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Battles, J.B., Dixon, N.M., Borotkanics, R.J., and others (2006, August). "Sensemaking of patient safety risks and hazards." HSR: Health Services Research 41(4), pp. 1555-1575.

In order for organizations to become learning organizations, they must make sense of their environment and learn from safety events, according to the authors of this paper. The ultimate goal of sensemaking is to build the understanding that can inform and direct actions to eliminate risk and hazards that are a threat to patient safety. Sensemaking is an essential part of the design process leading to risk-informed design, a conceptual framework to bring together well-established approaches to assessment of risk and hazards. These include using root cause analysis (RCA) at the single event level, using failure modes effects analysis (FMEA) at the processes level, and using probabilistic risk assessment (PRA) at the system level. The results of these separate or combined approaches are most effective when end users in conversation-based meetings add their expertise and knowledge to the data produced by the RCA, FMEA, and/or PRA in order to make sense of the risks and hazards.

Reprints (AHRQ Publication No. 06-R059) are available from the AHRQ Publications Clearinghouse.

Bertakis, K.D. and Azari, R. (2006, June). "The influence of obesity, alcohol abuse, and smoking on utilization of health care services." (AHRQ grant HS06167). Family Medicine 38(6), pp. 427-434.

Researchers found that obese patients had significantly more primary care visits and diagnostic services, as well as higher primary care clinic charges, over a 1-year study period. Problem drinking predicted more frequent emergency department (ED) visits, as well as more diagnostic tests. Cigarette smoking was associated with more specialty care clinic visits and hospitalizations. Smoking also significantly predicted subsequent medical charges and appeared to have a stronger association with increased costs (especially costs for ED visits and hospitalizations) than obesity or alcohol abuse. Smokers had nearly 11 percent higher total charges for their use of health care services than nonsmokers, even after accounting for patient health status, depression, age, education, income, and gender.

Brewer, C.S., Kovner, C.T., Wu, Y-W., and others (2006, June). "Factors influencing female registered nurses' work behavior." (AHRQ grant HS11320). Health Services Research 41(3), pp. 860-886.

An analysis of data from the 2000 National Sample Survey of Registered Nurses, 2001 regional market analysis data, and the 2002 Area Resource File indicates that the market environment has little effect on whether a female nurse works, but influences how much she works. Researchers examined the impact of demographic, job-related, and metropolitan statistical area-level variables on the work of female nurses. In 2000, about 81.7 percent of registered nurses (RNs) were employed in nursing, down from 82.7 percent in 1996. Of those RNs not employed in nursing, about 7.7 percent were seeking nursing employment, 27.2 percent had another occupation, and 65.1 percent were not in the labor force. Some market factors appear to affect why female RNs work (WK) or do not work (NW) in nursing and whether they work full-time (FT) or part-time (PT). Overall, a greater number of market-level factors influenced FT/PT than WK/NW behavior. Being age 55 and older, other family income, and prior other work experience in health care were negatively related to working as an RN. The wage was not related to working as an RN, but negatively influenced FT work. Older age, children, minority status, student status, other income, and some job settings had a negative impact on working FT. Previous health care work had a positive effect on whether married RNs worked. Married RNs who were more dissatisfied with their jobs were less likely to work FT.

Davis, K.S., Magruder, K.M., Lin, Y., and others (2006, April). "Brief report: Trainee provider perceptions of group visits."(AHRQ grant HS10871). Journal of General Internal Medicine 21, pp. 357-359.

One approach to the limited time physicians have to address problems of complex patients is to have group visits with 15 to 20 patients simultaneously, during which patients can discuss educational topics and receive medical care. Health care provider trainees may feel tentative about group visits; however, this study suggests that their opinions improve significantly after observing one or more group visits, regardless of trainee gender, type, or level of training. In the study, 32 trainees assigned to month-long rotations at a primary care clinic observed between 1 and 4 group visits. They completed a Group Visit Questionnaire (GVQ) evaluating their perceptions of group visits as a method of health care delivery both before and after observing such visits. The post-observation GVQ scores significantly improved after observing at least one group visit.

DiSantostefano, R.L., Biddle, A.K., and Lavelle, J.P. (2006). "The long-term cost effectiveness of treatments for benign prostatic hyperplasia." (AHRQ grant HS14719). Pharmacoeconomics 24(2), pp. 171-191.

Half of men aged 60 years and older have frequent symptoms from benign prostatic hyperplasia (BPH), such as urinary frequency, incomplete emptying, and urinary urgency. Using $50,000 per quality adjusted life year (QALY) as the threshold for cost-effectiveness, transurethral resection of the prostate and alpha-blockers appear to be the most cost-effective treatments for BPH patients with moderate and severe symptoms, respectively. Transurethral microwave thermotherapy is promising for patients with moderate symptoms and the oldest patients with severe symptoms, but was otherwise dominated by the other two approaches.

Feudtner, C., Silveira, M.J., Shabbout, M., and Hoskins, R.E. (2006, May). "Distance from home when death occurs: A population-based study of Washington state, 1989-2002." (AHRQ grant T32 HS00002). American Academy of Pediatrics 117, pp. 932-939.

