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Research Briefs

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Bird, C.E., Fremont, A., Wickstrom, S., and others (2003, July-August). "Improving women's quality of care for cardiovascular disease and diabetes: The feasibility and desirability of stratified reporting of objective performance measures." (AHRQ contract 290-00-0012). Women's Health Issues 13, pp. 150-157.

These authors examined evidence that supports stratifying measures of management of primary and secondary cardiovascular risk factors by sex and discuss potential use of these stratified data. They evaluated differences between male and female patients in rates of receipt of 10 National Committee for Quality Assurance (NCQA) Health Plan Employer Data and Information Set (HEDIS) measures of recommended cardiovascular disease and diabetes care for enrollees in 10 commercial and 9 Medicare plans. They found small to moderate average differences for a number of care quality indicators. Among commercial plan enrollees, an average of 73.6 percent of men and 63.8 percent of women without a contraindication were prescribed a beta-blocker after a heart attack. However, among the three plans with significant male-female differences, all favored men (ranging from an advantage of 23.4 to 40 percentage points). They discuss potential benefits of and barriers to routine stratified reporting of objective performance measures for evaluating quality of care.

Reprints (AHRQ Publication No. 04-R020) are available from the AHRQ Publications Clearinghouse.

Cao, H., Stetson, P., and Hripcsak, G. (2003). "Assessing explicit error reporting in the narrative electronic medical record using keyword searching." (AHRQ grant HS11806). Journal of Biomedical Informatics 36, pp. 99-105.

Identifying medical errors is a critical step for managing and preventing errors. These authors assessed the explicit reporting of medical errors in the narrative sections (discharge summaries, signout notes, and outpatient notes) of the electronic medical records of a medical center from 1991 to 2000. They used five search terms: "mistake," "error," "incorrect," "inadvertent," and "iatrogenic." This keyword search combined with manual review identified 222 explicitly reported medical errors, but it had a low sensitivity and moderate positive predictive value, which varied by search term. The identified errors covered a broad range and were related to several types of care providers as well as non-health care professionals.

Carter, R., Holiday, D.B., Stocks, J., and Tiep, B. (2003, August). "Peak physiologic responses to arm and leg ergometry in male and female patients with airflow obstruction." (HS08774). Chest 124, pp. 511-518.

To examine the work capacity for the arms and legs of patients with moderate to severe chronic obstructive pulmonary disease (COPD), these researchers completed demographic and medical history questionnaires, pulmonary function studies, and peak exercise ergometry with gas exchange for the arms and legs. They also asked patients to rate their assessment of perceived dyspnea and extremity fatigue using Borg scores during exercise. Arm work was reduced by 38 percent of that of the legs. More modest reductions were noted for oxygen uptake and minute ventilation, suggesting greater mechanical efficiency for leg work compared with arm work. These data may help clinicians in prescribing rehabilitation or estimating arm exercise ability when arm testing is unavailable.

Ensign, J. (2003). "Ethical issues in qualitative health research with homeless youths." (AHRQ grant HS11414). Journal of Advanced Nursing 43(1), pp. 43-50.

This author points out the main challenges of conducting qualitative research with homeless youths. These include establishing and maintaining healthy researcher roles and boundaries, addressing the risks of researcher burn-out and safety issues, assuring optimal confidentiality, and avoiding sensationalism and voyeurism. The findings were based on a review of professional guidelines for the ethical conduct of adolescent health research, national and international bioethics bibliographic searches, and personal experiences with qualitative research among homeless youths.

Hartz, A., and Marsh, J.L. (2003). "Methodologic issues in observational studies." (AHRQ grant HS10739). Clinical Orthopaedics and Related Research 413, pp. 33-42; and Hartz, A., Benson, K., Glaser, J., and others (2003). "Assessing observational studies of spinal fusion and chemonucleolysis." (AHRQ grant 10739). Spine 28, pp. 2268-2275.

