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Research Briefs

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Andrews, J.E., Pearce, K.A., Sydney, C., and others (2004). "Current state of information technology use in a U.S. primary care practice-based research network." (AHRQ grant HS13487). Informatics in Primary Care 12, pp. 11-18, 2004.

Greater attention should be given to enhancing information technology (IT) infrastructure in primary care, according to this study of Kentucky primary care practices. While interest in use of IT in primary care was high among the practices, IT adoption was variable, with use of several key technologies reported as low. All but one practice had Internet access; yet 34 percent had only dial up service. Only 21 percent of practitioners used an electronic medical record (EMR), with cost being the barrier to use reported most frequently (58 percent). More than half of the office managers were "somewhat interested" (45 percent) or "very interested" (17 percent) in a low-cost standardized EMR. For practitioners, 71 percent were either somewhat or very interested in such as system.

Bakken, S., and Hripcsak, G. (2004, May). "An informatics infrastructure for patient safety and evidence-based practice in home healthcare." (AHRQ grant HS11806). Journal for Healthcare Quality 26(3), pp. 24-30.

Patient safety problems in home health care range from improper medication administration to injuries related to falls and wound infections. The authors of this paper outline the components of the informatics infrastructure of patient safety and evidence-based practice in home health care. Informatics infrastructure components include data acquisition methods; health care standards, including standardized terminologies, data repositories, and clinical event monitors; data-mining techniques; digital sources of evidence; and communication technologies. Applications that bring these components together to promote patient safety and enable evidence-based practice have demonstrated promising results in the acute care setting. However, the authors discuss a number of challenges that hinder their implementation in home health care.

Bent, S., Shojania, K.G., and Saint, S. (2004, June). "The use of systematic reviews and meta-analyses in infection control and hospital epidemiology." (AHRQ grant HS11540). American Journal of Infection Control 32, pp. 246-254.

Traditional narrative review of infection control and other research studies allow authors to pick and choose the studies they discuss and the depth at which they discuss them, a process prone to bias. By adhering to a prospectively defined protocol that specifies how studies should be identified, evaluated, and statistically combined, systematic reviews can reduce the bias inherent in traditional narrative reviews. This article discusses the essential elements of a systematic review and provides a framework for evaluating the quality of articles that will help the infection control professional and hospital epidemiologist determine whether the results of such reviews should change clinical practice.

Bundy, D.G., and Feudtner, C. (2004, May). "Preparticipation physical evaluations for high school athletes: Time for a new game plan." (AHRQ grant K08 HS00002). Ambulatory Pediatrics 4(3), pp. 260-263.

Sports-related injuries among high school athletes are common, ranging from 20 to 40 injuries per 100 athletes each year. For several decades, doctors have conducted preparticipation physical evaluations (PPEs) hoping to reduce the morbidity and mortality associated with high school sports. However, the authors of this commentary argue that the PPE as currently practiced is ineffective and illogical. Medical history and examination are inadequate to reliably detect and exclude rare life-threatening conditions. The evaluation is seldom connected with followup care to ensure that resulting recommendations are carried out. Finally, the PPE program is inconsistently and incompletely delivered. The authors propose a research agenda that would result in recommendations to more effectively promote the health of young athletes.

Dionne, C.E., and Chenard, M. (2004). "Back-related functional limitations among full-time homemakers: A comparison with women employed full-time outside the home." (AHRQ grant HS06168). Spine 29, pp. 1375-1383.

This study found that the functional consequences of back pain had a similar nature and 2-year evolution among full-time homemakers and women employed full-time outside the home. The researchers compared these two groups of women, who were enrolled in a large health maintenance organization and had consulted a physician for nonspecific back pain. They conducted telephone interviews with the women 4 to 6 weeks after the consultation and 1 and 2 years later. Two-year back-related functional limitations were significantly associated with symptoms of depression, pain intensity, and the number of days with back pain in the previous 6 months but not with employment status.

