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Amthauer, H., Gaglio, B., Glasgow, R.E., and others (2003, July). "Lessons learned: Patient strategies for a type 2 diabetes intervention in a primary care setting." (AHRQ grant HS10123). Diabetes Educator 29(4), pp. 673-681.
Recruitment of patients and physicians willing to participate in clinical trials continues to be a challenge. These authors report on the methods and strategies they used to increase participation in the Diabetes Priority Program to enhance diabetes self-management and care practices. A mailing recruitment process resulted in a participation rate of 83 percent among patients who were contacted and eligible. In contrast, only 3 percent of primary care physicians took part in the program despite efforts to make the program brief, nonintrusive, and compatible with usual care.
Baughman, K., Logue, E., Sutton, K., and others (2003). "Biopsychosocial characteristics of overweight and obese primary care patients: Do psychosocial and behavior factors mediate sociodemographic effects?" (AHRQ grant HS08803). Preventive Medicine 37, pp. 129-137.
These authors used available baseline data on 665 overweight or obese primary care patients from an ongoing obesity intervention trial to examine whether psychosocial and behavioral factors mediate the relationships between sociodemographic factors and body mass index (BMI). Lower educational attainment was associated with a higher BMI after controlling for decisional balance, social support, self-efficacy, energy intake, and energy expenditure. In contrast, ethnicity was not associated with BMI after controlling for psychosocial and behavioral factors. However, the researchers did not find several expected relationships between psychosocial variables and behavior or BMI. They conclude that cross-sectional relationships between demographic, psychosocial, or behavioral variables and BMI appear to be complex. They call for more research so that better management strategies can be developed.
Bennett, S.J., Oldridge, N.B., Eckert, G.J., and others (2003, July). "Comparison of quality of life measures in heart failure." (AHRQ grant HS09822). Nursing Research 52(4), pp. 207-216.
This study compared the ability of three quality of life measures to detect clinically important changes in heart failure patients over time. The investigators used the Chronic Heart Failure Questionnaire (CHQ), the Minnesota Living with Heart Failure Questionnaire (LHFQ), and the General Health Survey Short-form-12 (SF-12) during interviews with 211 patients with heart failure at baseline and at 4, 8, and 26 weeks after baseline (which 165 patients completed). Overall, patients reported low-to-moderate health-related quality of life. While all three instruments were reliable and valid, the CHQ and LHFQ were more sensitive than the SF-12 in detecting clinically important changes over time.
Carter, R., Holiday, D.B., Stocks, J., and others (2003, August). "Predicting oxygen uptake for men and women with moderate to severe chronic obstructive pulmonary disease." (AHRQ grant HS08774). Archives of Physical Medicine and Rehabilitation 84, pp. 1158-1164.
These authors developed regression equations for estimating peak oxygen consumption (Vo2) for men and women with moderate to severe chronic obstructive pulmonary disease (COPD) from the 6-minute walk test (6MWT). Knowledge of the peak Vo2 can be used for patient assessment, serial monitoring, evaluating disability, and as a common index of function. The investigators completed pulmonary function testing, cycle ergometry with gas exchange, and the 6MWT with 124 patients with moderate to very severe COPD. Of these tests, 6MWT was the strongest independent predictor of peak Vo2. They then used generalized regression modeling to develop equations for the estimation of peak Vo2 for the 6MWT. The resulting model accounted for 79 percent of the variance for estimation of peak V02 in the patients studied.
Casillas, J.N., Woods, W.G., Hunger, S.P., and others (2003, August). "Prognostic implications of t(10;11) translocations in childhood acute myelogenous leukemia: A report from the children's cancer group." (AHRQ National Research Service Award training grant T32 HS00020). Journal of Pediatric Hematology/Oncology 25(8), pp. 594-600.