The first of these papers explores the methodologic issues in observational studies. The authors point out that all observational studies should report factors influencing relevance (characteristics of patients, treatments, and outcome measures), and factors that influence validity (methods to obtain information and patient risk factors that may differ between treatments). They assert that improved standards for reporting observational studies will facilitate the interpretation of results and the comparison of studies with conflicting results. In the second study, the researchers reviewed the literature to find several observational studies that compared the same spinal surgeries. They identified potential confounding factors by a survey of spinal surgeons. Results suggest that review of several comparable observational studies may help evaluate treatment, identify patient types most likely to benefit from a given treatment, and provide information about study features that can improve the design of subsequent observational or randomized controlled studies.

Hays, R.D., Chong, K., Brown, J., and others (2003, September). "Patient reports and ratings of individual physicians: An evaluation of the DoctorGuide and Consumer Assessment of Health Plans Study provider-level surveys." (AHRQ grant HS9204). American Journal of Medical Quality 18(5), pp. 190-196.

Because consumers place a high value on being able to choose their doctors, there is increasing interest in assessing health care delivered at the individual physician level. This study compared physician-level survey instruments, the Consumer Assessment of Health Plans Study (CAHPS®) survey and the DoctorGuide survey, to estimate the number of patients needed per physician to provide reliable estimates of health care. The researchers mailed surveys to patients of 100 primary care physicians in three health plans and one large physician group. A total of 4,245 CAHPS® surveys and 5,519 DoctorGuide surveys were returned. The number of patient responses needed to obtain a reliability of 0.70 at the physician level for the access to care, communication, and preventive care scales was similar for both survey instruments, suggesting parallel psychometric performance.

Heslin, K.C., Andersen, R.M., and Gelberg, L. (2003, September). "Use of faith-based social service providers in a representative sample of urban homeless women." (AHRQ grant HS08323). Journal of Urban Health 80(3), pp. 371-382.

This survey of 974 homeless women in Los Angeles found that 52 percent of those surveyed were using the services of faith-based providers. Homeless women with no religious affiliation were less likely than Christian women to use faith-based providers, and blacks and Latinas were less likely than white women to use them. The benefits of increased funding through a Federal faith-based policy initiative may accrue primarily to subgroups of clients already using faith-based programs, conclude the researchers. They interviewed homeless women at 78 homeless shelters and meal programs in Los Angeles County.

Hope, C., Overhage, J.M., Seger, A., and others (2003). "A tiered approach is more cost effective than traditional pharmacist-based review for classifying computer-detected signals as adverse drug events." (AHRQ grant HS11169). Journal of Biomedical Informatics 36, pp. 92-98.

These investigators compared the sensitivity and cost of two approaches to identifying outpatient adverse drug events (ADEs) and medical errors (MEs) using electronic medical records and human review at two health care systems. A traditional pharmacist-based review process was used at one site while a tiered approach—using tiers of layers of personnel of varying expertise—was used at the other. The proportion of computer-generated signals identified as ADEs was similar using the two approaches, while the number of MEs was nearly double with tiered reviews, suggesting the same or better sensitivity. The tiered approach cost $42.40 to detect an ADE compared with $68.70 for the traditional pharmacist review. Thus, the tiered approach was more cost-efficient.

Hripcsak, G., Bakken, S., Stetson, P.D., and Patel, V.L. (2003). "Mining complex clinical data for patient safety research: A framework for event discovery." (AHRQ grant HS11806). Journal of Biomedical Informatics 36, pp. 120-130.

Given the volume of patients seen at medical centers, detecting medical events automatically from electronic medical record data would greatly facilitate patient safety work. Toward that end, these authors created a framework for electronic detection. Key steps include: selecting target events, assessing what information is available electronically, transforming raw data such as narrative notes into a coded format, querying the transformed data, verifying the accuracy of event detection, characterizing the events using systems and cognitive approaches, and using what is learned to improve detection.

Kivimaki, M., Head, J., Ferrie, J.E., and others (2003, August). "Sickness absence as a global measure of health: Evidence from mortality in the Whitehall II prospective cohort study."(AHRQ grant HS06516). British Medical Journal 327, pp. 364-368.

