Research Activities, December 2009: Research Briefs

Research Briefs

*Clancy, C. (2009). "Building the path to high-quality care." HSR: Health Services Research 44(1), pp. 1-4. Reprints (AHRQ Publication No. 09-R090) are available from the AHRQ Publications Clearinghouse.

Recent assessments of health care quality consistently reflect a substantial and persistent gap between high-quality evidence-based care and that which is routinely delivered, according to the director of the Agency for Healthcare Research and Quality. She discusses two studies in this issue of the journal on the science of improvement. The first study reported on the outcome of a multifaceted intervention to improve pain management for elderly patients with hip fractures. The second study focused on the organizational costs of a depression care quality improvement program. The work described in these studies is far more challenging than some traditional research areas because it requires effective engagement with policymakers, clinicians, health care leaders, and patients, notes the author. She encourages investments in improvement methods, new approaches to training, and demonstrations.

*Donihi, A. C., Weber, R. J., Sirio, C. A., and others (2009). "Instructional design and assessment. An advanced pharmacy practice experience in inpatient medication education." (AHRQ grant HS15851). American Journal of Pharmaceutical Education 73(1), pp. 1-6.

This report describes how a multidisciplinary medication education program was modified to include pharmacy students in providing medication education to high-risk patients. The program, called the Enhanced Patient Safety Intervention to Optimize Medication Education (EPITOME), had already been implemented in a 674-bed academic hospital but time constraints made it difficult for pharmacists to provide a meaningful education experience for the patients. After consultation, hospital and pharmacy school staff proposed an Inpatient Medication Education advanced pharmacy practice experience. Students were trained to independently assess patients' needs and identify drug-related problems. Under supervision by clinical staff pharmacists, they provided medication education and performed medication therapy management. In the first 3 months of the program, more than twice as many patients were assessed than in the 3 months prior to the program.

*Facco, F., You, W., and Grobman, W. (2009, June). "Genetic thrombophilias and intrauterine growth restriction: A meta-analysis." (AHRQ grant T32 HS00078). Obstetrics and Gynecology 113(6), pp. 1206-1216.

Pregnant women who suffer from blood disorders that cause excessive clotting (thrombophilias) are sometimes given blood thinning medication to prevent intrauterine growth restriction (IUGR). IUGR is a term used to describe a fetus that is smaller than normal (below the 10th percentile for a given gestational age), a condition associated with fetal death and long-term illnesses, including cardiovascular disease. The authors performed a literature review for three inherited thrombophilitic mutations: homozygous or heterozygous factor V Leiden, prothrombin G20210A mutations, and homozygous methylenetetrahydrofolate reductase (MTHTR) C677T mutation. For the 19 studies that were included in the meta-analysis, they found no clear association between inherited thrombophilias and IUGR. The findings of statistically significant associations between IUGR and two of the mutations (MTHTR and Factor V Leiden) appeared to be influenced by publication bias in case-control studies.

*Friedman, B., Encinosa, W., Jiang, H. J., and Mutter, R. (2009, May). "Do patient safety events increase readmission?" Medical Care 47(5), pp. 1-8. Reprints (AHRQ Publication No. 09-R051) are available from the AHRQ Publications Clearinghouse.

The effects of patient safety events in hospitals on readmissions have rarely been analyzed. The researchers examined nine types of patient safety events developed by AHRQ's Healthcare Cost and Utilization Project. These safety problems ranged from postoperative sepsis to health care-associated infections. The study included nearly 1.5 million surgery patients from 1,088 short-stay hospitals. Hospitalized patients who experienced one or more events that jeopardized their safety had a 3-month readmission rate of 25 percent (compared with 17 percent for patients with no safety events). The study also found that patients experiencing a safety event had a higher in-hospital death rate (9.2 percent vs. 1.3 percent for patients with no safety events). Two safety events, pulmonary embolism/deep vein thrombosis and accidental puncture or laceration, had the highest event rates, with large patient populations at risk for these events.

*Gallagher, T.H. (August 2009). "Clinical Crossroads: A 62-year-old woman with skin cancer who experienced wrong-site surgery." (AHRQ grant HS16097). Academic Medicine 84(8), pp. 1135-1143.

