Research Briefs

Goldstein, R.B., Asarnow, J.R., Jaycox, L.H., and others (2007). "Correlates of 'non-problematic' and 'problematic' substance use among depressed adolescents in primary care." (AHRQ grant HS09908). Journal of Addictive Diseases 26(3), pp. 39-52.

Substance use, abuse, and dependence are major public health problems whose treatment is complicated by the co-occurrence of depression. In this study, the researchers examined factors associated with substance abuse in a sample of 451 primary care patients 13 to 21 years old who had high levels of depressive symptoms. They found that substance use was highly prevalent and problematic use was frequent. The proportions of both problematic and nonproblematic users rose with increasing age: at ages 13 to 15, 14 percent were problematic users and 9 percent nonproblematic users; by ages 19 to 21, the proportions had risen to 26 and 25 percent, respectively. In addition to older age, problematic use was associated with male gender, externalizing symptoms, Caucasian/White ethnicity/race, and having more friends. The most widely used substances were tobacco, alcohol, and marijuana; other substances included amphetamines, barbiturates, cocaine, LSD, tranquilizers, and heroin and other opioids. Primary care clinicians should probe carefully for substance use risk in this group of patients.

Hartzema, A.G., Winterstein, A.G., Johns, T.E., and others (2007, February). "Planning for pharmacy health information technology in critical access hospitals." (AHRQ grant HS15325). American Journal of Health System Pharmacy 64, pp. 315-321.

The purpose of this project was to develop a plan for the implementation of medication-related health information technology (HIT) in 12 critical access hospitals (CAH) to improve safety and reduce medication errors. A CAH is a rural acute care facility qualified for the Medicare Rural Hospital Flexibility Program. A key specific aim of the project was to select pharmacy HIT (pHIT) components based on CAH needs and the components' potential to address the 12 strategies recommended by the Institute of Medicine for reducing medication errors.

The researchers conducted interviews in each hospital to determine how, where, and what HIT was being used, and held two planning conferences. A consensus was reached that a pHIT platform should be implemented at CAHs in three phases consisting of a pharmacy information management system, automated dispensing cabinets, and smart intravenous infusion pumps. Together, these components would help avoid drug prescribing, transcribing, dispensing, and administrative errors. However, certain barriers to implementation would need to be overcome; these included funding, staff resistance, small staff size, and limited space in hospitals for HIT equipment.

Keyhani, S., Kleinman, L.C., Rothschild, M., and others (2008, January) "Clinical characteristics of New York City children who received tympanostomy tubes in 2002." (AHRQ grant HS10302). Pediatrics 121(1), pp. e24-e33.

Although two clinical practice guidelines caution against insertion of ear tubes for children who suffer from middle ear inflammation (otitis media), a recent study shows some doctors do not follow the guidelines. Researchers at New York's Mount Sinai School of Medicine reviewed the records of 1,046 children seen in 5 New York City hospitals in 2002 and found that 75 percent of the children had surgery at less than the 42-day mark, and more than 50 percent had surgery after fewer than 77 days of inflammation. The authors suggest that surgeries performed before the 90-day mark may indicate an overuse of ear-tube insertions because parents may feel pressure to take action to help their child, who is in pain and whom they fear will sustain long-term hearing loss. These pressures may stir parents to insist on medical action in lieu of watchful waiting or antibiotics. If this is the case, pediatricians could alleviate parents' concerns by explaining how common middle ear inflammation is among children and educate parents about appropriate treatment options.

McCormick, D.P., Chandler, S.M., and Chonmaitree, T. (2007, July). "Laterality of acute otitis media: Different clinical and microbiologic characteristics." (AHRQ grant S10613). The Pediatrics Infectious Disease Journal 26(7), pp. 583-588.

Researchers analyzed 1,216 cases of children with middle ear infections and found that very young children with infections in both ears may need antibiotics to kill the bacteria causing their discomfort. For 70 percent of children with ear infections in both ears, cultures showed bacteria were present. Bacteria found included H. influenzae (the most common when both ears were infected), S. pneumonia, M. catarrhalis, and S. aureus. In contrast, only 57 percent of the children with one infected ear had bacteria present. The researchers suggest that the wait-and-see approach recommended for treating children with ear infections should be set aside when children younger than 2 years old have an infection in both ears, especially when H. influenzae is present. Without antibiotics, their symptoms and suffering will likely persist.

