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Research Briefs

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Clancy, C., Sharp, B.A., and Hubbard, H.B. (2005, November). "Guest editorial: Intersections for mutual success in nursing and health services research." Nursing Outlook 53, pp. 263-265.

In this editorial, Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality, and colleagues discuss the importance of the AHRQ-sponsored conference, "The Intersection of Nursing and Health Services Research." Articles from the conference are profiled in the same journal issue. The conference addressed issues of access to care/nursing workforce, health behavior, quality of care, cost/cost-effectiveness, and organization/ delivery of care. These topics represent an agenda that can provide a roadmap for success for nursing health services research, notes Dr. Clancy. AHRQ has commissioned a report—"The Effect of Health Care Working Conditions on Patient Safety"—to provide guidance to nurse partners on how to design a work environment in which nurses can provide safer patient care. AHRQ has also funded a special program of research on working conditions, with most projects focusing on nursing. Reprints (AHRQ Publication No. 06-R026) are available from the AHRQ Publication Clearinghouse.

Cohen, S.B., Ezzati-Rice, T., and Yu, W. (2005). "The utility of probabilistic models to identify individuals with future high medical expenditures." Journal of Economic and Social Measurement 30, pp. 135-144.

Oversampling techniques are often used in nationally representative population-based surveys in order to ensure sufficient sample size for certain subgroups, such as race/ethnicity, gender, or age. However, achieving sample size targets for population subgroups that are more dynamic in nature—for example, the poor or near poor, individuals with high levels of medical expenditures, and the uninsured—is a more difficult task. The authors of this paper present an evaluation model to assess the utility of probabilistic models in successfully oversampling policy-relevant population subgroups subject to transitions. This type of modeling effort enhances the ability to discern the causes of high health care expenses and the characteristics of the individuals who incur them. Reprints (AHRQ Publication No. 06-R033) are available from the AHRQ Publication Clearinghouse.

Collins-Sharp, B.A., Hubbard, H., and Jones, C.B. (2005). "Translating research into practice: Agency for Healthcare Research and Quality." Nursing Outlook 53(1), pp. 46-48.

This article cites several opportunities for nurses to work with AHRQ intramural programs to help translate research into practice. External nurses routinely serve on AHRQ research study sections and the National Advisory Council, and can volunteer for evidence-based practice initiatives. AHRQ also provides research opportunities for senior nurse scientists through the collaborative AHRQ-American Academy of Nursing Nurse Scholars Program to develop areas of investigation that integrate clinical nursing care questions with AHRQ portfolios of research. Finally, AHRQ provides a number of publications and databases of use to nurses, to aid them in translating research into practice. For more details, go to the Nursing Research section of the Agency's Web site at http://www.ahrq.gov/about/nursing/. Reprints (AHRQ Publication No. 06-R025) are available from the AHRQ Publication Clearinghouse.

Gellad, W.F., Huskamp, H.A., Phillips, D.A., and Haas, J.S. (2006, January). "How the new Medicare drug benefit could affect vulnerable populations." (AHRQ grants HS10771 and HS10856). Health Affairs 25(1), pp. 248-255).

Lower-income seniors and those with chronic illnesses could continue to have difficulty paying for their medications under the new Medicare prescription drug benefit, which became effective in January 2006, concludes this study. It estimated how out-of-pocket drug costs could change for vulnerable populations (racial and ethnic minorities, the near-poor, and seniors with a multiple chronic conditions) who qualify for the standard Medicare drug benefit. Although the new benefit might be associated with modest-to-moderate declines in out-of-pocket spending for seniors who do not qualify for subsidies, it may not reduce financial barriers to medication use for vulnerable groups. The deductible and benefit structure (a gap in coverage known as the doughnut hole) will require substantial out-of-pocket drug spending for many beneficiaries.

Glance, L.G., Dick, A.W., Osler, T.M., and Mukamel, D.B. (2006, February). "Does date stamping ICD-9-CM codes increase the value of clinical information in administrative data?" (AHRQ grant HS13617). HSR: Health Services Research 41(1), pp. 231-251.

