National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (8)
- (-) Adverse Events (89)
- Ambulatory Care and Surgery (3)
- Arthritis (1)
- Blood Clots (3)
- Blood Thinners (1)
- Cancer (2)
- Cancer: Breast Cancer (2)
- Cancer: Lung Cancer (1)
- Cancer: Prostate Cancer (1)
- Cardiovascular Conditions (4)
- Care Coordination (1)
- Caregiving (1)
- Central Line-Associated Bloodstream Infections (CLABSI) (1)
- Children/Adolescents (6)
- Clinical Decision Support (CDS) (2)
- Clostridium difficile Infections (2)
- Colonoscopy (1)
- Communication (2)
- Comparative Effectiveness (7)
- Critical Care (2)
- Data (1)
- Dementia (1)
- Diabetes (1)
- Diagnostic Safety and Quality (2)
- Elderly (4)
- Electronic Health Records (EHRs) (2)
- Emergency Department (1)
- Evidence-Based Practice (3)
- Falls (3)
- Guidelines (2)
- Healthcare-Associated Infections (HAIs) (15)
- Healthcare Cost and Utilization Project (HCUP) (6)
- Healthcare Costs (2)
- Health Information Technology (HIT) (6)
- Health Insurance (1)
- Health Services Research (HSR) (1)
- Heart Disease and Health (2)
- Hospital Discharge (2)
- Hospitalization (4)
- Hospital Readmissions (2)
- Hospitals (4)
- Injuries and Wounds (13)
- Inpatient Care (4)
- Intensive Care Unit (ICU) (5)
- Kidney Disease and Health (2)
- Labor and Delivery (2)
- Maternal Care (1)
- Medical Devices (1)
- Medical Errors (13)
- Medical Liability (1)
- Medication (11)
- Medication: Safety (2)
- Mortality (4)
- Neonatal Intensive Care Unit (NICU) (1)
- Neurological Disorders (4)
- Newborns/Infants (5)
- Nursing (2)
- Nursing Homes (3)
- Obesity (1)
- Opioids (1)
- Orthopedics (2)
- Outcomes (13)
- Patient-Centered Outcomes Research (11)
- Patient Safety (54)
- Practice Patterns (1)
- Pregnancy (3)
- Prevention (2)
- Primary Care (2)
- Provider: Health Personnel (1)
- Public Reporting (3)
- Quality Improvement (6)
- Quality Indicators (QIs) (3)
- Quality of Care (8)
- Quality of Life (1)
- Registries (2)
- Respiratory Conditions (2)
- Risk (15)
- Rural Health (1)
- Shared Decision Making (1)
- Surgery (36)
- Teams (2)
- Telehealth (1)
- Transplantation (2)
- Treatments (1)
- Vaccination (1)
- Women (2)
- Workflow (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 89 Research Studies DisplayedWarnock DG, Powell TC, Donnelly JP
Categories of hospital-associated acute kidney injury: time course of changes in serum creatinine values.
The objective of this study was to categorize hospital-associated acute kidney injury (HA-AKI) based on the timing of minimum and peak inpatient serum creatinine (sCr) and describe the association with inpatient mortality. It concluded that risk of short-term inpatient mortality is associated with AKI, and this risk is attenuated with recovery of kidney function in the hospital.
AHRQ-funded; HS013852.
Citation: Warnock DG, Powell TC, Donnelly JP .
Categories of hospital-associated acute kidney injury: time course of changes in serum creatinine values.
Nephron 2015;131(4):227-36. doi: 10.1159/000441956.
.
.
Keywords: Kidney Disease and Health, Adverse Events, Hospitalization, Mortality
Liang C, Gong Y
Enhancing patient safety event reporting by K-nearest neighbor classifier.
The debate on structured or unstructured data entry reveals not only a trade-off problem among data accuracy, completeness, and timeliness, but also a technical gap on text mining. The reesarchers suggested a text classification method for predicting subject categories. Their results demonstrated the feasibility of their system and indicated the advantage of such an application to raise data quality and clinical decision support in reporting patient safety events.
AHRQ-funded; HS022895.
Citation: Liang C, Gong Y .
Enhancing patient safety event reporting by K-nearest neighbor classifier.
Stud Health Technol Inform 2015;218:40603.
.
.
Keywords: Adverse Events, Medical Errors, Patient Safety, Public Reporting, Clinical Decision Support (CDS), Health Information Technology (HIT), Data
Rehder KJ, Giuliano JS, Jr., Napolitano N
Increased occurrence of tracheal intubation-associated events during nights and weekends in the PICU.