Fiscella, K., Franks, P., and Meldrum, S. (2004). "Estimating racial/ethnic disparity in mammography rates: It all depends on how you ask the question." (AHRQ grant HS10295). Preventive Medicine 39, pp. 399-403.

This study examined the impact of different survey methods on estimates of racial disparity in mammography. The investigators compared responses from 3,090 women aged 40 and older to two different questions from the 1996 Medical Expenditure Panel Survey. They asked the women when they had last obtained a mammogram versus what medical services, including mammography, they received over a 4-month interval, aggregated across 1 year. There was no significant racial disparity in 1-year mammography prevalence based on the first question (3.3 percent difference between black and white women). In contrast, there was a 13.1 percent difference in 1-year mammography prevalence based on the medical services question. These results caution against exclusive reliance on annual self-reports for monitoring disparities in preventive care.

Guagliardo, M.F., Jablonski, K.A., Joseph, J.G., and Goodman, D.C. (2004). "Do pediatric hospitalizations have a unique geography?" (AHRQ grant HS11021). BMC Health Services Research 4(2), pp. 1-9.

U.S. small-area health services research studies are often based on hospital service areas (HSAs), which are determined by the geographic origins of Medicare Part A hospital patients, most of whom are seniors. However, Medicare-based HSAs may not be appropriate for all age groups and service types throughout the country, according to this study. The investigators conducted a cross-sectional analysis of California hospital discharges for two age groups, non-newborns 0 to 17 years of age and seniors, to identify the percentage of residents hospitalized in their home HSA (index of localization). The mean localization index for pediatric cases was 20 percentage points lower than it was for Medicare cases.

Halpern, J., Johnson, M.D., Miranda, J., and Wells, K.B. (2004, May). "The Partners in Care approach to ethics outcomes in quality improvement programs for depression." (AHRQ grant HS08349). Psychiatric Services 55(5), pp. 532-539.

These authors describe an approach to addressing patient centeredness and equity in a randomized trial of quality improvement (QI) for depressed primary care patients. For four ethics goals (autonomy, distributive justice, beneficence, and avoiding harm), the authors identify intervention features, study measures, and hypotheses implemented in Partners in Care, a trial of two QI interventions relative to usual care for depression. They conclude that it is feasible to address ethics outcomes in QI programs for depression, but substantial marginal resources may be required. Nevertheless, interventions so modified can increase a practice's ability to realize ethics goals.

Hogg, J.C., Chu, F., Utokaparch, S., and others (2004, June). "The nature of small-airway obstruction in chronic obstructive pulmonary disease." (Cosponsored by AHRQ, NHLBI, and CMS). New England Journal of Medicine 350(26), pp. 2645-2653.

Chronic obstructive pulmonary disease (COPD) is a major public health problem associated with long-term exposure to toxic gases and particles. This study, a component of the National Emphysema Treatment Trial, examined the evolution of the pathological effects of airway obstruction in patients with COPD by surgically resecting lung tissue from 159 patients with stage 0 (at risk), 39 with stage 1, 22 with stage 2, 16 with stage 3, and 43 with stage 4 (very severe) COPD. The progression of COPD was associated with the accumulation of inflammatory mucous exudates in the lumen of the small airways and infiltration of the wall by innate and adaptive inflammatory immune cells that form lymphoid follicles. These changes were coupled to a repair or remodeling process that thickened the walls of these airways.

Hripcsak, G., Stetson, P.D., and Gordon, P.G. (2004, June). "Using the Federated Council for Internal Medicine curricular guide and administrative codes to assess IM residents' breadth of experience." (AHRQ grant HS11806). Academic Medicine 79(6), pp. 557-563.

These investigators estimated the breadth of experience of 41 internal medicine residents at one medical center over a 3-year period using a published curricular guide and an electronic medical record (EMR). They mapped residents to the patients they cared for, the diagnoses those patients were assigned, and the Federated Council for Internal Medicine competencies covered. Residents covered 76 percent of priority 1 competencies (those learned through direct responsibility for patients) and 67 percent of all competencies. Thus, internal medicine residents had the potential to achieve most competencies via direct patient care, but no residents achieved full coverage. The EMR may provide a way to track residents and study training programs.