The clinical information used in patient risk adjustment is captured in the primary and secondary diagnoses coded using the International Classification of Diseases (ICD-9-CM) system. These administrative data sets, however, fail to distinguish between conditions present at admission (preexisting conditions) and those that develop subsequent to admission (complications). Adding the condition present at admission (CPAA) modifier to administrative data would significantly enhance the ability of the Dartmouth/Charlson index and the Elixhauser algorithm to accurately map ICD-9-CM codes to diagnostic categories, concludes this study. For example, in analysis of 178,838 patients hospitalized in California in 2000, the Dartmouth/Charlson index underestimated the prevalence of problems such as heart attack or paraplegia by 65 to 70 percent. The Elixhauser comorbidity measure misclassified complications as preexisting conditions for 43 percent of coagulopathies and 18 percent of cardiac arrhythmias.

Glaser, B.E., and Bero, L.A. (2005). "Attitudes of academic and clinical researchers toward financial ties in research: A systematic review." (AHRQ grant T32 HS00086). Science and Engineering Ethics 11(4), pp. 553-573.

Private industry has become increasingly involved in academic and clinical research since the early 1980s. Private companies not only sponsor research, but individual investigators often have stock ownership or consulting fees from the same company that sponsors their research. This review of 17 studies on researchers' attitudes toward industry involvement revealed their concerns about the impact of financial ties on choice of research topic, research conduct, and publication. Researchers approve of industry collaboration and financial ties when the ties are indirectly related to the research, disclosure is upfront, and results and ideas are freely publicized. However, the authors suggest that their trust in disclosure as a way to manage conflicts may be naive.

Jacobson, M., O'Malley, A.J., Earle, C.C., and others (2006, March). "Does reimbursement influence chemotherapy treatment for cancer patients?" (AHRQ grant HS10803). Health Affairs 25(2), pp. 437-443.

Medicare reimbursement has little effect on who gets cancer treatment, but it does influence the kind of treatment received, according to this study. The researchers examined the effect of physician reimbursement on chemotherapy treatment of 9,357 elderly Medicare beneficiaries with metastatic lung, breast, colorectal, or other gastrointestinal cancers between 1995 and 1998. A physician's decision to administer palliative chemotherapy to metastatic cancer patients was not measurably affected by higher Medicare reimbursement for chemotherapy drugs, but it appeared to have affected the choice of drugs used. Providers who were more generously reimbursed prescribed more costly chemotherapy regimens. However, recent changes in Medicare drug reimbursement substantially limit physician profit from certain drugs. This, the researchers believe, should prompt physicians to choose drugs based more on clinical considerations and patients' preferences and less on reimbursement decisions.

Marsden, P.V., Landon, B.E., Wilson, I.B., and others (2006, February). "The reliability of survey assessments of characteristics of medical clinics." (AHRQ grant HS10227). HSR: Health Services Research 41(1), pp. 265-282.

Combining reports from multiple organizational informants may raise the reliability of survey assessments of organizational characteristics of medical clinics, concludes this study. The investigators surveyed 330 informants (clinicians and medical directors) in 91 medical clinics providing care to HIV-infected people to assess the reliability of survey measures of organizational characteristics (barriers to quality care, quality improvement activities, priorities assigned to aspects of HIV care) based on reports of single and multiple informants. Medical directors tended to give more optimistic assessments of clinics than clinicians. For most measures studied, obtaining adequate reliability required multiple informants.

Miller, G.E., Moeller, J.F., and Stafford, R.S. (2006). "New cardiovascular drugs: Patterns of use and association with non-drug health expenditures." Inquiry 42(4), pp. 397-412.

The potential role of new drugs in reducing expenditures for non-drug health services such as hospital stays has received considerable attention in recent policy debates. The authors of this study used nationally representative data from the Medical Expenditure Panel Survey to determine whether the use of newer drugs to treat cardiovascular conditions was associated with lower non-drug health expenditures (for example, inpatient, outpatient, and home health care) for these conditions. They failed to substantiate the findings of previous research that newer drugs were associated with reductions in non-drug expenditures for cardiovascular conditions. There may be specific instances where newer drug therapies outperform older drugs by reducing non-drug expenses in treating specific cardiovascular conditions or older drugs outperform newer drugs by the same standards. Reprints (AHRQ Publication No. 06-R027) are available from the AHRQ Publication Clearinghouse.

Neumann, P.J., Lin, P.-J., Greenberg, D., and others (2006, January). "Do drug formulary policies reflect evidence of value?" (AHRQ grant HS10919). The American Journal of Managed Care 12, pp. 30-36.

