Using AHRQ Patient Safety Indicators to Detect Postdischarge Adverse Events in the Veterans Health Administration

This weekly compilation of articles appearing in recently released journals and newsletters includes:

• Articles funded by the Agency for Healthcare Research and Quality (AHRQ) or authored by AHRQ researchers.
• Articles mentioning or discussing AHRQ staff, activities, and publications/products.
• Articles related to AHRQ-funded Evidence-based Practice Centers.
• Articles related to the U.S. Preventive Services Task Force or Put Prevention into Practice program.
• Articles mentioning the National Healthcare Disparities Report and National Healthcare Quality Report.
• Other research using AHRQ data or products.

AHRQ-Funded/Authored Articles

American Journal of Medical Quality
Mull HJ, Borzecki AM, Chen Q, Shin MH, et al. Using AHRQ Patient Safety Indicators to detect postdischarge adverse events in the Veterans Health Administration. Am J Med Qual 2013 Aug 12. [Epub ahead of print. Uses AHRQ's Patient Safety Indicators (PSIs), citing AHRQ publications, Advances in Patient Safety: From Research to Implementation, Volume 2, 2005, AHRQ Guide to Patient Safety Indicators, Version 3.1a, 2007, and AHRQ Present on Admission (POA): User Overview (as published on AHRQ's Quality Indicators Web site.]  Select to access the abstract.

BMJ Quality and Safety
Cox ED, Carayon P, Hansen KW, et al. Parent perceptions of children's hospital safety climate.  BMJ Qual Saf 2013 Aug; 22(8):664-71. [Supported by R18 grant (to first author); adapts and validates AHRQ's Hospital Survey on Patient Safety Culture, citing AHRQ-funded article by Sorra and Dyer (BMC Health Serv Res, 2010), and AHRQ publications, Guide to Patient and Family Engagement: Environmental Scan Report, 2012, Surveys on Patient Safety Culture, 2012, and Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. Composite-level Results for the 2011 Database, Table 6-3, 2011; mentions AHRQ's Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).] Select to access the abstract.

Zwaan L, Schiff GD, Singh H. Advancing the research agenda for diagnostic error reduction. BMJ Qual Saf 2013 Oct; 22 Suppl 2:ii52-ii57. [Supported by grant R18 HS17820 (to third author).] Select to access the abstract.

Health Services Research
Berkowitz SA, Aragon K, Hines J, Seligman H, Lee S, Sarkar U. Do clinical standards for diabetes care address excess risk for hypoglycemia in vulnerable patients? A systematic review. Health Serv Res 2013 Aug; 48(4):1299-1310. [Supported by grant K08 HS17594 (to last author); uses AHRQ's definition of "quality metric," citing Inclusion Criteria on AHRQ's Quality Measures Web site; also uses AHRQ's National Guideline Clearinghouse™ (NGC) and National Quality Measures Clearinghouse™ (NQMC) as data sources.] Select to access the abstract.

Brooks JM, Ohsfeldt RL. Squeezing the balloon: propensity scores and unmeasured covariate balance. Health Serv Res 2013 Aug; 48(4):1487-507. [Supported by Centers for Education and Research on Therapeutics (CERTs) cooperative agreement 5 U18 HS16094 and grant R01 HS18381.] Select to access the abstract.

JAMA
Peterson PN, Greiner MA, Qualls LG, et al. QRS duration, bundle-branch block morphology, and outcomes among older patients with heart failure receiving cardiac resynchronization therapy. JAMA 2013 Aug 14; 310(6):617-26. [Supported by contract HHSA 290-2005-0032-I to the Duke University Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Center and grant K08 HS19814 (to first author).] Select to access the abstract.

AHRQ-Related Articles

AAACN Viewpoint
Parker DM, McCall BS. Shingles (herpes zoster): vaccine for a healthy future. AAACN Viewpoint 2013 Jul-Aug; online. [Mentions that AHRQ "estimated that an average of $566 million per year is spent on health care for shingles and its complications (CDC, 2008)".]

