National Healthcare Quality and Disparities Report
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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 25 of 95 Research Studies DisplayedVenema DM, Skinner AM, Nailon R
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals.
AHRQ-funded; HS021429.
Citation: Venema DM, Skinner AM, Nailon R .
Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.
BMC Geriatr 2019 Dec 11;19(1):348. doi: 10.1186/s12877-019-1368-8..
Keywords: Falls, Injuries and Wounds, Patient Safety, Elderly, Risk, Hospitals, Adverse Events
Xu X, Lin H, Wright JD
Association between power morcellation and mortality in women with unexpected uterine cancer undergoing hysterectomy or myomectomy.
Despite concerns that power morcellation may adversely affect prognosis of patients with occult uterine cancer, empirical evidence has been limited and inconclusive. In this study, the investigators aimed to determine whether uncontained power morcellation at the time of hysterectomy or myomectomy was associated with increased mortality risk in women with occult uterine cancer.
AHRQ-funded; HS024702.
Citation: Xu X, Lin H, Wright JD .
Association between power morcellation and mortality in women with unexpected uterine cancer undergoing hysterectomy or myomectomy.
J Clin Oncol 2019 Dec 10;37(35):3412-24. doi: 10.1200/jco.19.00562..
Keywords: Cancer, Mortality, Women, Surgery, Risk, Adverse Events
Napolitano N, Laverriere EK, Craig N
Apneic oxygenation as a quality improvement intervention in an academic PICU.
The objective of this prospective pre/post observational study was to evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. The investigators concluded that implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. They suggest that use of apneic oxygenation should be considered when intubating critically ill children.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Napolitano N, Laverriere EK, Craig N .
Apneic oxygenation as a quality improvement intervention in an academic PICU.
Pediatr Crit Care Med 2019 Dec;20(12):e531-e37. doi: 10.1097/pcc.0000000000002123..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Patient Safety, Adverse Events
Stoops C, Stone S, Evans E
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
The purpose of this study was to test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. The authors concluded that a systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.
AHRQ-funded; HS023763.
Citation: Stoops C, Stone S, Evans E .
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
J Pediatr 2019 Dec;215:223-28.e6. doi: 10.1016/j.jpeds.2019.08.046..
Keywords: Newborns/Infants, Medication, Medication: Safety, Patient Safety, Kidney Disease and Health, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Prevention, Adverse Drug Events (ADE), Adverse Events
Shafer G, Singh H, Suresh G
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
In this narrative review, the authors discuss how the concept of diagnostic errors framed as missed opportunities can be applied to the non-linear nature of diagnosis in a critical care environment such as the NICU. They then explore how the etiology of an error in diagnosis can be related to both individual cognitive factors as well as organizational and systemic factors - all of which often contribute to the error.
AHRQ-funded; HS022087.
Citation: Shafer G, Singh H, Suresh G .
Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.
Semin Perinatol 2019 Dec;43(8):151175. doi: 10.1053/j.semperi.2019.08.004..
Keywords: Newborns/Infants, Diagnostic Safety and Quality, Neonatal Intensive Care Unit (NICU), Medical Errors, Adverse Events, Patient Safety
Patel SA, Araujo T, Rodriguez LP
Long peripheral catheters: a retrospective review of major complications.
The risk of infectious and noninfectious complications associated with long peripheral catheters (LPCs) is unknown. In this retrospective study of 539 catheters, the investigators did a retrospective review of major complications. Among other discoveries, they found LPCs were often placed for the indications of difficult access and long-term antibiotics.
AHRQ-funded; HS025891.
Citation: Patel SA, Araujo T, Rodriguez LP .
Long peripheral catheters: a retrospective review of major complications.
J Hosp Med 2019 Dec;14(12):758-60. doi: 10.12788/jhm.3313..
Keywords: Healthcare-Associated Infections (HAIs), Adverse Events, Patient Safety, Central Line-Associated Bloodstream Infections (CLABSI), Blood Clots, Infectious Diseases, Risk
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Gaufberg E, Olmsted MW, Bell SK
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
The authors discuss an AHRQ conference held to establish a research agenda on patient and family emotional harm after medical errors. Topics include implications for quality and safety, educational innovation, and qualitative research.
