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Research Briefs

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Arozullah, A.M., Lee, S-Y., Khan, T., and others (2006, February). "The roles of low literacy and social support in predicting the preventability of hospital admission." (AHRQ Grant HS13004). Journal of General Internal Medicine 21(2), pp. 140-145.

Preventable hospitalizations among veterans do not seem to be influenced by low literacy, but they can be predicted by binge drinking, less social support for medical care (someone to accompany them to the hospital or doctor), fewer clinic visits, and a larger social network. Overall, 77 percent of preventable hospitalizations for the veterans in this study were attributed to medication nonadherence (30 percent), alcohol or drug use (25 percent), or inadequate outpatient care in the previous 2 weeks (22 percent). Neither low literacy (less than completion of the 7th grade) nor very low literacy (less than completion of the 4th grade) was significantly associated with preventability of hospitalization.

Ayanian, J.Z., Zaslavsky, A.M., Guadagnoli, E., and others (2005, September). "Patients' perceptions of quality of care for colorectal cancer by race, ethnicity, and language." (AHRQ Grant HS09869). Journal of Clinical Oncology 23(27), pp. 6576-6586.

This study found that blacks, Hispanics, Asian/Pacific Islanders, and non-English-speaking white patients are significantly more likely than English-speaking white patients to report problems in quality of colorectal cancer care. Problems with coordination of cancer care were most strongly correlated with lower ratings of overall quality of care.

The results were based on survey responses of 1,067 patients with colorectal cancer in northern California. Blacks reported more problems than whites with coordination of care, psychosocial care, access to care, and health information. Asian/Pacific Islanders reported more problems than did whites with coordination of care (a difference of 13.2 points), access to care, and health information.

Hispanics tended to report more problems with coordination of care, access to care, and treatment information. Non-English-speaking whites reported more problems than other whites with coordination of care, psychosocial care, access to care, and treatment information. Non-English-speaking Hispanics reported more problems than other Hispanics with confidence in providers.

Cunningham, W.E., Hays, R.D., Duan, N., and others (2005 November). "The effect of socioeconomic status on the survival of people receiving care for HIV infection in the United States." (AHRQ Grant HS08578). Journal of Health Care for the Poor and Underserved 16, pp. 655-676.

A new HIV Costs and Service Utilization Study reveals that HIV-infected people of low socioeconomic status (SES) have worse survival rates than others infected with HIV. The study correlated SES with survival among a nationally representative group of people receiving HIV/AIDS care in the United States starting in 1996. By December 2000, 20 percent of the sample had died (13 percent from HIV, 7 percent from non-HIV causes). Those with no accumulated financial assets had an 89 percent greater risk of death, and those with less than a high school education had a 53 percent greater risk of death than their counterparts, after adjusting for sociodemographic and clinical variables. Further adjusting for use of health care services and antiretroviral treatment diminished, but did not eliminate, the elevated relative risk of death for those with low SES for three of four SES measures: annual income, wealth, educational attainment, and current work status.

Halm, E.A., Wisnivesky, J.P., and Leventhal, H. (2005, October). "Quality and access to care among a cohort of inner-city adults with asthma: Who gets guideline concordant care?" (AHRQ Grants HS09973 and HS13312). Chest 128(4), pp. 1943-1950.

A study of inner-city adults hospitalized for asthma found suboptimal asthma care and significant underuse of recommended asthma care options. Researchers tracked several indicators of asthma care quality for 198 inner-city adults with asthma at 1 hospital upon admission and at 1 month and 6 months later. At all study intervals, inhaled corticosteroids (ICs), a mainstay of asthma prevention and stabilization, were underprescribed by physicians, underused by patients, and used less often when asthma symptoms were absent. ICs were prescribed for 77 percent of patients prior to hospital admission, 83 percent at 1 month, and 67 percent at 6 months. Adherence rates for other asthma care recommendations were 89 percent for receipt of inhaler instructions, 68 percent for use of spacers for inhaled medications, 80 percent for peak flow meters (which measure expiration force to gauge lung capacity and need for medication), 31 percent for written action plans for worsening asthma, and 22 percent for written plans for asthma attacks.

Kanwal, F., Gralnek, I.M., Hays, R.D., and others (2005, September). "Impact of chronic viral hepatitis on health-related quality of life in HIV: Results from a nationally representative sample." (AHRQ Grant HS08578). American Journal of Gastroenterology 100, pp. 1984-1994.