American Family Physician
Petterson SM, Phillips RL Jr, Bazemore AW, et al. Relying on NPs and PAs does not avoid the need for policy solutions for primary care. Am Fam Physician 2013 Aug 15; 88(4):230. [Adapts findings from AHRQ publication, The Number of Nurse Practitioners and Physician Assistants Practicing Primary Care in the United States, Primary Care Workforce Facts and Stats, 2011, completed under contract HHSA 290-2007-10008-TO 1.]

BMJ Quality and Safety
Ahmed M, Arora S, Baker P. et al. Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. BMJ Qual Saf 2013 Aug; 22(8):618-25. [Cites AHRQ publication, Advances in Patient Safety: From Research to Implementation, Volume 4: Programs, Tools, and Products, 2005.] Select to access the abstract.

Sullivan PJ, Harris ML, Coyle C, et al. Assessment of the validity of the English National Health Service Adult In-Patient Survey for use within individual specialties. BMJ Qual Saf 2013 Aug; 22(8):690-6. [Notes the similarity of the subject survey with AHRQ's HCAHPS, citing CAHPS Hospital Survey as accessed on the HCAHPS Online Web site and HCAHPS Three State Study Pilot Analysis Results, 2003, as published on the Centers for Medicare and Medicaid Services (CMS) Web site; also cites AHRQ-authored article by Goldstein, Farquhar, Crofton (second and third authors are former and current AHRQ researchers) et al. (Health Serv Res, 2005).] Select to access the abstract.

Health Services Research
Phibbs CS. Are the observed mortality and length of stay disparities for uninsured neonates real? Health Serv Res 2013 Aug; 48(4):1227-31. [Comments on article by Morriss (Health Serv Res, 2013) cited in Research by Others Using AHRQ Data or Products below.]

Troyer JL, Sause W. Association between traditional nursing home quality measures and two sources of nursing home complaints. Health Serv Res 2013 Aug; 48(4):1256-78. [Cites AHRQ-funded article by Castle and Ferguson (Gerontologist, 2010).]  Select to access the abstract.

Rahman M, Grabowski DC, Intrator O, et al. Serious mental illness and nursing home quality of care. Health Serv Res 2013 Aug; 48(4):1279-98. [Cites AHRQ-funded articles by Grabowski et al. (Health Aff, 2009) and Mor et al. (Milbank Q, 2004).] Select to access the abstract.

Werner RM, Konetzka RT, Polsky D. The effect of pay-for-performance in nursing homes: evidence from state Medicaid programs. Health Serv Res 2013 Aug; 48(4):1393-414. [Cites AHRQ-authored articles by Li, Cai, Glance, Spector (researcher in AHRQ's Center for Delivery, Organization, and Markets) et al. (Health Serv Res, 2009) and Mukamel, Glance, Weimer, Spector, et al. (Med Care, 2008), and AHRQ-funded articles by Rosenthal and Frank (Med Care Res Rev, 2006) and Rosenthal et al. (N Engl J Med, 2006).] Select to access the abstract.

Bowblis JR, Hyer K. Nursing home staffing requirements and input substitution: effects on housekeeping, food service, and activities staff. Health Serv Res 2013 Aug; 48(4):1539-50. [Cites AHRQ-authored articles by Mukamel, Weimer, Harrington, Spector, et al. (Health Serv Res, 2012) and Mukamel, Li, Harrington, Spector, et al. (Med Care, 2011).] Select to access the abstract.

Healthcare Financial Management
Natale CV, Gross D. The ROI of engaged patients. Healthc Financ Manage 2013 Aug; 67(8):90-7. [Mentions HCAHPS' use in rating results of the discussed health system's improvement program.] Select to access the abstract.

JAMA
Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA 2013 Aug 14; 310(6):577-8. [Cites AHRQ-funded article by Pronovost et al. (J Crit Care, 2008).]