AHRQ-funded; HS024463.
Citation: Gaufberg E, Olmsted MW, Bell SK .
Third things as inspiration and artifact: a multi-stakeholder qualitative approach to understand patient and family emotions after harmful events.
J Med Humanit 2019 Dec;40(4):489-504. doi: 10.1007/s10912-019-09563-z..
Keywords: Medical Errors, Adverse Events, Clinician-Patient Communication, Communication, Patient and Family Engagement, Patient Safety
Khan A, Yin HS, Brach C
AHRQ Author: Brach C
Association between parent comfort with English and adverse events among hospitalized children.
The purpose of this study was to examine the association between parents’ limited comfort with English (LCE) and adverse events in a cohort of hospitalized children. Participants included Arabic-, Chinese-, English-, and Spanish-speaking parents of patients 17 years and younger in the pediatric units of seven North American hospitals. Findings showed that hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.
AHRQ-authored; AHRQ-funded; HS022986.
Citation: Khan A, Yin HS, Brach C .
Association between parent comfort with English and adverse events among hospitalized children.
JAMA Pediatr 2020 Dec;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215..
Keywords: Children/Adolescents, Caregiving, Cultural Competence, Clinician-Patient Communication, Communication, Adverse Events, Patient Safety, Inpatient Care, Hospitalization
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
Adediran T, Drumheller BC, McCunn M
Sex differences in in-hospital complications among older adults after traumatic brain injury.
This study examined sex differences in in-hospital complications among older adults after traumatic brain injury (TBI). Previous evidence has suggested that women have better outcomes than men after TBI. A retrospective cohort study was conducted of adults aged 65 years and older treated for moderate to severe TBI at R. Adams Cowley Shock Trauma Center from 1996 to 2012. The investigators identified TBI using ICD-9 CM codes and inclusion in the study required an abbreviated injury scale head score of 3 or greater, abbreviated injury scale scores for other body regions of 2 or greater, and a blunt injury mechanism. Out of 2511 patients, 51.1% were men, and 25.1% developed an in-hospital complication. Men had a complication rate of 28.1% versus 22.0% for women.
AHRQ-funded; HS024560.
Citation: Adediran T, Drumheller BC, McCunn M .
Sex differences in in-hospital complications among older adults after traumatic brain injury.
J Surg Res 2019 Nov;243:427-33. doi: 10.1016/j.jss.2019.05.053..
Keywords: Elderly, Sex Factors, Adverse Events, Hospitalization, Brain Injury
Stolldorf DP, Schnipper JL, Mixon AS
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, the investigators evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.
AHRQ-funded; HS025486.
Citation: Stolldorf DP, Schnipper JL, Mixon AS .
Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study.
BMJ Open 2019 Nov 2;9(11):e030834. doi: 10.1136/bmjopen-2019-030834.
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Keywords: Medication, Quality Improvement, Hospitals, Medication: Safety, Patient Safety, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Implementation
Lewkowitz AK, Rosenbloom JI, Lopez JD
Association between stillbirth at 23 weeks of gestation or greater and severe maternal morbidity.
Researchers conducted this retrospective cohort study to estimate whether stillbirth at 23 weeks of gestation or more is associated with increased risk of severe maternal morbidity compared with live birth, when stratified by maternal comorbidities. Data from HCUP’s Florida State Inpatient Database was used. The researchers found that, although severe maternal morbidity is overall uncommon, delivering a stillborn fetus at 23 weeks of gestation or greater is associated with increased likelihood of severe maternal morbidity, particularly among women with comorbidities. They conclude that health care providers must be vigilant about severe maternal morbidity during stillbirth delivery.
AHRQ-funded; HS019455.
Citation: Lewkowitz AK, Rosenbloom JI, Lopez JD .
Association between stillbirth at 23 weeks of gestation or greater and severe maternal morbidity.