The distance between home residence and the hospital where death occurs has increased over time, and is greatest for children, according to this study. These findings have implications for the design of local and regional pediatric end-of-life supportive care services, note the researchers. They measured the driving distance between home residence and location at the time of death for Washington State residents who died from 1989 to 2002. The overall mean distance from home to the hospital where death occurred increased by 1 percent annually. The mean distance from home to the hospital where death occurred was 37.4 km for neonates and 50.9 km for children aged 1 to 9 years, compared with 19.9 km for adults aged 60 to 79 years and 14 km for those older than 79 years.

Franks, P., Hanmer, J., and Fryback, D.G. (2006, May). "Relative disutilities of 47 risk factors and conditions assessed with seven preference-based health status measures in a national U.S. sample." (AHRQ grant T32 HS00083). Medical Care 44(5), pp. 478-485.

Preference-based health measures yield summary scores that are compatible with cost-effectiveness analyses of various clinical interventions. This study examined how different measures weight health conditions. It concluded that absolute incremental cost-effectiveness analyses of a given problem would likely vary depending on the measure used. However, the relative ordering of incremental cost-effectiveness analyses of a series of problems would likely be similar regardless of the measure chosen, as long as the same measure is used in each series of analyses. The findings were based on analysis of data from 11,421 adults in the 2000 Medical Expenditure Panel Survey of representative U.S. households. The researchers regressed 7 preference-based health measures on 43 medical conditions and 4 risk factors (smoking, overweight, obesity, and lack of health insurance) to determine the disutility associated with the problem, adjusting for sociodemographics.

Hanmer, J., Lawrence, W.F., Anderson, J.P., and others (2006, August). "Report of nationally representative values for the noninstitutionalized U.S. adult population for 7 health-related quality-of-life scores." (AHRQ grant T32 HS00083). Medical Decision Making 26, pp. 391-400.

Despite widespread use of generic health-related quality-of-life (HRQOL) scores, few have published nationally representative U.S. values. The authors of this study created the first publicly available set of current nationally representative values for seven of the most common HRQOL scores, stratified by age and sex. To accomplish this, they used data from the 2001 Medical Expenditure Panel Survey to calculate six HRQOL scores. These included categorical self-rated health, EuroQol-5D with U.S. scoring, EuroQol-5D with UK scoring, EuroQol Visual Analog Scale, mental and physical component summaries from the SF-12 health status questionnaire, and SF-6D. The authors also estimated Quality of Well-being Scale scores from the 2001 National Health Interview Survey. These values are important for use in both generalized comparisons of health status and in cost-effectiveness analyses.

Hays, R.D., Eastwood, J-A., Kotlerman, J., and others (2006, April). "Health-related quality of life and patient reports about care outcomes in a multidisciplinary hospital intervention." (AHRQ grant HS10734). Annals of Behavioral Medicine 31(2), pp. 173-178.

Researchers from the University of California, Los Angeles divided the general medicine floor of a hospital into a control unit (626 patients) and an intervention unit (581 patients). The control unit consisted of a multidisciplinary team, including a nurse specialist, discharge planner, social worker, home health nurse, utilization review nurse, nutritionist, and physical therapist. The intervention unit added a nurse practitioner plus daily multidisciplinary rounds, a hospital medical director, and attending hospitalists. The researchers examined patient evaluations of hospital care 30 days after study inception, and assessed health-related quality of life (HRQOL) at baseline, 30 days later, and 4 months later.

Patients in the intervention unit reported higher emotional support and physical comfort from health care providers than the control group. However, these effects became nonsignificant after adjusting for multiple comparisons. The hospital care rating and HRQOL summary scores improved significantly from baseline to the followup 30 days and 4 months later, but were similar for both groups. Patient ratings of care were not associated with subsequent HRQOL. The multidisciplinary model of care did reduce costs, while maintaining positive perceptions of care and preserving HRQOL among hospitalized patients. Thus, it was cost-effective.

Kumar, V., Norton, E.C., and Encinosa, W.E. (2006). "OBRA 1987 and the quality of nursing home care." International Journal of Health Care Finance and Economics 6, pp. 49-81.

The 1987 Omnibus Budget Reconciliation Act (OBRA) was a sweeping government reform to improve the quality of nursing home care. However, because the minimum government standards imposed by OBRA regulate only part of the nursing home market, they may have unintended effects, suggest the authors of this paper. They examined how the effect of OBRA standards on the quality of nursing home care—measured by resident outcomes—varied with nursing home profitability. After controlling for the endogenous effects of regulation, they found that this landmark legislation had a negative effect on the quality of care in less profitable nursing homes, but improved the quality in more profitable nursing homes during the initial period after OBRA. However, OBRA had no significant effect in the later period when the regulation was weakly enforced.

Reprints (AHRQ Publication No. 06-R069) are available from the AHRQ Publications Clearinghouse.

