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Research Briefs

Amin, M.G., Wolf, M.P., TenBrook, Jr., J.A., and others (2004, December). "Expanded criteria donor grafts for deceased donor liver transplantation under the MELD system: A decision analysis." (AHRQ training grant T32 HS00060). Liver Transplantation 10(12), pp. 1468-1475.

About 5,000 liver transplants are performed each year in the United States while three to four times as many candidates wait for liver transplants. In response to this unmet need, criteria for donor livers have been expanded to include so-called "marginal" donor livers. However, these expanded criteria donor (ECD) liver grafts have a higher likelihood of primary graft failure (PGF) compared with standard criteria donor (SCD) grafts. Despite the higher risk for PGF, transplantation with an available ECD graft should be preferred over waiting for an SCD organ for patients with advanced MELD scores (greater than 20, indicating more severe end-stage liver disease). At less advanced MELD scores, the survival benefit depends on the risk of PGF associated with the ECD organ, according to this study. The findings were based on a decision model that estimated 1-year survival comparing use of both types of donor livers.

Atkins, D., Eccles, M., Flottorp, S., and others (2004, December). "Systems for grading the quality of evidence and the strength of recommendations. I: Critical appraisal of existing approaches." BMC Health Services Research 4(38), online at

The authors of this paper critically appraise six prominent systems for grading levels of evidence underlying health care recommendations and the strength of these recommendations. There was poor agreement among 12 raters on the sensibility of the six systems. Only one system was suitable for all four types of questions considered (effectiveness, harm, diagnosis, and prognosis). None of the systems was considered usable for all of the target groups considered (professionals, patients, and policymakers). The raters found low reproducibility of judgments made using all six systems. Systems used by 51 organizations that sponsor clinical practice guidelines include a number of minor variations of the six systems considered by these authors. Reprints (AHRQ Publication No. 05-R045) are available from the AHRQ Publications Clearinghouse.

Bell, J.F., Zimmerman, F.J., Cawthon, M.L., and others (2004). "Jail incarceration and birth outcomes." (AHRQ grant T32 HS13853). Journal of Urban Health 81(4), pp. 630-644.

Women of childbearing age are the fastest growing segment of the U.S. jailed population, and at least 6 percent of them are pregnant at the time of arrest. Women in their 30s who are in an urban jail during pregnancy are more likely than similar women not in jail to have low-birthweight (LBW, less than 5.5 lbs) and preterm babies, while incarcerated women older than 39 years are less likely to have LBW or preterm babies. The researchers compared outcomes for 496 births to women who were in jail for part of their pregnancy with 4,960 Medicaid-funded births as matched community controls. There were no significant differences in the odds of LBW between women in the jail and control groups at ages 18 to 29. However, jailed women ages 30-34 were nearly twice as likely as unjailed women to have an LBW infant and three times as likely to do so at ages 35-39. None of the incarcerated women older than 39 had an LBW infant. The researchers suggest that younger women may be more resilient to stress, in better general health, less drug dependent, and/or more successful in drug treatment programs.

Brazil, K., Ozer, E., Cloutier, M.M., and others (2005). "From theory to practice: Improving the impact of health services research." BMC Health Services Research 5(1), online at

These authors discuss how integrating theory into health services research can improve research methodology and encourage stronger collaboration with decisionmakers and ultimately improve the delivery of health care. However, this integration requires new expectations in the practice of health services research, including the formation of interdisciplinary research teams, broadening training for those who will practice health services research, and supportive organizational conditions that promote collaboration between researchers and decisionmakers.

Chamberlain, J.M., Patel, K.M., and Pollack, M.M. (2005, February). "The Pediatric Risk of Hospital Admission score: A second-generation severity-of-illness score for pediatric emergency patients." (AHRQ grant HS10238). Pediatrics 115(2), pp. 388-395.

These investigators developed and validated in a large sample of hospitals a second-generation severity-of-illness score, the Pediatric Risk of Admission (PRISA II) score, which is applicable to pediatric emergency patients. In the development sample, 442 mandatory admissions were predicated and 442 were observed, and in the validation sample, 136.6 were predicted and 145 were observed. These performance characteristics indicate that the PRISA II will be useful for institutional comparisons, benchmarking, and controlling for severity of illness when enrolling pediatric patients in clinical trials.

