Research Activities January 2013, No. 389
Alexander, G.C., and Lambert, B.L. (2012). "Is treatment heterogeneity an Achilles' heel for comparative effectiveness research?" (AHRQ grant HS18960). Pharmacotherapy 32(7), pp. 583-585.
Criticism of comparative effectiveness research highlights individual differences in treatment response (treatment heterogeneity) and warns against the perils of overreliance on "average effects." This editorial highlights misuse of the concept of treatment heterogeneity by those seeking to diminish any leverage that comparative effectiveness research may be able to achieve in improving health care value.
Baiocchi, M., Small, D.S., Yang, L., and others (2012, June). "Near/far matching: A study design approach to instrumental variables." (AHRQ grant HS18403). Health Services and Outcomes Research Methodology.
Near/far matching is capable of estimating causal effects when the outcome is not continuous and also when unmeasured covariates produce selection bias. The authors illustrate near/far matching by using Medicare data to compare the effectiveness of carotid arterial stents with cerebral protection versus carotid endarterectomy for the treatment of carotid stenosis.
Bright, T.J., Wong, A., Dhurjati, R., and others (2012). "Effect of clinical decision-support systems. A systematic review." (AHRQ Contract No. 290-07-10066). Annals of Internal Medicine 157, pp. 29-43.
This systematic review adds to the literature by summarizing trials of clinical decision support systems (CDSSs) implemented in a clinical setting to aid decisionmaking at the point of care or for a specific care situation. From their review of 148 randomized, controlled trials, the authors concluded that both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings. However, evidence for clinical, economic, workload, and efficiency outcomes remains sparse.
Clancy, C. (2012). "Eliminating central line-associated blood stream infections. Progress continues on a national patient safety imperative." Journal of Nursing Care Quality 27(3), pp. 191-193. Reprints (AHRQ Publication No. 12-R101) are available from the AHRQ Publications Clearinghouse.
The director of the Agency for Healthcare Research and Quality (AHRQ), discusses AHRQ's efforts to eliminate central line-associated blood stream infections. A key part of this effort is the implementation of the Comprehensive Unit-based Safety Program which has now been extended to 46 States.
Clancy, C., Brach, C., and Abrams, M. (2012). "Assessing patient experiences of providers' cultural competence and health literacy practices: CAHPS item sets." Medical Care 50(9) suppl. 2, pp. S1-S2. Reprints (AHRQ Publication No. 12-R100) are available from the AHRQ Publications Clearinghouse.
This article introduces a special issue focusing on two supplements to the Clinicians Group Consumer Assessment of Healthcare Providers and Systems (CAHPS)—the CAHPS Cultural Competence Item Set and the CAHPS Item Set for Addressing Health Literacy—and one supplement to the CAHPS Hospital Survey—the Hospital CAHPS Item Set for Addressing Health Literacy.
Concannon, T.W., Meissner, P., Grunbaum, J.A., and others (2012). "A new taxonomy for stakeholder engagement in patient-centered outcomes research." (AHRQ grant HS17726). Journal of General Internal Medicine 27(8), pp. 985-991.
No common taxonomy exists to guide researchers and stakeholders into the area of stakeholder-engaged research. The authors set out to develop such a taxonomy by offering definitions of "stakeholder" and "engagement," and addressing the following questions: (1) Who are the stakeholders in patient-centered outcomes research (PCOR) and comparative effectiveness research (CER)? (2) What roles and responsibilities can stakeholders have in PCOR and CER? (3) How can researchers start engaging stakeholders?
Dalal, A.J., Schnipper, J.L., Poon, E.G., and others (2012). "Design and implementation of an automated email notification system for results of tests pending at discharge." (AHRQ grant HS18229). Journal of the American Medical Informatics Association 19, pp. 523-528.
Physicians are often unaware of the results of tests pending at discharge (TPADs). The authors describe the design and implementation of an automated email notification system that pushes the final results of TPADs to the responsible inpatient-attending physician at discharge and facilitates communication with the primary care physician.
Desai, J.R., Wu, P., Nichols, G.A., and others (2012). "Diabetes and asthma case identification, validation, and representativeness when using electronic health data to construct registries for comparative effectiveness and epidemiologic research." (AHRQ grant HS19859). Medical Care 50, pp. S30-S35.
