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Bertakis, K.D. and Azari, R. (2007, November). "Patient gender and physician practice style." (AHRQ grant HS06167). Journal of Women's Health 16(6), pp. 859-868.

This study found that the content of women's visits to primary care doctors differs from that of men's visits. Researchers randomized 315 women and 194 men, who were new patients, to care by 105 primary care doctors. They collected data during a previsit interview on sociodemographic characteristics, health status, and lifestyle behaviors. They videotaped the entire medical visit for analysis of physician practice behaviors.

There was no significant gender difference in visit length or work intensity; however, women's visits involved more discussions about the result of therapeutic interventions, more preventive services, less physical examination, and fewer discussions about tobacco, alcohol, and other substance abuse. Since visit lengths were similar, spending more time on pelvic and breast exams may have precluded the physician from being able to perform more physical exams on women. The findings support other work showing that tobacco and alcohol abuse in women are under-diagnosed and undermanaged.

Cook, K.F., Taylor, P.W., Dodd, B.G., and others (2007). "Evidence-based practice for equating health status items: Sample size and IRT model." (AHRQ grant HS11040). Journal of Applied Measurement 8(2), pp. 175-189.

Developing new health outcome measures requires the testing of candidate items. To reduce the response burden, the pool of items is generally divided among two or more study samples. Since response scores to the items on the two or more forms are not equivalent, they require equating or adjusting to a common mathematical metric.

The authors of this paper tested the effects of sample size, test size, and the selection of item response theory (IRT) model in equating three forms of a health status measure. They found that the quality of equatings was greatly affected by sample size, much more so than the IRT model used or the test size. Their most noteworthy finding was the degree of variability in results when sample size was small. After systematically varying sample sizes (between 100 and 2,000 of an entire sample of 3,358 respondents to the Health of Seniors Survey), they concluded that a sample size of less than 300 was unacceptable; 300 to 500, fair; 750 to 1500, good; and 1500 and above, very good.

Darmody, J., Pawlak, R., Hook, M., and others (2007, July). "Substitution of hospital staff in concurrent utilization review." (AHRQ grant HS10667). Journal of Nursing Care Quality 22(3), pp. 239-246.

Insurers typically require hospitals to use utilization review to contain costs by reducing unnecessary or inappropriate medical care. Hospital staff other than registered nurses (RNs) can competently perform concurrent utilization review (CUR), which would allow RNs more time for patient care tasks and save the hospital money, according to this study.

Participating hospitals must free up staff (usually RNs) to report information based on requests from the insurance-based reviewers. Researchers analyzed the results of CURs by 37 staff in four job categories at an academic medical center. During the 2-year study, an average of 26,636 CURs were conducted for 39,196 admissions (about 33 percent of patients).

The study found no difference in the proportion of reimbursement denials at one hospital, whether the CURs (which took about 16 minutes) were performed by trained case managers (hospital cost of $9.25 per review), case manager associates ($4.78), social workers ($7.71), or RNs ($7.24). Less than 1 percent of reviews resulted in denial of certification for reimbursement, which is comparable with results of other studies.

Feurer, I.D., Russell, R.T., and Pinson, C.W. (2007, June). "Incorporating quality of life and patient satisfaction measures into a transplant outcomes assessment program: Technical and practical considerations." (AHRQ grant HS13136). Progress in Transplantation 17(2), pp. 121-128.

The authors of this paper summarize methods for incorporating the measurement of health-related quality of life (HRQOL) and patient satisfaction into a program assessing organ transplant outcomes. They also introduce basic terminology and psychometric concepts related to evaluating and selecting surveys.

The authors describe the evolution and current structure of the HRQOL outcomes assessment program at Vanderbilt Transplant Center, including an overview of the development and use of a transplant setting-specific patient satisfaction inventory. This inventory is a collection of six parallel forms that query patients' satisfaction with the transplantation system at different time points. It includes ten content themes, which range from understanding the risks and benefits of clinical processes to understanding out-of-pocket financial obligations.

In developing this inventory as part of a survey, the authors stress the importance of such considerations as the psychometric qualities of published instruments and handling of missing data, the breadth of construct representation, and the inclusion of preference-based utility measures.