Nayak, S., Olkin, I., Liu, H., and others (2006, June). "Meta-analysis: Accuracy of quantitative ultrasound for identifying patients with osteoporosis." (AHRQ grant T32 HS00028). Annals of Internal Medicine 144, pp. 832-841.

There is growing interest in quantitative ultrasound for osteoporosis screening because it predicts fracture risk, is portable, and is relatively inexpensive. However, this study concluded that results of calcaneal quantitative ultrasound at commonly used cutoff thresholds do not definitively exclude or confirm osteoporosis that was diagnosed by dual-energy x-ray absorptiometry (DXA). The authors call for additional research before use of this test can be recommended in evidence-based screening for osteoporosis. Their conclusions were based on a meta-analysis of 25 studies that evaluated the sensitivity and specificity of calcaneal quantitative ultrasound for identifying adults with osteoporosis, that is, those with DXA T-scores of -2.5 or less at the hip or spine.

Satcher, D., and Rust, G. (2006, Spring). "Achieving health equity in America."(AHRQ grant HS14748). Ethnicity & Disease 16, pp. S3-8-S3-13.

The authors of this paper assert that health equity can be achieved in America if people care enough, know enough, do enough, and persist long enough. Toward this end, they developed a three-dimensional model for the elimination of health disparities. The first dimension is surveillance, that is, continual measurement of racial-ethnic disparities in each specific disease, in its risk factors, and in outcome-relevant quality of care. The second dimension is research into the causes of disparities and potential intervention points to eliminate them. These can be found in an individual's biology or behavior, in their physical and social environment, or in the health care arena (quality and access). The third dimension is intervention, which requires translating clinical knowledge not only to the bedside, but also into each community and home.

Seow, H., Phillips, C.O., Rich, M.W., and others (2006, March). "Isolation of health services research from practice and policy: The example of chronic heart failure management." (AHRQ grant 11558). Journal of the American Geriatrics Society 54, pp. 535-540.

In this article, researchers cite heart failure management as one example of the slow rate of implementation of health services research into health care policy and practice. At least 30 studies have demonstrated the merits of outpatient management of chronic heart failure (CHF), yet 13 of 15 such U.S. studies ceased operating at the end of the research project. Nearly three-fourths (74 percent) of first authors on the U.S. studies attributed discontinuation of their projects to lack of financing. Financing problems stemmed largely from adverse incentives in Medicare's payment arrangements for CHF disease management. Fee-for-service Medicare does not pay well for services that yield lower hospitalization rates, including telephone advice at the first sign of worsening heart failure, continuity of critical medications, and counsel about diet and exercise. Medicare fees, however, are generally adequate to cover the costs for hospitalization for CHF. Optimal outpatient CHF services would reduce hospitalization income substantially, without engendering offsetting income from outpatient CHF care.

In contrast, reducing hospitalization rates is desirable in capitated Medicare. However, heart failure patients are usually much more expensive than their capitation rate (fixed rate per patient). Thus, managed care companies serving Medicare patients risk substantial losses if they gain a good reputation and disproportionately attract these patients to enroll for their services, note the researchers.

Swan, J.S., Lawrence, W.F., and Roy, J. (2006, August). "Process utility in breast biopsy." Medical Decision Making 26, pp. 347-359.

For most cost-utility analysis (CUA) models, measures of chronic health state preferences use standard gamble utilities, time tradeoff preferences, rating scale values, or generic indexes. Preference measures and health state classification designed for chronic states are problematic for quality-adjusting short-term events that may be important in studies of diagnostic tests or some interventions. However, this study found that the waiting tradeoff (WTO) is feasible for discriminating preferences for short-term health states in an acute medical scenario, where it might have been expected to be impracticable. The authors conducted WTO assessments with 75 women with past experience of either breast core-needle biopsy, more invasive excisional surgical biopsy (EXB), or both. The median paired and mean unpaired WTO scores indicated that women were willing to wait significantly longer to avoid EXB.

Reprints (AHRQ Publication No. 06-R083) are available from the AHRQ Publications Clearinghouse.

Turley, J.P., Johnson, T.R., Smith, D.P., and others (2006, April). "Operating manual-based usability evaluation of medical devices: An effective patient safety screening method." (AHRQ grant HS11544). Journal on Quality and Patient Safety 32(4), pp. 214-220.

Use of medical devices often directly contributes to medical errors. Because it is difficult or impossible to change the design of existing devices, the best opportunity for improving medical device safety is during the purchasing process. The authors propose a review of medical device operating manuals as a practical method of evaluating the device's usability. They examined operating manuals for five volumetric infusion pumps from three manufacturers. They evaluated each manual's safety message content to determine whether the message indicated a device design characteristic that violated known usability principles (heuristics) or indicated a violation of an affordance of the device. "Minimize memory load," with 65 violations, was the heuristic violated most frequently across pumps. Results suggest that prepurchase manual review can provide a proxy for heuristic evaluation of the actual medical device.

AHRQ Publication No. 06-0071
Current as of October 2006

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