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Asplin, B.R., Magid, D.J., Rhodes, K.V., and others (2003, August). "A conceptual model of emergency department crowding." (AHRQ contract 290-00-0015). Annals of Emergency Medicine 42(2), pp. 173-180.

Emergency department (ED) crowding has become a major barrier to receiving timely emergency care in the United States. The authors of this article present a conceptual model of ED crowding to help researchers, administrators, and policymakers understand its causes and develop potential solutions. The conceptual model partitions ED crowding into three interdependent components: input, throughput, and output. These components exist within an acute care system that is characterized by the delivery of unscheduled care. The goal of the model is to provide a practical framework on which to base an organized research, policy, and operations management agenda to alleviate ED crowding.

Bates, D.W., Kuperman, G.J., Wang, S., and others (2003, November). "Ten commandments for effective clinical decision support: Making the practice of evidence-based medicine a reality." (AHRQ grant HS07107). Journal of the American Medical Informatics Association 10(6), pp. 523-530

While evidence-based medicine has increasingly broad-based support in health care, actually getting physicians to practice evidence-based medicine continues to be a challenge. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors of this article believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions. Ideally, this should result in improved quality of care. Such clinical decision support can also be useful for finding and preventing many of the medical errors that are made by health care providers. Over the last 8 years, the authors have implemented and studied the impact of decision support across a broad array of domains. They describe a number of common elements they have found to be important to success.

Bhattacharya, J., Goldman, D., and Sood, N. (2003). "The link between public and private insurance and HIV-related mortality." (AHRQ grant HS10846). Journal of Health Economics 22, pp. 1105-1122.

This study estimated the impact of different types of insurance on the mortality of a nationally representative group of people infected with the human immunodeficiency virus (HIV) receiving regular medical care in the United States. The researchers found that ignoring observed and unobserved health status misleads one to conclude that insurance may not be protective for HIV patients. Second, after accounting for observed and unobserved heterogeneity among people with HIV disease, insurance does protect against premature death. Third, private insurance is more effective than public insurance. The better performance of private insurance can be explained in part by more restrictive Medicaid prescription drug policies that limit access to highly efficacious treatment.

Bliss, S.J., Moseley, R.H., Del Valle, J., and Saint, S. (2003, November). "A window of opportunity." (AHRQ grant HS11540). New England Journal of Medicine 349, pp. 1848-1853.

This article describes the gradual diagnosis of acute liver failure, due to herbal-induced liver toxicity, in a women who was hospitalized after arriving at the emergency department with severe and constant abdominal pain of 5 days duration. The woman also reported having anorexia, nausea, fatigue, night sweats, and chills, but not fever, vomiting, diarrhea, melena (bloody stool), jaundice, or weight loss. Tests for hepatitis were negative, and she continued to be given intravenous fluid and broad-spectrum antibiotics for the abdominal pain of unknown cause. Her son revealed that she had begun taking an unknown herbal remedy for her rheumatoid arthritis 2 weeks before the onset of her illness. The doctors considered herbal-induced liver toxicity as a potential cause of acute severe hepatitis, which had progressed to liver failure. A diagnosis of HSV (herpes simplex virus) hepatitis was made after the patient died. The authors discuss how this case could have been handled to quickly diagnose and treat HSV infection in this patient.

Casebeer, L.L., Strasser, S.M., Spettell, C.M., and others (2003). "Designing tailored Web-based instruction to improve practicing physicians' preventive practices." (AHRQ grant HS11124). Journal of Medical Internet Research 5(3), pp. e20.

Using Web design principles, these researchers designed and developed a Web site that included multimodal strategies for improving chlamydial screening rates among primary care physicians. The Web-based continuing medical education course introduced physician screening instructions in four phases over 11 months. The course provided a series of interactive, tailored, case vignettes with feedback on peer answers. It also featured a quality improvement toolbox that included clinical practice guidelines and printable patient education materials. Preliminary evaluation data from a randomized, controlled trial showed a significant increase in chlamydia knowledge, attitudes, and skills among course physicians compared with a control group.

Chan, I. Wells, W., Mukern, R., and others (2003). "Detection of prostate cancer by integration of line-scan diffusion, T2-mapping and T2-weighted magnetic resonance imaging: A multichannel statistical classifier." (AHRQ grant HS13234). Medical Physics 30(9), pp. 2390-2398.

