Beach, M.C., Duggan, P.S., Cassel, C.K., and Geller, G. (2007). "What does 'respect' mean? Exploring the moral obligation of health professionals to respect patients." (AHRQ grant HS13903). Journal of General Internal Medicine 22, pp. 692-695.
The authors of this paper develop a concept of respect that imposes a distinct moral duty on physicians, notably the respect for patients as persons. They challenge the idea that respect for autonomy is a complete or self-sufficient respect for persons.
The authors suggest that the type of respect that physicians owe to patients is independent of a patient's personal characteristics and ought to be accorded equally to all. Finally, they promote the concept of respect as both a cognitive dimension (believing that patients have value) and a behavioral dimension (acting in accordance with this belief).
Capezuti, E., Taylor, J., Brown, H., and others (2007). "Challenges to implementing an APN-facilitated falls management program in long-term care." (AHRQ grant HS11588). Applied Nursing Research 20, pp. 2-9.
Several clinical studies have demonstrated success in reducing falls among nursing home residents. However, the degree of adherence to these strategies varies widely among studies and nursing homes, especially following the removal of external consultants or advance practice nurses (APNs).
This paper identifies contextual factors that challenged the effective implementation of a falls reduction program. For nurses, the major problem with implementing the program involved inadequate nursing assessment and clinical decisionmaking. APNs, who influence nursing staff behavior with education and individual resident consultation, may fill the critical gap in falls management in nursing homes, conclude the authors.
Clancy, C.M. (2007, March). "Patient safety in the intensive care unit: Challenges and opportunities." Journal of Patient Safety 3(1), pp. 6-8.
In this article, the Director of the Agency for Healthcare Research and Quality (AHRQ) describes the current challenges and opportunities for ensuring patient safety in the intensive care unit (ICU) and AHRQ-supported initiatives related to ICU safety.
One is the ICU Safety Reporting System, a voluntary, anonymous, confidential, Web-based incident reporting system that collects information about adverse and near misses by ICU clinical staff.
The Agency also collaborates with the Department of Defense to develop ICU teamwork through a training resource called TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). Other projects include one that documents ICU scheduling and errors and one that examines the use of ICU staffing with intensivists.
Reprints (AHRQ publication no. 07-R054) are available from the AHRQ Publications Clearinghouse.
Clancy, C.M., and Tornberg, D.N. (2007, May). "TeamSTEPPS: Assuring optimal teamwork in clinical settings." American Journal of Medical Quality 22(3), pp. 214-217.
This commentary describes the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program to assure optimal teamwork in clinical settings, a collaborative effort between the Agency for Healthcare Research and Quality and the Department of Defense. The program offers a flexible, evidence-based toolkit to improve patient safety through enhanced communication and other teamwork skills. Typically, TeamSTEPPS initiatives occur in three continuous phases: assessment; planning, training, and implementation; and reinforcement and sustainment.
The TeamSTEPPS program offers a multifaceted, multimedia instructional model that includes classroom teaching, PowerPoint® presentations, videos, role playing, case studies, coaching exercises, and a handy pocket guide. It promotes competency in four core areas: team leadership, situation monitoring, mutual support (backup behavior), and communication.
Reprints (AHRQ publication no. 07-R024) are available from the AHRQ Publications Clearinghouse.
Cowgill, B.O., Beckett, M.K., Corona, R., and others (2007, February). "Guardianship planning among HIV-infected parents in the United States: Results from a nationally representative sample." (AHRQ grant HS08578). Pediatrics 119(2), pp. e391-e398.
Only one-fourth of unmarried parents infected with HIV who receive health care for their condition have a legally documented plan making provisions for a guardian to their children when they die.
In an analysis of data from interviews with 222 unmarried parents, researchers found that 12 percent of unmarried HIV-infected parents had not identified a guardian; 6 percent had identified a guardian but had not discussed their wishes with the individual; 53 percent said the identified guardian had agreed, but only 28 percent had prepared legal documentation.
