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Backer, E.L., Gregory, P., Jaen, C.R., and Crabtree, B.F. (2006, May). "A closer look at adult female health care maintenance visits." (AHRQ grant HS08776). Family Medicine 38(5), pp. 355-360.

Researchers analyzed data from observational field notes on actual health care maintenance (HCM) visits, medical record reviews, and in-depth interviews for overall content, process, and style of 95 visits with adult females (to 47 different clinicians) at 18 Midwestern urban, suburban, and rural family practices. The preventive services delivered in more than 50 percent of visits included blood pressure measurements (98 percent); weight (93 percent), breast (93 percent), and pelvic (88 percent) examinations; identification of smoking status (87 percent) and related counseling (63 percent); and mammography recommendations (70 percent). Key preventive issues less often addressed were cholesterol screening (21 percent of visits), colon cancer screening (12 percent), alcohol use (32 percent), and tetanus/influenza/ pneumococcal vaccinations (13, 18, and 21 percent, respectively). Clinicians were inconsistent in their health habit counseling about obesity.

Binkley, S., Fishman, N.O., LaRosa, L.A., and others (2006, July). "Comparison of unit-specific and hospital-wide antibiograms: Potential implications of selection of empirical antimicrobial therapy." (AHRQ grant HS10399). Infection Control and Hospital Epidemiology 27(7), pp. 682-687.

The selection of antibiotic therapy is based largely on antimicrobial susceptibility rates compiled in a hospital's antibiogram. The authors of this study collected antimicrobial susceptibility results for all inpatient clinical bacterial isolates recovered over a 3-year period. They evaluated a total of 9,970 bacterial isolates. The percentages of bacterial isolates resistant to antibiotics were significantly higher in the medical intensive care unit (ICU) and surgical ICU than the hospital-wide antibiogram would have predicted. In contrast, the percentages of isolates susceptible to antibiotics were significantly higher in the non-ICU units compared with the hospital overall. The authors conclude that unit-specific antibiograms are important for making informed decisions about antibiotic therapy.

Bradburn, M.J., Deeks, J.J., Berlin, J.A., and Localio, A.R. (2007). "Much ado about nothing: A comparison of the performance of meta-analytical methods with rare events." (AHRQ grant HS10399). Statistics in Medicine 26, pp. 53077.

Many methods of meta-analysis are based on large sample approximations, and may be unsuitable when events are rare. Through simulation, these authors evaluated the performance of 12 methods for pooling rare events, considering estimability, bias, coverage, and statistical power. Simulations were based on data sets from 3 case studies, each with between 5 and 19 trials. Most of the commonly used meta-analytical methods were biased when data were spare. At event rates below 1 percent, the Peto one-step odds ratio method was the least biased and most powerful method, and provided the best confidence interval coverage. This was the case if there was no substantial imbalance between treatment and control group sizes within trials and treatment effects were not exceptionally large. In other circumstances, the Mantel-Haenszel odds ratio method without zero-cell corrections, logistic regression, and the exact method performed similarly to each other, and were less biased than the Peto method.

Calfee, C.S., Shah, S.J., Wolter, P.J., and others (2007, February). "Anchors away." (AHRQ grant HS11540). New England Journal of Medicine 356(5), pp. 504-509.

This article recounts the case of a 50-year-old Asian woman who developed a papulonodular, erythematous rash on her legs below the knees, but had no fever, joint pain, or other systemic symptoms. The physician made an initial diagnosis of sarcoidosis, which was consistent with a chest x-ray that revealed scattered nodules and increased interstitial markings. She later developed dizziness, hoarseness, and inability to swallow liquids or solids. She also developed a fever, high blood pressure, and rapid heart rate. Further testing confirmed a diagnosis of lymphomatoid granulomatosis. She was put on a regimen of rituximab, etoposide, cylcophosphamide, vincristine, doxorubicin, and prednisone, followed by maintenance therapy with interferon alfa. She remained disease-free 2 years later.

Call, K.T., Davern, M., and Blewett, L.A. (2007). "Estimates of health insurance coverage: Comparing State surveys with the current population survey." (AHRQ contract 290-00-0017). Health Affairs 26(1), pp. 269-278.