McDaniel, S.H., Beckman, H.B., Morse, D.S., and others (2007, June). "Physician self-disclosure in primary care visits: Enough about you, what about me?" (AHRQ grant HS10610). Archives of Internal Medicine 167, pp. 1321-1326.

This study found when primary care doctors reveal personal information to their patients, it doesn't necessarily foster a closer patient-doctor relationship. Researchers analyzed the transcripts of primary care visits by 113 standardized patients (people trained to act as patients) for physician self-disclosure. In 34 percent of visits, physicians talked about personal emotions and experiences, families and/or relationships, and their professional life. These disclosures were a response to a patient question in only 14 percent of cases. Sixty percent of disclosures followed patients' symptoms, mention of family, or expression of feelings, and 40 percent were unrelated to patient discussion. In only 21 percent of cases did physicians return to the patient topic preceding the disclosure.

Overall, the research team considered 85 percent of physician self-disclosures to be useless to the patients and 11 percent to actually be disruptive (with the patient abruptly changing the topic in some cases). They considered only 4 percent of physician self-disclosures to be useful, that is, they provided patient education, support, explanation, or acknowledgement, or the patient indicated that the comments had been helpful.

Mora, P.A., Halm, E., Leventhal, H. and others (2007). "Elucidating the relationship between negative affectivity and symptoms: The role of illness-specific affective responses." (AHRQ grant HS09973). Annals of Behavioral Medicine 34 (1), pp. 77-86.

Much research has shown a positive relationship between trait negative affectivity (a general disposition to experience negative moods) with reports of physical symptoms. Trait negative affectivity (NA) might bias one to report benign emotional or psychophysiological symptoms unrelated to health status as symptoms of illness or accurately report on somatic states that are indicators of underlying disease. These researchers decided to investigate patients with asthma to find out whether trait NA should be regarded as a biasing factor, a source of accurate self-appraisal, or both. The subjects tested were 166 inner-city asthma patients who completed 3 questionnaires over the 6-month study period. Each patient was assessed for mood states, asthma symptoms, and nonasthma symptoms. Most patients (78 percent) correctly recognized their asthma symptoms as due to their asthma. Trait NA was not associated with the misattribution of asthma symptoms.

Orzano, A.J., Scott, J., Hudson, S.V., and others (2007). "Strategies for conducting complex clinical trials in diverse community practices." (AHRQ grant HS14018). Medical Care 45(12), pp. 1221-1226.

It is difficult to get individual primary care practices to participate in complex clinical trials focused on quality improvement strategies, since they typically lack sufficient resources to devote to data collection and the other demands of the study. This article describes a successful process for maintaining a high level of practice participation in a system-level complex clinical trial involving diverse primary care practices spread across two States. The goal was to improve care (as measured by guideline adherence) for management of diabetes, hypertension, asthma, hyperlipidemia, and smoking screening. Using a facilitator who meets with practice physicians and staff for ten 1-hour weekly sessions and the multimethod assessment process, the researchers sought to tailor a reflective practice team process for each of the 30 practices in the study. They collected data on practice disease management over a 4-year period ending in October 2007. The researchers present three case studies illustrating the five interrelated factors that appeared crucial to the success of the study implementation process: developing a structure and activities for relationship building, attending to consistent communication, sharing information in a timely manner, evolving a diverse research team, and providing technical assistance.

Raji, M.A., Reyes-Ortiz, C.A., Kuo, Y., and others (2007, September). "Depressive symptoms and cognitive change in older Mexican Americans." (AHRQ grant HS11618). Journal of Geriatric Psychiatry and Neurology 20(3), pp. 145-152.

The authors of this study examined a group of 2,812 Mexican Americans over age 65 for 7 years to determine what links exist between depressive symptoms and cognitive decline. They found that persons with depressive symptoms at the beginning of the study had a greater decline in cognitive skills during the 7-year period than did those without such symptoms. The link between depressive symptoms and cognitive decline was independent of age, gender, education, baseline cognitive score, limitations in the activities of daily living, diabetes, stroke, heart attack, and vision impairment. Depression was measured by the Center for Epidemiologic Studies Depression Scale (a score over 16 was considered depressive) and cognitive skills were measured by the Mini-Mental State Examination (MMSE). The MMSE was given at the outset of the study to create a baseline and subsequently at 2, 5, and 7 years. It is not clear whether treating depression will reduce the onset of cognitive decline.

