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Beach, C., Croskerry, P., and Shapiro, M. (2003, April). "Profiles in patient safety: Emergency care transitions." (AHRQ grant HS11592) Academic Emergency Medicine 10, pp. 364-367.

Medical errors during transitions in care from one doctor or nurse to another are common in emergency departments (EDs) and can jeopardize patient safety, concludes this study. Transition errors are likely to increase as ED attempts to limit failures due to staff fatigue require more frequent shift changes. These transitions at shift changes have long been thought to be sources of error in emergency care, and this study documents one such case. The investigators retrospectively tracked each clinical step and transition in care of a 59-year-old man who arrived at the ED with a chief complaint of panic attacks. In total, the man was evaluated by 14 faculty physicians, two fellows, and 16 residents from emergency medicine, cardiology, neurology, psychiatry, and internal medicine. Multiple transitions in care were responsible, in part, for the continued failure to accurately diagnose an underlying heart problem. The authors recommend ways to improve transitions to reduce such errors.

Cook, A.F., Hoas, H., and Guttmannova, K. (2003, March). "Project seeks to assess and aid patient safety in rural areas." (AHRQ grant HS11930) Biomedical Instrumentation & Technology, pp. 128-130.

The ability to recognize and respond to potentially unsafe situations may be compromised by factors that technology alone cannot solve. These factors include staffing patterns, workplace communication, and the overall lack of resources and training, claim these researchers. They base these claims on data from nine studies conducted in rural communities in a 14-State area, as well as data from an ongoing patient safety research project. For instance, their studies indicate that 67 percent of rural nurses have not attained baccalaureate level training and typically work in three departments on a daily basis. Opportunities for direct communication are limited, even during shift changes, and there are few opportunities for training or continuing education, all factors that affect patient safety. A survey of physicians, nurses, pharmacists, and administrators from 30 rural hospitals underscored the need for education and training, staffing and scheduling changes, and better communication to reduce errors.

Fitzgibbons, R.J., Jonasson, O., Gibbs, J., and others (2003, May). "The development of a clinical trial to determine if watchful waiting is an acceptable alternative to routine herniorrhaphy for patients with minimal or no hernia symptoms." (AHRQ grant HS09860) Journal of the American College of Surgeons 196, pp. 737-742.

An estimated 700,000 operations to repair inguinal hernias were performed in the United States in 2001. Surgeons are taught that all inguinal hernias should be repaired at diagnosis, even if asymptomatic, to prevent a later complication of strangulation, which requires emergency surgery that might increase mortality ten-fold compared with elective surgery. These authors describe the development of a clinical trial to determine if watchful waiting is an acceptable alternative to routine hernia repair for adult men with minimally symptomatic or asymptomatic inguinal hernias. Men are randomized to watchful waiting or a standard open operation and are followed for a minimum of 2 years. The primary outcomes to be measured at 2 years are pain or discomfort interfering with normal activities and the physical component summary score of the SF-36 health-related quality-of-life survey. As of November 1, 2002, 637 patients from five centers had been randomized, 85 percent of the target enrollment (753 patients).

Fries, B.E., Norris, J.N., Aliaga, P., and Jones, R. (2003, March). "Risk adjusting outcome measures for post-acute care." (AHRQ grant HS09455) American Journal of Medical Quality 18(2), p. 66-72.

This paper examines whether different risk adjusters are needed for home care outcome measures for postacute care clients. The researchers tested multiple risk adjusters that met clinical and policy criteria on a sample of 4,403 postacute home care clients from Michigan. Two of the six outcome measures—activities of daily living (ADLs) and bladder incontinence—had substantially different risk adjusters for the postacute care population versus the general home care population. The researchers conclude that there may be subpopulations within a home care program whose care quality is not measured accurately by home care quality indicators or their related outcome measures when these are derived from the total home care population. Although some outcome measures can be applied consistently to both postacute and other home care populations, others need completely different risk adjustments.

Hennessy, S., Bilker, W.B., Weber, A., and Strom, B.L. (2003). "Descriptive analyses of the integrity of a U.S. Medicaid claims database." (AHRQ grant HS10399 and National Research Service Award fellowship F32 HS00066) Pharmacoepidemiology and Drug Safety 12, pp. 103-111.

