Research Activitie Newsletter. November 2008, No. 339

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					                                              RESEARCH
                                              ACTIVITIES
                                              U.S. Department of Health and Human Services • No. 339, November 2008




Highlights                                      AHRQ awards $3 million to help reduce central
                                                line-associated bloodstream infections
Departments
Patient Safety and Quality . . 2
                                                     he Agency for Healthcare          30,000 to 62,000 patients who get
Child/Adolescent Health . . . . 3

Women’s Health . . . . . . . . . . . 5
                                              T      Research and Quality
                                                     (AHRQ) has awarded nearly
                                              $3 million for a contract to help
                                                                                       the infections die as a result,
                                                                                       according to the Centers for
                                                                                       Disease Control and Prevention.
                                              reduce central line-associated              The comprehensive program,
Elderly/Long-Term Care . . . . 6              bloodstream infections in hospital       designed to survey and improve an
                                              intensive care units (ICUs) by           intensive care unit’s patient safety
Disparities/Minority Health . . 9             spreading the knowledge gained           culture, was developed by
                                              from a previous AHRQ-funded              researchers at the Johns Hopkins
Outcomes/Effectiveness
                                              project. The Health Research &           University and has been used in
Research . . . . . . . . . . . . . . . . 10                                            more than 100 ICUs in Michigan.
                                              Educational Trust, an affiliate of the
                                              American Hospital Association, has       The program includes tools to help
Mental Health . . . . . . . . . . . . 13
                                              been selected to coordinate the new      health care professionals identify
Primary Care Research . . . . 14              3-year project, which is part of an      opportunities to reduce potential
                                              AHRQ initiative to reduce health         health care-associated infections
Pharmaceutical Research . . 17                care-associated infections.              and implement policies to make
                                                 The project will continue work        care safer. Within 3 months of
Health Care Costs and                         started by the Johns Hopkins             implementation in Michigan, the
Financing. . . . . . . . . . . . . . . . 18   University in Baltimore and the          program helped reduce infection
                                              Michigan Health & Hospital               rates to zero in more than 50
Public Health                                 Association to implement a               percent of participating hospitals.
Preparedness . . . . . . . . . . . . 20       comprehensive unit-based patient            The project will be funded
                                              safety program to help prevent           through AHRQ’s Accelerating
Complementary/Alternative                     infections related to the use of         Change and Transformation in
Medicine . . . . . . . . . . . . . . . . 20   central line catheters. Often            Organizations and Networks
                                              referred to as central venous            initiative, an implementation model
Regular Features                              catheters, central line catheters are    of field-based research designed to
                                              tubes placed into a large vein in a      promote innovation in health care
Agency News and Notes . . . 21                patient’s neck, chest, or groin to       delivery by accelerating the
                                              administer medication or fluids or       diffusion of research into practice.
Announcements . . . . . . . . . . 23          to collect blood samples. Each year,     For more information on AHRQ’s
                                              an estimated 250,000 cases of            patient safety research, visit
Research Briefs . . . . . . . . . . 26        central line-associated bloodstream      http://www.ahrq.gov/qual/
                                              infections occur in hospitals in the     errorsix.htm. I
                                              United States, and an estimated



                                                             Advancing Excellence in Health Care
Patient Safety and Quality

Organizational style influences clinical departmental differences
in dealing with patient safety
         ow physicians deal with           and resident physicians in the            group learning or reflection on

H        patient safety and medical
         errors depends, in large part,
on how their clinical department is
                                           surgery, medical ICU, and
                                           emergency departments at an
                                           academic medical center. He looked
                                                                                     errors, and its hierarchical structure
                                                                                     tended to place the blame for errors
                                                                                     on individuals. Although the
organized and the flow of work in it.      at permeability (the speed and ease       physicians in the emergency
For example, the hierarchical structure    with which both physicians and            department also had little time for
of the surgery department and its          patients moved in and out of a            reflection, the department had a
emphasis on individual blame for           clinical setting), the complexity and     nonhierarchical style and accepted
mistakes contrasts with the more           predictability of the clinical work,      that errors sometimes were due to
collegial environment, available           the extent and quality of time            factors beyond the physician’s
physician downtime, and work               available for physicians to do and        control. For change in patient safety
predictability of the medical intensive    reflect on the clinical work, social      behavior to occur, there must be an
care unit (ICU). The emergency             relations between physicians in each      understanding of the context of the
department, though the most                setting, and specifics of the clinical    work environment in a particular
egalitarian, suffers from intense          workload.                                 clinical setting, and of the
workload, excessive disruptions, and          On the basis of Dr. Hoff’s             interventions most likely to improve
high unpredictability of its clinical      observations, the medical ICU             patient safety in each setting,
work. Each of these factors influences     appeared to have the highest              suggests Dr. Hoff. His study was
the ability of the clinical unit to        potential capacity for dealing with       funded by the Agency for
respond to medical errors effectively.     patient safety and quality of care.       Healthcare Research and Quality
   To determine the differences            This was due, in part, to much            (HS11697).
between the work environments in           “downtime” for the ICU physicians            More details are in “How work
these clinical units, Timothy J. Hoff,     to discuss medical errors that            context shapes physician approach
Ph.D., of the University of Albany         happened or were caught before any        to safety and error,” by Dr. Hoff, in
(State University of New York),            injury to the patient occurred. In        the April–June 2007 Quality
observed and interviewed (over             contrast, the physicians on the           Management in Health Care 17(2),
three 3-week periods) the attending        surgical unit had little time for         pp. 140–153. I


 Research Activities is a digest of research findings that have been produced with    Also in this issue:
 support from the Agency for Healthcare Research and Quality. Research Activities
 is published by AHRQ’s Office of Communications and Knowledge Transfer. The          Helping children manage their
 information in Research Activities is intended to contribute to the policymaking     weight, see page 4
 process, not to make policy. The views expressed herein do not necessarily
 represent the views or policies of the Agency for Healthcare Research and            Risk of pressure ulcers in
 Quality, the Public Health Service, or the Department of Health and Human            nursing home patients,
 Services. For further information, contact:                                          see page 7

                                                                                      Prostate removal among elderly
 AHRQ                                     Gail Makulowich
                                                                                      men with prostate cancer,
 Office of Communications                 Assistant Managing Editor
                                                                                      see page 10
   and Knowledge Transfer                 Mark Stanton, Karen Fleming-Michael,
 540 Gaither Road                         David Lewin                                 Depression and screening for
 Rockville, MD 20850                      Contributing Editors                        alcohol misuse, see page 13
 (301) 427-1360                           Joel Boches
                                                                                      Prescription medication
                                          Design and Production
 Barbara L. Kass, MPH, CHES                                                           differences between women and
                                          Karen Migdail
 Managing Editor                                                                      men, see page 17
                                          Media Inquiries




2
Number 339, November 2008                                                                            http://www.ahrq.gov/
The rate of care quality improvement has slowed, but nurses are
well-positioned to advocate for quality, equitable care
       he rate of quality improvement in care has slowed.    included how many Medicare surgery patients had not