Kass-Bartelmes, B.L., and Hughes, R. (2004). "Advance care planning: Preferences for care at the end of life." Journal of Pain & Palliative Care Pharmacotherapy 18(1), pp. 87-109.

These authors discuss predictors of patient wishes for end-of-life care and the influence of family and clinicians, as well as research findings on patient decisions regarding preferences for end-of-life-care. They note that most patients have not participated in advance care planning. The authors document the need for more effective planning and describe appropriate times to discuss such planning. They describe patient responses to hypothetical scenarios of terminal cancer, chronic obstructive pulmonary disease, AIDS, stroke, and dementia. They also discuss the invasiveness of interventions, prognosis, and other factors that favor or discourage patient preferences for end-of-life care.

Reprints (AHRQ Publication No. 04-R060) are available from the AHRQ Publications Clearinghouse

Keating, N.L., Landon, B.E., Ayanian, J.Z., and others (2004, May). "Practice, clinical management, and financial arrangements of practicing generalists." (AHRQ grant HS09936). Journal of General Internal Medicine 19, pp. 410-418.

These researchers surveyed 619 generalist physicians caring for managed care patients in three Minnesota health plans during 1999. They collected information about physicians' personal characteristics, features of their practices, their compensation arrangements, and practice management strategies that are often used by health care organizations to influence care. They found that 26 percent of the physicians felt pressure to limit referrals, and 62 percent felt pressure to see more patients. One-fourth (24 percent) of the physicians surveyed said they were dissatisfied with their career in medicine. Physicians who reported pressure to limit referrals were 12 percent more likely to be dissatisfied than other physicians, and those who reported pressure to see more patients were 37 percent more likely to be dissatisfied. Pressure to see more patients was more frequent among physicians in practices owned by health systems, those using physician extenders (for example, certified nurse practitioners), and among physicians who were paid by salary with performance adjustment or received at least some income through capitation.

Kennedy, M.J., Abdel-Rahman, S.M., Kashuba, A.D., and Leeder, J.S. (2004). "Comparison of various urine collection intervals for caffeine and dextromethorphan phenotyping in children." (AHRQ grant HS10397). Journal of Clinical Pharmacology 44, pp. 708-714.

Caffeine and dextromethorphan have been used successfully both alone and in combination to assess phenotype and enzyme activity in children of various ages. These researchers calculated the cumulative metabolite recoveries and molar ratios in urine collected from 24 children at 2, 4, 6, and 8 hours after caffeine (11.5 mg) and dextromethorphan (.5 mg/kg) administration to determine when respective urinary molar ratios stabilize and thus are likely to accurately reflect enzyme activity. The findings suggest that a 4-hour urine collection is adequate for the concurrent assessment of hepatic CYP1A2, NAT-2, XO, and CYP2D6 activity in children ages 3 to 8 years who are CYP2D6 extensive metabolizers using standard caffeine and dextromethorphan phenotyping methods. Longer collection periods may be required, however, in younger children and in those who are CYP2D6 poor metabolizers.

Morales, L.E., Elliott, M., Brown, J., and others (2004). "The applicability of the Consumer Assessments of Health Plans survey (CAHPS®) to preferred provider organizations in the United States: A discussion of industry concerns." (AHRQ grant HS09204). International Journal for Quality in Health Care 16(3), pp. 219- 227.

These authors examined the applicability of a leading group of patient surveys, the Consumer Assessments of Health Plans Study (CAHPS®) surveys, to preferred provider organizations (PPOs) in the United States. They conducted interviews with CAHPS users about experiences with and concerns about using the CAHPS surveys in PPO settings. Those interviewed included representatives of State and Federal government health care purchasers, commercial PPO plans, and survey vendors. Respondents raised concerns about the influence of out-of-network care on CAHPS reports and ratings of PPO health plans. Suggestions were made for adding PPO-relevant items to CAHPS, such as after-hours care, numbers and types of specialists in the PPO network, and disease management.

