Baily, M.A., Bottrell, M., Lynn, J., and Jennings, B. (2006, July). "The ethics of using QI methods to improve health care quality and safety." (AHRQ grant HS13369). The Hastings Center Report 36(4), pp. S1-S40.
The authors of this report discuss the ethics of using quality improvement (QI) methods to improve health care quality and safety. They point out that QI is appropriate and vital to health care, and obligatory for both professionals and patients, but QI can pose risks to some patients. However, not undertaking QI in the face of recognized quality deficiencies in care also puts patients at risk. QI itself should be implemented ethically and low-risk QI should have the same review and standards as routine health delivery. Higher-risk QI should undergo review by an advisory group or other arrangement. Projects that are both QI and research involving human subjects should meet the review requirements for protection of human subjects in research.
Basu, J. and Friedman, B. (2006, December). "A re-examination of distance as a proxy for severity of illness and the implications for differences in utilization by race/ethnicity." Health Economics, available online at http://www.interscience.wiley.com.
This study analyzed the hospitalization patterns of elderly residents to examine whether the relation between distance traveled for care and severity of illness was uniform across racial/ethnic subgroups. The authors examined hospital discharge data for New York residents from the Healthcare Cost and Utilization Project, which they linked to other data files. They found that minorities had to be more severely ill than whites before they sought distant hospital care. However, these conclusions depended on the type of medical condition. If costly elective services were regionalized to take advantage of high volume for both cost and quality of care, some extra outreach efforts might be needed to reduce disparities in appropriate care, conclude the authors.
Reprints (AHRQ Pub No. 07-R029) are available from the AHRQ Publications Clearinghouse.
Clancy, C.M. (2006, November). "Getting to 'smart' health care." Health Affairs, pp.w589-w591 (available online at http://www.healthaffairs.org).
Comparative effectiveness research is tightly linked with health care delivery in the Information Age, notes the Director of the Agency for Healthcare Research and Quality in this paper. She points out that advances in biomedicine and health information technology present exciting opportunities to provide timely, relevant information about the comparative effectiveness of health care services. However, successful growth will require a transparent, participatory approach and new partnerships between the public and private sectors to achieve the goal of producing valid evidence for decision making.
Reprints (AHRQ Pub No. 07-R025) are available from the AHRQ Publications Clearinghouse.
Clancy, C.M. (2006, November). "Care transitions: A threat and an opportunity for patient safety." American Journal of Medical Quality 21(6), pp. 415-417.
Developing strategies to improve the care of patients during transitions from one care site to another is one of several priorities of AHRQ-supported research in 2007, notes the Director of the Agency for Healthcare Research and Quality in this paper. She points out that care transitions, or "handoffs," almost always involve passing critical medical information through multiple individuals in different settings. The Director cites an emergency department (ED) case that illustrates the oversights that can happen when a patient is transitioned from the ED to another hospital service. She also summarizes some of the more promising strategies identified by researchers for improving transitions in EDs.
Reprints (AHRQ Pub No. 07-R026) are available from the AHRQ Publications Clearinghouse.
Croyle, R.T., Barger, S.D., Loftus, E.F., and others. (2006). "How well do people recall risk factor test results? Accuracy and bias among cholesterol screening participants." (AHRQ grant HS06660). Health Psychology 25(3), pp. 425-432.
The authors of this study assessed how accurately 496 community residents recalled results of cholesterol screening 1, 3, or 6 months after screening. Only 38 percent of participants accurately recalled their exact cholesterol levels, but 89 percent correctly recalled their cardiovascular risk category. Recall errors showed a systematic bias. Individuals who received the most undesirable test results were most likely to remember their cholesterol scores and cardiovascular risk categories as lower (that is, healthier) than those actually received. The findings suggest that recall of self-relevant health information is susceptible to self-enhancement bias.
Dickison, P., Hostler, D., Platt, T.E. and Wang, H.E. (2006). "Program accreditation effect on paramedic credentialing examination success rate." (AHRQ grant HS13628). Prehospital Emergency Care 10, pp. 224-228.
In the future, only paramedics who graduate from nationally accredited paramedic programs may be eligible for national certification. This study found that students who attended an accredited paramedic program were 58 percent more likely to achieve a passing score on a national paramedic credentialing examination than those in nonaccredited programs, after accounting for other factors. The findings were based on analysis of data from 12,773 students who completed the National Registry Paramedic Certification Examination for 2002. The researchers call for studies to identify the aspects of program accreditation that lead to improved examination success.
Dinh, P. and Zhou, X-H. (2006, June). "Nonparametric statistical methods for cost-effectiveness analyses." (AHRQ grant HS13105). Biometrics 62, pp. 576-588.
Two measures often used in cost-effectiveness analysis are the incremental cost-effectiveness ratio (ICER) and the net health benefit (NHB). The authors of this article derived the Edgeworth expansions for the studentized t-statistics expansions to study the theoretical performance of existing confidence intervals based on normal theory and to derive new confidence intervals for the ICER and NHB. They conducted a simulation study to compare their new intervals with several existing methods such as Taylor's interval, Fieller's interval, the bootstrap percentile interval, and the bootstrap bias-corrected acceleration interval. They found that their new intervals gave good coverage accuracy and were narrower than the current recommended intervals.