Infection with hepatitis B (HBV) or hepatitis C (HCV) does not appear to affect the quality of life of patients already infected with HIV. Researchers analyzed data on 1,874 adults from the nationally representative HIV Cost and Services Utilization Study. They examined the health status of HIV-infected patients interviewed in 1996 (baseline) and again in 1997 and 1998. Overall, they identified 1,493 adults with HIV monoinfection, 279 with HIV-HCV coinfection (15 percent), and 122 (6 percent) with HIV-HBV coinfection.

Despite significant differences in sociodemographic characteristics between the three groups, there were no differences between them in the baseline scores for physical or mental health, overall QOL, overall health, or disability days. HRQOL did not decline significantly over time for the HIV patients with or without HCV or HBV coinfections. All groups reported similar changes over time in HRQOL scores for all measures, ranging from the ability to feed and dress oneself to doing household tasks, shopping, and working at a job.

Kivimaki, M., Ferrie, J.E., Brunner, E., and others (2005, October). "Justice at work and reduced risk of coronary heart disease among employees." (AHRQ Grant HS06516). Archives of Internal Medicine 165, pp. 2245-2251.

This study linked lack of justice at work to greater risk of coronary heart disease among 6,442 male British civil servants aged 35 to 55 years. The men did not have coronary heart disease (CHD) at baseline in Phase 1 of the study (1985-1988). The researchers determined if workers perceived justice at work and other work-related psychosocial factors by the men's responses to a questionnaire at Phase 1 and 2 (1989-1990). They then examined medical records to determine dates of CHD death, first nonfatal heart attack, or definite angina occurring from Phase 2 through 1999, for an average followup of nearly 8 years.

After adjustment for age and employment grade, employees who experienced a high level of justice at work had a 35 percent lower risk of incident CHD than employees with a low or an intermediate level of justice. This risk did not change after additional adjustment for baseline cholesterol, body mass index, hypertension, smoking, alcohol consumption, and physical activity. Although other psychosocial factors, such as job strain and effort-reward imbalance, also predicted CHD, the level of justice remained an independent predictor of CHD after adjustment for these factors.

Mein, G.K., Shipley, M.J., Hillsdon, M., and others (2005, June). "Work, retirement and physical activity: Cross-sectional analyses from the Whitehall II study." (AHRQ Grant HS06516). European Journal of Public Health 15(3), pp. 317-322.

To explore the relationship between work, retirement, and physical activity, researchers analyzed data on work hours and physical activity among 6,224 civil servants aged 45-69 years who participated in Phase 5 of the Whitehall II longitudinal study. They found a dose-response relationship between hours worked and the prevalence of physical activity, with a lower prevalence of recommended physical activity among participants working full-time (30 or more hours a week), higher prevalence among those working part-time (less than 30 hours a week), and the highest prevalence among those who were not working at all.

Physical activity rates did not increase greatly among participants who had retired from the civil service and who had gone on to do further full-time work. Also, workers in lower grade occupations were less likely to meet recommended physical activity levels than those in higher grades.

Rochon, P.A., Field, T.S., Bates, D.W., and others (2006, January). "Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care." (AHRQ grants HS10481 and HS15430). Canadian Medical Association Journal 174(1), pp. 52-54.

This paper describes the case of an 89-year-old woman with multiple medical problems living in a long-term care facility, for whom a simple prescribing decision initiated a cascade of errors culminating in an adverse drug event (ADE). The authors use this case to illustrate how computerized physician order entry (CPOE) with clinical decision support (CDS) could have avoided the prescribing errors involved and prevented the ADE. They point out that, like the case patient, residents of long-term care facilities are prescribed an average of more than six concurrent drug therapies and are often very elderly and frail—all conditions that markedly increase their potential for ADEs. They conclude that CPOE—CDS is a promising new technology that may be very useful in long-term care settings.

Rockman, C.B., Halm, E.A., Wang, J.J., and others (2005, November). "Primary closure of the carotid artery is associated with poorer outcomes during carotid endarterectomy." (AHRQ Grant HS09754). Journal of Vascular Surgery 42(5), pp. 870-877.

A new study of several carotid endarterectomy (CEA) techniques found that primary closure during CEA has poorer outcomes than either standard endarterectomy with patch angioplasty or eversion endarterectomy. Primary closure was associated with more than double the rate of perioperative stroke or death than the other two techniques (6.0 vs. 2.5 percent), despite similar symptoms in the patients prior to surgery.

