National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (3)
- (-) Adverse Events (16)
- Ambulatory Care and Surgery (1)
- Blood Clots (1)
- Cancer (2)
- Cancer: Colorectal Cancer (1)
- Care Coordination (1)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Children/Adolescents (1)
- Chronic Conditions (1)
- Clinician-Patient Communication (1)
- Communication (2)
- Community-Acquired Infections (1)
- Disparities (1)
- Elderly (4)
- Healthcare-Associated Infections (HAIs) (3)
- Healthcare Delivery (1)
- Health Information Technology (HIT) (2)
- Health Literacy (1)
- (-) Hospital Discharge (16)
- Hospitalization (3)
- Hospital Readmissions (2)
- Injuries and Wounds (2)
- Long-Term Care (2)
- Medical Errors (2)
- Medication (4)
- Medication: Safety (2)
- Nursing Homes (2)
- Opioids (2)
- Outcomes (1)
- Patient-Centered Healthcare (1)
- Patient-Centered Outcomes Research (2)
- Patient Experience (1)
- Patient Safety (4)
- Patient Self-Management (1)
- Quality Improvement (1)
- Quality of Care (1)
- Racial and Ethnic Minorities (1)
- Risk (5)
- Rural Health (1)
- Surgery (7)
- Telehealth (1)
- Transitions of Care (3)
- Urban Health (1)
- Urinary Tract Infection (UTI) (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 16 of 16 Research Studies DisplayedCarroll AR, Johnson JA, Stassun JC
Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial.
This study’s objective was to test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children. This parallel, randomized clinical trial was conducted from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis. Observed dosing errors were the main outcome measured, and secondary outcomes included caregiver-reported medication knowledge. Among 198 randomized caregivers (mean age 31.4 years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 percentage points). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group. The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%], and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]).
AHRQ-funded; HS026122.
Citation: Carroll AR, Johnson JA, Stassun JC .
Health literacy-informed communication to reduce discharge medication errors in hospitalized children: a randomized clinical trial.
JAMA Netw Open 2024 Jan 2; 7(1):e2350969. doi: 10.1001/jamanetworkopen.2023.50969..
Keywords: Children/Adolescents, Health Literacy, Communication, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Clinician-Patient Communication, Hospital Discharge, Medication: Safety
Li RD, Joung RH, BC BC
Comprehensive evaluation of the trends in length of stay and post-discharge complications after colon surgery in the USA.
The purpose of this study focusing on colon surgery was to 1) describe temporal changes in length of stay (LOS) and post-discharge complications and 2) assess risk factors related with post-discharge complications. The study found that of the 98,136 patients who underwent colon resection between 2012 and 2018, the median LOS decreased from 5 days in 2012 to 4 days in 2018. Overall, the 30-day complication rate was 21.5%, which decreased during the study period. Of the 13 individual complications evaluated, 4 demonstrated a significant increase in the proportion of post-discharge events including overall SSI, superficial SSI, wound disruption, and UTI. Factors associated with the development of any post-discharge complication included female sex, ASA III/IV/V, dependent functional status, and higher BMI. Intraoperative factors included wound class, operation time, and approach. The study concluded that LOS and 30-day complications decreased over time, however the percentage of incidents taking place post-discharge increased for a number of complications.
AHRQ-funded; HS024516; HS026385
Citation: Li RD, Joung RH, BC BC .
Comprehensive evaluation of the trends in length of stay and post-discharge complications after colon surgery in the USA.
J Gastrointest Surg 2022 Oct;26(10):2184-92. doi: 10.1007/s11605-022-05391-0..
Keywords: Surgery, Adverse Events, Hospital Discharge
Herzig SJ, Anderson TS,, Jung y
Risk factors for opioid-related adverse drug events among older adults after hospital discharge.
This study examined patient- and prescribing-related risk factors for opioid-related adverse drug events (ADEs) after hospital discharge among medical patients. Administrative billing codes and medication claims were used to define potential opioid-related ADEs within 30 days of hospital discharge. Findings showed that potential opioid-related ADEs occurred in 7% of older adults discharged from a medical hospitalization with an opioid prescription. Recommendations included using identified risk factors to inform physician decision-making, having conversations with older adults about risk, and increasing development and targeting of harm reduction strategies.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS,, Jung y .
Risk factors for opioid-related adverse drug events among older adults after hospital discharge.
