Beyea, S.C., Simmons, D., Hicks, R.W. (2007, March). "Caution: Tubing misconnections can be deadly." (AHRQ grant HS11544). AORN Journal 85(3), pp. 633-635.
Tubing misconnections occur when one end of a tube or catheter is unintentionally connected to the wrong tube or device. The U.S. Pharmacopeia has collected over 300 incident reports identifying many misconnection errors, including the connection of intravenous (IV) fluids to indwelling urinary catheters, epidural catheters, nasogastric tubes, the distal port of a pulmonary artery catheter, and external dialysis catheters.
One factor allowing misconnection errors to occur is that there are no published manufacturing standards to guide manufacturers in their use of varied connections. The Joint Commission considered the problem serious enough to issue an alert in 2006. It recommends prevention strategies such as: avoiding the purchase of non-IV equipment that can connect with IV line connectors; testing new tubing and catheter purchases for performance, safety, and usability; and tracing tubes and catheters to the point of origin before connecting a new device or infusion.
Butt, A. A., Tsevat, J., Ahmad, J., and others (2007, May). "Biochemical and virologic parameters in patients co-infected with hepatitis C and HIV versus patients with hepatitis C mono-infection." (AHRQ grant HS13220). American Journal of the Medical Sciences 333(5), pp. 271-275.
Liver fibrosis and disease is accelerated in patients co-infected with HIV and hepatitis C virus (HCV) compared with patients infected only with HIV. Previous studies of the effects of HIV co-infection on serum alanine aminotransferase (ALT), a biochemical marker of liver injury, and HCV RNA levels have had conflicting results. This study examined ALT and HCV RNA levels among 390 patients; 315 were HCV mono-infected and 75 were HCV-HIV co-infected.
In contrast to previous studies that found no difference in ALT levels or higher ALT levels in co-infected patients, this study found that co-infected patients had lower ALT levels, but were more likely to have detectable HCV RNA and to have HCV RNA levels greater than 6 log 10. The authors concluded that criteria for performing liver biopsy (not often performed in HIV-infected patients) and treating HCV infection in co-infected patients may need to be revisited.
Califf, R.M. (2007, January). "Benefit assessment of therapeutic products: The Centers for Education and Research on Therapeutics." (AHRQ grant HS10548). Pharmacoepidemiology and Drug Safety 16 (1), pp. 5-16.
Payers, providers, and patients increasingly are expressing concern that research is not geared toward producing information needed to guide medical decisionmaking. This Center for Education and Research on Therapeutics workshop, held at Duke University Medical Center, brought together experts from industry, academia, practice, and government to design a research agenda of benefit assessment of medications and medical devices.
The issues discussed included those that can be identified before a study begins, those that commonly arise after a study is completed, biomarkers and surrogates, use of benefit findings in defining quality and performance indicators, implementation of findings into health systems and formularies, and methods of comparative trials.
The workshop participants concluded that a research agenda for improving benefits assessment should investigate a number of issues. These issues include how therapeutic benefit should be communicated to a variety of audiences, key methodological issues in study design, key methods of assessing biomarkers, and the use of formularies and coverage decisions to provide information linking benefit assessment to clinical practice.
Chamberlain, J.M., Joseph, J.G., Patel, K.M., and others (2007, June). "Differences in severity-adjusted pediatric hospitalization rates are associated with race/ethnicity." (AHRQ grant HS10238). Pediatrics 119, pp. e1319-e1324.
This study tested whether severity-adjusted emergency department pediatric admission rates are associated with race/ethnicity in a 13-site sample of 8,952 children (3,112 white, 3,288 black, and 2,552 Hispanic). The sickest children (those in the two highest illness-severity quintiles) in all three groups were admitted at similar rates; yet, white patients in the two lowest illness-severity quintiles were admitted at 1.5 to 2 times the expected rate. The Pediatric Risk of Admission (PRISA) score, developed by the study authors, revealed that white children were overadmitted when
not severely ill rather than that black and Hispanic patients were being denied essential admissions.
Clancy, C. (2007, June). "Putting the patient in patient safety." Journal of Patient Safety 3(2), pp. 65-66.
This commentary by the director of the Agency for Healthcare Research and Quality (AHRQ) emphasizes the need to include the patient as a participant in efforts to improve the safety of health care. To help achieve this goal, AHRQ, in partnership with the Ad Council, has launched the campaign "Questions are the Answer: Get More Involved With Your Health Care." Its goal is to get patients to become partners in their health care by asking questions of their clinicians, including physicians, nurses, pharmacists, and others.