Obstet Gynecol 2019 Nov;134(5):964-73. doi: 10.1097/aog.0000000000003528..
Keywords: Healthcare Cost and Utilization Project (HCUP), Pregnancy, Maternal Care, Women, Adverse Events
Lambert BL, Galanter W, Liu KL
Automated detection of wrong-drug prescribing errors.
Investigators assessed the specificity of an algorithm designed to detect look-alike/sound-alike (LASA) medication prescribing errors in electronic health record (EHR) data. They found that automated detection of LASA medication errors is feasible and can reveal errors not currently detected by other means. Additionally, real-time error detection is not possible with the current system. They suggested that further development should replicate their analysis in other health systems and on a larger set of medications and should decrease clinician time spent reviewing false-positive triggers by increasing specificity.
AHRQ-funded; HS021093.
Citation: Lambert BL, Galanter W, Liu KL .
Automated detection of wrong-drug prescribing errors.
BMJ Qual Saf 2019 Nov;28(11):908-15. doi: 10.1136/bmjqs-2019-009420..
Keywords: Adverse Drug Events (ADE), Adverse Events, Clinical Decision Support (CDS), Electronic Health Records (EHRs), Health Information Technology (HIT), Medical Errors, Medication, Patient Safety
Leeds IL, DiBrito SR, Canner JK
Cost-benefit limitations of extended, outpatient venous thromboembolism prophylaxis following surgery for Crohn's disease.
This goal of this study was to assess the cost-effectiveness of extended prophylaxis in patients with Crohn's disease after abdominal surgery. A decision tree model was used to assess cost-effectiveness and cost-per-case averted with extended-duration venous thromboembolism prophylaxis following abdominal surgery. Results showed that extended prophylaxis in patients with Crohn's disease postoperatively is not cost-effective when the cumulative incidence of posthospital thrombosis remains less than 4.9%. These findings are driven by the low absolute risk of thrombosis in this population and the considerable cost of universal treatment.
AHRQ-funded; HS024547.
Citation: Leeds IL, DiBrito SR, Canner JK .
Cost-benefit limitations of extended, outpatient venous thromboembolism prophylaxis following surgery for Crohn's disease.
Dis Colon Rectum 2019 Nov;62(11):1371-80. doi: 10.1097/dcr.0000000000001461..
Keywords: Prevention, Digestive Disease and Health, Surgery, Healthcare Costs, Adverse Events, Patient Safety, Blood Clots, Shared Decision Making, Medication
Fritz BA, Cui Z, Zhang M
Deep-learning model for predicting 30-day postoperative mortality.
The currently available prediction tools using summaries of intraoperative data are limited by their inability to reflect shifting risk associated with intraoperative physiological perturbations. In this study the investigators sought to compare similar benchmarks to a deep-learning algorithm predicting postoperative 30-day mortality. They concluded that a deep-learning time-series model improved prediction compared with models with simple summaries of intraoperative data.
AHRQ-funded; HS024581.
Citation: Fritz BA, Cui Z, Zhang M .
Deep-learning model for predicting 30-day postoperative mortality.
Br J Anaesth 2019 Nov;123(5):688-95. doi: 10.1016/j.bja.2019.07.025..
Keywords: Adverse Events, Health Information Technology (HIT), Mortality, Risk, Surgery
Allen JA, Reiter-Palmon R, Kennel V, et al.
Group and organizational safety norms set the stage for good post-fall huddles.
In this study, the investigators explored group and organizational safety norms as antecedents to meeting leader behaviors and achievement of desired outcomes in a special after-action review case-a post-fall huddle. Findings indicated that organizational and group safety norms related to perceived huddle meeting effectiveness through appropriate huddle leader behavior in a partial mediated framework.
AHRQ-funded; HS024630; HS021429.
Citation: Allen JA, Reiter-Palmon R, Kennel V, et al..
Group and organizational safety norms set the stage for good post-fall huddles.
J Leadersh Organ Stud 2019 Nov;26(4):465-75. doi: 10.1177/1548051818781820..