Forrest, C.B., Sahadmi, E., Nutting, P.A., and Starfield, B. (2007, July-August). "Specialty referral completion among primary care patients: Results from the ASPN referral study." (AHRQ grant HS09377). Annals of Family Medicine 5(4), pp. 361-367.

Patients who have known their primary care doctor awhile, and whose doctor or staff help them schedule their specialty appointment, are more likely to complete referrals to specialists, according to a new study. The researchers observed a group of 776 patients referred to specialists from the offices of 133 doctors in 81 practices and 30 States. The most common reason for referral was to obtain a therapeutic procedure (for example, surgery) or diagnostic test (for example, endoscopy). Physicians reported that 79.2 percent of patients referred had a specialist visit, and 83 percent of patients indicated they had seen the specialist to whom they had been referred.

The most common reasons for not completing the referral were lack of time (37.3 percent) and patient belief that the health problem had resolved (47.5 percent). In 26.5 percent of cases, the patient disagreed with the physician on the need for referral. Medicaid-insured patients were less likely than others to complete the referral, and were more likely to experience a health plan denial. Scheduling the appointment with the specialist at the time the referral was made had a strong positive effect on referral completion.

Gallagher, T.H., Denham, C.R., Leape, L.L., and others (2007, September). "Disclosing unanticipated outcomes to patients: The art and practice." (AHRQ grants HS14012 and HS16658). Journal of Patient Safety 3(3), pp. 158-165.

Ethicists and professional organizations have long recommended the disclosure of unanticipated outcomes to patients. This practice is also increasingly being mandated by hospital accreditation requirements and some State laws. Yet, research shows that there is infrequent disclosure of both unanticipated outcomes and harmful errors in patient care. The authors of this paper argue that disclosure is a part of patient-centered care and a core patient safety activity. They also see disclosure as reflecting the core institutional value of transparency.

The authors describe a National Quality Forum (NQF) Safe Practice on disclosure of serious unanticipated events and list steps that organizations can take to implement it. The NQF Safe Practice outlines a process for disclosure and describes an institutional disclosure support system that includes policies, education, coaching, and emotional support for caregivers.

Citing recent research, the authors conclude that the likelihood of negative lawsuit outcomes could well diminish following the adoption of such a disclosure program.

Harrison, M.I., Koppel, R., and Bar-Lev, S. (2007, September). "Unintended consequences of information technologies in health care—an interactive sociotechnical analysis." (AHRQ grant HS11530). Journal of the American Medical Informatics Association 14(5), pp. 542-49.

The introduction of new health information technologies (HIT) such as electronic medical records, computerized physician order entry, and decision support systems, has resulted in many unintended and undesired consequences. These consequences can arise from the interplay between new HIT and the provider organization's existing social and technical systems—including their workflows, culture, social interactions, and technologies.

Building on earlier models, the authors of this study propose their own Interactive Sociotechnical Analysis (ISTA) model that offers a framework and typology specifying important relationships among new HIT, workflows, clinicians, and organizations. The authors' model reviews five types of interaction, which range from how new HIT can change an existing social system to HIT-social system interactions engendering HIT redesign. These interactions are illustrated by cases in the published literature By its emphasis on the emergent and recursive interactions among HIT and existing social systems, technologies, and physical environments, ISTA can increase awareness by clinicians and others of unanticipated consequences that only become evident during HIT implementation.

Reprints (AHRQ Publication No. 08-R008) are available from the AHRQ Publications Clearinghouse.

Henriksen, K. and Patterson, M.D. (2007, September). "Simulation in health care: Setting realistic expectations." Journal of Patient Safety 3(3), pp. 127-134.

The introduction of new and intricate surgical and medical procedures in the training of new practitioners raises the risks of unintentional harm to patients. Thus, the traditional model of using live patients in the training process needs to be supplemented by the use of simulation for medical training. The primary advantages of simulation in other high-risk industries (safety, creation of optimal conditions for learning, integration of multiple skills, and return on investment) may also apply to health care, note the authors of this paper. Despite the enthusiasm for simulation training, there are some challenges.