To examine the integrity of six Medicaid databases for use in pharmacoepidemiology research, the researchers performed a descriptive analysis of four types of potential data errors: incomplete claims for certain time periods, absence of an accurate indicator of inpatient hospitalizations, missing hospitalizations for those aged 65 years and over (since Medicare is usually the primary payer for this group), and diagnostic codes in demographic groups in which those conditions should be rare. Prescription claims appeared to be missing intermittently in some States, and no valid marker of inpatient hospitalizations could be found for three of six States. Hospitalizations appeared to be missing to varying degrees for those aged 65 and over. Gross errors in diagnostic codes and demographic data did not appear to be widespread.

Loeppke, R., Hymel, P.A., Lofland, J.H., and others (2003, April). "Health-related workplace productivity measurement: General and migraine-specific recommendations from the ACOEM expert panel." (AHRQ grant K08 HS00005) Journal of Occupational and Environmental Medicine 45, pp. 349-359.

Productivity costs to employers due to migraine headaches and other employee ailments are typically two to three times the medical costs paid by employers. In this article, members of an expert panel conducted a literature search to identify health-related productivity measurement tools. The panel recommended absenteeism, presence at work, and employee turnover/replacement costs as key elements of workplace health-related productivity measurement. They also recommended that productivity measurement tools should have supporting scientific evidence, be applicable to the particular work setting, be supportive of effective business decisionmaking, and be practical. The panel reviewed six productivity measurement tools based on these and other criteria. The goal is to help employers and other stakeholders develop strategies to measure the impact of employee health problems on workplace productivity loss.

Lynch, A., McDuffie, Jr., R., Stephens, J., and others (2003, April). "The contribution of assisted conception, chorionicity and other risk factors to very low birthweight in a twin cohort." (AHRQ grant HS10700) British Journal of Obstetrics and Gynecology 110, pp. 405-410.

The recent increase in multiple births in the United States, due primarily to a variety of infertility treatments, has contributed to an upward trend in the number of low birthweight (LBW, less than 5 pounds) or very low birthweight (VLBW, less than 3 pounds) babies. Twins born to women who have received ovulation induction medication or assisted reproductive technology are no more likely to be of VLBW than spontaneously conceived twins. However, a history of preterm birth and one placenta for both twins are leading risk factors for VLBW, according to these authors. They examined the birthweight of 562 sets of twins delivered after 20 weeks of gestation, between January 1994 and December 2001, to women insured by the same HMO. They studied the impact on twin birthweight of assisted conception with either assisted reproductive technology (procedures that involved handling human oocytes or embryos) or ovulation induction medicine (clomiphene citrate or human menopausal gonadotropins). They also obtained data on other risk factors for VLBW, such as smoking and preterm delivery. Two-thirds (66 percent) of the sets of twins were unassisted pregnancies, but one-third (34 percent) were assisted and most often involved older women who had not previously given birth. There was no difference in the distribution of LBW and VLBW, discordant growth, or preterm delivery between assisted and unassisted twin gestations.

McDonald, C.J., Huff, S.M., Suico, J.G., and others. "LOINC, a universal standard for identifying laboratory observations: A 5-year update." (AHRQ grant HS07719) Clinical Chemistry 49(4), pp. 624-633.

This paper presents a 5-year update of the Logical Observation Identifier Names and Codes (LOINC) database, a universal standard for identifying laboratory observations. Most laboratory and diagnostic systems in the United States deliver their results electronically via Health Level Seven (HL7) messages to their hospital, office practice, HMO, or other clients. The HL7 message carries one record for each separate test observation, for example, blood sugar level. The LOINC database provides a universal code system for reporting laboratory and other clinical observations. Its purpose is to identify observations in electronic messages, so that when hospitals, HMOs, and others receive such messages from multiple sources, they can automatically file the results in the right slots of their medical records, research, and/or public health systems. LOINC codes are being used by large reference laboratories and Federal agencies.

Mehr, D.R., van der Steen, J.T., Kruse, R.L., and others (2003). "Lower respiratory infections in nursing home residents with dementia: A tale of two countries." (AHRQ grant HS08551) Gerontologist 43(II), pp. 85-93.