Routinely collected sickness-related work absence data could be used as a global measure of health differentials between employees. However, such approaches should focus on medically certified or long-term absences rather than self-certified absences, according to this study. The researchers examined the association between sickness absence and mortality compared with associations between established health indicators and mortality. They used results from a medical exam and survey conducted in 1985-1988 and sickness absence records from 1985-1998 for personnel at 20 civil service departments in London. In a multivariate model including numerous health indicators and additional health risk factors, medically certified sickness absence (but not self-certified absence) remained a significant predictor of mortality.

Paneth, N., Qiu, H., Rosenbaum, P., and others (2003, September). "Reliability of classification of cerebral palsy in low-birth weight children in four countries." (AHRQ grant HS08385). Developmental Medicine and Child Neurology 45(9), pp. 628-633.

This study assessed the reliability of classification of cerebral palsy (CP) in low birthweight children (2 to 8 years of age) by using clinical and research study records sampled from population-based cohort studies in the United States, the Netherlands, Canada, and Germany. The researchers submitted records of neurological examination findings and functional motor assessments to up to five pediatricians with expertise in CP diagnosis, who grouped children into three categories: disabling CP, non-disabling CP, and no CP. Discrimination between any CP and no CP was only fair. However, when motor function information was used, children with disabling CP could be distinguished on the basis of records from those without CP or non-disabling CP.

Rudy, E.T., Detels, R., Douglas, W., and Greenland, S. (2003, May). "Factors affecting hepatitis vaccination refusal at a sexually transmitted disease clinic among men who have sex with men." (AHRQ training grant T32 HS00046). Sexually Transmitted Diseases 30(5), pp. 411-418.

Rates of vaccination for hepatitis A virus (HAV) and hepatitis B virus (HBV) among men who have sex with men (MSM) attending sexually transmitted disease (STD) clinics are suboptimal. This survey of MSM eligible for vaccinations at one STD clinic identified a few factors affecting vaccination refusals. Rates of refusal of HAV and HBV were 36 percent and 38 percent, respectively. Health motivation was associated with acceptance, while clinical barriers such as "want to test first for immunity" and "want to talk to own doctor first" were associated with refusal. "Not enough time this evening" was most strongly predictive of refusal and may be a partial excuse. Clinic staff should address other factors that may underlie refusal.

Saint, S., Zemencuk, J.K., Hayward, R.A., and others (2003). "What effect does increasing inpatient time have on outpatient-oriented internist satisfaction?" (AHRQ grant HS11540). Journal of General Internal Medicine 18, pp. 725-729.

Findings from this study imply that there may be a tension between the practice of inpatient and outpatient medicine by general internists and suggest that fewer hospital duties may increase career satisfaction for outpatient-oriented internists. The investigators analyzed responses from 339 clinically active outpatient-oriented general internists to a national survey that measured sociodemographic and practice characteristics of physicians, as well as aspects of job satisfaction. Even after controlling for total hours worked and other factors, they found that increased time working in the hospital was significantly associated with decreased satisfaction with administration, specialty, autonomy, and personal time and significantly associated with an increase in life stress and burnout.

Schneeweiss, S., Wang, P.S., Avorn, J., and Glynn, R.J. (2003, August). "Improved comorbidity adjustment for predicting mortality in Medicare populations." (AHRQ grant HS10881). Health Services Research 38(4), pp. 1103-1120.

In epidemiologic studies of the elderly, a modified diagnosis-based score using empirically derived weights provides improved adjustment for comorbidity and enhances the validity of findings, concludes this study. The goal was to define and improve the performance of existing comorbidity scores in predicting mortality in Medicare enrollees. The researchers computed frequently used comorbidity scores for 235,881 New Jersey Medicare enrollees in 1994 and 230,913 Pennsylvania Medicare enrollees in 1995 to determine 1-year mortality during the following year. A score based on ICD-9 diagnoses (Romano score) performed 60 percent better than one based on patterns of medication use (Chronic Disease Score). The Romano score was slightly improved by including the number of different prescription drugs used during the past year. It was further improved when elderly-specific weights for 17 conditions included in the score were considered.

