Research Activities, May 2013
Anderson, J.E., Lassiter, R., Bickler, S.W., and others (2012, September). "Brief tool to measure risk-adjusted surgical outcomes in resource-limited hospitals." (AHRQ grant HS19913). Archives of Surgery 147(9), pp. 798-803.
To improve surgery in less developed and developed countries, quality measurement tools must be broadly and internationally applicable. The researchers developed and validated a risk-adjusted tool to measure surgical outcomes in resource-limited hospitals. They found that fewer than six variables may be necessary to predict inpatient mortality, reducing the cost of collecting variables by 95 percent.
Bhavsar, N.A., Kottgen, A., Coresh, J., and Astor, B.C. (2012). "Neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule 1 (KIM-1) as predictors of incident CKD stage 3: The atherosclerosis risk in communities (ARIC) study." (AHRQ grant T32 HS19488). American Journal of Kidney Disease 60(2), pp. 233-240.
Although proteinuria strongly predicts progression of kidney disease, other factors such as neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule 1 (KIM-1) have also been identified as potential markers of acute kidney injury. This study that included 286 participants has found that higher NGAL levels, but not higher KIM-1 levels, are significantly associated with incident chronic kidney disease stage 3.
Burke, J.F., Lisabeth, L.D., Brown, D.L., and others (2012). "Determining stroke’s rank as a cause of death using multicause mortality data." (AHRQ grant HS17690). Stroke 43, pp. 2207-2211.
Although stroke remains the leading cause of severe adult disability in the United States, it has fallen from second to fourth among the leading organ and disease-specific causes of death over the last decade. This study found that changes in mortality attribution methodology are not likely responsible for stroke’s decline as a leading cause of death.
Cooper, P.F., Manski, R.J., and Pepper, J.V. (2012, September). "The effect of dental insurance on dental care use and selection bias." Medical Care 50(9), pp. 757-763. Reprints (AHRQ Publication No. 13-R016) are available from the AHRQ Publications Clearinghouse.
The researchers sought to reanalyze the effect of having dental insurance on use of dental care services by controlling for selection bias. They compared a number of different statistical techniques to control for selection bias, and found that the probit and instrumental variable models gave similar estimates of the effect of dental insurance on probability of seeking dental care. Based on this, the researchers conclude that selection bias is not an issue in such analyses.
Gierisch, J.M., Straits-Tröster, K., Calhoun, P.S., and others (2012, February). "Tobacco use among Iraq- and Afghanistan-era veterans: A qualitative study of barriers, facilitators, and treatment preferences." (AHRQ grant T32 HS00079). Preventing Chronic Disease 9, 2012 [8 pp].
Although military veterans are interested in smoking cessation, their reasons for wanting to do so are poorly understood—as are their treatment preferences. In focus group discussions, the key reasons that veterans wanted to stop using tobacco include improving personal health, becoming tired of dependence on cigarettes, and preventing their family from becoming smokers. They called for a personalized approach to smoking cessation programs, such as personalized telephone counseling with the opportunity for in-person counseling.
Grabowski, D.C., Huckfeldt, P.J., Sood, N., and others (2012, September). "Medicare postacute care payment reforms have potential to improve efficiency of care, but may need changes to cut costs." (AHRQ grant HS18541). Health Affairs 31(9), pp. 1941-1950.
The researchers examined the changes the Affordable Care Act mandates in payment policies for Medicare postacute care services. After examining the effects of the adoption of Medicare prospective payment systems for postacute care a decade ago, they suggest that the current reforms could produce decreased access to postacute care for less profitable patients, impair patient outcomes, and curb spending only briefly.
Hendel, R.C., Ruthazer, R., Chaparro, S., and others (2012, June). "Cocaine-using patients with a normal or nondiagnostic electrocardiogram: Single-photon emission computed tomography perfusion imaging and outcome." (AHRQ grant HS09110). Clinical Cardiology 35(6), pp. 354-358.