Without a formal guardianship plan, caregivers may not have the authority to enroll children in school or provide consent for medical procedures. Parents with the lowest CD4 counts (indicator of worse HIV disease progression) and parents living without other adults were more likely to have completed the guardianship planning process.
Curtis, J.R., Martin, C., Saag, K.G., and others (2007, March). "Confirmation of administrative claims-identified opportunistic infections and other serious potential adverse events associated with tumor necrosis factor a antagonists and disease-modifying antirheumatic drugs?" (AHRQ grant HS10389). Arthritis & Rheumatism 57(2), pp. 343-346.
Opportunistic infections such as tuberculosis have been associated with the use of tumor necrosis factor a (TNFa) antagonists such as infliximab and etanercept drugs that are increasingly used to treat rheumatoid arthritis (RA), Crohn's disease, and a variety of other inflammatory conditions.
The authors of this study used a case identification strategy that searched for one or more diagnostic codes representing adverse events (AEs) possibly associated with a TNFa antagonist use. This approach had low predictive value to identify confirmed AEs, and overestimated the rates of at least some AEs.
The researchers conclude that claims data are useful as an initial screen to identify uncommon adverse outcomes associated with TNFa antagonists and disease-modifying antirheumatic drugs. However, rare events and those requiring highly specific diagnoses need medical record confirmation as a second step to improve specificity and positive predictive value.
Ellis, R.P. and McGuire, T.G. (2007). "Predictability and predictiveness in health care spending." (AHRQ grant HS10803) Journal of Health Economics 26, pp. 45-48.
This paper reexamines the relationship between the predictability of health care spending and incentives due to adverse selection. The authors use a model of health plan decisions about service levels to show that predictability (how well spending on certain services can be anticipated), predictiveness (how well the predicted levels of certain services covary with total health care spending), and demand responsiveness all matter for adverse selection incentives. They quantify the relative magnitude of adverse selection incentives bearing on various types of health care services in Medicare to develop an index of incentives that can readily be applied to data from other payers.
Encinosa III, W.E., Gaynor, M., and Rebitzer, J.B. (2007). "The sociology of groups and the economics of incentives: Theory and evidence of compensation systems." Journal of Economic Behavior and Organization 62, pp. 187-214.
When people work together, they engage in noncontractual and informal interactions that constitute the sociology of the group. The authors of this paper use behavioral models and a unique survey of medical groups to analyze how group sociology influences physician incentive pay and behavior. They consider four possible explanations: risk aversion, income norms, effort norms, and mutual help activities.
Their findings indicate that none of these models of incentive pay can individually account for all the patterns in the data. They conclude that informal interactions among group members influence pay practices and behaviors, but the relationship is complex. The data may be consistent with a richer model in which the sociology of the group and risk aversion of individual members together determine the groups' incentive pay policy.
Reprints (AHRQ publication no. 07-R056) are available from the AHRQ Publications Clearinghouse.
Hadler, N.M., Tait, R.C., and Chibnall, J.T. (2007, April). "Back pain in the workplace." (AHRQ grant HS13087). Journal of the American Medical Association 297(14), pp. 1594-1596.
The workers' compensation system is transferring most of its largesse to provide the worker with back injury treatment tinged with racial bias, ineffective surgery, and invalid, if not fatuous, determinations of residual disability, assert the authors of this commentary. They propose an alternative view of the "injury" paradigm of backache, which views backache as an
intermittent and remittent predicament of life.
In some cases, work-related backache may be intolerable and disabling because the job is intolerable, unsatisfying, or insecure. In these cases, back "injury" may be a surrogate complaint. Such surrogate complaints might be countenanced if launching a workers' compensation claim benefitted the worker who is hurting. However, expenditures to fix the "injured" spine demand that the worker prove that the injury is disabling. This misses the central issue of backache that reflects a worker who feels stressed and undervalued.
