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Bagchi, A., Sambamoorthi, U., McSpiritt, E., and others (2004). "Use of antipsychotic medications among HIV-infected individuals with schizophrenia." (HS11825). Schizophrenia Research 71, pp. 435-444.

People who have schizophrenia typically find it difficult to consistently follow care and medication recommendations, including the complex antiretroviral therapy (ART) regimens used to control HIV infection. According to this study, people who have both HIV infection and schizophrenia who use the newer atypical antipsychotics are more likely to continue using their medications than those using the older antipsychotics, which have more serious side effects. The researchers used New Jersey HIV/AIDS surveillance data and Medicaid claims data to examine the correlates of use of antipsychotic medications among 350 HIV-infected individuals with schizophrenia. They defined medication persistence as at least 2 months of medication use in a quarter. Overall, 81 percent of those studied had at least one claim for an antipsychotic medication at some point between 1992 and 1998. Of the 282 patients using antipsychotics, 34 percent had at least one claim for an atypical antipsychotic, but fewer Latinos (17 percent) and blacks (34 percent) than whites (50 percent) had a prescription for an atypical antipsychotic. Users of atypical antipsychotics were 4.25 times as likely to persist in taking their medication as those taking only older antipsychotics.

Black, C.C., and Cummings, P. (2004, November). "Observational studies in radiology." (AHRQ grant HS11291). American Journal of Radiology 183, pp. 1203-1208.

This paper describes the commonly used observational study designs—that is, cohort and case-control studies—used in radiology research, including their strengths and limitations. The authors point out that these study designs are particularly useful in determining the influence of radiology intervention on patient outcomes, for example, the impact of mammography on breast cancer mortality. They also are useful for determining clinical risk factors for disease that aid selection of optimal imaging strategies. For instance, mechanism of injury (such as a high-speed motor vehicle crash that is a predictor of spinal fracture) can be used to select between computerized tomography and radiography to evaluate the cervical spine in trauma patients.

Calderon, J.L., Zadshir, A., and Norris, K., (2004, October). "Structure and content of chronic kidney disease information on the World Wide Web: Barriers to public understanding of a pandemic." (AHRQ grant HS10858). Nephrology News & Issues, pp. 76-84.

The World Wide Web (WWW) has little utility for informing populations at greatest risk for chronic kidney disease (CKD), according to this study. The authors assessed the technical (number of hyperlinks), content (number of six core CKD and risk factor information domains), and linguistic (readability and variation in readability) barriers for Web sites offered by 12 kidney disease associations. They concluded that having lower socioeconomic status, less access to computers and the WWW, multiple Web site hyperlinks, incomplete information, readability problems, and significant variation in readability of CKD information on the WWW are social, structural, and content barriers to communicating CKD information. This may contribute to racial/ethnic disparities in CKD health status globally.

Choi, J., Bakken, S., Larson, E., and others (2004, November). "Perceived nursing work environment of critical care nurses." (AHRQ grant HS13114). Nursing Research 53(6), pp. 370-378.

These investigators used the Perceived Nursing Work Index-(PNWE) instrument in a national survey of critical care nurses from 68 hospitals across the Nation to assess its validity in evaluating how these nurses perceive their work environment. The PNWE, with its 7 subscales and 42 items, exhibited sound psychometric properties. The subscales exhibited moderate to high reliability ranging from 0.70 to 0.91, except for one subscale. Nurses employed at magnet hospitals (those that have the ability to attract and retain nurses) had more positive perceived work environments than those employed at nonmagnet hospitals, and they showed higher mean scores in four of the seven subscales.

Chumney, E.C., Biddle, A.K., Simpson, K.N., and others (2004). "The effect of cost construction based on either DRG or ICD-9 codes or risk group stratification on the resulting cost-effectiveness ratios." (AHRQ grant HS10871). Pharmacoeconomics 22(18), pp. 1209-1216.