A key feature of the campaign is a Web site (http://www.ahrq.gov/questionsaretheanswer) that features a "Question Builder," allowing patients to select from a series of targeted questions. Patients can then bring their personalized list to their clinician to make their care more efficient. AHRQ is also asking clinicians to establish systems and practices that include the patient as an active participant.
Reprints (AHRQ Publication No. 07-R076) available from the AHRQ Publications Clearinghouse.
Fan, M. and Zhou, X. (2007, June). "A simulation study to compare methods for constructing confidence intervals for the incremental cost-effectiveness ratio." (AHRQ grant HS13105). Health Services & Outcomes Research Methodology 7, pp. 57-77.
The incremental cost-effectiveness ratio (ICER) measures cost-effectiveness in the health sciences. Since a ratio of random variables is complex, constructing an appropriate confidence interval for the ICER is challenging. This paper contains an extensive simulation to compare the most commonly used methods of constructing confidence intervals as well as new methods that have not been previously evaluated. The researchers simulated samples from a wide range of distributions, and considered the less desired scenarios when the true standardized incremental effect was near zero. The results suggest that confidence methods based on Fieller's method, bootstrap-percentile method, and bootstrap-standard method consistently yield reasonable coverage percentages across different sample distributions.
Hayward, R.A., Heisler, M., Adams, J., and others (2007, August). "Overestimating outcome rates: Statistical estimation when reliability is suboptimal." (AHRQ grant H511540). Health Services Research 42(4), pp. 1718-1738.
Up to 100,000 Americans die in hospitals each year due to medical errors. Using this statistic as a case study, the researchers demonstrate how and why ignoring measurement error can result in a large bias in estimating the prevalence of an outcome. They outline several ways to recognize and avoid such bias in future work. For example, most estimates of the rate of preventable deaths in U.S. hospitals rely upon classifying cases using one to three physician reviewers (implicit review), a method with low to moderate statistical reliability.
When the true outcome rate is low (less than 20 percent), using an outcome measure that has low-to-moderate reliability will generally result in substantially overestimating the proportion of the population having the outcome, unless statistical methods that adjust for measurement error are used. With reference to the preventable deaths literature, the researchers believe that implicit review finds very few clear-cut "preventable deaths" in which a majority of reviewers would rate the case as "preventable." Yet, there are many deaths in which a substantial proportion of reviewers would rate the death as "preventable."
Henggeler S. W. (2007, May). "Juvenile drug courts: Emerging outcomes and key research issues." (AHRQ grant HS10871). Current Opinions in Psychiatry 20, pp. 242-246.
The purpose of this review was to examine the effectiveness of juvenile drug courts and suggest priorities for juvenile drug court research. The author describes the emergence of juvenile drug courts (400 of them operate in the United States), their critical components, and findings from both the adult and juvenile drug court research. The author also summarizes the findings of a randomized controlled trial study in which the juvenile drug court was more effective than the family court in decreasing substance abuse and criminal behavior.
However, rearrest rates and incarceration rates were similar. The author suggests that the intensive and continuous surveillance experienced by drug court participants increased the probability that their fewer transgressions would be identified and receive consequences. The author outlines priorities for future research on juvenile drug courts and concludes that the integration
of evidence-based treatments of adolescent substance abuse holds the potential to further enhance the effectiveness of juvenile drug courts.
Hermann, R.C., Rollins, C.K., and Chan, J.A. (2007, March/April). "Risk-adjusting outcomes of mental health and substance-related care: A review of the literature." (AHRQ grant HS10303). Harvard Review of Psychiatry 15(2), pp. 52-69.
Assessing outcomes of mental health and substance abuse problems requires adjustment for patient risk factors. However, risk adjustment for these conditions lags behind other areas of medicine. These researchers reviewed 72 models on risk adjustment addressing utilization, 74 models of expenditures, and 15 models of clinical outcomes.
Models based on diagnostic and sociodemographic information derived from administrative data sets explained on average 6.7 percent of variance in patient outcomes, whereas models using more detailed sources of data explained a more robust 22.8 percent. The low explanatory power of models based on administrative data sets suggests that clinically richer sources of data will be needed for risk adjustment. The researchers conclude that further development of methods for risk adjustment, along with broader application and testing of models for mental health and substance abuse conditions, constitutes a substantial agenda for the future.
