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Research Briefs

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Barkin, S., Ip, E., Richardson, I., and others (2006, April). "Parental media mediation styles for children aged 2 to 11 years." (AHRQ grant HS10913). Archives of Pediatric and Adolescent Medicine 160, pp. 395-401.

Children in the United States use electronic media (television, video, and computer) an average of more than 4 hours a day—twice the recommended limit of 2 hours per day for children older than 2 years. Researchers conducted a survey of parents during well-child visits for children 2 to 11 years in physician offices. The majority of parents (59 percent) studied used some type of strategy to control and inform their children's use of electronic media. About 23 percent used a restrictive approach and 11 percent used an instructive approach, with some using multiple approaches. Only 7 percent of parents allowed unlimited media use and engaged in no mediation strategy.

Unlimited media use was twice as common when parents permitted a television in the child's bedroom (36 percent of the parents in this study), or were Latino or black. The restrictive approach was associated with the least media exposure (mean of 2.4 hours), and an unlimited approach was associated with the most exposure (4.1 hours). In single-parent homes and black and Latino homes, parents used less active mediation.

Barton M.B. (2006, April). "Exploring and crossing the disparity divide in cancer mortality." Annals of Internal Medicine 144(8), pp. 614-616.

The author of this editorial discusses two articles in this journal issue relevant to cancer screening in special populations. One article reports on two potential sources of the disproportionate burden of death due to breast cancer borne by black women: less frequent screening and more advanced-stage tumors. After controlling for different mammography screening rates by ethnic group, breast cancer differences in tumor stage were no longer present between white and black women. However, black women still had less favorable tumor grades. The second article examined the effectiveness of using "prevention coaches" as a means to increase use of cancer screening by largely Hispanic and black women at community and migrant health centers. Women with coaches had significantly higher rates of Pap smears, mammography, and colorectal cancer screening than women without coaches. Reprints (AHRQ Pubication No. 06-R065) are available from the AHRQ Publications Clearinghouse.

Baser, O., Gardiner, J.C., Bradley, C.J., and others (2006, May). "Longitudinal analysis of censored medical cost data." (AHRQ grant HS14206). Health Economics 15, pp. 513-525.

The authors of this paper used a statistical method to examine how various treatment regimens affected the cost of lung cancer care per month. They examined care costs over 2 years after lung cancer diagnosis among Medicare patients diagnosed between 1994 and 1997. They applied the inverse probability weighted (IPW) least-squares method to estimate the effects of treatment on total medical cost, subject to censoring, in a panel-data setting. Because total medical cost might not be independent of survival time under administrative censoring, unweighted pooled ordinary-least squares and random effects models cannot be used with censored data to assess the effects of certain explanatory variables. Even under the violation of this independency, IPW estimation provided consistent asymptotic normal coefficients with easily computable standard errors.

Bell, C.M., Urbach, D.R., Ray, J.G., and others (2006, March). "Bias in published cost effectiveness studies: Systematic review." (AHRQ grant HS10919). British Medical Journal 332, pp. 699-701.

Most published cost effectiveness analyses report favorable incremental cost effectiveness ratios, that is, below $20,000, $50,000, and $100,000 per quality adjusted life year (QALY) gained, concludes this study. Researchers found that half of reported incremental cost effectiveness ratios were below $20,000 per QALY. Studies funded by industry were twice as likely to report ratios below $20,000 per QALY. Studies of higher methodological quality and those conducted in Europe and the U.S. rather than elsewhere were less likely to report ratios below $20,000 per QALY. The authors caution that more rigor and openness are needed before decisionmakers and the public can be confident that cost effectiveness analyses are conducted and published in an unbiased manner. Their findings were based on a systematic review of 494 English language studies measuring health effects in QALYs published up to December 2001.

Clancy, C.M. (2006, March). "Informing quality health care." Healthcare Financial Management 60(3), pp. 64-68.

In this commentary, the Director of the Agency for Healthcare Research and Quality (AHRQ) emphasizes the importance of evidence-based findings of effectiveness research as the foundation for measuring health care quality. In 2005, AHRQ launched its new Effective Health Care Program, which is systematically identifying key effectiveness research needs. It is also disseminating findings to providers, payers, and consumers to better inform their health care decisions. The author points out that the Federal government's role helps guarantee comprehensive and unbiased findings to help inform medical practices. She asserts that to achieve a true quality-based healthcare system, payment systems must reward evidence-based practice and good health outcomes. Investment in health information technology—for example, electronic health records for Americans and clinical decision support systems for providers—will make a leap in quality care possible. Reprints (AHRQ Publication No. 06-R057) are available from the AHRQ Publications Clearinghouse.