T      Nurses, in particular, are well-positioned to
       advocate on behalf of all patients for higher
quality, more equitable care. Agency for Healthcare
                                                             received timely antibiotics to prevention infection, the
                                                             portion of elderly patients who had been given
                                                             potentially harmful prescription drugs, or how many
Research and Quality (AHRQ) researchers, Karen Ho,           patients developed post-surgery complications.
M.H.S., and Jeffrey Brady, M.D., M.P.H., along with             There were notable opportunities for improvement
AHRQ director Carolyn M. Clancy, M.D., summarize             such as the lack of improvement in communication
findings from the fifth annual National Healthcare           between hospital patients and their physicians and
Quality Report and National Healthcare Disparities           nurses about new medications and discharge
Report to underscore the slow progress in quality            information, which even worsened for some age groups
improvement in a recent commentary. The reports              between 2005 and 2007. Also troubling was the lack of
showed that while some areas of health care made             diversity among the nursing workforce; nearly 82
important gains, overall quality improved by an average      percent of registered nurses (RNs) in 2004 were white.
of only 1.5 percent per year between 2000 and 2005.          However, the number of racial/ethnic minority RNs
This took place despite ongoing efforts around the           increased threefold from 1980 to 2004 from 119,512 to
country to improve care quality and reduce disparities.      311,177.
   The 2007 reports showed some notable gains, such             More details are in “Improving quality and reducing
as the portion of heart attack patients who received         disparities: The role of nurses,” by Ms. Ho, Dr. Brady,
recommended tests, medications, or counseling to quit        and Dr. Clancy, in the July-September Journal of
smoking, and the reduction in disparities in childhood       Nursing Care Quality 23(3), pp. 185-188. Reprints
vaccines among blacks, Asians, and Hispanics.                (AHRQ Publication No. 08-R085) are available from
Measures of patient safety, however, showed an average       AHRQ.* I
annual improvement of only 1 percent. These areas


  Child/Adolescent Health
Infant health determines parental satisfaction with neonatal
intensive care
       arental satisfaction with the     California. The infants had no major   most were satisfied with the NICU

P      care their newborn infant
       receives in the neonatal
intensive care unit (NICU) is
                                         anomalies or chromosomal disorders
                                         and were born between 30 and 34
                                         weeks of gestation.
                                                                                care. However, satisfaction with
                                                                                care varied significantly by
                                                                                hospital. Neither infertility
primarily due to the infant’s health 3      The parents were asked about        treatments, cesarean delivery, or
months after hospital discharge rather   care satisfaction 3 months after the   other delivery-related treatments
than to NICU treatments or neonatal      infant’s discharge and about issues    affected parental satisfaction. Most
complications, according to a new        such as the NICU staff’s emotional     of the infants did not experience
study. In contrast to what many          support, information, or education.    neonatal complications. Thus, there
clinicians might think, the infant’s     They were also asked to rate their     was little need for NICU
severity of illness and medical care     child’s health, subsequent care use,   interventions such as mechanical
received had far less impact, notes      sociodemographic characteristics,      ventilation, which nevertheless
Marie C. McCormick, M.D., Sc.D.,         and mother’s history of infertility    were not associated with parental
of the Harvard School of Public          treatment. The researchers used        satisfaction. All of the factors
Health. She and colleagues examined      medical charts to identify NICU        studied explained only a modest 19
factors influencing parental             interventions.                         percent of varied satisfaction rates
satisfaction with NICU care for 677         Of the 621 predominantly white,     among the 10 NICUs studied. This
moderately premature infants in 10       well-educated older mothers who        suggests the need for more studies
hospitals in Massachusetts and           completed the satisfaction survey,



                                                                                                                     3
                                                                                               continued on page 4




 http://www.ahrq.gov/                                                                      Number 339, November 2008
Infant health                             Healthcare Research and Quality        Dr. McCormick, Gabriel J. Escobar,
continued from page 3                     (HS10131).                             M.D., Zheng Zheng, B.S., and
to better understand factors                 See “Factors influencing parental   Douglas K. Richardson, M.D.,
                                          satisfaction with neonatal intensive   M.B.A., in the June 2008 Pediatrics
                                                                                 121(6), pp. 1111-1118. I
affecting parental satisfaction with
NICU care. The study was                  care among the families of
supported by the Agency for               moderately premature infants,” by


Behavioral modification programs help obese children manage
their weight
         bese school-age kids and teens can lose weight or    of 14 pounds, compared with a 4.2-pound weight gain

O        prevent further weight gain if they participate in
         medium- to high-intensity behavioral
management programs, according to a new report
                                                              among those who took a placebo. In another trial,
                                                              adolescents who took orlistat as part of their weight
                                                              management program gained an average of 1.2 pounds,
released by the Agency for Healthcare Research and            compared with their peers who took a placebo and
Quality (AHRQ). The new report, Effectiveness of              gained nearly 7 pounds.
Weight Management Programs in Children and                       While there were no reported harms from behavioral
Adolescents, found that after completing weight               intervention alone, there were side effects from
management programs, obese children weigh between             prescription drugs. These included mild increases in
3 pounds and 23 pounds less, on average, than obese           heart rate or blood pressure from the use of
children not involved in such programs. Among those           sibutramine. Among those taking orlistat, up to one-
enrolled, the weight difference is greatest among             third reported abdominal pain, oily spotting, or fecal
heavier children as well as in those enrolled in more         urgency; 9 percent reported fecal incontinence.
intensive programs. Researchers also found that weight           The report, Effectiveness of Weight Management
improvements could be maintained for up to a year             Programs in Children and Adolescents, (Publication
after the program ended.                                      No. 08-E014) is available at www.ahrq.gov/clinic/
   The report also showed that adding prescription            tp/chwghttp.htm and can also be ordered directly from
drugs to a behavioral weight management program               the AHRQ Clearinghouse.*
helped extremely obese adolescents lose weight.                  Editor’s note: AHRQ also has a free DVD for
However, no studies evaluated maintenance of weight           families and children aged 5 to 9 called Max’s Magical
loss after drug treatment ended.                              Delivery: Fit for Kids (Product No. 04-0088-DVD).
   The two primary drugs reviewed were sibutramine            The 30-minute DVD teaches children and their parents
(Meridia®), which is an appetite suppressant, and             about smart eating and physical activity. Copies can be
orlistat (Xenical®), which helps block fat absorption. In     ordered electronically at www.ahrq.gov/child/
one 12-month study, adolescents taking sibutramine as         dvdobesity.htm or from the AHRQ Clearinghouse.* I
part of a weight management program lost an average




 Visit the AHRQ Patient Safety Network Web Site
 AHRQ’s national Web site—the AHRQ Patient Safety Network, or AHRQ PSNet—continues to be a valuable
 gateway to resources for improving patient safety and preventing medical errors and is the first comprehensive
 effort to help health care providers, administrators, and consumers learn about all aspects of patient safety. The
 Web site includes summaries of tools and findings related to patient safety research, information on upcoming
 meetings and conferences, and annotated links to articles, books, and reports. Readers can customize the site
 around their unique interests and needs through the Web site’s unique “My PSNet” feature. To visit the AHRQ
 PSNet Web site, go to http://psnet.ahrq.gov/.