Little is known about how the incidence of tracheal intubation-associated events is affected by the time of day, day of the week, or presence of in-hospital attending-level intensivists. After analyzing 5,096 tracheal intubation courses from the prospective multicenter National Emergency Airway Registry for Children, the researchers found that a higher occurrence of tracheal intubation-associated events was observed during nights and weekends, due primarily to emergent intubations.
AHRQ-funded; HS022464; HS021583.
Citation: Rehder KJ, Giuliano JS, Jr., Napolitano N .
Increased occurrence of tracheal intubation-associated events during nights and weekends in the PICU.
Crit Care Med 2015 Dec;43(12):2668-74. doi: 10.1097/ccm.0000000000001313.
.
.
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Adverse Events, Patient Safety, Critical Care
Fernandez R, Grand JA
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
This article highlights guiding team science principles from the organizational psychology literature that can be applied to the study of teams in healthcare. The authors' goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations.
AHRQ-funded; HS020295; HS022458.
Citation: Fernandez R, Grand JA .
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
Curr Probl Pediatr Adolesc Health Care 2015 Dec;45(12):370-7. doi: 10.1016/j.cppeds.2015.10.005.
.
.
Keywords: Patient Safety, Teams, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Rajaram R, Ju MH, Bilimoria KY
National evaluation of hospital readmission after pulmonary resection.
The study’s objectives were to (1) assess readmission rates and timing after pulmonary resection, (2) report the most common reasons for rehospitalization, and (3) identify risk factors for unplanned readmission after pulmonary resection. It found that experiencing a postoperative complication was strongly associated with unplanned readmission.
AHRQ-funded; HS000078.
Citation: Rajaram R, Ju MH, Bilimoria KY .
National evaluation of hospital readmission after pulmonary resection.
J Thorac Cardiovasc Surg 2015 Dec;150(6):1508-14.e2. doi: 10.1016/j.jtcvs.2015.05.047..
Keywords: Hospital Readmissions, Risk, Surgery, Quality Indicators (QIs), Adverse Events
Liang C, Gong Y
On building an ontological knowledge base for managing patient safety events.
The authors developed a semantic web ontology based on the WHO International Classification for Patient Safety (ICPS) and AHRQ Common Formats for patient safety event reporting. The ontology holds potential in enhancing knowledge management and information retrieval, as well as providing flexible data entry and case analysis. They detailed their efforts in data acquisition, transformation, implementation and initial evaluation of the ontology.
AHRQ-funded; HS022895.
Citation: Liang C, Gong Y .
On building an ontological knowledge base for managing patient safety events.
Stud Health Technol Inform 2015;216:202-6.
.
.
Keywords: Adverse Events, Medical Errors, Patient Safety, Electronic Health Records (EHRs), Health Information Technology (HIT)
Dicks KV, Baker AW, Durkin MJ
Short operative duration and surgical site infection risk in hip and knee arthroplasty procedures.
The purpose of this paper was to determine the association between shorter operative duration and surgical site infection (SSI) and also between surgeon median operative duration and SSI risk among first-time hip and knee arthroplasties. The researchers concluded that short operative durations were not associated with a higher SSI risk for knee or hip arthroplasty procedures in their analysis.
AHRQ-funded; HS023866.
Citation: Dicks KV, Baker AW, Durkin MJ .
Short operative duration and surgical site infection risk in hip and knee arthroplasty procedures.
Infect Control Hosp Epidemiol 2015 Dec;36(12):1431-6. doi: 10.1017/ice.2015.222.
.
.
Keywords: Healthcare-Associated Infections (HAIs), Orthopedics, Patient Safety, Adverse Events, Surgery, Injuries and Wounds
Slagle JM, Anders S, Porterfield E
Significant physiological disturbances associated with non-routine event containing and routine anesthesia cases.
The researchers sought to compare anesthesia providers' reporting of non-routine events (NREs) with the incidence of significant physiological disturbances (SPDs) detected via retrospective videotape review. They concluded that SPDs occur more often in NRE-containing cases. The incidence of approximately one NRE-independent SPD per case was similar in NRE-containing and routine case.
AHRQ-funded; HS011375.
Citation: Slagle JM, Anders S, Porterfield E .
Significant physiological disturbances associated with non-routine event containing and routine anesthesia cases.
J Patient Saf 2015 Dec;11(4):198-203. doi: 10.1097/pts.0000000000000081.
.
.
Keywords: Patient Safety, Adverse Events, Adverse Drug Events (ADE), Medication
O'Brien EC, Simon DN, Thomas LE
The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation.
