Research Activities, November-December 2013
Boatright, D.H., Byyny, R.L., Hopkis, E., and others (2013). "Validation of rules to predict emergent surgical intervention in pediatric trauma patients." (AHRQ grant HS19464). Journal of the American College of Surgeons 216, pp. 1094-1102.
Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department on patient arrival. This study tested a decision rule from Loma Linda University and found it to be insufficiently accurate to recommend its routine use; however, the study had a small number of outcomes.
Cronholm, P.F., Shea, J.A., Werner, R.M., and others (2013). "The patient centered medical home: Mental models and practice culture driving the transformation process." (AHRQ grant HS19150). Journal of General Internal Medicine 28(9), pp. 1195-1201.
The authors characterize the key constructs describing role transformation related to the patient-centered medical home (PCMH) paradigm that participants associated with perceptions of improved clinical care in a large multi-payer PCMH demonstration project. They concluded that practice redesign focusing on patient-centered care and improved quality requires shifts in practice culture and the mental models of individuals.
Davidoff, A.J., Zuckerman, I.H., Pandya, N., and others (2013). "A novel approach to improve health status measurement in observational claims-based studies of cancer treatment and outcomes." Journal of Geriatric Oncology 4, pp. 157-165. Reprints (AHRQ Publication No.13-R038) are available from AHRQ.
The researchers developed and provided initial validation for a multivariate, claims-based prediction model for disability status (DS) among older adults. Their results demonstrate that health care service use indicators from administrative claims can be used to predict DS, and that the resulting predicted value is associated with survival in an older adult Medicare population.
Gawron, A.J., and Pandolfino, J.E. (2013). "Ambulatory reflux monitoring in GERD—which test should be performed and should therapy be stopped?" (AHRQ grant T32 HS00078). Current Gastroenterology Reports 15, p. 316-318.
This review focuses on the limitations of the current diagnostic paradigm and highlights how reflux testing can be helpful in the diagnosis and management of patients with poor response to proton pump inhibitor (PPI) therapy. The researchers conclude that ambulatory reflux monitoring, when used appropriately, is useful in distinguishing etiologies driving a lack of response to PPI therapy.
Glance, L.G., Dick, A.W., Osler, T.M., and others (2012). "The association between nurse staffing and hospital outcomes in injured patients." (AHRQ grant HS16737). BMC Health Services Research 12(247), [online only] 8 pp.
Replacing care by registered nurses (RNs) of patients at level I and level II trauma centers with care by licensed practical nurses (LPNs) can result in increased rates of mortality and sepsis in these patients, the researchers report. An increase of 1 percent in LPN hours per patient day (hppd) compared to total nursing hppd (LPN hours plus RN hours) was associated in the study with a statistically significant 4 percent increased risk of mortality.
Goode, A.P., Carey, T.S., and Jordan, J.M. (2013). "Low back pain and lumbar spine osteoarthritis: How are they related?" (AHRQ grant HS19479). Current Rheumatology Reports 15, pp. 305-310.
The relationship between low back pain and lumbar spine osteoarthritis (OA), both very common conditions, is complex and poses many clinical and research challenges. Specific conservative treatments for spine degeneration have not been established. However, there is emerging interest in the use of exercise therapy because of some moderate benefits in treating chronic low back pain.
Govindarajan, P., Dickert, N.W., Meeker, M., and others (2013). "Emergency research: Using exception from informed consent, evaluation of community consultations." (AHRQ grant HS17965). Academic Emergency Medicine 20, pp. 98-103.
These researchers assessed the views of community consultation (CC) meeting attendees regarding the CC process, their understanding and views of exception from informed consent research relating to the specific research trial under discussion, and their level of trust in physician-investigators. Overall, community members had relatively high levels of support for the study and trust in physician-investigators.
Hartling, L., Milne, A., Hamm, M. P., and others (2013). "Testing the Newcastle Ottawa Scale showed low reliability between individual reviewers." (AHRQ Contract No. 290-07-1002). Journal of Clinical Epidemiology 66, pp. 982-993.