4
Number 339, November 2008                                                                       http://www.ahrq.gov/
Bronchiolitis-related outpatient and hospital visits have risen
markedly among Medicaid-insured infants in Tennessee
        he number of Medicaid-            explain the researchers. They              infants of mothers 20 to 29 years of

T       insured infants in Tennessee
        seeking medical care for
bronchiolitis has risen markedly,
                                          retrospectively studied 103,670
                                          term, non-low-birth weight infants
                                          enrolled in Tennessee Medicaid
                                                                                     age, infants of mothers 15 to 19
                                                                                     years of age had a small increased
                                                                                     risk of having a bronchiolitis visit,
reveals a new study. Bronchiolitis is a   from 1995-2003, and identified             whereas infants of older mothers
lower respiratory tract infection         their health care visits for               (30-39 and 40-44) were less likely
caused by respiratory syncytial virus     bronchiolitis in the first year of life.   to have a visit for the illness.
(RSV) and other viruses. The              The researchers examined risk              Higher infant birth weight was
infection causes coughing, wheezing,      factors for bronchiolitis during           another protective factor. The study
abnormally rapid breathing, and/or        infancy and rates of various types         was supported in part by the
rales (crackling sounds that indicate     of health care for the disease.            Agency for Healthcare Research
fluid in the air sacs of the lungs).         During the 9-year study period,         and Quality (HS10384).
RSV infects most children in the first    rates of bronchiolitis visits were            See “Increasing burden and risk
year of life and typically causes         238 outpatient visits, 77 emergency        factors for bronchiolitis-related
yearly epidemics of bronchiolitis         department (ED) visits, and 71             medical visits in infants enrolled in
between November and April,               hospitalizations per 1,000 infant-         a state health care insurance plan,”
resulting in about 80,000 infant          years. However, average annual             by Kecia N. Carroll, M.D., M.P.H.,
hospitalizations per year.                rates for bronchiolitis visits jumped      Tebeb Gebretsadik, M.P.H., Marie
   Although the majority of infants       41 percent, from 188 visits per            R. Griffin, M.D., M.P.H., and others
affected are generally healthy,           1,000 infant-years to 265 visits per       in the July 2008 Pediatrics 122, pp.
younger maternal age and lower            1,000 infant-years from 1996-1997          58-64. I
birth weight are risk factors,            to 2002-2003. Compared with



Women’s Health

Less receipt of effective treatment by elderly black women with
ovarian cancer may underlie their poorer survival
           ost women with ovarian cancer are diagnosed         the followup period than those who did not, regardless

M          with late-stage disease with poor survival rates
           due to lack of obvious cancer symptoms and an
effective screening tool. Several studies have shown that
                                                               of race. Yet, fewer blacks received chemotherapy than
                                                               whites (50 vs. 65 percent).
                                                                  Socioeconomic status played a role in ethnic
black women are less likely to receive recommended             variations in receipt of these treatments. There was no
chemotherapy in addition to surgery for advanced ovarian       significant difference in survival between black and
cancer than white, Hispanic, or Asian women, which may         white women with ovarian cancer after controlling for
contribute to their poorer survival, suggests a new study.     patient demographics, tumor characteristics, and
   A University of Texas team led by Xianglin L. Du,           treatments. The study was supported by the Agency for
M.D., Ph.D., studied 5,131 elderly women diagnosed             Healthcare Research and Quality (HS16743).
with ovarian cancer between 1992 and 1999 with up to              More details are in “Ethnic differences in
11 years of followup. Overall, 72 percent of white             socioeconomic status, diagnosis, treatment, and
women and 70 percent of black women were diagnosed             survival among older women with epithelial ovarian
with advanced stage disease (stage 3 or 4). Of the             cancer,” by Dr. Du, Charlotte C. Sun, Dr.PH, Michael
4,264 women with stage 4 disease, those who                    R. Milam, M.D., and others, in the International
underwent ovarian surgery and received adjuvant                Journal of Gynecological Cancer 18, pp. 660-669,
chemotherapy were 50 percent less likely to die during         2008. I




                                                                                                                      5
 http://www.ahrq.gov/                                                                          Number 339, November 2008
 Centers that offer screening mammograms only and have a
 breast specialist on site provide more accurate readings
            any studies have explored      diagnostic mammograms, had a           facilities that offer the best quality

 M          how the characteristics of
            women and radiologists
 affect the accuracy of mammogram
                                           breast imaging specialist on staff,
                                           and conducted audits of
                                           radiologists’ performance two or
                                                                                  in screening mammograms
                                                                                  because, while they can usually
                                                                                  control what mammography
 interpretation. In a recent study,        more times a year. Facility            facility is visited, they cannot
 researchers examined how                  mammography volume did not             control who will read the
 variations in the actual facility         appear to affect accuracy after the    mammogram. This study was
 providing the mammogram affect            volume of radiologists was taken       funded in part by the Agency for
 the results. They reviewed 5 years        into consideration.                    Healthcare Research and Quality
 of mammogram data and results of             Researchers were also surprised     (HS10591).
 surveys received from 43 facilities       that having two or more                   See “Mammography facility
 and their 128 radiologists from the       radiologists read mammograms           characteristics associated with
 Pacific Northwest, New Hampshire,         (double reading) did not increase      interpretive accuracy of screening
 and Colorado. The researchers             accuracy rates, because this           mammography,” by Stephen
 controlled for patient characteristics,   finding contradicts earlier studies.   Taplin, M.D., M.P.H., Linn
 such as breast density, age, and time     They suggest that either double        Abraham, M.S., William E.
 between mammograms, and                   reading may not be effectively         Barlow, Ph.D., and others in the
 radiologist characteristics, such as      employed at the facilities studied     June 18, 2008 Journal of the
 years of experience in reading            or the team’s definition of double-    National Cancer Institute 100(12),
 mammograms and the volume of              reading did not include methods        pp. 876-887. I
 mammograms read.                          that do work.
    The most accurate facilities              These findings can assist
 offered screening but not                 physicians and women in choosing



Elderly/Long-Term Care

Hospital stay duration and cost for the elderly with non-dementia
psychiatric illnesses varies by care settings
           hile dementia is the psychiatric illness most         Mean inpatient length of stay for NDPI illnesses fell

W          often associated with elderly hospitalizations,
           other conditions, such as depression, bipolar
disorder, and substance abuse, also often require inpatient
                                                              from nearly 14.9 days in 1992 to just 12.1 days in
                                                              2002. Similarly, mean Medicare expenditures per stay
                                                              declined from $8,461 to $6,207. The authors point out
treatment. General hospitals, psychiatric units, long-stay    that these declines occurred during a period of
hospitals, and skilled nursing facilities (SNFs) are the      increased use of outpatient service and drug therapy.
inpatient settings where these conditions, called non-           Each of the four types of facilities treating these
dementia psychiatric illnesses (NDPI), are treated.           patients was impacted differently during the 10-year
Medicare’s cost-cutting reimbursement strategies and caps     period. The portion of NDPI stays that were in general
on stay lengths in addition to treatment advances have        hospitals fell from 34.5 percent to 27.4 percent, and the
affected how the elderly receive their care, a new study      portion in long-stay hospitals fell from 19.5 percent to
finds. Researchers used Centers for Medicare and              11.3 percent. Except for SNFs, all facility types saw
Medicaid Services data from 1992 to 2002 to study if the      mean Medicare expenditures, covered days, and
decline in Medicare hospital admissions and expenditures      beneficiary expenditures per NDPI stay fall from 1992
that occurred in the 1990s continued into the following       to 2002. However, SNFs witnessed mean Medicare-
decade for this group of patients.                            covered days per NDPI stay remain stable, while mean
                                                                                                  continued on page 7



