ transplantation before and after 2003. PRA, a quantitative method for system risk assessment, uses mathematical models to determine the effect of specific process faults on various types of transplant failure. In the model, transplantation matching is a series of five events, starting with the use of a match-list or open offer and proceeding to confirmation testing of ABO compatibility versus no confirmation testing. According to findings generated from the PRA, the initially low likelihood of an ABO-incompatible thoracic organ transplantation event was reduced by about sixtyfold because the United Network for Organ Sharing changed its procedures following the March 2003 incident. At a likelihood of 1 in 4.5 million instances of transplantation, such an event is on an order of risk of being killed by lightning in the next year.

Cox, E.D., Smith, M.A., Brown, R.L., and Fitzpatrick, M.A. (2008). "Assessment of the physician-caregiver relationship scales (PCRS)." (AHRQ grant HS13183). Patient Education and Counseling 70, pp. 69-78.

As with physician-patient relationships, physician-caregiver relationships determine adherence to physician guidance, health outcomes, and care satisfaction. However, measures of this important relationship are lacking. Toward this end, these authors developed and validated the physician-caregiver relationship scales (PCRS), incorporating the relationship domains of liking, understanding, and dominance. They analyzed videotapes of 100 children's medical visits using verbal measures (personal remarks, laughter, agreements, approvals, concerns, reassurances, back channels, and empathy) and nonverbal measures (touch initiations, upright postures, and leaning toward a participant), as well as summary measures (physician portion of total talk and number of questions). The findings supported the value of the PCRS domains of liking, understanding, and dominance as measures of physician-caregiver relationships.

Curtis, J.R., Xi, J., Patkar, N., and others (2007, December). "Drug-specific and time dependent risks of bacterial infection among patients with rheumatoid arthritis who were exposed to tumor necrosis factor alpha antagonists." (AHRQ grant HS10389). Arthritis & Rheumatism 56(12), pp. 4226-4227.

Patients with rheumatoid arthritis (RA) who are treated with tumor necrosis factor alpha (TNF alpha) antagonists incur an increased risk of being hospitalized with a serious bacterial infection, as compared with those patients with RA who receive methotrexate (MTX), according to an earlier study by these researchers. To further characterize drug-specific risks, they evaluated the comparative effects of antibody-based and non-antibody-based TNF alpha antagonists on the risk of hospitalization for bacterial infection. The patients who were studied following the initiation of TNF alpha therapy consisted of one group (850) who received the antibody-based infliximab and another group (1,412) who received the non-antibody-based etanercept. The comparison group (2,933) received MTX only. The incidence of a serious bacterial infection was highest during the first 6 months after initiation of a TNF alpha antagonist; however, this finding was only significant among patients exposed to antibody-based infliximab. This risk did not persist beyond 6 months. Since there is a relatively low absolute risk of infection, for many, the expected benefits likely will outweigh even the modestly increased risks of associated adverse events.

Geisinger, K.R., Vrbin, C., Grzybicki, D.M., and others (2007). "Interobserver variability in human papillomavirus test results in cervicovaginal cytologic specimens interpreted as atypical squamous cells." (AHRQ grant HS13321). American Journal of Clinical Pathology 128, pp. 1010-1014.

Greater knowledge about possible interobserver variability (IOV) in the interpretation of Pap tests may help to enhance its accuracy, suggest the authors of this study. They examined interpretations of Pap specimens by five pathologists in the same laboratory over a 2-year period to determine variability in the proportions of human papillomavirus (HPV) DNA specimen cells interpreted as belonging to one of two categories. These cells may be classified as either atypical squamous cells of undetermined significance (ASCUS) or atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesion (ASC-H). Overall, among 3,680 specimens reviewed by a pathologist over the 2-year period, 1,299 (35.3 percent of all pathologist diagnoses) had an interpretation of ASCUS and 222 (6.0 percent of all pathologist diagnoses) had an interpretation of ASC-H. During this same interval, a diagnosis of low-grade squamous intraepithelial lesion (LSIL) or high-grade squamous intraepithelial lesion (HSIL) was made in 1,444 specimens (7.1 percent of total specimens), making the ratio of ASCUS plus ASC-H/SIL to be 1.05. This ratio varied among the five pathologists from 0.58 to 1.53. Although these differences were not statistically significant, the researchers believe that this is the first time such objective IOV has been shown.