This study finds that myocardial perfusion imaging can reduce the number of unneeded hospitalizations among patients seen in the emergency department for chest pain associated with a normal or nondiagnostic electrocardiogram (ECG), regardless of a patient’s history of cocaine use (or nonuse). The researchers compared the characteristics and outcomes of 2,475 chest pain patients with normal ECGs in a group that included 294 cocaine users and 2,181 cocaine nonusers.
Kale, A., Keohane, C.A., Maviglia, S., and others (2012, November). "Adverse drug events caused by serious medication administration errors." (AHRQ grant HS14083). BMJ Quality & Safety 21(11), pp. 933-938.
This study found that potential adverse drug events (ADEs) at the medication administration stage can cause serious patient harm. Ten actual ADEs resulted from the 133 serious and life-threatening potential ADEs found in their study of 14,041 medication administrations. Half of the ADEs were caused by dosage and monitoring errors for antihypertensive medications.
Kearns, W.D., Fozard, J.L., Becker, M., and others (2012). "Path tortuosity in everyday movements of elderly persons increases fall prediction beyond knowledge of fall history, medication use, and standardized gait and balance assessments." (AHRQ grant HS18205). Journal of the American Medical Directors Association 13, pp. 665e7-665e13.
This study investigated the relationship between falls by assisted living facilities residents over a 1-year period to their movement path variability (tortuosity) over the same period. The study found that high fractal D levels, detected using commercially available telesurveillance technologies, lead to an increased likelihood of falls.
Kleinman, L.C., and Dougherty, D. (2013, March). "Assessing quality improvement in health care: Theory for practice." Pediatrics 131, suppl 1, pp. S110-S119. Reprints (AHRQ Pub. No. 13-R042) are available from the AHRQ Publications Clearinghouse.
This article argues for the centrality of science, including rigorous theory development and testing, in moving the nation’s quality aims forward. The authors identify gaps in the current theory and practice of quality improvement(QI) research and evaluation in health care. They suggest that specific designs should be matched to specific circumstances for considering health care improvement and its evaluation. Finally, they suggest how practical experience can help to build a theory of applied QI in health care.
Levine, R., Shore, K., Lubalin, J., and others (2012). "Comparing physician and patient perception of quality in ambulatory care." (AHRQ grant HS13193). International Journal for Quality in Health Care 24(4), pp. 348-356.
A survey of 168 patients and 39 clinicians found that the vast majority of patients and physicians agreed on three major categories that were critical elements of quality care: clinical skill, rapport, and health-related communication behaviors. The latter category includes such things as giving complete and accurate information to the patient and explaining things. Patients placed greater value than did physicians on behaviors such as providing information on non-medical ways to care for their condition.
Lorch, S.A. (2013, January). "Quality measurements in pediatrics. What do they assess?" (AHRQ grant HS20508). JAMA Pediatrics 167(1), pp. 89-90.
This editorial discusses important areas for future research and use of quality measurements raised by Profit, et al. in their paper on the correlation of neonatal intensive care unit performance across multiple measures of quality of care. These areas include the use of properly developed composite measurements and the need for measurements that assess the underlying principles of high-quality care.
Patel, M.B., Guillamondegui, O.D., Ott, M.M., and others (2012). "Oh surgery case log data, where art thou?" (AHRQ grant T32 HS13833). Journal of the American College of Surgery 215, pp. 427-431.
Using the American College of Surgery’s Case Log, the researchers have developed a method of data capture, categorization, and reporting of acute care surgeons’ experiences. They created 15 report types consisting of operative experience by service, procedure by major category (cardiothoracic, vascular, solid organ, abdominal wall, hollow viscus, and soft tissue), total resuscitations, ultrasound, airway, intensive care unit services, basic neurosurgery, and basic orthopedics.
