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

Despite the age and frailty of home health care recipients and the complexity of care that puts them at risk, adverse events in home health care have received little attention, note the authors of this paper. They describe the components of an informatics infrastructure for patient safety and evidence-based practice (EBP) in home health care. These include data acquisition methods, health care standards, data repositories and clinical event monitors, data-mining techniques, digital sources of evidence, and communication technologies. These components and the applications that bring them together to promote patient safety and enable EBP have shown promising results in the acute care setting. Yet, a number of challenges hinder their implementation in home health care. The authors detail these challenges and call on key stakeholders to resolve them.

Beach, M.C., Roter, D., Larson, S., and others (2004, September). "Is physician self-disclosure related to patient evaluation of office visits?" and "What do physicians tell patients about themselves?" (AHRQ grant HS07289) Journal of General Internal Medicine 19, pp. 905-910, 911-916.

Physician self-disclosure is a physician's description of a personal experience that has medical and/or emotional relevance for the patient. It has been viewed either positively (fosters trust and rapport) or negatively (violates professional boundaries). The first study of audiotaped primary care and surgical visits found that physician self-disclosure was significantly associated with higher patient satisfaction ratings for surgical visits and lower ratings for primary care visits. The second study of audiotaped routine office visits revealed that self-disclosing statements that were self-preoccupied or intimate were rare. Self-disclosure generally fell into the following categories: reassurance ("I've used quite a bit of that medicine myself"), counseling (usually intended to guide action, such as "I just got my flu shot"), rapport-building, casual, intimate ("I cried a lot with my divorce too"), and extended narratives, which were generally irrelevant to the patient.

Begun, J.W., and Jiang, H.J. (2004). "Changing organizations for their likely mass-casualties future." Advances in Health Care Management 4, pp. 163-180.

The threat of bioterrorism presents an opportunity for health care organizations to transform into more resilient learning organizations, according to these authors. They recommend that rather than focusing solely on preparing for what might be expected in a bioterrorist attack, organizations strengthen their infrastructures to better manage surprises of all types. They advocate a combination of guidelines that advocate leadership commitment, self-organization, culture change, and interorganizational connections. In self-organization, people and groups interact with one another in the absence of an overall system-wide blueprint. Informal networks are formed through self-organization so that different expertise can be rapidly pooled to handle a crisis.

Reprints (AHRQ Publication No. 05-R004) are available from the AHRQ Publications Clearinghouse.

Breugelmans, J.G., Ford, D.E., Smith, P.L., and Punjabi, N.M. (2004). "Differences in patient and bed partner-assessed quality of life in sleep-disordered breathing." (AHRQ grant HS10786). American Journal of Respiratory and Critical Care Medicine 170, pp. 547-552.

Sleep-disordered breathing (SDB) is a chronic condition that is characterized by frequent episodes of partial or complete upper airway collapse that usually interrupts sleep. It often causes daytime sleepiness and impaired quality of life. Bed-partner ratings can be useful in evaluating the quality of life of patients with SDB, concludes this study. Patients with SDB generally rated their quality of life (physical functioning, general health, and vitality) higher than their respective bed partners. Yet, no differences were noted in the self-assessments of quality of life done by people without SDB or by their bed partners. Results are based on responses to a questionnaire assessing quality of life by 122 patients with SDB and their bed partners and by 15 people without SDB and their bed partners.

Clarke, P.S. (2004, July). "Causal analysis of individual change using the difference score." (AHRQ grant HS06516). Epidemiology 15(4), pp. 414-421.

Causal analysis of change in time-related characteristics such as health or disease is an increasingly important area of epidemiology. This article focuses on analyzing individual change by asking whether exposure affects the way in which individuals change over time. Longitudinal studies are used in social epidemiology to measure the effect of social exposures (such as socioeconomic status) on health. In areas such as clinical epidemiology, longitudinal intervention studies allow assessment of whether drug exposure slows or halts disease progression. Thus, the focus is on individual change rather than change in population characteristics such as prevalence. The authors illustrate this approach by applying it to data from the Whitehall II study of British civil servants.

Deshefy-Longhi, T., Dixon, J.K., Olsen, D., and Grey, M. (2004). "Privacy and confidentiality issues in primary care: Views of advanced practice nurses and their patients." (AHRQ grant HS11196). Nursing Ethics 11(4), pp. 378-393.