It is important to identify relevant research questions, determine simulation and training expectations, match fidelity levels to research and training objectives, and develop well-rounded curricula. Individual competence in performing high-risk surgical procedures is very important. However, there is also a need to use simulation for training of enhanced capability and resiliency in dynamic, complex, and unpredictable clinical environments.

Reprints (AHRQ Publication No. 08-R009) are available from the AHRQ Publications Clearinghouse.

Hustey, F.M., Mion, L.S., Connor, J.T., and others (2007, August). "A brief risk stratification tool to predict functional decline in older adults discharged from emergency departments." (AHRQ grant HS09725). Journal of the American Geriatric Society 55, p. 1269-1274.

A six-item questionnaire can identify older emergency department (ED) patients who are at risk for subsequent functional decline when they are discharged home from the ED, and who would probably benefit from referrals for further evaluation or monitoring.

In the Triage Risk Screening Tool (TRST), a nurse asks about six yes/no issues: presence of cognitive impairment; difficulty walking, transferring, or recent fall; living alone with no available caregiver; taking five or more prescription medications; having used the ED in the previous 30 days or been hospitalized in the prior 90 days; and nurse concern (for example, about patient's alcohol use). Older patients with cognitive impairment or two or more risk factors were considered at high risk for functional decline upon hospital discharge.

The researchers examined the functional status of 650 community-dwelling elderly persons, who arrived at the ED of 2 urban hospitals and were discharged home, at baseline and 30 days and 120 days after hospital discharge. TRST scores correlated with baseline impairment in activities of daily living (ADL) such as bathing or dressing, impairments in instrumental activities of daily living (IADLs) such as shopping or doing housework, and self-perceived physical health at all points. A TRST score of two or more was moderately predictive of decline in ADLs or IADLs a month after discharge and ADLs 120 days later, but not perceived physical health.

Kash, B.A., Hawes, C., and Phillips, C.D. (2007). "Comparing staffing levels in the Online Survey Certification and Reporting (OSCAR) system with the Medicaid cost report data: Are differences systematic?" (AHRQ grant HS16229). The Gerontologist 47(4), pp. 480-489.

This study evaluated the accuracy of nursing home staffing data reported through the Online Survey Certification and Reporting (OSCAR) system by comparing it with audited Medicaid Cost Report (MCR) data, widely considered a more accurate source. The researchers also sought to determine if there were any systematic differences in reporting. They found that mean staffing levels were 38 percent higher in OSCAR for registered nurses, and 4 percent higher for certified nursing assistants. The factors contributing to the likelihood of overreporting were low Medicare and Medicaid census, high market concentration, and for-profit ownership.

Certain types of facilities consistently overreported staffing levels. These reporting errors will affect the validity of consumer information systems, regulating activities, and health services research results. Quality studies using OSCAR data may systematically underestimate the strength of the relationship between staffing and quality in American nursing homes.

Lanfear, D.E., Jones, P.G., Marsh, S., and others (2007, September). "Connexin37 (GJA4) genotype predicts survival after an acute coronary syndrome." (AHRQ grant HS11282). American Heart Journal 154(3), pp. 561-566.

Some genotypes are associated with the risk of heart attack. The authors of this study tested several of these genotypes to determine whether they were also associated with long-term mortality after acute coronary syndrome (ACS).

Using a previously defined set of genetic markers in a prospective study of 726 patients with ACS, they discovered a significant association between the GJA4 1019 C>T genotype and 3-year survival after an ACS. Patients with this genotype had a 70 percent increased risk of death over 3 years. This gene-mortality relationship was similar for both men and women. If confirmed in future studies, this genetic variant may become an important tool to risk-stratify patients with ACS. It can also serve to focus future trials of intensified or novel interventions to further improve outcomes in high-risk patients.

Plantinga, L.C., Fink, N.E., Jaar, B.G., and others (2007). "Relation between level or change of hemoglobin and generic and disease-specific quality of life measures in hemodialysis." (AHRQ grant HS08365). Quality of Life Research 16, pp. 755-765.

One consequence of chronic kidney disease is anemia, as reflected by low hemoglobin and hematocrit levels. Effective treatment of anemia has been shown to improve quality of life (QOL). The authors of this study examined the impact on various aspects of QOL of raising hemoglobin levels to 11 g/dl (the minimum guideline established by the Kidney Disease Outcomes Quality Initiative) among 438 hemodialysis patients with kidney failure. These aspects included such QOL domains as physical, social, and cognitive functioning, and domains related to fatigue levels such as sexual functioning, work, and recreation.