Resnick, B. and Galik, E. (2007). "The reliability and validity of the physical activity survey in long-term care." (AHRQ grant HS13372). Journal of Aging and Physical Activity 15, pp. 439-458.

The authors of this study developed and tested a measure of physical activity for residents of a long-term care facility, the Physical Activity Survey in Long-Term Care (PAS-LTC). The PAS-LTC includes 66 activities that include routine physical activity, personal care activities, structured exercise, recreational activities, caretaking activities, and repetitive activities. The researchers tested the measure on 13 residents. There was some evidence of validity of the measure, with significant correlations between PAS-LTC recorded during the evening and night shifts and the number of counts of activity per an ActiGraph and calories estimated. The PAS-LTC completed during the day shift and total activity based on the PAS-LTC showed nonsignificant correlation with ActiGraph activity counts and calories.

Rodriguez, H.P., Marsden, P.V., Landon, B.E., and others (2008, February). "The effect of care team composition on the quality of HIV care." (AHRQ grant HS10227). Medical Care Research and Review 65(1), pp. 88-113.

A new study reveals some disadvantages along with the advantages of having multiple clinicians for persons with HIV disease. Patients with two physicians and a nurse practitioner (NP) or physician assistant (PA) or with three or more physicians were more likely to receive drugs to prevent pneumocystis carinii pneumonia (PCP) than patients with a single physician (52 and 59 vs. 36 percent, respectively), after adjusting for physician and site specialization. Patients without a usual clinician were less likely to receive highly active antiretroviral therapy (HAART) than were those with a single physician (66 vs. 87 percent), but there were no other differences in HAART use among types of care teams. Women were more likely to receive a pap smear during the year if their care team included three or more physicians than a single physician (90.5 vs. 75 percent). Patients with care teams including a PA or NP or with three or more physicians were more likely to have an inappropriate emergency department visit than patients of single physicians (23 and 33 vs. 17 percent, respectively).

Rose, J. (2008, January). "Industry influence in the creation of pay-for-performance quality measures." (AHRQ grant T32 HS00059). Quality Management in Health Care 17(1), pp. 27-34.

Pay-for-performance programs are likely to pick up speed in the coming years. Thus, it is important to ensure that the quality measures used in these initiatives are based on the best possible clinical evidence and expert consensus. This article examines the financial ties between those who—both directly and indirectly—help create the standards used in pay-for-performance programs and those firms whose revenues will increasingly depend on the substance of these measures. The authors caution about the need to ensure that these groups remain independent from financial connections to industries (such as pharmaceutical and device companies), whose revenues could be affected by the content of the measures. They cite several examples of inappropriate industry influence in the drafting of clinical practice guidelines by professional societies. They also discuss policy options for minimizing the effects of these conflicts of interest on the development of quality measures.

Starks, H. and Trinidad, S.B. (2007, December). "Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory." (AHRQ grant T32 HS13853). Qualitative Health Research 17(10), pp. 1372-1380.

The authors of this paper compared three qualitative approaches that can be used in health research: phenomenology, discourse analysis, and grounded theory. They note that the goal of phenomenology is to study how people derive meaning from their lived experience. Discourse analysis examines how language is used to accomplish personal, social, and political projects. Grounded theory develops explanatory theories of basic social processes studied in context. The authors describe a model that captures the similarities and differences among these approaches, and discuss their historical development, goals, methods, audience, and products. They underscore their differences by applying them to the same set of data. They contend that by familiarizing themselves with the origins and details of these approaches, investigators can make better matches between their research question(s) and the goals and products of their study.

Stulberg, J. "The physician quality reporting initiative—A gateway to pay for performance: What every health care professional should know." (AHRQ grant T32 HS00059). Quality Management in Health Care 17(1), pp. 2-8.