Petterson, S.M., Liaw, W.R., Phillips, R.L., Jr., and others (2012, November/December). "Projecting US primary care physician workforce needs: 2010–2025." (AHRQ Contract No. 233-09-00359). Annals of Family Medicine 10(6), pp. 503-509. Reprints (AHRQ Publication No. 13-R029).
The researchers estimated the number of primary care physicians (PCPs) required to meet U.S. health care’s utilization needs through 2025 in light of the Affordable Care Act. They estimated the total yearly number of PCP office visits to grow from 462 million (2008) to 565 million (2025). Therefore, there will be a need for an additional 52,000 PCPs by 2025.
Poon, E.G., Kachalia A., Puopolo, A.L., and others (2012). "Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: A process analysis of closed malpractice claims." (AHRQ grant HS11886). Journal of General Internal Medicine 27(11), pp. 1416-1423.
The researchers used 56 cases of missed and delayed diagnosis in performing structured analyses to identify specific points in the diagnostic process in which errors occurred. They found that cognitive errors and logistical breakdowns were common among missed and delayed diagnoses of breast and colorectal cancers. The clinical activity most prone to cognitive error was the selection of the diagnostic strategy.
Saag, K.G., Mohr, P.E., Esmail, L., and others (2012). "Improving the efficiency and effectiveness of pragmatic clinical trials in older adults in the United States." (AHRQ grant HS16956). Contemporary Clinical Trials 33, pp. 1211-1216.
The authors summarize viewpoints on novel and lower-cost approaches to the design of pragmatic clinical trials (PCTs) resulting from a meeting of stakeholders and from discussions among the listed authors. The viewpoints include optimizing the use of community-based practices through partnership with Practice-Based Research Networks, using information technology to simplify PCT subject recruitment, consent and randomization processes, and using linkages to large administrative databases, such as Medicare.
Scholle, S.H., Vuong, O., Ding, L., and others (2012, November). "Development of field test results for the CAHPS PCMH Survey." (AHRQ grants HS16978, HS16980). Medical Care 50(11), suppl 3, pp. S2-S10.
The goal of this study was to develop survey questions to assess patient experiences that reflect key elements of the Patient-Centered Medical Home model. Ten items in four new domains and four items in two existing domains were selected to be supplemental items to be used in conjunction with the adult Clinical and Group Consumer Assessment of Healthcare Providers and Systems 1.0 Survey. This study provides support for the reliability and validity of these new items.
Sittig, D.F., and Singh, H. (2012, November). "Electronic health records and national patient-safety goals." (AHRQ grant HS17820). New England Journal of Medicine 367(19), pp. 1854-1860.
To account for the variation in the stages of implementation and levels of complexity across clinical practice settings, the authors propose a three-phase framework for the development of electronic health record-specific patient-safety goals. The first phase includes goals to mitigate risks that are unique and specific to technology. The second phase addresses misuse or inappropriate use of technology. The third phase concerns the use of technology to monitor health care processes.
Steiner, J.F. (2012). "Rethinking adherence." (AHRQ grant HS19859). Annals of Internal Medicine 157, pp. 580-585.
The author argues that improving medication adherence for patients being treated for diabetes, hypertension, or hyperlipidemia requires recognition that adherence is a set of interacting behaviors influenced by individual, social, and environmental forces. Additionally, adherence interventions must be broadly based, rather than targeted to specific population subgroups. Finally, counseling with a trusted clinician needs to be complemented by outreach interventions and removal of structural and organizational barriers.
Taylor, J.L., McPheeters, M.L., Sathe, N.A., and others (2012, September). "A systematic review of vocational interventions for young adults with autism spectrum disorders." (AHRQ Contract No. 290-07-10065). Pediatrics 130(3), pp. 531-538.
The researchers undertook a systematic review to assess the impact of vocational interventions on teenagers and young adults with autism spectrum disorders. Because of the poor quality of the six studies identified, no conclusions could be drawn. Five of the six studies involved small populations and failed to randomly assign subjects to the intervention and control arms.
