Research Briefs

Research Activities, March 2011, No. 367

AbuDagga, A., Resnick, H.E., and Alwan, M. (2010, September). "Impact of blood pressure telemonitoring on hypertension outcomes: A literature review." (AHRQ Contract No. 290-06-0002). Telemedicine and e-Health 16(7), pp. 832-838.

Blood pressure (BP) measurement and monitoring are critical for management of hypertension. BP monitoring traditionally done in the doctor's office is now supplemented by BP telemonitoring in which the patient measures and transmits their BP and other information to the doctor between visits. After reviewing 15 studies, the authors found that BP telemonitoring significantly reduced BP. Declining BP ranged from 3.9 to 13.0 mm Hg for systolic blood pressure and from 2.0 to 8.0 mm Hg for diastolic blood pressure. These results are comparable to those of efficacy trials of some antihypertensive drugs. The authors concluded that BP can be managed in the community, with the patients taking an active role in their own disease management.

Anastaro, M.P., Rodriguez, H.P, Gallagher, P.M., and others (2010, October). "A randomized trial comparing mail versus in-office distribution of the CAHPS Clinician and Group Survey." (AHRQ Contract No. 290-09-0001). HSR: Health Services Research 45(5), pp. 1345-1359.

This study compared responses to a survey handed out at physicians' offices with a mailed survey from the offices of 15 primary care physicians in a large multispecialty medical group in New York. They compared physician and site-level response rates, the characteristics of respondents, and response patterns between surveys distributed using the different methods. Respondents to surveys distributed by hand reported significantly better experiences on all but three survey items. Handout surveys had lower overall response rates (40 percent vs. 58 percent) compared with mailed surveys. An incomplete distribution rate (74 percent) observed in-office, together with between-office differences in distribution rates and declining rates over time, suggest staff may be burdened by the process and selective in their choice of patients to survey.

Chan, K.S., Fowles, J.B., and Weiner, J.P. (2010). "Review: Electronic health records and the reliability and validity of quality measures: A review of the literature." (AHRQ Contract No. 290-07-1006). Medical Care Research and Review 67(5), pp. 503-527.

The authors reviewed evidence from studies on electronic health record (EHR) data quality published between 2004 and 2009, with an emphasis on data attributes that are important to quality measurement. Their goal was to examine how the reliability and validity of quality-of-care measures may be influenced by the evolving electronic data environment. Many of the 35 studies evaluated multiple aspects of data quality or comparability, such as data accuracy and measure validity. Based on the findings, the authors suggest that future research focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability. They also propose roles that health care organizations and third-party regulatory or accreditation organizations should play to enhance the value of EHR data for quality measurement.

Chokshi, D.A., Avorn, J., and Kesselheim, A.S. (2010). "Designing comparative effectiveness research on prescription drugs: Lessons from the clinical trial literature." (AHRQ grant HS18465). Health Affairs 29(10), pp. 1842-1848.

Comparative effectiveness research (CER) is particularly relevant to medication choices, because some drugs are approved in the United States after only demonstrating efficacy compared with a placebo. However, a review of recent CER trials suggests that poor-quality studies continue to be done. The authors identify three areas of special concern: choice of comparison treatments, study time frame, and "external validity," i.e., the extent to which the study's results can be reliably applied to the population as a whole. They then make several recommendations. First, the appropriate comparators must be relevant to the best available alternatives. Second, surrogate endpoints should be used judiciously. Third, CER should be oriented around pragmatic clinical trials comparing real-world management options. Finally, selection of patient populations should ideally provide information to help address health disparities.

Clancy, C. (2010, November). "Quitting smoking—You can do it." AARP Bulletin. Reprints (AHRQ Publication No. 11-R013) are available from the AHRQ Publications Clearinghouse.

The Director of the Agency for Healthcare Research and Quality, outlines a pathway that smokers who want to quit smoking can follow. After mentioning various resources available to stop smoking and discussing some of its consequences, she discusses a three-step program to follow: (1) get ready—set a quit date; (2) get medicine—nicotine products and other medications; and (3) get help—talk to health care workers for advice. Finally, she discusses in more detail resources available to those wanting to quit smoking such as Medicare,, and counseling available at 1-800 QUIT-NOW.