The researchers assessed the reliability of the Newcastle Ottawa Scale (NOS) for cohort studies between individual raters. It also assessed the validity of the NOS by examining whether effects vary according to quality. They found that interrater reliability between reviewers ranged from poor to substantial, but was poor to fair for most domains. No associations were found between individual quality domains or overall quality score and effect estimates.
Huang, S.S., Septimus, E., Kleinman, K., and others (2013). "Targeted versus universal decolonization to prevent ICU infection." (AHRQ and CDC cooperative agreement). New England Journal of Medicine 368(24), pp. 2255-2265.
The researchers tested three ways to prevent intensive care unit infection: targeted decolonization, universal decolonization, and MRSA screening and isolation. They found that, in routine practice, universal decolonization was more effective than either of the other two methods in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen.
Huesch, M.D., and Doctor, J.N. (2013). "Cesarean delivery on maternal request" [Letter to the Editor]. (AHRQ grant HS21868). Journal of the American Medical Association 310(9), p. 978.
In response to the article by J. Ecker on cesarean delivery on maternal request, the authors raise several larger concerns, including the importance of parsimonious medicine, personal accountability, and the risk of spillovers to other physician decisions in other patients. They point to the difficulty in upholding a standard of adherence to medical indications in the more complex intrapartum situation, while relaxing those standards in the simpler pre-partum situation.
Hundt, A.S., Adams, J.A., Schmid, J.A., and others (2013). "Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit." (AHRQ grant HS15274). International Journal of Medical Informatics 82(1), pp. 25-38.
The researchers describe the use of a proactive risk assessment (PRA) prior to implementation of computerized physician order entry in an intensive care unit. Prioritizing the vulnerabilities allowed those with the potentially most negative consequences to be corrected prior to or promptly after implementation. Results from the various evaluations demonstrate the value of developing an efficient PRA method that meets organizational and contextual requirements and constraints.
Johnson, T.J., and King, C. (2013). "An 11-year-old girl with right-sided weakness secondary to cerebral abscess." (AHRQ grant T32 HS17587). Pediatric Emergency Care 29(3), pp. 360-363.
This case report reviews the clinical presentation, evaluation, and management of a child with a brain abscess, an unusual but potentially life-threatening condition.
Jonnalagadda, S.D., Del Fiol, G., Medlin, R., and others (2013). "Automatically extracting sentences from Medline citations to support clinicians' information needs." (AHRQ grant HS18352). Journal of the American Medical Informatics Association 20, pp. 995-1000.
The researchers assessed the feasibility of automatically generating knowledge summaries for a particular clinical topic composed of relevant sentences extracted from Medline citations. Their approach, combining information retrieval and semantic extraction techniques, was tested in two case studies on the treatment alternatives for depression and Alzheimer's disease.
Kistler, C.E., and Goldstein, A.O. (2012, December). "The risk of adverse cardiovascular events from varenicline balanced against the benefits in mortality from smoking cessation" (AHRQ grant HS19468). Nicotine & Tobacco Research 14(12), pp. 1391-1393.
A meta-analysis published in 2011 reported a higher annual rate of adverse cardiovascular events (ACEs)—but not mortality—in smokers given the smoking cessation drug varenicline than those given placebo (1.06 vs. 0.82 percent), but the authors of a new commentary on the meta-analysis say that varenicline (currently the most effective smoking cessation drug) will actually save lives.
Kruse, G.B., Polsky, D., Stuart, E.A., and others (2012, December). "The impact of hospital pay-for-performance on hospital and Medicare costs." (AHRQ grant HS18409). HSR: Health Services Research 47(6), pp. 2118–2134.
For patients hospitalized for acute myocardial infarction (AMI), their hospital's participation in the Centers for Medicare & Medicaid Services' pay-for-performance demonstration program (260 hospitals) did not significantly affect hospital revenues, costs, and margins, or Medicare payments (for the index hospitalization and 1 year after admission) when compared with AMI patients treated at 780 matched, nonparticipating hospitals.