The authors of this study developed a multichannel classifier for detecting prostate cancer by combining information from three different magnetic resonance (MR) imaging methodologies: T2-weighted, T2-maping, and line scan diffusion imaging. They concluded that, by integrating MR imaging information from multiple images and enhancing prostate tumor features in these images, summary statistical maps have the potential to improve image-guided prostate biopsy accuracy and enhance tumor target identification for the delivery of localized therapies. They demonstrated the utility of two multichannel classifiers with feature enhancements using machine vision techniques for prostate cancer detection. They also showed that the classifiers had statistically superior performance over single-channel intensity-based classifiers.

Col, N.F. (2003, October). "The use of gene tests to detect hereditary predisposition to chronic disease: Is cost-effectiveness analysis relevant?" (AHRQ grant HS13329). Medical Decision Making 23, pp. 441-448.

The ability to screen for genetic susceptibility to common diseases provides new opportunities for disease prevention. However, credible cost-effectiveness analyses (CEAs) are needed to provide guidance about screening decisions, according to this study. The author asserts that genetic tests have often proceeded directly from development and preliminary validation into clinical practice, with little understanding of their clinical, economic, and psychosocial implications. For example, the accuracy of the test to screen for BRCA mutations implicated in breast cancer, and the effectiveness of many interventions among those who screen positive, remain in question. CEAs do not seem to have played an important role in identifying whom to offer genetic testing nor how to manage those found to carry the gene marker.

Cole, S.R., Hernan, M.A., Robins, J.M., and others (2003). "Effect of highly active antiretroviral therapy on time to acquired immunodeficiency syndrome or death using marginal structural models." (Women's Interagency HIV Study). American Journal of Epidemiology 158, pp. 687-694.

To estimate the overall effect of highly active antiretroviral therapy (HAART) on time to acquired immunodeficiency syndrome (AIDS) or death, these authors used inverse probability-of-treatment weighted estimation of a marginal structural model, which can appropriately adjust for time-varying confounders affected by prior treatment or exposure. They followed 1,498 HIV-positive men and women in two ongoing studies between 1995 and 2002. Sixty-one percent of participants initiated HAART during 6,763 person-years of followup; 382 participants developed AIDS or died. The risk of AIDS or death among those taking HAART from a standard time-dependent Cox model was 0.81. In contrast, the risk of clinical AIDS or death was markedly reduced to 0.54 from a marginal structural survival model, suggesting a clinically meaningful net benefit of HAART (reducing risk of death or AIDS by nearly half).

Croskerry, P. (2003). "The importance of cognitive errors in diagnosis and strategies to minimize them." (AHRQ grant HS11592). Academic Medicine 78(8), pp. 775-780.

Diagnostic errors are associated with proportionately more problems than other types of medical errors. For example, about half of all malpractice suits brought against emergency physicians arise from delayed or missed diagnoses. Many diagnostic errors stem from cognitive errors, for example, those associated with failures in perception and biases (so-called cognitive dispositions to respond, CDRs). The author lists 32 CDRs, which range from anchoring (tendency to lock onto salient features in the patient's initial presentation too early in the diagnostic process and failing to adjust this impression in light of later information) to aggregate bias (when doctors believe that aggregated data, such as those used to develop clinical practice guidelines, do not apply to their patient, whom they believe is somehow exceptional or atypical). Several strategies may be used to eliminate bias and thereby reduce diagnostic errors. For example, consider alternatives. Decrease reliance on memory and use cognitive aids such as clinical practice guidelines and hand-held computers. Use cognitive forcing strategies, that is, develop generic and specific strategies to avoid predictable bias in particular clinical situations. Minimize time pressures by providing adequate time for quality decisionmaking. Establish clear accountability and followup for decisions made. Provide rapid and reliable feedback to decisionmakers so that errors are immediately identified, understood, and corrected.

Dickersin, K., Munro, M., Langenberg, P., and others (2003). "Surgical Treatment Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB): Design and methods. (AHRQ grant HS09506). Controlled Clinical Trials 24, pp. 591-609.

The Surgical Treatment Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB) was a multicenter, randomized clinical trial that assessed the efficacy and effectiveness of hysterectomy vs. endometrial ablation in women for whom medical management has not provided relief. The authors talk about recruitment, extending of followup, translation of study materials into Spanish, and other topics related to study design and the methods used in the study.