Gelberg, L., Lu, M.C., Leake, B.D., and others (2008). "Homeless women: Who is really at risk for unintended pregnancy?" (AHRQ grant HS08323). Maternal and Child Health 12, pp. 52-60.

One-third of homeless women surveyed in Los Angeles used contraception rarely or never in the past year, found this study. Women who had a partner, were monogamous, and did not engage in the sex trade were 2.4 times more likely to not use or rarely use contraception. Women who disliked their partner or were uncertain about which contraceptive to use were 2.6 times more likely to fail to use contraception. Having a regular source of care and having been encouraged to use contraception protected against failure to use contraception. Clearly, homeless women, even those at apparently low risk for unintended pregnancy, need to be targeted with integrative services that include contraception education, a regular source of medical care, and encouragement to use contraception, suggest the researchers. Their findings were based on a survey of 974 homeless women in Los Angeles County in 1997.

Glance, L.G., Osler, T.M., Mukamel, D.B., and Dick, A.W. (2008, February). "Impact of the present-on-admission indicator on hospital quality measurement." (AHRQ grant HS13617). Medical Care 46(2), pp. 112-119.

The Agency for Healthcare Research and Quality has constructed Inpatient Quality Indicator (IQI) mortality measures to assess hospital quality using routinely available administrative data. However, with the exception of California, New York, and Wisconsin, administrative data do not include a present-on-admission (POA) indicator to distinguish between a patient's preexisting conditions and complications of their hospital stay. This could distort ratings of hospital quality performance, assert the authors of this study. They retrospectively examined the impact of the POA indicator on hospital quality assessment based on over 2 million inpatient admissions between 1998 and 2000 in the California State Inpatient Database. The inclusion of the POA indicator frequently resulted in changes in the quality ranking of hospitals classified as high-quality or low-quality using routine administrative data. These findings emphasize the need to include a POA indicator if administrative data are to serve as the information infrastructure for reporting of care quality.

Green, N.S., Rinaldo, P., Brower, A., and others (2007, November). "Committee report: Advancing the current recommended panel of conditions for newborn screening." Genetics in Medicine 9(11), 792-796.

The Advisory Committee on Heritable Disorders and Genetic Diseases in Newborns and Children is charged with advising the secretary of the Department of Health and Human Services in areas relevant to heritable conditions, especially newborn screening (NBS). This report summarizes a new process to nominate and review conditions to the recommended universal NBS panel. The process consists of the following stages proposed by the Criteria Work Group: submission of a nomination form; an administrative review of the form led by the Health Resources and Services Administration; a review by the Committee to determine if the nomination should go to a formal scientific review conducted by an Evidence Review Work Group or be deferred for review until additional information can be provided by the nominator. Conditions proposed for newborn screening occur at very low frequency in children, but pose serious health risks to those affected. These conditions usually lack studies based on randomized controlled trials. This means that new ground rules for weighing evidence will be needed to assess the validity of claims for health benefits to justify newborn screening for each disorder.

Hill, S. (2007/2008, Winter). "The accuracy of reported insurance status in the MEPS." Inquiry 44, pp. 443-468.

The author assessed the level of accuracy in the reporting of private insurance and uninsurance among the nonelderly by the Medical Expenditures Panel Survey Household Component (MEPS-HC), a nationally representative household survey conducted by the Agency for Healthcare Research and Quality. He used four methods of validation, including surveys of employers and providers, and enrollees' documentation of insurance such as insurance cards or policy booklets. He also reviewed survey methodology and validation studies of reported insurance status; described various features of MEPS-HC; discussed variables associated with misreporting and nonresponse analyses; and compared his findings with other studies. Based on a variety of validation data, reported private insurance and lack of insurance in the MEPS-HC is reasonably accurate, with families, employers, and insurance companies agreeing about private insurance status for 97 percent of the nonelderly. The author concluded that this high level of accuracy supports using MEPS-HC to track trends and analyze policies.