Lannon, C.M., and Peterson, L.E. (2013). "Pediatric collaborative improvement networks: Background and overview." (AHRQ grant HS21114). Pediatrics 131, pp. S189-S195.
The authors describe how pediatric collaborative improvement networks can serve to close the quality gap and accelerate the translation of evidence into practice, resulting in improved care and outcomes for children. The specific topics discussed include: developing a framework for subspecialty maintenance of certification, the Children's Oncology Group, additional support for the value of the network model, and additional needs of mature networks.
Lannon, C.M., and Miles, P.V. (2013). "Pediatric collaborative improvement networks: Bridging quality gaps to improve health outcomes." (AHRQ grant HS21114). Pediatrics 131, pp. S187-S188.
This article introduces a group of papers that summarize and expand on several key presentations from a national meeting on Collaborative Improvement Networks in Children's Healthcare sponsored by the American Board of Pediatrics Foundation.
Lannon, C.M., Miles, P.V., and Stockman, J.A. (2013). "The path forward: Collaborative networks and the future for children's health care." (AHRQ grant HS21114). Pediatrics 131, pp. S226-S227.
The authors discuss the value of collaborative networks for the future of children's health care and the importance of accelerating the spread of this model. Various challenges are also mentioned, such as the lack of robust evidence in certain areas to develop recommended care processes, the need for more basic research, the usefulness of a data infrastructure, and the need for financial support for transactional costs such as human subjects review.
Margolis, P.A., Peterson, L.E., and Seid, M. (2013). "Collaborative chronic care networks (C3Ns) to transform chronic illness care." (AHRQ grants HS2111, HS20024). Pediatrics 131, pp. S219-S223.
Given that the overall U.S. system of chronic illness care does not work well, a new paradigm is needed: a Collaborative Chronic Care Network (C3N). A C3N is a network-based production system that harnesses the collective intelligence of patients, clinicians, and researchers and distributes the production of knowledge, information, and know-how over large groups of people. The authors also discuss the social, technical, and scientific operating systems and policy implications.
Miles, P.V., Conway, P.H., and Pawlson, G. (2013). "Physician professionalism and accountability: The role of collaborative improvement networks." (AHRQ grant HS21114). Pediatrics 131, pp. S204-S209.
The authors discuss the need for physicians to demonstrate professionalism and accountability in a different way that includes quality and clinical outcomes, but also resource utilization, appropriateness, and patient-centeredness of recommended care, and the responsibility to improve systems of care. Physician participation in pediatric collaborative improvement networks will be an important part of this process of transforming care.
Miller, M. (2013). "Roles for children's hospitals in pediatric collaborative improvement networks." (AHRQ grant HS21114). Pediatrics 131, pp. S215-S218.
The author believes that children's hospitals and their associated subspecialty clinics are uniquely positioned to achieve significant outcomes and cost savings through coordinated quality-improvement efforts. Large-scale pediatric collaborative improvement networks can link children's hospitals in networks to build the evidence for what works for children.
Mody, L., Bradley, S.F., and Huang, S.S. (2013). "Keeping the 'home' in nursing home." (AHRQ grant HS19979). JAMA Internal Medicine 173(10), pp. 833-834.
To maintain a home-like environment and enhance the quality of life for older long-stay residents in nursing homes (NHs), NH residents are being given greater autonomy in determining their daily care and other activities. Close relationships between residents, families, and staff are encouraged. The author discusses the dichotomy between these valuable changes and the need to reduce healthcare-associated complications in higher-acuity short-stay residents.
Mueller, S.K., Kripalani, S., Stein, J., and others (2013, August). "A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS)." (AHRQ grant HS19598). Joint Commission Journal on Quality and Patient Safety 39(8), pp. 371-382.
Medication errors are common during transitions of care such as those that occur at hospital admission and discharge. Medication reconciliation is a strategy to reduce the occurrence of medication discrepancies than may occur during care transitions. The authors describe the development of a toolkit of the best-practice recommendations for medication reconciliation and a multihospital quality improvement project in which each site adapts and implements the tools for its own environment.
