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American Burn Association. (2003, September). "Outcomes measurement in pediatric burn care: An agenda for research." (AHRQ grant HS10950). Journal of Burn Care & Rehabilitation 24, pp. 269-274.
Each year, over 250,000 U.S. children are burned seriously enough to require medical attention. Relatively little is known about access to care for pediatric burn victims, the cost and cost-effectiveness of various treatment strategies on outcomes, and the impact of burn injury and medical treatment on the lives of children and their families. In response to these concerns, the American Burn Association held a national conference, "Outcomes Measurement in Pediatric Burn Care: An Agenda for Research." This paper discusses the research agenda developed at the conference, which focuses on three areas: psychosocial factors of the child and family; financing and delivery of pediatric burn care; and pediatric burn treatment and interventions.
Brown, M.D., Lau, J., Nelson, R.D., and Kline, J.A. (2003, November). "Turbidimetric D-dimer test in the diagnosis of pulmonary embolism: A metaanalysis." (AHRQ grant HS13328). Clinical Chemistry 49, pp. 1846-1853.
These investigators conducted a meta-analysis of nine studies on use of the D-dimer test using latex turbidimetric methods in the diagnosis of pulmonary embolism (PE) in adult emergency department (ED) patients with suspected PE. Combining the studies yielded an overall sensitivity of 0.93 and an overall specificity of 0.51. Thus, the turbidimetric D-dimer test is sensitive but nonspecific for the detection of PE in the ED setting. D-Dimer tests using latex turbidimetric methods appear to have test characteristics comparable to those of ELISA methods.
Califf, R.M. (2004, January). "Defining the balance of risk and benefit in the era of genomics and proteomics." (AHRQ grant HS10548). Health Affairs 23(1), pp. 77-87.
The ability to measure the function of genes (genomics) and proteins (proteomics) has spawned the construct of personalized medicine in which patients' own risks and preferences are used to choose diagnostic and therapeutic strategies. However, the complexity of clinical data required to guide personalized medicine calls for improvements in the system of clinical research, according to this paper. The author outlines three areas that need improvement: overhauling the system to produce networks that can do adequate-size pragmatic trials; synchronization of regulatory and payment systems to encourage adequate studies; and an investment in educating providers and patients to improve their understanding of the probabilistic predictions forming the basis of personalized medicine.
Centor, R.M., Allison, J.J., Weissman, N.W., and others (2003). "Diffusion of troponin testing in unstable angina patients: Adoption prior to guideline release." (AHRQ grant HS08843). Journal of Clinical Epidemiology 56, pp. 1236-1243.
The American College of Cardiology/American Heart Association released guidelines in 2000 recommending measurement of troponin (a biomarker for cardiac ischemia) in all patients with acute coronary syndromes such as angina. These authors identified unstable angina admissions from Medicare files for 22 Alabama hospitals for two time periods: March 1997-February 1998 and January 1999-December 1999. In the earlier period, 21 percent of unstable angina patients had troponin measured compared with 70 percent in the later period. Patients with abnormal troponin levels more often received angiotensin-converting enzyme inhibitors, cardiac catheterization, and percutaneous coronary intervention. These findings suggest that sometimes guidelines codify currently accepted practice and do not always disseminate new knowledge.
Col, N.F., and Pauker, S.G. (2003, December). "The discrepancy between observational studies and randomized trials of menopausal hormone therapy: Did expectations shape experience?" (AHRQ grant HS13329). Annals of Internal Medicine 139, pp. 923-929.
Unlike the randomized Women's Health Initiative (WHI) trial that showed no benefit of menopausal hormone therapy (HR) on coronary heart disease (CHD), observational studies like the Nurses' Health Study (NHS) found it to be protective. These differences have been attributed to the fact that women who choose to use HT tend to be healthier than those who do not. However, reporting biases of physicians and women who believe that HT reduces CHD risks (described in this paper) may have affected the ascertainment of CHD outcomes in observational studies. Combining these reporting biases with socioeconomic differences between users and nonusers could explain discrepancies between the observational and WHI trials.
Cook, A.F., Hoas, H., and Guttmannova, K. (2003). "Project seeks to assess and aid patient safety in rural areas." (AHRQ grant HS11930). Biomedical Instruments, pp. 128-130.
Without attention to the human/technology interface, even well-intentioned interventions may be resisted or used inappropriately, note the authors of this commentary. They make these claims based on data stemming from nine studies conducted in rural communities in a 14-State area, as well as data from an ongoing patient safety research project. The studies suggest that the ability to recognize and respond to potentially unsafe situations may be compromised by factors that technology alone cannot solve, including staffing patterns, problems in workplace communication, and overall lack of resources and training.
Corser, W.D. (2004). "Postdischarge outcome rates influenced by comorbidity and interdisciplinary collaboration." (AHRQ grant HS10792). Outcomes Management 8(1), pp. 45-51.