Coopey, M., Nix, M.P., and Clancy, C.M. (2006). "Translating research into evidence-based nursing practice and evaluating effectiveness." Journal of Nursing Care Quality 21(3), pp. 195-202.

Evidence-based practice is clearly being adopted and practiced in nursing, note the authors of this commentary. The Director of AHRQ and fellow Agency researchers note that the AHRQ-sponsored National Guideline Clearinghouse currently contains 106 clinical practice guidelines (about 5 percent of the total) developed by 14 nursing organizations or departments. The guidelines cover a wide range of clinical topics, including family bereavement support, pressure ulcer prevention and treatment, and breastfeeding. AHRQ awarded more than 151 grants to nurse principal investigators between 1989 (when AHRQ was established) and March 2005, which have contributed to the evidence base of nursing. The California Nursing Outcomes Coalition project is one example of how nursing research evidence on fall risk assessment and prevention is being used to reduce patient falls and fall-related injuries in hospitals. Reprints (AHRQ Publication No. 06-R061) are available from the AHRQ Publications Clearinghouse.

Gardiner, J.C., Luo, Z., Liu, L., and Bradley, C.J. (2006). "A stochastic framework for estimation of summary measures in cost-effectiveness analyses." (AHRQ grant HS14206). Expert Review of Pharmacoeconomics Outcomes Research 6(3), pp. 347-358.

Markov modeling has become the paradigm for studying the progression of patients through various states of health following an intervention or treatment. This review describes the use of a nonhomogeneous Markov process to describe the occurrence of patient events and related costs as they unfold over time. States of the process represent health conditions or health states (for example, well, ill, or dead). Commonly used measures of health outcomes, such as life expectancy and quality-adjusted survival, are defined in terms of expected values of functions of the process. Costs are incurred through medical resource use while sojourning in health states, and in transitions between health states. By combining these expenditure streams, the authors define net present values for expected total cost over a specified time period.

Glance, L.G., Dick, A., Osler, T.M., and Mukamel, D.B. (2006, April). "Impact of changing the statistical methodology on hospital and surgeon ranking." (AHRQ grant HS13617). Medical Care 44(4), pp. 311-319.

Adjustment for patient risk factors is central to the generation of health outcome report cards such as the New York State (NYS) Coronary Artery Bypass Graft (CABG) Surgery Report Card. This study examined how various patient risk adjustment models affected the NYS CABG Surgery Report Card. The researchers used data from the NYS Cardiac Surgery Reporting System on all patients undergoing CABG in New York who were discharged between 1997 and 1999. They found that shrinkage estimators based on random-effects models were slightly more conservative in identifying quality outliers (surgeons or hospitals that performed better or worse than most) than the traditional approach based on fixed-effects modeling and standard regression. Explicitly modeling surgeon provider effect (fixed-effects and random-effects models) did not significantly alter the distribution of quality outliers when compared with standard logistic regression (which does not model provider effect).

Glazer, J. and McGuire, T.G. (2006, March). "Optimal quality reporting in markets for health plans." (AHRQ grant HS10803). Journal of Health Economics 25, pp. 295-310.

Better-informed consumers may choose health care providers more appropriately, researchers say. Furthermore, consumers and patients choosing on the basis of quality conveys incentives to providers to improve care quality in the first place. This paper casts the decision about what information to report to consumers about health plans as a policy decision. In a market with adverse selection, complete information about quality leads to inefficient outcomes, according to the authors. They use a model to show that averaging quality information into a summary report can enforce pooling in health insurance. By choice of the right weights in the averaged report, a payer or regulator can induce first-best quality choices. The authors conclude that an optimal quality report is as powerful as optimal risk adjustment in correcting adverse selection inefficiencies.

Levy, D.E. and Meara, E. (2006, March). "The effect of the 1998 Master Settlement Agreement on prenatal smoking." (AHRQ grant HS00055). Journal of Health Economics 25, pp. 276-294.

