Chapter 2. Methods
Our methods
consisted of four parts: 1) We developed a database of child health activities
(including extramural research, intramural research, conferences, meetings, workshops,
training grants, and centers); 2) We identified publications derived from and
the funding associated with these activities; 3) We sorted the activities into
categories and coded the resulting publications according to potential impact,
determined the number of times the publication had been cited, and recorded the
impact factor of the journal in which the publication had appeared; and 4) We
identified case studies and interviewed individuals associated with these case
studies along with key stakeholders. We
describe each of these in turn.
Developing the Database of Child Health Activities
There was no
single database that contained all or only children's health activities for the
entire time period under study. As a
consequence, we developed a strategy that used all available sources to
assemble the comprehensive list. This
list is included as Appendix A.8
External activities
To identify
external AHRQ funded activities related to children's health for the period of
1990 to 2005, we searched the following sources:
- AHRQ Web site, specific populations, child and
adolescent health, 9
- Funded projects, New Starts 1996-2005 pages.10 Total of 361 external activities
identified.
- Conference and Workshops links. 12 activities identified, 1 of which
also identified in New Starts—11 additional external activities.
- Child Health Insurance Research Initiative (CHIRI™).11 9 activities identified, 8 of which
also identified in New Starts—1 additional external activity.
- State Children's Health Insurance Program (SCHIP)
page.12 4 activities identified, none of which
identified through New Starts—4 additional external activities.
- Information technology and children's healthcare
(IT) page.13 8 activities identified, 6 of which
identified through New Starts—2 additional external activities.
- GOLD (which covers 1999-2006), child subcategory. Total of 141 activities identified. 6 were duplicates and 117 were identical to
activities identified in search 1, leaving 18 additional external activities.
- GOLD external research abstracts using "child" or
"adolescent" or "infant" or "pediatric" as keywords. 237 activities identified. 178 had already been identified through
search 1 or 2, leaving 59 additional external activities.
As the public
sources did not have information regarding external activities prior to 1996,
we had AHRQ search an internal database, Agency Management Information System
(AMIS) using the keywords "adolescent" or "child" or "infant" or
"pediatric." This search identified 362
external activities for the period of 1990-2004. 247 activities had already been identified
through searches 1-3, leaving 114 additional external activities.
After identifying a total of 570 unique external activities related to children's health, we applied
the following criteria:
- Include if: i) The activity has as one of its primary focuses child or adolescent
health; ii) The activity includes both children and adults in its target
population and involves a topic that directly affects child or adolescent
health (i.e., asthma or diabetes); or iii) The activity is related to pregnancy, pre-natal care or
obstetrics.
- Exclude if: i) The activity
is related to parents of children under 18 but includes no direct study of
impact on children; ii) The activity is only tangentially related to children's
health (children mentioned in the abstract but not really a focus of the study
or a part of the target population); iii) The activity is related to fertility;
iv) The activity had nothing to do with children.
Initially, one researcher
reviewed all 570 external activities using the foregoing criteria, identifying
those activities to be excluded. All the
excluded external activities were then independently reviewed by another
researcher using the same criteria. The
discrepancies between the two reviewers were resolved through a discussion with
the entire project team.
Using these criteria and
methods, we excluded 56 activities as set forth in Table 1. After the exclusions, we were left with 514
unique, includable external activities. We grouped these activities into 6 different categories: external
research (407 activities), contracts (8 activities), EPC related activities (18
activities), APA support (16 activities), conferences, meetings, workshops,
trainings (60 activities), and centers (5 activities).
Intramural activities
The only source of
information we could locate for activities by AHRQ staff was in GOLD, which is
a relatively new database that covers the time period of 1999-2006. Searching the AHRQ staff research abstracts
using the keywords "child" or "adolescent" or "infant" or "pediatric," we
identified a total of 27 unique activities. Using the same criteria as applied to the external activities, we
included 24 and excluded 3 (activities not substantially related to children's
health (2); activities only tangentially related to children's health
(1)).
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Identifying
Associated Publications
External activities
After identifying external
activities, we searched for publications or reports related to the 222 activities
initiated from 1996 to 2002. Prior to
1996, our list of activities was not comprehensive as our only source of
information was the AHRQ internal AMIS database (as opposed to 1996 and after,
where we cross-referenced activities from several sources, including the AHRQ
Web site, GOLD and AMIS). We also did not
search for publications from projects initiated after 2002, since it would be
unrealistic to expect these projects to have published all potential manuscripts
by the time of our study.
