National Healthcare Quality and Disparities Report
Latest available findings on quality of and access to health care
Data
- Data Infographics
- Data Visualizations
- Data Tools
- Data Innovations
- All-Payer Claims Database
- Healthcare Cost and Utilization Project (HCUP)
- Medical Expenditure Panel Survey (MEPS)
- AHRQ Quality Indicator Tools for Data Analytics
- State Snapshots
- United States Health Information Knowledgebase (USHIK)
- Data Sources Available from AHRQ
Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (2)
- Adverse Events (4)
- Care Coordination (3)
- Children/Adolescents (3)
- Chronic Conditions (1)
- Communication (3)
- Education: Patient and Caregiver (1)
- Elderly (5)
- Healthcare-Associated Infections (HAIs) (3)
- Healthcare Delivery (2)
- Health Information Technology (HIT) (4)
- Health Literacy (2)
- Home Healthcare (1)
- (-) Hospital Discharge (23)
- Hospitalization (3)
- Hospital Readmissions (2)
- Hospitals (7)
- Injuries and Wounds (1)
- Inpatient Care (1)
- Intensive Care Unit (ICU) (1)
- Labor and Delivery (1)
- Long-Term Care (2)
- Maternal Care (1)
- Medical Errors (2)
- Medical Liability (1)
- Medication (7)
- Medication: Safety (5)
- Mortality (1)
- Nursing Homes (3)
- Opioids (1)
- Outcomes (1)
- (-) Patient Safety (23)
- Patient Self-Management (2)
- Provider (1)
- Provider: Pharmacist (1)
- Quality Improvement (1)
- Quality of Care (2)
- Risk (2)
- Surgery (1)
- Transitions of Care (11)
- Workflow (1)
AHRQ Research Studies
Sign up: AHRQ Research Studies Email updates
Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 23 of 23 Research Studies DisplayedSchnipper JL, Reyes Nieva H, Yoon C
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
The objective of this study was to assess the association of patient exposure to system-level intervention and receipt based on the results of the second Multicenter Medication Reconciliation Quality Improvement Study, which demonstrated a marked reduction in medication discrepancies per patient. Researchers conducted an on-treatment analysis of system-level interventions at 17 North American hospitals. The patient-level interventions most associated with discrepancy reductions were receipt of a best-possible medication history of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were also associated with a minor reduction in discrepancies for the average patient. The researchers concluded that these findings might be used to help hospitals and health systems prioritize interventions to improve medication safety during care transitions.
AHRQ-funded; HS023757.
Citation: Schnipper JL, Reyes Nieva H, Yoon C .
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.
BMJ Qual Saf 2023 Aug; 32(8):457-69. doi: 10.1136/bmjqs-2022-014806..
Keywords: Medication, Medication: Safety, Quality Improvement, Quality of Care, Patient Safety, Hospital Discharge
Shannon EM, Mueller SK, Schnipper JL
Patient, caregiver, and clinician experience with a technologically enabled pillbox: a qualitative study.
The purpose of this study was to explore whether medication safety could be improved by the use of a technologically-enabled pillbox prescribed to patients at hospital discharge. The study included semi-structured telephone interviews with patients, patient caregivers, and inpatient and outpatient clinicians who participated in the Smart Pillbox Transition Study. The researchers utilized the Systems Engineering Initiative for Patient Safety (SEIPS) framework to develop an interview guide, which included the a priori domains of 1) barriers to implementation, 2) facilitators of the intervention, and 3) general feedback regarding experience with the intervention. The study found patient-endorsed barriers in the theme of technology and tools included signal issues, inappropriate alarms, and portability. Barriers in the theme of logistics and tasks included coordination with pharmacists in the event of a prescription change. Barriers mentioned by clinicians included patients who were poor fits for the intervention and competing demands at discharge (under the themes of personnel and patients, and logistics and tasks, respectively). Facilitators that were reported often by patients and caregivers in the theme of technology and tools included useful alarms and ease of use. Clinicians reported that communication with pharmacy and study staff facilitated the intervention.
AHRQ-funded.
Citation: Shannon EM, Mueller SK, Schnipper JL .
Patient, caregiver, and clinician experience with a technologically enabled pillbox: a qualitative study.
ACI Open 2023 Jul; 7(2):e61-e70..
Keywords: Medication, Health Information Technology (HIT), Patient Self-Management, Hospital Discharge, Medication: Safety, Patient Safety
Bourgoin A, Balaban R, Hochman M
AHRQ Author: Perfetto D, Hogan EM
Improving quality and safety for patients after hospital discharge: primary care as the lead integrator in postdischarge care transitions.