Ness, R.B., Brunham, R.C., Shen, C., and others (2004, May). "Associations among human leukocyte antigen (HLA) class II DQ variants, bacterial sexually transmitted diseases, endometritis, and fertility among women with clinical pelvic inflammatory disease."(AHRQ grant HS08358). Sexually Transmitted Diseases 31(5), pp. 301-304.

These authors investigated associations between HLA class II DQ alleles, chlamydial and gonococcal cervicitis, endometritis, and infertility among 92 women with clinical signs and symptoms of mild-to-moderate pelvic inflammatory disease (PID). Among these women, carriage of the DQA *0301, DQA *0501, and DQB *0402 alleles altered the occurrence of lower genital tract infection, upper genital tract inflammation, and infertility. Chlamydial cervicitis, gonococcal cervicitis, endometritis, and infertility were all more common among women carrying the DQA *0301 allele after adjustment for race. Endometritis and infertility were somewhat less common (or pregnancy more common) among women carrying the DQA *0501 and DQB *0402 alleles.

Neumann, P.J. (2004, May). "Why don't Americans use cost-effectiveness analysis?" (AHRQ grant HS10919). American Journal of Managed Care 10, pp. 308-312.

Cost-effectiveness analysis (CEA) offers decisionmakers a structured, rational approach with which to improve the return on resources expended. Yet, decades after its widespread promotion to the medical community, policymakers in the United States remain reluctant to use the approach formally. Indeed, the resistance to economic evidence in the United States in an era of evidence-based medicine is perhaps the most notable development of all, according to the author of this paper. He examines the resistance to CEA in the United States and explores ways to advance the field.

Reed, S.D., Lee, T.A., and McCrory, D.C. (2004). "The economic burden of allergic rhinitis." (AHRQ contract 290-97-0014). Pharmacoeconomics 22(6), pp. 345-361.

These authors review the numerous economic analyses of allergic rhinitis that have been conducted, most of which have been burden-of-illness studies. Most estimates of the annual cost of allergic rhinitis range from $2 billion to $5 billion. The wide range of estimates can be attributed to differences in identifying patients with allergic rhinitis, differences in cost assignments, limitations of available data, and difficulties in assigning indirect costs of allergic rhinitis. To date, the medical literature lacks a comprehensive economic evaluation of general treatment strategies of allergic rhinitis. The authors suggest development of a consensus on a summary measure of effectiveness that could be used in cost-effectiveness analyses of therapies for allergic rhinitis.

Saag, K.G., Olivieri, J.J., Patino, F., and others (2004, June). "Measuring quality in arthritis care: The Arthritis Foundation's quality indicator set for analgesics." (AHRQ grant HS10389). Arthritis & Rheumatism 51(3), pp. 337-349.

To develop systematically validated quality indicators (QIs) addressing analgesic safety, these authors reviewed the literature on existing quality measures, clinical guidelines, and evidence supporting potential QIs concerning nonselective (traditional) nonsteroidal antiinflammatory drugs (NSAIDs) and newer cyclooxygenase 2-selective NSAIDs. An expert panel then validated or refuted potential indicators. A final 10 QIs for the safe use of NSAIDs focused on informing patients about risk, NSAID choice and gastrointestinal prophylaxis, and side-effect monitoring.

Unruh, M.L., Levey, A.S., D'Ambrosio, C., and others (2004, May). "Restless legs symptoms among incident dialysis patients: Association with lower quality of life and shorter survival." (AHRQ grant HS08365). American Journal of Kidney Diseases 43(5), pp. 900-909.