Reprints (AHRQ Publication No. 08-R051) are available from the AHRQ Publications Clearinghouse.

Hsieh, M., Auble, T.E., and Yealy, D.M. (2008, January). "Validation of the acute heart failure index." (AHRQ grant HS10888). Annals of Emergency Medicine 51(1), pp. 37-44.

Acute care and emergency physicians often overestimate the probability of short-term death or severe complications for heart failure patients, and tend to treat them in more intense care settings. To improve physician risk assessment and more appropriately guide site of care, the authors of this study validated a clinical prediction rule for heart failure patients admitted through the emergency department. They retrospectively studied 8,384 adult patients admitted to Pennsylvania hospitals in 2003 and 2004 with a diagnosis of heart failure. They reported the proportions of inpatient death, serious medical complications before discharge, and 30-day death in the patients identified as low-risk by the prediction rule. The prediction rule classified 19.2 percent of patients as low-risk. In this group, there were 0.7 percent inpatient deaths, 1.7 percent of patients survived to hospital discharge after a serious complication, and 2.9 percent died within 30 days after hospitalization. The findings suggest the rule could assist physicians in making site-of-care decisions for this group.

Hughes, R.G. and Clancy, C.M. (2008, January). "Research linking nurses' work hours to errors prompts more state restrictions." AORN Journal 87(1), pp. 209-211.

Based on evidence linking nurses' fatigue from long work hours to a higher risk for medical errors, more than a dozen States now either prohibit or restrict mandatory overtime. Whether the solution is a ban or a restriction on mandatory overtime, it is necessary to create working conditions that ensure the safety of patients and well-being of nurses, assert the authors of this paper. They summarize findings of several studies that demonstrate significant risk to patient safety when nurses work beyond 12 hours. In one study, 65 percent of nurses in critical care units reported struggling to stay awake at work at least 1 day during the 28-day study period, and 27 percent reported making at least one error during that time. Another study found that nurses who work more than 12.5 consecutive hours have three times the risk of making an error than nurses who work fewer hours.

Hyle, E.P., Bilker, W.B., Gasink, L.B., and others (2007). "Impact of different methods for describing the extent of prior antibiotic exposure on the association between antibiotic use and antibiotic-resistant infection." (AHRQ grant HS10399). Infection Control and Hospital Epidemiology 28(6), pp. 647-654.

The use of different methods for describing the extent of a person's prior antibiotic exposure may substantially alter the identified risk factors for infection with antibiotic-resistant organisms. This has important implications for the choice of antibiotics, note the authors of this study. They systematically reviewed studies that investigated the risk factors for extended-spectrum Beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella species to identify variability in past methods for describing the extent of antibiotic use. The 25 studies revealed a variety of methods used to describe the extent of a patient's prior antibiotic exposure, with results varying substantially depending on the methods used. For example, use of third-generation cephalosporins was a risk factor for infection with ESBL-producing E. coli and Klebsiella species when antibiotic use was described as a continuous variable, but not when antibiotic use was described as a categorical variable.

Kelly, P.J., Morrow, J.D., Ning, M-M., and others (2008, January). "Oxidative stress and matrix metalloproteinase-9 in acute ischemic stroke." (AHRQ grant HS11392). Stroke 39, pp. 100-104.

Experimental cell culture and animal stroke model studies indicate that oxidative stress is a key factor in ischemic brain injury. Oxidative stress is also implicated in activation of matrix metalloproteinases (MMPs) and blood-brain barrier injury after ischemia-reperfusion. This study measured F2-isoprostanes (F2IPs), free-radical induced products of neuronal arachadonic acid peroxidation, in acute ischemic stroke, to determine the change in plasma F2IP levels over time and their relationship with plasma MMP-9 in tPA-treated and tPA-untreated stroke patients. Individuals without prior stroke were controls. In 52 cases and 27 controls, early (median 6 hours postonset) F2IPs were elevated in stroke cases compared with controls. No difference in F2IPs was present at later time points. Early plasma F2IPs correlated with MMP-9 in all patients and the tPA-treated subgroup. This evidence of increased oxidative stress and a relationship with MMP-9 expression in early human stroke supports findings from experimental studies.