The researchers sought to develop and validate a novel bleeding risk score using routinely available clinical information to predict major bleeding in a large, community-based in atrial fibrillation (AF) population. They concluded that their five-element ORBIT bleeding risk score had better ability to predict major bleeding in AF patients when compared with HAS-BLED and ATRIA risk scores.
AHRQ-funded; HS021092.
Citation: O'Brien EC, Simon DN, Thomas LE .
The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation.
Eur Heart J 2015 Dec 7;36(46):3258-64. doi: 10.1093/eurheartj/ehv476.
.
.
Keywords: Blood Thinners, Heart Disease and Health, Cardiovascular Conditions, Adverse Drug Events (ADE), Adverse Events, Risk, Registries, Patient-Centered Outcomes Research, Evidence-Based Practice
Okafor NG, Doshi PB, Miller SK
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. The researchers found that the utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012.
AHRQ-funded; HS017586.
Citation: Okafor NG, Doshi PB, Miller SK .
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
West J Emerg Med 2015 Dec;16(7):1073-8. doi: 10.5811/westjem.2015.8.27390.
.
.
Keywords: Emergency Department, Adverse Events, Medical Errors, Patient Safety, Public Reporting, Quality of Care
Robinson JC, Brown TT, Whaley C
Association of reference payment for colonoscopy with consumer choices, insurer spending, and procedural complications.
The researchers ascertained the effect of reference payment on facility choice, insurer spending, consumer cost sharing, and procedural complications for colonoscopy. They concluded that Implementation of reference payment for colonoscopy was associated with reduced spending and no change in complications.
AHRQ-funded; HS022098.
Citation: Robinson JC, Brown TT, Whaley C .
Association of reference payment for colonoscopy with consumer choices, insurer spending, and procedural complications.
JAMA Intern Med 2015 Nov;175(11):1783-9. doi: 10.1001/jamainternmed.2015.4588..
Keywords: Colonoscopy, Healthcare Costs, Adverse Events, Health Insurance
Gagne JJ, Kesselheim AS, Choudhry NK
Comparative effectiveness of generic versus brand-name antiepileptic medications.
The objective of this study was to compare treatment persistence and rates of seizure-related events in patients who initiate antiepileptic drug (AED) therapy with a generic versus a brand-name product. It concluded that patients who initiated generic AEDs had fewer adverse seizure-related clinical outcomes and longer continuous treatment periods before experiencing a gap than those who initiated brand-name versions.
AHRQ-funded; HS018465.
Citation: Gagne JJ, Kesselheim AS, Choudhry NK .
Comparative effectiveness of generic versus brand-name antiepileptic medications.
Epilepsy Behav 2015 Nov;52(Pt A):14-8. doi: 10.1016/j.yebeh.2015.08.014.
.
.
Keywords: Adverse Drug Events (ADE), Adverse Events, Comparative Effectiveness, Medication, Medication: Safety, Neurological Disorders, Patient Safety
Morgans AK, van Bommel AC, Stowell C
Development of a standardized set of patient-centered outcomes for advanced prostate cancer: an international effort for a unified approach.
The International Consortium for Health Outcomes Measurement assembled a multidisciplinary working group to develop a standard set of outcomes relevant to men with advanced prostate cancer to follow during routine clinical care. The international multidisciplinary group identified clinical data and patient-reported outcome measures that serve as a basis for international health outcome comparisons and quality-of-care assessments. The set will be revised annually.
AHRQ-funded; HS022990.
Citation: Morgans AK, van Bommel AC, Stowell C .
Development of a standardized set of patient-centered outcomes for advanced prostate cancer: an international effort for a unified approach.
Eur Urol 2015 Nov;68(5):891-8. doi: 10.1016/j.eururo.2015.06.007.
.
.
Keywords: Cancer: Prostate Cancer, Patient-Centered Outcomes Research, Quality of Life, Adverse Events, Quality Indicators (QIs)
Donnelly JP, Wang HE, Locke JE
Hospital-onset Clostridium difficile infection among solid organ transplant recipients.
The researchers examined hospital-onset Clostridium difficile infection (CDI) from 2012 to 2014 among transplant recipients in the University HealthSystem Consortium, which includes academic medical center-affiliated hospitals in the United States. They found that factors associated with CDI among transplant recipients included transplant type, risk of mortality, comorbidities, and inpatient complications.
AHRQ-funded; HS013852.
Citation: Donnelly JP, Wang HE, Locke JE .
Hospital-onset Clostridium difficile infection among solid organ transplant recipients.
Am J Transplant 2015 Nov;15(11):2970-7. doi: 10.1111/ajt.13491.
.
.