Hermann, R.C., Palmer, H., Leff, S., and others (2004, December). "Achieving consensus across diverse stakeholders on quality measures for mental healthcare." (AHRQ grant HS10303). Medical Care 42(12), pp. 1246-1253.

In this study, a 12-member panel of stakeholders from national mental health care organizations used a structured consensus process to identify a core set of mental health care quality measures that would be meaningful and feasible for various stakeholders. The panel identified and rated 28 measures addressing a range of treatment modalities, clinical settings, diagnostic categories, vulnerable populations, and other dimensions of mental health care. Responses were obtained on a 9-point scale: 1 to 3 indicating agreement, 4 to 6 neither agreement nor disagreement, and 7 to 9 disagreement. Mean ratings for meaningfulness ranged from 2.29 for clinical importance and 2.59 for perceived gap between actual and optimal care to 2.61 for association between improved performance and outcome. Mean ratings for feasibility were 3.39 for clarity of specifications, 4.77 for acceptability of data collection burden, and 4.20 for adequacy of case mix adjustment.

Horton, S. (2004). "Different subjects: The health care system's participation in the differential construction of the cultural citizenship of Cuban refugees and Mexican immigrants." (AHRQ grant HS09703). Medical Anthropology Quarterly 18(4), pp. 472-489.

In this article, the author explores the public health system's differential treatment of Mexican and Cuban immigrants. Faced with implementing Medicaid managed care with limited resources, hospital administrators created new categories of "deserving" and "undeserving" immigrants. For instance, a Mexican immigrant going to a New Mexico hospital will be referred to a public health clinic, since the hospital cannot provide care to undocumented immigrants unless they pay a $50 fee, which few can afford. On the other hand, a Cuban refugee, recently resettled by the Federal Government, can be treated there because he or she is eligible for medical benefits for up to 8 months, food stamps, welfare, rental assistance, and even job training. The authors illustrate that this uneven treatment leads to unmet health needs and poor health outcomes.

Iezzoni, L.I., Davis, R.B., Soukup, J., and O'Day, B. (2004, December). "Physical and sensory functioning over time and satisfaction with care: The implications of getting better or getting worse." (AHRQ grant HS10223). Health Services Research 39(6), pp. 1635-1652.

The authors analyzed data from the 1996 and 1997 Medicare Current Beneficiary Survey (MCBS) to determine whether those individuals whose sensory or physical functioning improved or worsened over the course of 1 year were more or less satisfied with their health care. They assessed five categories of sensory or physical functioning for 9,974 MCBS respondents—vision, hearing, walking, reaching overhead, and grasping and writing—and compared 1996 and 1997 responses to identify whose functioning improved or worsened. Worsened functioning was strongly associated with older age, low income, and low educational attainment. Improved functioning was rarely significantly associated with care satisfaction. However, worsened function was often significantly associated with care dissatisfaction.

Jasso-Aguilar, R., Waitzkin, H., and Landwehr, A. (2004). "Multinational corporations and health care in the United States and Latin America: Strategies, actions, and effects." (AHRQ grant HS13251). Journal of Health and Social Behavior 45, pp. 136-157.

These authors analyze the corporate dominance of health care in the United States and the dynamics that have motivated the international expansion of multinational health care corporations, especially in Latin America. They identify the strategies, actions, and effects of multinational corporations in health care delivery and public health policies. Their findings are based on bibliographical research and in-depth interviews in the United States, Mexico, and Brazil. The researchers suggest that the falling rate of profit is an economic motivator of corporate actions, silent reform, and the subordination of polity to economy.

Johnson, J.A., Luo, N., Shaw, J.W., and others (2005, March). "Valuations of EQ-5D health states. Are the United States and United Kingdom different?" and Shaw, J.W., Johnson, J.A., and Coons, S.J., "U.S. valuation of the EQ-5D health states: Development and testing of the D1 valuation model." (AHRQ grant HS10243). Medical Care 43(3), pp. 203-220, 221-228.