The way in which health care professionals engage in discharge planning collaboration (DPC) may indeed influence the rates of some patient outcomes after hospital discharge, suggests this study. The investigators examined the relationship between health care professionals' ratings of their DPC and other patient characteristics with rates of postdischarge outcomes experienced by a sample of elderly veterans. The significant influence of interdisciplinary discharge planning collaboration was demonstrated by fewer emergency room visits and postdischarge falls by elderly veterans.
Cosby, K.S. (2003, December). "A framework for classifying factors that contribute to error in the emergency department." (AHRQ grant HS11552). Annals of Emergency Medicine 42, pp. 815-823.
This author provides a framework for classifying factors that contribute to error in the emergency department (ED). In its most basic form, the framework is a comprehensive checklist of all the sources of error uncovered in the course of investigating hundreds of cases referred to one hospital's emergency medicine quality assurance committee over the past decade. The author begins with a look at error in the ED and then moves ahead to examine error in the context of the wider health care system. The framework incorporates ideas from safety engineering, transportation safety, human factors engineering, and the author's own experiences in the ED of an urban, public, teaching hospital.
Eitel, D.R., Travers, D.A., Rosenau, A.M., and others (2003, October). "The emergency severity index triage algorithm version 2 is reliable and valid." (AHRQ grant HS10381). Academic Emergency Medicine 10(10), pp. 1070-1080.
Emergency department (ED) triage separates patients into urgency categories to prioritize patients for evaluation and treatment. A new approach to ED triage, the Emergency Severity Index (ESI) asks not only, "Who should be seen first?" but also, "What does this patient need to reach a disposition?" The ESI is used to rate patients on arrival to the ED and ranges from level 1 (most sick) to level 5 (least resource-intensive). After pilot implementation and validation, the ESI was revised to include pediatric and updated vital signs criteria. These authors assessed ESI version 2 reliability and validity at seven EDs in three States. The ESI version 2 produced reliable, valid stratification of patients across seven EDs.
Glasgow, R.E., Davis, C.L., Funnell, M.M., and Beck, A. (2003, November). "Implementing practical interventions to support chronic illness self-management." (AHRQ grant HS10123). Joint Commission Journal on Quality and Safety 29(11), pp. 563-574.
Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. These authors outline a model of SMS applicable across different chronic illnesses and health care systems. They also present recommendations for assisting health care professionals and practice teams to make changes, and they provide tips and lessons learned. The authors note that successful SMS programs involve changes at multiple levels: patient-clinician interactions; office environment changes; and health system, policy, and environmental supports.
Murray, M.E., and Darmody, J.V. (2004). "Clinical and fiscal outcomes of utilization review." (AHRQ grant HS10667). Outcomes Management 8(1), pp. 19-25.
U.S. health care expenditures are expected to rise to over $3 trillion by 2012, putting pressure on health care providers to cut costs. Concurrent utilization review (UR) is both a quality improvement tool and a cost-containment strategy used by managed care organizations. The UR process requires that hospital staff communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers than make a decision whether to certify the care for reimbursement. This study provides data which suggest that denials of certification have little impact on clinical and fiscal outcomes of patient care.
Needleman, J., Buerhaus, P.I., Mattke, S., and others (2003, December). "Measuring hospital quality: Can Medicare data substitute for all-payer data?" (AHRQ grant HS09958). Health Services Research 38 (6, Part I), pp. 1487-1508.
The goal of this study was to assess whether adverse outcomes in Medicare patients can be used as a surrogate for measures from all patients in quality-of-care research using administrative datasets. The researchers used patient discharge abstracts from State data systems for 799 hospitals in 11 States, national MedPar discharge data for Medicare patients from 3,357 hospitals, State hospital staffing surveys or financial reports, and 1997-1998 data from the American Hospital Association Annual Survey. They calculated rates for 10 adverse patient outcomes, examined the correlation between all-patient and Medicare rates, and examined other variables to compare results using all-patient and Medicare patient data. They conclude that analyses of quality of care for medical patients using Medicare-only and all-patient data are likely to have similar findings.
Okada, P.J., Young, K.D., Baren, J.M., and others (2003, October). "Neurologic outcome score for infants and children." (AHRQ grant F32 HS00091). Academic Emergency Medicine 10(10), pp. 1034-1039.
Many approaches for improving the neurologic outcomes of children after brain injury are under investigation, including accurate triage to specialized centers, medical and surgical therapies, and rehabilitation. However, the efficacy of interventions cannot be evaluated unless neurologic outcome can be reliably measured. These investigators developed and tested a measure of neurologic outcome–the Neurologic Outcome Scale for Infants and Children (NOSIC)—in 100 children of varying ages with a wide range of levels of neurologic function. Results showed that the NOSIC is a practical, reliable, valid, instrument applicable to infants and children with a broad range of neurologic deficits.
