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Research Activities, January 2012: Research Briefs
Alexander, C. (2011). "Seeding trials and the subordination of science." (AHRQ grant HS18996). Archives of Internal Medicine 171(12), pp. 1107-1108.
A seeding trial is a study of an approved drug or device in which the primary objective is marketing, not scientific investigation. Such trials necessarily depend on deception, according to the author. The author comments in detail on an article analyzing a trial of the drug Neurontin, which concludes that the trial was actually a seeding trial used to promote and increase the prescribing of the drug.
Austad, K.E., Avorn, J., and Kesselheim, A.S. (2011, May). "Medical students' exposure to attitudes about the pharmaceutical industry: A systematic review." (AHRQ grant HS18465). PLoS Medicine 8(5) online.
Given the controversy over the pharmaceutical industry's role in undergraduate medical training, synthesizing the current state of knowledge is useful for setting priorities for changes to educational practices. A systematic review of 32 studies concerning the frequency and nature of medical students' exposure to the drug industry found that a substantial proportion of students believe that gifts from industry influence prescribing.
Bracha, Y., Brottman, G., and Carlson, A. (2011). "Physicians, guidelines, and cognitive tasks." (AHRQ Contract No. 290-2006-00020). Evolution and the Health Professions 34(3), pp. 310-335.
This article compares the workflows and knowledge requirements of primary care practice to a set of clinical guidelines, Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Treatment of Asthma, a summary report prepared by the authors for the Agency for Healthcare Research and Quality. It finds discrepancies between the physician workflow and the structure of the EPR-3 and suggests that alternative ways be found to represent guidelines' knowledge and recommendations.
Burda, B.U., Norris, S.L, Holmer, H.K., and others (2011). "Quality varies across clinical practice guidelines for mammography screening in women aged 40-49 years as assessed by AGREE and AMSTAR instruments." (AHRQ grant HS18500). Journal of Clinical Epidemiology 64, pp. 968-976.
This study assessed the quality of clinical practice guidelines for mammography screening for breast cancer in asymptomatic average-risk women 40-49 years of age. It found that among the eleven guidelines appraised, the quality varies considerably. Also, more than one-half of these guidelines have poor-quality evidence reviews and are not recommended for use in practice.
Clancy, C. (2011). "Best practices in systems interventions to reduce the burden of fractures." Osteoporosis International 22(Suppl 3), pp. S441-S444. Reprints (AHRQ Publication No. 12-R008) are available from the AHRQ Publications Clearinghouse.
In a keynote address to the 2010 Bone Health Conference, Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality (AHRQ), discusses some medical care encounters and relates them to various aspects of the Agency's work. She discusses AHRQ's comparative effectiveness research, the Patient-centered Outcomes Research Institute, the scientific infrastructure needed to identify and implement effective systems-based interventions, and the National Health Care Quality Strategy.
Cohen, S.B., Ezzati-Rice, T.M., Zodet, M., and others (2011). "An assessment of the impact of two distinct survey design modifications on health care utilization estimates in the Medical Expenditure Panel Survey." Journal of Economic and Social Measurement 36, pp. 33-69. Reprints (AHRQ Publication No. 12-R004) are available from the AHRQ Publications Clearinghouse.
In 2007, the Medical Expenditure Panel Survey was upgraded to a windows-based Computer Assisted Personal Interview platform and a sample redesign as a result of its linkage to the National Health Interview Survey. This study examined the impact of these survey design modifications on the national estimates of health care utilization patterns.
Croswell, J.M., Kramer, B.S., and Crawford, E.D. (2011, May). "Screening for prostate cancer with PSA testing: Current status and future directions." Oncology 25(6), pp. 1-15. Reprints (AHRQ Publication No. 12-R009) are available from the AHRQ Publications Clearinghouse.
Screening for prostate cancer by prostate-specific antigen (PSA) testing has been advocated as a means of reducing mortality from this disease. However, the best quality evidence currently available suggests that PSA screening for prostate cancer is either ineffective at reducing deaths due to prostate cancer, or confers a modest mortality advantage, but at the cost of an important degree of overdiagnosis and overtreatment.
Curtis, J.R., Delzell, E., Chen, L., and others (2011). "The relationship between bisphosphonates adherence and fracture: Is it the behavior or the medication? Results from the placebo arm of the fracture intervention trial." (AHRQ grant HS16956). Journal of Bone and Mineral Research 26(4), pp. 683-688.