Greenwald, J.L., Halasyamani, L., Greene, J., and others (2010, October). "Making inpatient medication reconciliation patient centered, clinically relevant and implementable: A consensus statement on key principles and necessary first steps." (AHRQ grant HS17520). Journal of Hospital Medicine 5(8), pp. 477-485.

Medication errors and adverse events caused by them are common during and after a hospitalization. Medication reconciliation is important in reducing such errors. It is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. It is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. The authors present a consensus statement that originated in a 2009 stakeholder conference on hospitalized patients convened by the Society of Hospital Medicine. A basic principle emerging from the conference was that medication reconciliation should be viewed as an important element of patient safety, not as an accreditation function. The core of the paper discussed ten different areas that need to be addressed and suggests first steps toward doing so.

Henriksen, K. (2010). "Partial truths in the pursuit of patient safety." Quality and Safety in Health Care 19 (Suppl. 3), pp. i3-i7. Reprints (AHRQ Publication No. 11-R016) are available from the AHRQ Publications Clearinghouse.

The author describes what he calls "partial truths" that undermine a full understanding of the issue of patient safety. He characterizes these partial truths as "bipolar orientations." They include evidence-based medicine versus quality improvement, knowledge in the head' versus knowledge in the world,' sharp end versus blunt end, reporting systems versus local knowledge, changing beliefs versus changing behavior, and system components versus system interpendencies. He cautions against creating such partial truths or dichotomies that tend to assert too much. He further explains how the different sides of these dichotomies exist in tension with each other, sometimes overlapping and at other times conflicting. The dangers of such dichotomies are oversimplification, neglect of subtlety and interdependencies, and short-term appeal. He encourages investigators of patient safety to rise above these bipolar orientations in their pursuit of a fuller understanding of patient safety problems.

Henriksen, K., and Albolino, S. (2010). "Towards a safer healthcare system." Quality and Safety in Health Care 19 (Suppl. 3), pp. i1-i2. Reprints (AHRQ Publication No. 11-R017) are available from the AHRQ Publications Clearinghouse.

This article introduces a series of articles, most of which were presented at the second international conference "Healthcare Systems Ergonomics and Patient Safety" held in Strasbourg in 2008. The articles cover a diverse range of topics including the opinions and experiences of Italian health care workers in reporting adverse events to incident-reporting systems, the discrepancies between medication orders for infusion as entered into a computer physician entry system and the medication actually infused, and the need for valid and reliable assessment of provider performance. Representing six countries, the authors of the supplement's articles are united in the belief that fundamental to the needed change is a dedicated and sustained focus on improving patient safety and the quality of care.

Kaafarani, H.M.A., Rosen, A.K., Nebeker, J.R., and others (2010). "Development of trigger tools for surveillance of adverse events in ambulatory surgery." (AHRQ Contract No. 290-06-0001). Quality and Safety in Health Care 19, pp. 425-429.

As ambulatory or same-day surgeries become more complex, the incidence of postoperative adverse events (AEs) in this setting will probably increase. To address this problem, the trigger tool methodology uses surveillance algorithms (triggers) derived from clinical logic to flag' medical records where AEs have most likely occurred. The authors describe a four-step methodology to create these algorithms that is based on the evidence in the literature, end users' suggestions, and experts opinion. Emerging from this process is an initial set of ten surgical triggers including five global triggers and five AE-specific triggers. They culled the list to a final list of five trigger tools. These ranged from an emergency room visit within 21 days of surgery and unscheduled readmission within 30 days of surgery to an unscheduled procedure or reoperation within 30 days of surgery.

Luo, Z., Gardiner, J.C., and Bradley, C.J. (2010). "Applying propensity score methods in medical research: Pitfalls and prospects." (AHRQ grant HS14206). Medical Care Research and Review 67(5), pp. 528-554.