The Master Settlement Agreement (MSA) between the major U.S. tobacco companies and 46 States created an abrupt 20 percent increase in cigarette prices in November 1998. This study found that, after adjusting for secular trends in smoking, prenatal smoking declined by less than half what was predicted—from 2.5 to nearly 8 percent compared with the 7 to 20 percent decline that had been predicted—in response to the MSA. However, the effect was slightly stronger among the youngest and oldest pregnant smokers. Thus, policymakers should be aware that not all populations of smokers, and therefore not all smoking-related illnesses (such as low birth weight), will be affected equally by cigarette price increases, caution the researchers. They examined changes in smoking during pregnancy by analyzing birth records on 9.8 million U.S. births between January 1996 (prior to the MSA) and February 2000 (after the MSA).

Morales, L.S., Elliott, M., Weech-Maldonado, R., and Hays, R.D. (2006, February). "The impact of interpreters on parents' experiences with ambulatory care for their children." (AHRQ grant HS09204). Medical Care Research and Review 63(1), pp. 110-128.

Hispanic and Asian/Pacific Islander (API) parents who always use interpreters during outpatient medical visits for their children report similar or significantly better care access and quality than their counterparts who don't always use interpreters. They also report better service from their health plan and better care on several dimensions when compared with health plan members who do not need interpreters. The use of interpreters reduced white-Hispanic disparities in reports of care by up to 28 percent and white-API disparities by as much as 21 percent. In this study, the average proportion of plan members who needed and always used an interpreter was only 47 percent (ranging from a low of 15 percent to a maximum of 57 percent in individual plans).

The researchers estimated that increasing the use of interpreters by health plan members who need them could potentially result in a 6-point improvement in provider and staff communication for Hispanics, a 4-point increase in access to care, and 2-point increase in health plan customer service. The impact of always providing interpreters to APIs was more dramatic, with corresponding increases of 15 points, 8 points, and 11 points. These findings were based on analysis of Consumer Assessment of Health Plans Survey (CAHPS®) data on members enrolled in the California State Children's Health Insurance Program in 2000 and 2001. A total of 26,671 members of 26 health plans completed CAHPS® surveys.

Roughead, E.E., Zhang, F., Ross-Degnan, D., and Soumerai, S. (2006, April). "Differential effect of early or late implementation of prior authorization policies on the use of Cox II inhibitors." (AHRQ grant HS10391). Medical Care 44(4), pp. 378-382.

State Medicaid programs introduce many types of drug prescribing restrictions to manage pharmaceutical use and expenditures. Implementing prescribing restrictions at market entry of COX-2 inhibitors was effective in restricting uptake. The researchers examined the impact on overall use of COX-2 inhibitors of prior authorization policies implemented at market entry versus at least 2 years after market entry. Despite the difficulty in changing well-established prescribing patterns, COX-2 utilization in States implementing policies 2 years after market entry approached that of the early adopting States within 1 year. However, the clinical outcomes of such policies remain unknown.

Sedrakyan, A., Atkins, D., and Treasure, T. (2006, April). "The risk of aprotinin: A conflict of evidence." Lancet 367, p. 1376-1377.

There is conflicting evidence about whether use of aprotinin increases or reduces postoperative problems after heart surgery, note the authors. Research has repeatedly shown that the drug reduces blood loss and the need for transfusion after heart surgery, and one meta-analysis showed that patients who underwent coronary artery bypass grafting showed no increased risk of heart attack, renal failure, or stroke after treatment with aprotinin. However, a recent observational study of high-risk patients reported double the number of cardiac, renal, and cerebral complications in patients treated with aprotinin compared with patients not receiving antifibrinolytics (drugs that decrease the breakdown of fibrin, a protein essential to blood clotting). The researchers call for more studies on the impact of antifibrinolytics on complications following heart surgery. Reprints (AHRQ Publication No. 06-R066) are available from the AHRQ Publications Clearinghouse.

Siegel, J.E., and Clancy, C.M. (2006, April-June). "Relative value in healthcare: Cost-effectiveness of interventions." Journal of Nursing Care Quality 21(2), pp. 99-103.