The U.S. Census Bureau produces annual State-level estimates of health insurance coverage using the Current Population Survey (CPS) Annual Social and Economic Supplement. More than 40 States also conduct their own surveys to get better State-level estimates of health insurance coverage.

In most cases, the State survey estimates of uninsurance are lower than the estimates produced by the CPS. This discrepancy fuels debate about the true count of uninsured Americans and changes in that number over time. This paper compares State survey and CPS estimates of uninsurance, highlights key reasons for these differences, and discusses the policy implications of this persistent discrepancy.

Callahan, C.M., Boustani, M.A., Unverzagt, F.W., and others (2006, May). "Effectiveness of collaborative care for older adults with Alzheimer disease in primary care." (AHRQ grant HS10884). Journal of the American Medical Association 295(18), pp. 2148-2157.

Collaborative care by an interdisciplinary group who use Alzheimer's disease treatment guidelines can significantly improve the quality of primary care of these patients and reduce behavioral symptoms such as aggression or psychosis. Researchers randomized 153 older adults with Alzheimer's disease and their caregivers to receive either collaborative care management (84 adults) or augmented usual care (69 adults) at primary care practices within 2 university-affiliated health care systems during an 18-month period. Collaborative care patients were more likely to receive cholinesterase inhibitors (79.8 vs. 55.1 percent) and antidepressants (45.2 vs. 27.5 percent) than the controls. They also had significantly fewer behavioral and psychological symptoms of dementia as measured by the total Neuropsychiatric Inventory score at 12 months, when the collaborative care program ended, as well as 18 months later. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Caregivers also showed improvement in depression.

Chan, K.S., Bird, C.E., Weiss, R., and others (2006). "Does patient-provider gender concordance affect mental health care received by primary care patients with major depression?" (AHRQ grant HS08349). Women's Health Issues 16, pp. 122-132.

An analysis of 1,428 patients of 389 providers from the Quality Improvement for Depression Collaboration Study and 714 patients of 157 providers from the Partners-In-Care subproject for detection of anxiety disorder and alcohol or drug problems found that 40 percent of patients suffering from major depression were diagnosed and treated or referred by their primary care provider during health screening visits. Only 25 percent of depressed patients with anxiety and 9 percent of those at risk for drinking or substance abuse problems reported that their provider talked to them about these issues during their visit. With few exceptions, rates of depression diagnosis and care were comparable regardless of the gender of the doctor or whether the gender of the doctor and the patient were the same. The few exceptions were that female providers were more likely to counsel their depressed patients about anxiety.

Also, female providers were less likely than male providers to counsel on alcohol or drug use (2 vs. 8 percent), and female patients were less likely to be counseled compared with male patients (3 vs. 12 percent). Male patients of male providers reported the most counseling and female patients of female providers reported the least counseling (14 vs. 1 percent) about drug or alcohol use.

Clancy, C.M. (2006). "Closing the health care disparities gap: Turning evidence into action." Journal of Health Care Law & Policy 9(1), pp. 121-135.

The Agency for Healthcare Research and Quality (AHRQ) publishes the National Healthcare Disparities Report each year, documenting health care disparities in many areas. In this paper, the AHRQ director recounts the disparities uncovered by AHRQ research, and emphasizes the importance of closing the gap for low-income and minority groups. She notes that many of the same factors that put the residents of New Orleans and other devastated communities in harm's way, such as poverty, lack of insurance, and community neglect, contribute to health disparities for poor and minority children and adults across the United States. The author concludes with examples of AHRQ's efforts to translate evidence on care disparities into action to close the gap in health care disparities.

Reprints (AHRQ Publication No. 07-R039) are available from the AHRQ Publications Clearinghouse.

Clancy, C.M. (2007, January). "Emergency departments in crisis: Implications for accessibility, quality, and safety." American Journal of Medical Quality 22(1), pp. 59-62.

