Research Briefs

Ardery, G., Herr, K.A., Titler, M.G., and others (2003, February). "Assessing and managing acute pain in older adults: A research base to guide practice." (AHRQ grant HS10482). Medsurg Nursing 12(1), pp. 7-18.

Research has demonstrated better patient outcomes, shorter hospital stays, and reduced resource use as a result of effective pain management and mobility. Older adults often undergo medical and surgical treatments that result in acute pain, yet they frequently receive much less medication for pain than younger patients suffering from similar pain. These researchers reviewed and critiqued existing literature on acute pain management in older adults and developed an evidence-based guideline on the topic that addresses the following general areas of practice related to acute pain in the elderly: pain assessment, pain assessment in confused elders, monitoring pain in older adults, education of the patient and family, pharmacologic management, and nonpharmacologic management. This article presents key recommendations from the guideline and selected references.

Blackmore, C.C., Richardson, M.L., Linnau, K.F., and others (2003, May). "Web-based image review and data acquisition for multiinstitutional research." (AHRQ grant K08 HS11291). American Journal of Radiology 180, pp. 1243-1246.

These authors describe a user-friendly Web-based interface that allows review of images, combined with integrated data collection and entry, for use at multiple sites involved in a large multicenter research project. The system simplifies the complex logistics of using multiple sites and reviewers for radiology research while preserving human subject confidentiality. The researchers tested the system using a large-scale multicenter cohort study of pelvic fracture-related hemorrhage and found it to provide seamless remote image interpretation and acquisition.

Bradley, E.H., Holmboe, E.S., Mattera, J.A., and others (2003). "The roles of senior management in quality improvement efforts: What are the key components?" (AHRQ grant HS10407). Journal of Healthcare Management 48(1), pp. 15-28.

Senior managers are personally engaged in five types of quality improvement (QI) efforts at higher versus lower performing hospitals, according to this study. These senior managers actively advocate for QI activities both within the hospital, for example, through QI teams, and with the board; have good working relationships with the medical staff; support norms of interdepartmental and multidisciplinary collaboration through shared goal setting and novel approaches; and ensure the availability of resources needed to conduct QI efforts, such as information technology capability and quality management and data collection staff. These activities were not apparent in the lower performing hospitals. These findings are based on interviews with 45 key clinical and administrative staff members involved with improving the prescribing of beta-blockers for heart attack patients discharged from eight hospitals. The researchers used data from the National Registry of Myocardial Infarction to identify high-performing and low-performing hospitals and compared beta-blocker use during the followup period (April 1998 to September 1999) with rates during the baseline period (October 1996 to March 1998) at each hospital.

Campbell, W.H., and Califf, R.M. (2003). "Improving communication of drug risks to prevent patient injury: Proceedings of a workshop." (AHRQ grant HS10548 and HS10397). Pharmacoepidemiology and Drug Safety 12, pp. 183-194.

This paper presents the results of the first workshop in a series conducted by the Centers for Education & Research on Therapeutics (CERTs). The two-day meeting focused on communication of drug risks to health care professionals and patients. Fifty workshop participants from the medical products industry, academia, consumer groups, regulatory bodies, and the media sought to identify and understand barriers to successful risk communication, identify tools or methods to improve risk communication, and develop research and educational agendas that could lead to better risk communication in the future.

Carter, R., Holiday, D.B., Nwasuruba, C., and others (2003, May). "6-minute walk work for assessment of functional capacity in patients with COPD." (AHRQ grant HS08774) CHEST 123, pp. 1408-1415.

The 6-minute walk (6MW) test is commonly used to assess exercise capacity in patients with COPD and to track functional change resulting from disease progression or therapeutic intervention. However, distance walked does not account for differences in body weight that are known to influence exercise capacity. This study evaluated the 6-minute distance x body weight product (6MWORK) as an improved outcome measure on 124 men and women with moderate-to-severe COPD. The researchers calculated correlation coefficients and receiver operative characteristic (ROC) curves for the 6-minute walk distance (6MWD) and 6MWORK with indexes of pulmonary function, work performance, and Borg scores for dyspnea and effort. They concluded the 6MWORK is an improved outcome measure for the 6MW.