These authors discuss the concepts of privacy and confidentiality in relation to health care information in primary health care settings. They also present findings from patient and nurse practitioner focus groups, which were held to elicit concerns of the two groups regarding privacy and confidentiality in their respective primary care settings. The focus groups were held prior to the implementation of the Health Insurance Portability and Accessibility Act in the United States, which set standards for individual health information security to assure privacy of such information. Even this law contains phrases such as "minimum necessary disclosures of protected health information," which are open to a range of interpretations by all parties involved.

Feurer, I.D., Moore, D.E., Speroff, T., and others (2004). "Refining a health-related quality of life assessment strategy for solid organ transplant patients." (AHRQ grant HS13036). Clinical Transplantation 19(Suppl 12), pp. 39-45.

These researchers evaluated three generic health-related quality of life (HRQOL) assessment instruments to identify a reliable, valid, and non-redundant battery to measure outcomes in organ transplant patients. They assessed functional performance and HRQOL in 371 liver, heart, kidney, and lung transplant patients using the Karnofsky scale, the SF-36 Health Survey, and Psychosocial Adjustment to Illness Scale (PAIS). The SF-36 mental and physical components and PAIS summary scales were internally consistent, but statistically redundant (except for the PAIS). Thus, either one could be used to measure generic HRQOL in solid organ transplant candidates and recipients. The SF-36 has the advantages of wider use, more norms, and lesser response burden. The researchers developed a transplant-specific patient satisfaction inventory in place of the more generic PAIS.

Fiore, M.C., Croyle, R.T., Curry, S.J., and others (2004). "Preventing 3 million premature deaths and helping 5 million smokers quit: A national action plan for tobacco cessation." American Journal of Public Health 94(2), pp. 205-210.

In August 2002, the Interagency Committee on Smoking and Health (ICSH) Subcommittee on Cessation was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The goals were to help 5 million smokers quit within 1 year, reduce the national smoking rate by at least 10 percent within a year, deter 6 million youths from becoming smokers, and prevent 3 million premature deaths. Examples of recommendations include: create a national toll-free Tobacco Cessation Quitline to be managed by the States; launch a paid national media campaign to encourage Americans to quit using tobacco; include tobacco cessation medication and counseling in benefits provided in all federally funded health insurance programs; and invest in training and education to ensure that all U.S. clinicians are competent to help their patients quit tobacco use.

Reprints (AHRQ Publication No. 05-R003) are available from the AHRQ Publications Clearinghouse.

Johantgen, M., Trinkoff, A., Gray-Siracusa, K., Muntaner, C., and Nielsen, K. (2004). "Using state administrative data to study nonfatal worker injuries: Challenges and opportunities." (AHRQ grant HS11990). Journal of Safety Research 35, pp. 309-315.

Despite some limitations, State administrative data are an untapped resource that can be used to study nonfatal worker injury patterns and etiologies, concludes this study. The researchers used State administrative databases to examine organizational influences on both worker and patient injuries in hospitals and nursing homes in four States. Worker injury data varied in terms of inclusion criteria, variables, and coding schemes used. Linkages to organizational level characteristics can be difficult. Nevertheless, as State worker compensation data systems become more consistent, administrative data can provide a clearer understanding of the variations and etiologies of worker injury.

Konetzka, R.T., Spector, W., and Shaffer, T. (2004, October). "Effects of nursing home ownership type and resident payer source on hospitalization for suspected pneumonia." Medical Care 42(10), pp. 1001-1008.

The risk of hospitalization for suspected pneumonia varies widely by nursing home ownership type and resident payer source, with the lowest overall risk for residents of not-for-profit nursing homes, found this study. The investigators analyzed data from the 1996 Medical Expenditure Panel Survey Nursing Home Component, a nationally representative sample of 5,899 nursing home residents in 815 facilities. They used regression analysis to assess factors affecting the decision to hospitalize the 766 elderly residents with suspected pneumonia. Residents with suspected pneumonia in not-for-profit facilities were hospitalized at a rate half that of for-profit facilities. The difference was most pronounced for residents who were older and more cognitively impaired and for those who were covered by Medicare or private funds.

Reprints (AHRQ Publication No. 05-R002) are available from the AHRQ Publications Clearinghouse.