Researchers retrospectively studied consecutive CEAs performed by 81 surgeons during 1997 and 1998 in 6 regional hospitals. They reviewed medical charts, surgical records, and hospital administrative databases to ascertain clinical data on each case and all deaths and nonfatal strokes within 30 days of surgery. A total of 1,972 CEAs were performed on patients whose average age was 72 years. Nearly 29 percent of patients had preoperative neurologic symptoms and 71 percent had no symptoms prior to surgery. Primary closure was performed in 12 percent, patch angioplasty in 70 percent, and eversion endarterectomy in 18 percent, with no significant difference in preoperative symptom status among groups.

Schwartz, L.M., Woloshini, S., and Birkmeyer, J.D. (2005, September). "How do elderly patients decide where to go for major surgery? Telephone interview survey." (AHRQ Grant HS1304). British Medical Journal 331, pp. 821-827.

This study indicates that most elderly Medicare patients still rely on their referring physicians' opinion when selecting a hospital for major surgery. Researchers conducted a telephone survey with 510 randomly selected elderly Medicare beneficiaries who had undergone an elective, high-risk procedure about 3 years earlier. These procedures included abdominal aneurysm repair, heart valve replacement, or surgery for bladder, lung, or stomach cancer. Although all respondents could choose where to have surgery, only 55 percent said there was an alternative hospital in their area where they could have gone, and 10 percent of them seriously considered going elsewhere for surgery. Few (11 percent) looked for information to compare hospitals. Nearly all those interviewed thought their hospital and surgeon had good reputations (94 and 88 percent, respectively), beliefs mostly determined by what their referring doctors said.

When the elderly advised a friend where to go for surgery, a surgeon's reputation was the most influential factor (78 percent said it would influence their advice a lot), followed by the hospital having "nationally recognized" surgeons (63 percent).

Seid, M. and Stevens, G.D. (2005, December). "Access to care and children's primary care experiences: Results from a prospective cohort study." (AHRQ Grant HS10317). HSR: Health Services Research 40(6), pp. 1758-1780.

This study found that having a regular provider and obtaining needed care have a greater impact on children's primary care experiences than having health insurance. A continuously insured child was found to have, on average, a total primary care score 6.2 points higher than one continuously uninsured, based on the Parents' Perceptions of Primary Care (P3C) measure. Children with a regular physician had a score 10.9 points higher, on average, than those who never had a regular physician. Finally, children who never had to forego needed care had scores 10.7 points higher, on average, than those who report foregone care (unmet needed care).

After controlling for other factors that affect the primary care experience, such as parent's language and mother's education level, gaining or losing insurance during the 1-year study period did not have a significant effect on primary care experiences. Gaining a regular physician was associated with primary care scores no different from always having had one, but losing a regular physician was associated with scores an average of 9.2 points lower on the P3C.

Singh-Manoux, A. and Marmot, M. (2005, December). "High blood pressure was associated with cognitive function in middle-age in the Whitehall II study." (AHRQ Grant HS06516). Journal of Clinical Epidemiology 58, pp. 1308-1315.

A new Whitehall II study of British civil servants links elevated blood pressure—both systolic (SBP) and diastolic (DBP)—to poor cognitive performance among middle-aged men and women as well. Researchers analyzed blood pressure data obtained at baseline or Phase I (1985-1988), when the 5,838 civil workers were an average of 44 years old, and again at Phase 3 (1991-1994), and Phase 5 (1997-1999), when they were an average of 56 years old. They assessed cognitive function using five standard tasks (a memory test, AH 4-1 test of verbal and mathematical reasoning, Mill-Hill vocabulary test, phonemic fluency, and semantic fluency) and examined the relationship between both baseline and current blood pressure with cognitive performance.

Overall, there was a small but significant inverse relationship between blood pressure and cognitive ability, with both elevated SBP and DBP associated with poor cognitive performance. Blood pressure was particularly related to verbal fluency (both phonemic and semantic), AH 4-1, and memory. In women, an elevated SBP predicted poor performance on all the cognitive outcomes.

Tebb, K.P., Pantell, R.H., Wibbelsman, C.J., and others (2005, October). "Screening sexually active adolescents for Chlamydia trachomatis: What about the boys?" (AHRQ Grant HS10537) American Journal of Public Health 95(10), pp. 1806-1810.

Routine screening for Chlamydia trachomatis (CT) infection is currently recommended for sexually active women aged 15 to 25 years. Only the American Medical Association recommends CT urinalysis screening for sexually active male adolescents. This study found that a quality improvement (QI) team at pediatric clinics can substantially improve screening of CT among male adolescents.