For the external research
activities funded during 1996-2002, we had originally proposed to search
PubMed® by grant number. During the
course of this evaluation, however, we discovered that AHRQ grant numbers are
not consistently reported in PubMed®. As
a result, we used a somewhat less precise method for identifying
publications. We searched PubMed® and Web
of Science using PI name (last name and first letter of first name—smith j*
[au]) and keywords from the activity description, restricting searches to the
dates after which the activity was funded. After publications were identified, we reviewed the publications for
grant numbers. If the publication had a
grant number listed, it was included if it matched the activity grant number
and the publication appeared from the abstract to be related to children's
health, and it was excluded if it did not match the activity grant number. For those publications that did not have a
grant number listed, we compared the publication abstract with the activity
description and included the publication if it seemed substantially related to
the activity and children's health. After the keyword search, we conducted an additional PubMed® search using
the PI name combined with a generic AHRQ grant number search (smith j* [au] AND
hs* [gr]). If there were any additional
publications that had a matching grant number and were related to children's
health, they were included.
From the foregoing
searches, we were unable to identify any publications for 46 of the 222
External Research Activities funded during 1996-2002. For these activities, we worked with an AHRQ
librarian who also searched, but she ultimately did not find any additional publications.
For the activities
listed as contracts, Evidence-based Practice Centers (EPC) related activities, Ambulatory
Pediatrics Association (APA) support, conference, meetings, workshops,
training, and centers, we used the search engine on the AHRQ Web site to find
relevant publications. We searched by
grant number (if available) and principal investigator to identify publications
from these activities.
Intramural
activities
Given the
relatively limited information we had about internal children's health
activities, we felt it would be more productive and comprehensive to elicit
relevant publications from AHRQ researchers. The Senior Advisor on Child Health, Denise Dougherty, sent an e-mail to
all AHRQ staff asking that they identify their publications relating to
children's health.
Within AHRQ,
intramural research regarding children's health is generally done in either the
Center for Financing, Access and Cost Trends (CFACT) or the Center for
Delivery, Organization & Markets (CDOM). Jessica Banthin, who works in CFACT, provided a list of child health publications
for the period of 1990-2004 for CFACT researchers, which was compiled from a
survey of CFACT researchers. Additionally, two other CFACT researchers, Chad Meyerhoefer and Samuel
Zuevekas, provided a list of their relevant publications, none of which had
been included in the CFACT list. From
these sources, a total of 54 publications were identified.
For CDOM, we only
received a response from two researchers. Anne Elixhauser identified 8 publications, 3 of which were also
identified in the CFACT list. Cindy
Brach, the CDOM researcher who led the CHIRI™ project, referred us to the AHRQ
CHIRI™ Web page for her publications related to the CHIRI™ project. But the publications listed on which Ms.
Brach was a co-author had already been identified through the external
publication search. To avoid double
counting, we did not include them in the list of intramural publications. In an attempt to locate additional CDOM
publications, we spoke with Carol Stocks, who maintains a list of publications
related to the Healthcare Utilization Project, but she stated that most of
those publications were from external research projects. And she was unable to identify any additional
CDOM intramural research publications or sources. We also reviewed the AHRQ Web page for
publications by CDOM which identified
an additional 17 publications, although we were told by AHRQ employees that the
Web page was not comprehensive or completely up to date. Denise Dougherty identified 9 additional
publications. Finally, the AHRQ
librarian assisted with the search and identified an additional 92 internal
publications.
In sum, we identified a total of 177 publications
resulting from intramural research on children's health: 51 from CFACT, 22 from CDOM, 3 jointly from
CFACT and CDOM, 9 from Denise Dougherty and 92 from the AHRQ librarian.
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Determining
Funding
Once all of the relevant
grant awards were identified, the funding detail for each of the grant awards was extracted from
the RaDiUS Database14 using the award numbers to match the records. Since the RaDiUS Database
was created in FY 1993, it does not contain any information grant activities that
occurred prior to
that year. And, because information on the grant awards
made by the Federal
Government in the final quarter of FY 2005 had not yet been officially released by the
Federal Government at the time of this analysis, FY 2004 is the most recent year for which
complete information
on such activities is available in RaDiUS. Working within these parameters, the
federal funds obligated to the relevant grant awards from 1993 through 2004 were extracted by
fiscal year from
RaDiUS and provided to the team for analysis.
As a
cross-reference, we compared these numbers to the funding listed in the AMIS
database. In many cases, the numbers
matched. If the two numbers differed, we
used the higher number as the best estimate of the total grant funding. For those activities for which funding was
not identified through RaDiUS or AMIS, we used the search engine on the AHRQ
Web site to find information on grant awards. We searched by grant number (if available) and principal investigator
for mentions of grant awards and amounts.
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Categorizing Activities and Coding Publications
Categorizing activities
We categorized each activity according to three
different schemes: AHRQ strategic goals,
AHRQ children's health plan strategic goals and AHRQ portfolios of work. In Chapter 3, we describe each categorization
scheme and the distribution, within each, of activities, funding, and
publications. We categorized
publications based on the activity from which they were derived. Intramural publications were not assigned to
categories because the list of publications was developed separately from the
list of internal activities. We were not
able to link the internal publications identified through our sources to
specific activities in a systematic way.
