National Healthcare Quality and Disparities Report
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AHRQ Research Studies Date
Topics
- (-) Adverse Events (12)
- Blood Clots (2)
- Children/Adolescents (1)
- Diagnostic Safety and Quality (2)
- Electronic Health Records (EHRs) (1)
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- Healthcare-Associated Infections (HAIs) (3)
- Healthcare Cost and Utilization Project (HCUP) (1)
- Health Information Technology (HIT) (2)
- Hospital Readmissions (1)
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- Infectious Diseases (1)
- Injuries and Wounds (1)
- Medical Errors (5)
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- Patient-Centered Outcomes Research (1)
- Patient Safety (8)
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- Public Reporting (2)
- Quality Improvement (8)
- Quality Indicators (QIs) (1)
- (-) Quality of Care (12)
- Surgery (5)
- Teams (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 12 of 12 Research Studies DisplayedShi J, Hurdle JF, Johnson SA
Natural language processing for the surveillance of postoperative venous thromboembolism.
The objective of the study was to develop a portal natural language processing approach to aid in the identification of postoperative venous thromboembolism events from free-text clinical notes. The investigators concluded that accurate surveillance of postoperative venous thromboembolism may be achieved using natural language processing on clinical notes in 2 independent health care systems. They indicated that these findings suggest natural language processing may augment manual chart abstraction for large registries such as National Surgical Quality Improvement Program.
AHRQ-funded; HS025776.
Citation: Shi J, Hurdle JF, Johnson SA .
Natural language processing for the surveillance of postoperative venous thromboembolism.
Surgery 2021 Oct;170(4):1175-82. doi: 10.1016/j.surg.2021.04.027..
Keywords: Blood Clots, Health Information Technology (HIT), Quality Improvement, Quality of Care, Surgery, Adverse Events
Zhu Y, Simon GJ, Wick EC
Applying machine learning across sites: external validation of a surgical site infection detection algorithm.
Surgical complications have tremendous consequences and costs. Complication detection is important for quality improvement, but traditional manual chart review is burdensome. Automated mechanisms are needed to make this more efficient. The purpose of the study was to understand the generalizability of a machine learning algorithm between sites; automated surgical site infection (SSI) detection algorithms developed at one center were tested at another distinct center.
AHRQ-funded; HS024532.
Citation: Zhu Y, Simon GJ, Wick EC .
Applying machine learning across sites: external validation of a surgical site infection detection algorithm.
J Am Coll Surg 2021 Jun;232(6):963-71.e1. doi: 10.1016/j.jamcollsurg.2021.03.026..
Keywords: Healthcare-Associated Infections (HAIs), Surgery, Adverse Events, Diagnostic Safety and Quality, Electronic Health Records (EHRs), Health Information Technology (HIT), Quality Improvement, Quality of Care
Aasen DM, Bronsert Rozeboom, PD
Relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned readmissions in the ACS NSQIP database.
This study looked at the relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned hospital readmissions after surgery. Data from the American College of Surgeons National Surgical Quality Improvement database from 2012 to 2017 across nine surgical specialties was used to analyze 30-day postoperative infectious complications including sepsis, surgical site infections, pneumonia, and urinary tract infections. Postoperative infectious complications were identified in 5.2% of cases, of which 59.8% were postdischarge. The specific postdischarge complications identified were 73.4% of surgical site infections, 34.9% of sepsis cases, 26.5% of pneumonia cases, and 53.2% of urinary tract infections. These postoperative infections were associated with an increased risk of readmission. Most infections were diagnosed postdischarge. The trend towards shorter length of stays postoperation also contribute to the increase in infections detected after discharge and the rate of unplanned related postoperative readmissions.
AHRQ-funded; HS026019.
Citation: Aasen DM, Bronsert Rozeboom, PD .
Relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned readmissions in the ACS NSQIP database.
Surgery 2021 Feb;169(2):325-32. doi: 10.1016/j.surg.2020.08.009..
Keywords: Hospital Readmissions, Adverse Events, Healthcare-Associated Infections (HAIs), Infectious Diseases, Quality Improvement, Quality of Care, Surgery
Marshall TL, Ipsaro AJ, Le M
Increasing physician reporting of diagnostic learning opportunities.
This study investigated methods to improve physician reporting of diagnostic errors at the pediatric division of a hospital. In that pediatric hospital medicine (PHM) division only 1 diagnostic-related safety event was reported in the preceding 4 years. The authors aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. The improvement team used the Model for Improvement and used the term diagnostic learning opportunity (DLO) with clinicians as opposed to diagnostic error to lessen the stigma. They developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. Over the course of 13 weeks, there was an increase from 0 to 1.6 per patient admission reports files. Most events (66%) were true diagnostic errors.
AHRQ-funded; HS023827.
Citation: Marshall TL, Ipsaro AJ, Le M .
Increasing physician reporting of diagnostic learning opportunities.
Pediatrics 2021 Jan;147(1). doi: 10.1542/peds.2019-2400..
Keywords: Children/Adolescents, Diagnostic Safety and Quality, Medical Errors, Adverse Events, Patient Safety, Hospitals, Quality Improvement, Quality of Care
Fernandez R, Grand JA
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
This article highlights guiding team science principles from the organizational psychology literature that can be applied to the study of teams in healthcare. The authors' goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations.
AHRQ-funded; HS020295; HS022458.
Citation: Fernandez R, Grand JA .
Leveraging social science-healthcare collaborations to improve teamwork and patient safety.