Gaba, D.M., Singer, S.J., Sinaiko, A.D., and others (2003, Summer). "Differences in safety climate between hospital personnel and naval aviators." (AHRQ grant HS11114). Human Factors 45(2), pp. 173-185.

Hospitals may need to make substantial changes to achieve a safety climate consistent with the status of high-reliability organizations such as naval aviation, according to these authors. They administered safety climate surveys, containing a subset of 23 similar questions, to employees from 15 hospitals and to naval aviators from 226 squadrons. Overall, the problematic response (suggesting an absence of a safety climate) rate was 5.6 percent for naval aviators versus 17.5 percent for hospital personnel. The problematic response rate was 20.9 percent in high-hazard hospital domains such as emergency departments and operating rooms. Problematic responses among health care workers were up to 12 times greater than those of aviators on certain questions.

Gesteland, P.H., Gardner, R.M., Tsui, F-C., and others (2003, November). "Automated syndromic surveillance for the 2002 winter Olympics." (AHRQ contract 290-00-0009). Journal of the American Medical Informatics Association 10(6), pp. 547-554.

This article describes implementation of the Real-time Outbreak and Disease Surveillance (RODS) system, an electronic biosurveillance system, to adequately cover the large region in Utah involved in the 2002 Olympic Winter Games. A team of specialists in informatics and public health from Salt Lake City and Pittsburgh implemented the RODS system in Utah for the Olympic Games in just 7 weeks. These authors discuss the strategies and challenges of implementing the system in such a short time. Overall, the system monitored over 114,000 acute care encounters between February 8 and March 31, 2002. No outbreaks of public health significance were detected. The system was successful and remains operational today.

Hargraves, J.L., Hays, R.D., and Cleary, P.D. (2003, December). "Psychometric properties of the Consumer Assessment of Health Plans Study (CAHPS®) 2.0 adult core survey." (AHRQ grant HS09205). Health Services Research 38(6), Part I, pp. 1509-1527.

The purpose of the Consumer Assessment of Health Plans Study (CAHPS®) surveys is to give employers and other purchasers, as well as consumers, the information they need to judge different aspects of health plan performance. This study used survey data from individuals in health plans serving public and private employers to assess plan-level and internal consistency, reliability, and the construct validity of five variables (getting care quickly, doctors who communicate well, helpful/courteous office staff, getting needed care, and health plan customer service) to summarize consumer experiences with health plans and health professionals. Two of the five CAHPS® 2.0 reporting composites had higher internal consistency and plan-level reliability. The other three summary measures were reliable at the plan level and approached acceptable levels of internal consistency. The researchers conclude that consumer reports using CAHPS® surveys should provide feedback using five composites.

Insinga, R.P., and Fryback, D.G. (2003). "Understanding differences between self-ratings and population ratings for health in the EuroQOL." (AHRQ grant T32 HS00083). Quality of Life Research 12, pp. 611-619.

This study examined the source and magnitude of differences between self-ratings of health and ratings of corresponding health state profiles by the general population contained in the EuroQOL (a multidimensional measure of health-related quality of life). Overall, mildly ill individuals provided lower self-ratings (3-4 points) and moderately ill individuals higher self-ratings (7 points) than ratings provided by the general population for the same health states. Sociodemographic characteristics and difficulties in rating task completion did not explain differences between self and general population ratings. The researchers conclude that EQ-5D health state descriptions may be too sparse to comprehensively describe certain health states. Adding new health state levels or dimensions or changing the nature and tone of health state descriptions may be useful steps for improvement.

Localio, A.R., Berlin, J.A., and Ten Have, T.R. (2003). "Confounding due to cluster in multicenter studies: Causes and cures." (AHRQ grant HS10399). Health Services & Outcomes Research Methodology 3, pp. 195-210.

Investigators should anticipate the potential for bias from confounding by center when they employ common statistical methods for the analysis of multicenter studies, suggest these researchers. They performed simulations for 1,080 combinations of number of centers, center size, the baseline risk of outcome, the relative risk of exposure and outcome, and the degree of association between center and exposure and between center and outcome. They analyzed datasets using five commonly used methods of logistic regression for multicenter studies and found that the direction and size of the bias caused by confounding are unpredictable when the primary research interest lies in the within-center effects. Bias can be in either direction, depending not only on the degree and direction of association among exposure, outcome, and center, but also on the method employed to adjust for the effects of clustering of patients within centers.