6
Number 339, November 2008                                                                          http://www.ahrq.gov/
Hospital stay duration                                            was funded in part by the Agency for Healthcare
continued from page 6                                             Research and Quality (HS16097).
Medicare-covered costs rose from $4,153 to $6,375.                   See “Medicare inpatient treatment for elderly non-
These increases may result from more SNFs becoming                dementia psychiatric illnesses 1992-2002; length of
certified by Medicare (the number of certified SNFs               stay and expenditures by facility type,” by Donald R.
rose from nearly 4,000 in 1992 to more than 6,800 in              Hoover, Ph.D., M.P.H., Ayse Akincigil, Ph.D., Jonathan
2002). Thus, these SNFs could be reimbursed by                    D. Prince, Ph.D., and others in the July 2008
                                                                  Administration and Policy in Mental Health 35(4), pp.
                                                                  231-240. I
Medicare for services at a higher rate than they would
be for services provided under Medicaid. This study


Some U.S. nursing homes need more specific evacuation plans
to better respond to natural or other disasters
     n the wake of Hurricane Katrina,       evacuation plans, and fire drills) to     plans, 2.1 percent in staff training,

I    residents at 5 of 13 Louisiana
     nursing homes suffered adverse
effects such as dehydration,
                                            determine the types of nursing
                                            homes cited for deficiencies in their
                                            evacuation plans. They also
                                                                                      1.2 percent in written evacuation
                                                                                      plans, and 7.9 percent in fire drills.
                                                                                      Only 3 percent of nursing homes
depression, and skin tears, which           surveyed nursing home                     were compliant with all 25
were primarily attributed to lack of        administrators in 2006 about their        evacuation plan requirements. For-
effective emergency planning.               evacuation plans.                         profit nursing homes were more
Indeed, some nursing homes lack a              In general, most nursing homes         likely, and those with a higher
critical part of emergency                  were well prepared to shelter in          average Medicaid census and with a
planning—specific evacuation plans,         place. Most facilities (86 percent)       high percentage of residents with
concludes a new study. U.S. nursing         had a hazard analysis plan to ensure      dementia were less likely to be
homes are subject to citations and          water supply (96 percent) and had         cited for evacuation plan
fines for care deficiencies if the          detailed evacuation procedures (92        deficiencies. The study was
Medicare or Medicaid survey and             percent). Fewer facilities had a          supported in part by the Agency for
certification process determines that       procedure to meet specific resident       Healthcare Research and Quality
they do not have adequate written           needs (37 percent), a plan for            (HS16547).
evacuation plans.                           serving as a host facility (63               See “Nursing home evacuation
   The University of Pittsburgh             percent), and an evacuation route         plans,” by Nicholas G. Castle,
study analyzed national data from           (31 percent). The rate of citations       Ph.D., M.H.A., A.G.S.F, in the July
1997 to 2005 on 2,134 nursing               was relatively stable throughout the      2008 American Journal of Public
homes for 4 specific deficiency             study period. Each year about 0.6         Health 98(7), pp. 1235-1240. I
citations (written emergency plans,         percent of facilities were found to
staff emergency training, written           be deficient in written emergency


New care tracking tool helps identify nursing home patients at
risk for pressure ulcers
         espite knowledge of clinical guidelines to prevent       integrate into their current processes and structures,

D        and treat pressure ulcers among nursing home
         residents, it remains difficult for staff to integrate
this knowledge into their daily work. A new pressure
                                                                  explains AHRQ researcher William Spector, Ph.D.
                                                                     The tools include a daily care documentation form
                                                                  completed by certified nursing assistants (CNAs), an
ulcer reduction program, the On-Time Quality                      audit report of the form’s completeness, and four
Improvement for Long Term Care (On-Time), was                     weekly clinical reports that help identify residents at
developed by the Agency for Healthcare Research and               high risk for developing pressure ulcers. The heart of
Quality (AHRQ) with support from the California Health            the program lies in the CNA daily reports on care
Care Foundation, to close the gap between staff                   relevant to pressure ulcer risk factors such as nutrition
knowledge and staff practice. The On-Time program uses            and behavior. The data are stored in a database, which
a set of newly developed tools that staff may adapt and                                               continued on page 8



                                                                                                                            7
 http://www.ahrq.gov/                                                                            Number 339, November 2008
Pressure ulcers                                               residents over time, help staff monitor the effectiveness
continued from page 7                                         of care in a timely fashion, and foster teamwork and
then produces clinical reports that can be used by            communication. Two preliminary evaluations of the
nurses, dietitians, physicians, and other professionals       program showed that it reduced high-risk pressure ulcer
providing resident care.                                      quality measures by 33 percent in a span of 18 months
   The reports summarize information about residents’         and 13 percent in 6 months. Reprints (AHRQ
nutritional status, behavior, pressure ulcer triggers         Publication No. 08-R084) are available from AHRQ.*
(such as substantial weight loss, daily urinary                  See “Pressure ulcer plan is working,” by Sandra
incontinence, or presence of a Foley catheter), and           Hudak, M.S., R.N., Siobhan Sharkey, M.B.A., Michal
                                                              Engleman, M.H.S., and others, in the May 2008
                                                              Provider, pp. 34-39. I
priority areas for intervention. The On-Time reports
identify residents at highest risk for pressure ulcer
development, show trends in outcomes for these


Changes in cost to patients reduce new use of antidepressants
among the elderly, but have less impact on continued use
        reater cost-sharing               requiring patients to pay a 25          increase over time. Introduction of