Keywords: Adverse Events, Falls, Organizational Change, Patient Safety
Yarrington ME, Anderson DJ, Dodds Ashley E
Impact of FDA black box warning on fluoroquinolone and alternative antibiotic use in southeastern US hospitals.
This study’s objective was the quantify the effect of the 2016 FDA “black box” update on the use of fluoroquinolone antibiotics among a cohort of southeastern US hospitals. Fluoroquinolone was given a black box warning after many serious adverse events were reported. Antibiotic use data from 29 southeastern US hospitals over a 5-year period was analyzed. Fluoroquinolone use declined both and before after the FDA advisory update in 2016.
AHRQ-funded; HS023866.
Citation: Yarrington ME, Anderson DJ, Dodds Ashley E .
Impact of FDA black box warning on fluoroquinolone and alternative antibiotic use in southeastern US hospitals.
Infect Control Hosp Epidemiol 2019 Nov;40(11):1297-300. doi: 10.1017/ice.2019.247..
Keywords: Antibiotics, Medication, Practice Patterns, Healthcare Utilization, Hospitals, Adverse Drug Events (ADE), Adverse Events
Mathis MR, Duggal NM, Likosky DS
Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery.
In this study, the authors hypothesized that a bundled intraoperative protective ventilation strategy was independently associated with decreased odds of pulmonary complications after cardiac surgery. They identified an intraoperative lung-protective ventilation bundle as independently associated with pulmonary complications after cardiac surgery. Their findings offer insight into components of protective ventilation associated with adverse outcomes and may serve as targets for future prospective interventional studies investigating the impact of specific protective ventilation strategies on postoperative outcomes after cardiac surgery.
AHRQ-funded; HS022535.
Citation: Mathis MR, Duggal NM, Likosky DS .
Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery.
Anesthesiology 2019 Nov;131(5):1046-62. doi: 10.1097/aln.0000000000002909..
Keywords: Adverse Events, Cardiovascular Conditions, Patient Safety, Respiratory Conditions, Surgery
Crossnohere NL, Richardson DR, Reinhart C
Side effects from acute myeloid leukemia treatment: results from a national survey.
Acute myeloid leukemia (AML) is experiencing a therapeutic renaissance due to the heightened biomedical understanding of AML and patient-focused drug development (PFDD). Many AML patients now live long-term with the side effects of treatment. This study documents the prevalence and severity of AML treatment-related side effects. This study documents the prevalence and severity of AML treatment-related side effects.
AHRQ-funded; HS000032.
Citation: Crossnohere NL, Richardson DR, Reinhart C .
Side effects from acute myeloid leukemia treatment: results from a national survey.
Curr Med Res Opin 2019 Nov;35(11):1965-70. doi: 10.1080/03007995.2019.1631149..
Keywords: Adverse Drug Events (ADE), Adverse Events, Cancer, Medication, Quality of Life
Goswami E, Ogden RK, Bennett WE
Evidence-based development of a nephrotoxic medication list to screen for acute kidney injury risk in hospitalized children.
This paper describes an initiative to develop an evidence-based list of nephrotoxic medications to screen for acute kidney injury (AKI) risk in hospitalized children. This initiative, called the Nephrotoxic Injury Negated by Just-in-time Action quality improvement collaborative, convened a Nephrotoxic Medication (NTMx) Subcommittee composed of pediatric nephrologists, a pharmacist, and a pediatric intensivist. The committee reviewed NTMx lists, conducted a literature review of the disputed medications, and assigned an evidence grade based on the association between nephrotoxicity and the quality of the data. The subcommittee then came to a majority consensus to which medications should be included on the list. The list was presented to the larger collaborative and voted on. This list will be continually updated and voted on annually.
AHRQ-funded; HS023763.
Citation: Goswami E, Ogden RK, Bennett WE .
Evidence-based development of a nephrotoxic medication list to screen for acute kidney injury risk in hospitalized children.
Am J Health Syst Pharm 2019 Oct 30;76(22):1869-74. doi: 10.1093/ajhp/zxz203..