In the first article, the authors describe the development of a statistical model for generating U.S. population-based EQ-5D preference weights for assessing how individuals value various health states. They asked a sample from the U.S. adult community population to value 13 of 243 EQ-5D health states using the time trade-off (TTO) method (how much life they were willing to give up in one state to trade it for a better state). The model yielded a good fit for the observed TTO data. The second article compares directly elicited valuation for EQ-5D health states between the U.S. and U.K. general adult populations. The authors found meaningful differences in directly elicited TTO valuations of EQ-5D health states between the U.S. and U.K. general populations. They conclude that EQ-5D index scores from the U.S. population should be used for studies aiming to reflect health state preferences of the American public.

Lin, H-M., Lyles, R.H., Williamson, J.M., and Kunselman, A.R. (2005). "Estimation of the intervention effect in a non-randomized study with pre- and post-mismeasured binary responses." (AHRQ grant HS11452). Statistics in Medicine 24, pp. 419-435.

Subjects in experimental studies often undergo an initial screening to determine the existence of a pre-specified condition, after which those so identified receive an intervention. Measurement of the outcome upon subsequent followup then provides a basis for estimating the intervention effect. In this paper, the authors analyze the change in event probability resulting from the implementation of an intervention in a single-arm (non-comparative) study. They consider a scenario in which the subjects are selected for a study based on a positive diagnostic test at screening. The disease status is then reassessed at the end of the intervention. The authors propose methods for estimating the change in event probability resulting from implementing the intervention, while adjusting for the misclassification that produces the regression effect.

Lukela, M., DeGuzman, D., Weinberg, S., and Saint, S. (2005, January). "Unfashionably late." (AHRQ grant HS11540). New England Journal of Medicine 352(1), pp. 64-69.

The authors describe the eventual diagnosis of a case of chronic granulomatous disease in an 18-year-old man whose presentation was atypical. The patient had a history of pneumonia but was otherwise in good health. Lung imaging and lack of fever over several weeks suggested a noninfectious inflammatory disease, specifically bronchiolitis obliterans with organizing pneumonia. He was given antibiotics and sent home on two occasions only to return to the hospital later. The lung biopsies were not conclusive. After ruling out other options and cystic fibrosis, the doctors concluded that the young man did in fact have chronic granulomatous disease, a disease usually diagnosed in childhood. Even though he had two previous episodes of pneumonia, the reappearance of extensive lung disease and the subacute presentation should have raised the possibility of an underlying inherited disease at an earlier stage of his evaluation, conclude the authors.

M'ikanatha, N. M., Julian, K.G., Kunselman, A.R. (2005). "Patients' request for and emergency physicians' prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak." (AHRQ grant HS13036). BMC Public Health 5(2), online at

Public fears may lead to a high demand for antibiotic prophylaxis during bioterrorism events, concludes this study. The investigators conducted a random telephone survey of emergency physicians in Pennsylvania to assess patients' request for and receipt of prescriptions for antimicrobial agents during the 2001 anthrax attacks. Two-thirds of the 99 physicians who completed the survey had received requests from patients for anthrax prophylaxis; 25 percent of these physicians prescribed antibiotics to a total of 23 patients. Ten physicians prescribed ciprofloxacin, and eight physicians prescribed doxycycline.

Moore, D.E., Feurer, I.D., Speroff, T., and others (2005, March). "Impact of donor, technical, and recipient risk factors on survival and quality of life after liver transplantation." (AHRQ grant 13036). Archives of Surgery 140, pp. 273-277.

These researchers retrospectively studied 483 adults undergoing liver transplantation from 1991 to 1993 at one hospital to examine the impact of donor, technical, and recipient risk factors on survival and quality of life after liver transplantation. Five-year graft survival was 72 percent for recipients of livers from donors younger than 60 years and 35 percent for livers from donors 60 years and older. A shorter 5-year graft survival was associated with a cold ischemia time (CIT) of 12 hours or more (71 vs. 58 percent) and a United Network for Organ Sharing (UNOS) status 1 or 2A verus 2B or 3 (60 vs. 71 percent). Cumulative effects of these risk factors can be modeled to predict posttransplant survival.

Morikawa, Y., Marikainen, P., Head, J., and others (2004). "A comparison of socio-economic differences in long-term sickness absence in a Japanese cohort and a British cohort of employed men." (AHRQ grant HS06516). European Journal of Public Health 14, pp. 413-416.