Hughes, R.G. and Clancy, C.M. (2007, February). "Improving the quality of nursing care using the medical expenditure panel survey data." Journal of Nursing Care Quality 22(2), pp. 93-96.
This commentary describes the Medical Expenditure Panel Survey (MEPS), a national probability survey of health care use and expenses with a household component, medical provider component, and insurance component. The authors list recent findings from analyses of the MEPS that nurses can use as benchmarks to improve the delivery of health care services and patient outcomes. They point out that nurses can use the MEPS to assess specific health care conditions sensitive to nursing care when there are at least 800,000 cases of a condition per year. Nurses can also use data on the impact of expenditures on access and utilization of health care services to better understand the challenges patients encounter within the health care system.
Reprints (AHRQ publication no. 07-R055) are available from the AHRQ Publications Clearinghouse.
LaPointe, N.M., Pappas, P., Deverka, P., and Anstrom, K.J. (2007, January). "Patient receipt and understanding of written information provided with isotretinoin and estrogen prescriptions." (AHRQ grant HS10548). Journal of General Internal Medicine 22, pp. 98-101.
Medication guides (MG) and mandatory patient package inserts (MPPI) are required for prescription medications with potentially serious risks. Researchers at the Duke University Center for Education and Research on Therapeutics asked 200 patients who were taking isotretrinoin (e.g., Accutane®) and 300 patients taking estrogen to complete a telephone survey about the MG or MPPI and their understanding of the medication's risks.
Most respondents said they had confidence in their knowledge of the medication they were taking (86 percent for isotretinoin and 75 percent for estrogen). Less than half of the women taking estrogen were aware that the drug may increase their risk of heart attack, but more than half of the women were aware that estrogen may increase their risk of uterine cancer. In addition, 96 percent of patients taking isotretinoin knew it could cause birth defects.
Lee, G.M. (2007, April). "Varicella vaccination in adults: Is it cost-effective?" (AHRQ grant 13908). Clinical Infectious Diseases 44, pp. 1049-1050.
This commentary discusses the issue of whether varicella vaccination is cost-effective in adults. Although 96 percent of adults 20 to 29 years of age and 99 percent of adults 30 years and older are immune to varicella (chicken pox), those who do become infected as adults sometimes suffer serious problems. Immigrants and refugees are disproportionately susceptible to varicella compared with adults from industrialized countries.
One study of refugees and immigrants in Canada found that selective blood testing followed by vaccination of susceptible 30-year-old adults was cost-saving in base-case analysis. This approach also prevented half of congenital and neonatal varicella cases. On the basis of this and other analyses, selective serological testing of adults with a negative or uncertain history of varicella, followed by vaccination of those who are found to be susceptible, appears to be a reasonably cost-effective and perhaps even a cost-saving approach for younger adults, immigrants, and refugees, conclude the authors.
Lynn, J., Baily, M.A., Bottrell, M., and others (2007). "The ethics of using quality improvement methods in health care." (AHRQ grant HS13369). Annals of Internal Medicine 146, pp. 666-673.
Quality improvement (QI) activities can improve health care, but they must be conducted ethically, assert the authors of this paper. They describe the discussions of a group of experts who convened to address the ethical requirements for QI and their relationship to regulation protecting human subjects of research. They agreed that both clinicians and patients have an ethical responsibility to participate in QI, provided that it complies with specified ethical requirements. Most QI activities are not human subjects research and should not undergo review by an institutional review board. Rather, appropriately calibrated supervision of QI activities should be part of professional supervision of clinical practice.
McInnes, D.K., Landon, B.E., Wilson, I.B., and others (2007, May). "The impact of a quality improvement program on systems, processes, and structures in
medical clinics." (AHRQ grant HS10227). Medical Care 45(5), pp. 463-471.
This study found that a quality improvement collaborative for HIV clinics resulted in modest organizational changes. Researchers surveyed clinicians, medical directors, and HIV program administrators before and after an 18-month quality improvement collaborative at 54 intervention and 37 control clinics providing HIV care. Intervention clinics reported greater computer availability and use, attendance at more local and national conferences, and a higher rating of their leaders' ability to implement quality improvement than control clinics.