The Physician Quality Reporting Initiative (PQRI) is a pay-for-reporting initiative sponsored by the Centers for Medicare and Medicaid Services, which is open to all health care providers that treat Medicare patients. This initiative provides financial incentives for participation and, unlike most pay-for-performance programs, there are no penalties for poor performance. Thus, PQRI offers Medicare providers nationwide a low-risk opportunity to gain experience with reporting procedures likely to be incorporated into pay-for-performance reimbursement schemes. Also, its 74 measures are applicable to both generalist and specialist providers. The combination of provider-level measurement and reimbursement and efforts to assess care delivered by both generalist and specialist Medicare providers highlights how this pay-for-reporting initiative is a gateway to a pay-for-performance reimbursement system.

Sullivan, A.F., Camargo, C.A., Cleary, P.D., and others (2007). "The national emergency department safety study: Study rationale and design." (AHRQ grant HS13099). Academic Emergency Medicine 14, 1182-1189.

The National Emergency Department Safety Study (NEDSS) is a response to the need for methods to reduce error with a focus on the correction of suboptimal safety processes in emergency departments (EDs). If reports by personnel about processes of care and attributes of the ED and its clinical environment are significantly correlated with the occurrence of errors, then this reporting system could be used to determine an ED's level of risk of errors. It could also identify processes for quality improvement.

This paper describes the methods used to develop and implement the NEDSS. The authors revised the NEDSS survey from an earlier instrument. They refined it by interviews with key informants and by focus groups at 3 EDs, and by psychometric testing at 10 EDs. It was then administered to a random sample of 80 ED staff at 60 participating sites. The survey asked about potentially unsafe processes and safety-related ED attributes, as well as ED management of three conditions (asthma, heart attack, and dislocations that were reduced using procedural sedation); chart review was done to detect rates of error for patients treated for these conditions.

Talbot, T.R., Tejedor, S.C., Greevy, R.A., and others (2007, December). "Survey of infection control programs in a large national healthcare system." (AHRQ grant HS15934). Infection Control and Hospital Epidemiology 28(12), pp. 1401-1403.

Prevention of healthcare-associated infections (HAIs) has become a concern of consumers and regulators and a central focus of quality improvement programs in recent years. Initiatives addressing infection control, which require timely and accurate detection and reporting of HAI data, have boosted demands on hospital infection control programs. As part of a project to evaluate different strategies for reducing HAIs, this study assessed infection control practices and resources by surveying 134 hospitals owned by one group. Both infection control practices and resources varied substantially among the hospitals. Many hospitals reported difficulty acquiring the data they needed to report infection rates. These findings underscore the need for hospitals to reexamine the process of HAI surveillance and the resources devoted to infection control programs.

Uding, N., Sety, M., and Kieckhefer, G.M. (2007). "Family involvement in health care research: The 'Building on Family Strengths' case study." (AHRQ grant HS13384). Families, Systems, & Health 25(3), pp. 307-322.

Thirteen percent of U.S. children have special health care needs (CSHCN), yet parents have little preparation for living with these children in the context of everyday family life. By emphasizing mutually beneficial partnerships among patients, families, and health care providers, family-centered care offers a framework out of which health care services can be planned and delivered. However, families have rarely become involved in "participatory research" in which they become partners in the design and implementation of research meant for families' benefit.

The "Building on Family Strengths" (BFS) program is a psychoeducational program for parents or other primary caregivers of CSHCN to assist them in managing their child's needs in the context of overall family life. Families were involved in all four phases of BFS by acting as: partners in planning meetings; participants in focus groups discussing curriculum content; cofacilitators in implementing the seven-session program; and, finally, as coinvestigators who interpreted and disseminated results to community groups and providers. The authors conclude that family involvement in health services research is essential for efficient, effective, respectful, and meaningful research about families.

Vartak, S., Ward, M.M., and Vaughn, T.E. (2008, January). "Do postoperative complications vary by hospital teaching status?" (AHRQ grant HS15009). Medical Care 46(1), pp. 25-32.

Using patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality (AHRQ), the researchers sought to determine whether six postoperative complications varied by hospital teaching status. The six PSI complications are hip fracture, hemorrhage or hematoma, physiologic and metabolic derangement, respiratory failure, pulmonary embolism or deep vein thrombosis, and sepsis. The study sample consisted of 400 nonteaching, 207 minor teaching, and 39 major teaching hospitals, which together treated over a million patients. The major teaching hospitals had higher observed rates for all six PSIs except for hip fracture. After adjusting for hospital and patient characteristics, major teaching hospitals had higher odds for pulmonary embolism and sepsis, and lower odds for respiratory failure than the other hospitals. When hospital and patient characteristics were included in the models, minor teaching hospitals did not vary significantly from nonteaching hospitals for any of the six PSIs.