G       requirements reduce the
        likelihood that elderly adults
with depression will begin using
                                          percent coinsurance once an
                                          income-based deductible was met.
                                          This “natural experiment” allowed
                                                                                  coinsurance in May 2003 reduced
                                                                                  the rate of increase per month by
                                                                                  0.03 per 1,000 seniors.
needed antidepressant medications,        the researchers to study the effect        Depression is thought to be
but has little effect on those who are    of the cost changes on the starting,    undertreated among seniors in the
already taking such medications,          usage, and stopping of                  United States, and programs have
according to a new study. The             antidepressant therapy by British       been developed to increase the use
researchers used two closely timed        Columbian seniors from January          of antidepressants in this
changes in costs to elderly patients in   1997 through December 2005.             population. To be effective, these
the Canadian Province of British          They found that, as the British         programs may need to take into
Columbia to shed light on the likely      Columbia health plan moved from         account (and perhaps intervene) to
impact of changes in prescription         complete coverage of prescriptions      counter the effects of patient cost
drug coverage in the United States as     to requiring a copayment and, later,    sharing on antidepressant use, the
persons go from private insurance         to coinsurance after meeting a          researchers concluded. The study
copayments (fixed payment per             deductible, the rate of initiation of   was funded in part by the Agency
prescription) for medications to          antidepressant therapy slowed           for Healthcare Research and
Medicare coinsurance (fixed               significantly. The level of             Quality (HS10881).
percentage of the cost per                antidepressant initiation increased        More details are in “The impact
prescription) with deductibles.           from 4.3 starts per 1,000 seniors       of cost sharing on antidepressant
   In January 2002, the British           per month in 1997 to 5.0 starts per     use among older adults in British
Columbia Government switched              1,000 in December 2001.                 Columbia,” by Philip S. Wang,
from paying the full cost of              Implementation of the copay policy      M.D., Dr.P.H., Amanda R. Patrick,
prescriptions for seniors to              in January 2002 reduced the             M.S., Colin R. Dormuth, Sc.D., and
requiring a copay of $25 Canadian         antidepressant therapy start level by   others, in the April 2008
($10 for low-income seniors). In          0.38 per 1,000 seniors per month        Psychiatric Services 59(4), pp.
May 2003, the program began               without changing the rate of            377–383. I



 Note: Only items marked with a single (*) asterisk are available from the AHRQ Clearinghouse. Items with a
 double asterisk (**) are available from the National Technical Information Service. See the back cover of
 Research Activities for ordering information. Consult a reference librarian for information on obtaining copies of
 articles not marked with an asterisk.




8
Number 339, November 2008                                                                        http://www.ahrq.gov/
Disparities/Minority Health

  Pediatricians show less implicit race bias than others
           lthough racial and ethnic       concepts that are more readily          medical care.” The pediatricians’

  A        disparities in care exist in
           pediatrics, pediatricians are
  less likely to harbor attitudes that
                                           associated mentally than concepts
                                           that are more weakly associated.
                                           To measure quality of care, they
                                                                                   Race Attitude IAT results revealed
                                                                                   a much smaller implicit preference
                                                                                   for whites relative to blacks than
  favor white Americans than other         asked the pediatricians how they        found with other physicians and
  physicians and individuals, suggests     would treat patients using four         the over one million individuals
  a new study. Implicit attitudes and      pediatric case vignettes (each were     who have taken the Race Attitude
  stereotypes are by nature outside of     given two black patients and two        IAT. On the Race and Compliant
  personal awareness, and may              white patients) to determine if         Patient, researchers found a
  unknowingly influence quality of         there were racial differences in        moderate “perceived compliance
  care. However, the University of         treatment recommendations for           and race” stereotype. The
  Washington researchers found no          pain control, management of             researchers did not find a strong
  link between pediatricians’ implicit     urinary tract infection, attention      relationship between difference in
  racial attitudes and stereotypes and     deficit hyperactivity disorder, and     treatment recommendations by
  quality of pediatric care, and they      asthma control.                         patient race (quality of care) and
  call for more studies to examine the        Most (82 percent) of the             implicit measures. The study was
  complex relationship between             surveyed pediatricians were white,      supported in part by the Agency
  implicit attitudes and stereotypes       and 93 percent were American-           for Healthcare Research and
  and medical care.                        born. The majority of pediatricians     Quality (HS15760).
     Researchers surveyed academic         reported no difference in feelings         More details are in “Physician
  pediatricians about their implicit       toward racial groups. However,          implicit attitudes and stereotypes
  and explicit racial attitudes and        when asked about patients in their      about race and quality of medical
  stereotypes using the Implicit           own practices, the pediatricians        care,” by Janice A. Sabin, Ph.D.,
  Association Test (IAT). The IAT          reported attitudes that strongly        M.S.W., Frederick P. Rivara, M.D.,
  asks test takers to quickly sort and     associated whites (but not blacks)      M.P.H., and Anthony G.
  categorize two pairs of images and       with the concept of “compliant          Greenwald, Ph.D., in the July 2008
  words, and it assumes that the test      patient,” and unexpectedly              Medical Care 46(7), pp. 678-685. I
  taker will more quickly sort             associated blacks with “preferred



Minority children are half as likely as white children to receive
specialized therapies
        new study finds that 3.8 percent of children who        MEPS, which collects national medical care use and

A       are 18 or younger obtain specialized therapies
        from the health care system. These include
physical, occupational, and speech therapy or home
                                                                expenditure data at the person and household levels.
                                                                   Functional limitations, chronic conditions, injuries,
                                                                or hospitalizations that lasted one or more days serve as
health services. When therapies provided through the            predictors for which children received therapies.
special education system are included in the total, the         Children most likely to use specialized therapies tend
percentage rises to just 4.3, indicating that the educational   to be male (59.7 percent), white (80.6 percent), and
system is not a large a provider of therapies. Researcher       have chronic conditions (38.8 percent). Black,
Karen Kuhlthau, Ph.D., of Massachusetts General                 Hispanic, and children from other non-Hispanic
Hospital and Harvard Medical School, and her colleagues         race/ethnic groups were much less likely to receive
used Medical Expenditure Panel Survey (MEPS) data to            therapies than white children. These results suggest that
examine therapy use for children and its indicators. The        either minority children are underusing therapies or
Agency for Healthcare Research and Quality sponsors                                               continued on page 10




                                                                                                                         9
 http://www.ahrq.gov/                                                                         Number 339, November 2008
Specialized therapies                                          expenditures for children in the top user category. The
continued from page 9                                          authors suggest that their study will assist policymakers
white children are overusing them, according to the            and insurers by providing evidence about the
researchers.                                                   determinants of specialized therapy use in different
   The average cost per child who used therapy was             settings. This study was funded in part by the Agency
$266 for physical or occupational therapy and $1,333           for Healthcare Research and Quality (HS13757).
for home health services. Costs for the top 10 percent            See “Correlates of therapy use and expenditures in
of therapy users averaged $997 for physical or                 children in the United States,” by Dr. Kuhlthau, Kristen
occupational therapy and $7,279 for home health                Hill, M.P.H., Christina Fluet, M.P.H., and others in the
                                                               April-June 2008 Developmental Neurorehabilitation
                                                               11(2), pp. 115-123. I
services. Therapy and home health service use
comprised nearly half (46 percent) of overall health


Outcomes/Effectiveness Research

 Prostate removal is better than radiation or watchful waiting for
 elderly men with local/regional prostate cancer
          adical prostatectomy (surgical   men who underwent radical                   Nevertheless, any benefit of