Researchers randomized 10 pediatric clinics in a health maintenance organization in the San Francisco Bay area into 2 groups. Five QI clinics participated in a QI program that included a QI team to establish protocols for gathering adolescents' confidential sexual histories, collecting urine samples, and examining ways to reduce barriers to CT screening. The five control clinics received traditional information on CT screening. A total of 1,088 sexually active male adolescents 14 to 18 years old visited the QI clinics and 1,134 visited the control clinics.

Researchers found CT infection in 4 percent of sexually active male adolescents screened at pediatric clinics. QI clinics increased CT screening among adolescent boys during pediatric health maintenance visits from 0 percent at baseline to 60 percent 18 months later. Screening at control clinics only changed from 0 to 5 percent.

Thompson, D.A., Lubomski, L., Holzmueller, C., and others (2005, October). "Integrating the intensive care unit safety reporting system with existing incident reporting systems." (AHRQ Grant HS11902). Journal on Quality and Patient Safety 31(10), pp. 585-592.

Researchers at Johns Hopkins University found that, in some hospitals, leadership on incident reporting was minimal, and even when a voluntary system such as the anonymous, Web-based Intensive Care Unity Safety Reporting System (ICUSRS) was integrated with existing reporting system(s), few reports were submitted. Reporting of an adverse event that could be linked to a provider was often associated with shame and blame. In the most successful units, reporting was transparent rather than secretive, and staff were reminded to report on patient care rounds.

Despite enthusiasm about the ICUSRS, risk managers at several hospitals were concerned about disclosure laws within their States and were the largest opponents of ICUSRS implementation. Three out of 30 responding hospitals ultimately withdrew because of existing disclosure laws, even though the ICUSRS has two levels of confidentiality and protection of data against discoverability, both as an institutionally approved research project and as a Federally funded project.

Tsai, A.C., Votruba, M., Bridges, J.F., and Cebul, R.D. (2006, February). "Overcoming bias in estimating the volume-outcome relationship." (AHRQ grants T32 HS00059 and HS14151). HSR: Health Services Research 41(1), pp. 252-264.

This study examined the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models. The researchers concluded that use of only administrative data for volume-outcomes research may generate spurious findings. What's more, conventional estimates of the volume-outcome relationship may be contaminated by the effects of selective referral to certain hospitals. These results suggest that efforts to concentrate hospital-based CHF care in high-volume hospitals may not reduce mortality among elderly patients. The findings were based on analysis of data on comorbid conditions, vital signs, clinical status, and laboratory test results for 21,555 elderly Medicare-insured patients hospitalized for CHF in Ohio from 1991 to 1997.

Zhang, S., Sun, D., He, C.Z., and Schootman, M. (2006). "A Bayesian semi-parametric model for colorectal cancer incidences." (AHRQ grant HS14095). Statistics in Medicine 25, pp. 285-309.

Most studies that have explored the relationship between colorectal cancer trends and factors like age, gender, and race, have examined trends over large areas like States, but not smaller areas like counties. However, Bayesian empirical and hierarchical approaches have been recently used for solving small-area estimation problems. In this paper, the authors propose a Bayesian semi-parametric model to capture the interaction among demographic effects (age and gender), spatial effects (county), and temporal effects of colorectal cancer incidences simultaneously. Data analysis showed significant spatial correlation only existed in the age group of 50 to 59 years. Males and females in their 50s and 60s showed fairly strong correlation, which suggests that gender correlation cannot be ignored in this model.

Zhou, K.H., Greve, D.N., Wang, M., and others (2005, December). "Reproducibility of functional MR imaging: Preliminary results of prospective multi-institutional study performed by biomedical informatics research network." (AHRQ grant HS13234). Radiology 237, pp. 781-789.

Functional magnetic resonance (MR) imaging has substantially contributed to our understanding of normal and diseased brains in humans. However, much variability in the magnitude, spatial distribution, and statistical significance of the corresponding functional MR imaging maps often exists, owing to differences in the equipment used and to subject- and site-specific differences. The researchers prospectively investigated the factors—including subject, brain hemisphere, study site, field strength, MR imaging unit vendor, imaging run, and examination visit—that affect the reproducibility of functional MR imaging activations based on a repeated sensory-motor task performed by five healthy men aged 20-29 years at 10 sites. MR imaging at 3.0-T and 4.0-T yielded higher reproducibility across sites and significantly better results than 1.5-T imaging. The effects of subject, k-space, and field strength on examination reproducibility were significant.

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