JAMA Internal Medicine
Virani SS, Woodard LD, Wang D, et al. Correlates of repeat lipid testing in patients with coronary heart disease. JAMA Intern Med 2013 Aug 12; 173(15):1439-44. [Cites AHRQ-sponsored Institute of Medicine (IOM) report, Crossing the Quality Chasm: A New Health System for the 21st Century, 2001.] Select to access the abstract.

McWilliams JM, Chernew ME, Zaslavsky AM, et al. Delivery system integration and health care spending and quality for Medicare beneficiaries. JAMA Intern Med 2013 Aug 12; 173(15):1447-56. [Cites AHRQ-authored article by Zuvekas and Cohen (researchers in AHRQ's Center for Financing, Access, and Cost Trends) (Health Aff, 2010).] Select to access the abstract.

Smith GR, Devisetty VK, Mitra DL. Perceptions of safety are shaped by the hospital environment. JAMA Intern Med 2013 Aug 12; 173(15):1471-2. [Cites AHRQ-authored article by Elixhauser, Steiner, and Fraser (first two authors are researchers in and third author is director of AHRQ's Center for Delivery, Organization, and Markets, respectively) (Health Aff, 2003) and AHRQ-funded article by Birkmeyer et al. (N Engl J Med, 2002).]

Sinsky CA, Dugdale DC. Medicare payment for cognitive vs procedural care: minding the gap. JAMA Intern Med 2013 Aug 12. [Epub ahead of print. Cites AHRQ-funded article by Rosenthal et al. (N Engl J Med, 2006).] Select to access the abstract.

Worldviews on Evidence-based Nursing
Brown J. A review of the evidence on technology-based interventions for the treatment of tobacco dependence in college health. Worldviews Evid Based Nurs 2013 Aug; 10(3):150-62. [Summarizes findings and recommendations from AHRQ-sponsored guideline, Treating Tobacco Use and Dependence: 2008 Update, 2008.] Select to access the abstract.

U.S. Preventive Services Task Force (USPSTF)-Related Articles

American Family Physician
Bell AL, Rodes ME, Collier Kellar L. Childhood eye examination. Am Fam Physician 2013 Aug 15; 88(4):241-8. [Uses USPSTF recommendations and AHRQ's NGC as data sources and cites USPSTF recommendations on vision screening for children 1 to 5 years of age (Pediatrics, 2011).] Select to access the abstract.

American Journal of Public Health
Sams LD, Rozier RG, Wilder RS, et al. Adoption and implementation of policies to support preventive dentistry initiatives for physicians: a national survey of Medicaid programs. Am J Public Health 2013 Aug; 103(8):e83-e90. [Cites USPSTF recommendations on prevention of dental caries in preschool children (Am J Prev Med, 2004).] Select to access the abstract.

Cancer Epidemiology, Biomarkers and Prevention
Bellcross CA, Leadbetter S, Alford SH, et al. Prevalence and healthcare actions of women in a large health system with a family history meeting the 2005 USPSTF recommendation for BRCA genetic counseling referral. Cancer Epidemiol Biomarkers Prev 2013 Apr; 22(4):728-35. [Evaluates the prevalence of individuals meeting one or more of the USPSTF increased-risk family history patterns for BRCA, citing USPSTF recommendations on genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility and associated evidence review (both in Ann Intern Med, 2005).] Select to access the abstract.

Clinical Gastroenterology and Hepatology
Mittal S, Lin YL, Tan A, et al. Limited life expectancy among a subgroup of Medicare beneficiaries receiving screening colonoscopies. Clin Gastroenterol Hepatol 2013 Aug 22. [Epub ahead of print. Cites USPSTF recommendations on screening for colorectal cancer (Ann Intern Med, 2008).] Select to access the abstract.