In 2003, 501,000 ambulances were diverted to other hospitals due to emergency department (ED) overcrowding—an average of 1 every minute. There is reason to question the capacity of U.S. EDs to handle a mass casualty event such as Hurricane Katrina or bioterrorism, notes the author of this commentary. She examines the role hospital EDs play in emergency care and more routine treatment, and discusses some of the Agency for Healthcare Research and Quality's (AHRQ's) activity in this area.

Examples of AHRQ-supported projects include the multi-institutional Center for Safety in Emergency Care; the development of the Emergency Severity Index, a five-level ED triage algorithm; studies of ED crowding causes and consequences; and significant investments in information technology to improve ED safety and quality of care.

Reprints (AHRQ Publication No. 07-R041) are available from the AHRQ Publications Clearinghouse.

Classen, D.C., Avery, A.J., and Bates, D.W. (2007). "Evaluation and certification of computerized provider order entry systems." (AHRQ contract 290-04-0016). Journal of the American Medical Information Association 14, pp. 48-55.

The increasing implementation of commercial computerized physician order entry (CPOE) systems in various settings of care has revealed that they may actually cause new errors or even harm. This paper describes initial attempts at evaluation and certification of CPOEs. For example, new initiatives to evaluate CPOE systems have been undertaken by both vendors and other groups who evaluate vendors.

In addition, an electronic health record vendor certification process is ongoing under the province of the Certification Commission for Health Information Technology, which will affect the purchase and use of these applications by hospitals and clinics and their participation in public and private health insurance programs. Finally, some large employers have linked evaluation of CPOE systems to reimbursement through pay-for-performance programs.

Cohen, S.B., Ezzati-Rice, T., and Yu, W. (2006). "The impact of survey attrition on health insurance coverage estimates in a national longitudinal health care survey." (AHRQ grant HS10904). Health Services Outcomes and Research Methods 6, pp. 111-125.

Criteria that have been used to produce annual estimates of the uninsured include: those uninsured for a full year, those ever uninsured during a year, and those uninsured at a specific point in time. The Medical Expenditure Panel Survey (MEPS), one of the core health care surveys in the United States, supports all three types of estimates.

The authors of this paper summarize the survey operations, informational materials, the interviewer training and experience of the field force, and the refusal conversion techniques employed in the MEPS to maintain respondent cooperation for five rounds of interviewing in order to minimize sample attrition. They also assess the impact of nonresponse attributable to survey attrition with respect to national health insurance coverage estimates derived from the MEPS.

Dayton, E. and Henriksen, K. (2007, January). "Communication failure: Basic components, contributing factors, and the call for structure." Journal on Quality and Patient Safety 33(1), pp. 34-47.

An intricate web of individual, group, and organizational factors—more specifically, cognitive workload, implicit assumptions, authority gradients, diffusion of responsibility, and transitions of care—complicate communication, note the authors of this paper. They suggest that when a patient's safety is at risk, providers should speak up to draw attention to the situation before harm is caused. They should clearly explain and understand each other's diagnosis and recommendations to ensure well coordinated delivery of care. The authors suggest more structured and explicitly designed forms of communication such as read-backs, situation-background-assessment-recommendation, critical assertions, briefs, and debriefings, which are increasingly being used in health care.

Deb, P., Munkin, M.K., and Trivedi, P.K. (2006). "Bayesian analysis of the two-part model with endogeneity: Application to health care expenditure." (AHRQ grant HS10904). Journal of Applied Econometrics 21, pp. 1081-1099.

This paper studies the effect of managed care insurance plans on medical expenditures using a model in which the insurance status is assumed to be endogenous. The authors model insurance plan choice through the multinomial probit model. The medical expenditure variable, the outcome of interest, has a significant proportion of zeros that are handled using the two-part model, extended to handle endogenous insurance. The estimation approach is Bayesian, based on the Gibbs Sampler. The model is applied to a sample of 20,460 individuals obtained from the Medical Expenditure Panel Survey. The results provide substantial evidence of selectivity.

Elder, N.C., Graham, D., Brandt, E., and others (2006, March). "The testing process in family medicine: Problems, solutions, and barriers as seen by physicians and their staff." (AHRQ grant HS13554). Journal of Patient Safety 2(1), pp. 25-32.

