Research Activities, November 2012, No. 387
Abraham, J., Kannampallil, T.G., and Patel, V. (2012). "Bridging gaps in handoffs: A continuity of care based approach." (AHRQ grant HS17586). Journal of Biomedical Informatics 45, pp. 240-254.
To gain deeper insights about the handoff process, the authors developed a clinician-centered methodological approach. It is predicated on understanding the handoff communication activity within the context of clinician workflow. It uses the "continuity of care" model not only to capture the nuances of the handoff process and potential interdependencies within the process, but also to trace interdependent activities that mediate and affect the communication exchanges between clinicians.
Caverly, T.J., Al-Khatib, S.M., Kutner, J.S., and others (2012, July). "Patient preference in the decision to place implantable cardioverter-defibrillators." (AHRQ grant HS16964). Archives of Internal Medicine 172(14), pp. 1104-1105.
The researchers conducted a study to determine how physicians weigh patient preferences and the evidence of mortality benefit in their decision to recommend an implantable cardioverter-defibrillator for primary prevention to potentially eligible patients. Their survey of 1,210 cardiologists found that for 85.6 percent, mortality benefit data mattered "a great deal," while patient preferences mattered "a great deal" for only 37.7 percent.
Chang, S.M. and Slutsky, J. (2012). "Debunking myths of protocol registration." Reprints (AHRQ Publication No. 12-R089) are available from the AHRQ Publications Clearinghouse. Systematic Reviews 1(4), pp. 1-2.
Developing and registering protocols may seem like an added burden to systematic review investigators. However, these authors discuss benefits of protocol registration and debunk common misperceptions of the barriers of protocol registration. Protocol registration is easy to do, reduces the duplication of effort and benefits the review team by preventing later confusion.
Etchegaray, J.M., and Thomas, E.J. (2012). "Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety." (AHRQ grant HS17145). BMJ Quality and Safety 21, pp. 490-498.
This study found that two patient safety culture surveys, when administered to the same participants, had similar reliability and predictive validity. The study is the first to directly compare the ability of these two surveys to predict self-reported safety outcomes and whether or not the survey scores can be converted. The scores could be converted between the surveys, although much variance remained unexplained.
Gagne, J.J., Rassen, J.A., Walker, A.M., and others (2012, March). "Active safety monitoring of new medical products using electronic healthcare data. Selecting alert rules." (AHRQ grant HS18088). Epidemiology 23(2), pp. 238-246.
The researchers compared the performance of five classes of algorithms in simulated data using a sequential matched-cohort framework. They applied the results to two electronic health care databases to replicate monitoring of cerivastatin-induced rhabdomyolysis. They found substantial variation in performance of algorithms that could be used to generate safety alerts in prospective medical product monitoring systems, such as the Food and Drug Administration's Sentinel System.
Graber, M.L., Kissam, S., Payne, V.L., and others (2012). "Cognitive interventions to reduce diagnostic error: A narrative review." Reprints (AHRQ Publication No. 12-R090) are available from the AHRQ Publications Clearinghouse. BMJ Quality and Safety 21, pp. 535-557.
The authors conducted an analytic review of the literature to identify interventions to reduce the likelihood of cognitive errors or error-related harm in health care. They found a surprisingly wide range of possible approaches to reducing the cognitive contributions to diagnostic error. Not all the suggestions have been tested and, of those that have, the evaluations typically involved trainees in artificial settings, making it difficult to extrapolate the results to actual practice.
Greevey, R.A., Grijalva, C.G., Roumie, C.L., and others (2012). "Reweighted Mahalanobis distance matching for cluster-randomized trials with missing data." (AHRQ Contract No. 290-10-00016). Pharmacoepidemiology and Drug Safety 21(S2), pp. 148-154.
The researchers introduce an improved tool for designing matched-pairs randomized trials. This tool, reweighted Mahalanobis distance (RMD) matching, provides a user-friendly method for researchers to incorporate into the matching process their clinical knowledge and the relative difficulty of balancing important covariates. The RMD matching achieved better balance than simple randomization or MD randomization.
Hammill, B.G., Curtis, L.H., and Setoguchi, S. (2012). "Performance of propensity score methods when comparison groups originate from different data sources." (AHRQ grant HS17731). Pharmacoepidemiology and Drug Safety 21(S2), pp. 81-89.