Symptoms of restless legs (overwhelming urge to move legs caused by uncomfortable or unpleasant sensations in the legs, which often interferes with sleep) are common among patients with kidney failure who are treated with long-term hemodialysis According to this study, symptoms of restless legs are severe in about 15 percent of dialysis patients. The researchers analyzed survey responses of 894 dialysis patients age 45 or older who participated in the CHOICE study from October 1995 to June 1998 and responded to questions about the severity of restless legs symptoms. The CHOICE study is a national prospective cohort study of patients undergoing hemodialysis or peritoneal dialysis in one of 80 clinics in Nashville, TN, and New Haven, CT. According to the study findings, restless legs is associated with lower quality of life and an increased risk of death. The prevalence of symptoms associated with restless legs were similar among patients regardless of dialysis mode and did not vary by race. Sleep quality was significantly improved among patients with severe restless legs who were prescribed opioids.

Uribe, J.I., Ralph, W.M., Glaser, A.Y., and Fried, M.P. (2004, March). "Learning curves, acquisition, and retention of skills trained with the endoscopic sinus surgery simulator." (AHRQ grant HS11866). American Journal of Rhinology 18, pp. 87-92.

Intensive proctored training on the endoscopic sinus surgery simulator (ED3) can train inexperienced medical students to perform endoscopic sinus surgery (ESS) close to that of experienced sinus surgeons on the ED3, concludes this study. The investigators trained 26 medical students. In the novice mode (three-dimensional abstract images are used to teach the use of endoscopic surgical equipment) after 7 to 10 trials, the students reached a plateau in their learning curves to within 90 percent of that of experienced sinus surgeons. In the intermediate mode (ESS is performed on a simulated patient with teaching aids), students were able to reach a plateau in their learning curves to within 80 percent of that of experienced surgeons. This performance was sustained in the advanced mode (simulate surgery without teaching aids).

Wang, P.S., Schneeweiss, S., Glynn, R.J., and others (2004, April). "Use of case-crossover design to study prolonged drug exposures and insidious outcomes." (AHRQ grant HS10881). Annals of Epidemiology 14, pp. 296-303.

The case-crossover design was originally intended to study brief exposures with immediate and transient effects and acute outcomes with abrupt onsets. The study investigated whether case-crossover methods can be used to study prolonged exposures and insidious outcomes. It involved 8,220 elderly patients with central nervous system (CMS) adverse events such as delirium who were enrolled in several New Jersey health benefits programs between 1991 and 1995. The researchers assessed their exposures to active drugs with deleterious CNS effects and inactive regimens (multivitamins and statins) during case and control time periods lasting from 1 to 4 months. They observed significantly elevated risks for all three active drugs, regardless of which time window was used, which increased with longer time windows. No increased risks were observed for the two inactive regimens, regardless of window duration. These results suggest that, with lengthened exposure assessment windows, case-crossover methods may be useful for studying exposures with prolonged effects and outcomes with insidious onsets.

Wolff, J.L., and Agree, E.M. (2004). "Depression among recipients of informal care: The effects of reciprocity, respect, and adequacy of support." (AHRQ grant T32 HS00029). Journal of Gerontology 59B(3), pp. S173-S180.

Perceived quality of the informal care arrangement has a bearing on the psychological health of care recipients, according to this study. The researchers found that individuals in more reciprocal relationships and in relationships where they felt respected and valued were less likely to be depressed than their counterparts. The researchers used generalized estimating equations to generate models of prevalent depression using a sample of 420 disabled elderly community-dwelling women receiving informal care. Findings confirmed a substantial prevalence of depression among older women with disabilities. Perceived reciprocity and respect afforded by one's primary caregiver as well as adequacy of instrumental support were associated with a lower likelihood of women being categorized as depressed, even after controlling for factors known to be related to depression.

Wolinsky, F.D., Metz, S.M., Tierney, W.M., and others (2004). "Test-retest reliability of the Mirowsky-Ross 2x2 index of the sense of control." (AHRQ grant HS11635). Psychological Reports 94, pp. 725-732.