These authors compared the magnitude of socioeconomic differences in sickness absence rates between Japanese and British groups of middle-aged employees over an 8-year period. The first-time sickness absence rates were about twice as high among British men compared with Japanese men. The rate ratio of lower to higher employment grade was 1.2, 1.3, and 2.1 among Japanese white-collar, Japanese blue-collar, and British white-collar employees, respectively. Baseline self-rated health and smoking habit predicted sickness absence in both groups. However, socioeconomic differences in sickness absence were only partly explained by these factors.

Ness, R.B. (2004, December). "The consequences for human reproduction of a robust inflammatory response." (AHRQ grant HS10592). Quarterly Review of Biology 79(4), pp. 383-393.

This article suggests that immune hyperresponsiveness may limit a woman's reproductive capacity. Normal pregnancy elicits a maternal inflammatory reaction. This can be understood on the basis of maternal-fetal conflict theory: inflammation is a component of the maternal attempt to limit excessive fetal demands. However, an overly aggressive inflammatory reaction has been shown to be related to a variety of adverse reproductive outcomes. The author reviews several examples, including the fallopian tube damage that results from pelvic inflammatory disease, the upregulated inflammatory response among women who develop preeclampsia, an association between immune hyperresponsiveness and premature delivery, and the relationship between autoimmune diseases and multiple adverse pregnancy outcomes.

Piotrowski, M.M. (2005, January). "Introducing the national patient safety goals department: Sharing programs of excellence from individual organizations." (AHRQ grant HS11540). Journal on Quality and Patient Safety 31(1), pp. 43-46.

This article introduces a new section in this journal of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The section will focus on sharing programs of excellence in patient safety from individual organizations, including innovative ways to meet JCAHO requirements. JCAHO is the leading health care accrediting body in the United States, which surveys about 16,000 health care organizations. JCAHO national patient safety goals are tailored for home care, ambulatory care, behavioral health care, disease-specific care certification, laboratories, long-term care, and assisted living.

Pronovost, P.J., Thompson, D.A., Holzmueller, C.G., and others (2005). "Defining and measuring patient safety."(AHRQ grant HS11902). Critical Care Clinics 21, pp. 1-19.

These authors review the definition of safety and error and discuss approaches to measuring safety. In doing so, they provide a framework for investigating incidents that reveal risk to patients and discuss how the systems in which care is delivered may contribute to adverse incidents. The authors discuss ways to measure quality, for example, by use of patient safety indicators and safety and process versus outcome measures. Efforts to evaluate adverse events, if done from a systems approach, can help to improve safety, contend the authors. Measuring defect rates, however, is more challenging. Finally process of care measures are probably more readily available than outcome measures.

Rector, T.S., Wickstrom, S.L., Shah, M., and others (2004, December). "Specificity and sensitivity of claims-based algorithms for identifying members of Medicare+Choice health plans that have chronic medical conditions." (AHRQ grant HS09630). Health Services Research 39(6), Part I, pp. 1839-1860.

Highly specific and sometimes sensitive algorithms for identifying members of health plans with several chronic conditions can be developed using claims data, according to this study. The authors extracted physician, facility, and pharmacy claims data from Medicare+Choice health plans on 3,633 continuously enrolled beneficiaries who responded to a survey that included questions about chronic diseases. For instance, specificity of algorithms was significantly improved by 0.03 to 0.17 when both a medical claim with a diagnosis and a pharmacy claim for a medication commonly used to treat the condition were required. Sensitivity improved significantly by 0.01 to 0.20 when the algorithm relied on a medical claim with a diagnosis or a pharmacy claim, and by 0.05 to 0.17 when 2 years rather than 1 year of claims data were analyzed.

Shaffer, E.R., Waitzkin, H., Brenner, J., and Jasso-Aquilar, R. (2005, January). "Ethics in public health research: Global trade and public health." (HS13251). American Journal of Public Health 95(1), pp. 23-34.

Global trade and international trade agreements have transformed the capacity of governments to monitor and protect public health, regulate occupational and environmental health conditions and food products, and ensure affordable access to medications. Yet, public health professionals and organizations rarely participate in trade negotiations or in resolution of trade disputes. The linkages among global trade, international trade agreements, and public health deserve more attention than they have received to date, note the authors of this paper. They analyze key global trade issues that affect public health, describe the forces shaping them, and discuss their implications for public health.