Keywords: Clostridium difficile Infections, Healthcare-Associated Infections (HAIs), Transplantation, Adverse Events, Mortality
Ellis MC, Paugh TA, Dickinson TA
Nadir hematocrit on bypass and rates of acute kidney injury: does sex matter?
Recent literature has suggested that women, although more often exposed to lower nadir hematocrit (Hct), have a lower risk of postoperative renal dysfunction. The researchers assessed whether this relationship held across a large multicenter registry. They found that lower nadir Hct was associated with an increased risk of AKI, and the effect appears to be stronger among men than women.
AHRQ-funded; HS022535; HS022909.
Citation: Ellis MC, Paugh TA, Dickinson TA .
Nadir hematocrit on bypass and rates of acute kidney injury: does sex matter?
Ann Thorac Surg 2015 Nov;100(5):1549-54; discussion 54-5. doi: 10.1016/j.athoracsur.2015.05.080..
Keywords: Risk, Cardiovascular Conditions, Surgery, Adverse Events, Patient Safety
Likosky DS, Wallace AS, Prager RL
Sources of variation in hospital-level infection rates after coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons Adult Heart Surgery Database.
This descriptive study characterized the hospital-level variability in healthcare-acquired infection (HAI) rates across hospitals participating in The Society of Thoracic Surgeons Adult Cardiac Surgery Database. It found substantial hospital-level variation exists in postoperative HAIs among patients undergoing coronary artery bypass graft surgery, driven predominantly by pneumonia.
AHRQ-funded; HS022535; HS022909.
Citation: Likosky DS, Wallace AS, Prager RL .
Sources of variation in hospital-level infection rates after coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons Adult Heart Surgery Database.
Ann Thorac Surg 2015 Nov;100(5):1570-5; discussion 75-6. doi: 10.1016/j.athoracsur.2015.05.015.
.
.
Keywords: Healthcare-Associated Infections (HAIs), Surgery, Adverse Events, Injuries and Wounds, Registries
Croft LD, Liquori M, Ladd J
The effect of contact precautions on frequency of hospital adverse events.
The researchers sought to determine whether use of contact precautions on hospital ward patients is associated with patient adverse events. They concluded that hospital ward patients on contact precautions were less likely to experience noninfectious adverse events during their hospital stay than patients not on contact precautions.
AHRQ-funded; HS018111.
Citation: Croft LD, Liquori M, Ladd J .
The effect of contact precautions on frequency of hospital adverse events.
Infect Control Hosp Epidemiol 2015 Nov;36(11):1268-74. doi: 10.1017/ice.2015.192.
.
.
Keywords: Adverse Events, Patient Safety, Prevention, Hospitals
Steiner CA, Maggard-Gibbons M, Raetzman SO
Return to acute care following ambulatory surgery.
This study determined the rates of all-cause, unplanned revisits (i.e., not for routine medical care) within 30 days of ambulatory surgery and whether revisits were related to the operation. It found that acute care revisits following ambulatory operations in low-risk patients occurred with notable frequency across 6 diverse types of operations.
AHRQ-authored
Citation: Steiner CA, Maggard-Gibbons M, Raetzman SO .
Return to acute care following ambulatory surgery.
JAMA 2015 Oct 6;314(13):1397-9. doi: 10.1001/jama.2015.12210..
Keywords: Healthcare Cost and Utilization Project (HCUP), Ambulatory Care and Surgery, Surgery, Adverse Events
Gephart S, Carrington JM, Finley B
A systematic review of nurses' experiences with unintended consequences when using the electronic health record.
The purpose of this article is to present the state of the science on nurses' experiences with unintended consequences of electronic health records (EHRs). Findings demonstrate that nurses experience changes to workflow, must continually adapt to meet patient's needs in the context of imperfect EHR systems, and have difficulty accessing the information they need to make patient care decisions. Implications for nurse administrators include the need for continual engagement with nurses along the continuum of EHR design, as well as the need to encourage nurses to speak up and acknowledge workflow changes that threaten patient safety or do not support work efficiency.
AHRQ-funded; HS021074.
Citation: Gephart S, Carrington JM, Finley B .
A systematic review of nurses' experiences with unintended consequences when using the electronic health record.
Nurs Adm Q 2015 Oct-Dec;39(4):345-56. doi: 10.1097/naq.0000000000000119.
.
.
Keywords: Adverse Events, Clinical Decision Support (CDS), Electronic Health Records (EHRs), Nursing, Workflow
Hollenbeck BK, Dunn RL, Suskind AM
Ambulatory surgery centers and their intended effects on outpatient surgery.