After one year, patients who had achieved 11 g/dl for at least 6 months, had significantly higher QOL for physical functioning, bodily pain, mental health, social functioning, cognitive functioning, as well as diet restriction and dialysis access domains. In addition, even incremental increases of 1 g/dl over initial hemoglobin levels were correlated with higher QOL scores for most domains.

Rumptz, M.H., Tobias, C., Rajabiun, S., and others (2007). "Factors associated with engaging socially marginalized HIV-positive persons in primary care." (AHRQ grant HS10858). AIDS Patient Care and STDs 21(Suppl.1), pp. S30-S39.

Engagement in medical care is essential, if people living with HIV disease are going to benefit from life-prolonging HIV care and treatment. This study examined factors related to persons with HIV disease who were only somewhat engaged in care or not at all engaged in care. Of the 984 socially marginalized patients initially surveyed, 40 percent were somewhat engaged and 12 percent were not at all engaged in HIV primary care. Twelve months later, according to a followup survey, 58 percent of those not initially engaged in care had become more fully engaged in HIV primary care.

The use of HIV primary care had increased as the major barriers to care (drug use, structural barriers, belief barriers, and unmet needs) were discontinued or reduced. These patients were part of a multisite demonstration study in which the barriers to care were addressed by one or more of 10 types of outreach interventions.

Smith, M.J. and Pawar, V. (2007, June). "Medical services and prescription use of asthma and factors that predict corticosteroid use among African-American children covered by Medicaid." (AHRQ grant HS015390). Journal of Asthma 44, pp. 357-363.

In this study, the researchers examined the records of 300 black children from West Virginia who were insured through Medicaid and diagnosed with asthma, to determine the types of medications children used to treat their asthma. Most of the children received quick-relief medications (90.3 percent), while just more than half (56 percent) had prescriptions for corticosteroids to forestall attacks. In particular, 38 percent had prescriptions for an inhaled corticosteroid (ICS). Only 35 percent of the children in this study made two trips to physicians' offices during the 1-year study period. Children who used an ICS were more likely to visit their primary care physician regularly. In contrast, children who were hospitalized or visited the emergency room because of their asthma were less likely to have used an ICS.

Tobias, C., Cunningham, W.E., Cunningham, C.O., and others. (2007). "Making the connection: The importance of engagement and retention in HIV medical care." (AHRQ grant HS10858). AIDS Patient Care and STDs 21(Suppl.1), pp. S3-S8.

This paper is an introduction to a supplemental journal issue reporting on the results of a 5-year multisite Outreach Initiative to engage and retain patients in HIV care. It focuses on HIV patients not receiving ongoing HIV care and the barriers to care that they face. It also discusses intervention options and the public policy implications of this issue. Barriers to care may be structural, financial, or personal/cultural, according to a framework developed by the Institute of Medicine.

Structural barriers include unavailable or inconveniently located services, as well as subsistence needs competing with health care priorities. Financial barriers include lack of insurance, underinsurance, or the cost of services. Personal/cultural barriers include individual attitudes and beliefs as well as racism, sexism, and homophobia. To counteract these different barriers, the researchers used relationship building, service linking, and advocacy as part of the outreach initiative.

The journal supplement provides new evidence about outreach and related strategies that promote sustained participation in HIV care by underserved populations.

Tschirch, P. and Kritek, P.B. (2007). "A national telehealth nursing research agenda. Conference report." (AHRQ grant HS11596). Journal of Telemedicine and Telecare 13, pp. 157-158.

Until recently, there has not been a concerted effort to create a common framework for defining or evaluating telehealth nursing as a practice area. A conference was held in 2005 to reach consensus on research priorities among those involved in telenursing.

Following a series of presentations, the conference participants responded to a series of eight questions. For example, respondents felt that the telehealth interventions showing the greatest potential for demonstrating cost effectiveness were enhanced self-care management, early detection of health deterioration, and symptom management. In addition, they concluded that research priorities for the future of telenursing should focus on evidence-based practice and public policy implications. Finally, nurses felt that the pursuit of studies with clearly defined populations, standard outcomes, and standard methodologies to support the cost effectiveness of telehealth should be the highest priority for the field of telenursing.