A case of wrong-site surgery for skin cancer served as the framework for a discussion of medical error and its disclosure to the patient by the surgeon and the hospital. The case, in which a woman had skin adjacent to her squamous cell carcinoma removed instead of the cancerous skin, is put into a larger context by the author. He notes that while medication errors are relatively common (approximately 3 per 1,000 prescription orders), wrong-site surgeries are relatively rare. A study published in 2006 of 2.8 million U.S. operations uncovered only 25 wrong-site surgeries, a rate of 1 error per 112,994 operations. Only one of these errors was associated with permanent injury. The error was apparent to the patient as soon as she removed the bandages, and her doctor and the hospital administration made themselves available to apologize for the error and discuss possible compensation. The author reviews the state of error disclosure in U.S. hospitals, discussing studies that suggest that error disclosure can reduce lawsuits and the amount of damages if a suit goes to trial. He summarizes the barriers to disclosure and potential solutions—as well as recent developments in disclosure undertaken by Federal agencies, universities, and national quality organizations.

*Gerhard, T., Chavez, B., Olfson, M., and Crystal, S. (2009). "National patterns in the outpatient pharmacological management of children and adolescents with autism spectrum disorder." (AHRQ grant HS16097). Journal of Clinical Psychopharmacology 29 (3), pp. 307-310.

The authors characterize national trends and patterns in the outpatient pharmacological management of children and adolescents with autism spectrum disorder (ASD). Ten years of data (1996-2000, 2001-2005) from the National Ambulatory Medical Care Survey and the outpatient portion of the National Hospital Ambulatory Medical Care Survey were analyzed. During the study period, annual nonadult ASD visits per 100,000 people increased from 168 in 1996-2000 to 543 in 2001-2005. During this latter period, visits were made by patients who were overwhelmingly male, white, and non-Hispanic, with a mean age of 10.6 years. Over this same period, the proportion of ASD visits with psychotropic prescriptions significantly increased from 39 percent to 79 percent. Stimulants, antidepressants, and antipsychotics were the most commonly prescribed medications. The mean number of psychotropic medication classes prescribed at a given visit was 2.4. Almost one-half of visits reported a comorbid mental disorder, often a disruptive behavioral disorder (30 percent). A limitation of this study is that it cannot determine to what extent psychotropic medications are being prescribed for ASDs or the codiagnosed mental disorders.

*Glance, L. G., Osler, T. M., Mukamel, D. B., and Dick, A. W. (2009). "Grading intensive care unit performance—Does one size fit all?" (AHRQ grant HS16737). Critical Care Medicine 37(8), pp. 2479-2480.

It is impossible to compare the performance of intensive care units (ICUs) without accounting for differences in inpatient case mix, assert these authors. They comment on another article in the issue by Nathanson and colleagues that explored whether the quality ranking of ICUs in the Project IMPACT database changes when subgroup models based on the Mortality Probability Models (MPM-III), but customized to specific subgroups of patients (e.g., trauma, neurosurgical patients), are used for risk adjustment instead of a single general MPM-III. They found that the use of subgroup models yields virtually identical observed-to-expected mortality rates, irrespective of whether MPM-III or subgroup models based on MPM-III are used to assess overall ICU quality. Outside the ICU, where the use of a single risk adjustment model for diverse surgical procedures may lack face validity, separate risk-adjustment models can be used to estimate the expected mortality rates for patients undergoing high-risk procedures. The observed and expected mortality rates could be aggregated together to jointly produce a hospital quality metric for several high-risk procedures. The work of Nathanson, et al. suggests a simple solution to the problem caused by small sample sizes for patient populations outside the ICU.

*Hellinger, F. J. (2009, February). "Tax-exempt hospitals and community benefits: A review of state reporting requirements." Journal of Health Politics, Policy and Law 34(1), pp. 37-61. Reprints (AHRQ Publication No. 09-R048) are available from the AHRQ Publications Clearinghouse.

The Internal Revenue Service (IRS) has made major changes in its reporting requirements for tax-exempt hospitals starting this year. Hospitals must now submit detailed information on the percentage of total expenses attributable to charity care, unreimbursed Medicaid costs, and community health improvement programs. The researcher summarizes information from 16 States that already have laws requiring hospitals to place a monetary value on community benefits they provide. Under these various State laws, hospitals appear to have no trouble quantifying such things as charity and uncompensated care. These should be easily reportable on the newly redesigned IRS Form 990 for 2009 tax returns submitted. Other services, such as health promotion and disease prevention programs, are more difficult to quantify. In order to keep their Federal tax exemption, not-for-profit hospitals will have to submit a detailed Schedule H as part of Form 990. State officials will use these data to set guidelines for determining if community-benefit levels are large enough to justify exclusion from State taxes.