Kumari, M., Head, J., and Marmot, M. (2004, September). "Prospective study of social and other risk factors for incidence of type 2 diabetes in the Whitehall II study." (AHRQ grant HS06516). Archives of Internal Medicine 164, p. 1873-1880.

An inverse relationship exists between social position and incidence of diabetes that is partly explained by health behaviors and other risk factors, concludes this study. The investigators prospectively studied the diagnosis of diabetes among 10,308 British civil servants at baseline (1985-1988) and followup at phases 2 (1989), 3 (1992-1993), 4 (1995), and 5 (1997-1999); they studied glucose tolerance tests in phases 3 and 5. The incidence of diabetes was twice as high for women and three times as high for men in the lower employment grades, compared with workers in higher employment grades. High body mass index and other risk factors considered traditional for type 2 diabetes were found in the lower employment group.

Luo, W., Wang, F., and Douglass, C. (2004, June). "Temporal changes of access to primary health care in Illinois (1990-2000) and policy implications." (AHRQ grant HS11764). Journal of Medical Systems 28(3), pp. 287-299.

These authors examined temporal changes of access to primary health care in Illinois between 1990 and 2000. They used census data in 1990 and 2000 to define the population (demand), distribution, and related socioeconomic attributes. They used the Physician Masterfile of the American Medical Association in corresponding years to define the physician (supply) distribution at the zip code level. They measured spatial access by considering locations of physicians and populations and the travel times between them. Spatial accessibility to primary care physicians for the majority of the State improved over the study period. Worsened accessibility was primarily concentrated in rural areas, some limited pockets in urban areas, and among populations that were socioeconomically disadvantaged, had sociocultural barriers to care access, or had increased health care needs.

Macnee, C.L., and McCabe, S. (2004). "Satisfaction with care among homeless patients: Development and testing of a measure." (AHRQ grant HS09834). Journal of Community Health Nursing 21(3), pp. 167-178.

The purpose of this study was to establish the reliability and validity of the Homeless Satisfaction with Care Scale (HSCS) and to examine selected predictors of satisfaction with care. The investigators compared the newly developed measure of satisfaction with two established satisfaction measures in a sample of 168 homeless clients who used either a rural or urban clinic. The HSCS was reliable and valid. Generally, patient characteristics were not associated with satisfaction level. However, black homeless clients were significantly less satisfied than their white counterparts, and satisfaction differed between rural and urban sites. The researchers conclude that HSCS provides an appropriate measure of satisfaction with care for future studies of the homeless.

Maiuro, L.S., Schneider, H., and Bellows, N. (2004, September). "Endangered species? Not-for-profit hospitals face tax-exemption challenge." (AHRQ grant T32 HS00086). Healthcare Financial Management, pp. 74-77.

Not-for-profit hospitals have been under increased scrutiny as local and State governments have placed more emphasis on holding these hospitals accountable to their communities for their tax-exempt benefits. As yet, there is no consensus on how charity care or community benefits should be measured. Results of one study by the authors disclosed a 26-fold difference in average hospital costs, depending on how charity care was defined. Differences in how States define charity care could have a bearing on any State's decision about whether or not a hospital should be allowed to retain its tax-exempt status, note the authors. They discuss the issues involved and suggest what hospital leaders can do to retain their tax-exempt status.

Poker, A., Hubbard, H., and Collins, B.A. (2004, December). "The first national reports on United States healthcare quality and disparities." Journal of Nursing Care Quality 19(4), pp. 316-321.

In the Healthcare Research and Quality Act of 1999, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce annual reports on health-related quality and disparities in the United States. AHRQ released the first National Healthcare Quality Report and the first National Healthcare Disparities Report in 2003. The second reports will be released in the near future. These reports include broad sets of performance measures to portray the Nation's progress toward improving the quality of care provided to all Americans. This article provides an overview of the framework, development, and future uses of the reports by consumers, practitioners, researchers, and policymakers.

Reprints (AHRQ Publication No. 05-R001) are available from the AHRQ Publications Clearinghouse.

Reis, B.Y., and Mandl, K.D. (2004, September). "Syndromic surveillance: The effects of syndrome grouping on model accuracy and outbreak detection." (AHRQ contract no. 290-00-0020). Annals of Emergency Medicine 44(3), pp. 235-241.