J Am Geriatr Soc 2022 Jan;70(1):228-34. doi: 10.1111/jgs.17453..
Keywords: Elderly, Opioids, Risk, Adverse Drug Events (ADE), Adverse Events, Medication, Hospital Discharge
Herzig SJ, Anderson TS, Jung Y
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
This retrospective cohort study’s objective was to determine the incidence and risk of post-discharge adverse events among opioid claims in the week after hospital discharge, compared to those with nonsteroidal anti-inflammatory drugs (NSAIDs) claims alone. A national sample of Medicare beneficiaries age 65 and older who were hospitalized in the United States in 2016 was used. Beneficiaries who were admitted from or discharged to a facility were excluded. The authors used 3:1 propensity matching to match beneficiaries with an opioid claim in the week after discharge (13,385) with beneficiaries with NSAID claim alone (4,677). Beneficiaries receiving opioids had a higher incidence of death, healthcare utilization, and any potential adverse effect compared to those with an NSAID claim only. Specific adverse effects included higher relative risk of fall/fracture, nausea/vomiting, and slowed colonic motility.
AHRQ-funded; HS026215.
Citation: Herzig SJ, Anderson TS, Jung Y .
Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: a nationwide cohort study.
PLoS Med 2021 Sep 27;18(9):e1003804. doi: 10.1371/journal.pmed.1003804..
Keywords: Elderly, Opioids, Medication, Medication: Safety, Adverse Drug Events (ADE), Adverse Events, Patient Safety, Risk, Hospital Discharge
Costello WG, Zhang L, Schnipper J
Post-discharge adverse events among African American and Caucasian patients of an urban community hospital.
This study compared post-discharge adverse events (AEs) among African American and Caucasian patients at an urban community hospital. This prospective cohort study was conducted from December 2011 to October 2012. The cohort included 589 English-speaking patients who were discharged home and could be contacted after discharge for evaluation. Two nurses performed 30-day post-discharge telephone interviews, and two physicians reviewed health records to determine AEs using a previous methodology. African Americans had a slightly higher incidence of post-discharge AEs than Caucasian patients (30.6 vs. 29.9%) but it was not statistically significant.
AHRQ-funded; HS018694.
Citation: Costello WG, Zhang L, Schnipper J .
Post-discharge adverse events among African American and Caucasian patients of an urban community hospital.
J Racial Ethn Health Disparities 2021 Apr;8(2):439-47. doi: 10.1007/s40615-020-00800-z..
Keywords: Adverse Events, Racial and Ethnic Minorities, Urban Health, Disparities, Hospital Discharge
Schlick CJR, Liu JY, Yang AD
Pre-operative, intra-operative, and post-operative factors associated with post-discharge venous thromboembolism following colorectal cancer resection.
Venous thromboembolism (VTE) is the most common preventable cause of 30-day post-operative mortality, with many events occurring after hospital discharge. High-level evidence supports post-discharge VTE chemoprophylaxis following abdominal/pelvic cancer resection; however, some studies support a more tailored approach. The objectives of this study were to (1) identify risk factors associated with post-discharge VTE in a large cohort of patients undergoing colorectal cancer resection and (2) develop a post-discharge VTE risk calculator.
AHRQ-funded; HS024516; HS026385.
Citation: Schlick CJR, Liu JY, Yang AD .
Pre-operative, intra-operative, and post-operative factors associated with post-discharge venous thromboembolism following colorectal cancer resection.
J Gastrointest Surg 2020 Jan;24(1):144-54. doi: 10.1007/s11605-019-04354-2..
Keywords: Cancer: Colorectal Cancer, Cancer, Surgery, Blood Clots, Adverse Events, Risk, Hospital Discharge
Hu QL, Livhits MJ, Ko CY MJ, Ko CY
Same-day discharge is not associated with increased readmissions or complications after thyroid operations.
The purpose of this study was to determine whether same-day discharge following thyroid surgery resulted in increased rehospitalization. Data from the American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database was used to identify patients who underwent thyroid resections. Results showed that, in a national cohort of patients undergoing thyroid surgery, same-day discharge was not associated with greater rates of readmission or complications when compared with discharge 1 or 2 days after thyroid surgery.
AHRQ-funded; 233201500020I.
Citation: Hu QL, Livhits MJ, Ko CY MJ, Ko CY .
Same-day discharge is not associated with increased readmissions or complications after thyroid operations.