McGuire, T.G. (2003). "Setting prices for new vaccines (in advance)." (AHRQ grant HS10803). International Journal of Health Care Finance and Economics 3, pp. 207-224.

New vaccines have high social value, but the incentives to firms to develop new vaccines appear to be weak. This author recommends setting a procurement price for a new vaccine prior to the vaccine's development, with the price based on the anticipated benefits from developing the vaccine. The price paid to vaccine suppliers is not equal to the price charged to consumers supplied by public or private sources, so a high price does not choke off demand. A supply price leading to efficient levels of investment can be figured in advance based on cost-effectiveness analyses. Calculations indicate that efficient vaccine prices are considerably above prices currently paid for new vaccines.

Meenan, R.T., Goodman, M.J., Fishman, P.A., and others (2003). "Using risk-adjustment models to identify high-cost risks." (AHRQ grant HS10688). Medical Care 41(11), pp. 1301-1312.

Risk models can efficiently identify HMO enrollees who are likely to generate future high costs and thus could benefit from case management, according to this study. The researchers examined the ability of five risk models: the Global Risk-Adjustment Model (GRAM), Diagnostic Cost Groups (DCGs), Adjusted Clinical Groups (ACGs), RxRisk, and Prior-expense, to identify high-cost individuals and enrollee groups using multi-HMO administrative data for 1995 and 1996. For high-cost prevalence targets of 1 percent and 0.5 percent, ACGs, DCGs, GRAM, and Prior-expense were very comparable in overall discrimination. Given a 0.5 percent prevalence target and a 0.5 percent prediction threshold, DCGs, GRAM, and Prior-expense captured about 3 percent more high-cost sample dollars than other models. DCGs captured the most high-cost dollars among enrollees with asthma, diabetes, and depression.

M'ikanatha, N.M., Southwell, B., and Lautenbach, E. (2003, September). "Automated laboratory reporting of infectious diseases in a climate of bioterrorism." (AHRQ grant HS10399). Emerging Infectious Diseases 9(9), pp. 1053-1057.

Newly available electronic transmission methods can increase timeliness and completeness of infectious disease reports. However, limitations of this technology may unintentionally compromise detection of, and response to, bioterrorism and other outbreaks, caution these investigators. They reviewed implementation experiences for five electronic laboratory systems and identified problems with data transmission, sensitivity, specificity, and user interpretation. The results suggest a need for backup transmission methods, validation, standards, preserving human judgment in the process, and provider and end-user involvement. Challenges encountered in deployment of existing electronic laboratory reporting systems could guide further refinement and advances in infectious disease surveillance.

Olsen, I.E., Richardson, D.K., Schmid, C.H., and others (2003). "The impact of early transfer bias in a growth study among neonatal intensive care units." (AHRQ grant HS07015). Journal of Clinical Epidemiology 56, pp. 998-1005.

Transfer of infants between hospitals or their discharge home may bias comparisons of the performance across neonatal intensive care units (NICUs). This study found that sampling strategies to minimize infants lost to followup were more successful than replacement strategies in limiting transfer bias in an NICU growth study. To limit transfer bias in a neonatal growth study of extremely premature infants in six tertiary NICUs, the investigators restricted eligibility to infants younger than 30 weeks gestation at birth and substituted matched replacements for early transfers (infants transferred or discharged prior to the 16th day of life). The restriction strategy was successful, reducing the overall early transfer rate from 16.4 to 3.6 percent and the range of transfer rates among individual NICUs from 0.6-32.7 percent to 0-11 percent. Replacement of matched substitutes had a much smaller effect because of the small number of early transfers and the inability to match on all factors distinguishing early transfer.

Ornstein, S. (2003, August). "Practicing beautiful medicine beautifully: Hiram Curry's vision in the 21st century." (AHRQ grant HS11132). Journal of the South Carolina Medical Association 99, pp. 227-232.

This author discusses the vision of Dr. Hiram Curry, the founding Chair of Medical University of South Carolina's Department of Family Medicine, reviews the quality of health care in the United States today, and discusses how Dr. Curry's vision applies to 21st century health care. The author points out that much of Dr. Curry's vision agreed with recommendations to improve quality of care in a recent Institute of Medicine report. For example, he recommended multidisciplinary team care, respect for behavioral science and the patient, practice analysis, and performance evaluation.