Several studies have reported a strong inverse relation between high compliance with oral bisphosphonates and fracture risk. Among women participating in the Fracture Intervention Trial who were randomized to placebo, there were no significant associations between compliance with placebo and fractures. However, high compliance with placebo was associated with total-hip bone loss and a similar trend was observed for changes in femoral neck bone mineral density.
Daly, J.M., Ely, J.W., Levy, B.T., and others (2011). "Primary care clinicians' perspectives on management of skin and soft tissue infections: An Iowa research network study." Journal of Rural Health 27, pp. 319-328.
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is resistant to several commonly used antibiotics and that resistance is increasing. Analysis of a series of 9 focus groups conducted with 78 primary care clinicians found that no well-accepted diagnostic or treatment algorithms were used by physicians attending the focus groups. The clinicians in the study noted that there was considerable confusion and inconsistency in the management of skin and soft tissue infections.
Edwardsen, E.A., Horwitz, S.H., Pless, N.A., and others (2011, June). "Improving identification and management of partner violence: Examining the process of academic detailing: A qualitative study." (AHRQ grant HS11490). BMC Medical Education 11(36), pp.10-14.
Many physicians still do not routinely inquire about intimate partner violence (IPV). After receiving a seven-session modular curriculum over a 10 week period from a non-physician academic detailer, three physicians reported increased clarity with regard to the scope of their responsibility to their patients suffering from IPV. Academic detailing may improve physician attitudes and practices towards patients in violent relationships.
Fagnan, L.J., Dorr, D.A., Davis, M., and others (2011). "Turning on the care coordination switch in rural primary care. Voices from the practices—clinician champions, clinician partners, administrators, and nurse care managers." (AHRQ Contract No. 290-07-10016). Journal of Ambulatory Care Management 34(30), pp. 304-318.
Implementing care coordination to improve chronic illness care faces monumental challenges. This qualitative analysis explored convergence and divergence in perceptions among the four practice cohorts (clinician champions, clinicians, administrators, and nurse care managers) regarding implementation of nurse care management in medium to large rural primary care practices. Based on their analysis of interviews with the different cohorts, the researchers identified seven factors needed to assure the overall success of a care coordination program.
Gadd, C.S., Ho, Y.-X., Cala, C.A., and others (2011). "User perspectives on the usability of a regional health information exchange." (AHRQ Contract No. 290-04-0006). Journal of the Medical Informatics Association 18, pp. 711-716.
The need for electronic health records with information from multiple sites has steadily grown since 1990. The study used a rapid deployment model to develop a health information exchange (HIE). By surveying HIE users, the researchers found that three usability factors were positively predictive of system usage: overall reactions, learning, and system functionality.
Handley, M.A., Shillinger, D., and Shihoski, S. (2011, October). "Quasi-experimental designs in practice-based research settings: Design and implementation considerations." (AHRQ grant HS17261). Journal of the American Board of Family Medicine 24(5), pp. 589-596.
In the area of practice-based research (PBR), quality improvement, and public health, there are many situations where randomization is not possible. The researchers present a review of design features and practical considerations for PBR implementation of the stepped-wedge and wait-list design. They also discuss published examples from studies of clinic-based interventions using these designs. These features allow for the collection of control data, but also permit all participants to receive the intervention.
Haukoos, J.S. (2011, July). "Rethinking how we perform HIV testing in the emergency department." (AHRQ grant HS17526). Annals of Emergency Medicine 58(1), S160-S163.
The author's goals are to briefly summarize a conceptual framework for performing HIV testing in emergency departments (EDs) and to discuss what is generally known about how these approaches work in clinical practice, with an emphasis on the performance of nontargeted opt-out screening. He also provides a few focused thoughts about how to proceed with the evaluation and implementation of ED-based HIV testing both in terms of clinical practice and academic development.
Hayes, H., Parchman, M.L., and Howard, R. (2011, September/October). "A logic model framework for evaluation and planning in a primary care practice-based research network (PBRN)." Journal of the American Board of Family Medicine 24(5), pp. 576-582.
A logic model is a framework for describing the relationships between resources, activities, and results as they relate to a specific program or project goal. The purpose of this article is to describe the development of a logic model and how the framework has been used in a primary care practice-based research network, the South Texas Ambulatory Research Network.
Johnson, K.B., Unertl, K.M., Chen, Q., and others (2011). "Health information exchange usage in emergency departments and clinics: The who, what, and why." (AHRQ Contract No. 290-04-006). Journal of the American Medical Informatics Association 18, pp. 690-697.
