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Aita, V., McIlvain, H., Susman, J., and Crabtree, B. (2003, December). "Using metaphor as a qualitative analytic approach to understand complexity in primary care research." (AHRQ grant HS08776). Qualitative Health Research 13(1), pp. 1419-1431.

Metaphors can identify and explore tacit knowledge and behaviors that are embedded in complex organizations and shape health care practices. The authors of this article explore the theoretical rationale, background, and advantages of using metaphor as an analytic approach to understand complexity in primary care research. They illustrate the advantages and implications of this approach using an analysis of 18 family practices in a comparative case study designed to explore office practice strategies for delivering cancer prevention services. Examples of practice metaphors used included the "franchise," the "mission," and the "family," which described the overall nature of a practice and captured the dominant value that seemed to be motivating practice behaviors.

Asch, S.M., Fremont, A.M., Turner, B.J., and others (2004). "Symptom-based framework for assessing quality of HIV care." (AHRQ grant HS08578). International Journal for Quality in Health Care 16(1), pp. 41-50.

Symptom-based indicators for quality of HIV care may provide a useful supplement to conventional measures, according to this study. Using a symptom-based framework for quality, the researchers found that HIV care for several common, burdensome symptoms was suboptimal. Of HIV-infected patients who reported being at least moderately bothered by one of three symptoms (cough with fever and/or shortness of breath, significant weight loss, or severe diarrhea), 41, 74, and 65 percent, respectively, reported receiving all indicated care for the most bothersome symptom in the previous 6 months. Care was better for patients with more severe HIV disease (CD4 cell count less than 50 cells/microliter).

Bradley, E.H., Holmboe, E.S., Mattera, J.A., and others (2004). "Data feedback efforts in quality improvement: Lessons learned from U.S. hospitals." (AHRQ grant HS10407). Quality & Safety in Health Care 13, pp. 26-31.

Data feedback, the process of monitoring practice performance, is a central component of quality improvement efforts. This study illustrates the diversity of hospital-based efforts at data feedback. It also highlights successful strategies and common pitfalls in designing and implementing data feedback to support performance improvement. It is based on interviews with 45 clinical and administrative staff in eight U.S. hospitals. Those interviewed made several points. Physicians must perceive the data as valid to motivate change, it takes time to develop the credibility of data within a hospital, benchmarking improves the meaningfulness of data feedback, and data feedback must persist to sustain improved performance.

Callahan, E.J., Strange, K.C., Bertakis, K.D., and others (2003). "Does time use in outpatient residency training reflect community practice?" (AHRQ grants HS08029 and HS06167). Residency Education 35(6), pp. 423-427.

This study found that experienced family physicians provide more technical and less preventive and psychosocially oriented care than residents. Thus, time use in outpatient residency training does not reflect actual community practice, conclude the researchers. They compared time use during visits by 244 new adult outpatients to 33 second- and third-year residents in a university clinic to time use during 277 new adult outpatient visits to 92 community practice family physicians. Controlling for patient mix, residents had longer visits, a less technical focus, and spent more of the visit on efforts to promote health behavior change and counseling. The differences in time use between the two groups may reflect differences in patient mix, practice setting, physician experience, or the time and financial pressures of community practice.

Carder, P.C., and Hernandez, M. (2004). "Consumer discourse in assisted living." (AHRQ grant HS09886). Journal of Gerontology: Social Sciences 59B(2), pp. S58-S67.

This article discusses organizational strategies employed by assisted living practitioners to promote consumer choice and independence while mediating potential risks to assisted living residents. The investigators used field notes, participation in manager-training programs, and interviews with residents and family members during a nearly 2-year study of three Oregon assisted living facilities. They found that consumer discourse that treats older residents as active consumers rather than recipients of long-term care services was evident in State rules, manager-training programs, organizational practices, and an institutional belief in specific consumer demands like independence and choice. The authors discuss the benefits and pitfalls of this approach.

Conrad, K.J., and Smith, E.V. (2004, January). "International conference on objective measurement: Applications of Rasch analysis in health care." (AHRQ grant HS10941). Medical Care 42(1Suppl.), pp. 1-6.