The researchers used data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample on hospital stays in select States to examine the implications of different disease coding mechanisms on costs and the magnitude of error that could be introduced in head-to-head comparisons of resulting cost-effectiveness ratios (CERs). The authors based their analyses on a previously published Markov model for HIV/AIDS therapies. Contrary to expectations, they found that the choice of coding/grouping assumptions that are disease-specific by either DRG codes, ICD-9 codes, or risk group resulted in very similar CER estimates for highly active antiretroviral therapy.

Dellefield, M.D. (2004, November). "Prevalence rate of pressure ulcers in California nursing homes." (AHRQ grant HS10022). Journal of Gerontological Nursing 30(11), pp. 13-21.

State surveyors under contract with the Centers for Medicare & Medicaid Services visit nursing homes about once a year to assess compliance with regulatory standards. Compliance data gathered during the visits is added to a database—the Online Survey, Certification, and Reporting (OSCAR) system—that includes factors on facility, resident, and staffing characteristics and quality of care deficiencies. Publicly reported OSCAR data are widely used by consumers and researchers to assess quality of nursing home care. This study illustrates how the OSCAR database was used to develop a risk-adjustment model for the prevalence rate of pressure ulcers, a key indicator of quality of care, in 883 California nursing homes.

Ding, L., Landon, B.E., Wilson, I.B., and others (2005, March). "Predictors and consequences of negative physician attitudes toward HIV-infected injection drug users." (AHRQ grant HS10227). Archives of Internal Medicine 165, pp. 618-623.

This study of HIV care found that negative physician attitudes toward HIV-infected injection drug users (IDUs) may lead to less than optimal care for IDUs and other marginalized populations. The researchers evaluated physicians' training, experience, and practice characteristics and examined associations between their attitudes toward HIV-infected individuals who also use injection drugs. Nationally 23.2 percent of HIV-infected patients had physicians with negative attitudes toward IDUs. Seeing more IDUs, having higher HIV treatment knowledge scores, and treating fewer patients per week were associated with more positive attitudes toward IDUs. Injection drug users who were cared for by physicians with negative attitudes were significantly less likely to receive highly active antiretroviral therapy. The researchers note that their findings that attitudes toward particular patients are associated with quality of care and that experience, knowledge, time pressures, and stress are related to attitudes may apply also to other groups of difficult to treat patients with a broad range of conditions.

Drew, B.L., Mion, L.C., Meldon, S.W., and others (2004, December). "Effect of environment and research participant characteristics on data quality." (AHRQ grant HS09725). Western Journal of Nursing Research 26(8), pp. 909-921.

Elderly people who are cognitively intact reliably report their health care use, even in a potentially challenging environment like a hospital emergency department (ED), according to this study. The researchers interviewed 612 elderly men and women visiting an ED. They then rated characteristics of the ED and compared elderly patients' self-reports of ED use and hospitalization during the previous 4 weeks with data from hospital records. Overall, 3.6 percent of the patients overreported and 2.2 percent underreported visits to the ED, and 2.6 percent overreported and 1.2 percent underreported hospitalizations. Discrepancies between self-report and hospital records were associated with male sex, cognitive deficits, and risk status, but they were not related to any of the ED environmental variables.

D'Souza-Vazirani, D., Minkovitz, C.S., and Strobino, D.M. (2005, February). "Validity of maternal report of acute health care use for children younger than 3 years." (AHRQ grant HS13053). Archives of Pediatric and Adolescent Medicine 159, pp. 167-172.

National household surveys often rely on parents' recall to assess children's use of health care services. This study found that mothers have good recall for acute health care events during the first 3 years of their children's lives. The investigators compared children's medical records with their mothers' recall of emergency department (ED) visits and hospitalizations of their children since birth and in the preceding 12 months using data on 2,937 families who participated in the Healthy Steps for Young Children national evaluation. Absolute agreement was high for hospitalizations (90 percent or higher) at both time points. It was high for ED use (greater than 90 percent) only at 2 to 4 months after a child's birth.