Kent, D. M., Ruthazer, R., Griffith, J.L. and others (2008). "A percutaneous coronary intervention-thrombolytic predictive instrument to assist choosing between immediate thrombolytic therapy versus delayed primary percutaneous coronary intervention for acute myocardial infarction." (AHRQ grant HS08212). American Journal of Cardiology 101, pp. 790-795.

Primary percutaneous coronary intervention (PCI) has been found to decrease mortality for patients with ST-segment elevation myocardial infarction (STEMI), especially for those at high risk. For physicians considering the risks and benefits of delayed PCI compared with more immediate thrombolytic therapy, the researchers, building on a previously developed thrombolytic predictive instrument (TPI), developed a mathematical model (PCI-TPI) that can be adapted for incorporation into a conventional computerized electrocardiogram (ECG). The model's predictions were tested using data on 377 patients from the Atlantic Cardiovascular Patient Outcomes Research Team's trial of PCI versus thrombolytic therapy at 11 Massachusetts and Maryland hospitals. The mean predicted 30-day mortality from those in the thrombolytic therapy arm was 6.3 percent (compared with an actual 6.0 percent); for those in the PCI arm, the mean predicted 30-day mortality was 4.5 percent (compared with an actual 3.9 percent). If incorporated into conventional computerized ECGs, the PCI-TPI could potentially be used in emergency departments and prehospital emergency medical settings to assist physicians considering tradeoffs between immediate thrombolytic therapy and PCI with some delay.

Keohane, C.A., Bane, A.D., Featherstone, E., and others (2008, January). "Quantifying nursing workflow in medication administration." (AHRQ grant HS14053). The Journal of Nursing Administration 38(1), pp. 19-26.

New medication administration systems, such as barcoding technology, show promise for improving patient safety at the point of care. However, organizations need to know how nurses spend their time, so that the new systems can support nurses' workflow and maximize time spent at the patient's bedside. Toward that end, this time-motion study measured the proportion of time that nurses spent on 112 discrete patient care tasks, including medication administration, during a 2-hour period. These observations were performed on the inpatient units of an academic medical center over a 6-month period. Findings from 116 2-hour observation periods revealed that nurses spent 26.9 percent of their time on medication-related activities and 73.1 percent of their time on other activities. The average time spent on medication-related activities ranged from 22.8 percent in the intensive care unit setting to 29.1 percent in combined medical/surgery units.

Kraus, S., Barber, T.R., Briggs, B., and others (2008, February). "Implementing computerized physician order management at a community hospital." (AHRQ grant HS15076). The Joint Commission Journal on Quality and Patient Safety 34(2), pp. 74-84.

Four community hospitals belonging to the same health system decided to implement computerized physician order management (CPOM) as the first phase of an electronic medical record project. The project created an organizational structure consisting of a steering committee, a medical executive committee, physician and patient advisory groups, an implementation committee, and task forces on communications, process redesign, training, and security. Work-flow redesign and software configuration were the most intense efforts of the project. A new process was devised for developing regional standard order sets to move toward evidence-based practice and reduce undesirable variation. Although verbal orders were to be discouraged, a process for verbal ordering was also developed. Physicians received 3 hours of training focused on using the computer to create patient lists, enter orders, and use order sets. After two pilot projects in obstetrics and behavioral medicine, one of the four hospitals took the lead in implementing a full CPOM system. After 1 month, the hospital had achieved the first-year goal of 40 percent physician entry; by the end of the first year, physician entry had reached 75 percent.