Clancy, C.M. (2003, June). "Health services research: From galvanizing attention to creating action." Health Services Research 38(3), pp. 777-782.

A critical challenge facing the field of health services research in general, and the Agency for Healthcare Research and Quality specifically, is to go beyond simply identifying a problem to doing what needs to be done to make a difference. In other words, health services research must go beyond galvanizing attention to creating action, notes AHRQ's Director in this editorial. Making sure that researchers conduct relevant studies and that the results are used by decisionmakers represent the next quantum leap for the field. When there is a clear hand-off between research and action, collaboration can lead to success. An excellent example is the Quality Improvement Organizations and their ongoing activity to improve quality in the Medicare program. A 2003 evaluation of the Medicare program indicated that a typical beneficiary had a 73 percent chance of receiving appropriate care on a given measure in 2000-2001, up from 69 percent in 1998-1999.

Reprints (AHRQ Publication No. 03-R043) are available from the AHRQ Publications Clearinghouse.

Cornia, P.B., Amory, J.K., Fraser, S., and others (2003, April). "Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients." (AHRQ grant HS11540). American Journal of Medicine 114, pp. 404-407.

Urinary catheters are a leading cause of hospital-acquired infection, and about one in five is unnecessary. Computer-based order entry for inserting an indwelling urinary catheter and reminders to remove the catheter shortened the duration of catheterization by about one-third (3 days) in this study. The computer order also required that an indication be selected for its placement, provided routine catheter care instructions, and noted a default stop date of 72 hours after placement. Residents on the floor who used the computer-based system, could use the computer study order, enter a standard written order, or not enter an order. The computer study order was not available for residents located on the control ward. After 8 weeks, study and control wards switched.

Fisman, D.N., Hook III, E.W., and Goldie, S.J. (2003). "Estimating the costs and benefits of screening monogamous, heterosexual couples for unrecognized infection with herpes simplex virus type 2." (T32 HS00020). Sexually Transmitted Infections 79, pp. 45-52.

About one in five Americans is infected with Herpes simplex virus type 2 (HSV-2), the most common cause of genital ulcers. However, HSV-2 infection is commonly unrecognized. To evaluate the cost-effectiveness of strategies to prevent HSV-2 transmission in couples with no history of the infection, these researchers created a mathematical model to simulate the natural history and costs of HSV-2 transmission and the expected impact of HSV-2 prevention strategies (ranging from universal condom use to blood screening) in monogamous, heterosexual couples. They concluded that serological screening for unrecognized HSV-2 infection in this group is expected to decrease the incidence of HSV-2 infection but will increase health care costs.

Frank, R.G., Huskamp, H.A., and Pincus, H.A. (2003, May). "Aligning incentives in the treatment of depression in primary care with evidence-based practice." (AHRQ grant HS10803). Psychiatric Services 54(5), pp. 682-687.

Deficits in the quality of treatment for depression in the primary care sector have been documented in multiple studies. Several clinical models for improving primary care treatment of depression have been shown to be cost effective in recent years but have not proved to be sustainable over time due to a variety of financial and organizational barriers. The authors of this paper provide a brief overview of models for improving depression treatment in primary care and discuss financial incentives that discourage improvements. They also describe recent institutional changes that influence incentives and give examples of economic and organizational changes that could address the problems inhibiting the long-term sustainability of clinical models of quality improvement.

Gelberg, L., Leake, B., Lu, M.C., and others (2002, December). "Chronically homeless women's perceived deterrents to contraception." (AHRQ grant HS08323). Perspectives on Sexual and Reproductive Health 34(6), pp. 278-285.

This survey of 974 homeless women in Los Angeles County in 1997 revealed that they had substantial deterrents that reduced their use of contraceptives to prevent unintended pregnancy. The most commonly cited deterrents to contraceptive use were side effects, fear of potential health risks, partner's dislike of contraception, and cost (20-27 percent). Women who reported substantial deterrents were significantly less likely than others to use contraceptives consistently. Hispanic women were much more likely than white women to cite not knowing how to use contraceptives or which method to use as a deterrent. Black women were more likely than white women to cite not knowing which method to use, lack of storage, health risks, and discomfort as barriers to use.

Goldie, S.J., and Kuntz, K.M. (2003, June). "A potential error in evaluating cancer screening: A comparison of 2 approaches for modeling underlying disease progression." (AHRQ grant HS07317). Medical Decision Making 23, pp. 232-241.

