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Adams, J.R., Eltin, L.S., Lyman, G.H., and others (2004, January). "Use of erythropoietin in cancer patients: Assessment of oncologists' practice patterns in the United States and other countries." (AHRQ grant HS10370). American Journal of Medicine 116, pp. 28-34.
Erythropoietin, a hormone that acts on bone marrow stem cells to stimulate red blood cell production, improves hemoglobin levels and reduces transfusion requirements among patients who become anemic due to cancer or its treatment. The goal of this study was to assess physician use of erythropoietin in the United States and in 19 other countries. Questionnaires about erythropoietin use in practice with cancer patients were mailed to 2,000 oncologists/hematologists. Response rates were 30 percent in the United States and 25 percent internationally. Frequent erythropoietin use (defined as at least 10 percent of cancer patients) was higher in the United States than elsewhere. Among U.S. physicians, those who said they used erythropoietin frequently were more likely to be in fee-for-service than managed care settings. Those who reported never using it practiced in countries that had lower annual per capita health care expenditures, lower proportions of privately funded health care, and a national health service. Financial considerations and a hemoglobin level lower than 10 g/dL appear to influence erythropoietin use in the United States, whereas financial considerations alone determined its use abroad.
Arcury, T.A., Preisser, J.S., Gesler, W.M., and Sherman, J.E. (2003). "Complementary and alternative medicine use among rural residents in western North Carolina." (AHRQ grant HS09624). Complementary Health Practice Review 8, pp. 1-10.
These authors examine the use of complementary and alternative medicine (CAM) by adults living in rural Appalachian North Carolina based on a survey of 1,059 adults residing in 12 counties in the area. The most widely used CAM is "home remedies," with 46 percent of those surveyed using a home remedy, and 26 percent using the home remedy, "honey-lemon-vinegar-whisky." Herbs, teas, and traditional remedies are also used. The use of specific home remedies is associated with age, sex, and education. Chiropractors are the only widely used alternative therapists, with an estimated 7 percent using them. Traditional remedies are used most often for infections or allergies. Respiratory, throat, and mouth conditions, as well as general well-being are most often treated with home remedies.
Bravata, D.M., McDonald, K.M., Szeto, H., and others (2004, March). "A conceptual framework for evaluating information technologies and decision support systems for bioterrorism preparedness and response." (AHRQ contract 290-97-0013). Medical Decision Making 24, pp. 192-206.
These authors sought to develop a conceptual framework for evaluating whether existing information technologies and decision support systems (IT/DSSs) would assist decisionmaking by clinicians and public health officials preparing for and responding to bioterrorism. They reviewed reports of natural and bioterrorism-related infectious outbreaks, bioterrorism preparedness exercises, and advice from experts to identify key decisions (they identified eight), tasks, and information needs of clinicians and public health officials while responding to bioterrorism. When evaluating 217 currently available IT/DSSs that could potentially support bioterrorism-related decisions, the authors found little evidence on the accuracy of IT/DSSs.
Day, F.C., Schriger, D.L., and La, M. (2004, March). "Automated linking of free-text complaints to reason-for-visit categories and International Classification of Diseases diagnoses in emergency department patient record databases." (AHRQ fellowship F32 HS00141). Annals of Emergency Medicine 43(3), pp. 401-409.
Current methods for assigning a standardized reason-for-visit category to an emergency department (ED) visit, such as those using International Classification of Diseases, Ninth Edition (ICD-9) codes, are generally not usable until after the visit has been completed and coded. This makes identification of symptom patterns and real-time intervention impossible. This study addressed whether information captured earlier in the ED visit, such as the plain-text chief complaint, could be processed quickly to assign a reason-for-visit category. The researchers developed a text-parsing algorithm that assigned 77 percent of all complaints from one dataset and 67 percent from a second dataset to 1 of 20 standardized reason-for-visit categories. On review, the automated assignments were reasonably reliable.