Linkin, D.R., Fishman, N.O., Landis, R., and others (2007, December). "Effect of communication errors during calls to an antimicrobial stewardship program." Infection Control and Hospital Epidemiology 28(12), pp. 1374-1381.

Hospital antimicrobial stewardship programs (ASPs) seek to improve antibiotic prescribing practices by antimicrobial formulary restrictions, education, and prior-approval requirements. In prior-approval programs, hospital clinicians obtain permission from ASP practitioners (typically infectious disease-trained physicians or pharmacists) to prescribe restricted antibiotics. However, this study found that inaccurate communication of patient data, particularly microbiological data, during prior-approval calls was associated with double the likelihood of inappropriate antibiotic recommendations from the ASP. The authors suggest that clinicians and ASP practitioners work to confirm that critical data has been communicated accurately prior to use of that data in prescribing decisions. Their findings were based on analysis of 163 ASP prior-approval telephone calls at one medical center.

Lipkus, I.M. (2007, September). "Numeric, verbal, and visual formats of conveying health risks: Suggested best practices and future recommendations." (AHRQ contract no. 290-05-136). Medical Decision Making 27, pp. 696-713.

The author of this paper reviews the strengths and weaknesses of numeric, verbal, and visual formats for conveying health risks. Numbers are precise, convey an aura of scientific credibility, can be converted from one metric to another, can be verified for accuracy (assuming enough observations), and can be computed using algorithms. However, they lack sensitivity expressing gut-level reactions and intuitions. Verbal terms allow for fluidity in communication; express the level, source, and imprecision of uncertainty; encourage one to think of reasons why an event will or will not occur; and may better capture a person's emotions. However, they are subject to a high degree of variability in interpretation. Visual displays, increasingly used as adjuncts to numeric and verbal communications of risk, are able to summarize a great deal of data, and reveal patterns that would otherwise go undetected. However, they can mislead by calling attention to certain elements and away from others. Given the current lack of critical tests and theoretical inadequacies, few overall recommendations can be made across the three formats. The author recommends areas for future research.

Melnyk, B.M., Fineout-Overhold, E., Hockenberry, M., and others (2007, December). "Improving healthcare and outcomes for high-risk children and teens: Formation of the national consortium of pediatric and adolescent evidence-based practice." (AHRQ grant HS11675). Pediatric Nursing 33(6), pp. 525-529.

Many evidence-based interventions shown to improve child and adolescent health and development are not being used in clinical practice. Conversely, many clinical practices are being implemented without sufficient evidence to support their use. This paper describes the processes used and outcomes generated from the first Evidence-Based Practice (EBP) Leadership Summit focused on children and adolescents, which was held in February 2007. Several nationally recognized EBP experts and health care leaders from a number of children's hospitals and colleges of nursing across the U.S. participated in the summit. One outcome of the summit was the launching of the new National Consortium for Pediatric and Adolescent EBP. Future Consortium initiatives will include the development of evidence-based clinical practice guidelines, collaborative research/EBP initiatives, tools/resources, and the development of EBP mentors to improve the care and health of the nation's children and adolescents.

Moy, E., and Dayton, E. (2007, November). "Frontiers in gender-based research: Health care quality data." Women's Health Issues 17, pp. 334-337.

The National Healthcare Disparities Report (NHDR), produced by the Agency for Healthcare Research and Quality, reports only a handful of measures from the perspective of gender-based research each year. Given that women have higher rates of certain illnesses than men and are also disproportionately more likely to live in poor households, it is appropriate to highlight some underused data sources included in the NHDR appendices that are useful for gender-based analyses. The authors briefly discuss nine different data sources of possible interest to researchers. For example, the Centers for Medicare & Medicaid Services sponsors an End Stage Renal Disease Clinical Performance Measures Project and the United States Renal Data System (USRDS) with data on kidney disease, dialysis, transplantation, survival, and costs. Another example sponsored by the Centers for Disease Control and Prevention is the National Asthma Survey, the most comprehensive national data set on asthma prevalence and care. These and other surveys mentioned in this article offer great possibilities for future research, especially with regard to some components of care of particular importance to women.