Van der Steen, J.T., Mitchell, S.L., Fritjers, D.H.M., and others (2007, September). "Prediction of 6-month mortality in nursing home residents with advanced dementia: Validity of a risk score." (AHRQ grant HS08551). Journal of the American Medical Directors Association 8, pp. 464-468.

Seventy percent of U.S. patients with dementia die in nursing homes. Families and physicians of these patients can make use of prognostic information to make decisions about palliative care. The authors developed a risk score based on variables from the Minimum Data Set to predict 6-month mortality in 269 Dutch nursing home patients with advanced dementia and 270 Missouri nursing home patients with both advanced dementia and lower respiratory infections. The risk score identified residents at low and moderate risk of 6-month mortality (up to 40 percent) with reasonable accuracy. As mortality rates rose incrementally in each group, the risk score increased. It performed less well for residents with a higher risk of mortality; however, very few residents were estimated to have a mortality risk of well over 50 percent. Well-derived risk scores, while not suitable as a sole guide, can add important information for those making palliative care decisions.

Wakefield, D.S., Halbesleben, J.R.B., Ward, M.M., and others (2007, September). "Development of a measure of clinical information systems expectations and experiences." (AHRQ grant HS15196). Medical Care 45(9), pp. 884-890.

The authors of this study developed and tested the Information Systems Expectations and Experiences (I-SEE) survey to determine the expectations and experiences of registered nurses concerning the implementation of a new hospital clinical information system. They first administered the survey to nurses in four hospitals when a new clinical information system was implemented (the expectations section of the survey), then later, when the new system had been in place for 6 months (the experience section of the survey).

The nurses surveyed worked in different hospital units and used multiple electronic health record system applications. The findings suggest that the I-SEE survey offers a coherent and reliable tool for assessing the perceived impact of new clinical information technology on work process and outcomes.

Organizations may use I-SEE to determine which aspects of communication their employees see as most affected by new technology or what technologies support accuracy, timeliness, and effective decision-making to improve care.

Westrick, S.C. and Mount, J.K. (2007). "Evaluating telephone follow-up of a mail survey of community pharmacies." (AHRQ grant HS14512). Research in Social and Administrative Pharmacy 3, pp. 160-182.

This study assessed the effectiveness of a telephone follow-up survey of 262 randomly selected pharmacists who did not respond to a mail survey of 1,143 pharmacies. Mail surveys of the general population are usually less expensive than telephone surveys, but also yield fewer responses. The subject was pharmacy participation in immunization activities.

With a response rate of 26.7 percent, the mail survey presented a problem of nonresponse bias: respondents were much more likely to have an in-house immunization program than the outsourcing alternative. The telephone survey had a response rate (83.6 percent) over three times greater than the mail survey. Although the mail survey had a cost per sample unit of $1.20, when the cost per usable response was compared, the mail survey cost more than the phone survey ($4.37 vs. $1.99).

The authors conclude that a telephone survey is a viable survey mode that holds promise in pharmacy practice research.

Whitney, S.N. and McCullough, L.B. (2007). "Physicians' silent decisions: Because patient autonomy does not always come first." (AHRQ grant HS11289). The American Journal of Bioethics 7(7), pp. 33-38.

Although patients today are increasingly participating in medical decisionmaking about their care, there remains a context in which physicians may justifiably make silent decisions about patient care, i.e., they may consider and reject decisions without informing the patient. Silent decisions may represent the physician's choice to follow a widely recognized guideline, to invoke an accepted exception to the guideline, or to take some other action that is justified by an individual patient's circumstance. Such decisions are frequent, inevitable, and entirely appropriate, according to these authors. For example, the physician, by the exercise of his professional clinical judgment, may determine that a procedure offers no net benefit to the patient and therefore does not mention it to the patient. The authors discuss several examples of silent decisions. In the process, they make an ethical case for a limited set of clinically significant, ethically valid silent decisions.

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AHRQ Publication No. 08-0009
Current as of December 2007


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