The Mid-South eHealth Alliance is an operational health information exchange (HIE). The study evaluates this exchange to characterize the extent and patterns of use as they relate to different HIE workflows, and to inform the national discussion about both HIE implementation strategies and usage benchmarks. Its data should form an important foundation as other sites embark upon HIE implementation.
Kahn, J.M., Hill, N.S., Lilly, C.M., and others (2011, July). "The research agenda in ICU telemedicine." (AHRQ grant HS19946). Chest 140(1), pp. 230-238.
The Critical Care Societies Collaborative convened a working group to provide a conceptual and practical framework for intensive care unit (ICU) telemedicine research. It included experts in critical care delivery, telemedicine delivery, organizational science, health services research, and health care policy. The goals were to examine the state of the science underlying ICU telemedicine, identify key methodological and knowledge gaps, and develop a focused agenda for future research.
Kamalian, S., Maas, M.B., Goldmacher, G.V., and others (2011). "CT cerebral blood flow maps optimally correlate with admission diffusion-weighted imaging in acute stroke but thresholds vary by postprocessing platform." (AHRQ grant HS11392). Stroke 42, pp. 1923-1928.
The purposes of this study were to: (1) determine the optimal computed tomography perfusion parameter to define infarct core using various postprocessing platforms; and (2) establish the degree of variability in threshold values between these different platforms. The researchers found that the marked variability in quantification among different postprocessing software limits generalizability of parameter map thresholds between platforms.
Kappelman, M.D., Dorn, S.D., Peterson, E., and others (2011). "Quality of care for gastrointestinal conditions: A primer for gastroenterologists."(AHRQ grant HS19468). American Journal of Gastroenterology 106, pp. 1182-1187.
The authors review current efforts to measure and improve the quality of care for digestive diseases, with a focus on colonoscopy, inflammatory bowel diseases, gastroesophageal reflux disease, chronic hepatitis C virus infection, and liver transplantation. Incorporation of quality improvement principles into clinical practice will ultimately be needed to improve care and outcomes for patients with these diseases.
Kauffmann, R.M., Landman, M.P., Shelton, J., and others (2011, July/August). "The use of a multidisciplinary morbidity and mortality conference to incorporate ACGME general competencies." (AHRQ grant HS13833). Journal of Surgical Education 68(4), pp. 303-308.
The Department of Surgery at Vanderbilt University Medical Center implemented a multidisciplinary morbidity and mortality (MM&M) conference as a means to establish a culture of safety, while teaching the Accreditation Council of Graduate Medical Education General Competencies to surgery residents. The results discussed in this paper are largely qualitative in nature and describe the process of implementing an MM&M conference.
Kudyakov, R., Bowen, J., Ewen, E., and others (2011, August). "Electronic health record use to classify patients with newly diagnosed versus preexisting type 2 diabetes: Infrastructure for comparative effectiveness research and population health management." (AHRQ Contract No. 290-05-00361). Population Health Management 14. (E-pub ahead of print).
The authors describe a practical approach to identifying a cohort of newly diagnosed type 2 diabetes cases in an electronic health record (EHR). The EHR has advantages over administrative data and prospective clinical trials as a data source for comparative effectiveness research and population management. However, use of data from current systems mandates significant tailoring for application in research. Verifications of EHR data with external data sources is a high-yield step.
Leach, C.R., Schoenberg, N.E., and Hatcher, J. (2011). "Factors associated with participation in cancer prevention and control studies among rural Appalachian women." (AHRQ grant HS16347). Family and Community Health 34(2), pp. 119-125.
In terms of their cancer burden, underserved populations, including minorities and rural residents, tend to be underrepresented in cancer prevention and control research. The two case studies discussed here demonstrate certain overlapping as well as distinctive strategies that can be used to deal with barriers to recruitment and retention of rural participants in research studies.
Loit, E., Tricco, A.C., Tsouros, S., and others (2011). "Pre-analytic and analytic sources of variations in thiopurine methyltransferase activity measurement in patients prescribed thiopurine-based drugs: A systematic review." (AHRQ Contract No. 290-2007-10059). Clinical Biochemistry 44, pp. 754-757.
The authors' review summarizes the evidence regarding thiopurine methyltransferase (TPMT) testing in chronic autoimmune disease. Their review showed that sufficient pre-analytical data were available to recommend preferred specimen collection, stability, and storage conditions for determination of TPMT status. There was no clinically significant effect on TPMT activity of age, gender, various co-administered drugs, or most morbidities.