Reprints (AHRQ Publication No. 08-R048) are available from the AHRQ Publications Clearinghouse.

Murray, D.J., Boulet, J.R., Avidan, M., and others (2007). "Performance of residents and anesthesiologists in a simulation-based skill assessment." (AHRQ grant HS16652). Anesthesiology 107, pp. 705-713.

These researchers sought to determine if a group of simulations could be used to provide a reliable and valid measure of anesthesia residents' and anesthesiologists' performances in a simulated intraoperative environment. They tested a dozen scenarios with 99 participants who were residents beginning their first year, advanced first-year residents, second- and third-year residents, and experienced anesthesiologists. Each 5-minute scenario involved an electromechanical mannequin undergoing an event such as acute hemorrhage, anaphylaxis, blocked endotracheal tube, and bronchospasm. Participants were instructed to perform all diagnostic or therapeutic actions in "real" time and verbalize each step they were performing to allow accurate coding and response by simulation staff to any requests by the participant. Scoring measured three to six key diagnostic or therapeutic actions. The majority of more experienced participants readily managed many of the easier scenarios. The authors concluded that the scenarios provided a valid method to discriminate between residents beginning their first year and those with greater anesthesia practice experience and training.

Oken, A, Rasmussen, M.D., Slagle, J.M., and others (2007, December). "A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting." (AHRQ grant HS11521). Anesthesiology 107, pp. 909-922.

Certain areas of suboptimal care may not be captured by traditional quality assurance (QA) clinician self-reporting methods. Such reporting may also be limited by cognitive bias and the reluctance of clinicians to report mistakes. In order to develop a supplement to traditional QA reporting, the researchers conducted a pilot study of nonroutine events (NREs) for patients receiving anesthesia using a Comprehensive Open-ended Nonroutine Event Survey (CONES). The surveillance system used in CONES (open-ended questions, live interviewers) is designed to avoid precategorized events, be nonjudgmental in character, facilitate discovery of latent conditions, and provide ample data to inform intervention strategies. During a 30-month study period at a hospital where 8,303 procedures with anesthesia were performed, 183 CONES surveys were administered. Of this sample, 183 (31.1 percent) of the cases contained an NRE, compared with 159 evaluated by traditional QA analysis. The results of the CONES survey, when extrapolated, suggest a higher overall incidence of anesthesia-related injury than that found (7.7 percent vs. 1.0 percent) by the traditional QA method.

Perry, M., Williams, R.L., Wallerstein, N., and Waitzkin, H. (2008, February). "Social capital and health care experiences among low-income individuals." (AHRQ grant HS09703). American Journal of Public Health 98(2), pp. 330-336.

Social capital—social support, psychosocial interconnectedness, and community participation—is associated with the health care experiences of low-income individuals, found this study. The researchers conducted a Statewide survey of 1,216 low-income New Mexico residents to examine associations between social capital and barriers to health care access, use of care services, satisfaction with care, and quality of provider communication. Social support was inversely related to reported barriers to care, but was not associated with care use or satisfaction or perceived quality of provider communication. Psychosocial interconnectedness was significantly associated with care satisfaction, but not with care access or use or perceived quality of provider communication. These findings provide further support for the theory that community dynamics influence health.

Riegel, B., Moser, D. K., Rayens, M.K., and others (2008). "Ethnic differences in quality of life in persons with heart failure." (AHRQ grant HS09822). Journal of Cardiac Failure 14(1), pp. 41-47.

Much has been written about the Hispanic paradox, which refers to the epidemiologic finding that Hispanics in the United States tend to paradoxically have significantly better health than non-Hispanic whites, despite their higher poverty rate, less education, and worse care access. The major finding of this study, supported by earlier research, was that Hispanics with heart failure improved more over time than whites or blacks after controlling for demographic, clinical, and treatment group differences. Explanations for this phenomenon such as illness chronicity, some inherent cultural strengths, or differences in language will require further research. The study compared health-related quality of life (HRQL) in 1,212 adult heart failure patients who were Hispanic (63 percent), black (19 percent), and white (18 percent). The Minnesota Living with Heart Failure Questionnaire, a 21-item disease-specific measure of HRQL available in either English or Spanish versions, was used to track HRQL at baseline and 3 and 6 months later.