Use of propensity score (PS) methods in medical research to estimate causal effects from nonexperimental data has grown considerably over the past decade. Focusing on assumptions for the validity of instrumental variables and PS methods, the authors review experimental and nonexperimental causal inference methods. They provide guidance in four areas for the analysis and reporting of PS methods in medical research. They selectively evaluate mainstream journal articles from 2000 to 2005 in the four areas: examination of balance, overlapping support description, use of estimated PS for evaluation of treatment effect, and sensitivity analyses. They conclude that appropriate PS applications can create experimental conditions using observational data when randomized controlled trials are not feasible. In this way, they lead researchers to an efficient estimator of the average treatment effect.

Moyer, V.A., Singh, H., Finkel, K.L., and others (2010). "Transitions from neonatal intensive care unit to ambulatory care: Description and evaluation of the proactive risk assessment process." (AHRQ grant HS17122). Quality and Safety in Health Care 19, pp. i26-i30.

Over 20,000 newborn babies make the risky transition from the neonatal intensive care unit (NICU) to home each year in the U.S., often to the care of primary care physicians they have never met. The researchers describe the use of Health Care Failure Mode and Effects Analysis (HFMEA) to proactively assess the risks of this transition and present a qualitative evaluation of the HFMEA process. The 10-member HFMEA team worked within a large pediatric hospital between October 2007 and April 2008 to identify the main processes and possible errors involved in the discharge of a high-risk infant. The researchers conducted a facilitated debriefing session with the team, interviews of key informants, and a content analysis of documentation generated by the project. They identified 40 high-risk failure modes and 75 associated high-risk causes. Their conclusion was that while the HFMEA holds promise for improving patient safety during care transitions, the value of applying this tool to transitions from the NICU requires further study.

Mushlin, A.I., and Ghomrawi, H.M.K. (2010). "Comparative effectiveness research: A cornerstone of healthcare reform." (AHRQ grant HS16075). Transactions of the American Clinical and Climatological Association 121, pp. 141-155.

Comparative effectiveness research (CER) has recently emerged as a major theme in the health policy arena and as a component of health care reform legislation. The authors review the distinctive elements of CER, which differentiate it from the research currently required for approval of new drugs and devices. They illustrate some of the methods of CER, as well as its potential value, through examples from the authors' prior and current work. Finally, they argue that CER should be viewed by the medical community and by academic medicine, on balance, as an asset and not as a threat of rationing, of cookbook medicine, or to the doctor-patient relationship.

Outterson, K., Powers, J.H., Gould, I.M., and Kesselheim, A.S. (2010). "Questions about the 10 x 20 Initiative." (AHRQ grant HS18465). Clinical Infectious Diseases 51, pp. 750-751.

The initiative to develop 10 new antimicrobial drugs by 2020 seems reasonable, but raises certain questions, assert the authors of this paper. The initiative does not distinguish between quantity and quality. Too often, the focus is on new drugs or specific organisms rather than the serious disease caused by those organisms. Also, the clinical trials on which clinicians and patients base therapeutic decisions need to be improved. In addition, the 10 x 20 initiative makes little mention of working to extend the useful life of the drugs already available. Priorities need to be set between antibiotic conservation and new drug development, focusing on policies that will best serve the public interest.

Pham, J.C., Gianci, S., Battles, J., and others (2010). "Establishing a global learning community for incident-reporting systems." Quality and Safety in Health Care 19, pp. 446-451. Reprints (AHRQ Publication No. 11-R018) are available from the AHRQ Publications Clearinghouse.

Incident reporting systems (IRS) are a cornerstone of patient safety improvement efforts. An international group of patient safety experts convened in Baltimore in June 2008 to establish a global community to learn how IRS could improve patient safety. This paper summarizes the experiences of various organizations managing IRS and describes a global community to help advance the science of learning from mistakes. To organize their findings, they used a conceptual model for learning from adverse events, and explored how reporting systems are used to identify, analyze, and prioritize incidents; mitigate the hazards discovered; and evaluate whether risk-reduction interventions were effective. They conclude by discussing the challenges facing incident reporting systems and short-term goals such as exploring an international list of serious adverse events.