Herman, P.M., Sherman, K.J., Erro, J.H., and others. (2006, July). "A method for describing and evaluating naturopathic whole practice." (AHRQ grant HS09565 and HS08194). Alternative Therapies in Health and Medicine 12(4), pp. 20-28.
Most research on complementary and alternative medicine (CAM) has focused on single therapies, even though CAM is generally practiced as distinct systems of medicine. This paper presents a proposed method to measure treatment criteria for three conditions (menopausal symptoms, bowel dysfunction, and fatigue/ fibromyalgia) in studies of the naturopathic medical system. The researchers defined a set of meaningful, measurable treatment criteria based on the naturopathic practice principles, which could have generated 82 to 93 percent of treatment prescriptions given at visits for these conditions. Several treatment criteria components were common across all three conditions studied and might be appropriate for all visits to doctors of naturopathy. Others were specific to each condition.
Jaana, M., Ward, M.M., Pare, G., and Sicott, C. (2006, October). "Antecedents of clinical information technology sophistication in hospitals." (AHRQ grant HS15009). Health Care Management Review 31(4), pp. 289-299.
The authors of this study developed and tested a model for assessing the organizational antecedents of hospital innovativeness with regard to clinical information technology (IT) applications. They surveyed a sample of 74 U.S. hospitals to assess 3 dimensions of clinical IT sophistication. A significant 45 to 61 percent of the variance in clinical IT sophistication was explained, mostly by leadership and knowledge-sharing capacities. In particular, IT tenure and technical knowledge resources were significantly related to clinical IT sophistication. Financial resources and structural capacity did not play an important role.
Just, S., Scheper, G., Piotrowski, M.M., and others. (2006, July). "Improving the safety of intravenous admixtures: Lessons learned from a Pentostam¨ overdose." (AHRQ grant HS11540). Journal on Quality and Patient Safety 32(7), pp. 366-372.
This article describes the case of a young soldier diagnosed with cutaneous leishmaniasis who, despite several processes in place to prevent medication errors, received a 10-fold intravenous (IV) overdose of Pentostam®, a rarely used drug. Weaknesses were identified in staff communication, quality assurance checks, and product labeling. Also, nurses and pharmacists had less than adequate information about new or unusually dosed medications. Based on the lessons learned from this case, the hospital developed a form to accompany the preparation of complex IV drugs. In addition, the pharmacy service developed information sheets for 12 high-risk drugs frequently used in IV admixtures.
Katz, D.A., Aufderheide, T.P., Bogner, M., and others. (2006, November). "The impact of unstable angina guidelines in the triage of emergency department patients with possible acute coronary syndrome." (AHRQ grant HS10466). Medical Decision Making 26, pp. 606-616.
Researchers examined triage decisions for 1,140 adults with suspected acute coronary syndrome (ACS, unstable angina or heart attack), both before and after emergency physicians were trained in use of the Agency for Healthcare Research and Quality Unstable Angina Practice Guideline. They observed no significant difference in physician triage decisions before and after the guideline intervention. Physicians' risk ratings showed superior discrimination in identifying patients with confirmed ACS compared to the guideline-defined risk groups. Physicians disagreed with the triage recommendation of the guideline algorithm 25 to 34 percent of the time. They routinely considered variables that were not included in the guideline such as tempo of angina and cardiac enzymes, which have since been incorporated into the American College of Cardiology/American Heart Association guidelines for unstable angina. Strict adherence to guideline recommendations would have resulted in hospitalizing 9 percent more non-ACS patients without lowering the rate of missed ACS. When used alone, the ACS risk groups defined by the guideline had relatively low sensitivity for identifying emergency department patients with ACS. In the very low-risk group, about 2 percent of patients had confirmed ACS.
Kaul, D.R., Flanders, S.A., Beck, J.M., and Saint, S. (2006, November). "Incidence, etiology, risk factors, and outcome of hospital-acquired fever." (AHRQ grant HS11540). Journal of General Internal Medicine 21, pp. 1184-1187.
Limited information is available to guide an evidence-based approach to hospital-acquired fever, this study concludes. The authors systematically reviewed studies on hospital-acquired fever conducted from 1970 to 2005. Of over 1,000 studies reviewed, only 7 met the criteria for inclusion. The incidence of hospital-acquired fever ranged from 2 to 17 percent and the etiology of fever was infection in 37 to 74 percent of cases. Rates of antibiotic use for patients with a noninfectious cause of fever ranged from 29 to 55 percent for a mean duration of 6.6 to 9.6 days. Studies varied widely in their methodology and the patient population studied.
Krein, S.L., Olmsted, R.N., Hofter, T.P., and others. (2006). "Translating infection prevention evidence into practice using quantitative and qualitative research." (AHRQ grant HS11540). American Journal of Infection Control 34, pp. 507-512.