*Ito, K., Hollenberg, J. P., and Charlson, M. E. (2009). "Using the osteoporosis self-assessment tool for referring older men for bone densitometry: A decision analysis." (AHRQ grant T32 HS00066). Journal of the American Geriatric Society 57, pp. 218-224.

As the U.S. population ages, men are developing osteoporosis and related fractures, which cost an estimated $4.1 billion in 2005. Since osteoporosis in men is rarely identified and treated, the researchers compared the health benefits and costs of three screening strategies for 70-year-old community-dwelling white men with no history of osteoporotic fractures: no bone densitometry, selective bone densitometry using the Osteoporosis Self-Assessment Tool (OST), and universal bone densitometry screening. They calculated that selective bone densitometry using the OST would cost $100,000 per additional life year gained, compared with no bone densitometry. Universal bone densitometry would cost $483,500 for additional life year gained, compared with selective bone densitometry. They concluded that a reasonably cost-effective strategy is to stratify 70-year-old men for osteoporosis risk using a questionnaire (OST), perform bone densitometry to diagnose osteoporosis only for the high-risk group (OST score of -2 or less), and then give men diagnosed with osteoporosis generic alendronate, an antiosteoporotic medication.

*Kitahata, M. M., Gange, S. J., Abraham, A. G., and others (2009, April 20). "Effect of early versus deferred antiretroviral therapy for HIV on survival." (AHRQ Contract No. 290-01-0012). New England Journal of Medicine 360(18), pp. 1815-1826.

The availability of antiretroviral medications to treat HIV infection has done much to reduce disease progression and death among patients. Yet when to start treatment remains uncertain. Current guidelines recommend starting therapy for asymptomatic patients with CD4+ cell counts (a marker of how well the immune system is performing) of less than 350 cells per cubic millimeter. The researchers studied a total of 17,517 asymptomatic patients with HIV infection in the U.S. and Canada. In the first analysis, among the 8,362 patients who had CD4+ cell counts of 351 to 500 cells per cubic millimeter, those who deferred therapy until their CD4+ cell count fell below the range had a 60 percent greater risk of death than patients who began therapy while in the range. In a second analysis, the 76 percent of patients who deferred therapy until their CD4+ cell counts fell below 500 had a 94 percent greater risk of death than those who began therapy at a count above 500. The researchers suggest starting antiretroviral therapy even earlier (when CD4+ cell count is higher) to improve survival in patients with HIV infection.

*Levtzion-Korach, O., Alcalai, H., Orav, E. J., and others (2009, March). "Evaluation of the contributions of an electronic web-based reporting system: Enabling action." (AHRQ grant HS11046). Journal of Patient Safety 5(1), pp. 9-15.

Incident reporting represents a key tool in safety improvement. The researchers sought to characterize a Web-based reporting system by evaluating the rate and content of the incident reports and their consequent actions and followup. The system they studied was implemented at a large urban hospital, where 14,179 reports were submitted over a 31-month period. Researchers looked at the frequency of reporting, severity of patient harm, location in the hospital, followup actions, and ease of reporting. Most reports involved laboratory results (30.4 percent), followed by medications (17.2 percent), and falls (10.9 percent), among others. Personnel found the system easy to use and submitted most reports within 24 hours. The majority of reports (70 percent) were reviewed by an average of four people within 72 hours. As a result of the system, a number of actions were implemented to facilitate and improve patient safety hospital-wide. The researchers concluded that this Web-based hospital reporting system effectively captured patient safety incidents, the actions taken in response, and the followup.

*Likosky, D. S. (2009). "Optimizing multi-center perfusion data." (AHRQ grant HS15663). The Journal of ExtraCorporeal Technology 41, pp. P7-P10.

This commentary provides some insight on how to optimize the quality of a multicenter registry and how to ensure that perfusion data collected through such a consortium may be perfected and used effectively. The key principles discussed are the quality of datasets, the use of the data to inform practice, and developing and maintaining social capital. To ensure the quality of the dataset, the author emphasizes the importance of involving frontline teams in developing and defining variables. To effectively use data to inform clinical practice, the registry consortium should focus on understanding the root cause of variability in key processes of care. To develop and maintain social capital, each of the units in every medical center in the consortium should participate in all facets of the consortium, including social events. Although the discussion focuses on the structure and function of the Perfusion Down Under Consortium to maximize the opportunity to improve the quality of care delivered to a specific patient population, these principles are applicable to any perfusion registry.