 R        removal of the prostate)
          prolongs survival more than
 radiation or watchful waiting for
                                           prostatectomy (81 percent),
                                           followed by radical prostatectomy
                                           in combination with radiotherapy
                                                                                    radical prostatectomy on survival
                                                                                    must be weighted against the
                                                                                    potential side effects of the surgery
 elderly men with local/regional           (67.6 percent), radiotherapy (60.5       such as impotence and urinary
 prostate cancer who have at least 10      percent), and watchful waiting           incontinence. The results may not
 years of life expectancy, concludes a     (50.7 percent). There was a similar      be generalizable to younger men
 new study. The University of Texas        pattern for 10-year prostate-            with prostate cancer. The study
 researchers followed up to nearly 12      specific cancer survival. After          was supported in part by the
 years 5,845 men who were diagnosed        adjusting for other factors affecting    Agency for Healthcare Research
 in 1992 with local/regional stage         mortality such as age, ethnicity,        and Quality (HS16743).
 prostate cancer at age 65-74 and who      hormone therapy, chemotherapy,              See “Long-term survival after
 were potential candidates for radical     and coexisting illnesses, men who        radical prostatectomy compared to
 prostatectomy. The researchers            underwent radical prostatectomy or       other treatments in older men with
 identified the men from the               radical prostatectomy plus               local/regional prostate cancer,” by
 population-based Surveillance,            radiation therapy were only one-         Liqian Liu, M.D., M.S., Ann L.
 Epidemiology, and End Results             third as likely to die from all          Coker, Ph.D., Xianglin L. Du,
 (SEER) and Medicare linked data.          causes as men who received               M.D., Ph.D., and others in the June
    Overall, 10-year all-cause             watchful waiting.                        2008 Journal of Surgical Oncology
 survival rates were the highest for                                                97, pp. 583-591. I



Study of the benefit of prophylactic antibiotics prior to major
surgery raises questions about pay for performance
         growing number of organizations are paying            Although most of the patients did get PA prior to surgery,

A        clinicians and hospitals for quality of care
         measures, such as achieving low rates of surgical
site infections (SSIs). Timely administration of
                                                               they did not receive it in a timely window (1 to 2 hours
                                                               prior to surgical incision). It may be that the metric for
                                                               timely antibiotic administration is too restrictive to be able
prophylactic antibiotics (PA) prior to major surgery is        to discriminate between PA practices that significantly
thought to reduce SSIs. However, a new study did not link      prevent SSIs, explain the researchers.
timely PA to overall patient or hospital SSI rates.                                                 continued on page 11



10
Number 339, November 2008                                                                             http://www.ahrq.gov/
Pay for performance                                               About 86 percent of patients received timely PA.
contiued from page 10                                          Overall, timely PA did not markedly contribute to
   They note that these data do not dispute the efficacy       overall patient or hospital SSI rates. In hospital-level
of timely PA administration for surgical procedures.           analysis, hospital case volume and hospital case mix
However, they do challenge whether this measure                were much more important predictors of hospital SSI
appropriately guides patients to higher quality hospitals      rate than the hospital’s rate of timely PA. The study was
and whether those hospitals and physicians should be           supported in part by the Agency for Healthcare
financially rewarded for performance. The investigators        Research and Quality (HS13852).
studied SSI rates for 9,195 elective orthopedic, colon,           More details are in “Association of timely
and vascular procedures performed in 95 Department             administration of prophylactic antibiotics for major
of Veterans Affairs hospitals. They compared patient           surgical procedures and surgical site infection,” by
and hospital data from the External Peer Review                Mary T. Hawn, M.D., M.P.H., F.A.C.S., Kamal M. Itani,
Program Surgical Care Improvement Project with                 M.D., F.A.C.S., Stephen H. Gray, M.D., and others, in
                                                               the May 2008 Journal of the American College of
                                                               Surgeons 206, pp. 814-821. I
matched data from the National Surgical Quality
Improvement Program data.

Pancreatic surgery with islet cell autotransplant is safe and
effective to treat the pain of chronic pancreatitis
       or appropriately selected              Pancreatic surgery without             At 6 months after surgery, 80 percent

F      patients, pancreatic surgery
       with autotransplantation of islet
cells (pancreatic cells that produce
                                           transplanting islet cells recovered
                                           from the patient’s own pancreas to
                                           their liver can create several
                                                                                     of reporting patients had decreased
                                                                                     or eliminated their use of narcotic
                                                                                     medication, and all total
insulin to regulate blood-sugar levels)    problems, explain the University of       pancreatectomy patients required
is a safe and effective treatment of       Alabama researchers. It can induce        insulin (mean of 23 units per day).
the intractable pain associated with       total insulin dependency (and             Also, patients still had a 13 percent
chronic inflammation of the pancreas       diabetes-related problems) as well as     weight loss, underscoring the need
(pancreatitis), concludes a new study.     the reduction or absence of other         for pancreatic enzymes to prevent
This condition, most often due to          regulatory hormones, resulting in         malabsorption. The study was
alcoholism, typically causes               “brittle” diabetes, an unstable           supported in part by the Agency for
intermittent anorexia, nausea,             metabolic state that is difficult to      Healthcare Research and Quality
vomiting, and abdominal pain. As the       control.                                  (T32 HS13852).
disease becomes severe, many                  The researchers retrospectively           See “Pancreatic resection with
patients become malnourished and           studied 21 patients who underwent         islet cell autotransplant for the
develop debilitating chronic               total pancreatic surgery and 6            treatment of severe chronic
abdominal pain. Surgery is usually         patients who underwent partial            pancreatitis,” by Joshua L. Argo,
recommended when medical                   removal of the pancreas with              M.D., Juan L. Contreras, M.D., Mary
management (with alcohol cessation,        autotransplantation of islet cells at 1   M. Welsey, M.P.H., and John D.
diet modification, pancreatic enzyme       hospital from April 2005 to               Christein, M.D., in the June 2008
replacement, and pain control) and         December 2007. They examined              The American Surgeon 74(6), pp.
endoscopic therapies for obstructing       medical charts and hospital clinical      530-537. I
stones or other problems don’t work.       databases to track patient outcomes.

Cirrhosis of the liver does not increase risk during surgical repair
of umbilical hernias, unless the procedure is an emergency
        epairing umbilical hernias before they create          (abdominal protrusions through the area of the belly

R       problems requiring emergency surgery may
        improve the overall outcomes for patients with
cirrhosis of the liver, according to a new study of patients
                                                               button) had increased morbidity and mortality compared
                                                               with patients without cirrhosis. In contrast, the new study
                                                               found no increased risk for patients with cirrhosis who
treated at Department of Veterans Affairs (VA) hospitals.      underwent the procedure as elective surgery, that is,
Earlier studies had shown that patients with cirrhosis who     when it was not an emergency.
underwent emergency surgery to repair umbilical hernias                                           continued on page 12