Sherman, K.J., and Cherkin, D.C. (2003, September). "Developing methods for acupuncture research: Rationale for and design of a pilot study evaluating the efficacy of acupuncture for chronic low back pain." (AHRQ grant HS09989). Alternative Therapies 9(5), pp. 54-60.

Despite the publication of more than 10 randomized trials evaluating acupuncture as a treatment for chronic low back pain, its efficacy and effectiveness for this common problem remains unclear due to poorly designed studies. These authors discuss the rationale for and design of a five-arm randomized controlled pilot clinical trial that addresses the major methodological shortcomings of previous studies (for example, poorly justified treatment and control groups and lack of masking). The pilot study also lays the groundwork for a full-scale trial evaluating acupuncture as a treatment for chronic low back pain.

Shiffman, R.N., Shekelle, P., Overhage, M., and others (2003). "Standardized reporting of clinical practice guidelines: A proposal from the conference on guideline standardization." (AHRQ grant HS10962). Annals of Internal Medicine 139, pp. 493-498.

The quality of clinical practice guidelines varies considerably. The Conference on Guideline Standardization (COGS) was convened in April 2002 to define a standard for guidelines reporting that would promote guideline quality and facilitate implementation. A group of 23 guideline experts agreed on which guideline components they considered to be necessary. In a second round of discussions, they rated necessity for validity and necessity for practical application, eventually resulting in a number of items considered as necessary guideline components. After their review by representatives of 22 organizations active in guideline development, items were consolidated into 18 topics to create the COGS checklist. This checklist provides a framework to support more comprehensive documentation of practice guidelines.

Sirio, C.A., Segel, K.T., Keyser, D.J., and others (2003, September). "Pittsburgh Regional Healthcare Initiative: A systems approach for achieving perfect patient care." (AHRQ grant HS11926). Health Affairs 22(5), pp. 157-165.

This paper describes the Pittsburgh Regional Healthcare Initiative (PRHI), an innovative model to improve health care on a regional basis. By linking patient outcomes data with processes of care and sharing that information widely, PRHI supports measurable improvements in region-wide clinical practice and patient safety. In addition, through the redesign of problem solving at the front lines of care, PRHI helps health care organizations to evolve toward becoming sustainable systems of high quality patient care. The authors detail PRHI's design for change, review the progress and limitations of the shared learning model, and offer a set of broader policy considerations.

Spettell, C.M., Wall, T.C., Allison, J., and others (2003). "Identifying physician-recognized depression from administrative data: Consequences for quality measurement." (AHRQ grant HS09446). Health Services Research 38(4), pp. 1081-1102.

Several factors limit identification of patients with depression from administrative data, which are often used to drive many quality measurement and reporting systems. This study's findings raise concern about interpreting depression quality reports based on administrative data. The authors investigated two algorithms for identification of physician-recognized depression among a sample of patients of primary care physicians of a large managed care organization. The first algorithm required at least two criteria in any combination: an outpatient diagnosis of depression or a pharmacy claim for an antidepressant. Algorithm 2 included the same criteria, but required a diagnosis of depression for all patients. Both algorithms had high false-positive rates.

Swanson, K.A., Andersen, R., and Gelberg, L. (2003). "Patient satisfaction for homeless women." (AHRQ grant HS08323). Journal of Women's Health 12(7), pp. 675-686.

Homeless women are not very satisfied with the care they receive, concludes this study. The researchers interviewed 974 homeless women from 60 shelters and 18 meal programs in Los Angeles County about satisfaction with the care they receive. Care satisfaction was associated with care at homeless-focused health care sites (shelter/outreach clinics and mobile vans). Health care at private doctors' offices was also associated with quality, access, and appointment satisfaction when compared with care received at county/government clinics. The researchers suggest that policymakers encourage health care sites that serve homeless women to improve their care by learning from shelter-outreach clinics and private doctors.

Weinger, M.B., Slagle, J., Jain, S., and Ordonez, N. (2003). "Retrospective data collection and analytical techniques for patient safety studies." (AHRQ grant HS11521). Journal of Biomedical Informatics 36, pp. 106-119.