The researchers examined the performance of propensity score-based methods for estimating relative risks when exposed and comparison subjects are selected from different data sources. When so used, propensity score methods resulted in consistent estimates of relative risk in most situations reflected in the simulation study.
Hebert, P.L., Sisk, J.E., Tuzzio, L., and others (2011). "Nurse-led disease management for hypertension control in a diverse urban community: A randomized trial." (AHRQ grant HS10859). Journal of General Internal Medicine 27(6), pp. 630-639.
For a group of black and Hispanic patients with treated but uncontrolled hypertension, this study tested the effectiveness on blood pressure of home blood pressure monitors alone or in combination with follow-up by a nurse manager. It found that the combined effect of a home blood pressure monitor plus follow-up by nurse manager over 9 months was associated with a statistically significant reduction in systolic, but not diastolic, blood pressure compared to usual care.
Hilligoss, B., and Cohen, M.D. (2012, May). "The unappreciated challenges of between-unit handoffs: Negotiating and coordinating across boundaries." (AHRQ grant HS18758). Annals of Emergency Medicine [Epub ahead of print].
The authors argue that the structural features of between-unit handoffs create several contextual factors that produce unique challenges for negotiating and coordinating during between-unit transitions. They draw on their examinations of the literature and their own observations of both physicians and nurses engaged in within-unit handoffs in pediatrics, general internal medicine, critical care, and the emergency department.
Jena, A.B., Meltzer, D.O., Press, V.G., and Arora, V.M. (2012). "Why physicians work when sick." (AHRQ grant HS16967). Archives of Internal Medicine 172(14), pp. 1107-1109.
The researchers surveyed 150 resident physicians to discover whether they had worked with flu-like symptoms in the prior training year and, if so, their reasons for doing so. Over half reported working with such symptoms in the last year. The most frequently reported reasons were obligations to colleagues and patients.
Koo, D., Feliz, K., Dankwa-Mullan, I., and others (2012). "A call for action on primary care and public health integration." Reprints (AHRQ Publication No. 12-R091) are available from the AHRQ Publications Clearinghouse. American Journal of Preventive Medicine 42(6S2), pp. S89-S91.
In 2012, the Institute of Medicine (IOM) released a report exploring the integration of primary care and public health. This article introduces an online-only, jointly published supplement that complements the recent IOM study. Four Federal agencies (the Agency for Healthcare Research and Quality, the Center for Disease Control and Prevention, the Health Resources and Services Administration, and the National Institute of Minority Health and Health Disparities) sponsored the supplement to showcase and support additional efforts in this critical area.
Meltzer, D. (2012). "Economic analysis in patient safety: A neglected necessity." (AHRQ grant HS16967). BMJ Quality and Safety 21, pp. 443-445.
In arguing for economic analysis in this area, the author states that because of costs involved, efforts to improve patient safety typically mean foregoing other initiatives that could improve health. He discusses reasons why there are not many studies in this area, for example, patient safety should be pursued for its own sake and economic evaluations of patient safety interventions are not easy to do. He believes that economic analysis can strengthen the scientific basis of patient safety.
Nelson, H.D., Bougatsos, C., and Blazina, I. (2012). "Screening women for intimate partner violence: A systematic review to update the U.S. Preventive Services Task Force Recommendation." (AHRQ Contract No. 290-07-10057). Annals of Internal Medicine 156(11), pp. 796-808.
The panel reviewed new evidence on the effectiveness of screening and interventions in reducing intimate partner violence (IPV) and related health outcomes, the diagnostic accuracy of screening instruments, and adverse effects of screening and interventions. It found that screening instruments accurately identify women experiencing IPV and that screening can provide benefits that vary by population. Potential adverse effects have minimal effect on most women.
Neugebauer, R., Fireman, B., Roy, J.A., and others (2012). "Dynamic marginal structural modeling to evaluate the comparative effectiveness of more or less aggressive treatment intensification strategies in adults with type 2 diabetes." (AHRQ Contract No. 290-05-0033). Pharmacoepidemology and Drug Safety 21(S2), pp. 99-113.
The authors reviewed the principles behind dynamic marginal structural modeling (MSM) and describe its application in an observational study of type 2 diabetes patients. They concluded that inverse probability weighting estimation to fit dynamic MSM is a viable and appealing alternative to inadequate standard modeling approaches in many comparative effectiveness problems, where time-dependent confounding and informative loss to followup are expected.