This study identified 11 children out of 470 children newly diagnosed with acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS), whose blasts carried t(10;11) reciprocal translocations or other complex rearrangements involving chromosomes 10p and 11q. Nine of these patients relapsed within 12 months, an 82 percent relapse rate. This was higher than the 46 percent relapse rate of other AML children studied and higher than children with AML with other 11q23 chromosomal abnormalities. However, survival and event-free survival at 6 years was not different from other children with AML studied. Further research is needed to determine the changes occurring at the molecular level for patients with t(10;11) translocations and other rearrangements of chromosomes 10 and 11 to gain insight into the mechanisms causing this clinical phenotype, which is associated with such a poor prognosis.
Collard, H.R., Gruber, M.P., Weinberger, S.E., (2003, September). "Anatomy of a diagnosis." (AHRQ grant HS11540). New England Journal of Medicine 349, pp. 987-992.
In this article, a clinician presents the step-by-step diagnosis of a 33-year-old man who was initially seen for coughing up a tablespoon of bright red blood (hemoptysis). The eventual diagnosis underscores the importance of paying close attention to a patient's history, in this case a childhood heart surgery. Initial physical examination and complete blood count were normal, but the chest x-ray was suggestive of possible pneumonia. The patient was put on antibiotics but 5 weeks later spit up a full cup of blood. Following a series of tests, he was given a high dose of corticosteroids, frequently used as a nonspecific treatment for many forms of diffuse alveolar hemorrhage, and discharged home. He was readmitted to the hospital 2 weeks later, after he coughed up two large cups of bright red blood. Magnetic resonance angiography of the aorta, site of a childhood surgical repair, revealed a pseudoaneurysm. Emergency surgery was performed to repair the aneurism and to repair an aortobronchial fistula, which solved the problem.
Cress, R.D., Zaslavsky, A.M., West, D.W., and others (2003). "Completeness of information on adjuvant therapies for colorectal cancer in population-based cancer registries." (AHRQ grant HS09869). Medical Care 41(9), pp. 1006-1012.
Population-based cancer registries represent a potentially valuable tool to evaluate treatment. However, completeness of treatment data in these registries varies by patient and hospital characteristics. Thus, use of registry data without supplementation could bias estimates of the proportion of patients treated and of the patient and provider characteristics associated with treatment, concludes this study. The investigators surveyed physicians or reviewed office records of 1,956 northern California patients diagnosed with colorectal cancer during 1996 and 1997 regarding use of adjuvant chemotherapy and radiation therapy. Receipt of chemotherapy and radiation therapy was in the original registry records for only 82 percent and 90 percent of patients, respectively. Completeness of therapy reporting in the registry varied by patient and hospital characteristics.
Gardiner, J.C., Bradley, C.J., Polverejan, E., and others (2003). "Longitudinal assessment of cost in health care interventions." (AHRQ grant HS09514). Health Services & Outcomes Research Methodology 3, pp. 149-168.
Identifying important determinants of cost and health outcomes is a critical step in the economic evaluation of health care interventions. These authors developed a method to estimate the cumulative cost of health interventions over a specified duration, while controlling for a mix of patient-specific variables using data on total cost and associated length of treatment. They estimated a two-equation model for total cost and duration of treatment and applied their method to hospital costs and length of stay of patients undergoing cardiac procedures. In this case, the method accounted for the differential impact of treatment duration on total cost.
Gill, C.J., Lau, J., Gorbach, S.L., and Hamer, D.H. (2003, August). "Diagnostic accuracy of stool assays for inflammatory bacterial gastroenteritis in developed and resource-poor countries." (AHRQ National Research Service Award training grant T32 HS00060). Clinical Infectious Diseases 37, pp. 365-375.
Because acute bacterial gastroenteritis, a common cause of severe diarrhea, is often inflammatory, rapid stool assays that detect intestinal inflammation can be used to distinguish patients with bacterial (versus viral, parasitic, or toxin-caused) gastroenteritis who are more likely to benefit from antibiotic therapy. The researchers performed a meta-analysis of studies of rapid stool assays that test for lactoferrin, fecal leukocytes, fecal erythrocytes, and occult blood in developed and resource-poor countries. In developing countries, rapid stool assays performed poorly, whereas in developed countries, tests for fecal leukocytes, lactoferrin, and occult blood were moderately useful and could identify patients who were more likely to benefit from antibiotic therapy.