This paper provides an overview of some of the methods available to collect and analyze retrospective data about medical errors, near misses, and other relevant patient safety events. Second, it introduces a methodological approach that focuses on non-routine events (NRE), defined as all events that deviate from optimal clinical care. Using this approach, the authors identified 27 percent of completed anesthetic cases that contained a non-routine event, of which 17 percent had patient impact, and 7 percent led to patient injury. Using traditional quality improvement processes in the same hospitals over a 2-year period identified only 0.7 to 2.7 percent of NREs; 89 percent had patient impact, and 55 percent led to patient injury. These findings show the potential value of the NRE approach for early detection of risks to patient safety.

Wyrich, K.W., Nelson, H.S., Tarn, W.M., and others (2003, August). "Clinically important differences in health-related quality of life for patients with asthma: An expert consensus panel report."(AHRQ grant HS10234 and HS11635). Annals of Allergy, Asthma, and Immunology 91, pp. 148-153.

These investigators organized an eight-person panel of expert physicians familiar with measuring health-related quality of life (HRQOL) to reach consensus on clinically important difference (CID) standards for small, moderate, and large changes in the Juniper Asthma Quality of Life Questionnaire (AQLQ) and Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) for patients with asthma. The expert panel's thresholds for detecting CIDs in the domains of the AQLQ were much higher than previously established levels using patient-perceived changes. CIDs for asthma for the SF-36 were also markedly greater than previously cited cross-sectional differences between patient groups. Thus, the expert panel's CID standards identify a potential distinction between patient and physician perspectives of important HRQOL changes in patients with asthma.

Youngblade, L.M., and Shenkman, E.A. (2003). "Congruence between parents' and adolescents' reports of special health care needs in a Title XXI program." (AHRQ grant HS10465). Journal of Pediatric Psychology 28(6), pp. 393-401.

Parents and adolescents tend to agree on whether or not the adolescent has a special health care need, according to this study. Using the Children with Special Health Care Needs (CSHCN) Screener, the researchers conducted telephone surveys with 522 adolescents and their parents who were new enrollees in Florida's State Children's Health Insurance Program. Analyses revealed substantial agreement as to whether or not the adolescent had a chronic condition. However, a full 15 percent of pairs disagreed, usually for parents reporting adolescents' mental health conditions that the adolescents did not report. These results showed higher parent-adolescent congruence using the consequence-based CSHCN screener than is typically reported for diagnosis-based approaches.

Yu, F., Morgenstern, H., Hurwitz, E., and Berlin, T.R. (2003). "Use of a Markov transition model to analyze longitudinal low-back pain data." (AHRQ grant HS07755). Statistical Methods in Medical Research 12, pp. 321-331.

These investigators used a Markov transition model to analyze longitudinal data on low back pain for 681 adult managed care patients with low back pain. The patients were randomized to four treatment groups: medical care with and without physical therapy, and chiropractic care with and without physical modalities. Followup information (including the patient's perception of pain) via questionnaires was obtained at 2 and 6 weeks, 6, 12, and 18 months, and by telephone interview at 4 weeks. Since a patient's perception of improvement may be influenced by past experience, the outcome was analyzed using a transitional Markov model. This approach allowed the researchers to assess not only the effects of treatment assignment and baseline characteristics, but also the effects of past outcomes in analyzing the longitudinal data.

Zhang, J., Johnson, T.R., Patel, V.L., and others (2003). "Using usability heuristics to evaluate patient safety of medical devices." (AHRQ grant HS11544). Journal of Biomedical Informatics 36, pp. 23-30.

Heuristic evaluation, when modified for medical devices, is a useful, efficient, and low cost method for evaluating patient safety features of medical devices through the identification of usability problems and their severities, concludes this study. The researchers modified heuristic evaluation—a usability inspection method commonly used for software usability evaluation—and extended it for medical devices. They used the modified method to evaluate and compare the patient safety of two one-channel volumetric infusion pumps. The method categorized 192 heuristic violations for 89 usability problems identified for pump 1 and 121 heuristic violations for the 52 usability problems identified for pump 2.

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