Forrest, C.B., Riley, A.W., Vivier, P.M., and others, "Predictors of children's healthcare use: The value of child versus parental perspectives on health care needs;" Riley, A.W., Forrest, C.B., Starfield, B., and others, "The parent report form of the CHIP-Child Edition: Reliability and validity;" and Riley, A.W., Forrest, C.B., Rebok, G.W., and others, "The child report form of the CHIP-Child Edition: Reliability and validity." (2004, March). (AHRQ grant HS00003). Medical Care 42(3), pp. 232-238, 210-220, and 221-231.
The first study examined the relationship between health care use and children's health care needs as assessed from the perspectives of children themselves and their parents (based on the child and parent report forms of the CHIP-Child Edition, CE), and health care practitioners. The investigators studied 384 parents and their children aged 6 to 11 years enrolled in a California health maintenance organization or a Medicaid managed care program in Rhode Island. For both child- and parent responders, low satisfaction and comfort scale scores from the CHIP-CE were significant predictors of number of physician visits. CHIP-CE information collected from children explained more variation in total physician visits than models using parent-respondent data, and it was a better predictor of children's care use than needs as assessed by physician-diagnosed disorders. The second and third studies confirm the reliability and validity of the parent report form and child report form of the CHIP-CE, respectively.
Gardiner, J.C., Sirbu, C.M., and Rahbar, M.H. (2004). "Update on statistical power and sample size assessments for cost-effectiveness studies." (AHRQ grant HS09514). Expert Review of Pharmacoeconomics Outcomes Research 4(1), pp. 89-98.
With rising health care costs and constrained budgets, economic evaluation studies are increasingly being performed to ascertain which medical interventions can deliver additional health benefits at a reasonable cost. The design of a cost-effectiveness study for two competing treatments requires assessments of statistical power and sample size in demonstrating both effectiveness and/or cost-effectiveness. This article reviews some statistical approaches to formulating tests of hypotheses on the cost-effectiveness ratio or net health cost and assessing power and sample size for cost-effectiveness studies.
Guller, U., and DeLong, E.R. (2004, March). "Interpreting statistics in medical literature: A vade mecum for surgeons." (AHRQ grant HS09940). Journal of the American College of Surgeons 198(3), pp. 441-458.
Current trends toward evidence-based medicine can only flourish in a culture of statistical literacy. Unfortunately, there is ample evidence that many physicians are ill prepared to accurately interpret statistical computations in medical literature. Furthermore, a significant association between the number of years out of medical training and loss of statistical knowledge has been reported. This article provides a series of nontechnical explanations of basic statistical operations in medicine, coupled with intuitive examples drawn from the field of surgery. The goal is to facilitate the surgeon's critical appraisal of medical literature and its implementation in clinical practice.
Haley, S.M., Andres, P.L., Coster, W.J., and others, "Short-form activity measure for post-acute care;" and Haley, S.M., Coster, W.J., Andres, P.L., and others, "Score comparability of short forms and computerized adaptive testing: Simulation study with the activity measure for post-acute care." (2004, April). (cofunded by AHRQ and others). Archives of Physical Medicine and Rehabilitation 85, pp. 649-660, 661-666.
As patients recover from illness or injury, a system is needed to assess their functional skills throughout the continuum of postacute care services. The first paper describes the development of a set of short forms, the short-form Activity Measure for Post-Acute Care (AM-PAC), that measure activity in order to monitor functional recovery. The AM-PAC measures three types of activity: physical and movement, applied cognition, and personal care and instrumental activities such as shopping. The second study compares the simulated short-form and computerized adaptive testing (CAT) scores with scores obtained from complete item sets for each of the three activity domains of AM-PAC in 485 adult volunteers who were receiving skilled rehabilitation services in six postacute health care networks in the Boston area. Results showed that accurate scoring estimates for AM-PAC domains can be obtained with either the setting-specific short forms or the CATs. The CAT may have additional advantages over short forms in practicality, efficiency, and the potential for providing more precise scoring estimates for individuals.
Kennedy, M.J., Scripture, C.D., Kashuba, A.D., and others (2004, March). "Activities of cytochrome P450 1A2, N-acetyltransferase 2, xanthine oxidase, and cytochrome P450 2D6 are unaltered in children with cystic fibrosis."(AHRQ grant HS10397). Clinical Pharmacology & Therapeutics 75, pp. 163-171.