There is no current reliable information about which infection prevention practices are being used in U.S. hospitals to prevent common device-related infections, note the authors of this paper. The reasons why hospitals are or are not using some preventive practices must be explored more fully in order to understand how best to translate research into practice. This paper provides a framework for proposed research to promote the successful translation of proven infection prevention practices (related to the use of urinary catheters, central venous catheters, and mechanical ventilation) to decrease healthcare-associated infections.
Raab, S.S., Grzybicki, D.M., Sudilovsky, D., and others. (2006). "Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error." (AHRQ grant HS13321). American Journal of Clinical Pathology 126, pp. 585-592.
These researchers compared the diagnostic error frequency of a thyroid aspiration service before and after implementation of error reduction initiatives consisting of adoption of a standardized diagnostic terminology scheme and an immediate specimen interpretation service. A total of 2,424 patients underwent thyroid gland fine-needle aspiration. Following terminology standardization, the false-negative rate decreased from 42 to 19 percent. The specimen nondiagnostic rate increased from 6 to 20 percent, and the sensitivity increased from 70 to 91 percent. Cases with an immediate specimen interpretation had a lower noninterpretable specimen rate than those without immediate interpretation.
Talcott, J.A., Clark, J.A., Manola, J., and Mitchell, S.P. (2006, October). "Bringing prostate cancer quality of life research back to the bedside: Translating numbers into a format that patients can understand." (AHRQ grant HS08208). The Journal of Urology 176, pp. 1558-1564.
Using symptom indexes to define levels of function produces a quality of life metric that is valid and may be more useful to patients, concludes this study. The researchers surveyed men with clinically localized prostate cancer before treatment and at several intervals thereafter. Based on the men's responses to distress measures, the authors defined three levels of function: normal—no abnormal symptom; intermediate—any abnormal symptom, but none severely abnormal; and poor—any severely abnormal symptom. They compared average symptom distress scores in patients at each symptom level and found that large differences in distress scores separated patients at successive levels in all symptom indexes. A table of 24-month outcomes, based on pretreatment symptom level and treatment, provides a useful tool for patients considering treatment choices.
Wang, M.C., Hyun, J.K., Harrison, M.I., and others. (2006, November). "Redesigning health systems for quality: Lessons for emerging practices." Journal on Quality and Patient Safety 32(11), pp. 599-611.
Successful health system redesign requires coordinating and managing a complex set of changes across multiple levels rather than isolated projects, concludes this study. The researchers analyzed interviews with 16 health care providers and researchers at organizations involved in system redesign. They also reviewed research studies and discussions from a national meeting of experts, identifying many promising and innovative examples of redesign. Providers reported four success factors as crucial in overcoming redesign barriers, ranging from directly involving top- and middle-level leaders to strategically aligning and integrating improvement efforts with organizational priorities.
Reprints (AHRQ Pub No. 07-R030) are available from the AHRQ Publications Clearinghouse.
Wetterneck, T.B., Skibinski, K.A., Roberts, T.L., and others. (2006, August). "Using failure mode and effects analysis to plan implementation of smart I.V. pump technology." (AHRQ grant HS14253). American Journal of Health Systems Pharmacy 63, pp. 1528-1538.
Misuse of intravenous (IV) pumps and other parenteral delivery systems is a common cause of medication error. A new type of IV infusion pump, the smart IV pump, has been developed to decrease pump programming errors by providing a medication dose double-check at the bedside. A drug library imbedded into the software alerts when the pump is programmed above or below the recommended drug dose limit, which can improve patient safety. However, the new pump also introduces changes to the IV pump programming process and user interaction with the pump, note the authors of this study. They found that failure mode and effects analysis can identify potential problems when users begin to use new smart IV pumps.
Zeng, F., O'Leary, J.F., Sloss, E.M., and others. (2006, October). "The effect of Medicare health maintenance organizations on hospitalization rates for ambulatory care-sensitive conditions." (AHRQ grant HS10256). Medical Care 44(10), pp. 900-906.
This study found that members of Medicare HMO plans had at least 14 percent lower hospitalization rates and fewer total inpatient days for 15 ambulatory-care-sensitive conditions (ACSCs) than members of Medicare fee-for-service (FFS) plans. Researchers estimated the effect of HMO enrollment on hospitalization for ACSCs by linking California Medicare enrollment data to State hospital discharge data for 1996. They analyzed hospitalization for ACSCs for a total of 10,488 HMO members and 11,803 FFS members. Based on a selection model, they estimated that the rate of ACSC hospitalizations among FFS beneficiaries would decline from 51.2 to 44.2 per 1,000 members and mean total inpatient days would shrink from 7.5 to 5.1 days, if all FFS beneficiaries joined an HMO. The study found no impact of Medicare HMOs on the hospitalization rate for non-ACSCs.
AHRQ Publication No. 07-0021
Current as of March 2007
Internet Citation:
Research Activities Newsletter. March 2007, No. 319. AHRQ Publication No. 07-0021. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/mar07/
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