The purpose of this study was to explain primary care-based transition workflow processes for hospitalized patients. The researchers conducted interviews with primary care thought leaders, staff at 9 primary care sites, community agency staff, and recently discharged patients. The researchers found that primary care postdischarge workflows vary across the different settings, rarely include communications with the patient or the inpatient team during the hospitalization and vary widely across settings. The researchers recommended the use of principles for primary care practices to encourage active participation in the full spectrum of postdischarge care, from admission through the first postdischarge visit to primary care.
AHRQ-authored; AHRQ-funded; 233201500019I/HHSP23337002T.
Citation: Bourgoin A, Balaban R, Hochman M .
Improving quality and safety for patients after hospital discharge: primary care as the lead integrator in postdischarge care transitions.
J Ambul Care Manage 2022 Oct-Dec;45(4):310-20. doi: 10.1097/jac.0000000000000433..
Keywords: Quality of Care, Patient Safety, Hospital Discharge, Transitions of Care, Hospitals, Workflow
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
Arbaje AI, Werner NE, Kasda EM
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
This study used malpractice claims data to evaluate safety risks during care transitions from hospital to home and to help develop care transitions planning tools and pilot test them. The authors analyzed closed malpractice claims for 230 adult patients discharged from 4 hospital sites. Two structured focus groups were also conducted for stakeholders to review concerns. This led to the development of two care transitions planning tools – one for patients/caregivers and one for healthcare providers. Feasibility on 53 patient discharges were tested for both tools. A total of 33 risk factors corresponding to hospital work system elements, care transitions processes, and care outcomes were found using qualitative analysis. Providers found the tool easy to use and patients felt the length and response of the tool was acceptable.
AHRQ-funded; HS022916; HS019519.
Citation: Arbaje AI, Werner NE, Kasda EM .
Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.
J Patient Saf 2020 Mar;16(1):52-57. doi: 10.1097/pts.0000000000000238.
.
.
Keywords: Medical Liability, Transitions of Care, Risk, Hospital Discharge, Hospitals, Patient Safety
Hoffman GJ, Min LC, Liu H
Role of post-acute care in readmissions for preexisting healthcare-associated infections.
Researchers examined the risk of preexisting healthcare-associated infections (HAIs) readmissions according to patient discharge disposition and comorbidity level. They found that skilled nursing facility discharges were associated with fewer avoidable readmissions for preexisting HAIs compared with home discharges. They recommended further research to identify modifiable mechanisms to improve posthospital infection care at home.
AHRQ-funded; HS025838; HS025451.
Citation: Hoffman GJ, Min LC, Liu H .
Role of post-acute care in readmissions for preexisting healthcare-associated infections.
J Am Geriatr Soc 2020 Feb;68(2):370-78. doi: 10.1111/jgs.16208..
Keywords: Healthcare-Associated Infections (HAIs), Hospital Readmissions, Hospital Discharge, Hospitals, Patient Safety, Elderly
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
Campbell Britton M, Hodshon B, Chaudhry SI
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
This study focused on increasing better communication during transfers from hospitals and skilled nursing facilities (SNFs). Warm handoffs between hospital and SNF physicians was implemented. Participation in warm handoffs gradually increased – starting at 15.78% in stage 1 and increasing to 46.89% in stage 3. A total of 2417 patient discharges were included in this study.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Hodshon B, Chaudhry SI .
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
J Patient Saf 2019 Sep;15(3):198-204. doi: 10.1097/pts.0000000000000529..
Keywords: Communication, Patient Safety, Hospital Discharge, Transitions of Care, Care Coordination, Hospitals, Nursing Homes
Auger KA, Shah SS, Davis MM
Counting the ways to count medications: the challenges of defining pediatric polypharmacy.
Polypharmacy, the practice of taking multiple medications to manage health conditions, is common for children. Polypharmacy has been linked to a variety of pediatric and adult outcomes, including medication errors and readmission. In this paper, the authors sought consensus on how to count discharge medications through a series of informal interviews with hospitalists, nurses, and parents.
AHRQ-funded; HS024735.
Citation: Auger KA, Shah SS, Davis MM .
Counting the ways to count medications: the challenges of defining pediatric polypharmacy.
J Hosp Med 2019 Aug;14(8):506-07. doi: 10.12788/jhm.3213..