Ho, K., Kelley, E., Brady, J., and Clancy, C. (2007, July/August). "Missed opportunities for quality improvement." American Journal of Medical Quality 22(4), pp. 296-299.
In January 2007, AHRQ released two companion reports, the 2006 National Healthcare Quality Report and the 2006 National Healthcare Disparities Report. These reports have been published annually for the last four years. The quality report tracks quality measures such as the proportion of heart attack patients who receive recommended care when they arrive at a hospital and the disparities report summarizes differences in quality and access experienced by different racial, ethnic, and income groups.
These two volumes show that progress has been made since 2005, but also that more can be done prevent the occurrence and progression of illness. The quality report shows that of the 40 core measures with trend data, 26 showed significant improvement. However, the use of proven prevention strategies such as colorectal cancer screenings and diabetes screenings lagged significantly behind other gains in health care. The disparities report shows that blacks, Hispanics, and low-income people received poorer quality of care in more than 70 percent of the measures. >Disparities in access to care for Hispanics are increasing, whereas they are decreasing among other racial and ethnic groups.
The authors further urge patients and their caregivers to become partners in their health care through the "Questions are the Answer: Get More Involved With Your Health Care" campaign (http://www.ahrq.gov/questionsaretheanswer).
Reprints (AHRQ publication no. 07-R075) are available from the AHRQ Publications Clearinghouse.
Jordan, H.S., Pine, M., Elixhauser, A., and others (2007, June). "Cost-effective enhancement of claims data to improve comparisons of patient data." (AHRQ contract no. 233-02-0088). Journal of Patient Safety 3(2), pp. 82-90.
This study was designed to examine the cost-effectiveness of incremental additions of clinical data to an administrative data set to improve the usefulness of the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) for risk-adjustment of hospitals' adverse-event outcome rates. PSIs are an administrative data-based tool that is increasingly being used to measure potential in-hospital patient safety problems.
The authors of this study constructed a series of risk-adjustment models, using progressively more complex data elements. They used hospital discharge data from 188 Pennsylvania hospitals gathered between July 2000 and June 2003 and supplied by the Pennsylvania Health Care Cost Containment Council. In general, adding a "present on admission" (POA) code to secondary diagnoses resulted in modest improvements in predictive power, whereas numerical laboratory data produced substantial improvements. Adding both of these elements resulted in relatively small cost increases per unit increase in effectiveness. This result contrasts with the relatively high cost and low return of abstracting clinical findings from medical charts.
Reprints (AHRQ publication no. 07-R063) are available from the AHRQ Publications Clearinghouse.
Levine, R.S., Briggs, N.C., Hollar, D. and others (2007, Spring). "Descriptive and analytic epidemiologic studies to identify modifiable determinants of disparities in mortality rates between blacks and whites." (AHRQ grant HS11131). Ethnicity and Disease 17, pp. 280-283.
Epidemiological studies have shown no sustained proportional decrease in the disparity in national mortality rates between blacks and whites since World War II, despite Federal, State, and local Healthy People 2010 efforts. The authors of the study examined 41 mid-sized geographic areas with similar demographic characteristics but dissimilar health outcomes to see if this approach could lead to the formulation of hypotheses regarding modifiable determinants of disparities in mortality rates between blacks and whites.
Although 39 of the 41 areas had a black-white mortality rate ratio (MRR) of greater than 1.0, there were 4 distinct black-white mortality patterns: relatively high mortality rates for both blacks and whites and a low black-white MRR; high mortality rates for blacks but low mortality rates for whites, with a high black-white MRR; low mortality rates for both blacks and whites with equal MRR; and low mortality rates for blacks but relatively high mortality rates for whites with a MRR approximating unity.
Nyman, J.A., Barleen, N.A., Dowd, B.E., and others (2007, July). "Quality-of-life weights for the U.S. population. Self-reported health status and priority health conditions, by demographic characteristics." (AHRQ grant HS014097). Medical Care 45, pp. 618-628.
