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Baker, R.S., Bazargan, M., Calderon, J.L., and Hays, R.D. (2006, August). "Psychometric performance of the National Eye Institute Visual Function Questionnaire in Latinos and non-Latinos." (AHRQ grant HS14022). Opthalmology 113, pp. 1363-1371.

A growing number of health surveys are being adapted for the large Spanish-speaking population and other ethnic groups in the United States. This study found that the overall performance of the National Eye Institute Visual Function Questionnaire (NEI VFQ) in the Latino population was adequate. However, in the absence of modifications to improve the reliability of specific Spanish version subscales, comparisons between Latino and non-Latino groups using the NEI VFQ must be interpreted with caution, note the researchers. They compared the psychometric performance of Spanish versions of the 25-item NEI VFQ and the 30-item NEI VFQ administered to Latino patients with the psychometric performance of the same tests administered to non-Latino patients.

Corriveau, C., and Slonim, A.D. (2006). "Improving access to intensive care: Is insurance the problem?" (AHRQ grant HS14009). Critical Care Medicine 34(8), pp. 2235-2236.

This commentary discusses a study of data from five States that found that critically ill uninsured adults were less likely to be hospitalized, less likely to be admitted to the intensive care unit (ICU), and more likely to die than their insured counterparts. This study helps to draw attention to the effect of the problem of the uninsured, note the commentary authors. It also demonstrates that true differences in hospital and ICU care exist among multiple subgroups of the uninsured. They assert that critically ill patients need to receive definitive services warranted by their medical condition, not their insurance status or discriminators such as age, race, or ethnicity.

Dellefield, M.E. (2006). "Organizational correlates of the risk-adjusted pressure ulcer prevalence and subsequent survey deficiency citation in California nursing homes." (AHRQ grant HS10022). Research in Nursing & Health 29, pp. 345-358.

The proportion of nursing home residents who suffer from pressure ulcers (PUs), many of which are preventable and treatable, is an important measure of nursing home quality of care. This study examined the relationships between risk-adjusted pressure ulcer prevalence and subsequent nursing home deficiency citations with selected organizational variables such as nurse staffing levels and facility ownership. Organizational variables explained a small amount of the variation in PU prevalence. A higher PU prevalence was associated with lower licensed nurse centralization, and facilities participating exclusively in the Medicaid program. Receipt of a deficiency was less likely in facilities having a higher total nurse staffing level. It was more likely in facilities having a higher risk-adjusted PU prevalence, more licensed nurses, a size of 160 beds or more, and survey teams from specific counties.

Halpern, S.C., Barton, T.D., Gross, R., and others (2005). "Epidemiologic studies of adverse effects of anti-retroviral drugs: How well is statistical power reported?" (AHRQ grant HS10399). Pharmacoepidemiology and Drug Safety 14, pp. 155-161.

Regulatory approval of a new drug typically occurs after it is studied in samples large enough to document efficacy, but too small to adequately document safety. That is the job of post-marketing surveillance programs and pharmacoepidemiologic studies. Researchers studied all published pharmacoepidemiologic studies of adverse drug effects (ADEs) associated with 15 anti-retroviral drugs approved through the end of 1999. The poor reporting of statistical power in the 48 studies examined suggests a need for guidelines to improve the reporting of pharmacoepidemiologic studies of ADEs, conclude the researchers. They call for more studies to determine whether the observed paucity of industry-sponsored observational studies of anti-retroviral ADEs extends to other clinical areas, and if so, to identify the causes of this phenomenon.

Miller, N., Eggleston, K., and Zeckhauser, R. (2006). "Provider choice of quality and surplus." (AHRQ grant HS13362). International Journal of Health Care Finance and Economics 6, pp. 103-117.

Health care providers such as physicians, hospitals, and health maintenance organizations (HMOs), must trade off the quality of care they deliver against financial returns. The authors of this paper studied the quality choices of institutional health care providers such as hospitals, assuming that the utility function of the key organizational decisionmaker includes both quality of care and financial surplus. Using a coefficient of relative risk aversion as a measure of the providers' utility-from-money function, they show that increasing the surplus retention rate (fraction of surplus remaining after deducting all outside claims) increases (decreases) quality if the provider's coefficient of relative risk aversion is greater than (less than) 1.