This study underscores the paucity of published cost-utility data available to drug formulary committees. The researchers used 1998-2001 data from a large registry of cost-effectiveness analyses to examine the cost-utility ratios of preferred and nonpreferred drugs from formularies of two large health plans, the 2004 Florida Medicaid preferred drug list and the 2004 Harvard Pilgrim Pharmacy Program 3-tier formulary. Few drugs on the formularies had any cost-utility data available. Of those that did, the cost-utility ratios were somewhat higher (less favorable) for Florida's preferred drugs compared with nonpreferred drugs ($25,465 vs. $13,085). Ratios did not differ for drugs on tiers 1 and 2 of the Harvard Pilgrim formulary, although they were higher for tier 3 and for excluded drugs. The authors call for more and better data to move toward value-based formulary decisionmaking.

Nix, M.P., Coopey, M., and Clancy, C.M. (2006, March). "Quality tools to improve care and prevent errors." Journal of Nursing Care Quality 21(1), pp. 1-4.

The current nursing shortage has intensified the need for nurses to be able to access already developed usable evidence-based information and tools that can be adapted to their clinical situation, note the authors. The Agency for Healthcare Research and Quality has funded the creation of many quality tools and resources that can be readily adapted to clinical settings. Nurses can find more than 600 quality tools at AHRQ's QualityTools Web site, http://www.innovations.ahrq.gov. AHRQ's National Guideline Clearinghouse™ can be accessed at http://www.guideline.gov, which can help nurses and other health care providers implement clinical guidelines in practice. Tools developed for use in patient safety programs can be identified through AHRQ's new Web site, the AHRQ Patient Safety Network at http://psnet.ahrq.gov/. Nurses are encouraged to submit tools that meet the criteria for submission, which can be found on each site. Reprints (AHRQ Publication No. 06-R034) are available from the AHRQ Publication Clearinghouse.

Paliwal, P., Gelfand, A.E., Abraham, L., and others (2006). "Examining accuracy of screening mammography using an event order model." (AHRQ grant HS10591). Statistics in Medicine 25, pp. 267-283.

The authors of this study examined the accuracy of screening mammography to detect breast cancer using an event order model. For each mammogram, they considered the initial assessment, a follow-up assessment if the initial one was positive, and, eventually, a determination of whether cancer was present or not. The model can be built at each stage reflecting effects due to patient characteristics, the facility where the mammogram was performed, and the radiologist reading the mammogram. They illustrate this approach with screening mammography data from the Group Health Cooperative in Seattle, Washington. After adjusting for patient characteristics, they found significant differences in radiologists with regard to initial assessment of the mammogram. They are currently surveying radiologists and facilities to explain differences in radiologists and facilities in accuracy of screening mammography.

Raab, S.S., Andrew-JaJa, C., Condel, J.L., and Dabbs, D.J. (2006). "Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods." (AHRQ grant HS13321). American Journal of Obstetrics and Gynecology 194, pp. 57-64.

New costly technological advances (for example, liquid-based preparations, automated screening, and human papillomavirus testing) that have improved Pap test sensitivity have increased the detection of low-grade cervical cancer lesions, without increasing the detection of invasive disease. However, redesign of clinical office workflow using the Toyota production system (TPS) without new technology also can improve Pap testing, concludes this study. The researchers implemented a TPS, 1-by-1, continuous workflow process in the office of a single gynecologist and cytology laboratory. They examined 464 case and 639 control women who had a Pap test performed in the practice during an 8-month period. After the TPS intervention, the proportion of Pap tests with a diagnosis of atypical squamous cells of undetermined significance decreased from 7.8 to 3.9 percent. The frequency of error per correlating cytologic-histologic specimen pair decreased from 9.52 to 7.84 percent.

Ridley, D.B., Kramer, J.M., Tilson, H.H. and others (2006, March). "Spending on postapproval drug safety." (AHRQ grant HS10548). Health Affairs 25(2), pp. 429-436.

Recent market withdrawals of high-profile drugs have focused attention on the safety of marketed drugs, whose risks often only become evident after the drug has been widely used in the market. The drug firms that spend the most on postapproval drug safety produce more new and "blockbuster" drugs than their competitors, concludes this study. The researchers surveyed 25 large drug manufacturers regarding drug safety efforts. Mean spending on postapproval safety per company in 2003 was $56 million or 0.3 percent of sales, with nearly 70 percent of this cost dedicated to personnel. The researchers estimated that total spending on postapproval safety by the top 20 drug manufacturers was $800 million in 2003. Safety spending and full-time-equivalent personnel were highly correlated with new drugs and blockbuster drugs.

Current as of May 2006
AHRQ Publication No. 06-0042

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