Shapiro, M.J., Morey, J.C., Small, S.D., and others (2004). "Simulation based teamwork training for emergency department staff: Does it improve clinical team performance when added to an existing didactic teamwork curriculum?" (AHRQ grants HS11553 and HS11905). Quality and Safety in Health Care 13, pp. 417-421.

Simulator-based training may enhance didactic teamwork training, according to this study. The investigators compared team performance between emergency department (ED) staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC) and also received an 8-hour intensive experience in an ED simulator in which they encountered three scenarios of graduated difficulty. A comparison group, also ETCC trained, was assigned to work together in the ED for an 8-hour shift. The experimental team showed a trend towards improvement in the quality of team behavior, while the comparison group showed no change in team behavior during the two observation periods.

Shea, J.A., Aguirre, A.C., Sabatini, J., and others (2005, January). "Developing an illustrated version of the Consumer Assessment of Health Plans (CAHPS®)." (AHRQ grant HS10299). Journal on Quality and Patient Safety 31(1), pp. 32-42.

The Consumer Assessment of Health Plans (CAHPS®) is the most commonly used tool to assess member satisfaction with health plans. However, this complex survey may be confusing for less-educated patient populations. The authors of this article describe the development of an illustrated version of CAHPS® for low-literacy groups. They developed illustrations to support the central themes in each of 63 CAHPS® text items. Illustrations were tested and revised to reflect feedback. Following interviews with more than 900 patients, all but 7 (11 percent) of the 63 items met the criterion that no more than 25 percent of the sample who saw the illustration could be rated as having "limited/no understanding." By the final pilot test, a median of 66 percent of patients had "full understanding," 20 percent had "partial understanding," and 14 percent had "limited/no understanding" of the 43 illustrations that had been revised.

Wong, H.S., Zhan, C., and Mutter, R. (2005). "Do different measures of hospital competition matter in empirical investigations of hospital behavior?" Review of Industrial Organization 26, pp. 61-87.

Considerable controversy exists about the appropriate way hospital competition should be measured. These authors used data from the Healthcare Cost and Utilization Project, the American Hospital Association, and other supplemental data sources to create and evaluate hospital competition measures. Most measures were highly correlated. Inferences about the effect of competition on hospital cost remained the same when alternative hospital competition measures were employed. However, the authors caution researchers against using this finding to arbitrarily select a competition measure when the magnitude of the estimates is important. Reprints (AHRQ Publication No. 05-R050) are available from the AHRQ Publications Clearinghouse.

Yaeger, K.A., Halamek, L.P., Coyle, M., and others (2004, December). "High-fidelity simulation-based training in neonatal nursing." (AHRQ grant 12022). Advances in Neonatal Care 4(6), pp. 326-331.

Simulation-based training has the potential to greatly improve neonatal nursing, according to these researchers. Through realistic clinical scenarios, simulation-based training requires trainees to develop higher order cognitive skills and provides the opportunity to acquire and refine cognitive, technical, and behavioral skills by solving complex, multidimensional problems in an environment without risk to patients' well-being. The constructive debriefings immediately following these scenarios further reinforce positive aspects of performance and pinpoint areas for improvement in a nonjudgmental manner. Finally, simulation-based training programs are better accepted by adult learners than traditional programs.

Zatzick, D.F., Russo, J., Pitman, R.K., and others (2005). "Reevaluating the association between emergency department heart rate and the development of posttraumatic stress disorder: A public health approach." (AHRQ grant HS11372). Biological Psychiatry 57, pp. 91-95.

This study revealed an independent association between elevated emergency department (ED) heart rate of 95 or more beats per minute (BPM) and posttraumatic stress disorder (PTSD) symptoms in a representative sample of 161 acutely injured surgical inpatients. The investigators assessed heart rate at ED presentation and PTSD symptoms at the time of hospitalization and at 1, 4-6, and 12 months postinjury. An ED heart rate of 95 BPM or higher was a significant predictor of PTSD symptoms in analyses that adjusted for relevant injury and patient clinical and demographic characteristics. Incorporating acute care biological parameters such as heart rate has the potential to improve the quality of mental health care delivered to injured survivors of individual and mass trauma, conclude the researchers.

Current as of June 2005
AHRQ Publication No. 05-0087

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