The researchers describe selected conceptual and practical challenges related to development of multisite diabetes and asthma registries, including development of case definitions, validation of case identification methods, and variations in electronic health data sources. They also discuss the representativeness of registry populations, including the impact of attrition.
Etchgaray, J.M., Gallagher, T.H., Bell, S.K., Dunlap, B., and Thomas, E.J. (2012). "Error disclosure: A new domain for safety culture assessment." (AHRQ grant HS17145). BMJ Quality and Satisfaction 21, pp. 594-599.
The authors developed and tested survey items that measure error disclosure culture, examined relationships among error disclosure culture, teamwork culture, and safety culture, and sought to establish predictive validity for survey items measuring error disclosure culture. They found two factors to measure error disclosure culture: one focused on the general culture of error disclosure and the other one focused on trust.
Garfinkel, S. (2012, July 5). "Making health care lean." H&HN Daily. Reprints (AHRQ Publication No. 12-R102) are available from the AHRQ Publications Clearinghouse.
To find out how Lean (an industrial improvement approach rooted in Toyota Production Systems) fits health care, the Agency for Healthcare Research and Quality commissioned the first independent comparative study of Lean implementation among organized delivery systems. The author offers a preliminary report of findings from 13 projects in diverse delivery systems.
Gold, R., Angier, H., Mangione-Smith, R., and others (2012, July). "Feasibility of evaluating the CHIPRA care quality measures in electronic health record data." (AHRQ grant HS18569). Pediatrics 130(1), pp. 139-149.
The Children's Health Insurance Program Reauthorization Act of 2009 includes 24 measures designed to be evaluated by using claims data from health insurance plan populations. The authors outline how to operationalize many of these measures for application in electronic health record (EHR) data through a case study of a network of more than 40 outpatient community health centers with a single EHR.
Hamilton Lopez, M., Holve, E., Sarkar, I.N., and Segal, C. (2012). "Building the informatics infrastructure for comparative effectiveness research (CER). A review of the literature." (AHRQ grant HS19564). Medical Care 50, pp. S38-S48.
This review examines peer-reviewed literature at the intersection of comparative effectiveness research (CER) and clinical informatics. The authors' aims are to characterize this new body of literature on CER and clinical informatics, as well as identify cross-cutting themes and gaps in the literature.
Holve, E., Segal, C., Lopez, M. H., and others (2012). "The Electronic Data Methods (EDM) Forum for comparative effectiveness research (CER)." (AHRQ grant HS19564). Medical Care 50, pp. S7-S10.
The EDM Forum is focused on identifying and sharing lessons learned to advance the national dialogue on the use of electronic clinical data to conduct comparative effectiveness research and patient-centered outcome research. This report provides a brief review of research networks participating in the EDM Forum and is based on an environmental scan conducted by the EDM Forum.
Holve, E., Segal, C., and Lopez, M.H. (2012). "Opportunities and challenges for comparative effectiveness research (CER) with electronic clinical data. A perspective from the EDM Forum." (AHRQ grant HS19564). Medical Care 50, pp. S11-S18.
This paper discusses crosscutting challenges and opportunities for 11 comparative effectiveness research (CER) projects that are participating in the Electronic Data Methods (EDM) forum. The EDM forum is a 3-year grant from the Agency for Healthcare Research and Quality to facilitate learning and foster collaboration among these projects.
Hsu, J.Y., Lurch, S.A., and Small, D.S. (2012). "Perils and prospects of using aggregate area level socioeconomic information as a proxy for individual level socioeconomic confounders in instrumental variable regression." (AHRQ grant HS01569). Health Services Outcomes and Research Methodology 12, pp. 119-140.
The instrumental variable method is an approach to estimating a causal relationship in the presence of unmeasured confounding variables. The authors study the effects on the bias of the two-stage least squares estimates in instrumental variables regression when using an area-level variable as a controlled confounding variable that may be correlated with the instrument.
Issel, L.M., Bekemeier, B., and Kneipp, S. (2012). "A public health nursing research agenda." (AHRQ grant HS18852). Public Health Nursing 29(4), pp. 330-342.