Researchers evaluated discussions about the laboratory, imaging, and diagnostic testing process from 18 focus groups involving 139 physicians and staff at 8 geographically diverse family practices. Participants said that filing, charting, and other problems existed in most steps in the testing process. Examples of problems cited were the wrong test being ordered or the order not transmitted fully; test results were delayed or not returned from laboratories; results went to the wrong provider; unclear test results; delayed or no patient notification or the wrong results given to the patient.

Underlying contributing factors included not following procedures, inadequate tracking systems, lack of standardization (for example, who gives results to the patients) and communication problems. Perceived barriers to improvements were both cultural (leadership and staff support) and process-related (costs, staff and work environment, external support). Desired improvements included technology (such as electronic medical records, new or better equipment, or onsite lab or x-ray), more staffing, and improved systems (for charting, filing, tracking, and communication).

Horn, K., Hamilton, C., and Noerachmanto, N. (2007, January). "Efficacy of an emergency department-based motivational teenage smoking intervention."(AHRQ grant HS10736). Preventing Chronic Disease 4(1), pp. 1-12.

These researchers randomized teenagers visiting the emergency department (ED) to receive brief advice to quit smoking (a motivational tobacco intervention, MTI) or to usual care. Six-month followup smoking cessation rates were nonsignificant—two teenagers quit smoking. Nevertheless, motivational interviewing may be a clinically relevant counseling model for use in teenage smoking interventions, suggest the study authors. However, many questions remain, and the current literature lacks studies on trials with significant outcomes using motivational interviewing in smoking cessation. Finally, more studies are needed to examine the suitability of the ED for MTI-type interventions.

Lautenbach, E., Fishman, N.O., Metlay, J.P., and others (2006, July). "Phenotypic and genotypic characterization of fecal Escherichia coli isolates with decreased susceptibility to fluoroquinolones: Results form a large hospital-based surveillance initiative." (AHRQ grant HS10399). Journal of Infectious Diseases 194, pp. 79-85.

The fluoroquinolone antibiotics have established themselves as a vital component of the present antibiotic arsenal. Yet this study of fecal surveillance at two hospitals for 3 years found that colonization by Escherichia coli bacteria with reduced fluoroquinolone susceptibility is common. In addition, fluoroquinolone-resistance characteristics differ significantly over time. Of 789 fecal samples, 149 isolates (19 percent) revealed E. coli with reduced susceptibility to fluoroquinolones. Of 149 isolates, 144 demonstrated resistance to nalidixic acid. Resistance to nalidixic acid may be useful in the identification of E. coli with early resistance mutations, suggest the authors.

Linder, J.A., Rose, A.F., Palchuk, M.B., and others (2006). "Decision support for acute problems: The role of the standardized patient in usability testing." (AHRQ grants HS15169, HS14563, and HS14420). Journal of Biomedical Informatics 39, pp. 648-655.

One reason for poor use of electronic health records (EHRs) is lack of usability and integration into the clinical workflow. Standardized patients (SPs) should be considered in EHR usability testing, especially if an application is to be used during the patient interview, concludes this study. The authors used hypothetical scenarios and SPs to collect quantitative and qualitative results in testing an early prototype of a new application, the Acute Respiratory Infection (ARI) Smart Form. The SP fit well into the usability testing sessions. Clinicians responded positively to the SPs and behaved as they normally would during a clinical encounter. Users of the Smart Form thought it had impressive functionality and the potential to save time but that it could have better visual design and navigation. The authors are modifying the ARI Smart Form for use in actual patient care.

Linkin, D.R., Paris, S., Fishman, N.O., and others (2006, July). "Inaccurate communications in telephone calls to an antimicrobial stewardship program." (AHRQ grants HS10399 and HS13982). Infection Control and Hospital Epidemiology 27(7), pp. 688-694.

Antimicrobial stewardship programs (ASPs) for physicians decrease unnecessary antibiotic use, decrease antibiotic resistance, and improve outcomes of hospitalized patients. To determine the incidence of inaccurate communication of patient data during ASP interactions at one medical center, these authors retrospectively evaluated the communicated patient data for clinically important inaccuracies using the patients' medical records as the gold standard.