Journal of General Internal Medicine
Kadivar H, Goff BA, Phillips WR, et al. Guideline-inconsistent breast cancer screening for women over 50: a vignette-based survey. J Gen Intern Med 2013 Aug 14. [Epub ahead of print. Defines desired outcome using U.S. Preventive Services Task Force (USPSTF) recommendations on screening for breast cancer (Ann Intern Med, 2009).] Select to access the abstract.

MMWR: Morbidity and Mortality Weekly Report
Centers for Disease Control and Prevention (CDC). Locations and reasons for initial testing for hepatitis C infection—chronic hepatitis cohort study, United States, 2006-2010. MMWR Morb Mortal Wkly Rep 2013 Aug 16; 62(32):645-8. [Cites USPSTF recommendations on screening for hepatitis C virus infection in adults (Ann Intern Med, 2013).] Select to access the abstract.

New England Journal of Medicine
LeFevre M. A role for finasteride in the prevention of prostate cancer? N Engl J Med 2013 Aug 15; 369(7):670-1. [Cites USPSTF recommendations on screening for prostate cancer (Ann Intern Med, 2012).]

Worldviews on Evidence-based Nursing
Buchholz SW, Wilur J, Ingram D, et al. Physical activity text messaging interventions in adults: a systematic review. Worldviews Evid Based Nurs 2013 Aug; 10(3):163-73. [Cites USPSTF recommendations on behavioral counseling in primary care to promote physical activity (Am J Nurs, 2003) and USPSTF publication, Guide to Clinical Preventive Services, 2003.]

Evidence-based Practice Centers (EPC)-Related Articles

American Family Physician
CME quiz. Am Fam Physician 2013 Aug 15; 88(4):227-8. [Includes questions based on article by Bell, Rodes, and Collier Kellar (Am Fam Physician, 2013) cited in U.S. Preventive Services Task Force (USPSTF)-Related Articles and on article by Salisbury-Afshar cited below in this section.]

Salisbury-Afshar E. ADHD interventions in children younger than six years. Am Fam Physician 2013 Aug 15; 88(4):266-8. [Based on AHRQ comparative effectiveness review, Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-risk Preschoolers, Long-Term Effectiveness in All Ages, and Variability in Prevalence, Diagnosis, and Treatment, 2011.]

BMJ Quality and Safety
Saber Tehrani AS, Lee H, Mathews SC, et al. 25-year summary of US malpractice claims for diagnostic errors 1986- 2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013 Aug; 22(8):672-80. [Cites AHRQ Evidence Report/Technology Assessment summary, The Autopsy as an Outcome and Performance Measure, 2002, and associated AHRQ-funded systematic review by Shojania et al. (JAMA, 2003); also cites AHRQ publications, Diagnosing Diagnosis Errors: Lessons From a Multi-Institutional Collaborative Project, 2005, and Special Emphasis Notice (SEN): AHRQ Announces Interest in Research on Diagnostic Errors in Ambulatory Care Settings, 2007, as published on the National Institutes of Health Grants Web site.] Select to access the abstract.

Breastfeeding Review
Binns C, James J, Lee MK. Breastfeeding and the developing brain. Breastfeed Rev 2013 Jul; 21(2):11-13. [Cites AHRQ Evidence Report/Technology Assessment, Breastfeeding and Maternal and Child Health Outcomes in Developing Countries, 2007.]

Gilmour C, Monk H, Hall H. Breastfeeding mothers returning to work: experiences of women at one university in Victoria, Australia.  Breastfeed Rev 2013 Jul; 21(2):23-30. [Cites article summary of AHRQ Evidence Report/Technology Assessment, Breastfeeding and Maternal and Child Health Outcomes in Developing Countries, 2007 (Breastfeed Med, 2009).] Select to access the abstract.

Tawia S. Childhood obesity and being breastfed. Breastfeed Rev 2013 Jul; 21(2):42-8. [Cites AHRQ Evidence Report/Technology Assessment, Breastfeeding and Maternal and Child Health Outcomes in Developing Countries, 2007.]