*Likosky, D. S. (2009). "An epidemiologist's review of the case for pulsatile flow during cardiopulmonary bypass." (AHRQ grant HS15663). The Journal of ExtraCorporeal Technology 41, pp. P30-P32.

During cardiopulmonary bypass (CPB), continuous rather than pulsatile flow has been used since it is technologically easier to accomplish. However, pulsatile flow has many inherent and theoretical advantages over continuous flow. Although ample reviews have focused on addressing the efficacy and effectiveness of pulsatile flow in the setting of CPB, few have focused their attention on critically appraising the methodology of the literature. Using a previously published review article by Alghamdi and Latter on pulsatility with respect to patients undergoing elective coronary artery bypass grafting procedures, the author focuses on sample size and statistical power as it relates to pulsatile flow. The author mostly agrees with the reviewers' analysis of the eight articles meeting the review's inclusion criteria. However, he identifies either inadequate sample size or inadequate statistical power in these studies, which can prevent knowing whether the reported findings of the relationship between pulsatile flow and the outcomes of mortality, myocardial infarction, stroke, and renal failure are real or chance-related.

*Likosky, D. S. (2009). "Forming a research question from a multi-center database." (AHRQ grant HS15663). The Journal of ExtraCorporeal Technology 41, pp. P33-P36.

The author highlights the principles for formulating a research question from an existing multicenter consortium, the Northern New England Cardiovascular Disease Study Group (NNECDSG). The author first describes the general process which the NNECDSG uses to translate ideas to research questions. This process includes the sorts of questions that must be addressed, the review of the peer-reviewed literature, and the series of steps (meetings, conference calls) taken to solicit critique, feedback, and general comments. He also stresses the importance of considering questions of sample size and statistical power during the development of the project, and not just at the end. The author then describes the steps taken and the results achieved when the group sought to determine whether a survival benefit exists from the use of an intra-aortic balloon pump. His conclusion is that the model he describes is generalizable and applicable to the formulation and execution of sound observational studies.

*Miller, E. K., Edwards, K. M., Weinberg, G. A., and others (2009, January). "A novel group of rhinoviruses is associated with asthma hospitalizations." (AHRQ grant HS13833). Journal of Allergy and Clinical Immunology 123(1), pp. 98-104.

Human rhinoviruses (HRVs) can cause a variety of respiratory tract infections in children and are linked to asthma episodes in adults and children. A third group of HRVs, called group C (HRVC), has been identified. Researchers sought to determine how HRVC affected disease among young hospitalized children. They studied 1,123 children admitted to hospitals during a 2-year period. All had either respiratory symptoms or fever. Out of 1,052 viral samples tested, 167 were positive for HRVs. HRVC accounted for at least half of all HRV-associated illnesses, particularly asthma. Older children with HRVs were more likely to have HRVCs. Children with Group C strains tended to have underlying high-risk conditions (41.6 percent) compared with children with Group A strains (23.4 percent). More HRVC strains were detected in October, compared with more HRVA strains detected in April. This may explain the seasonal peak in asthma hospitalizations during the month of September.

*Napoles, A. M., Gregorich, S. E., Santoyo-Olsson, J., and others (2009, August). "Interpersonal processes of care and patient satisfaction: Do associations differ by race, ethnicity, and language?" (HS10599). HSR: Health Services Research 44(4), pp. 1326-1344.

This study sought to explore whether patient satisfaction differed among blacks, English- and Spanish-speaking Latinos, and whites. The researchers interviewed 1,664 adult general medicine patients from 9 university-based practices in San Francisco staffed by general internists, family medicine physicians, and nurse practitioners. The survey related the effects of seven interpersonal processes of care (IPC) on three measures of patient satisfaction (satisfaction with health care, satisfaction with physician, and whether the patient would recommend the physician to family or friends). Among Spanish-speaking Latinos (but not for the other three groups) lack of clarity was significantly and negatively related to satisfaction with physicians and health care. The association of four IPC scales (lack of clarity, explained results, compassionate/respectful, and disrespectful staff) with the two global satisfaction measures (satisfaction with health care and satisfaction with physician) differed by race/ethnicity, suggesting that some interpersonal processes may be more important to patients from some groups than others.