Insinga, R.P. Dasbach, E.J., and Myers, E.R. (2003, June). "The health and economic burden of genital warts in a set of private health plans in the United States." (AHRQ National Research Service Award training grant T32 HS00083). Clinical Infectious Diseases 36, pp. 1397-1403.
Genital warts, caused by infection with the human papillomavirus (HPV), is estimated to be the most commonly occurring sexually transmitted disease in the United States. On average, individual episodes of care for genital warts involve 3.1 physician visits and incur costs of $436, concludes this study. The researchers examined the prevalence of and costs associated with genital warts using claims data from a sample of 3,664,686 privately insured individuals. They identified 5,095 cases of genital warts (1.7 cases per 1,000 person-years) billed through health plans during 2000. The prevalence of and health plan costs associated with genital warts were highest among women aged 20-24 years (6.2 cases and $1,692 in costs per 1,000 person-years) and men aged 25-29 years (5 cases and $1,717 in costs per 1,000 person-years).
Ma, J., Stafford, R.S., Cockburn, I.M., and Finkelstein, S.N. (2003, February). "A statistical analysis of the magnitude and composition of drug promotion in the United States in 1998." (AHRQ grant HS13405). Clinical Therapeutics 25, pp. 1503-1517.
According to this study, the pharmaceutical industry invests heavily in promoting its products and concentrates its promotional expenditures on a small number of medications. Although promotion to professionals remains dominant, direct-to-consumer advertising has become key for a subset of common medications. The researchers analyzed nationally representative data on expenditures for the 250 most promoted medications in the United States in 1998 and the five most commonly used modes of promotion. During that year, the pharmaceutical industry spent $12,724 million promoting its products in the United States, of which 86 percent was accounted for by the top 250 drugs and 52 percent by the top 50 drugs. Direct-to-consumer advertising was more concentrated on a small subset of medications than was promotion directed to professionals.
Mofidi, M., Strauss, R., Pitner, L.L., and Sandler, E.S. (2003, May). "Dental students' reflections on their community-based experiences: The use of critical incidents." (National Research Service Award training grant T32 HS00032). Journal of Dental Education 67(5), pp. 515-523.
The purpose of this study was to gain insight into the community-based experiences of dental students as documented in their critical incident essays and explore what learning outcomes and benefits students reported. Following two required community-based clinical rotations, each student wrote a reflection essay on a self-defined critical incident that occurred during the rotations. Rotations took place in settings such as a public health clinic, special needs facilities, hospitals, and correctional institutions. Analysis of the essays revealed that as a result of these rotations, students developed increased self-awareness, empathy, communication skills, and self-confidence, and increased their appreciation for the influence of dentistry on people's lives. The researchers conclude that community-based dental education that includes a process for reflection holds promise as a dental education strategy.
Murray, M.E., and Henriques, J.B. (2003, July). "An exploratory cost analysis of performing hospital-based concurrent utilization review." (AHRQ grant HS10667). American Journal of Managed Care 9, pp. 512-518.
The purpose of this study was to determine the monetary costs to the hospital associated with conducting concurrent utilization review (UR). This is a process of evaluating a provider's plan of clinical care against the criteria of medical necessity, appropriateness, and the terms of the contract with a payer. Care that meets these criteria is certified for reimbursement. The researchers divided the 29 clinical services of a 500-bed academic health center into nine clinical groups. They used time sampling and cost analysis methods to determine the cost to the hospital of conducting UR for the nine clinical groups. The pediatrics group spent more time preparing for the review than the cardiology and oncology groups. The total cost of the UR process was nearly $166,000 annually. Given a denial rate of less than 2 percent and the high cost of the process, it may be beneficial to investigate alternative processes for conducting UR, conclude the researchers.
Nielsen, K., and Trinkoff, A. (2003, May). "Applying ergonomics to nurse computer workstations." (AHRQ grant HS11990). Computers, Informatics, Nursing 21(3), pp. 150-157.