To illustrate a potential error in modeling disease progression among healthy people with a history of a precancerous lesion, these researchers constructed two models with four basic health states: disease-free, presence of a precancerous lesion, presence of cancer, and dead. They calibrated the models to predict the same 10-year cancer incidence. Using the first model, life expectancy without screening was 2.4 months longer than with screening. This error did not occur using the second model, in which the transition from precancerous lesions to cancer was not conditional on a history of a lesion.

Gustafson, D.H., Sainfort, F., Eichler, M., and others (2003, April). "Developing and testing a model to predict outcomes of organizational change." (AHRQ grant HS10246). Health Services Research 38(2), pp. 751-776.

These authors used a panel of experts and literature on organizational change to identify factors predicting the outcome of 221 healthcare improvement projects in three countries. They developed a Bayesian model to estimate probability of successful changing using subjective estimates of likelihood ratios and prior odds elicited from the panel of experts. They validated the model by a retrospective empirical analysis of change efforts in 198 health care organizations. Results showed that the subjective Bayesian model was effective in predicting the outcome of actual improvement projects. The researchers suggest additional prospective evaluations, as well as testing the impact of this model as an intervention.

Hadley, J., Polsky, D., Mandelblatt, J.S., and others (2003). "An exploratory instrumental variable analysis of the outcomes of localized breast cancer treatments in a Medicare population." (AHRQ grant HS08395). Health Economics 12, pp. 171-186.

These investigators compared two statistical approaches, ordinary least-squares and instrumental variables regression analysis, to estimate the outcomes (3-year posttreatment survival) of three treatments for early stage breast cancer in elderly women: mastectomy, breast conserving surgery with radiation therapy, and breast conserving surgery only, using Medicare claims data. Contrary to randomized clinical trial results, analysis with the observational data found highly significant differences in survival among the three treatment alternatives. The researchers conclude that such observational data should not be used for cost-effectiveness studies on outcomes of treatment for localized breast cancer.

Haggerty, C.L., Ness, R.B., Amortegui, A., and others (2003, January). "Endometritis does not predict reproductive morbidity after pelvic inflammatory disease." (AHRQ grant HS08358). American Journal of Obstetrics & Gynecology 188, pp. 141-148.

This study investigated the association between endometritis and reproductive problems among 614 women in the PID Evaluation and Clinical Health (PEACH) Study. The researchers compared women with endometritis, Neisseria gonorrhea, or Chlamydia trachomatis upper genital tract infection (UGTI), or both to women without endometritis/UGTI for outcomes of pregnancy, infertility, recurrent pelvic inflammatory disease (PID), and chronic pelvic pain, adjusting for age, race, education, PID history, and baseline infertility. Among women with clinically suspected mild-to-moderate PID treated with standard antibiotics, endometritis/UGTI was not associated with reduced pregnancy, elevated infertility, or recurrent PID.

Hahn, E.A., and Cella, D. (2003, April). "Health outcomes assessment in vulnerable populations: Measurement challenges and recommendations." (AHRQ grant HS10333). Archives of Physical Medicine and Rehabilitation 84(Suppl. 2), pp. S35-S42.

Innovative techniques are required for collecting and evaluating data on health outcomes of vulnerable populations. Research is also needed to better understand the causal pathways linking vulnerability with health outcomes, note these authors. In this article, they focus on patients with a chronic illness (cancer) who also have low literacy and/or poor English language skills. They summarize the association among literacy, language, ethnicity, and health outcomes; describe innovative technologies to enhance communication; and discuss the advantage of using psychometric measurement models in health outcomes assessment. Finally, they offer specific recommendations for clinical practice and research to address medically underserved and vulnerable populations.

Hermann, R.C., and Provost, S. (2003, May). "Interpreting measurement data for quality improvement: Standards, means, norms, and benchmarks." (AHRQ grant HS10303). Psychiatric Services 54(5), pp. 655-657.