Wakefield, D.S., Ward, M.M., Groath, D., and others (2008, January-February). "Complexity of medication-related verbal orders." (AHRQ grant HS15196). American Journal of Medical Quality 23(1), pp. 7-17.

Medication-related verbal orders, like other communications, are subject to miscommunication or misunderstanding. Studies examining the factors related to the complexity and potential for verbal-order communications to result in error and patient harm are nearly absent in the literature. The researchers sought to identify those factors by analyzing one hospital's medication-related verbal order events for a 1-week period. During this time period, there were 1,222 verbal-order events, which included 4,197 medication orders. There was great variability in the number of medication-related verbal-order events among the 11 patient care units. For example, the cardiovascular recovery unit had just 19 events compared with 268 for the cardiac step-down unit. For all units combined, there was an average of 3.4 medications ordered per verbal-order event. The authors proposed at least three primary categories of factors contributing to complexity and the potential for error and harm during verbal orders. These categories are verbal ordering process and contents, verbal order makers (physicians, etc.), and verbal order takers (nurses and pharmacists).

Wolfstadt, J.I., Gurwitz, J.H., Field, T.S., and others (2008, April). "The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: A systematic review." (AHRQ grants HS10481 and HS15430). Journal of General Internal Medicine 23(4), pp. 451-458.

Computerized physician order entry (CPOE) with clinical decision support (CDS) has been promoted as an effective strategy to prevent the development of a drug injury defined as an adverse drug event (ADE). This systematic review of studies evaluated the effects of CPOE with CDS on the development of an ADE. The authors found few studies in this area, and concluded that more research is needed to evaluate the efficacy of CPOE with CDS across various clinical settings. The researchers grouped by hospital or ambulatory setting the 10 out of 543 studies that met inclusion criteria. No long-term care studies were identified. CPOE with CDS contributed to a significant decrease in ADEs in 5 of the 10 studies. Four studies reported a nonsignificant reduction in ADE rates, and one study demonstrated no change in ADE rates.

Wyrwich, K.W., Metz, S.M., Kroenke, K., and others (2007, December). "Triangulating patient and clinician perspectives on clinically important differences in health-related quality of life among patients with heart disease." (AHRQ grants HS10234 and HS11635). HSR: Health Services Research 42(6), Part I, pp. 2257-2274.

Using several measurement strategies can help to reduce the deficiencies that flow from the use of just one method. To examine clinically important differences (CIDs) in health-related quality of life (HRQoL) among patients with heart disease, the researchers relied on three different groups: the patients themselves, an expert panel familiar with the use of a disease-specific and a generic HRQoL instrument for patients with heart disease, and the primary care physicians who cared for these patients. Among the 656 initial patients completing baseline HRQoL interviews, there were 3,336 interviews completed over a 1-year period. The two HRQoL instruments used were the Modified Chronic Heart Failure Questionnaire and the Medical Outcomes Study Short Form 36-Item Health Status Survey. The findings revealed that there was little consensus among the three groups as to what constituted CIDs over the period studied. However, using these three methods is useful in better understanding the three groups and their approaches to estimating CID thresholds for patient-reported outcomes.

Yazdany, J., Yelin, E.H., Panopalis, P., and others (2008, January). "Validation of the systemic lupus erythematosus activity questionnaire in a large observational cohort." (AHRQ grant HS13893). Arthritis Care & Research 59(1), pp. 136-143.

These authors found that the Systemic Lupus Erythematosus Activity Questionnaire (SLAQ) demonstrated adequate reliability, construct validity, and responsive-ness in a large community-based group of persons with systemic lupus erythematosus (SLE). Thus, it appears to represent a promising tool for studies of SLE outside the clinical setting. SLAQ scores were strongly correlated with other health indices, including the Short Form 12 Physical Component Summary and Short Form 36 Physical Functioning Subscale. Scores were significantly higher for respondents reporting an SLE flareup, more disease activity, hospitalization in the last year, concurrent use of immunosuppressive medication, and work disability. The SLAQ demonstrated a small to moderate degree of responsiveness for those reporting clinical worsening and improvement, respectively.

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