Paliwal, P., and Gelfand, A.E. (2006). "Estimating measures of diagnostic accuracy when some covariate information is missing." (AHRQ grant HS10951). Statistics in Medicine 25, pp. 2981-2993.

The authors of this paper propose a generic approach to estimate measures of diagnostic accuracy, when one or more risk factors in an explanatory model is not available. They refer to these as conditional rates, that is, rates conditioned on only a subset of risk factors. They perform a simulation study to compare these estimated conditional rates with frequently used ad hoc estimates. They also illustrate the proposed methodology to compute the conditional positive predictive value for a screening mammography data set.

Reinertsen, J.L., and Clancy, C. (2006, August). "Foreword to: Keeping our promises: Research, practice, and policy issues in health care reliability. A special issue of Health Services Research." HSR: Health Services Research 41(4), pp. 1535-1538.

The health care system is not doing a very good job of keeping its promise not to harm patients and to do everything possible for patients who come to the system for care. That's the assertion of the authors of this foreword to a special journal issue on health care reliability. The issue papers fall into three broad categories. The first three papers focus on how principles of reliability can address the problem of not harming patients. The second set of papers clusters around a particularly important factor in an organization's reliability—the patterns of behavior that constitute the organization's culture, such as its safety culture. The third set of papers focuses on translation of reliability theory into practice.

Reprints of this article (AHRQ Publication No. 06-R074) are available from the AHRQ Publications Clearinghouse.

Schroeder, M.E., Wolman, R.L., Wetterneck, T.B., and Carayon, P. (2006, August). "Tubing misload allows free flow event with smart intravenous infusion pump." (AHRQ grant HS14253). Anesthesiology 105, pp. 434-435.

The clinical introduction of new medical products may result in unanticipated consequences despite preintroduction evaluation, institution-specific usability testing, and carefully planned user training. Such training cannot be relied on to overcome design flaws in equipment, conclude the authors of this paper. They describe one such case of a problem with a "smart" intravenous infusion pump. Despite all the testing and training, a door gap caused by "front loading" the hard plastic upper fitment resulted in free flow of nitroglycerin during heart surgery on a patient. The failure mode and effects analysis conducted before initial use of the pump was lengthy and thorough, but did not predict the failure mode causing the free flow. Second, the alarm message displayed during setup indicated an occlusion as opposed to a potential free flow. Finally, this event occurred despite intensive user training before implementation that emphasized correct upper fitment loading.

Stockwell, D.C., and Slonim, A.D. (2006). "Volume-outcome relationships: Is it the individual or the team?" (AHRQ grant HS14009). Critical Care Medicine 34(9), pp. 2495-2497.

Policymakers, health services researchers, and clinicians tend to view volume-outcome relationships differently, according to the authors of this paper. They refer to a large Canadian study of the relationship between hospital volume of mechanical ventilation and patient outcomes. Hospital volume was not associated with the mortality of mechanically ventilated surgical patients. Yet, mechanically ventilated medical patients at the lowest-volume hospitals had an increased risk of mortality. For the policymaker, this study investigated population-based outcomes and may suggest the need for regionalization of ventilatory care. For the researcher, the study provides several important methodologic considerations for future work, for example, the use of clustering to control for institution-level effects. The clinician tends to view this study from the perspective of process of care and teamwork.

Tamuz, M., and Harrison, M.I. (2006, August). "Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory." HSR: Health Services Research 41(4), pp. 1654-1676.

This paper discusses the distinct contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five popular patient safety practices. These include double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA). According to the authors, HRT highlights how double-checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high-reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT calls attention to one feature of CPOE; it tightens the coupling of the medication ordering process. This, in turn, boosts the chances of rapid spread of infrequent, but harmful errors.

Reprints of this article (AHRQ Publication No. 06-R076) are available from the AHRQ Publications Clearinghouse.

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