Dutton, G.R., Grother, K.B., Jones, G.N., and others (2004). "Use of the Beck Depression Inventory-II with African American primary care patients." (AHRQ grant HS11834). General Hospital Psychiatry 26, pp. 437-442.

The Beck Depression Inventory-II (BDI-II) is one of the most common self-report instruments used for depression screening, but it has been used on predominantly white patient populations. This study found that, similar to findings with predominantly white patients, the BDI-II is an appropriate and accurate instrument to screen for depression among black primary care patients. The study included 220 black primary care patients who completed the BDI-II and were administered a diagnostic interview to establish depressive diagnoses.

Gordon, B.D., and Asplin, B.R. (2004). "Using online analytical processing to manage emergency department operations." (AHRQ grant HS13007). Academic Emergency Medicine 11, pp. 1206-1212.

Research on emergency department (ED) crowding indicates a critical need to improve the efficiency of ED patient flow and capacity management in U.S. hospitals. Online analytical processing (OLAP) may help EDs accomplish this, according to this study. An OLAP system has the ability to provide managers, providers, and researchers with the necessary information to make decisions quickly and effectively by allowing them to examine patterns and trends in operations and patient flow. OLAP software quickly summarizes and processes data acquired from a variety of data sources, including computerized ED tracking systems. This article describes OLAP software tools and provides examples of potential OLAP applications for ED care improvement projects.

Graham, M.J., Kubose, T.K., Jordan, D., and others (2004). "Heuristic evaluation of infusion pumps: Implications for patient safety in intensive care units." (AHRQ grant HS11544). International Journal of Medical Informatics 73, pp. 771-779.

Heuristic evaluation methodology provides a simple and cost-effective approach to identifying deficiencies in medical devices that may adversely affect patients, according to this study. Four raters used a heuristic evaluation methodology to uncover physical design and user interface deficiencies of infusion pumps currently in use in intensive care units. Each expert independently generated a list of heuristic violations based on a set of 14 heuristics developed in previous research. Overall, 231 violations of the usability heuristics were considered. The primary interface location (where loading the pump, changing doses, and confirming drug settings takes place) had the most heuristic violations.

Haukoos, J.S., Lewis, R.J., and Niemann, J.T. (2004). "Prediction rules for estimating neurologic outcome following out-of-hospital cardiac arrest." (AHRQ fellowship F32 HS11509). Resuscitation 63, pp. 145-155.

These researchers developed a prediction model for neurological outcome and potentially meaningful survival (minor brain injury or no injury) following out-of-hospital cardiac arrest using variables available during resuscitation. The investigators examined data on consecutive adult cardiac arrest patients between 1994 and 2001 to assess variables ranging from site of arrest to paramedic response time. The decision rule for survival with a Glasgow Coma Score (GCS) of 13 (13 and 14 correspond to mild brain injury) incorporated whether the arrest was witnessed and the patient's age. The decision rule for survival with a GCS of 14 incorporated the initial arrest rhythm, whether the arrest was witnessed, and the patient's age. The rule for survival with a GCS of 15 incorporated only the interval between collapse and the initiation of life support.

Hellinger, F.J., and Young, G.J. (2005, February). "Health plan liability and ERISA: The expanding scope of State legislation." American Journal of Public Health 95(2), pp. 217-223.

The U.S. health care delivery system is regulated through a maze of overlapping State and Federal laws and regulations. In recent years there has been a steady stream of State legislation affecting the way in which managed care plans conduct their business. In large part, these laws have been enacted in response to the rapid growth of managed care plans and concerns about the impact these plans have on quality of care. This article examines the intent, scope, and impact of recent laws passed in 10 States that attempt to expand the legal rights of health plan enrollees to sue their plans. Reprints (AHRQ Publication No. 05-R039) are available from the AHRQ Publications Clearinghouse.

Janssen, W.J., Dhaliwal, G., Collard, H.R., and Saint, S. (2004, December). "Why 'why' matters." (AHRQ grant HS11540). New England Journal of Medicine 351(23), pp. 2429-2434.