Pham-Kanter, G., Alexander, G.C., and Nari, K. (2012, May). "Effect of physician payment disclosure laws on prescribing." (AHRQ grant HS18960). Archives of Internal Medicine 172(10), pp. 819-821.
The researchers studied States that have implemented sunshine laws requiring pharmaceutical manufacturers to disclose certain payments made to physicians to determine if these laws affected the prescribing of brand-name statins and selective serotonin reuptake inhibitors. These are two drug classes within which individual drugs are highly substitutable for one another. The researchers observed minimal switching from brands to generics.
Polinski, J.M., Schneeweiss, S., Glynn, R.J., and others (2012). "Confronting confounding by health system use in Medicare Part D: Comparative effectiveness of propensity score approaches to confounding adjustment." (AHRQ grant HS18088) Pharmacoepidemology and Drug Safety 21(S2), pp. 90-98.
The researchers studied death and cardiovascular health outcomes among patients who reached the Medicare Part D coverage gap spending threshold for prescription drugs. They found that having no financial assistance to pay for drugs in the coverage gap was associated with no greater likelihood of death or cardiovascular outcomes during the coverage gap period. Although the propensity score-matched analysis suggested elevated but non-significant hazards of death among patients with no financial assistance during the gap, the high-dimensional propensity score produced lower estimates that were stable across sensitivity analyses.
Porterfield, D.S., Hinnant, L.W., Kane, H., and others (2012). "Linkages between clinical practices and community organizations for prevention. A literature review and environmental scan." (AHRQ Contract No. 290-06-00001). American Journal of Preventive Medicine 42(6S2), pp. S162-S171.
The researchers conducted a literature review and environmental scan to develop a framework for interventions that use linkages between clinical practices and community organizations for the delivery of preventive services. They found 49 interventions, of which 18 described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes.
Powers, B., Coeytaux, R.R., Dolor, R.J., and others (2012). "Updated report on comparative effectiveness of ACE inhibitors, ARBs, and direct renin inhibitors for patients with essential hypertension: Much more data, little new information." (AHRQ Contract No. 290-02-0025). Journal of General Internal Medicine 27(6), pp. 716-729.
This updating of a 2007 systematic review found that in spite of substantial new evidence, none of the conclusions from the 2007 review changed. The updated review included 36 studies new since 2007. The level of evidence remains high for equivalence between angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) for lowering blood pressure and use as single hypertension agents, as well as for superiority of ARBs for short-term adverse events.
Rassen, J.A., Shelat, A.A., Myers, J., and others (2012). "One-to-many propensity score matching in cohort studies." (AHRQ grant HS18088). Pharmacoepidemiology and Drug Safety 21(S2), pp. 69-80.
The researchers evaluated several methods of propensity score matching in cohort studies through simulation and empirical analyses. These included a commonly used greedy matching technique, pairwise nearest neighbor matching with a caliper, and a balanced pairwise nearest neighbor approach. Variable ratio, parallel, balanced nearest neighbor matching generally yielded the lowest bias and mean-squared error.
Reid, M.C., Bennett, D.A., Chen, W.G., and others (2011). "Improving the pharmacologic management of pain in older adults: Identifying the research gaps and methods to address them." (AHRQ grants HS18721, HS19461). Pain Medicine 12, pp. 1336-1357.
A expert panel convened by several of the National Institutes of Health discussed identifying research priorities that could, if addressed, lead to improved pharmacologic management of chronic pain in older adults. Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort were felt to be practical methods for building an age-appropriate evidence base to improve pharmacologic management. Specific focus was on identifying gaps about use of opioid and nonsteroidal anti-inflammatory medications, because of continued uncertainty about their risks and benefits.
Schneeweiss, S., Seeger, J.D., and Smith, S.R. (2012). "Methods for developing and analyzing clinically rich data for patient-centered outcomes research: An overview." (AHRQ Contract No. 290-05-0016). Pharmacoepidemiology and Drug Safety 21(S2), pp. 1-5.
This editorial introduces a supplement representing some of the presentations from a symposium convened in June 2011 by the Agency for Healthcare and Quality on research methods for comparative effectiveness and patient-centered outcomes research. It is intended to be a resource for researchers interested in learning, applying, and improving different methodological approaches to the design and analysis of patient-centered outcomes research studies.
Shamiliyan, T., Wyman, J.F., Ramakrishnan, R., and others (2011). "Benefits and harms of pharmacologic treatment for urinary incontinence in women." (AHRQ Contract No. 290-07-10064). Annals of Internal Medicine 156(12), pp. 861-874.