Of telephone calls requesting prior approval from ASP practitioners, 39 percent contained at least one inaccuracy in patient data (for example, the wrong current antibiotic therapy) with the potential to affect the prescribing of antibiotics. The authors conclude that inaccurate communications may compromise the utility of ASPs that use a prior approval system for optimizing antibiotic use.

Menezes, N.M., Ay, H., Zhu, M.W., and others (2007). "The real estate factor: Quantifying the impact of infarct location on stroke severity." (AHRQ grant HS11392). Stroke 38, pp. 194-197.

The severity of neurological problems after ischemic stroke is moderately correlated with infarct volume. To quantify the impact of infarct location on neurological deficit severity, these authors developed atlases of location-weighted values indicating the relative importance in terms of neurological deficit severity for every voxel of the brain. They applied these atlases to 80 first-ever stroke patients. Each patient had a magnetic resonance image and National Institutes of Health Stroke Scale (NIHSS) examination around the time of hospital discharge. Volume-based estimates of neurological deficit severity were only moderately correlated with measured NIHSS scores. The combination of infarct volume and location resulted in significantly better correlation with clinical deficit severity.

Modak, I., Sexton, J.B., Lux, T.R., and others (2007, January). "Measuring safety culture in the ambulatory setting: The safety attitudes questionnaire— ambulatory version." (AHRQ grant HS11544). Journal of General Internal Medicine 22(1), pp. 1-5.

These researchers adapted the Safety Attitudes Questionnaire (SAQ), designed to measure the safety attitudes of hospital providers, to the outpatient setting. They modified the SAQ to create a 62-item SAQ-ambulatory version (SAQ-A). They tested the survey with 409 outpatient staff, of whom 282 returned the survey. Physicians had the least favorable attitudes about perceptions of management, while managers had the most favorable attitudes. Nurses had the most positive stress recognition scores. All providers had similar attitudes toward teamwork climate, safety climate, job satisfaction, and working conditions. The authors conclude that the SAQ-A is a reliable tool for eliciting provider attitudes about the outpatient work setting.

Raab, S.S., Stone, C.H., Wojcik, E.M., and others (2006). "Use of a new method in reaching consensus on the cause of cytologic-histologic correlation discrepancy." (AHRQ grant HS13321). American Journal of Clinical Pathology 126, pp. 836-842.

When diagnosing cancer, pathologists differ widely in their assessment of error in cases of discrepancies in cytologic and histologic pathology results. This contributes to problems in designing ways to reduce these discrepancies. The authors of this observational study developed a visual method of adjudicating discrepancy cause, termed the No-Blame Box method. It consists of initially assessing specimen interpretability by separately evaluating specimen quality and the presence of tumor.

Five pathologists blindly adjudicated the cause of discrepancy in pulmonary specimens from 40 patients. The K statistics of all pathologist pairs using the No-Blame Box method ranged from 0.400 to 0.796, indicating acceptable to excellent agreement. Most discrepancies resulted from pathologists diagnosing noninterpretable samples.

Rogers, S.O., Wolf, R.E., Zaslavsky, A.M., and others (2006, December). "Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery." (AHRQ grant HS09869). Annals of Surgery 244(6), pp. 1003-1011.

This study found that 16 percent more colorectal patients died after undergoing surgery for colorectal cancer performed by surgeons who performed 1-12 surgeries over a 4-year period than those who were operated on by surgeons performing greater than 40 surgeries over 4 years. Also, 11 percent more patients died after undergoing surgery at hospitals that performed 83 or fewer such surgeries over a 4-year period than those who had the procedure at a hospital that performed over 219 such surgeries in that time.

Colorectal cancer patients with low-volume surgeons had higher rates of colostomy than those with high-volume surgeons, and patients in low-volume hospitals had significantly lower rates of adjuvant radiation therapy than those in high-volume hospitals. The effects of hospital and surgeon volume on 30-day mortality may be mediated by preoperative, intraoperative, and postoperative decision making by the surgeons and by the hospitals' resources such as radiation facilities, explain the researchers. Their findings were based on a study of 28,644 patients who underwent surgery for stage I to III colorectal cancer from 1996 to 1999, who were listed in the California Cancer Registry. They were followed up to 6 years after surgery.