This article provides an overview of papers on Rasch analysis that were presented at an international conference on objective measurement. The authors explain that use of Rasch models enables predictions of how people at each level of ability are expected to do on each item. For example, in the mental health field, if a person says they feel suicidal, the odds are strongly in favor of their citing other symptoms such as loneliness, nervousness, and depression, as these symptoms are easier to endorse than feeling suicidal. Other papers address some key measurement issues that can be studied and problems that can be solved using Rasch analysis, such as the issue of missing data.

Cook, R.L., May, S., Harrison, L.H., and others (2004, January). "High prevalence of sexually transmitted diseases in young women seeking HIV testing in Rio de Janeiro, Brazil." (AHRQ grant HS10592). Sexually Transmitted Diseases 31(1), pp. 67-72.

Sexually transmitted diseases (STDs) are a substantial health problem among young Brazilian women seeking HIV testing, concludes this study. The investigators administered a questionnaire to 200 women aged 14 to 29 years who visited an HIV testing site in central Rio de Janeiro and were tested for HIV, syphilis, chlamydia, and gonorrhea. HIV and other STDs were common (HIV, 8 percent; syphilis, 6.5 percent; chlamydial infection, 8 percent; and gonorrhea, 9.5 percent). HIV was associated with lower education and having an HIV-infected partner. Other STDs were associated with younger age at first intercourse, heavy alcohol consumption, and marijuana use.

Gershon, R.R., Stone, P.W., Bakken, S., and Larson, E. (2004, January). "Measurement of organizational culture and climate in health care." (AHRQ grant HS13114). Journal of Nursing Administration 34(1), pp. 33-40.

These investigators conducted a systematic review of the biomedical literature to clarify the definition of organizational culture and climate, begin the process of standardization of the terminology, and identify instruments that measure the constructs of organizational culture and climate. Based on the review, they categorized dimensions assessing organizational culture or climate into four areas: leadership characteristics, group behaviors and relationships, communications, and structural attributes of quality of work life. They also identified major health-care-related outcomes, the most common being patient satisfaction, job satisfaction, motivation, work stress, and turnover.

Gresenz, C.R., Rogowski, J., and Escarce, J.J. (2004, April). "Updated variable-radius measures of hospital competition." (AHRQ grant HS10770). Health Services Research 39(2), pp. 417-430.

The size of a hospital's market is influenced by a number of factors that include hospital characteristics and features of the local health care market. Using data from the 1997 State Inpatient Databases of the Healthcare Cost and Utilization Project for nine States, these investigators found several important correlates of a hospital's market size. These include population density, number of other hospitals in the local area, and hospital characteristics such as medical school affiliation, percentage of admissions that are Medicaid, and service offerings. However, the influence of population density and local hospital competition varied significantly depending on whether the hospital was in an urban or rural location.

Haley, S.M., Coster, W.J., Andres, P.L., and others, "Activity outcome measurement for postacute care;" and Coster, W.J., Haley, S.M., Andres, P.L., and others (2004, January). "Refining the conceptual basis for rehabilitation outcomes measurement." (Co-funded by AHRQ and the National Institute of Child Health and Human Development). Medical Care 42(1 Suppl.), pp. I49-I61, I62-I72.

In the first study, the investigators developed a model for measuring rehabilitation outcomes of postacute care. The 41-item Activity Measure for Postacute Care (AM-PAC) assesses an individual's execution of discrete daily tasks in his or her own environment across major content domains defined by the International Classification of Functioning, Disability, and Health. Three areas, applied cognition, personal care and instrumental activity, and physical and movement activities, accounted for 72 percent of variance among individuals. In the second study, the researchers administered the newly developed AM-PAC and other rehabilitation outcome instruments to 477 individuals from three different disability groups and four types of postacute rehabilitation care settings. The results support the validity of the personal care and instrumental activity dimension of the AM-PAC as a guide for future development of rehabilitation outcome instruments, such as linked, setting-specific short forms and computerized adaptive testing.