Surgery 2020 Jan;167(1):117-23. doi: 10.1016/j.surg.2019.06.054..
Keywords: Surgery, Ambulatory Care and Surgery, Hospital Readmissions, Hospital Discharge, Adverse Events, Patient-Centered Outcomes Research, Quality Improvement, Quality of Care
Kapoor A, Field T, Handler S
Characteristics of long-term care residents that predict adverse events after hospitalization.
This study examined the characteristics of long-term care (LTC) residents that predict adverse events (AEs) after discharge from recent hospitalization. This cohort study looked at AEs that occurred at 32 nursing homes from six New England states. AE incidents involving a total of 555 LTC residents with 762 transitions from the hospital back to LTC were reviewed. The association between all AEs and preventable AEs developing in the 45 days following discharge back to LTC was measured. There were 283 discharges with one or more AEs and 212 with preventable AEs. Characteristics independently associated with higher risk of AEs included hospital length of stay (LOS) 9 or more days, 18 or more regularly scheduled medications, and 19 and above on the dependency in activities of daily living (ADL) scale.
AHRQ-funded; HS024422.
Citation: Kapoor A, Field T, Handler S .
Characteristics of long-term care residents that predict adverse events after hospitalization.
J Am Geriatr Soc 2020 Nov;68(11):2551-57. doi: 10.1111/jgs.16770..
Keywords: Elderly, Long-Term Care, Nursing Homes, Hospitalization, Adverse Events, Transitions of Care, Hospital Discharge, Risk
Kapoor A, Field T, Handler S
Adverse events in long-term care residents transitioning from hospital back to nursing home.
This study looked at adverse event rates of long-term care residents transitioning back to their nursing home after hospitalization. A prospective cohort study of LTC residents discharged from hospital back to LTC from March 1, 2016, to December 31, 2017 was conducted, and residents were followed up for 45 days. A random sample of 32 nursing homes located in 6 New England states was used, and 555 LTC residents were selected, contributing 762 transitions from hospital back to the same LTC facility. Most of the cohort were female (65.5%) and non-Hispanic white (93.7%). The study used trained nurse abstractors to review nursing home records to determine if an adverse event occurred. Out of 762 discharges there were 379 adverse events. The most common adverse events were pressure ulcers, skin tears, and falls followed by health care-acquired infections. 145 adverse events were considered less serious, with 28 life-threatening, and 8 were fatal. Most of the adverse events were considered preventable or ameliorable.
AHRQ-funded; HS024596.
Citation: Kapoor A, Field T, Handler S .
Adverse events in long-term care residents transitioning from hospital back to nursing home.
JAMA Intern Med 2019 Sep;179(9):1254-61. doi: 10.1001/jamainternmed.2019.2005..
Keywords: Adverse Events, Long-Term Care, Nursing Homes, Transitions of Care, Elderly, Patient Safety, Hospital Discharge, Hospitalization
Elman MR, Williams CD, Bearden DT
Healthcare-associated urinary tract infections with onset post hospital discharge.
The objective of this study was to measure the incidence of potentially healthcare-associated (HA), community-onset (CO) urinary tract infection (UTI) in a retrospective cohort of hospitalized patients. Among 3,273 patients at risk for potentially HA-CO UTI, results found that the incidence of HA-CO UTI in the 30 days post discharge was 29.8 per 1,000 patients; independent risk factors included paraplegia, quadriplegia, indwelling catheter during index hospitalization, prior piperacillin-tazobactam prescription, prior penicillin class prescription, and private insurance. The authors conclude that HA-CO UTI may be common within 30 days following hospital discharge, and that their data suggests that surveillance efforts may need to be expanded to capture the full burden to patients and to better inform antibiotic prescribing decisions for patients with a history of hospitalization.
AHRQ-funded; HS020970.
Citation: Elman MR, Williams CD, Bearden DT .
Healthcare-associated urinary tract infections with onset post hospital discharge.
Infect Control Hosp Epidemiol 2019 Aug;40(8):863-71. doi: 10.1017/ice.2019.148..
Keywords: Adverse Events, Catheter-Associated Urinary Tract Infection (CAUTI), Community-Acquired Infections, Healthcare-Associated Infections (HAIs), Hospital Discharge, Hospitalization, Urinary Tract Infection (UTI)
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Krishnan N, Li B, Jacobs BL
The fate of radical cystectomy patients after hospital discharge: understanding the black box of the pre-readmission interval.