Thompson, D.A., Kass, N., Holzmueller, C., and others (2012, July/August). "Variation in local institutional review board evaluations of a multicenter patient safety study." (AHRQ grant HS18762). Journal for Healthcare Quality 34(4), pp. 33-39.
This study focused on characterizing the review procedures used by five hospital institutional review boards (IRBs) in their evaluation of a study on patient safety risks in cardiovascular operating room procedures. It found that the IRB process varied widely from hospital to hospital. Reviews ranged from full committee review and approval with consents required from patients and operating room staff to determining the study exempt from review and participant consent.
Touchette, D.R., Yang, Y., Tiryaki, F., and Galanter, W.L. (2012). "Economic analysis of alvimopan for prevention and management of postoperative ileus." (AHRQ grant HS16973). Pharmacotherapy 32(2), pp. 121-128.
This study finds that alvimopan is a potentially useful drug in the treatment of patients undergoing bowel resection surgery by laparotomy. The drug is likely to reduce hospital length of stay and total cost of care in this population, although limitations exist in the current reports that raise questions about the certainty of these findings. The data sources were four phase III clinical trials, two pooled analyses, and one meta-analysis.
Wang, S-Y., Olson-Kellogg, B., Shamliyan, T.A., and others (2012). "Physical therapy interventions for knee pain secondary to osteoarthritis." (AHRQ Contract No. 290-07-10064). Annals of Internal Medicine 157, pp. 632-644.
This review evaluates the efficacy and comparative effectiveness of available physical therapy interventions for adult patients with knee osteoarthritis (OA). It found that interventions that empower patients to actively self-manage knee OA (such as aerobic, strength, and proprioception exercise) improved patient-centered outcomes. No single intervention, however, improved all outcomes. The meta-analysis included 84 randomized controlled trials.
Ward, M.M., Vartak, S., Loes, J.L., and others (2012). "CAH staff perception of a clinical information system implementation." (AHRQ grant HS16156). American Journal of Managed Care 18(5), pp. 244-252.
This study of staff response to implementation of a clinical information system (CIS) at seven critical access hospitals found that providers had significant differences in their responses from nurses and other clinical staff. The hospitals were rural, with a median of 25 acute care beds. Staff were surveyed at baseline, before implementation of the CIS, and after implementation.
Winters, B., Custer, J., Galvagno, S.M., and others (2012). "Diagnostic errors in the intensive care unit: A systematic review of autopsy studies." (AHRQ grant HS17755). BMJ Quality and Safety 21, pp. 894-902.
The purpose of this study was to systematically estimate the prevalence and distribution of autopsy-confirmed diagnostic errors in the intensive care unit (ICU) population. It found that 28 percent of autopsied ICU patients had at least one misdiagnosis. Vascular events and infections were the leading potentially lethal misdiagnoses accounting for almost 82 percent of potentially lethal class I errors and almost 86 percent of the serious but not lethal class II errors.
Yabroff, K.R., Dowling, E., Rodriguez, J., and others (2012). "The Medical Expenditure Panel Survey (MEPS) experiences with Cancer Survivorship Supplement." Journal of Cancer Survival 6, pp. 407-419. Reprints (AHRQ Publication No. 13-R018) are available from the AHRQ Publications Clearinghouse.
The authors describe selected publicly available data sources for estimating the burden of cancer in the United States. They also describe a new collaborative effort to improve the quality of these data, the nationally representative Medical Expenditure Panel Survey Experiences with Cancer Survivorship Supplement.
Zima, B.T., Murphy, J.M., Scholle, S.H., and others (2013). "National quality measures for child mental health care: Background, progress, and next steps." (AHRQ grant HS20506). Pediatrics 131, pp. S38-S49.
This article reviews the following: recent relevant health policy initiatives; the selection of national child health quality measures; existing national standards for child mental health care, including the strength of the evidence supporting them; an update on development of new quality measures related to child mental health care; and early lessons from these national efforts.