Patients with advanced Alzheimer's disease and other types of dementia often develop immobility and swallowing disorders that predispose them to pneumonia and other lower respiratory infections (LRIs), which frequently lead to death. These patients are more likely to receive palliative care (focused on resident comfort rather than maximizing survival) in Dutch nursing homes than in U.S. nursing homes. The researchers compared treatment and deaths among 706 patients with pneumonia in 61 Dutch psychogeriatric nursing homes and 701 patients with LRI and likely dementia in 36 nursing homes in Missouri. Nursing home residents with dementia and LRI were more often treated without antibiotics in the Netherlands (23 percent) than in Missouri (15 percent). The Dutch tended to treat the less severely ill residents with antibiotics. Among the 23 percent of Dutch residents not treated with antibiotics, 90 percent died within 30 days, and 30 percent of those treated with antibiotics died within 30 days. In contrast, 85 percent of U.S. residents with dementia and LRI received antibiotics, but 30-day mortality was virtually identical for both those treated with and without antibiotics (16.7 percent and 17.5 percent, respectively). Also, hospitalization was quite rate in Dutch residents (0.6 percent), but 26 percent of U.S. residents were hospitalized within 30 days. Cultural differences may underlie some of these practices. For example, the Dutch are more accepting of physician-assisted death, and on-site nursing home physicians (rare in U.S. nursing homes) have a chance to know their patients, their families, and their wishes.

Mukamel, D.B., Watson, N.M., Meng, H., and Spector, W.D. "Development of a risk-adjusted urinary incontinence outcome measure of quality for nursing homes." (AHRQ grant HS08491) Medical Care 41(4), pp. 467-468.

Quality of nursing home care is of ongoing concern. The availability of uniform, patient-level information—the Minimum Data Set (MDS)—offers the opportunity to assess quality based on risk-adjusted health outcomes. The goal of this study was to develop a risk-adjusted measure of quality based on urinary incontinence (UI) outcomes for nursing homes, derived from the MDS. The researchers performed a retrospective statistical analysis of individual resident-level data for 46,453 residents of 671 nursing homes in New York State during 1995-1997. Improvement in UI status was defined based on the resident's UI status at 3 months post-admission relative to status at admission. Individual risk factors were also defined at admission. Facility level quality indicators were developed and showed substantial variation. An average facility, providing average quality care to a population of average risk would experience improvement in UI outcomes for 11 of its 25 admissions in a year. According to the authors, this study demonstrated the feasibility of measuring quality of UI care based on nationally available MDS data. The measures presented in this paper can be used to support internal quality improvement efforts, but before such measures can be used externally—either in the survey process or in quality report cards—they should be further validated.

Reprints (AHRQ Publication No. 03-R035) are available from the AHRQ Publications Clearinghouse.

Mukamel, D.B., and Spector, W.D. (2003). "Quality report cards and nursing home quality." Gerontologist 43 (II), pp. 58-66.

This study examined the potential role that publicly disseminated quality report cards can play in improving quality of care in nursing homes. The authors reviewed the literature and the experience gained over the last two decades with report cards from hospitals, physicians, and health plans, and considered the issues that were of particular importance in the context of nursing home care. Experience with report cards in other areas of the health care system suggests that nursing home quality reports may have a role to play in informing consumers' choices and providing incentives for quality improvement. Their impact may, however, not be large. The researchers discuss the methodological issues that may limit the accuracy of quality indicators and issues related to the design and comprehension of the information by consumers. The implications are that quality report cards should be viewed as one of several options to ensure higher quality nursing home care.

Reprints (AHRQ Publication No. 03-R036) are available from the AHRQ Publications Clearinghouse.

Page, S. (2003). "Virtual health care organizations and the challenges of improving quality." (AHRQ National Research Service Award training grant T32 HS00086) Health Care Management Review 28(1), pp. 79-92.

This article examines the challenges of improving health care quality continuously within and across "virtual" provider organizations, such as independent practice associations and physician-hospital organizations (PHOs). The author draws on recent research and theory about interorganizational networks in other fields to develop recommendations for securing physicians' commitment to quality improvement strategies in today's health care environment. Strategies proven to be successful in other work settings that may improve quality control include demonstration projects and informal teamwork, dividing activities into "bitable chunks," using "just-in-time" training, and having skilled facilitators and physician leaders use participative or nondirective leadership styles to transfer learning across projects and teams.

Radwin, L., Alster, K., and Rubin, K.M. (2003, March). "Development and testing of the oncology patients" perceptions of the quality of nursing care scale." (AHRQ grant K08 HS11625) Oncology Nursing Forum 30(2), pp. 283-290.

This article describes the development of the Oncology Patients' Perceptions of the Quality of Nursing Care Scale (OPPQNCS), which measures the quality of nursing care from the cancer patient's perspective. The researchers initially developed eight subscales and 112 items from a survey of 436 patients in active treatment for cancer. The final scale included 40 items in four care subscales: responsiveness (22 items), individualization (10 items), coordination (3), and proficiency (5). They created a short form (18 items). Psychometric properties indicated that both OPPQNCS forms adequately measured quality of cancer nursing care from the patient's perspective. This tool holds promise for nurses who wish to monitor and improve the quality of patient-centered nursing care for cancer patients and those who wish to investigate relations among care quality and health care system characteristics, patient characteristics, and nurse-sensitive patient outcomes.