These authors describe the puzzling case of a 38-year-old woman who arrived at the emergency department for evaluation of shortness of breath and jaundice. Her condition developed the day after she attended a wedding where she consumed Chinese dumplings containing salt-cured meat. No one else who attended the wedding became sick. A low hemoglobin level and elevated lactate dehydrogenase and bilirubin levels suggested ongoing hemolysis, which the treating physicians correctly identified. However, they did not initially identify the hemolytic process due to the patient's G6PD deficiency. They concluded that the sodium nitrite in the dumplings' salt-cured meat, which can cause brisk hemolysis in patients with G6PD, was the precipitating agent. They proceeded to shift treatment accordingly.

Jiang, H., and Zhou, X.H. (2004). "Bootstrap confidence intervals for medical costs with censored observations." (AHRQ grant HS13105). Statistics in Medicine 23, pp. 3365-3376.

In a cost-effectiveness study of treatments, the focus is often on the average of total medical costs over a certain time period in a given population. However, in analyses of medical cost data, only the mean, not the median, can be used to recover the total medical cost, which reflects the entire expenditure on health care in a given patient population. The authors of this paper propose a bootstrap confidence interval for the mean of medical costs with censored observations. In simulation studies, they show that the proposed bootstrap confidence interval had much better coverage accuracy than the normal approximation one when medical costs had a skewed distribution.

Lien, H.M., Ma, C.T., and McGuire, T.G. (2004). "Provider-client interactions and quantity of health care use." (AHRQ grant HS10803). Journal of Health Economics 23, pp. 1261-1283.

These authors consider three types of provider-client interactions that influence quantity of health care use: rationing, effort, and persuasion. Rationing refers to a quantity limit set by a provider; effort, the productive inputs supplied by a provider to increase a client's demand; and persuasion, the unproductive inputs used by a provider to induce a client's demand. The authors tested for the presence of each mechanism using data on patients receiving outpatient treatment for alcohol abuse in the Maine Addiction Treatment System. They found evidence for rationing (that providers did ration services to prevent high use by some clients) and persuasion but not for effort.

Manson, S.M., Garroutte, E., Goins, R.T., and Henderson, P.N. (2004, November). "Access, relevance, and control in the research process: Lessons from Indian country." (AHRQ grant HS10854). Journal of Aging and Health 16(5), pp. 58S-77S.

Most investigators are unprepared to address the demands of health research in American Indian (AI) communities, according to the authors of this study. Using case examples of health studies involving older AIs from three different tribes, they illustrate strategies for research on aging and health in AI communities that emphasize access, local relevance, and decisionmaking processes. They point out that local review and decisionmaking reflect the unique legal and historical factors underpinning AI sovereignty. Although specific approval procedures vary, there are common expectations across these communities that can be anticipated in conceptualizing, designing, and implementing health research among native elders.

Morimoto, T., Gandhi, T.K., Fiskio, J.M., and others (2004). "An evaluation of risk factors for adverse drug events associated with angiotensin-converting enzyme inhibitors." (AHRQ grant HS11169). Journal of Evaluation in Clinical Practice 10(4), pp. 499-509.

This study identified several factors that can help doctors recognize patients at elevated risk for adverse drug events (ADEs) because of angiotensin-converting enzyme (ACE) inhibitors. The investigators retrospectively examined ADEs among 2,225 outpatients administered ACE inhibitors at clinics affiliated with one urban hospital. In 19 percent of the total group, ACE inhibitors were discontinued because of ADEs. The researchers identified the following independent risk factors for discontinuation because of ADEs: age, female sex, ethnicity other than black or Latino, no history of previous ACE inhibitor use, history of cough caused by another ACE inhibitor, hypertension, anxiety or depression, no hemodialysis, and elevated creatinine.

Ness, R.B., Haggerty, C.L., Harger, G., and Ferrell, R. (2004). "Differential distribution of allelic variants in cytokine genes among African Americans and white Americans." (AHRQ grant HS10592). American Journal of Epidemiology 160(11), pp. 1033-1038.