Curr Probl Pediatr Adolesc Health Care 2015 Dec;45(12):370-7. doi: 10.1016/j.cppeds.2015.10.005.
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Keywords: Patient Safety, Teams, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Okafor NG, Doshi PB, Miller SK
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
A web-based, password-protected tool was developed by members of a quality assurance committee for ED providers to report incidents that they believe could impact patient safety. The researchers found that the utilization of this system in one residency program with two academic sites resulted in an increase from 81 reported incidents in 2009, the first year of use, to 561 reported incidents in 2012.
AHRQ-funded; HS017586.
Citation: Okafor NG, Doshi PB, Miller SK .
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.
West J Emerg Med 2015 Dec;16(7):1073-8. doi: 10.5811/westjem.2015.8.27390.
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Keywords: Emergency Department, Adverse Events, Medical Errors, Patient Safety, Public Reporting, Quality of Care
Healy MA, Krell RW, Abdelsattar ZM
Pancreatic resection results in a statewide surgical collaborative.
This study sought to investigate changes over time in adverse outcomes after pancreatectomy across hospitals with different caseloads in a statewide surgical collaborative. It concluded that participation in regional quality collaboratives by lower-volume hospitals can attenuate the volume–outcome relationship for pancreatic surgery.
AHRQ-funded; HS20937; HS000053.
Citation: Healy MA, Krell RW, Abdelsattar ZM .
Pancreatic resection results in a statewide surgical collaborative.
Ann Surg Oncol 2015 Aug;22(8):2468-74. doi: 10.1245/s10434-015-4529-9..
Keywords: Surgery, Patient Safety, Adverse Events, Hospitals, Quality Improvement, Quality of Care
Durkin MJ, Dicks KV, Baker AW
Postoperative infection in spine surgery: does the month matter?
The authors evaluated for seasonal variation of surgical site infection (SSI) following spine surgery in a network of nonteaching community hospitals. They found that the rate of SSI following fusion or spinal laminectomy/laminoplasty was higher during the summer in this network of community hospitals, most likely due to S. aureus rather than the July effect.
AHRQ-funded; HS023866.
Citation: Durkin MJ, Dicks KV, Baker AW .
Postoperative infection in spine surgery: does the month matter?
J Neurosurg Spine 2015 Jul;23(1):128-34. doi: 10.3171/2014.10.spine14559.
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Keywords: Surgery, Healthcare-Associated Infections (HAIs), Injuries and Wounds, Adverse Events, Patient Safety, Hospitals, Outcomes, Quality of Care
Crane S, Sloane PD, Elder N
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
This study assessed the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them. It found that all 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 quality improvement projects based on the reports.
AHRQ-funded; HS019558.
Citation: Crane S, Sloane PD, Elder N .
Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.
J Am Board Fam Med 2015 Jul-Aug;28(4):452-60. doi: 10.3122/jabfm.2015.04.140050..
Keywords: Adverse Events, Medical Errors, Patient Safety, Primary Care, Public Reporting, Quality Improvement, Quality of Care
Singh JA, Ramachandran R
Does hospital volume predict outcomes and complications after total shoulder arthroplasty in the US?
The researchers assessed the association of hospital procedure volume for total shoulder arthroplasty (TSA) with patient outcomes and complications. They found that, compared to low volume hospitals (<5, 5–9, or 10–14 procedures annually), patients receiving TSA at higher volume hospitals (15–24 or ‡25 procedures annually) had significantly lower likelihood of being discharged to an inpatient medical facility.
AHRQ-funded; HS021110.
Citation: Singh JA, Ramachandran R .
Does hospital volume predict outcomes and complications after total shoulder arthroplasty in the US?
Arthritis Care Res 2015 May;67(6):885-90. doi: 10.1002/acr.22507..
Keywords: Patient-Centered Outcomes Research, Adverse Events, Patient Safety, Quality of Care, Healthcare Cost and Utilization Project (HCUP)
Chung JW, Ju MH, Kinnier CV
Postoperative venous thromboembolism outcomes measure: analytic exploration of potential misclassification of hospital quality due to surveillance bias.
The authors discuss problems associated with AHRQ’s Patient Safety Indicator (PS112), Postoperative Venous Thromboembolism such as identifying truly poor-quality hospitals from those that only seem to be poor-quality because of hospital-to-hospital variations in imaging rates for venous thromboembolism (VTE). They call for the development of administrative codes that enable reliable identification and exclusion of sub-clinical VTE from the measure numerator.
AHRQ-funded; HS021857
Citation: Chung JW, Ju MH, Kinnier CV .
Postoperative venous thromboembolism outcomes measure: analytic exploration of potential misclassification of hospital quality due to surveillance bias.
Ann Surg. 2015 Mar;261(3):443-4. doi: 10.1097/sla.0000000000000850..
Keywords: Quality Indicators (QIs), Blood Clots, Quality of Care, Adverse Events
Clancy C, Fraser I
AHRQ Author: Clancy C, Fraser I
High-quality health care.
This chapter describes the current state of health care quality (including avoidable harms from care); reviews selected efforts to conceptualize, measure, and improve quality; describes how measures are used to guide improvements in care; addresses promising initiatives to improve care; and predicts how the health care landscape will evolve in the coming years.
AHRQ-authored
Citation: Clancy C, Fraser I .
High-quality health care.
In: Knickman J, Kovner AR, editors. Jonas and Kovner's health care delivery in the United States. 11 ed. New York: Springer; 2015. p. 273-96..
Keywords: Quality of Care, Patient Safety, Medical Errors, Adverse Events, Quality Improvement