Hayes, D.N., and Sege, R. (2003, December). "FiGHTS: A preliminary screening tool for adolescent firearms-carrying." (AHRQ grant T32 HS00060). Annals of Emergency Medicine 42(6), pp. 198-207.

These researchers analyzed responses of 15,000 high school students to the 1999 National Youth Risk Behavior Survey to develop a preliminary screening tool, FiGHTS, to identify adolescents at risk for carrying firearms. They found that four simple screening questions and male sex may be used to generate a FiGHTS score—fighting (Fi), gender (G), hurt while fighting (H), threatened (T), and smoker (S)—that appears to be fairly sensitive and specific for identifying youths who carry firearms. An extended 13-item FiGHTS score that includes questions about sexual behavior, substance abuse, and criminal behavior is even more sensitive.

Hoff, T., Jameson, L., Hannan, E., and Flink, E. (2004, March). "A review of the literature examining linkages between organizational factors, medical errors, and patient safety." (AHRQ grant HS11880). Medical Care Research and Review 61(1), pp. 3-37.

There is little evidence for asserting the importance of any individual, group, or structural variable in medical error prevention or enhanced patient safety at the present time, concludes this study. The authors conducted an extensive review of the literature examining linkages between organizational factors, medical errors, and patient safety. They conclude that two major issues bear on the development of future research in this area. The theoretical foundations of organizational research on patient safety must be strengthened, and problems associated with definitions and observation associated with error-focused dependent variables must be overcome.

Keren, R., Pati, S., and Feudtner, C. (2004). "The generation gap: Differences between children and adults pertinent to economic evaluations of health interventions." (AHRQ grant K08 HS00002). Pharmacoeconomics 22(2), pp. 71-81.

Appropriate accommodations for the special features and needs of children are relatively underdeveloped in cost-effectiveness studies of health care interventions, according to these authors. They discuss key areas warranting attention, such as the ways in which a child's distinctive biology modifies the cost and effectiveness of health care interventions and the challenges in assessing utilities for infants and young children, given their limited but developing cognitive capacity. Other areas to explore include accounting for how a child's age, dependency, and disability affect the selection of the appropriate time horizon and scope of analysis and what equity principles policymakers should employ in using economic evaluations to choose between child- and adult-focused interventions.

Lambert, M.C., Samms-Vaughan, M.E., Fairclough, M., and others (2003). "Is it prudent to administer all items for each Child Behavior Checklist cross-informant syndrome?" (AHRQ grant HS08385). Psychological Assessment 15(4), pp. 550-568.

The Child Behavior Checklist (CBCL) is widely used by researchers and clinicians in many countries to measure children's behavioral and emotional functioning. Designed according to a multi-informant approach to child assessment, the CBCL consists of parent, teacher, and youth (Youth Self-Report, or YSR) forms that rate the functioning of children being assessed. Through surveying children in 10 countries with these three forms of the CBCL, the authors derived cross-informant syndromes (CISs). This study used confirmatory factor analysis to test factor model fit for CISs on the YSR responses of 625 Jamaican children aged 11 to 18 years. More than three-fourths of the cross-informant items yielded little information. Eliminating such items could provide a more efficient behavioral measure.

Mark, B.A., Harless, D.W., McCue, M., and Xu, Y. (2004, April). "A longitudinal examination of hospital registered nurse staffing and quality of care."(AHRQ grant HS10135 Health Services Research 39(2), pp. 279-300.

This study's findings provide limited support for the prevailing notion that improving registered nurse (RN) staffing unconditionally improves quality of care. The investigators analyzed several systems of data for 422 hospitals from 1990 to 1995 to examine the association between nurse staffing and quality of care. Quality measures, adjusted for patient risk, included the in-hospital mortality ratio and the complication ratios for decubitus ulcers, pneumonia, and urinary tract infection. Increasing RN staffing had a diminishing marginal effect on reducing mortality ratio, but it had no consistent effect on any of the complications.

Miranda, J., Nakamura, R., and Bernal, G. (2003). "Including ethnic minorities in mental health intervention research: A practical approach to a long-standing problem." (AHRQ grant HS10858). Culture, Medicine, and Psychiatry 27, pp. 467-486.