Rajotte, E., Fuchs, C., and Zatzick, D. (2003, April). "Engaging and following trauma survivors in real world clinical investigations." (AHRQ grant HS11372) Journal of Nervous and Mental Disease 191(4), pp. 265-268.

Within 48 hours of the September 11, 2001 attacks on the World Trade Center in New York City, 1,103 physically injured survivors were seen at five Manhattan hospitals and trauma centers. From a public health perspective, injured patients triaged through trauma care systems may be at risk for mental health problems. Previous reports suggest that trauma survivors followed in real world settings may miss mental health screening and intervention procedures, and they can prove challenging to track and follow in longitudinal investigations. Situations such as homelessness, injury-related disability, and cultural and linguistic issues can impede followup. These authors suggest specific tracking and followup approaches to improve the retention of trauma survivors in clinical research, based on a review of studies and the research team's unique experiences with prospectively followed physically injured trauma survivors.

Satava, R.M., and Fried, M.P. (2002). "A methodology for objective assessment of errors: An example using an endoscopic sinus surgery simulator." (AHRQ grant HS11866) Otolaryngologic Clinics of North America 35, pp. 1289-1301.

To date, no scientific publication has published a classification of errors in endoscopic sinus surgery, a method for identifying how an error occurs, how to measure an error, or what outcomes should be reported. These authors used a well-proven methodology (the modified Delphi method) to generate a first-order approximation of errors that should be measured in a virtual reality surgical simulator (the ES3). Although some of the error measures are specific for sinus surgery, the same type of methodology can be used for other otolaryngologic, general, and subspecialty surgical procedures. The value of this process is that it can provide a uniform framework for investigators in surgical education and training to establish error measurements in their particular procedures or disciplines, and to generate data and outcomes that are comparable, interoperable, and capable of being shared with other investigators.

Seid, M., Castaneda, D., Mize, R., and others (2003, May). "Crossing the border for health care: Access and primary care characteristics for young children of Latino farm workers along the U.S.-Mexico border." (AHRQ grant HS10317) Ambulatory Pediatrics 3(3), pp. 121-130.

Young children of Latino farm workers who work along the U.S.-Mexico border may obtain more than half of their care in Mexico, regardless of their insurance status. These authors surveyed 297 parents at Head Start preschool centers primarily serving migrant farm workers in Southern California, near the Mexican border. Nearly 70 percent of parents surveyed had health insurance. Yet, more than half of the health care their children received was in Mexico, and half of those surveyed said their children received 75 percent or more of their health care in Mexico. Parents who traveled for work and earned more than $20,000 per year reported more care in Mexico. Children with chronic health conditions were as likely to receive care in Mexico as the United States. Parents of insured children reported slightly more U.S. care, yet even this group reported about half of their health care in Mexico. Among uninsured children, those who received most of their care in Mexico were less likely than those who received most of their care in the United States to have had a routine health care visit. This suggests that uninsured families may be using the Mexican health system primarily for sick care. Uninsured children reporting the most care in Mexico fared better in some aspects of primary care than uninsured children reporting most of their care in the United States. They also fared as well as insured children receiving care in the United States or Mexico.

Swan, J.S., Sainfort, F., Lawrence, W.F., and others (2003, March). "Process utility for imaging in cerebrovascular disease." (AHRQ grant HS10277) Academic Radiology 10(3), pp. 266-274.

Magnetic resonance (MR) angiography, which emphasizes vascular anatomy, is replacing conventional x-ray angiography in a number of diagnostic applications. Conventional angiography carries a small risk of stroke, as well as hemorrhage and renal toxic effects. MR angiography has less serious safety risks, given reasonable screening for infrequent contraindications. These authors modified a time-tradeoff technique variant, the "waiting trade-off" (WTO), in which a patient trades off waiting with symptoms for an "ideal" test result rather than undergoing a traumatic test followed by immediate treatment for cerebrovascular disease. Since stroke is a distinct possibility in these patients, they may be less willing to wait for an ideal test result from MR angiography. However, results from 90 patients with cerebrovascular disease confirmed that, on average, the more negative the patients' rating of conventional angiography, the more days they were willing to wait to avoid the traumatic test experience.

Current as of July 2003
AHRQ Publication No. 03-0039

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