In order to advance the science needed to guide public health nursing practice, a national research agenda-setting conference was held in 2010. The authors report on the process by which a set of high-priority research themes were identified, as well as describe corresponding research directions within each theme. They conclude by providing recommendations for advancing the health nursing research agenda.
Jiang, X., Boxwala, A.A., El-Kareh, R., and others (2012). "A patient-driven adaptive prediction technique to improve personalized risk estimations for clinical decision support." (AHRQ grant HS19913). Journal of the American Medical Informatics Association 19, pp. e137-e144.
The goal of this study was to develop a patient-driven adaptive prediction technique. The technique developed used individualized confidence intervals to select the most 'appropriate' model from a pool of candidates to assess the individual patient's clinical condition. This approach significantly outperformed the CROSS model selection strategy in terms of discrimination and calibration.
Kahn, M.G., Batson, D., and Schilling, L.M. (2012). "Data model considerations for clinical effectiveness researchers." (AHRQ grant HS19908). Medical Care 50, S60-S67.
The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) was one of 3 projects receiving AHRQ funds to create a scalable, distributed network to support comparative effectiveness research. SAFTINet's method of extracting and compiling data from disparate entities requires the use of a shared data model. After the researchers examined the suitability of several models, SAFTINet chose the Observations Medical Outcomes Partnership common data model.
Kahn, M.G., Raebel, M.A., Glanz, J.M., and others (2012). "A pragmatic framework for singlesite and multisite data quality assessment in electronic health record-based clinical research." (AHRQ grant HS19912-01). Medical Care 50, pp. S21-S50.
A conceptually based and systematically executed approach to data quality assessment is essential to achieve the potential of the electronic revolution in health care. The authors propose a "fit-for-use" conceptual model for data quality assessment and a process model for planning and conducting single-site and multisite data quality assessments. Using examples from prior multisite studies, they illustrate their approach.
Kahn, M.G., and Weng, C. (2012). "Clinical research informatics. A conceptual perspective." (AHRQ grants HS19908, HS19726). Journal of the American Medical Informatics Association 19, pp. e36-e42.
Clinical research informatics is the rapidly evolving subdiscipline within biomedical informatics that focuses on developing new informatics theories, tools, and solutions to accelerate the full translational continuum. The authors present a conceptual model based on an informatics-enabled clinical research workflow, integration across heterogeneous data sources, and core informatics tools and platforms.
Martinez, E.A., Thompson, D.A., Errett, N.A., and others (2012). "High stakes and high risk: A focused qualitative review of hazards during cardiac surgery." (AHRQ grants HS13904, HS18762). Anesthesia & Analgesia 112, pp. 1061-1072.
The goal of this review is to identify and classify types of hazards in cardiac surgery. This review fills a gap in the cardiac surgery literature by providing a comprehensive classification of intraoperative and immediate perioperative hazards among cardiac patients, recommendations for harm-reduction strategies, and priorities for future research.
Memtsoudis, S.G., Kirksey, M., Ma, Y., and others (2012). "Metabolic syndrome and lumbar spine fusion surgery." (AHRQ grant HS00514). Spine 37(11), pp. 989-995.
The researchers elucidate the epidemiology and perioperative impact of metabolic syndrome (MetS) in patients undergoing primary posterior lumbar spine fusion. Using the National Inpatient Sample, they found that patients with MetS had significantly longer length of stay, higher rates of nonroutine discharges, and increased rates of major life-threatening complications than patients without metabolic syndrome.
Memtsoudis, S.G., Sun, X., Chiu, Y-L., and others (2012, July). "Utilization of critical care services among patients undergoing total hip and knee arthroplasty." (AHRQ grant HS00514). Anesthesiology 117(1), pp. 107-116.
The authors sought to identify the incidence and risk factors for the use of critical care services (CCS) among patients undergoing total hip and knee arthroplasty and to compare the characteristics and outcomes of patients who require CCS to those who do not. They found that 3 percent of 528,495 patients undergoing this procedure required CCS. On average, CCS patients were older and had a higher comorbidity burden than those not requiring CCS.
M'ikanatha, N.M., Dettinger, L.A., Perry, A., and others (2012, March). "Culturing stool specimens for Campylobacter spp., Pennsylvania, USA." (AHRQ grant HS10399). Emerging Infectious Diseases 18(3), pp. 484-487.