Few studies provide information on outcomes of mental health care for ethnic minorities. In this paper, the authors examine this topic and discuss how to proceed in developing an evidence base for understanding mental health care for minorities. They conclude that entering representative numbers of ethnic minorities in efficacy trials is unlikely to produce useful information on outcomes of care because the numbers will be too small to produce reliable findings. Also, conducting randomized efficacy trials for all mental health interventions for each ethnic group would be impractical. Nevertheless, innovative and theoretically informed studies that focus on specific cultural groups are needed to advance the knowledge base.

O'Malley, A.S., Clancy, C., Thompson, J., and others (2004, March). "Clinical practice guidelines and performance indicators as related, but often misunderstood, tools." Joint Commission Journal on Quality and Safety 30(3), pp. 163-171.

Clinical practice guidelines (CPGs) and performance indicators (PIs) are tools that have been developed to address variation in medical practice. CPGs present available evidence for best practices. PIs measure and document practice performance to motivate organizations to improve through use of common metrics. The increasingly widespread use of PIs with CPGs risks lowering the standards of clinical care, since PIs are not intended to set optimal standards of care for any individual patient, according to these authors. Clinicians should not restrict their quality monitoring to focus on PIs because they could miss important opportunities to learn and to improve the care they deliver to their individual patients.

Reprints (AHRQ Publication No. 04-R037) are available from the AHRQ Publications Clearinghouse.

Peek, C.W., Koropeckyj-Cox, T., Zsembik, B.A., and Coward, R.T. (2004, March). "Race comparisons of the household dynamics of older adults." (AHRQ grant T32 HS00086). Research on Aging 26(2), pp. 179-201.

Very little is known about ethnoracial variation in household dynamics, such as patterns of coresidence and the composition of households over time. This study analyzed data from a sample of older people residing in Florida to describe differences according to race in longitudinal patterns of household change that occurred during four 6-month intervals. About one-fourth of respondents experienced some change in household composition during the 2-year study. Older blacks lived in larger and more dynamic households than whites and were more likely to form coresident relationships with grandchildren and nonrelatives. Age, sex, marital status, and disability were also associated with the likelihood of acquiring a new household member.

Wu, N., Miller, S.C., Lapane, K., and Gozalo, P. (2003, November). "The problem of assessment bias when measuring the hospice effect on nursing home residents' pain."(AHRQ grant HS10549). Journal of Pain and Symptom Management 26(5), pp. 998-1009.

These researchers studied the pain documented on nursing home resident assessments (minimum data sets, MDS) for 9,613 nursing home residents in six States who died in 1999 and 2000. The researchers compared the documented pain of residents who were enrolled or not enrolled in hospice care. At the time of their last assessment, residents in hospice were more likely to receive opioids for their moderate to severe pain than were non-hospice residents and residents enrolled in hospice after the last MDS assessments. However, hospice residents were twice as likely as non-hospice residents and 1.3 times as likely as residents who eventually enrolled in hospice to have pain documented, perhaps because of superior pain assessment by hospice.

Zou, K.H., Warfield, S.K., Fielding, J.R., and others (2003, December). "Statistical validation based on parametric receiver operating characteristic analysis of continuous classification data." (AHRQ grant HS13234). Academic Radiology 10(12), pp. 1359-1368.

The accuracy of diagnostic test and imaging segmentation is important in clinical practice because it has a direct impact on therapeutic planning. These authors developed two parametric models for diagnostic or imaging data, which they validated using three clinical examples. First, they applied a semiautomatic fractional segmentation algorithm to magnetic resonance imaging of nine cases of brain tumors. Second, they evaluated the predictive value of 100 cases of spiral computed tomography of urethral stone sizes, distributed as binormal after a non-linear transformation, under two treatment options. Third, they transformed and modeled by binormal distributions prostate-specific antigen level for 180 men in a prospective clinical trial on prostate cancer. In all examples, areas under the receiver operating characteristic curves were computed, showing fair to excellent accuracy.

Current as of May 2004
AHRQ Publication No. 04-0053

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