                                                                                                                     11
 http://www.ahrq.gov/                                                                          Number 339, November 2008
Umbilical hernias                                           percent) or repair of a recurrent hernia (11.8 percent)
continued from page 11                                      was significantly larger than for noncirrhotic patients
   Repair of umbilical hernias is relatively                (4.8 percent for emergency repair and 7.0 percent for
straightforward among patients considered to be good        recurrent repair). Complications after surgery occurred
surgical risks. In this group of patients, morbidity and    in 86 patients (6.1 percent); 6 deaths occurred within
mortality associated with the surgery is low. Because       30 days of the surgery, including 1 in a patient with
many surgeons consider patients with cirrhosis to be        cirrhosis. Patients with cirrhosis were significantly
high-risk, umbilical hernia repair is often delayed until   more likely than those without the condition to require
bowel-related complications occur, which only               bowel resection (8.7 percent versus 0.8 percent) or
increases the risk of surgery. To determine the influence   return to the operating room within 30 days of the
of elective versus emergency surgery on the outcome of      umbilical repair (7.9 percent versus 2.5 percent). The
umbilical hernia repair, the researchers looked at the      study was funded in part by the Agency for Healthcare
records for patients undergoing this procedure between      Research and Quality (T32 HS13852).
1998 and 2002 at 16 VA medical centers across the              More details are in “Umbilical herniorrhapy in
United States associated with surgical residency            cirrhosis: Improved outcomes with elective repair,” by
programs. Of the 1,421 procedures with enough               Stephen H. Gray, M.D., Catherine C. Vick, M.S., Laura
                                                            A. Graham, M.P.H., and others in the Journal of
                                                            Gastrointestinal Surgery 12(4), pp. 675–681, 2008. I
information for analysis (92.5 percent first-time repairs
and 7.5 percent rerepairs), 127 were in patients with
documented cirrhosis. The proportion of patients with
cirrhosis who underwent emergency repair (26.0


 Unplanned bowel resections during hernia operations lead to
 more complications and longer stays
        urgeons who set out to repair   who did not require resections.           Long-term steroid use was also

 S      a hernia caused by earlier
        surgeries (incisional hernia
 repair) at times end up also having
                                        These complications included
                                        wound infection (15), urinary tract
                                        infection (3), failing to wean from
                                                                               linked to unplanned bowel
                                                                               resections. The researchers suggest
                                                                               that these drugs may adversely
 to remove part of a patient’s bowels   ventilators (2), kidney problems       affect the tissues of the intestine,
 (enterotomy or unplanned bowel         (2), sepsis (2), and deep vein         putting them at risk for injury.
 resection). This additional            thrombosis (1). Unplanned bowel        They recommend patients who
 procedure leads to longer operating    resection nearly doubled operating     take steroids receive enemas
 room times, longer hospital stays,     room time, from 1.7 hours to 3.5       before undergoing elective hernia
 and increased chances for              hours, and caused the patients to      incision repairs. This study was
 complications after the surgery, a     spend 4 to 10 days in the hospital     funded in part by the Agency for
 new study finds.                       instead of 2 to 6.                     Healthcare Research and Quality
    Researchers reviewed records           Researchers found a strong link     (HS13852).
 of 1,124 patients who were             between unplanned bowel                   See “Risk of complications
 scheduled for elective incisional      resections and previous hernias        from enterotomy or unplanned
 hernia repair between January          that used mesh to hold in the          bowel resection during elective
 1998 and December 2008 at 16           bulging intestines. Foreign            hernia repair,” by Stephen H.
 Veterans Affairs medical centers.      materials often cause scar tissue      Gray, M.D., Catherine C. Vick,
 A total of 82 patients (7.3 percent)   that can damage the intestines.        M.S., Laura A. Graham, M.P.H.,
 required unplanned bowel               The researchers recommend future       and others in the June 2008
 resections. Thirty-two percent of      studies that examine newer mesh        Archives of Surgery 143(6), pp.
 patients who had bowel resections      products to see if these result in     582-586. I
 experienced complications after        fewer bowel injuries during
 surgery compared with 10 percent       surgery.




12
Number 339, November 2008                                                                      http://www.ahrq.gov/
Mental Health

Underserved blacks and Hispanics with depression often use
complementary and alternative medicine for their symptoms
         bout 5 to 10 percent of primary care patients          Among CAM users, biologically based practices

A        suffer from major depression, with another 16
         percent estimated to suffer from minor
depression. Primary care doctors who treat underserved
                                                             were the most often reported (58 percent), followed by
                                                             mind-body medicine (47 percent), manipulative and
                                                             body-based practices (9 percent), and whole medical
blacks and Hispanics with depression should be alert to      systems (8 percent). Nearly 13 percent of patients used
their frequent use of complementary and alternative          SAMe, St. John’s wort, or 5-hydroxytryptophan for
medicine (CAM) to manage their symptoms, suggests a          treatment of their depressive symptoms. Also, 22
new study. A team of California researchers analyzed         percent reported using a relaxation technique, and one
surveys and medical records of 315 patients who screened     of three studied reported using vitamin therapy to treat
positive for depression out of a total of 2,321 patients     depressive symptoms. These findings suggest that
from 2 large outpatient primary care clinics in Los          CAM use among minority underserved individuals may
Angeles. Two-thirds of the group were Hispanic and one-      serve as a substitute for conventional care when access
fifth were black.                                            to care is limited or unavailable. The study was
    Over 57 percent of the group reported using CAM          supported in part by the Agency for Healthcare
sometimes or often (24 percent) and frequently (33           Research and Quality (HS14022).
percent) to treat their depressive symptoms. Overall, 43        See “Correlates of complementary and alternative
percent said they rarely or never used CAM. Lack of          medicine utilization in depressed, underserved African
health care coverage was one of the strongest predictors     American and Hispanic patients in primary care
of CAM use after controlling for demographic                 settings,” by Mohsen Bazargan, Ph.D., Chizobam O.
characteristics. In addition, being moderately depressed,    Ani, M.D., M.P.H., David W. Hindman, Ph.D., and
use of psychotherapeutic prescription medications, and       others, in The Journal of Alternative and
poorer self-reported health status were all linked to        Complementary Medicine 14(5), pp. 537-544, 2008. I
increased frequency of CAM use to treat depression.

Screening for alcohol misuse among emergency department
patients may uncover depression
       creening for alcohol misuse in      Half of these patients (51            have suffered depressive symptoms

S      the emergency room (ED) may
       provide patients with early
evaluation, prevention, and treatment
                                        percent) reported depressive
                                        symptoms during the past week on
                                        a 20-item depression scale, such as
                                                                                 in the past week. Other factors
                                                                                 strongly linked to depressive
                                                                                 symptoms were being male, having
of depression, which may otherwise      loss of appetite, lack of energy, and    less than a high school education,
go undetected, suggests a new study.    crying spells. This rate is twice that   being unemployed, and being
It found that a group of mostly         of depressive symptoms in the            younger. The study was supported
Hispanic and black young adults         general adult population (24             in part by the Agency for
seeking care at an urban ED were        percent). More than one-fourth of        Healthcare Research and Quality
about twice as likely to suffer         the group (26 percent) reported at-      (HS14022).
depressive symptoms if they had         risk drinking, 28 percent scored            More details are in “Alcohol
problems misusing alcohol. The          positive on an alcohol problem           misuse and report of recent
researchers examined the association    screen, 25 percent reported alcohol      depressive symptoms among ED
between four levels of alcohol misuse   abuse, and 28 percent reported           patients,” by Shahrzad Bazargan-
(at-risk drinking, problem drinking,    binge drinking.                          Hejazi, Ph.D., Mohsen Bazargan,
alcohol abuse, and binge drinking)         Patients with at-risk drinking,       Ph.D., Tommie Gaines, M.D., and
and recent depressive symptoms          problem drinking, drinking abuse,        Michael Jemanez, M.D., in the
among a random sample of 412            and binge drinking were 2.5, 2.1,        American Journal of Emergency
adults seen at the ED.                  2.6, and 1.9 times more likely to        Medicine 26, pp. 537-544, 2008. I