Patients with cystic fibrosis (CF) tend to clear drugs more quickly from their body than others, which necessitates higher doses to achieve a level of medication exposure equal to that observed in healthy individuals. This study examined the activities of several enzymes: hepatic cytochrome P450(CYP) 1A2, N-acetyltransferase 2 (NAT-2), xanthine oxidase (XO), and CYP2D6 in 12 young children with mild CF and 12 age-matched healthy controls to determine if CF altered their metabolism. The researchers used standard caffeine and dextromethorphan phenotyping methods and collected urine for 8 hours to assess enzyme activity. There were no significant differences in the urinary molar ratios for any of the enzyme systems evaluated. These data suggest that CF does not alter the activities of CYP1A2, NAT-2, XO, and CYP2D6. The researchers conclude that altered biotransformation of drugs among children with CF is likely enzyme- and isoform-specific and thus is apparent for only selected compounds that are substrates for enzymes other than those evaluated in this study.
Lautenbach, E., Strom, B.L., Nachamkin, I., and others (2004, March). "Longitudinal trends in fluoroquinolone resistance among enterobacteriaceae isolates from inpatients and outpatients, 1989-2000: Differences in the emergence and epidemiology of resistance across organisms." (AHRQ grant HS10399). Clinical Infectious Diseases 38, pp. 655-662.
These investigators conducted a 12-year study to identify and compare trends in annual prevalence of enterobacteria resistance to the fluoroquinolone (FQ) class of antibiotics among inpatients and outpatients in a health care system. A total of 46,070 clinical Enterobacteriaceae isolates underwent antibiotic susceptibility testing. Although hospital-wide use of certain antibiotics correlated significantly with inpatient FQ resistance, these correlations differed substantially across types of bacteria. Efforts to elucidate the epidemiology of FQ resistance and identify targets for intervention must recognize and account for the variability of FQ resistance across organisms and clinical settings.
Lawrence, W.F., and Fleishman, J.A. (2004, March). "Predicting EuroQoL EQ-5D preference scores from the SF-12 health survey in a nationally representative sample." Medical Decision Making 24, pp. 160-169.
Several utility indexes have been developed, that is, systems for classifying patient preferences for certain health states, including the EuroQoL EQ-5D. The authors of this study used data from the 2000 Medical Expenditure Panel Survey to predict EQ-5D preference scores from the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the SF-12 health status questionnaire. The two-variable model predicted 61 percent of the variance in EQ-5D scores and provided reasonable ability to predict mean EQ-5D scores from mean PCS and MCS scores. This model allows researchers to estimate utility data for use in decision and cost-utility analyses.
Reprints (AHRQ Publication No. 04-R040) are available from the AHRQ Publications Clearinghouse.
McDonald, C.J., Overhage, M., Mamlin, B.W., and others (2004, March). "Physicians, information technology, and health care systems: A journey, not a destination." (AHRQ grant HS11889). Journal of the American Medical Informatics Association 11(2), pp. 121-124.
These authors, who developed the first PC-based computerized physician order entry (CPOE) system, discuss the benefits and limitations of CPOE. For example, CPOE eliminates illegible orders and provides opportunities for better ordering, but computer systems also introduce errors of their own. A slip of the mouse on a computer menu can lead to an order for the right medication for the wrong patient. Another issue is decision support overload. Too many nonspecific and repetitive reminders are the moral equivalent of E-mail "spam," perhaps warranting strict constraints on what reminder rules are adopted. CPOE systems also can have large and important benefits on institutional efficiency and costs, for example, by advising doctors about the least costly medication and by helping avoid unnecessary repeat testing.
Mikuls, T.R., MacLean, C.H., Olivieri, J., and others (2004, March). "Quality of care indicators for gout management." (AHRQ grant HS10389). Arthritis & Rheumatism 50(3), pp. 937-943.