Keywords: Children/Adolescents, Medication, Medication: Safety, Patient Safety, Hospital Discharge, Hospitals
Glick AF, Brach C, Yin HS
AHRQ Author: Brach C
Health literacy in the inpatient setting: implications for patient care and patient safety.
This article considers how health literacy plays a part in events that lead up to children's hospitalizations both during hospital admission and after discharge. The authors discussed interventions that incorporate health-literacy-informed strategies and that target patients, families, and health care systems that should be implemented to improve patient outcomes and patient-centered and family-centered care.
AHRQ-authored.
Citation: Glick AF, Brach C, Yin HS .
Health literacy in the inpatient setting: implications for patient care and patient safety.
Pediatr Clin North Am 2019 Aug;66(4):805-26. doi: 10.1016/j.pcl.2019.03.007..
Keywords: Children/Adolescents, Health Literacy, Hospital Discharge, Hospitalization, Hospitals, Inpatient Care, Patient Safety
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
Arbaje AI, Hughes A, Werner N
Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.
The goal of this study was to identify information management (IM) process failures made during home health visits to middle-aged and older adults after hospital discharge. Communication risks included information overload, information underload, information scatter, information conflict, and erroneous information.
AHRQ-funded; HS022916.
Citation: Arbaje AI, Hughes A, Werner N .
Information management goals and process failures during home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge: a multisite, qualitative study.
BMJ Qual Saf 2019 Feb;28(2):111-20. doi: 10.1136/bmjqs-2018-008163..
Keywords: Elderly, Home Healthcare, Hospital Discharge, Patient Safety, Transitions of Care
Statile AM, Unaka N, Auger KA
Preparing from the outside looking in for safely transitioning pediatric inpatients to home.
In this editorial, the authors discuss a paper by Rehm, et al. published in 2018 in Journal of Hospital Medicine entitled “Issues Identified by Post-Discharge Contact after Pediatric Hospitalization: A Multi-site Study.”
AHRQ-funded; HS024735.
Citation: Statile AM, Unaka N, Auger KA .
Preparing from the outside looking in for safely transitioning pediatric inpatients to home.
J Hosp Med 2018 Apr;13(4):287-88. doi: 10.12788/jhm.2935..
Keywords: Children/Adolescents, Hospital Discharge, Hospitalization, Patient Safety, Transitions of Care
Kerstenetzky L, Birschbach MJ, Beach KF
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
The authors of this study report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to skilled nurse facilities and long term care pharmacy staff.
AHRQ-funded; HS021984.
Citation: Kerstenetzky L, Birschbach MJ, Beach KF .
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
Res Social Adm Pharm 2018 Feb;14(2):138-45. doi: 10.1016/j.sapharm.2016.12.013..
Keywords: Adverse Drug Events (ADE), Hospital Discharge, Hospitals, Long-Term Care, Medical Errors, Medication, Medication: Safety, Nursing Homes, Patient Safety, Transitions of Care
Broecker M, Ponto K, Tredinnick R
SafeHOME: promoting safe transitions to the home.
This paper introduces the SafeHome Simulator system, a set of immersive Virtual Reality Training tools and display systems to train patients in safe discharge procedures in captured environments of their actual houses. The aim is to lower patient readmission by significantly improving discharge planning and training. The SafeHOME Simulator is a project currently under review.
AHRQ-funded; HS022548.
Citation: Broecker M, Ponto K, Tredinnick R .
SafeHOME: promoting safe transitions to the home.
Stud Health Technol Inform 2016;220:51-4.
.
.
Keywords: Transitions of Care, Health Information Technology (HIT), Patient Safety, Patient Self-Management, Hospital Discharge
Werner NE, Gurses AP, Leff B
Improving care transitions across healthcare settings through a human factors approach.
This article describes how a systems' approach known as Human Factors and Ergonomics can complement and further strengthen efforts to improve care transitions.
AHRQ-funded; HS022916.
Citation: Werner NE, Gurses AP, Leff B .
Improving care transitions across healthcare settings through a human factors approach.
J Healthc Qual 2016 Nov/Dec;38(6):328-43. doi: 10.1097/jhq.0000000000000025.
.
.
Keywords: Healthcare Delivery, Provider, Hospital Discharge, Patient Safety, Transitions of Care
Parriott AM, Arah OA
Patient volumes and pre- and postdischarge postpartum infection: a retrospective cohort study.
The researchers examined the association between hospital and clinician obstetric volume and postpartum infection risk in the pre- and postdischarge periods. They found that hospital obstetric volume is positively associated with predischarge postpartum infections, whereas clinician volume may be negatively associated with those predischarge infections.