The researchers surveyed 176 clinical laboratories in Pennsylvania about stool specimen testing practices for enteropathogens, including Campylobacter spp. Most of the labs routinely test for Campylobacter spp., but in 17 labs, a stool antigen test is the sole method for diagnosis. The authors recommend that laboratory practice guidelines for Campylobacter spp. testing be developed.
Nichols, G.A., Desai, J., Lfata, J.E., Lawrence, J.M., and others (2012). "Construction of a multisite datalink using electronic health records for the identification, surveillance, prevention, and management of diabetes mellitus: The SUPREME-DM Project." (AHRQ grant HS19969). Preventing Chronic Disease at: http://www.ncbi.nlm.nih.gov/pubmed/22677160
The objective of this study was to identify the number of people with diabetes from a diabetes DataLink developed as part of the SUPREME_DM (Surveillance, PREvention, and ManagEment of Diabetes Mellitus) project, a consortium of 11 integrated health systems that use comprehensive electronic health record data for research. The study identified 1,085,947 members of those systems that met one or more criteria for diabetes.
Norris, S.L., Burda, B.U., Holmer, H.K., and others (2012). "Author's specialty and conflicts of interest contribute to conflicting guidelines for screening mammography." (AHRQ grant HS18500). Journal of Clinical Epidemiology 65, pp. 725-733.
The goal of this study was to examine the relationship between financial, intellectual, and professional conflicts of interest, and the recommendations in guidelines for or against routine screening mammography for asymptomatic, average-risk women aged 40–49 years. The specific objectives were to examine the relationship between the guideline recommendations and (1) the specialty of physician guideline authors, (2) financial disclosures of physician authors, and (3) the focus of the lead guideline author's academic interests inferred from his or her publications.
Odukoya, O.K., and Chui, M.A. (2012, Spring). "Commentary on the Federal Government's role in influencing e-prescribing use and research." Perspectives in Health Information Management at http://www.ncbi.nlm.nih.gov/pubmed/22737095
The authors discuss the Federal Government's role influencing e-prescribing use and research. Financial incentive and penalties have encouraged many organizations to rapidly adopt e-prescribing systems. However, rapid implementation has uncovered long-term costs and unintended patient safety hazards. This has led to a shift in focus from e-prescribing usefulness to an emphasis on safety concerns and expanded use.
Quinn, M.A., Kats, A.M., Kleinman, K., and others (2012, August 13/27). "The relationship between electronic health records and malpractice claims." (AHRQ grant HS15397). Archives of Internal Medicine 172(15), pp. 1187-1189.
Given the potential of electronic health records (EHRs) to reduce adverse events and health care costs, the question of whether EHRs reduce the risk of malpractice lawsuits is a logical one. A survey of 189 Massachusetts physicians from different specialties has found that the rate of malpractice claims when EHRs were used was about one-sixth the rate when EHRs were not used. Unmeasured factors may, in part, account for the apparent sixfold reduction in malpractice claims.
Randhawa, G.S., and Slutsky, J.R. (2012). "Building sustainable multi-functional prospective electronic clinical data systems." Medical Care 50, pp.S3-S6. Reprints (AHRQ Publication No. 12-R098) are available from the AHRQ Publications Clearinghouse.
This paper highlights the Agency for Healthcare Research and Quality's (AHRQ) activities in building a sustainable, scalable electronic infrastructure designed to meet the needs of diverse users. It discusses the benefits of an electronic health record-based infrastructure as well as AHRQ's experience with distributed research networks. Finally, it discusses the goals of current American Recovery and Reinvestment Act comparative effectiveness research infrastructure projects with emphasis on AHRQ-related projects.
Reid, R.J., and Larson, E.B. (2012). "Financial implications of the patient-centered medical home." (AHRQ grant HS19129). Journal of the American Medical Association 308(1), pp. 83-84.
This editorial discusses an article by Nocon and colleagues that provides a detailed look at some of the financing aspects of a large and presumably diverse set of 669 federally funded community health centers. The study confirms that sizable and ongoing investments are needed to create and sustain medical homes. The impact of the Affordable Care Act and accountable care organizations on medical homes is also discussed.