These authors discuss how to interpret measurement data to improve the quality of mental health care: standards, means, norms, and benchmarks. Each can be useful in measuring quality, identifying best practices, and improving care, note the researchers. They describe a common situation: a community mental health center decides to adopt a report card of performance measures to assess quality of care. The center selects measures that reflect the needs of its patient population and staff concerns about where care might fall short, for example, patients not completing prescribed courses of antidepressants. The center can compare its results with statewide or nationwide studies, as well as benchmarks for ideal care. However, local patient characteristics may influence results for reasons unrelated to quality of care, and require case-mix adjustment. Once clinicians identify an opportunity for improvement, they can look for possible interventions and continue to assess quality of care.

Herndon, B., Asch, S.M., Kilbourne, A.M., and others (2003, May). "Prevalence and predictors of HIV testing among a probability sample of homeless women in Los Angeles County." (AHRQ grant HS08323). Public Health Reports 118, pp. 261-269.

This 1997 interview survey of homeless women in Los Angeles County revealed that 68 percent of the women had an HIV test in the past year, and 1.6 percent of them had been diagnosed with HIV at some point. Women who had been pregnant in the past year were three times more likely and women with a regular source of care were twice as likely to have had HIV testing in the past year. About one-fourth of homeless women with indications for HIV testing had not been tested in the past year. The reported HIV seroprevalence of greater than 1 percent suggests that providers should offer and encourage HIV testing for all homeless women in LA County.

Joines, J.D., Hertz-Picciotto, I., Carey, T.S., and others (2003). "A spatial analysis of county-level variation in hospitalization rates for low back problems in North Carolina." (AHRQ grant HS06664). Social Science & Medicine 56, pp. 2541-2553.

This study examines geographic variation in hospitalization rates for low back problems, while controlling for special dependence in the data. The researchers calculated county-level surgical and medical hospitalization rates using North Carolina hospital discharge data from 1990-1992. They estimated both non-spatial and spatial regression models using socioeconomic and health resource predictors. Non-spatial models explained 62 percent of the variation in surgical rates and 66 percent of variation in medical rates. However, using simple contiguity spatial weights, surgery rates increased with higher percent urban population, primary care physician density, and discharge rate for other causes. They decreased with higher percent college graduates, percent disabled, and occupied and unoccupied hospital bed density. The authors conclude that spatial effects are important and should be considered in small area analyses.

Lautenbach, E., LaRosa, L., Marr, A.M., and others (2003, February). "Changes in the prevalence of vancomycin-resistant enterococci in response to antimicrobial formulary interventions: Impact of progressive restrictions on use of vancomycin and third-generation cephalosporins." (AHRQ grant HS10399). Clinical Infectious Diseases 36, pp. 440-446.

These researchers analyzed all clinical enterococcal isolates identified at a large medical center during a 10-year period to assess the impact of restricting use of vancomycin and third-generation cephalosporins on vancomycin-resistant enterococci (VRE) prevalence. They evaluated changes in VRE prevalence after sequential restrictions on use of these medications. They also examined correlation between antibiotic use and VRE prevalence. Vancomycin use initially decreased by 23.9 percent but returned to preintervention levels by the end of the study. Third-generation cephalosporin use decreased by 85.8 percent. However, VRE prevalence increased steadily from 17.4 percent to 29.6 percent during the 10-year period. Clindamycin use was significantly correlated with VRE prevalence.

Lynn, J., and Goldstein, N.E. (2003, May). "Advance care planning for fatal chronic illness: Avoiding commonplace errors and unwarranted suffering." (AHRQ grant HS11558). Annals of Internal Medicine 138, pp. 812-818.

Patients with terminal illnesses often receive routine treatments in response to health problems rather than treatments arising from planning that incorporate the patient's situation and preferences. This paper considers the case of an elderly man with advanced lung disease. He underwent mechanical ventilation and aggressive intensive care, in part, because his nursing home clinician did not complete an advance care plan and his do-not-resuscitate order did not accompany him to the hospital. The authors use this case as a foundation to discuss serious, recurring, and generally unnoticed errors in planning for care near the end of life and possible steps toward improvement.

Macinko, J., Starfield, B., and Shi, L., (2003, June). "The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998." (NRSA training grant T32 HS00029). Health Services Research 38(3), pp. 831-865.