The HIV collaborative was based on a Chronic Care Model that included six core components necessary to achieve high quality chronic disease care: patient self-management support; decision support; information systems; community resources and policies; health system organization; and delivery system redesign.
Morgan, T.M., Krumholz, H.M., Lifton, R.P., and Spertus, J.A. (2007, April). "Nonvalidation of reported genetic risk factors for acute coronary syndrome in a large-scale replication study." (AHRQ grant HS11282). Journal of the American Medical Association 297(14), pp. 1551-1561.
There are numerous but inconsistent reports of genetic variants being associated with acute coronary syndromes (ACS). These authors systematically searched the literature to identify genetic variants previously reported as significant susceptibility factors for atherosclerosis or ACS. They restricted their analysis to 811 white patients with ACS at 2 Missouri hospitals. They genotyped them along with 650 age- and sex-matched controls for 85 variants in 70 genes and attempted to replicate previously reported associations. Of 85 variants tested, only 1 putative risk genotype was nominally significant. Only four additional genes were positive in model-free analysis. Their results provided no support that any of the 85 genetic variants tested is a susceptibility factor for ACS.
Pronovost, P.J., Holzmueller, C.G., Young, J., and others (2007, March). "Using incident reporting to improve patient safety: A conceptual model." (HS11902). Journal of Patient Safety 3(1), pp. 27-33.
This paper discusses the role of risk analysis and event taxonomies in patient safety reporting systems (PSRSs). It also presents a conceptual model that supports the use of reporting and analysis to help guide patient safety improvement efforts.
The authors examined methodologies being used for medical incident reports to improve patient safety. They found that PSRSs are widely recommended as a strategy to address the important problem of patient safety. Most efforts have focused on developing reporting systems and collecting incident data. The researchers outline a comprehensive conceptual model to help realize the full potential of reporting systems in patient safety improvement efforts.
Singh-Manoux, A., Gueguen, A., Martikainen, P., and others (2007, March/April). "Self-rated health and mortality: Short- and long-term associations in the Whitehall II study." (AHRQ grant HS06516). Psychosomatic Medicine 69, pp. 138-143.
How middle-aged men and women self-rate their health predicts their mortality strongly in the short term, but only weakly in the long term, according to a new Whitehall II Study, an ongoing national, long-term study of British civil servants. The study included 6,316 men and 3,035 women. Mortality rates were examined in the short term (in the first 10 years after self-rating) and long-term (more than 10 years afterwards).
Covariates included age, height and parental longevity, sociodemographics, health behaviors (tobacco and alcohol use, poor diet, low physical activity), and health (various illnesses, abnormalities, and sick days). More women reported poor or very poor health than men (7.1 vs. 3.7 percent). In nearly all cases, a decline in self-rated health was associated with increased mortality in the first 10 years. However, apart from the few men who rated their health as being "very poor," the relationship between self-rated health with long-term mortality was weaker and not significant.
Thomas, J.C., Isler, M.R., Carter, C., and Torrone, E. (2007, February). "An interagency network perspective on HIV prevention." (AHRQ grant HS10861). Sexually Transmitted Diseases 34(2), pp. 71-75.
This paper describes the network structures of agencies and individuals engaged in HIV prevention in a rural North Carolina county. The researchers interviewed participants about interactions with others in the network and examined network characteristics such as centralization and density.
The authors concluded that the HIV prevention agencies in the county were not functioning as a network, and thus were not benefiting the community to their full potential. The network of 11 agencies had an information exchange density of 14 percent. Exchanges of clients and funds were even rarer. The network of 17 individuals influential in HIV prevention was better connected, with a density of 42 percent.
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AHRQ Publication No. 07-0073
Current as of August 2007
Internet Citation:
Research Activities Newsletter. August 2007, No. 324. AHRQ Publication No. 07-0073. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/aug07/
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