The purpose of this study was to produce nationally representative Quality-of-Life (QOL) weights for self-reported health status and for 10 "priority" health conditions by demographic characteristics. The researchers used Medical Expenditures Panel Survey data on health status and data from a recent study that calculated QOL weights. The researchers suggest that these QOL weights would be useful for conducting cost-utility analyses for the impact of government policies or other "large" interventions on the health of populations. For example, prevention studies could assess population level interventions such as reducing the availability of soft drinks in schools as a way of reducing the incidence of diabetes among school children. If the intervention prevented diabetes in this group, the researchers could then calculate the difference in QOL between children with and without diabetes throughout their expected lifetimes.
Saag, K. (2007, June). "Mend the mind, but mind the bones! Balancing benefits and potential skeletal risks of serotonin reuptake inhibitors." (AHRQ grant HS014097). Archives of Internal Medicine 167, pp. 1231-1232.
In the treatment of depression, selective serotonin reuptake inhibitors (SSRIs) have long surpassed tricyclic antidepressants (TCAs) in the marketplace and now rank third among all drug classes in U.S. prescription drug sales. Two new studies in this issue raise concerns about a reduction in bone mineral density (BMD) in persons receiving SSRIs but not among persons receiving TCAs.
These studies were based on unique national cohorts; one was a cross-sectional study of men and the other a longitudinal analysis of women. These studies, along with other research, provide sufficient evidence to support a preliminary recommendation that depression, and in particular SSRIs, be added to the list of risk factors that prompt clinicians to more carefully consider a patient's bone health.
Schmittdiel, J., Vijan, S., Fireman, B., and others (2007, April). "Predicted quality-adjusted life years as a composite measure of the clinical value of diabetes risk factor control." (AHRQ contract no. 290-00-0015). Medical Care 45(4) pp. 315-321.
This study explored the use of quality-adjusted life years (QALYs) as a composite measure of the clinical value attributable to better control of the three major physiological risk factors (hemoglobin A1c, low-density lipoprotein-cholesterol (LDL-c), and systolic blood pressure). The researchers used a Markov model to simulate risk factor and case-mix variables among a large group of diabetic patients insured by one health insurance group. The effect of systolic blood pressure control on an increase in QALYs is substantially larger than that of the other two clinical markers, especially at higher levels of blood pressure. As measures of care quality, weighted QALYs might drive health plans, providers, and patients toward focusing on the most effective interventions or self-management changes.
Wren, T. A. L., Sheng, M., Hara, R., and others (2007, March). "Agreement among three instruments for measuring functional health status and quality of life in pediatric orthopaedics." (AHRQ grant HS014169). Journal of Pediatric Orthopaedics 27(2), pp. 233-240.
Three instruments are commonly used to measure function and quality of life for pediatric orthopedics patients: the Child Health Questionnaire (CHQ), the Pediatric Outcomes Data Collection Instrument (PODCI), and the Pediatric Evaluation and Disability Inventory (PEDI). This
study compared answers to specific questions from the CHQ, PODCI, and the PEDI to determine how consistent parents are in answering the same or similar questions, the impact of variations in wording, and if these results are influenced by language (English or Spanish).
The parents of 66 children with cerebral palsy completed all three questionnaires within a 1-day period. Of the eight questions that overlapped between the CHQ and PODCI, six had poor to fair agreement for parental responses. Only the two questions with nearly exact wording had similar parental responses. All five questions addressed by both the PODCI and the PEDI had poor agreement in parental responses. The results suggest that differences in wording have unpredictable and significant effects on parental responses to questionnaires.
Zhan, C., Elixhauser, A., Friedman, B., and others (2007, April). "Modifying DRG-PPS to include only diagnoses present on admission." Financial implications and challenges. Medical Care 45 (4), pp. 288-291.
Quality and safety research has been hindered by the inability to distinguish between present on admission (POA) comorbid conditions and those conditions acquired in the hospital. Pay-for-performance initiatives and new Medicare legislation requiring reduced payment for hospital-acquired infections increase the need for POA coding. By analyzing Health Care and Utilization Project (HCUP) data for 2003 from California and New York, the only two States currently requiring date-stamping for secondary diagnosis codes, the researchers determined that Medicare could have saved $56 million in California, $51 million in New York, and $800 million total in the United States, if Medicare had reimbursed hospitals only for POA conditions.
Reprints (AHRQ publication no. 07-R081) are available from the AHRQ Publications Clearinghouse.
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AHRQ Publication No. 07-0081
Current as of October 2007
Internet Citation:
Research Activities Newsletter. October 2007, No. 326. AHRQ Publication No. 07-0081. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/oct07/
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