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Research Briefs

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Aujesky, D., Auble, T.E., Yealy, D.M., and others (2005, April). "Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia." (AHRQ grant HS10048). American Journal of Medicine 118, pp. 384-392.

Researchers found that the Pneumonia Severity Index (PSI) was slightly more accurate than two other methods used to identify pneumonia patients who are at low risk of dying and, therefore, are candidates for outpatient rather than inpatient care. The investigators compared the ability of the PSI with the CURB (confusion, urea nitrogen, respiratory rate, and blood pressure) and CURB-65 severity scores to identify low-risk patients among 3,181 pneumonia patients from 32 hospital emergency departments. The PSI classified more patients as low risk (68 percent) than either a CURB score less than 1 (51 percent) or a CURB-65 score less than 2 (61 percent). Patients identified by the PSI as low-risk had a slightly lower mortality (1.4 percent) than those classified as low risk by the CURB or CURB-65 (1.7 percent).

Aujesky, D., Stone, R.A. Obrosky, D.S., and others (2005, April). "Using randomized controlled trial data, the agreement between retrospectively and prospectively collected data comprising the pneumonia severity index was substantial." (AHRQ grant HS10049). Journal of Clinical Epidemiology 58, pp. 357-363.

The Pneumonia Severity Index (PSI) uses 20 clinical variables to assign patients with community-acquired pneumonia (CAP) into five risk classes. Whether the clinical data are collected prospectively or retrospectively seems to result in a similar classification of patient risk of dying. The researchers analyzed data from a randomized trial of CAP patients managed in 32 hospital emergency departments. Among the 3,220 enrolled CAP patients, percent agreement between retrospectively and prospectively collected data was greater than 90 percent for 18 of 20 PSI variables.

Baker, D.P., Salas, E., King, H., and others (2005, April). "The role of teamwork in the professional education of physicians: Current status and assessment recommendations." (AHRQ contract 282-98-0029). Journal on Quality and Patient Safety 31(4), pp. 185-202.

The critical role that teamwork plays in patient safety is well recognized. Team members must possess specific knowledge, skills, and attitudes (KSAs), such as the ability to exchange information, which helps individual team members coordinate care. The authors describe the roles of different regulatory bodies in assessing team performance of physicians, where and when these assessments might take place (during physician medical education, board certification, licensure, and continuing practice), and how performance might be measured. These issues, combined with team KSA competencies, form their approach for measuring team performance in health care.

Boehm, D.A. (2005, March). "The safety net of the safety net: How federally qualified health centers 'subsidize' Medicaid managed care."(AHRQ grant HS09703). Medical Anthropology Quarterly 19(1), pp. 47-63.

The author examines the impact that Salud! New Mexico's Medicaid Managed Care program—has had on federally qualified health centers (FQHCs). FQHCs are safety-net organizations on the front lines of health care delivery to the poor. According to the author, the role of FQHCs has been transformed as a result of Medicaid managed care and they now serve as a primary safety net for Salud!

Chang, R.K., Qi, N., Larson, J., and others (2005, April). "Comparison of upright and semi-recumbent postures for exercise echocardiography in healthy children." (AHRQ grant HS13217). American Journal of Cardiology 95, pp. 918-921.

Placing children in a semi-recumbent position at a 70-degree angle with back support results in better quality images during exercise echocardiography procedures than a 90-degree upright position. In the semi-recumbent posture with back support, children were able to maintain torso stability during cycling to allow the acquisition of better quality images in a shorter period of time. Both positions had similar echocardiographic measurements.

Cook, R., and Rasmussen, J. (2005, July). "Going solid: A model of system dynamics and consequences for patient safety." (AHRQ grants HS11816 and HS14261). Quality and Safety in Health Care 14, pp. 130-134.

Practitioners are familiar with "bed crunch." It is a term used to describe situations where a busy unit in a hospital, such as a surgical intensive care unit, becomes saturated with work and results in an operational bottleneck. Other hospital units usually buffer the consequences of a localized bed crunch by absorbing workload, deferring transfers, etc. However, modern management techniques and information systems have allowed facilities to reduce inefficiencies in operation, which also reduces the buffers that previously accommodated care demand surges. This situation is called "going solid," a nuclear power slang term used to describe a technical situation that has become difficult to manage and has very little room for error. The authors use a dynamic safety model to help understand the implications of how "going solid" in health care facilities may lead to accidents.

Fuhlbrigge, A.O., Carey, F.J., Finkelstein, J.A., and others (2005, May). "Validity of the HEDIS criteria to identify children with persistent asthma and sustained high utilization." (AHRQ grant HS08368). American Journal of Managed Care 11, pp. 325-330.

The points in time when children with persistent asthma are identified and performance is assessed by HEDIS criteria should be closely related, concludes this study. The researchers examined whether a previously observed association between the HEDIS performance measure and asthma-related emergency department visits was robust when the period between the classification and outcome assessment was evaluated during a 2-year period. They studied nearly 3,000 children with asthma from three managed care organizations. The protective relationship between controller medication dispensing and asthma-related emergency department visits was no longer seen among children meeting the HEDIS criteria for persistent asthma when the period of observation was extended to 2 years.