Scharpf, T.P., Colabianchi, N., Madigan, E.A., and others (2006). "Functional status decline as a measure of adverse events in home health care: An observational study." (HS11962). BMC Health Services Research 6, pp. 162-171.

The authors of this study used data from a large urban home health care agency to develop models to predict functional decline for three indices of functional status as a way to measure adverse events during home health care. They defined these indices as substantial decline in three or more, two or more, and one or more activities of daily living (ADLs). The index of two or more ADLs yielded the best models with exceptional consistency. The researchers conclude that measuring substantial decline in two or more ADLs may be preferable in defining adverse events in the context of home health care.

Srinivasan, M., Franks, P., Meredith, L.S., and others (2006, December). "Connoisseurs of care? Unannounced standardized patients' ratings of physicians." (AHRQ grant HS01610 and HS09963). Medical Care 44(12), pp. 1092-1098.

Using unannounced standardized patients (SPs) may overcome some of the limitations of patient satisfaction surveys, note the authors of this study. They analyzed data from two studies of unannounced SPs in rating primary care physicians, when covertly presenting as real patients. Each SP rated 16 to 38 physicians on interpersonal skills, technical skills, and overall satisfaction. SPs varied significantly in overall satisfaction levels, but not other dimensions. These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings, conclude the researchers.

Stockwell, D.C. and Slonim, A.D. (2006). "Quality and safety in the intensive care unit." (AHRQ grant HS14009). Journal of Intensive Care Medicine 21, pp. 199-210.

The hospital intensive care unit (ICU) is particularly prone to medical errors, because of the complexity of the patients, interdependence of the practitioners, and dependence on team functioning. This review provides a starting point for understanding the context of patient safety in the ICU. It provides historical perspectives, research foundations, and a practical "how to" guide to improving care in the ICU. It also considers the organizational structure, the processes of care, and the occurrence of adverse outcomes in this setting. The authors assert that effective ICU quality and safety programs capitalize on institutional resources. These programs also have multidisciplinary input with clear leadership, input from quality improvement initiatives, a responsible yet nonpunitive culture, and data-driven assessment and monitoring to reduce medical errors.

Wakefield, D.B. and Cloutier, M.M. (2006). "Modifications of HEDIS and CSTE algorithms improve case recognition of pediatric asthma." (AHRQ grant HS11147). Pediatric Pulmonology 41, pp. 962-971.

These researchers applied Council of State and Territorial Epidemiologists (CSTE) and Health Plan Employer Data and Information Set (HEDIS) criteria to a study of 3,905 Medicaid-insured children with a confirmed diagnosis of asthma or no asthma using a validated survey instrument. They applied modified criteria to another group of 1,458 non-Medicaid-insured children from a managed care organization. CSTE identified 61 percent of children with "probable" asthma; HEDIS identified 44 percent of children with persistent asthma. However, a modified CSTE increased sensitivity from 0.61 to 0.90, while maintaining high specificity. Three new HEDIS algorithms increased sensitivity from 0.44 to more than 0.84, with specificity greater than 0.89. The authors conclude that studies using current CSTE or HEDIS algorithms for case recognition underestimate asthma prevalence and overestimate asthma severity in children. Modified algorithms improved the identification of "probable" and persistent asthma.

Zapka, J.G., Carter, R., Carter, C.L., and others (2006, December). "Care at the end of life: Focus on communication and race." (AHRQ grant HS10871). Journal of Aging and Health 18, pp. 791-813.

This pilot study included interviews with 90 patients (39 white and 51 black adults) with terminal illness about issues of communication with care providers at the end of life. Discussion of end-of-life topics was low. For example, only 30 percent reported discussion of advance directives, and 22 percent reported that their physician inquired about spiritual support. Patients with cancer were significantly more likely to be receiving pain and/or symptom management at home, aware of prognosis, and participating in hospice. Black patients who were under the care of black physicians were less likely to report pain and/or symptom management than other patient-physician racial matches.

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AHRQ Publication No. 07-0028
Current as of May 2007


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