Preliminary evidence suggests that medical errors in the treatment of gout are common, and there is no consensus on management standards. To guide physician practice, these authors developed 11 preliminary quality of care indicators for gout management based on a review of studies on gout therapy. They refined the indicators using a panel of community and academic rheumatologists, who added a 12th indicator. A second expert panel rated 10 of the quality indicators as valid. These pertained to the use of urate-lowering medications in chronic gout, the use of antiinflammatory drugs, and counseling on lifestyle modifications. These 10 indicators are an important initial step in quality improvement initiatives for gout care.
Patwardhan, M.B., McCrory, D.C., Matchar, D.B., and others (2004, April). "Alzheimer disease: Operating characteristics of PET—A meta-analysis." (AHRQ Contract No. 290-97-0014). Radiology 231, pp. 73-80.
Although not currently recommended in the routine evaluation of dementia, functional neuroimaging tests such as positron emission tomography (PET) and single photon emission computerized tomography (SPECT) have been proposed for the evaluation of individuals who may have Alzheimer disease. These researchers performed a meta-analysis of studies on use of PET using fluorine 18 fluorodeoxyglucose (FDG) to assess its sensitivity and specificity. The 15 studies that met inclusion criteria showed heterogeneity in sensitivity and specificity estimates. The summary sensitivity of FDH PET was 86 percent, and the summary specificity was 86 percent, but these were limited by both study design and patient characteristics. Therefore, the clinical value of these parameters is uncertain, and more research is needed.
Rosenthal, M.B., Fernandopulle, R., Song, H.R., and Landon, B. (2004, March). "Paying for quality: Providers' incentives for quality improvement." (AHRQ grant HS10803). Health Affairs 23(2), pp. 127-141.
Delivering high-quality care in the current U.S. health care system does not always pay. For example, an effective chronic care management program may lead to lower revenue for providers, since quality improvement (QI) activities are not billable, and acute care visits are reduced as a result. However, a growing number of health plans and other purchasers have implemented pay-for-performance systems to reward providers for delivering high-quality care and to motivate quality improvement. This article describes the prevalence and structure of these initiatives as they are now being adopted in the U.S. health care system.
Stryer, D.B., Siegel, J.E., and Rodgers, A.B. (2004, April). "Outcomes research: Priorities for an evolving field." Medical Care 42(4S), pp. III-1-III-5.
This article outlines priorities for the evolving field of outcomes research as developed at a workshop that was held June 10-11, 2002. The goal was to identify priorities that will support health professionals and administrators in the practical decisions that confront them. Priorities range from addressing the needs of priority populations such as the disabled and elderly and research and resources to support emerging strategies in health care delivery, to partnering effectively with patients to achieve the best care at the best value. The authors point out that users of outcomes research demand information across the range of factors that must be considered in decisionmaking. These include whether an effort will work in a particular health care system with its unique set of characteristics, what its impact will be on patients as well as on the organization, and how it can be implemented. The ultimate goal is to improve the effectiveness and efficiency of health care services to patients.
Reprints (AHRQ Publication No. 04-R045) are available from the AHRQ Publications Clearinghouse.
Tanabe, P., Gimbel, R., Yarnold, P.R., and Adams, J.G. (2004, February). "The emergency severity index (version 3) 5-level triage system scores predict ED resource consumption." (AHRQ training grant T32 HS00078). Journal of Emergency Nursing 30(1), pp. 22-29.
U.S. emergency departments (EDs) typically have used 3-level triage systems. However, nurses frequently do not agree on the triage acuity level of the same patient. The Emergency Severity Index (ESI) version 3 is a valid and reliable 5-level triage instrument that is gaining in popularity. A unique component of the ESI algorithm is prediction of resource consumption. This study retrospectively studied 403 ED patients at a large medical center to validate the ESI version 3 triage algorithm in a clinical setting for actual resource consumption and patient length of stay in the ED and hospital. The ESI algorithm accurately predicted ED resource intensity and gives administrators the opportunity to benchmark ED length of stay according to triage acuity level.
Current as of June 2004
AHRQ Publication No. 04-0062