Riley, W., Davis, S., Miller, K.M., and others (2010). "Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies." (AHRQ grant HS16728). Quality and Safety in Health Care 19, pp. i53-i56.

The researchers used in situ simulation to identify defensive barriers and classify the nature of active and latent breaches in these barriers in the context of team performance during obstetrics emergencies. In situ simulation is a team-based simulation strategy that occurs in patient care units involving interdisciplinary team members working within their own environments. The researchers conducted 46 trials in two phases at six different hospitals within one health care system. Of the 965 breaches identified, 461 were classified as latent conditions and 494 were classified as active failures. The latent condition category included policy, equipment, and systems processes. The active failure category included communications breakdowns and loss of situational awareness.

Schillaci, M.A., Waitzkin, H., Carson, E.A., and Romain, S.J. (2010, September). "Prenatal care utilization for mothers from low-income areas of New Mexico, 1989-1999." (AHRQ grant HS09703). PLoS ONE 5(9), p. e12809.

The researchers compared levels of prenatal care utilization and rates of adverse birth outcomes between mothers from low- and higher-income residential areas of New Mexico between 1989 and 1999. On average, mothers from the low-income areas started their prenatal care significantly later in their pregnancies than did mothers from higher-income areas. Despite this disparity in prenatal care, there were only minor differences between income groupings in the relative occurrence of negative birth outcomes. This finding suggests that mothers from low-income areas of New Mexico are either receiving an adequate level of prenatal care or that small differences in prenatal care have exerted little direct impact on birth outcomes.

Steinman, M.A., and Hanlon, J.T. (2010). "Managing medications in clinically complex elders: There's got to be a happy medium.'" (AHRQ grant HS17695). Journal of the American Medical Association 304(14), pp. 1592-1601.

Multiple medication use, common in older adults, may ameliorate symptoms, improve and extend quality of life, and occasionally cure disease. Unfortunately, it is also a major risk factor for prescribing and adherence problems, adverse drug events, and other adverse health outcomes. Using the case of an 84-year-old male patient taking multiple medications for various conditions, the authors summarize the evidence-based literature about improving medication use and withdrawing specific drugs and drug classes. They also describe a systematic approach for how professionals can assess and improve medication regimens to benefit patients and their caregivers and families. The success of this patient's care was due to his doctor using a careful, stepwise process that merged key principles of pharmacologic care with the clinical reality, social situation, and care goals for the patient.

Taekman, J.M., and Shelley, K. (2010). "Virtual environments in healthcare: Immersion, disruption, and flow." (AHRQ grant HS16653). International Anesthesiology Clinics 48(3), pp. 101-121.

The last decade has seen an increasing emphasis on simulation in health care education. Simulation encompasses a broad continuum that includes standardized patients, high-fidelity simulation, and virtual environments (VEs). The authors focus on VEs for health care education. This includes VEs as a disruptive technology, the psychological state of "Flow" and what it means for education. They also examine factors that are catalyzing a change in medical education and discuss the strengths and weaknesses of mannequin-based learning (MBL). The authors then discuss the topic of games-based learning and why it will have a prominent place in education, the theory behind why they work, the advantages of VEs over MBL, and their limitations. Finally, they explore the possible opportunities enabled by VEs.

Williams, R.L., Willging, C.E., Quintero, G., and others (2010, October). "Ethics of health research in communities: Perspectives from the southwestern United States." (AHRQ grant HS13208). Annals of Family Medicine 8(5), pp. 433-439.

Interest is growing in community-based participatory research, whereby community members have more involvement in all stages of the research process—raising concern about the adequacy of research protections. The researchers studied Hispanic/Latino and Native American minorities in the southwestern United States to assess views about community-based health research in order to gather data about appropriate methods for conducting research in communities. After conducting 18 focus groups with 155 participants, they found that overall research was viewed as beneficial. However, participants also cited negative aspects such as coercion and inadequate attention to language and cultural issues. Also, results were sometimes not adequately communicated. The researchers concluded that community-based health research should engage communities as active partners, focus on community priorities, and take extra precautions to assure privacy.