Because many diseases causing premature mortality among blacks are mediated by the immune system, these investigators explored the race-specific distribution of allelic variants in cytokine genes known to stimulate inflammation. They studied women seeking prenatal care and delivering single infants in uncomplicated first births at one hospital in 1997-2001. They evaluated 179 black women and 396 white women for functionally relevant allelic variants in cytokine genes. Black women were significantly more likely to carry allelic variants known to up- regulate proinflammatory cytokines; odds ratios increased with allele dose.

Solberg, L.I., Hurley, J.S., Roberts, M.H., and others (2004). "Measuring patient safety in ambulatory care: Potential for identifying medical group drug-drug interaction rates using claims data." (AHRQ contract 290-00-0015). American Journal of Managed Care 10(11), pp. 753-759.

Potential drug-drug interaction (DDI) rates calculated from health plan data may be useful for measurement in studies of medication safety, concludes this study. The authors combined administrative and pharmacy claims data from two large health plans to calculate the rates at which users of selected medications for chronic conditions were potentially exposed to a second drug known to pose a risk of harmful interactions. They divided 44 medication combinations with risk of adverse interactions into those with DDIs of moderate/severe clinical significance and those with DDIs of mild significance. The researchers then calculated yearly rates of potential DDIs in continuously enrolled members aged 19 and older from 1998 through 2001. One or more unique potential DDIs occurred in 6.2 to 6.7 percent of base-drug users and 2 to 2.3 percent of all adult health plan members per year.

Stafford, R.S., Li, D., Davis, R.B., and Iezzoni, L.I. (2004). "Modeling the ability of risk adjusters to reduce adverse selection in managed care." (AHRQ grant HS10152). Applied Health Economics and Health Policy 3(2), pp. 107-114.

Risk adjusters are statistical measures of risk that can be applied to predict the likelihood of resource consumption or other outcomes associated with patients' various health conditions. Using insurance claims data from 184,340 health plan members, these investigators compared the performance of three risk-adjustment methods for measuring the impact of risk adjustment on the likelihood that individual members will be at risk for adverse selection. They then compared these results with resource allocation based on age and sex. The predictive ability of alternative allocation schemes increased from 1.2 percent for age-sex allocation to 11.4 percent based on risk adjustment using diagnostic cost groups. However, the impact of risk adjustment on the proportion of members at risk for adverse selection was small, suggesting a need for other strategies.

Town, R., Kane, R., Johnson, P., and Butler, M. (2005). "Economic incentives and physicians' delivery of preventive care: A systematic review." (AHRQ contract 290-02-0009). American Journal of Preventive Medicine 28(2), pp. 234-240.

These authors systematically reviewed the literature examining the impact of financial incentives on provider preventive care delivery. Six studies met inclusion criteria, which generated eight different findings. Of the eight financial interventions reviewed (all small rewards), only one led to a significantly greater provision of preventive services. The results suggest that small rewards will not motivate doctors to change their preventive care routines. However, this does not necessarily imply that other financial incentives won't motivate them to do so.

Westfall, J.M., Fernald, D.H., Staton, E.W., and others (2004, Fall). "Applied strategies for improving patient safety: A comprehensive process to improve care in rural and frontier communities."(AHRQ grant HS11878). Journal of Rural Health 20(4), pp. 355-362.

A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in rural primary care settings, according to this study. The researchers describe the efforts of one of two practice-based research networks, the High Plains Research Network (HPRN), which participated in the Applied Strategies for Improving Patient Safety (ASIPS) demonstration project. This project was designed to collect and analyze medical error reports that had been voluntarily submitted by clinicians and staff and use the reports to develop and implement interventions aimed at decreasing errors. Fourteen HPRN practices with a total of 150 clinicians and staff have participated in ASIPS, submitting 128 reports. Diagnostic tests were involved in 26 percent, medication errors in 20 percent, and communication errors in 72 percent of medical errors.

Current as of May 2005
AHRQ Publication No. 05-0082

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