Nursing is an occupation at high risk for developing cumulative trauma disorders because of job-related repetitive tasks, heavy lifting, and awkward postures. With more computer time required, nurses' injury risks will only increase unless interventions are implemented before problems occur. For instance, nurses may work nearly 2 to 5 hours per shift at standing workstations in the future. This article provides information about ergonomic computer workstation design that may be applied to nursing workstations. The authors review the literature on ergonomic recommendations; describe additional ergonomic factors that pertain to the nurse-computer interaction, such as taking breaks; discuss recent ergonomic policies; and make recommendations for future research.
Nyden, P. (2003). "Academic incentives for faculty participation in community-based participatory research." Journal of General Internal Medicine 18, pp. 576-585.
Recognizing the need to overcome the obstacles of traditional university- and discipline-oriented research approaches, these authors present a variety of incentives to promote community-based participatory research (CBPR). They cite the following strategies for promoting CBPR: development of faculty research networks; team approaches to CBPR; mentoring faculty and students; using existing national CBPR networks; modifying tenure and promotion guidelines; development of appropriate measures of CBPR scholarship; earmarking university resources to support CBPR; using Institutional Review Boards to promote CBPR; making CBPR-oriented faculty appointments; and creating CBPR centers.
Patrick, D.L., Curtis, R., Engelberg, R.A., and others (2003). "Measuring and improving the quality of dying and death." (AHRQ grant HS09540) Annals of Internal Medicine 139, pp. 410-415.
Improving end-of-life experience is a major challenge, with the goal being deaths that are reasonably free of discomfort, in accordance with patients' wishes, and within acceptable professional and ethical standards. These authors developed a 31-item measure of the quality of dying and death and applied it in a community sample and a sample of hospice patients. They collected the scores on the Quality of Dying and Death Instrument and measures of perceived quality of care from patients' loved ones after death. Higher overall after-death ratings of the quality of care received from all providers and from physicians were associated with higher quality dying and death. How well patients' symptoms were controlled in the community study and how well wishes were followed and explained in the hospice study were associated with higher quality dying.
Punglia, R.S., D'Amico, A.V., Catalona, W.J., and others (2003, August). "Effect of verification bias on screening for prostate cancer by measurement of prostate-specific antigen." (AHRQ National Research Service Award training grant T32 HS00020). New England Journal of Medicine 349(4), pp. 335-342.
Lowering the current threshold level of prostate-specific-antigen (PSA) for recommending prostate biopsy from 4.1 ng/ml to 2.6 ng/ml in men younger than 60 years may improve the clinical value of the PSA test, concludes this study. Between 1995 and 2001, 6,691 men underwent PSA-based screening for prostate cancer. Of these men, 11 percent subsequently underwent biopsy of the prostate. The researchers used a mathematical model to estimate adjusted receiver-operating-characteristic (ROC) curves. Adjusting for verification bias significantly increased the area under the ROC curve of the PSA tests, as compared with unadjusted analysis. Based on those calculations, if the threshold PSA value for undergoing biopsy were set at 4.1 ng per milliliter, 82 percent of cancers in younger men and 65 percent of cancers in older men would be missed. Lowering the threshold for biopsy from 4.1 to 2.6 ng/ml in men younger than 60 years would double the cancer detection rate from 18 percent to 36 percent, whereas the specificity would fall only from 0.98 to 0.94.
Rosen, J., Mittal, V., Mulsant, B.H., and others (2003, May). "Educating the families of nursing home residents: A pilot study using a computer-based system." (AHRQ grant HS11976). Journal of the American Medical Directors Association 4, pp. 128-134.
Computer-based interactive videos can be used to educate family members of nursing home residents on dementia care, concludes this pilot study. Focus
groups guided the design and development of the Web-based system, which provided interactive educational videos on dementia, agitation/aggression, and caregiver strategies, as well as interactive communication between family members of nursing home residents and the homes. The researchers then tested its usability and functionality with 18 family members of nursing home residents. Based on a pretest and posttest, knowledge of key principles of dementia care improved significantly, and user satisfaction and "ease of use" received high ratings. A complete curriculum of education and interactive bulletin boards for family inclusion in care planning are currently under development.