These authors examined published studies and data from OECD Health Data 2001 to assess the contribution of primary care systems to a variety of outcomes in each of 18 wealthy OECD countries from 1970 to 1988. The strength of a country's primary care system was negatively associated with all-cause mortality, all-cause premature death, and cause-specific premature death from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease. This relationship was significant, albeit reduced in magnitude, even while controlling for determinants of population health (for example, percent of elderly and per capita income).

Meldon, S.W., Mion, L.C., Palmer, R.M., and others (2003, March). "A brief risk-stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department." (AHRQ grant HS09725). Academic Emergency Medicine 10, pp. 224-232.

The goal of this study was to evaluate the predictive ability of a simple six-item triage risk screening tool (TRST) to identify elderly emergency department (ED) patients at risk for ED revisits, hospitalization, or nursing home (NH) placement within 30 and 120 days following ED discharge. The researchers used the TRST to prospectively evaluate 650 community-dwelling elderly people who arrived at two urban EDs. Increasing cumulative TRST scores were associated with significant trends for ED use, hospital admission, or nursing home admission. Older ED patients with two or more risk factors on the TRST were at significantly increased risk for subsequent ED use, hospitalization, and nursing home admission.

Neumayer, L., Jonasson, O., Fitzgibbons, Jr., R., and others (2003, May). "Tension-free inguinal hernia repair: The design of a trial to compare open and laparoscopic surgical techniques." (AHRQ grant HS09860). Journal of the American College of Surgeons 196, pp. 743-752.

This multicenter clinical trial plans to randomize 2,200 men with inguinal hernias to either open tension-free inguinal hernia repair or laparoscopic tension-free repair. Randomization is stratified by hospital, whether the hernia is unilateral or bilateral, and whether the hernia is primary or recurrent. The researchers will compare patient outcomes over a minimum period of 2 years. When followup is complete, this study will provide data regarding both clinical (recurrence rates) and patient-centered outcomes.

Norman, G.R., Sloan, J.A., and Wyrwich, K.W. (2003). "Interpretation of changes in health-related quality of life." (AHRQ grant HS11635). Medical Care 41(5), pp. 582-592.

These investigators systematically reviewed the research literature to identify studies that computed a minimally important difference (MID) and contained sufficient information to compute an effect size (ES). Their goal was to determine whether there is consistency in the magnitude of MID estimates from different health-related quality of life (HRQOL) measures. For all but 6 of the 38 studies that met the criteria, the MID estimates were close to one half a standard deviation (SD). The researchers conclude that in most circumstances, the threshold of discrimination for changes in HRQOL for chronic diseases appears to be about half a SD.

Pekoz, E.A., Shwartz, M., Iezzoni, L.I., and others (2003). "Comparing the importance of disease rate versus practice style variations in explaining differences in small area hospitalization rates for two respiratory conditions." (AHRQ grant HS09832). Statistics in Medicine 22, pp. 1775-1786.

This paper describes a model-based approach for estimating the relative importance of the practice style effect (chance that patients diagnosed with a disease are admitted to a hospital) and the disease effect (geographic differences in the total amount of diagnosed disease) in explaining small area variations in hospitalization rates for two respiratory conditions (chronic bronchitis and emphysema and bacterial pneumonia). The researchers used 1997 Medicare data on both inpatient and outpatient visits across 71 small areas in Massachusetts. Results showed that for the two conditions, disease rate variation explained at least as much of the variation in hospitalization rates as did practice style variation.

Reeves, S.W., Tielsch, J.M., Katz, J., and others (2003, May). "A self-administered health questionnaire for the preoperative risk stratification of patients undergoing cataract surgery." (AHRQ grant HS08433). American Journal of Ophthalmology 135, pp. 599-606.

A self-administered health status questionnaire completed by candidates for cataract surgery can help identify patients with coexisting medical conditions and those at risk for adverse intraoperative and postoperative medical problems, concludes this study. The investigators analyzed data from a large, randomized clinical trial of 19,250 cataract surgeries performed between 1995 and 1997. They obtained preoperative data from a self-administered patient health questionnaire and a history and physical form completed by the patient's physician. Responses to 21 questions on the questionnaire were highly specific for 12 comorbid conditions identified by the physician history and physical.

Schneeweiss, S., Manstetten, A., Wildner, M., and others (2003, January). "Costs of measuring outcomes of acute hospital care in a longitudinal outcomes measurement system." (AHRQ grant HS09855). American Journal of Medical Quality 18(1), pp. 3-9.