Pace, W.D., Staton, E.W., Higgins, G.S., and others (2003, December). "Database design to ensure anonymous study of medical errors: A report from the ASIPS collaborative." (AHRQ grant HS11878). Journal of the American Medical Informatics Association 10(6), pp. 531-540.

These authors present the design and implementation of a database and administrative system to ensure anonymous study of medical errors as reported in the voluntary Applied Strategies for Improving Patient Safety (ASIPS). ASIPS is a multi-institutional, practice-based research project that collects and analyzes data on medical errors in primary care and develops interventions to reduce error. This system captures anonymous and confidential reports of medical errors. Confidential reports, which are quickly de-identified, provide better detail than do anonymous reports. However, concerns exist about the confidentiality of those reports should the data be subject to legal discovery or other security breaches. Standard database elements, for example, serial ID numbers, date/time stamps, and backups, could enable an outsider to link an ASIPS report to a specific medical error.

Polverejan, E., Gardiner, J.C., Bradley, C.J., and others (2003). "Estimating mean hospital cost as a function of length of stay and patient characteristics." (AHRQ grant HS09514). Health Economics 12, pp. 935-947.

This paper describes two regression models that permit estimation of mean hospital charges as a function of patient length of stay (LOS) and adjust for the influence of patient characteristics and treatment procedures on LOS and charges. In the first model, the mean charge over a specified duration is a weighted average of the expected cumulative charge, with weighting determined by the distribution of LOS. The second model for LOS and charge explicitly accounts for their correlation and yields estimates of the average charge per average LOS. The researchers applied these methods to assess mean charges and mean charge per day by cardiac procedure in a group of patients hospitalized for heart attack. They concluded that, for relatively short hospital stays when only total hospital charges are available, these models provide a flexible approach to estimating summary measures of resource use while controlling for the effects of covariates on LOS and charges.

Roeloffs, C., Sherbourne, C., Unutzer, J., and others (2003). "Stigma and depression among primary care patients." (AHRQ grant HS08349). General Hospital Psychiatry 25, pp. 311-315.

This study found that depression-related stigma was common in depressed primary care patients and was related to age, sex, ethnicity, social support, and chronic medical conditions. The investigators examined whether 1,187 depressed patients from 46 U.S. primary care clinics felt that the stigma of depression affected their employment, health insurance, and/or friendships. Results showed that 67 percent expected depression-related stigma to have a negative effect on employment, 59 percent on health insurance, and 24 percent on friendships. Stigma associated with depression was greater than for hypertension or diabetes but not for stigma associated with HIV. Stigma was not associated with use of health care services, but individuals with stigma concerns related to friendships reported greater unmet mental health care needs.

Segal, J.B., Bolger, D.T., Jenckes, M.W., and others (2003). "Outpatient therapy with low molecular weight heparin for the treatment of venous thromboembolism: A review of efficacy, safety, and costs." (AHRQ contract 290-97-0006). American Journal of Medicine 115, pp. 298-308.

These authors summarize the evidence comparing the efficacy, safety, and costs of outpatient and inpatient treatment of venous thromboembolism. Eight studies compared outpatient use of low molecular weight heparin with inpatient use of unfractionated heparin in 3,762 patients. The incidence of recurrent deep venous thrombosis was similar in the two groups, as was major bleeding. Use of low molecular weight heparin was also associated with shorter hospitalization and lower costs. The evidence indicates that outpatient treatment of deep venous thrombosis with low molecular weight heparin is likely to be efficacious, safe, and cost-effective.

Selby, J.V., Scanlon, D., Lafata, J.E., and others (2003, September). "Determining the value of disease management programs." (AHRQ grant HS12067). Joint Commission Journal on Quality and Safety 29(9), pp. 491-499.

This article summarizes a conference held in October 2002, which explored new approaches to measuring and reporting the value of disease management (DM) programs for diabetes mellitus. The participants concluded that quantifying the value of DM programs for diabetes requires measuring clinical benefit and net impact on health care costs for the entire population with diabetes. Natural history models combine the expected benefits of improvements in multiple indicators to yield a single, composite measure, the quality-adjusted life-year. Such metrics could fairly express, in terms of survival and prevention of complications, relatively disparate benefits of DM programs. Comparing value across programs may provide more accurate assessments of performance, enhance quality improvement efforts within systems, and contribute generalizable knowledge on the utility of DM approaches.