Small, S.B., and Barach P. (2002, December). "Patient safety and health policy: A history and review." (AHRQ grants HS11553 and HS11905). Hematology/ Oncology Clinics of North America 16(6), pp. 1463-1482.
In this study, the researchers describe the emergence of the patient safety movement, development of policy at the State level, the role of accreditation, and the role of large payers. They also examine organizational factors in patient safety, educational initiatives, and legal policy. They suggest that any approach to improving patient safety should, at a minimum, include a nonpunitive in-depth mechanism for reporting incidents, post-incident evaluations for identification of system changes to prevent subsequent occurrences, and State-guaranteed legislative protection from discovery for all aspects of information gathered to improve patient safety.
Whitehall II Study: Ferrie, J.E., Shipley, M.J., Stansfeld, S.A., and others (2003). "Future uncertainty and socioeconomic inequalities in health: The Whitehall II study." (AHRQ grant HS06516). Social Science & Medicine 57, pp. 637-646; and Stafford, M., and Marmot, M. (2003).
"Neighborhood deprivation and health: Does it affect us all equally?" (AHRQ grant HS06516). International Journal of Epidemiology 52, pp. 357-366.
These two papers examine results from the Whitehall II study, a longitudinal study of white-collar British civil servants. In the first study, the investigators examined the contribution of job and financial insecurity to health problems and cardiovascular risk factors. They observed dramatic increases in job insecurity among employed participants and in financial insecurity among both employed and unemployed participants, particularly non-employed men between 1985-1988 and 1997-1999. With the exception of depression, job insecurity had little effect on socioeconomic differences in health problems. However, financial insecurity contributed substantially to declines in self-rated health, longstanding illness, and depression in both employed and non-employed men, and substantially weakened ratings of health in non-employed women. The second study found no evidence that personal poverty combined with affluent neighborhood had negative health consequences. Rather, living in a deprived neighborhood may have the most negative health effects on poorer individuals, possibly because they are more dependent on collective resources in the neighborhood. These findings were based on linking individual data on socioeconomic status and perceived status from the Whitehall II study to census data on neighborhood deprivation.
Whitney, S.N. (2003). "A new model of medical decisions: Exploring the limits of shared decision making." (AHRQ grant K08 HS11289). Medical Decision Making 23, pp. 275-280.
This article proposes a model of medical decisions based on two fundamental characteristics of each decision: importance and certainty. The proposed model uses these characteristics to predict who will have decisional priority for any given decision and shows how one class of decisions lends itself particularly well to shared decisionmaking. Three other types of decisions are less well suited to collaborative decisions. For major choices that have low certainty, this author believes patients should be encouraged to be the primary decisionmakers, with physician assistance as needed. Most minor decisions that have high certainty are expected to be made by physicians. Major decisions that have high certainty are likely to cause serious conflict when patients and physicians disagree.
Wolinsky, F.D., Wyrwich, K.W., Babu, A.N., and others (2003). "Age, aging, and the sense of control among older adults: A longitudinal reconsideration." (AHRQ grants HS10234, HS11635). Journal of Gerontology: Social Sciences 58B (4), p. S212-S220.
These researchers conducted baseline face-to-face interviews and six followup telephone interviews over the following year with 1,662 chronically ill older patients at two medical centers. During the interviews, they used an eight-question survey to measure participants' sense of control over life events. They also considered factors that might confound the relationship between age and sense of control: demographic and socioeconomic status, psychosocial factors, physical and mental well-being, and the patient-practitioner relationship. Older age at baseline and followup was significantly associated with less sense of control. Modest yet enduring and significant increases in sense of control occurred for whites compared with minorities over time and for better educated as opposed to less educated patients. Aside from the effects of age and baseline sense of control, mental well-being had the most substantial impact on sense of control over time.
AHRQ Publication No. 04-0021
Current as of November 2003