Coding publications
We sorted
publications according to a scheme based on Stryer's four types of impact.
Stryer's four categories for outcomes research were:
- Studies that identify problems, generate hypotheses,
establish the effectiveness of interventions, and develop new tools to explore
these problems.
- Studies in which a policy or program is created as a
result of the research.
- Studies in which there is a documented change in what
clinicians or patients do.
- Studies that result in changes in health outcomes.
We modified these
categories by broadening the inclusion criteria to include studies that had
potential for impact, in addition to studies showing actual impact, for two
reasons. First, AHRQ's external research
on children's health includes types besides outcomes research, which was the
focus of the Stryer analysis. Second, as
most policy researchers and evaluators of research programs understand, there
is not a direct and linear relationship between a particular research finding
and a particular policy or clinical change. Our categories and their description are as follows:
- Research Findings: Studies that identify or describe problems, generate hypotheses, present
frameworks or conceptual models, or develop tools for methods or measurement.
- Policy Impact: Research with clear policy implications or that examines the effects of
policy or policy changes. This research
goes beyond describing a problem that could be amenable to policy; rather, it
shows the implications of a specific policy, shows differences between policy
choices, or evaluates the consequences of policy. Research showing that uninsured children have
less access to care would be category 1, whereas research showing that SCHIP
enrollees got more access to care compared to the year prior to enrollment or
research comparing access to care for children enrolled in SCHIP from different
States would be category 2.
- Clinical Impact: Research describing interventions that
influence practice or that are aimed at influencing clinical practice
(measuring or improving practice); or research developing or demonstrating
tools for clinical use. This research
goes beyond describing problems in clinical practice or the development of
tools for clinical practice. Rather, it
evaluates clinical behavior, demonstrates changes in clinical behavior, or
demonstrates the use of tools in a clinical setting. This research addresses how to get clinicians
to adhere to evidence-based practice. Research describing quality measures would be in category 1, whereas
research comparing providers or health care systems with these quality
measures, or showing how particular interventions affected scores on the
measures would be category 3.
- Outcomes Impact: Research determining which clinical or health behaviors affect health
outcomes, describing the effect of an intervention on health outcomes, or aimed
at influencing health outcomes. Research
describing measures of health status would be category 1. Research evaluating an intervention designed
to improve health status would be category 3 if there was no effect of the
intervention and category 4 if the intervention showed an effect. Research
establishing a link between a policy or practice and outcomes is category 4.
Publications were
categorized based on their titles and abstracts. We did not view the full text of the articles.
Publications for which an abstract was
not available in PubMed® were not categorized.15
In judging
publications, we privileged the results, rather than the implications of the
research. That is, a publication
describing problematic attitudes of clinicians towards medication error
reporting would be category 1 despite the clear implications that a) policies
encouraging reporting are necessary and b) medical errors impact both clinical
practice and health outcomes. In order to be category 2, the publication would
have to examine, for example, the impact of a no-fault reporting policy on
number of error reports. To be category
3, the publication could examine the effect of a tool to flag possible drug
interactions on the number of prescriptions corrected. To be category 4, the publication would, for
example, show the relationship between medical errors and mortality or
morbidity or how an error-reduction intervention shortened length of stay or
reduced complication rates. Two
researchers coded the publications independently, with discrepancies resolved
via consensus.
We also recorded bibliometric characteristics. We recorded the number of times each
publication had been cited, as reported in ISI Web of Science's Science
Citation Index-Expanded and Social Science Citation Index. We did not correct for self-citation. We recorded the impact factor of the journals
in which the articles had been published. The journal impact factor is the average number of times articles
from the journal published in the past two years have been cited in the Journal
Citation Reports year. The impact factor
is calculated by dividing the number of citations in the current year by the
total number of articles published in the two previous years. An impact factor of 1.0 means that, on
average, the articles published one or two years ago have been cited one
time. An impact factor of 2.0 means
that, on average, the articles published one or two year ago were cited two
times.
Because
publications were assigned to categories within the categorization schemes
based on the activities from which they were derived, we did not categorize internal
publications according to these categorization schemes. Therefore, descriptive analyses for the Stryer
categories, citations, and impact factor included the intramural publications
only for the overall analysis. We
excluded intramural publications when examining Stryer categories, citations,
and impact factors by categorization scheme.