Phillips, R.L., Phillips, K.A., Chen, F.M., and Melillo, A. (2003). "Exploring residency match violations in family practice." Family Medicine 35(10), pp. 717-720.
The National Resident Matching Program (NRMP) is a venue for matching residency applicants' and programs' preferences for each other in a consistent way and with a uniform timetable. The study investigators asked 15 student applicants to family practice residency programs in 2002 whether they experienced NRMP violations and how they were affected by perceived violations. Only six of the
students believed that they had experienced a violation. Only two students had experienced an actual Match guideline violation, and two more experienced potential violations. However, there was substantial confusion about what constituted a violation. There are opportunities to investigate violations and to train students to recognize and deal with violations, conclude the authors.
Reprints (AHRQ Publication No. 04-R024) are available from the AHRQ Publications Clearinghouse.
Saint, S., Hofer, T.P., Rose, J.S., and others (2003, November). "Use of critical pathways to improve efficiency: A cautionary tale." (AHRQ grant HS11540). American Journal of Managed Care 9, pp. 758-765.
Critical pathways are care strategies that specify patient goals and the sequence and timing of actions necessary to achieve these goals with optimal efficiency. More than 80 percent of U.S. hospitals use critical pathways for at least some of their patients. These researchers identified all critical pathways initiated in their medical center between 1993 and 1996 in which at least 50 adult patients would be evaluated in the year preceding and succeeding pathway implementation. The goal was to assess whether critical pathways successfully reduced length of hospital stay and resource use. Although some pathways did reduce length of stay, resource use, or both, most pathways reduced neither.
Sayre, M.R., White, L.J., Brown, L.H., and others (2003, October). "National EMS research agenda: Proceedings of the implementation symposium." (AHRQ grant HS12086). Academic Emergency Medicine 10(10), pp. 1100-1108.
This paper summarizes the proceedings of a two-day symposium to discuss implementation of the National Emergency Medical Services (EMS) research agenda for improving the conduct of EMS research in the United States. The participants suggested improving training opportunities for EMS researchers, stimulating increases in available funding resources, facilitating the integration of research into practice, and crafting alterations within the regulatory environment. They felt that EMS must be more broadly integrated into the public health continuum. Finally they asked Federal agencies, States, local governments, charitable foundations, and corporations to increase opportunities for participation in EMS research programs.
Singh-Manoux, A., Richards, M., and Marmot, M. (2003). "Leisure activities and cognitive function in middle age: Evidence from the Whitehall II study." (AHRQ grant HS06516). Journal of Epidemiology and Community Health 57, pp. 907-913.
Adults who engage in leisure activity entailing high cognitive effort or social interaction are more likely to have better cognitive ability, according to this large study of British civil servants aged 35-55 years. This suggests that seeking mental stimulation may have a beneficial effect on cognition in middle age, note the study authors. They examined data from the fifth data wave of the Whitehall II study of British civil servants and studied the effects of each leisure activity—adjusted for age and socioeconomic status—on cognition. They then examined the effects of two categories of leisure activities: those entailing high or low cognitive effort and social or individual activities.
Watson, N.M., Brink, C.A., Zimmer, J.G., and Mayer, R.D. (2003). "Use of the Agency for Health Care Policy and Research urinary incontinence guideline in nursing homes." (AHRQ grant HS08491). Journal of the American Geriatrics Society 51, pp. 1779-1786.
This study examined use of the AHRQ guideline on urinary incontinence (UI) in 52 nursing homes in upstate New York. Results suggest that assessment and treatment of UI is manageable (a total of 4.2 cases per 100 beds per 12 weeks), but quality of care is not adequate. On average, only 20 percent of the applicable clinical practice standards were met, due primarily to lack of awareness of new UI in patients and lack of familiarity with the guideline. For example, 81 percent of patients had a reversible cause of UI at the time of onset, but only 34 percent had all related problems addressed.
Zhou, X-H., and Castelluccio, P. (2004). "Adjusting for non-ignorable verification bias in clinical studies for Alzheimer's disease." (AHRQ grant HS08559). Statistics in Medicine 23, pp. 221-230.
A common problem for comparing the relative accuracy of two screening tests for Alzheimer's disease (AD) in a two-stage design study is verification bias. If the verification bias can be assumed to be ignorable, some have proposed a maximum likelihood approach to compare the relative accuracy of screening tests in a two-stage design study. However, if the verification mechanism also depends on the unobserved disease status, the ignorable assumption does not hold. In this paper, the authors discuss how to use a profile likelihood approach to compare the relative accuracy of two screening tests for AD without assuming the ignorable verification bias mechanisms.
Current as of March 2004
AHRQ Publication No. 04-0038