Winthrop, K.L., and Furst, D.E. (2010). "Rheumatoid arthritis and herpes zoster: Risk and prevention in those treated with anti-tumor necrosis factor therapy." (AHRQ grant HS17960). Annals of Rheumatic Diseases 69, pp. 1735-1737.

The authors discuss the following questions: are rheumatoid arthritis (RA) patients at increased risk for herpes zoster (HZ) due to their disease or their therapies? Should anti-tumor necrosis factor (TNF) in patients with a history of HZ be avoided? Can they be vaccinated and when? After reviewing recent studies, they found that HZ risk is elevated in RA and is further elevated 1.5-2.0-fold by prednisone. However, the inconsistent results for anti-TNF therapy are confusing. They further believe that the rationale for zoster vaccination goes beyond the goal of simply preventing hospitalized HZ. Strong evidence exists arguing for the protective effect and importance of vaccinating those 60 years of age and older. Since vaccination with live viruses is contraindicated while using biological therapies, it seems logical to target this group for vaccination before anti-TNF initiation.

Weir, R.C., Emerson, H.P., Tsent, W., Chin, M.H., and others (2010, November). "Use of enabling services by Asian American, Native Hawaiian, and other Pacific Islanders Patients at 4 community health centers." (AHRQ grant HS13401). American Journal of Public Health 100(11), pp. 2199-2205.

Community health centers (CHCs) are safety nets for some of the country's most vulnerable patients. But many of these patients are unable to access or use this needed medical care without enabling services. Such services include language interpretation, health education, and financial or insurance eligibility assistance. The impact of enabling services on medically underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients has not been studied until now. This study of four CHCs located in States (Hawaii, New York, and Washington) with a higher-than-average percentage of AANHOPIs found that eligibility assistance was the most widely used service. Compared with nonusers, users of enabling services were more likely to be older, female, AANHOPI, and uninsured.

Wu, A.W., Snyder, C., Clancy, C., and Steinwachs, D.M. (2010). "Adding the patient perspective to comparative effectiveness research." Health Affairs 29(10), pp. 1863-1871. Reprints (AHRQ Publication No. 11-R022) are available from the AHRQ Publications Clearinghouse.

The purpose of comparative effectiveness research is to help patients, clinicians, purchasers, and policymakers make informed decisions that will improve health care. The authors describe how questionnaires can be used systematically to capture the experience of patients directly to provide a complete picture of treatment impact. The key patient-reported outcomes such as health-related quality of life, symptoms, rating of the quality of care/satisfaction with care, use of health care services and health behavior are included unevenly in existing studies. The authors discuss how to improve this situation with respect to the main data sources: clinical trials, observational studies, clinical data, and administrative data.

Yu, H. and Dick, A.W. (2010). "Risk-adjusted capitation rates for children: How useful are the survey-based measures?" (AHRQ grant HS16742). HSR: Health Services Research 45(6), Part II, pp. 1948-1962.

Public insurance programs such as Medicaid and the State Children's Health Insurance Program increasingly contract with managed care organizations that use capitation rates that are not adequately adjusted for high-cost children. This encourages risk selection, i.e., encouraging the enrollment of low-risk, low-cost children and discouraging the enrollment of high-risk, high-cost children. However, few risk-adjustment models have been estimated especially for children. The authors correct this lack by estimating risk-adjustment models for children using survey measures, including those developed for children with special health care needs (CSHCN). They found that CSHCN information explained a higher proportion of variance in annual expenditures than subjectively rated health status. The inclusion of this information may help provide appropriate payments to managed care plans serving this vulnerable group of children.

Current as of March 2011
Internet Citation: Research Briefs: Research Activities, March 2011, No. 367. March 2011. Agency for Healthcare Research and Quality, Rockville, MD.