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Case
Studies and Key Informant Interviews
We used
qualitative methods to better understand the processes by which ARHQ and AHRQ
personnel contribute to impact, the perspectives of other stakeholders, and to
understand the impact of other children's health activities. We developed case studies of high impact
child health activities through reviewing existing documentation and interviewing
individuals involved in these cases. We
supplemented these case studies with key stakeholder interviews of AHRQ staff
and others to assess the impact of AHRQ's research products and other
children's health activities from the perspective of AHRQ staff, the users of
these products and other interested parties.
As mentioned
above, these case studies were designed to gain in-depth understanding of
high-impact activities (or groups of activities) and how this impact was
achieved.
Key stakeholder
interviews were designed to elicit the views of individuals who may or may not
have been directly involved in the impact cases, but whose perspective is of
particular interest, either because of their experiences with AHRQ, their
current or former roles, or their ability to represent the perspective of an
important group of stakeholders.
Potential cases
were identified by the research team through interviews with AHRQ staff, the
Impact Case Studies Program,16
and the data we collected on projects funded and manuscripts produced. We originally identified three case studies:
State Children's Health Insurance Program (SCHIP)/Children's Health Insurance
Research Initiative (CHIRI™); Asthma and attention-deficit hyperactivity
disorder (ADHD): Moving evidence to practice; and Quality Improvement. However, on further consultation with the TOO
and the Senior Advisor on Child Health, it was determined that the second two
case studies could be thought of in combination. Thus, our cases studies were SCHIP/CHIRI™ and
Translating Research Into Practice (TRIP)/Quality Improvement in asthma and
ADHD. For the case studies, we
considered a body of work (including externally funded research grants,
intramural research, conferences, tools, evidence-based reviews, partnering
with other organizations, and dissemination) rather than an individual research
project to be the 'case.'
We developed a
semi-structured interview protocol to serve both the case studies and the key
stakeholder interviews. The interview
protocol was designed to assess a) whether and to what extent AHRQ's children's
health activities (research, meetings, conference support, products, tools,
etc.) had an impact on policy, clinical processes, or health care outcomes; b) Which
processes influenced these activities' impact; c) The ways in which AHRQ staff
contributed to the impact of these activities; and d) The ways in which
structural or organizational characteristics of AHRQ contributed to the impact
of these activities. Additionally,
interviews with AHRQ staff included the following topics: how AHRQ
transmits/communicates its evidence-based, quality/safety philosophy and
whether outside entities (including other federal agencies) respond or
incorporate AHRQ's work; how much the Agency is asked for advice/input; how
much that advice/input is valued; and how much support the AHRQ CHAG and others
working on child health issues full or part-time get to focus on child health. The interview protocol was finalized in
consultation with the TOO and the Senior Advisor on Children's Health.
Interview topics, organized by Primary Objective, are shown in Table 2. The interview protocol is attached as
Appendix B—the same protocol, suitably modified, was used for both external
stakeholders and AHRQ staff.
Key stakeholders
were selected in consultation with the TOO and the Senior Advisor on Children's
Health, from the following groups: AHRQ staff, clinical stakeholders (such as
members of the Children's Health Accountability Initiative (CHAI), the National
Initiative for Children's Health Care Quality (NICHQ), and the American Academy
of Pediatrics (AAP)), policy stakeholders such as the National Association of
Children's Hospitals and Related Institutions (NACHRI) and others,
patient/family stakeholders (such as Family Voices, Parent to Parent), and
other funders traditionally interested in children's health (such as the David
and Lucille Packard Foundation, the Commonwealth Fund, the Robert Wood Johnson
Foundation). All those contacted consented to be interviewed. Given that the interviews were semi-structured
and adapted to the particular case or stakeholder, we did not ask the same
questions of more than 9 individuals.
Data for both the
key stakeholder interviews and the in-depth case study were in the form of
interview notes. These were summarized
in text matrices across groups where comparable questions are asked. From these raw data matrices, we identified
emerging topics and themes. Reports
describing qualitative findings focus on content themes and utilize
representative respondent quotes to illustrate key findings.
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Data
Analysis
We performed
descriptive analyses to address Primary Objectives 1 and 3. For Primary Objective 2, we performed both
descriptive and inferential analyses. We
used One-Way ANOVAS to assess the statistical significance of mean Stryer
codes, numbers of citations, and impact scores across the various
categorization schemes.
8. This list does not include the liaison and other activities of AHRQ staff and contract work reflected in products on the AHRQ Web site.
9. http://www.ahrq.gov/child/
10. http://www.ahrq.gov/child/fundprj.htm
11. http://www.ahrq.gov/chiri/
12. http://www.ahrq.gov/child/schip.htm
13. http://www.ahrq.gov/child/itchild.htm
14. https://radius.rand.org
15. We identified a total of 627 publications from external activities funded from 1996-2002. Of these, 601 had an abstract available from PubMed® or Web of Science.
16. http://www.ahrq.gov/research/jan02/0102RA22.htm
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