AHRQ-funded; HS000046.
Citation: Parriott AM, Arah OA .
Patient volumes and pre- and postdischarge postpartum infection: a retrospective cohort study.
Am J Infect Control 2016 Jan;44(1):30-5. doi: 10.1016/j.ajic.2015.08.018.
.
.
Keywords: Healthcare-Associated Infections (HAIs), Hospital Discharge, Labor and Delivery, Maternal Care, Patient Safety
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
Kennelty KA, Chewning B, Wise M
Barriers and facilitators of medication reconciliation processes for recently discharged patients from community pharmacists' perspectives.
The objectives of this study were to: 1) examine the barriers and facilitators community pharmacists face when reconciling medications for recently discharged patients; and 2) identify pharmacists’ preferred content and modes of information transfer regarding updated medication information for recently discharged patients. It found that major individual-level factors affecting the medication reconciliation process included: pharmacists’ perceived responsibility, relationships, patient perception of pharmacist, and patient characteristics.
AHRQ-funded; HS021984.
Citation: Kennelty KA, Chewning B, Wise M .
Barriers and facilitators of medication reconciliation processes for recently discharged patients from community pharmacists' perspectives.
Res Social Adm Pharm 2015 Jul-Aug;11(4):517-30. doi: 10.1016/j.sapharm.2014.10.008..
Keywords: Hospital Discharge, Medication, Patient Safety, Provider: Pharmacist
Mueller SK, Giannelli K, Boxer R
Readability of patient discharge instructions with and without the use of electronically available disease-specific templates.
The investigators examined the impact of the use of electronic, patient-friendly, templated discharge instructions on the readability of discharge instructions provided to patients at discharge. They concluded that the use of electronically available templated discharge instructions may be a viable option to improve the readability of written material provided to patients at discharge, although the library of available templates requires expansion.
AHRQ-funded; HS023331.
Citation: Mueller SK, Giannelli K, Boxer R .
Readability of patient discharge instructions with and without the use of electronically available disease-specific templates.
J Am Med Inform Assoc 2015 Jul;22(4):857-63. doi: 10.1093/jamia/ocv005.
.
.
Keywords: Education: Patient and Caregiver, Health Literacy, Hospital Discharge, Patient Safety
Liao JM, Roy CL, Eibensteiner K
Lost in transition: discrepancies in how physicians perceive the actionability of the results of tests pending at discharge.
Effective communication of pending hospital test results between inpatient and primary care physicians is sometimes challenging or nonexistent. This communication is essential for safe, quality transactions at discharge. Health information technology (such as email and fax) is an effective strategy for improving and reporting test-result management.
AHRQ-funded; HS018229
Citation: Liao JM, Roy CL, Eibensteiner K .
Lost in transition: discrepancies in how physicians perceive the actionability of the results of tests pending at discharge.
J Hospital Med. 2014 Jun;9(6):407-9. doi: 10.1002/jhm.2177..
Keywords: Communication, Care Coordination, Health Information Technology (HIT), Hospital Discharge, Patient Safety
Wagner J, Gabler NB, Ratcliffe SJ
Outcomes among patients discharged from busy intensive care units.
This study of 155 U.S. intensive care units (ICUs) found that when their capacities are strained, triage decisions seem to be affected such that patients are discharged from the ICU more quickly, and have slightly greater odds of being readmitted to the ICU. However, short-term patient outcomes are unaffected.
AHRQ-funded; HS018406
Citation: Wagner J, Gabler NB, Ratcliffe SJ .
Outcomes among patients discharged from busy intensive care units.
Ann Intern Med. 2013 Oct 1;159(7):447-55. doi: 10.7326/0003-4819-159-7-201310010-00004..
Keywords: Intensive Care Unit (ICU), Patient Safety, Outcomes, Hospital Discharge, Mortality
Clancy CM
AHRQ Author: Clancy CM
New hospital readmission policy links financial and quality incentives.
This article describes AHRQ-related projects to reduce hospital readmissions, including Porject RED (Re-Engineered Discharge), Project BOOST (Better Outcomes for Older adults through Safe Transitions), and Patient Safety Organizations (PSOs).
AHRQ-authored.
Citation: Clancy CM .
New hospital readmission policy links financial and quality incentives.
J Nurs Care Qual 2013 Jan-Mar;28(1):1-4. doi: 10.1097/NCQ.0b013e3182725d82.
.
.
Keywords: Elderly, Hospital Discharge, Patient Safety, Hospital Readmissions, Transitions of Care