*Selden, T. M. (2009, June). "The within-year concentration of medical care: Implications for family out-of-pocket expenditure burdens." Health Services Research 44(3), pp. 1029-1051. Reprints (AHRQ Publication No. 09-R070) are available from the AHRQ Publications Clearinghouse.

Researchers and policymakers often use annual out-of-pocket expenses to describe the burden U.S. families face in affording health care. Using 2003 and 2004 AHRQ Medical Expenditure Panel Survey data, the author found that nearly half of all families' medical care occurred within a single month, and 63 percent happened in a single quarter. Accompanying the surge in care use was an upswell in expenses, so that 27 percent of families had at least 1 month in which their out-of-pocket expenses totaled more than 20 percent of their incomes. Low-income families were especially vulnerable to these cost surges, because they were unlikely to have ample savings or extra money each month to allot for a payment plan. These findings suggest that viewing care use within the year, and not annually, gives a more realistic view of the financial pressures that families face in paying for surges in medical expenses.

*Selden, T. M., Kenney, G. M., Pantell, M. S., and Ruhter, J. (2009, July-August). "Cost sharing in Medicaid and CHIP: How does it affect out-of-pocket spending?" Health Affairs 28(4), pp. w607-w619. Reprints (AHRQ Publication No. 09-R072) are available from the AHRQ Publications Clearinghouse.

In 2007, many States increased the premiums and copayments charged for health care received by children insured by the Children's Health Insurance Program (CHIP). To determine the effect of increased cost-sharing arrangements, the researchers developed cost scenarios using data from AHRQ's Medical Expenditure Panel Survey. They found that parents would struggle with high out-of-pocket costs and financial burdens if premiums or copayments were increased for their children covered by CHIP. This burden would force many families to choose between pursuing medical care for their children or facing financial hardship. Cost-sharing arrangements may seem attractive to policymakers grappling with ways to reduce public spending. However, because half of the publicly insured children in the study were poor, even modest increases in cost-sharing arrangements would be burdensome for their families. Implementing caps on out-of-pocket spending, which are generally set at 5 percent of family income, can help address the spending burden for low-income families without reducing potential budgetary savings, the authors suggest.

*Smith, R. C., Gardiner, J. C., Luo, Z., and Rost, K. (2009, April). "The diagnostic accuracy of predicting somatization from patients' ICD diagnoses." (AHRQ grant HS14206). Psychosomatic Medicine 71(3), pp. 366-371.

Somatization is defined as having physical symptoms with little or no documented basis in underlying organic disease; when organic disease exists, the symptoms are inconsistent with or out of proportion to it. An earlier study had shown that ICD-9 diagnostic codes and other data from the administrative database (ADB) could identify somatization. In this study, the researchers sought to identify somatization in a new population through ADB screening based on increasing numbers of visits, female gender, and greater percent of ICD-9 primary diagnosis codes in musculoskeletal, nervous, gastrointestinal, and ill-defined body systems. All patients selected were 18-65 years old, enrolled in a staff-model HMO, with at least eight visits per year for the each of the 2 years prior to the study. Of the 1,364 patients studied, 319 who were high utilizers (12.8 visits per year) met the criterion standard for somatization. The somatizers differed in age, gender, total visits, and somatization potential.

*Tebb, K. P., Wibbelsman, C., Neuhaus, J. M., and Shafer, M. (2009, June). "Screening for asymptomatic chlamydia infections among sexually active adolescent girls during pediatric urgent care." (AHRQ grant HS10537). Archives of Pediatric and Adolescent Medicine 163(6), pp. 559-564.

Untreated Chlamydia trachomatis (CT) infections can lead to pelvic inflammatory disease, ectopic pregnancy, and infertility. Since most of these infections have no symptoms, routine screening is the only way to detect the majority of CT cases. Despite recommendations for annual screenings, screening rates remain low among all sexually active adolescents and young adults under 26 years of age. In a large California HMO, a team of providers and clinic staff redesigned their clinic system to improve CT screening during urgent care. As a result of the intervention, the change in the proportions of adolescent girls screened for CT in urgent care increased by almost 16 percent in the five intervention clinics compared with a decrease of over 2 percent in the comparison clinics. The intervention stressed patient confidentiality, education, and followup about the CT test results. It also addressed processes such as specimen collection, storage, and delivery.

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Research Activities, December 2009: Research Briefs