A sense of control measure, the 1991 Mirowsky-Ross 2x2 Index of the Sense of Control, has acceptable test-retest reliability and is appropriate for use in longitudinal research, according to this study. The researchers randomly selected 304 individuals for test-retest interviews occurring 1 to 4 days after their regularly scheduled first followup interview. They assessed test-retest reliability at the item level using percent agreement and weighted kappa and found moderate to substantial item-level agreement. At the scale score level there was substantial agreement. Also, calculation of intraclass correlation coefficients (ICGs) within categories of demographic, socioeconomic, psychosocial, and functional status characteristics found no appreciable differences in ICG values.

Wutoh, R., Boren, S.A., and Balas, A. (2004). "eLearning: A review of Internet-based continuing medical education." (AHRQ grant HS10472). Journal of Continuing Education in the Health Professions 24, pp. 20-30.

Internet-based continuing medical education (CME) programs are just as effective in imparting knowledge as traditional formats of CME, concludes this study. However, we do not know whether these positive changes in knowledge are translated into changes in practice, caution the authors. They reviewed the literature on the effect of Internet-based CME interventions on physician performance and medical outcomes. Of the 16 eligible studies, six studies generated positive changes in participant knowledge over traditional formats; only three studies showed a positive change in practice. The remainder of the studies showed no difference in knowledge levels between Internet-based interventions and traditional CME formats.

Wyrwich, K.W., Spertus, J.A., Kroenke, K., and others (2004, April). "Clinically important differences in health status for patients with heart disease: An expert consensus panel report." (AHRQ grant HS10234 and HS11635). American Heart Journal 147, pp. 615-622.

The purpose of this study was to develop clinically important difference (CID) standards for patients with coronary artery disease and congestive heart failure that identify small, moderate, and large intraindividual changes over time in a modified version of the Chronic Heart Failure Questionnaire (CHQ) and the Medical Outcomes Study Short-Form 36-item Health Survey (SF-36). Based on experience using these measures and an extensive review of articles describing the development and use of these instruments, an expert panel agreed on small, medium, and large clinically relevant changes in scores for the CHQ and SF-36. They provide a useful tool for determining whether routine clinical health status assessments will benefit patients and enhance physicians' decisionmaking capacity in clinical settings.

Yealy, D.M., Auble, T.E., Stone, R.A., and others (2004, June). "The emergency department community-acquired pneumonia trial: Methodology of a quality improvement intervention." (AHRQ grant HS10049). Annals of Emergency Medicine 43(6), pp. 770-782.

Nationwide, nearly 75 percent of community-acquired pneumonia (CAP) patients are initially evaluated and treated in hospital-based emergency departments (EDs). These investigators designed an ED-based quality improvement (QI) trial focused on the initial care of patients with CAP. The specific aims were to compare the effectiveness and safety of three guideline implementation interventions on site of treatment and process of care decisions by using established QI strategies at 32 sites in Pennsylvania and Connecticut. The QI interventions ranged in intensity from low to moderate to a multifaceted, high-intensity intervention.

Zou, K.H., Wells III, W.M., Kikinis, R., and Warfield, S.K. (2004). "Three validation metrics for automated probabilistic image segmentation of brain tumours." (AHRQ grant HS13234). Statistics in Medicine 23, pp. 1259-1282.

The validity of brain tumor segmentation is an important issue in image processing because it has a direct impact on surgical planning. The investigators examined segmentation accuracy based on three two-sample validation metrics against the estimated composite latent gold standard. The distribution functions of the tumor and control pixel data were parametrically assumed to be a mixture of two beta distributions with different shape parameters. The researchers estimated the corresponding receiver operating characteristic curve, Dice similarity coefficient, and mutual information over all possible decision thresholds. Based on each validation metric, they then computed an optimal threshold via maximization. They illustrated these methods on magnetic resonance imaging data from nine brain tumor cases of three different tumor types. The automated segmentation yielded satisfactory accuracy with varied optimal thresholds.

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