The authors conducted a systematic literature review of drugs for urgency urinary incontinence (UI) in women. Ninety-four randomized controlled trials were eligible, but the studies' inconsistent definitions of reduction in UI and quality of life hampered synthesis of evidence. The authors concluded that drugs for urgency UI showed similar small benefit. Evidence for long-term adherence and safety of treatments is lacking.
Shamiliyan, T., Kane, R.L., and Jansen, S. (2012). "Systematic reviews of synthesized evidence without consistent quality assessment of primary studies examining epidemiology of chronic diseases." (AHRQ Contract No. 290-07-10064). Journal of Clinical Epidemiology 65, pp. 610-618.
The authors evaluated how systematic reviews assess the quality of primary studies of incidence, prevalence, or risk factors for chronic diseases. They concluded that only rarely have systematic reviews of observational nontherapeutic research evaluated internal and external validity of individual studies. Diversity in how quality assessments are performed reflects the absence of uniformly accepted standards and tools to examine the quality of these studies.
Sobieraj, D.M., Lee, S., Coleman, C.I., and others (2012, May). "Prolonged versus standard-duration venous thromboprophylaxis in major orthopedic surgery: A systematic review." (AHRQ Contract No. 290-07-10067). Annals of Internal Medicine 156(10), pp. 720-727.
This systematic review compared the benefits and harms of prolonged versus standard-duration thromboprophylaxis after major orthopedic surgery in adults. Eight randomized controlled trials met the inclusion criteria. The findings suggest that the balance of benefits and harms is favorable for prolonged-duration prophylaxis, because it reduced the incidence of symptomatic venous thromboembolism, pulmonary embolism, and deep vein thrombosis. However, it did increase the risk for minor bleeding.
Souza, L.C.S., Payabvash, S., Wang, Y., and others (2012). "Admission CT perfusion is an independent predictor of hemorrhagic transformation in acute stroke with similar accuracy to DWI." (AHRQ grant HS11392). Cerebrovascular Diseases 33, pp. 8-15.
This study compared the utility of admission computerized tomographic perfusion (CTP) to that of magnetic resonance diffusion-weighted imaging (DWI) as a predictor of hemorrhagic transformation in acute stroke. The researchers found that the detection of severely ischemic tissue can be accomplished using CTP imaging with similar accuracy to that of DWI. These results suggest that CTP may have added value in the evaluation of acute stroke patients when magnetic resonance imaging is not available or contraindicated.
Toh, S., Rodriguez, L.A.G., and Hernan, M.A. (2012). "Analyzing partially missing confounder information in comparative effectiveness and safety research of therapeutics." (AHRQ grant HS19024). Pharmacoepidemiology and Drug Safety 21(S2), pp. 13-20.
Partially missing confounder information is common in comparative effectiveness and safety research of therapeutics. The researchers applied several methods to dealing with missing confounder information using data from a primary care electronic medical records database from the United Kingdom. They concluded that the unweighted complete-case analysis, the missing-category/indicator approach, and single imputation require often unrealistic assumptions and should be avoided.
Weiner, J.P., Fowles, J.B., Chan, K.S. (2012). "New paradigms for measuring clinical performance using electronic health records." (AHRQ Contract No. 290-05-0034). International Journal for Quality in Health Care 24(3), pp. 200-205.
The objectives of this article are to offer a typology of electronic measures of quality and safety and to identify key challenges, opportunities, and future priorities related to the development and application of these measures. If public and private systems of care are to effectively use health information technology to support and evaluate health care system quality and safety, the quality measurement field must embrace new paradigms and strategically address a series of technical, conceptual, and practical challenges.
Weiss, C.O., Segal, J.B., and Varadhan, R. (2012). "Assessing the applicability of trial evidence to a target sample in the presence of heterogeneity of treatment effect." (AHRQ Contract No. 290-05-0034). Pharmacoepidemiology and Drug Safety 21(S2), pp. 121-129.
The authors propose methods for the quantitative assessment of the applicability of evidence from a trial to a target sample using individual data in the presence of heterogeneity of treatment effect (HTE). These methods use individual-level data from both a trial and a target population, focus on HTE, and present an assessment of applicability through graphical presentation of the joint distribution of both beneficial and harmful treatment effects. They also address the practical issues of measurement discrepancy and missing data that can be important for patient-centered outcomes research.