Haukoos, J.S., and Lewis, R.J. (2005, April). "Advanced statistics: Bootstrapping confidence intervals for statistics with 'difficult' distributions." (AHRQ fellowship F32 HS11509). Academic Emergency Medicine 12(4), pp. 360-365.

The use of confidence intervals in reporting results of research has increased dramatically and is now required or highly recommended by editors of many scientific journals. This article describes the concept and limitations of bootstrapping, a computationally intensive statistical technique that allows the researcher to make inferences from data without making strong distributional assumptions about the data or the statistic being calculated.

Kaul, D.R., Flanders, S.A., and Saint, S. (2005, May). "Clear as mud." (AHRQ grant HS11540). New England Journal of Medicine 352, pp. 1914-1918.

This paper describes how an expert clinician unravels the diagnostic puzzle of a 17-year-old previously healthy boy who suddenly develops a torso rash, several days of low back pain, a high fever, headache, diffuse muscle pain (myalgia), and vomiting. He soon develops renal failure, anemia, and jaundice. The boy's parents mention that 2 weeks before he became sick, the boy rode an all-terrain vehicle through a park that included a lake and wetlands and returned home covered in mud. This exposure put him at risk for illnesses such as Rocky Mountain spotted fever, ehrlichiosis, and leptospirosis with Weil's syndrome, which can cause severe myalgias and other problems affecting the boy. The clinician added doxycycline (for possible leptospirosis) to piperacillin and tazobactam, initiated hemodialysis, and cultured the blood and urine which tested positive for leptospirosis.

Lee, G.M., Salomon, J.A., LeBaron, C.W., and Lieu, T.A. (2005, March). "Health-state valuations of pertussis: Methods for valuing short-term health states." (AHRQ grants T32 HS00063 and H13908). Health and Quality of Life Outcomes 3(17).

Waning immunity from childhood pertussis (whooping cough) vaccines has been thought to contribute to the particularly steep rise seen in pertussis among U.S. adolescents and adults over the past two decades. Acellular pertussis vaccines for adolescents and adults have been developed and may soon be available for use as booster vaccines. A telephone survey of 515 adult patients and parents of adolescent patients with pertussis in Massachusetts revealed that the majority considered pertussis to be worse than adverse events that can result from vaccination. Infant complications due to pertussis were considered worse than adolescent/adult disease.

Nelson, N.L. (2005, March). "Ideologies of aid practices of power: Lessons for Medicaid managed care." (AHRQ grant HS09703). Medical Anthropology Quarterly 19 (1), pp. 103-122.

The increased linking of corporate interests with State and nongovernmental interests in medical aid programs is ultimately producing a less centralized system of power and responsibility, according to the author. Ultimately, the devolution of power produces many unintended consequences for aid policy, which the author demonstrates in an analysis of New Mexico's Medicaid managed care program, Salud!. For the study, the author used interviews with welfare and Medicaid recipients, clerks, nurses, nurse practitioners, doctors, phone system employees, and others.

O'Toole, M., Kmetik, K., Bossley, H., and others (2005, Spring). "Electronic health record systems: The vehicle for implementing performance measures." (AHRQ grant HS13690). American Heart Hospital Journal 3, pp. 88-93.

This paper recounts a cardiovascular group's use of electronic health record systems to capture data needed for internal quality assessment and improvement as part of routine outpatient care. The 55-physician group has used an outpatient electronic health record system since 1997. Starting in 2003, the group integrated cardiovascular measurement sets developed by the Physician Consortium for Performance Improvement (convened by the American Medical Association) into its electronic health system. With this integration, the group has been able to capture critical disease management data for decision support, resulting in improvements in health care.

Shechter, S.M., Bryce, C.L., Alagoz, O., and others (2005, March). "A clinically based discrete-event simulation of end-stage liver disease and the organ allocation process." (AHRQ grant HS09694). Medical Decision Making 25, pp. 199-209.

The authors used data from multiple sources to simulate the organ allocation process for patients with end-stage liver disease. To validate the model, they compared simulation output with historical data. Simulation outcomes were within 1 to 2 percent of actual results for measures such as new candidates, donated livers, and transplants by year. The model overestimated the yearly size of the waiting list by 5 percent in the last year of the simulation and the total number of pretransplant deaths by 10 percent. Nevertheless, the model includes sufficient detail to estimate the effects of a wide range of questions regarding liver allocation and policy change.

Schneeweiss, S., and Avorn, J. (2005, April). "A review of uses of healthcare utilization databases for epidemiologic research on therapeutics." (AHRQ grant HS10881). Journal of Clinical Epidemiology 58, pp. 323-337.

This article addresses the strengths, limitations, and appropriate applications of health care utilization databases in epidemiology and health services research, with particular emphasis on the study of medications. Large health care utilization databases are often used in a variety of settings to study the use and outcomes of therapeutics. Their size allows the study of infrequent events that occur during routine clinical care, which makes it possible to study real-world effectiveness and utilization. In addition, their availability at relatively low cost without long delays makes them accessible to many researchers.

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