Using a twenty percent national sample of Medicare beneficiaries, the researchers assessed the impact of ambulatory surgery centers (ASCs) on rates of hospital-based outpatient procedures and adverse events. They found that opening of an ambulatory surgery center in a Hospital Service Area resulted in a decline in hospital-based outpatient surgery without increasing mortality or admission.
AHRQ-funded; HS020927; HS018726.
Citation: Hollenbeck BK, Dunn RL, Suskind AM .
Ambulatory surgery centers and their intended effects on outpatient surgery.
Health Serv Res 2015 Oct;50(5):1491-507. doi: 10.1111/1475-6773.12278..
Keywords: Ambulatory Care and Surgery, Adverse Events, Patient Safety
McElroy LM, Macapagal KR, Collins KM
Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study.
The goal of this study is to use qualitative research methods to describe clinician perceptions of OR-to-ICU handoffs, and to elucidate attributes of the handoff process associated with high quality, as well as those with poor quality that can lead to patient harm. The findings suggest that ambiguous roles and conflicting expectations of team members during the OR-to-ICU handoff can increase risk of patient harm.
AHRQ-funded; HS000078.
Citation: McElroy LM, Macapagal KR, Collins KM .
Clinician perceptions of operating room to intensive care unit handoffs and implications for patient safety: a qualitative study.
Am J Surg 2015 Oct;210(4):629-35. doi: 10.1016/j.amjsurg.2015.05.008..
Keywords: Patient Safety, Intensive Care Unit (ICU), Surgery, Adverse Events, Care Coordination
McNamara ER, Schaeffer AJ, Logvinenko T
Management of proximal hypospadias with 2-stage repair: 20-year experience.
The researchers describe their experience with 2-stage proximal hypospadias repair. They report outcomes, and patient and procedure characteristics associated with surgical complications. In their review of the largest cohort of patients undergoing this procedure at a single institution, they found that complications and, reoperation rates were approximately 50 percent in the setting of complex genital reconstruction.
AHRQ-funded; HS000063.
Citation: McNamara ER, Schaeffer AJ, Logvinenko T .
Management of proximal hypospadias with 2-stage repair: 20-year experience.
J Urol 2015 Oct;194(4):1080-5. doi: 10.1016/j.juro.2015.04.105..
Keywords: Newborns/Infants, Outcomes, Surgery, Adverse Events
Wiseman JT, Fernandes-Taylor S, Barnes ML
Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery.
This study explored the factors that lead to postdischarge surgical site infections (SSI), investigated the differences between risk factors for in-hospital vs postdischarge SSI, and developed a scoring system to identify patients who might benefit from postdischarge monitoring of their wounds. In a comparative analysis, it found that comorbidities were the primary driver of postdischarge SSI, whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI.
AHRQ-funded; HS023395.
Citation: Wiseman JT, Fernandes-Taylor S, Barnes ML .
Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery.
J Vasc Surg 2015 Oct;62(4):1023-31.e5. doi: 10.1016/j.jvs.2015.04.453..
Keywords: Surgery, Hospital Discharge, Healthcare-Associated Infections (HAIs), Patient Safety, Injuries and Wounds, Adverse Events
Downes KJ, Patil NR, Rao MB
Risk factors for acute kidney injury during aminoglycoside therapy in patients with cystic fibrosis.
The aim of this study was to identify factors associated with acute kidney injury (AKI) during intravenous aminoglycoside (AG) courses in this population. It identified receipt of an AG within 90 days prior to admission, longer duration of AG therapy, low serum albumin, and receipt of trimethoprim/ sulfamethoxazole as independent risk factors for developing AKI.
AHRQ-funded; HS021114.
Citation: Downes KJ, Patil NR, Rao MB .
Risk factors for acute kidney injury during aminoglycoside therapy in patients with cystic fibrosis.
Pediatr Nephrol 2015 Oct;30(10):1879-88. doi: 10.1007/s00467-015-3097-3..
Keywords: Adverse Events, Patient-Centered Outcomes Research, Patient Safety, Respiratory Conditions
Alruwaily AF, Eisner BH, Bierlein MJ
Statin use and risk of sepsis after percutaneous nephrolithotomy.
The researchers examined the association between statin medication use and sepsis risk after percutaneous nephrolithotomy (PCNL). They found that statin use is not associated with reductions in postoperative sepsis, nonfebrile urinary tract infections, ICU utilization, or hospital length of stay after PCNL.
AHRQ-funded; HS020927.
Citation: Alruwaily AF, Eisner BH, Bierlein MJ .
Statin use and risk of sepsis after percutaneous nephrolithotomy.
J Endourol 2015 Oct;29(10):1126-30. doi: 10.1089/end.2015.0042..
Keywords: Medication, Risk, Surgery, Adverse Events, Patient Safety