This study examined the effects of different syndrome grouping methods on model accuracy, a key factor in the ability of syndrome surveillance systems to detect disease outbreaks. The researchers analyzed daily emergency department visit rates from two urban hospitals for 1,680 consecutive days. They used three methods to group the visits into a respiratory-related syndrome category: relying on the patient's chief complaint, relying on diagnostic codes, or relying on a combination of the two. For both hospitals, the data grouped according to chief complaint alone yielded the lowest model accuracy and lowest detection sensitivity. Diagnostic codes yielded better accuracy and sensitivity. Combining the two methods yielded the best result in accuracy and sensitivity for detecting disease outbreaks.

Schmid, C.H., Stark, P.C., Berlin, J.A., and others (2004). "Meta-regression detected associations between heterogeneous treatment effects and study-level, but not patient-level, factors." (AHRQ grant HS10064). Journal of Clinical Epidemiology 57, pp. 683-697.

Randomized controlled trials collected for meta-analysis often exhibit substantial heterogeneity of treatment effects. Meta-regression can detect interactions of treatment with study-level factors when treatment effects are heterogeneous. However, individual patient data are needed for patient-level factors and homogeneous effects, concludes this study. The researchers used two investigations to evaluate Bayesian meta-regression for detecting treatment interactions. In the first meta-analysis of studies on the use of angiotensin converting enzyme (ACE) inhibitors for nondiabetic kidney disease, treatment effects were homogeneous, so meta-regression identified no interactions. However, analysis of individual patient data revealed that treatment reduced the glomerular filtration rate more among patients with higher baseline proteinuria.

Stahl, J.E., Rattner, D., Wiklund, R., and others (2004). "Reorganizing the system of care surrounding laparoscopic surgery: A cost-effectiveness analysis using discrete-event simulation." (AHRQ grant HS11637). Medical Decision Making 24, pp. 461-471.

These investigators used discrete-event simulation methods to compare the cost-effectiveness of currently used laparoscopic surgery with a new modular system in which patient care is handed off between two anesthesiologists. In the current system, an individual anesthesiologist remains with and is responsible for the patient from anesthesia induction through surgery and recovery. Results found the new strategy to be more effective but with similar costs to the current strategy ($5,327 vs. $5,289 average cost per patient day), with an incremental cost-effectiveness of $318 per additional patient treated per day. The surgical mortality rate must be over 4 percent or hand-off delay longer than 15 minutes before the new strategy is no longer more effective.

Taylor, S.L., Burnam, M.A., Sherbourne, C., and others (2004). "The relationship between type of mental health provider and met and unmet health needs in a nationally representative sample of HIV-positive patients." (AHRQ grant HS08578). Journal of Behavioral Health Services & Research 31(2), pp. 149-163.

Researchers used data from the HIV Cost and Services Utilization Study (HCSUS) mental health survey of 1,489 HIV-positive individuals conducted in 1997 and 1998 to examine the use of mental health services or perceived need for such services among adults with HIV and psychiatric disorders. They found that 70 percent of individuals with HIV needed mental health care. Of these, 30 percent had received no mental health services in the previous 6 months, 16 percent had received services from general medical providers only, and 54 percent had used mental health specialists. Patients who thought they needed mental health care were more likely to receive mental health services and to receive them from a mental health specialist (versus generalist) than those who had mental disorders but did not perceive a need for care.

Woolf, S.H., Kuzel, A.J., Dovey, S.M., and Phillips, R.L. (2004). "A string of mistakes: The importance of cascade analysis in describing, counting, and preventing medical errors." (AHRQ grant HS11725). Annals of Family Medicine 2(4), pp. 317-326.

Cascade analysis of physicians' error reports is helpful in understanding the precipitant chain of events, but physicians provide incomplete information about how patients are affected, according to this study. Miscommunication appears to play an important role in propagating diagnostic and treatment mistakes. Overall, 18 U.S. family physicians participating in a six-country international study filed 75 anonymous error reports. The researchers examined their narratives to identify the chain of events and predominant proximal errors, as well as the consequences to patients. The researchers documented a chain of errors in 77 percent of incidents. Physicians acknowledged that the patient was harmed in only 43 percent of cases in which their narratives described harms.

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