Keywords: Children/Adolescents, Medication: Safety, Medication, Patient Safety, Risk, Evidence-Based Practice, Adverse Drug Events (ADE), Adverse Events
Adelman JS, Applebaum JR, Southern WN
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
Researchers assessed the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and examined the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). They found that multiple-birth status in the NICU is associated with significantly increased risk of wrong-patient orders compared with singleton-birth status. Strategies to reduce this risk include using given names at birth, changing from temporary to given names when available, and encouraging parents to select names for multiple births before they are born when acceptable to families.
AHRQ-funded; HS024538.
Citation: Adelman JS, Applebaum JR, Southern WN .
Risk of wrong-patient orders among multiple vs singleton births in the neonatal intensive care units of 2 integrated health care systems.
JAMA Pediatr 2019 Oct 10;173(10):979-85. doi: 10.1001/jamapediatrics.2019.2733..
Keywords: Newborns/Infants, Intensive Care Unit (ICU), Adverse Drug Events (ADE), Adverse Events, Medication: Safety, Medication, Patient Safety, Electronic Prescribing (E-Prescribing), Health Information Technology (HIT)
Qi AC, Peacock K, Luke AA
Associations between social risk factors and surgical site infections after colectomy and abdominal hysterectomy.
The purpose of this study was to determine whether social risk factors, including race/ethnicity, insurance status, and neighborhood income, were associated with higher rates of surgical site infections (SSI) after colectomy or abdominal hysterectomy, 2 surgical procedures for which SSI rates are publicly reported and included in pay-for-performance programs by Medicare and other groups. The investigators report that inconsistent associations between social risk factors and SSIs were found.
AHRQ-funded; HS019455.
Citation: Qi AC, Peacock K, Luke AA .
Associations between social risk factors and surgical site infections after colectomy and abdominal hysterectomy.
JAMA Netw Open 2019 Oct 2;2(10):e1912339. doi: 10.1001/jamanetworkopen.2019.12339..
Keywords: Healthcare Cost and Utilization Project (HCUP), Risk, Surgery, Healthcare-Associated Infections (HAIs), Injuries and Wounds, Adverse Events, Social Determinants of Health
Mixon AS, Kripalani S, Stein J
An on-treatment analysis of the MARQUIS study: interventions to improve inpatient medication reconciliation.
This paper examined evidence-based interventions implemented in five US hospitals to improve inpatient medication reconciliation. The sites implemented one to seven interventions in 791 patients during a 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful reconciliation rates while two interventions were associated with significant increases. The positive interventions included: defining clinical roles and responsibilities, training, and hiring staff to perform discharge medication reconciliation. The negative interventions were training staff to take medication histories and implementing a new electronic health record (EHR) system.
AHRQ-funded; HS019598.
Citation: Mixon AS, Kripalani S, Stein J .
An on-treatment analysis of the MARQUIS study: interventions to improve inpatient medication reconciliation.
J Hosp Med 2019 Oct;14(10):614-17. doi: 10.12788/jhm.3308..
Keywords: Medication, Evidence-Based Practice, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Hospitals, Healthcare Delivery, Inpatient Care
Fung VC, Overhage LN, Sylvia LG
Complex polypharmacy in bipolar disorder: side effect burden, adherence, and response predictors.
Investigators assessed the associations between complex polypharmacy (CP), adherence, and side effect burden, and patient traits associated with clinical improvement in relationship to CP in patients with bipolar disorder. They found that bipolar disorder patients with CP were less likely to adhere to therapy, and those with worse adherence to CP were less likely to clinically respond. They recommended that clinicians assess medication adherence prior to adding another agent to medication regimens.
AHRQ-funded; HS019371.
Citation: Fung VC, Overhage LN, Sylvia LG .
Complex polypharmacy in bipolar disorder: side effect burden, adherence, and response predictors.
J Affect Disord 2019 Oct 1;257:17-22. doi: 10.1016/j.jad.2019.06.050..
Keywords: Adverse Drug Events (ADE), Adverse Events, Medication, Behavioral Health, Chronic Conditions, Patient Adherence/Compliance