Nuckols, T.K., Escarce, J.J., and Asch, S.M. (2013). "The effects of quality of care on costs: A conceptual framework." (AHRQ grant HS17594). Milbank Quarterly 91(2), pp. 316-353.
To describe how care quality influences cost, the authors developed the Quality-Cost Framework, drawing from the work of Donabedian, the RAND/UCLA Appropriateness Method, reports by the Institute of Medicine, and other sources. The Framework describes how health-related quality of care (aspects of quality that influence health status) affects health care and other costs.
Nundy, S., Razi, R.R., Dick, J.J., and others (2013). "A text messaging intervention to improve heart failure self-management after hospital discharge in a largely African-American population: Before-after study." (AHRQ grant T32 HS00084). Journal of Medical Internet Research 15(3), p. e53.
This study assessed the feasibility and acceptability of a text message-based (SMS: short message service) intervention in a largely African-American population with acute decompensated heart failure and explore its effects on self-management. Among the participants who completed the study, there was a high rate of satisfaction and preliminary evidence of improvements in heart failure self-management.
Olfson, M., and Marcus, S.C. (2013, June). "Decline in placebo-controlled trial results suggests new directions for comparative effectiveness research." (AHRQ grant HS21112). Health Affairs 32(6), pp. 1116-1125.
In their investigation of placebo-controlled trials reported in four medical journals between 1966 and 2013, the authors found a significant decline in average effect size or average difference in efficacy over placebo. On average, recently studied treatments offered only small benefits in efficacy over placebo.
Ozen, A., and Balasubramaniam, H. (2013). "The impact of case mix on timely access to appointments in a primary care group practice." (AHRQ grant HS18795). Health Care Management Science 16, pp. 101-118.
The authors quantify the impact of the size and case-mix of physician panels on the ability of a multi-provider practice to provide adequate patient access to appointments. They propose an integer non-linear programming formulation for redesigning panels that will allow practice managers to test various options and infer which options are the least disruptive to the group practice.
Simpson, L. (2013, June). "The adolescence of child health services research." (AHRQ grant HS19564). JAMA Pediatrics 167(6), pp. 509-510.
The author draws attention to three forces meriting particular attention for their potential to transform the conduct of child health services research: (1) the ever-expanding sources of data, particularly prospective, electronic clinical data, (2) the demand by research users for engagement throughout the life cycle of research, and (3) the need to develop better methods for understanding more quickly which innovations and improvement efforts are actually working.
Talbert-Slagle, K., Berg, D., and Bradley E.H. (2013). "Innovation spread lessons from HIV." (AHRQ grant HS17589). International Journal for Quality in Health Care 25(4), pp. 352-356.
Biology provides a model of successful spread in viruses, which have evolved to spread with maximum efficiency using minimal resources. The authors explore the molecular mechanisms of HIV spread and identify five steps that are also common to a recent example of spread in complex health systems, i.e., reduction in time to angioplasty for patients with ST-segment elevation myocardial infarction. They then describe a new model of innovation spread, called AIDED, based on mixed-methods research but informed by the conceptual framework of HIV spread among cells.
You, W.B., Chandrasekaran, S., Sullivan, J., and Grobman, W. (2013). "Validation of a scoring system to identify women with near-miss maternal mortality." (AHRQ grant T32 HS00078). American Journal of Perinatology 30, pp. 21-24.
The researchers' objective is to validate a five-factor scoring system (originally developed by Geller et al.) that identifies women with high risk for significant obstetric morbidity. Using data from 815 cases, they found that the scoring system produced similar results to those obtained at its initial development. It also demonstrated acceptable sensitivity and specificity for identifying near-miss morbidity.
Yu, Z., Liu, L. Bravata, D.M., and others (2013). "A semiparametric recurrent events model with time-varying coefficients." (AHRQ grant HS20263). Statistics in Medicine 32, pp. 1016-1026.
The authors consider a recurrent events model with time-varying coefficients motivated by two clinical applications (stroke and episodes of wheezing among young children). They use a random effects (Gaussian frailty) model to describe the intensity of recurrent events. Their model can accommodate both time-varying and time-constant coefficients.