Meddings, J., and Saint, S. (2011). "Disrupting the life cycle of the urinary catheter." (AHRQ grant HS19767). Clinical Infectious Diseases 52(11), pp. 1291-1293.
Tackling unnecessary urinary catheter use is certainly the most important goal in preventing catheter-associated urinary tract infection. However, kicking the catheter habit can be difficult. The authors discuss an article by Knoll, et al. in this issue describing a 5-year hospital-wide "catheter quit program," which is similar in its successes and challenges to aspects of other habit-changing programs such as treating an addiction to tobacco.
Meyers, D. (2011). "A tribute to Dr. David Lanier." Journal of the American Board of Family Medicine 24(5), pp. 494-495. Reprints (AHRQ Publication No. 12-R011) are available from the AHRQ Publications Clearinghouse.
Dr. David Meyers, director of the Agency for Healthcare Research and Quality's (AHRQ) Center for Primary Care, pays tribute to David Lanier, M.D., on the occasion of his retirement from AHRQ in December 2010. Over the past decade, Dr. Lanier provided visionary leadership as he designed, implemented, and nurtured AHRQ's primary care Practice-based Research Networks.
Murray, D.J. (2011, May). "Current trends in simulation training in anesthesia." (AHRQ grant HS18374). Minerva Anesthesiologica 77, pp. 528-533.
Simulation includes a number of devices and technologies that, when used in training, offer the potential to accelerate the acquisition of skills and expand the breadth of a trainee's clinical experiences. The purpose of this review is to highlight some of the more recent studies that have advanced simulation-based training and assessment strategies, with particular emphasis on those studies that either describe the results of a curriculum intervention or provide insight about the future uses of simulation.
Navathe, A.S., Clancy, C., and Glied, S. (2011). "Advancing research data infrastructure for patient-centered outcomes research." Journal of the American Medical Association 306(11), pp. 1254-1255. Reprints (AHRQ Publication No. 12-R013) are available from the AHRQ Publications Clearinghouse.
Much of patient-centered outcomes research relies on observational and quasi-experimental methods applied to data generated as a byproduct of providing care. While existing data sources have improved, there remain important data-related barriers to rapid, efficient research. The latest developments in information technology (virtual data access and distributed data network technologies) can help create an efficient data infrastructure supporting patient-centered care.
Newcomer, S.R., Steiner, J.F., and Bayliss, E.A. (2011). "Identifying subgroups of complex patients with cluster analysis." (AHRQ grant HS15476). American Journal of Managed Care 17(8), pp. e324-e332.
Cluster analyses are common in psychology and sociology, but have been used to a limited extent in health services research, mainly to discover patterns of multimorbidities. This study demonstrated the application of such methods for identifying clusters of patients with high health care utilization that may suggest opportunities for enhanced care management in a managed care setting.
Ritchie, C.S., Roth, D.L., and Allman, R.M. (2011). "Living with an aging parent. It was a beautiful invitation." (AHRQ grant HS 17786). Journal of the American Medical Association 306(7), pp. 746-753.
Increasing numbers of older parents are living with their adult children. Using the case of a couple receiving care from their daughter in her home, the authors review the prevalence and epidemiology of adult children caring for a parent in an adult child's home, important issues to consider, and a framework for clinicians to help guide their patients through this transition.
Sawchuk, C.N., Russo, J.E., Bogart, A., and others (2011, May). "Barriers and facilitators to walking and physical activity among American Indian elders." (AHRQ grant HS108542). Preventing Chronic Disease: Public Health Research, Practice, and Policy 8(3), pp. 1-9.
The researchers used descriptive statistics to report barriers and facilitators to walking and physical activity among older American Indians. Lack of willpower was the most commonly reported barrier. Health-related quality of life was inversely related to physical activity barriers, and poor mental health quality of life was more strongly associated with total barriers than poor physical health.
Schiff, G.D., Galanter, W.L., Duhig, J., and others (2011, July). "Principles of conservative prescribing." (AHRQ grant HS16973). Archives of Internal Medicine 171(16), pp. 1433-1440.
Prescribing is often driven by pharmaceutical marketing and by patients requesting drugs they hear advertised. To counterbalance these prescribing pressures, which include often unrealistic patient expectations, practice time constraints, and paucity of data and practical guidance, the authors (physicians, pharmacists, and educators) have identified principles for safer and more evidence-based prescribing.