The goal of this study was to evaluate the personnel and financial resources spent for a prospective assessment of outcomes of acute hospital care by health professionals in internal medicine. The study included 15 primary care hospitals and 2,005 patients over an average 6-month assessment period. Results showed that the total estimated cost for each hospital to assess outcomes of care for accreditation would be £9,700 and that continuous monitoring of outcomes would cost £12,400 per year. The researchers conclude that outcomes of acute hospital care can be assessed with limited resources, and that standardized training programs would reduce variability in overall costs.

Sutton, K., Logue, E., Jarjoura, D., and others (2003, May). "Assessing dietary and exercise stage of change to optimize weight loss interventions." (AHRQ grant HS08803). Obesity Research 11(5), pp. 641-652.

This study describes a multi-item algorithm of stage of change (SOC) for weight loss-related behaviors. The investigators collected data from participants randomly assigned to the treatment arm of a clinical trial comparing an SOC-based, cognitive-behavioral intervention (in which the intervention is geared to the patient's stage of readiness to change) with enhanced usual care for weight loss. Fifty percent fewer patients were classified in action or maintenance for dietary fat intake and portion control by the multiple-item algorithms, providing staging more consistent with the clinical presentation of obese individuals. For weight-loss interventions that target portion control and decreased fat intake, the multi-item SOC algorithms seem to be better guides for matching treatments to SOC, conclude the researchers.

Tallia, A.F., Stange, K.C., McDaniel, R.R., and others (2003, January). "Understanding organizational designs of primary care practices." (AHRQ grant HS08776). Journal of Healthcare Management 48(1), pp. 45-61.

These authors performed an in-depth case study of the organizational design of 18 family practices, including nine affiliated with five separate hospital systems. Results revealed a great variety in the organizational design of primary care practices. This variety appears to be influenced by the initial conditions under which the practice was organized. Hospital system design in and of itself did not predict the design of affiliated practices. However, hospital systems that allowed greater flexibility of practice organizational designs were more effective at integrating and managing practices.

Taxis, K., and Schneeweiss, S. (2003). "Frequency and predictors of drug therapy interruptions after hospital discharge under physician drug budgets in Germany." (AHRQ grant HS10881). International Journal of Clinical Pharmacology and Therapeutics 41(2), pp. 77-82.

This survey of 890 hospitalized patients found that discontinuation of drug therapy after hospital discharge was common, with the high costs of prescription drugs the most common reason. Overall, 95 percent of patients used prescription drugs at discharge. Of those, drug therapy was interrupted in 14 percent of patients. Reasons for discontinuation included excessive drug costs (54 percent), excessive number of drugs prescribed (26 percent), and differences in judgment on the clinical appropriateness of a drug (19 percent). Patients with gastroduodenal ulcer disease were more likely to discontinue medication after hospital discharge. Discontinuation also tended to be more likely in elderly patients but was slightly less likely in male patients.

Wolinsky, F.D., Wyrwich, K.W., Kroenke, K., and others (2003). "9-11, personal stress, mental health, and sense of control among older adults." (AHRQ grant HS09692, HS07632). Journal of Gerontology: Social Sciences 58B(3), pp. S146-S150.

Older adults who worked for pay, had a comfortable income, and reported greater religiosity were more likely than other older adults to lose a sense of control as a result of the September 11, 2001, terrorist attacks on the World Trade Center and the Pentagon, according to these authors. The increased risk of loss of control among this group may reflect the greater affinity of older adults with these characteristics for the "just world" perspective, which was shattered by the event, and the similarity of the 9/11 victims to themselves. These findings are based on six bimonthly followup interviews—three before 9/11 and three afterwards—with 1,662 patients from several outpatient facilities, as part of a larger study of a clinically relevant change in health-related quality of life. The researchers measured personal stress, mental health, and sense of control at each interview; 291 patients completed all six interviews. There were no noticeable changes in trends for personal stress or mental health associated with 9/11. However, 9/11 was associated with an aggregate decline in sense of control. This decline was greater among those who were working for pay, had more comfortable incomes, and reported being more religious.

Current as of August 2003
AHRQ Publication No. 03-0043