To be taken seriously within the financially constrained health care environments in which they work, nurses must demonstrate the economic feasibility of interventions they want to implement. The growing interest of nurses in the field of cost effectiveness analysis (CEA) can only serve to improve the relevance of cost-effectiveness studies of nursing interventions and improve decisions about health resource allocation, note the authors from the Agency for Healthcare Research and Quality (AHRQ). They note that the Agency makes some grants available specifically for CEA, while others ask for CEA to be appended to an effectiveness trial. AHRQ's activities in CEA, housed in the Research Initiative in Clinical Economics Program, support this commitment. AHRQ is also the primary funder of the CEA Registry, which provides public electronic access to more than 500 cost-utility ratios from research studies published from 1976 through 2001.

Smith, S.R., Catellier, D.J., Conlisk, E.A., and Upchurch, G.A. (2006, February). "Effect on health outcomes of a community-based medication therapy management program for seniors with limited incomes." American Journal Health-System Pharmacy 63, pp. 372-379.

A medication therapy management (MTM) program can help seniors with limited income to significantly reduce emergency department (ED) visits and hospitalizations and improve their health. Researchers analyzed data from the Senior PHARMAssist program. The program provided financial assistance to low-income seniors through pharmacy reimbursement for medications on a geriatric drug formulary, periodic review of seniors' medications by a program pharmacist (including screening for drug interactions or adverse effects, tailored health education, and monitoring of medication adherence), staff communication with prescribers and dispensing pharmacies, and tailored referrals to community and governmental programs.

Probability of any hospitalization declined from 47 percent at baseline to 23 percent at the end of followup. The rate of ED visits decreased during the first 12 months of the study and then increased, although the rate at 24 months remained lower than at baseline. Self-reported ratings of health improved over the study period, with 54 percent indicating that their health was better than a year ago and 79 percent saying it was better after 2 years of participating in the program. Also, those reporting at least one bed-bound episode in the previous 3 months declined from 43 percent at baseline to 28 percent at the end of followup. All participants maintained baseline functional status. Reprints (AHRQ Publication No. 06-R036) are available from the AHRQ Publications Clearinghouse.

Steinman, M.A., McQuaid, K.R., and Covinsky, K.E. (2006, March). "Age and rising rates of cyclooxygenase-2 inhibitor use." (AHRQ grant HS00006). Journal of General Internal Medicine 21, pp. 245-250.

Use of cyclooxygenase-2 (COX-2) inhibitors for arthritis and other painful or inflammatory conditions rose rapidly in all age groups, particularly the elderly, from 1998 to 2002, according to this study. COX-2 inhibitors are selective nonsteroidal anti-inflammatory drugs (NSAIDs). They generally do not cause the gastrointestinal bleeding associated with use of nonselective NSAIDs like ibuprofen; however, they do increase the risk of cardiovascular problems such as heart attack and stroke. Researchers found that by 2002, COX-2 inhibitors accounted for 67 percent of recorded NSAID use in visits by patients age 65 and older, compared with 33 percent of NSAID use in adults age 18 to 44, and 54 percent in adults age 45 to 64. Also, elderly NSAID users with cardiovascular disease were more likely to receive COX-2 inhibitors than those without cardiovascular disease (86 vs. 66 percent). Recommended co-administration of gastroprotective agents (proton pump inhibitors or misoprostol) with all types of NSAIDs was low for all age groups and for people taking COX-2 inhibitors and nonselective NSAIDs. These findings were based on medication use data from 1998 to 2002 from the National Ambulatory Medical Care Survey, a nationally representative sample of patient visits to community-based outpatient practices.

Zuckerman, I.H., Lee, E., Wutoh, A.K., and others (2006, April). "Application of regression-discontinuity analysis in pharmaceutical health services research." (AHRQ grant HS11673). HSR: Health Services Research 41(2), pp. 550-563.

Health services research is often challenged to evaluate the effectiveness of medical interventions or service programs outside of a controlled environment. For example, it is often not feasible to design a randomized controlled trial. This paper demonstrates how a relatively underused design, regression-discontinuity (RD), can provide robust estimates of medical intervention effects when stronger designs are impossible to implement. The researchers conducted a drug utilization review study to evaluate a letter to doctors treating Medicaid children with potentially excessive use of short-acting beta-agonist inhalers using RD design. They found that RD design was a useful quasi-experimental method that had significant advantages in internal validity compared with other pre-post designs. The findings were based on claims data from a State Medicaid program.

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