JAMA Internal Medicine
Huang AJ. Nonsurgical treatments for urinary incontinence in women: summary of primary findings and conclusions. JAMA Intern Med 2013 Aug 12; 173(15):1463-4 [Summarizes AHRQ comparative effectiveness review, Nonsurgical Treatments for Urinary Incontinence in Adult Women: Diagnosis and Comparative Effectiveness, 2012, performed by the University of Minnesota EPC; cites AHRQ Evidence Report/Technology Assessment, Treatment of Overactive Bladder in Women, 2009.]

JAMA Pediatrics
Bovbjerg ML, Amador C, Uphoff AE. Breastfeeding and childhood obesity: where do we go from here? JAMA Pediatr 2013 Oct 1; 167(10):894-5. [Cites AHRQ Evidence Report/Technology Assessment, Breastfeeding and Maternal and Child Health Outcomes in Developing Countries, 2007.]

Research by Others Using AHRQ Data or Products

American Family Physician
Ramar K, Olson EJ. Management of common sleep disorders. Am Fam Physician 2013 Aug 15; 88(4):231-8. [Uses AHRQ's NGC as a data source.] Select to access the abstract.

American Family Physician
Michels TC, Kelly KM. Parathyroid disorders. Am Fam Physician 2013 Aug 15; 88(4):249-57. [Uses AHRQ's NGC and evidence reports as data sources.] Select to access the abstract.

American Surgeon
Ang DN, Behrns KE. Using a relational database to improve mortality and length of stay for a department of surgery: a comparative review of 5200 patients. Am Surg 2013 Jul; 79(7):706-10. [Uses AHRQ's PSI regression models, as accessed on AHRQ's Quality Indicators Web site; cites AHRQ publication, Mortality Measurement: Mortality Risk Adjustment for University Health System Consortium, 2009.] Select to access the abstract.

Archives of Physical Medicine and Rehabilitation
Bishop JA, Suarez PA, DiPonio LA, et al. Surgical vs. nonsurgical treatment of femur fractures in people with spinal cord injury: an administrative analysis of risks. Arch Phys Med Rehabil 2013 Aug 12; [Epub ahead of print. Uses AHRQ's PSIs, citing PSI Technical Specifications as published on AHRQ's Quality Indicators Web site.] Select to access the abstract.

Epidemiologia & Prevenzione
Amato L, Colais P, Davoli M, et al. [Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data]. Epidemiol Prev 2013 Mar-Jun; 37(2-3 Suppl 2):1-100. Italian. [Uses AHRQ's NGC as a data source; cites AHRQ-authored articles by Hellinger (researcher in AHRQ's Center for Delivery, Organization, and Markets) (J Acquir Immune Defic Syndr, 2008), Kelly and Hellinger (Health Serv Res, 1987, and Med Care, 1986), and Elixhauser, Steiner, and Fraser (researchers in and director of AHRQ's Center for Delivery, Organization, and Markets) (Health Aff, 2003); cites article by Hervey et al. (J Bone Joint Surg Am, 2003) which uses HCUP NIS data, and cites several AHRQ-funded articles.] Select to access the abstract.

Health Services Research
Morriss FH Jr. Increased risk of death among uninsured neonates. Health Serv Res 2013 Aug; 48(4):1232-55. [Uses 2003, 2006, and 2009 Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) data, citing Introduction to the HCUP Kids' Inpatient Database (KID): Sample Weights, 2006, Healthcare Cost and Utilization Project:  Appendix A—Clinical Classification Software—Diagnoses, 2010, and Overview of the Kids' Inpatient Database (KID), 2011, all published on AHRQ's HCUP Web site.] Select to access the abstract.