Resnicow, K., Andrews, A.M., Zhang, N., and others (2012). "Development of a scale to measure African American attitudes toward organ donation." (AHRQ grant HS08574). Journal of Health Psychology 17, pp. 389-398.
This study reports the psychometric properties, initial results, and correlates of a measure of organ donation attitudes and practices for blacks. It is a part of a larger church-based organ donation intervention trial in southeast Michigan. The three subscales identified—Barriers, Family/Race Benefits, and Altruism: Helping Others—had good psychometric properties.
Rosenbloom, S.T., Daniels, T.L., Talbot, T.R., and others (2012). "Triaging patients at risk of influenza using a patient portal." (AHRQ grant HS19276). Journal of the American Medical Informatics Association 19, pp. 549-554.
At Vanderbilt University, which has a widely adopted patient portal, an interdisciplinary team developed and pilot-tested Flu Tool, a decision-support application targeted to patients with influenza-like illness and designed to be integrated into a patient portal. Early experience suggests that health care consumers are willing to use patient-targeted decision support.
Secola, R., Lewis, M.A., Pike, N., and others (2012). "Feasibility of the use of a reliable and valid central venous catheter blood draw bundle checklist." (AHRQ grant HS19103). Journal of Nursing Care Quality 27(3), pp. 218-225.
The researchers aimed to test the feasibility of creating a central venous catheter (CVC) blood draw bundle checklist to ensure adherence to the evidence-based blood draw procedure. The results show that it is feasible to create a checklist that can be used to assess CVC blood draw procedures among pediatric oncology patients.
Sittig, D.F., Hazlehurst, B.L., Brown, J., and others (2012). "A survey of informatics platforms that enable distributed comparative effectiveness research using multi-institutional heterogeneous clinical data." (AHRQ grant HS19828). Medical Care 50, pp. S49-S59.
The purpose of this paper is to compare and contrast 6 large-scale projects that are either developing or extending existing informatics platforms for comparative effectiveness research (CER). The focus is on specific CER projects that implement informatics platforms and highlight design requirements and solutions.
Truog, R.D., Kesselheim, A.S., and Joffe,S. (2012, July). "Paying patients for their tissue: The legacy of Henrietta Lacks." (AHRQ grant HS18465). Science 337, pp. 37-38.
The authors consider issues surrounding sharing revenues with patients who provide tissue for research. They discuss several actual examples, beginning with Henrietta Lacks, a poor woman who was the source of the first immortal cell line but received no financial compensation. After weighing various factors, they conclude that the stance that tissue donors are owed financial compensation is mistaken as a matter of policy and ethics.
Wilcox, A.B., Gallagher, K.D., Boden-Albala, B., and Bakken, S.R. (2012). "Research data collection methods. From paper to tablet computers." (AHRQ grant HS19853). Medical Care 50, pp. S68-S73.
Recent changes in consumer electronic devices, both in functionality and portability, have boosted the potential utility of mobile technologies for research data collection. This paper discusses these changes and their potential impact on the clinical research process, including specific case studies highlighting their use.
Yeh, H-C., Brown, T.T., Maruthur, N., and others (2012, September). "Comparative effectiveness and safety of methods of insulin delivery and glucose monitoring for diabetes mellitus." (AHRQ Contract No. 290-07-10061). Annals of Internal Medicine 157(5), pp. 336-347.
To critically evaluate current evidence and fill in the literature gaps, the authors performed a systematic review to see whether intensive insulin therapy (multiple daily injections vs. continuous subcutaneous insulin infusion) has a differential effect in persons with type 1 or 2 diabetes mellitus and whether outcomes differ by monitoring strategy.
Yehia, B.R., Fleishman, J.A., Metlay, J.P., and others (2012). "Sustained viral suppression in HIV-infected patients receiving antiretroviral therapy." Journal of the American Medical Association 308(4), pp. 339-342. Reprints (AHRQ Publication No. 12-R092) are available from the AHRQ Publications Clearinghouse.
The researchers examined the change in and the determinants of sustained viral suppression over time in HIV-infected adults receiving anti-retroviral therapy (ART). Despite various improvements in therapy, they found that in 2008–2010, only 64 percent to 72 percent of patients receiving ART had suppressed viral loads throughout the year.