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 in Health and Medicine 9(5), pp. 54-60.

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

Stewart, A.L., and Napoles-Springer, A.M. (2003). "Advancing health disparities research: Can we afford to ignore measurement issues?" (AHRQ grant HS11293). Medical Care 41(11), pp. 1207-1220.

The current national commitment to reduce health disparities may be compromised without more research on measurement quality. Integrated, systematic efforts are needed to move this work forward, including collaborative efforts and special initiatives, according to the conclusions of a conference convened by six Resource Centers for Minority Aging Research. This paper, based on the conference, presents two broad conceptual frameworks for health disparities research and describes the main research questions and measurement issues for four key concepts hypothesized as potential mechanisms of health disparities: socioeconomic status, discrimination, acculturation, and quality of care. Problems in the quality of the conceptualizations and measures were found for all four concepts, and little is known about the extent to which measures of these concepts can be interpreted similarly across diverse groups.

Tunis, S.R., Stryer, D.B., and Clancy. C.M. (2003). "Practical clinical trials: Increasing the value of clinical research for decision making in clinical and health policy." Journal of the American Medical Association 290(12), pp. 1624-1632.

Decisionmakers need reliable evidence to improve health care quality and to support efficient use of limited resources. These authors discuss the importance of consistent efforts to conduct clinical trials that are designed to meet the needs of decisionmakers. Clinical trials for which the hypothesis and study design are developed specifically to answer the questions faced by decisionmakers are called pragmatic or practical clinical trials. The characteristics of these trials are that they (1) select clinically relevant alternative interventions to compare, (2) include a diverse population of study participants, (3) recruit participants from heterogeneous practice settings, and (4) collect data on a broad range of health outcomes. A limited number of these trials are conducted. According to the authors, increasing the supply of such trials will depend on greater involvement of clinical and health policy decisionmakers in all aspects of clinical research, including priority setting, infrastructure development and funding.

Reprints (AHRQ Publication No. 04-R006) are available from the AHRQ Publications Clearinghouse.

Weinick, R.M. (2003, November). "Researching disparities: Strategies for primary data collection." Academic Emergency Medicine 10(11), pp. 1161-1168.

Comparatively little disparities research to date has focused on emergency medicine. However, the body of disparities research developed in other areas of health care has identified a number of issues that are directly applicable. To promote research on disparities in emergency medicine, this author addresses several issues related to collecting and classifying data on race/ethnicity and socioeconomic status, as well as selected methodologic issues that are particularly important for evaluating disparities.

Reprints (AHRQ Publication No. 04-R013) are available from the AHRQ Publications Clearinghouse.

Whitehall II Study: Martikainen, P. Adda, J., Ferrie, J.E., and others (2003). "Effects of income and wealth on GHQ depression and poor self-rated health in white collar women and men in the Whitehall II study." Journal of Epidemiology and Community Health 57, pp. 718-723; and Singh-Manoux, A., Britton, A.R., and Marmot, M. (2003). "Vascular disease and cognitive function: Evidence from the Whitehall II study." Journal of the American Geriatrics Society 51, pp. 1445-1450. (AHRQ grant HS06516).

The Whitehall II study, established in 1985, is a longitudinal study of 10,308 British civil servants to examine the socioeconomic gradient in health and disease. Baseline screening took place during 1985-1988. The first study of Whitehall participants reinterviewed between 1997-1999, concludes that the associations between income, particularly personal income, and morbidity can be largely accounted for by preexisting health and other measures of social position. The strong independent association between household wealth—a measure of income earned over decades and across generations—and morbidity are likely to be related to a set of early and current material and psychosocial benefits. The second Whitehall II study reveals an association between indications of vascular disease during the baseline screening (for example, angina or heart attack) with poor cognitive function during the 1997-1999 data collection. These findings support the view that vascular disease is predictive of poor cognitive function in the general population.

Ziv, A., Wolpe, P.R., Small, S.D., and Glick, S. (2003, August). "Simulation-based medical education: An ethical imperative." (AHRQ grants HS11553 and HS11905). Academic Medicine 78, pp. 783-788.

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk, note these authors. They examine four themes that provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. They explore these themes from the perspectives of patients, learners, educators, and society.

AHRQ Publication No. 04-0030
Current as of January 2004

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