Rasch EK, Gulley SP, Chan L. Use of emergency departments among working age adults with disabilities: a problem of access and service needs. Health Serv Res 2013 Aug; 48(4):1334-58. [Uses 2006-2008 Medical Expenditure Panel Survey (MEPS) data, citing MEPS Household Component Statistical Estimation Issues, 2007, as published on AHRQ's MEPS Web site, and AHRQ-authored article by Zuvekas and Olin (Health Serv Res, 2009).] Select to access the abstract.

Conti MS. Effect of Medicaid and disease management programs on emergency admissions and inpatient costs. Health Serv Res 2013 Aug; 48(4):1359-74. [Uses 2000-2008 HCUP Nationwide Inpatient Sample (NIS) data; cites AHRQ publications, Designing and Implementing Medicaid Disease and Care Management Programs: A User's Guide, 2008, and The High Concentration of U.S. Health Care Expenditures, AHRQ Research in Action, 2005, and AHRQ-authored article by Jiang, Stryer, Friedman, and Andrews (former and current AHRQ researchers) (Diabetes Care, 2003).]  Select to access the abstract.

JAMA
US Burden of Disease Collaborators. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA 2013 Aug 14; 310(6):591-608. [Uses data from AHRQ's HCUP State Inpatient Databases (SID) and MEPS, citing SID Related Reports as published on AHRQ's HCUP Web site and US Medical Expenditure Panel Survey 2000-2009, 2011.]

Journal of Arthroplasty
Chandwani HS, Strassels SA, Rascati KL, et al. Estimates of charges associated with emergency department and hospital inpatient care for opioid abuse-related events. J Pain Palliat Care Pharmacother 2013 Aug; 27(3):206-13. [Uses 2006, 2007, and 2008 HCUP Nationwide Emergency Department Sample (NEDS) data and AHRQ's Clinical Classifications Software, all accessed on AHRQ's HCUP Web site.] Select to access the abstract.

Journal of the Royal Statistical Society: Series C, Applied Statistics
Natarajan S, Lipsitz SR, Fitzmaurice GM, et al. An extension of the Wilcoxon Rank-Sum test for complex sample survey data. J R Stat Soc Ser C Appl Stat 2012 Aug; 61(4):653-64. [Uses 2002 MEPS data, citing AHRQ-authored article by Cohen (Med Care, 2003); mentions AHRQ's HCAHPS.] Select to access the abstract.

Medical Care Research and Review
Abraham JM, Karaca-Mandic P, Boudreaux M. Sizing up the individual market for health insurance: a comparison of survey and administrative data sources. Med Care Res Rev 2013 Aug; 70(4):418-33. [Uses 2009 MEPS Household Component (MEPS-HC) data, citing MEPS statistical brief Length of Coverage in the Individual Health Insurance Market for the Non-elderly U.S. Population, 2006, 2008.] Select to access the abstract.

Ophthalmic Plastic and Reconstructive Surgery
Ko MJ, Morris CK, Kim JW, et al. Orbital fractures: national inpatient trends and complications. Ophthal Plast Reconstr Surg 2013 Jul-Aug; 29(4):298-303. [Uses 2002-2008 HCUP NIS data and AHRQ's Elixhauser comorbidity measures (Elixhauser et al., Med Care, 1998).] Select to access the abstract.

Spine
Fineberg SJ, Oglesby M, Patel AA, et al. Incidence and mortality of perioperative cardiac events in cervical spine surgery. Spine 2013 Jul 1; 38(15):1268-74. [Uses 2002-2009 HCUP NIS data, citing Overview of the Nationwide Inpatient Sample (NIS), 2002-2009, as accessed on AHRQ's HCUP Web site. Also refer to articles by Mull et al. (Am J Med Qual, 2013), Cox et al. (BMC Qual Saf, 2013), and Berkowitz et al. (Health Serv Res, 2013) cited in AHRQ-Funded/Authored Articles and article by Bell, Rodes, and Collier Kellar (Am Fam Physician, 2013) cited in U.S. Preventive Services Task Force (USPSTF)-Related Articles.] Select to access the abstract.