Stukenborg, G.J., Wagner, D.P., Harrell, F.E., and others (2007). "Which hospitals have significantly better or worse than expected mortality rates for acute myocardial infarction patients?: Improved risk adjustment with present-at-admission diagnoses." (AHRQ grants HS10134 and HS11419). Circulation 116, pp. 2960-2968.

Reports on hospital mortality rates for heart attack patients are widely used indicators of hospital quality of care. These reports have been based on logistic regression models and related methods using existing hospital data that do not include present-at-admission diagnoses. No prior studies have examined how the availability of present-at-admission diagnoses influences risk-adjusted comparisons of hospital heart attack mortality rates. To improve the fairness of hospital comparisons based on earlier statistical models and to better identify hospitals with higher- or lower-than-expected mortality, the researchers applied patient-level risk adjustment models using present-at-admission diagnoses and three statistical methods (indirect standardization, adjusted odds ratios, and hierarchical models) to recalculate standardized mortality ratios. The study included 120,076 heart attack patients discharged from 416 California hospitals from January 1996 through November 1998. Each of the three models using present-at-admission diagnoses identified fewer hospitals as outliers than did California model A (based on the earlier methods). This large improvement in statistical performance is related to the newer models' inclusion of many more variables for comorbid disease.

Sulkowski, M.S., Mehta, S.H., Torbenson, M.S., and others (2007, October). "Rapid fibrosis progression among HIV/hepatitis C virus-co-infected adults." (AHRQ grant HS07809). AIDS 21(16), pp. 2209-2216.

Between 15 and 30 percent of HIV-infected individuals are co-infected with the hepatitis C virus (HCV). HIV co-infection is associated with more rapid progression of liver fibrosis leading to cirrhosis, with HCV-related liver disease being a leading cause of death among HIV-infected individuals. These researchers sought to determine the incidence of liver fibrosis progression among co-infected adults receiving HIV care and to test the hypothesis that HCV and HIV treatment alters the risk of liver disease. In a study population of 174 noncirrhotic patients, mostly black men being treated for HIV, there was little or no fibrosis in 136 patients (77 percent) at the time of initial liver biopsy. Followup biopsies performed at a median interval of 2.9 years revealed significant fibrosis progression in 41 patients (24 percent). HCV treatment, received by 37 patients (21 percent), was not associated with fibrosis progression and antiretroviral therapy was not associated with liver disease progression. The researchers conclude that factors other than HCV or HIV treatment alter the risk of fibrosis progression.

Wren, T.A.L., Do, K. P., Hara, R., and others (2007, October/November). "Gillette gait index as a gait analysis summary measure. Comparison with qualitative visual assessments of overall gait." (AHRQ grant HS14169). Journal of Pediatric Orthopaedics 27(7), pp. 765-768.

The Gillette Gait Index (GGI) is a summary measure incorporating 16 clinically important motion and time parameters for children with cerebral palsy. The researchers used the GGI to determine characteristics of the gait of 25 children with cerebral palsy as measured before and 1 year after corrective leg surgery. GGI scores, calculated from the large amount of data produced by modern computerized gait analysis, have been shown to correlate with other measures of gait. Since the researchers wanted to establish whether the GGI reflects observers' overall impressions of gait, they compared GGI scores with qualitative visual assessments of overall gait in individual patients. Twelve observers reviewed video recordings of 25 children with diplegic and quadriplegic cerebral palsy, who underwent multilevel lower extremity orthopaedic surgery to correct gait problems. The GGI scores were consistent with the mean scores of the observer group in 24 of 25 patients. The researchers concluded that the results support the validity of the GGI as a gait analysis summary score and suggest that GGI may be a useful outcome measure in patients undergoing gait analysis.

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AHRQ Advancing Excellence in Health Care