This study looked at reasons why bladder cancer patients who had undergone radical cystectomy surgery were readmitted to the hospital within 30 days. A retrospective cohort study was conducted for patients from 2005 to 2012. Researchers found that fever or difficulty with eating or maintaining their weight had the highest chance of being readmitted. Patients who had a higher pain tolerance or had noninfectious wounds or urinary concerns were less likely to be readmitted.
AHRQ-funded; HS018726.
Citation: Krishnan N, Li B, Jacobs BL .
The fate of radical cystectomy patients after hospital discharge: understanding the black box of the pre-readmission interval.
Eur Urol Focus 2018 Sep;4(5):711-17. doi: 10.1016/j.euf.2016.07.004..
Keywords: Adverse Events, Cancer, Hospital Discharge, Hospital Readmissions, Surgery
Wiseman JT, Fernandes-Taylor S, Barnes ML
Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery.
This study explored the factors that lead to postdischarge surgical site infections (SSI), investigated the differences between risk factors for in-hospital vs postdischarge SSI, and developed a scoring system to identify patients who might benefit from postdischarge monitoring of their wounds. In a comparative analysis, it found that comorbidities were the primary driver of postdischarge SSI, whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI.
AHRQ-funded; HS023395.
Citation: Wiseman JT, Fernandes-Taylor S, Barnes ML .
Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery.
J Vasc Surg 2015 Oct;62(4):1023-31.e5. doi: 10.1016/j.jvs.2015.04.453..
Keywords: Surgery, Hospital Discharge, Healthcare-Associated Infections (HAIs), Patient Safety, Injuries and Wounds, Adverse Events
Tsilimingras D, Schnipper J, Duke A
Post-discharge adverse events among urban and rural patients of an urban community hospital: a prospective cohort study.
The researchers aimed to determine the rate of postdischarge adverse events (AEs), classify the types of post-discharge AEs, and identify risk factors for post-discharge AEs in urban and rural patients. They found that post-discharge AEs were common in both urban and rural patients and many were preventable or ameliorable.
AHRQ-funded; HS018694.
Citation: Tsilimingras D, Schnipper J, Duke A .
Post-discharge adverse events among urban and rural patients of an urban community hospital: a prospective cohort study.
J Gen Intern Med 2015 Aug;30(8):1164-71. doi: 10.1007/s11606-015-3260-3..
Keywords: Adverse Events, Hospital Discharge, Outcomes, Risk, Rural Health
Sanger PC, Hartzler A, Han SM
Patient perspectives on post-discharge surgical site infections: towards a patient-centered mobile health solution.
This study explored patient experience of surgical site infections (SSI) and openness to a mobile health (mHealth) wound monitoring ‘‘app’’ as a novel solution to address the problem of patient perceptions about barriers experienced while seeking care for post-discharge SSI. It found that patients are dissatisfied with the current standard post-hospitalization care practice and were accepting of the concept of a patient-centered wound monitoring application.
AHRQ-funded; HS019482.
Citation: Sanger PC, Hartzler A, Han SM .
Patient perspectives on post-discharge surgical site infections: towards a patient-centered mobile health solution.
PLoS One 2014 Dec;9(12):e114016. doi: 10.1371/journal.pone.0114016..
Keywords: Surgery, Health Information Technology (HIT), Adverse Events, Patient Experience, Hospital Discharge
Sanger P, Hartzler A, Lober WB
Design considerations for post-acute care mHealth: patient perspectives.
The authors are developing an mHealth platform to engage patients in wound tracking to identify and manage surgical site infections (SSI) after hospital discharge. Their key design qualities include: meeting basic accessibility, usability and security needs; encouraging patient-centeredness; facilitating better, more predictable communication; and supporting personalized management by providers. In this article, they illustrated their application of these guiding design considerations and proposed a new framework for mHealth design based on illness duration and intensity.
AHRQ-funded; HS019482.
Citation: Sanger P, Hartzler A, Lober WB .
Design considerations for post-acute care mHealth: patient perspectives.
AMIA Annu Symp Proc 2014 Nov 14;2014:1920-9.
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Keywords: Telehealth, Patient Self-Management, Surgery, Injuries and Wounds, Healthcare-Associated Infections (HAIs), Hospital Discharge, Patient-Centered Healthcare, Patient-Centered Outcomes Research, Adverse Events