                                                                                                               13
 http://www.ahrq.gov/                                                                      Number 339, November 2008
Primary Care Research

Studies examine ways to improve delivery of colorectal cancer
screening in primary care practice
        bout 52,000 people died of    screening use. The supplement also       in primary care?,” pp. S23-

A       colorectal cancer in the
        United States in 2007.
However, in 2005 only about half of
                                      contains three synthesis articles that
                                      address the importance of building
                                      data systems to evaluate CRC
                                                                               S29.(AHRQ grant HS10864).
                                                                                  Informed deicisionmaking is
                                                                               lacking during discussions of CRC
adults aged 50 and older had been     screening practices and outcomes at      screening between patients and
screened in accordance with U.S.      the population level; implications of    their primary care providers,
Preventive Services Task Force        new CRC screening technologies           concludes this study. The authors
recommendations. The September        for primary care practice; and           analyzed audiotaped clinic visits
2008 supplement to Medical Care       research networks as vehicles for        between patients and primary care
46(9) describes and evaluates         improving CRC screening delivery         providers to assess the level of
several promising strategies for      in primary care.                         informed decisionmaking during
improving colorectal cancer                                                    discussions about CRC screening.
screening (CRC) rates within busy     Hawley, S.T., Volk, R.J.,                Six of the nine informed
primary care practices and among      Krishnamurthy, P., and others.           decisionmaking elements occurred
special populations.                  “Preferences for colorectal              in 20 percent or fewer visits, and
   The supplement was guest-edited    cancer screening among racially/         none of these elements were
by David Lanier, M.D., of the         ethnically diverse primary care          addressed in half or more of the
Agency for Healthcare Research        patients,” pp. S10-S16. (AHRQ            visits. Certain decisional elements
and Quality (AHRQ), and Carrie N.     grant HS11187).                          were negatively associated with
Klabunde, Ph.D., of the National         This study found that primary         screening. For example, CRC
Cancer Institute (NCI). The studies   care patients have distinct              screening occurred less often for
were funded over the past 5 years     preferences for CRC screening tests      those discussing the “pros and
by AHRQ and NCI. Summaries of         that can be linked to test attributes.   cons” of screening (12 vs. 46
the studies supported by AHRQ or      Thus, tailoring screening                percent) and “patient preferences”
conducted by AHRQ staff follow.       recommendations to patients’             (6 vs. 47 percent) compared with
Reprints of the supplement (AHRQ      preferences may increase screening       those who did not.
Publication No. 08-0111) are          adherence. The authors asked a
available from AHRQ.*                 diverse group of patients to rate        Nease Jr., D.E., Ruffin, M.T.,
                                      eight hypothetical CRC screening         Klinkman, M.S., and others.
Klabunde, C.N., Lanier, D.,           test scenarios comprised of              “Impact of a generalizable
Meissner, H.I., and others.           different combinations of five           reminder system on colorectal
“Improving colorectal cancer          attributes and six scenarios             cancer screening in diverse
screening through research in         designed to depict recommended           primary care practices,” pp. S68-
primary care settings,” pp. S1-S4.    CRC screening tests (e.g., fecal         S73. (AHRQ/NCI cooperative
   This introductory article          occult blood test, flexible              agreement).
describes the organization of the     sigmoidoscopy, colonoscopy, and             Implementing a generalizable
journal supplement into four          double-contrast barium enema),           computerized reminder system
thematic sections: informed           including new technology (e.g.,          (CRS) in diverse primary care
decisionmaking and patient-           virtual colonoscopy, and fecal           practices significantly improved
provider communication in primary     immunochemical test).                    CRC screening rates, according to
care; meeting the needs of diverse                                             this study. All but 1 practice
populations; provider- and health     Ling, B.S., Trauth, J.M., Fine,          increased their CRC screening
system-directed approaches to         M.J., and others. “Informed              rates, ranging from 41.7 to 50.9
improving CRC screening delivery;     decision-making and colorectal           percent across all 12 practices.
and formative evaluation of           cancer screening: Is it occurring        Technology capabilities influenced
strategies for increasing CRC                                                               continued on page 15




14
Number 339, November 2008                                                                     http://www.ahrq.gov/
Colorectal cancer                     Lane, D.S., Messina, C.R.,             occult blood test (FOBT) and
screening                             Cavanagh, M.F., and Chen, J.J.         linked to a Web page with more
continued from page 14                “A provider intervention to            information. The control group
                                      improve colorectal cancer              received a reminder letter from
printing days (74 percent for high-
                                      screening in county health             their physician. All patients were
technology vs. 45 percent for low-
                                      centers,” pp. S109-S116.               mailed an FOBT kit. Among
technology practices). Also,
                                      (AHRQ/NCI cooperative                  private access patients, 26 percent
practice cohesion influenced
                                      agreement).                            of the intervention and 23 percent
screening trends, with highly
                                         Publicly funded health centers      of the control group returned an
cohesive practices showing nearly
                                      care for disadvantaged groups who      FOBT. Among public access
twice the improvement in their
                                      typically underuse CRC screening.      patients, none of the intervention
CRC screening rate than not very
                                      This study found that when health      group, but 3 of 9 in the control
cohesive practices (15.3 vs. 7.9
                                      center providers received              group returned an FOBT.
percent). The findings were based
                                      continuing medical education with
on pre- and post-CRS                                                         Lanier, D. “Practice-based
                                      a teambuilding strategic planning
implementation CRC screening                                                 research networks: Laboratories
                                      exercise, provider referrals,
rates among patients seen at the 12                                          for improving colorectal cancer
                                      dispensing, and completion of CRC
practices during the 9-month study                                           screening in primary care
                                      screening significantly improved.
period.                                                                      practice,” pp. S147-S152.
                                      Intervention centers had a 16
                                      percent increase in CRC                   Practice-based research networks
Schneider, E.C., Rosenthal, M.,
                                      referral/dispensing/completion         (PBRNs), which AHRQ has
Gatsonis, C.G., and others, “Is
                                      compared with a 4 percent increase     supported since 1999, are a strong
the type of Medicare insurance
                                      among non-intervention centers.        resource for the study of best
associated with colorectal cancer
                                      Also, fewer patients at the            methods for improving CRC
screening prevalence and
                                      intervention centers cited lack of     screening in complex, time-
selection of screening strategy?”
                                      physician recommendation as a          pressured primary care offices,
pp. S84-S90. (AHRQ grant
                                      reason for not having CRC              notes the author of this article. He
HS11431).
                                      screening.                             focuses on two types of PBRNs
   The type of Medicare insurance
                                                                             currently active in the United States
a patient had in 2000 was linked to
                                      Chan, E.C. and Vernon, S.W.            —those composed mostly of
prevalence and type of CRC
                                      “Implementing an intervention to       smaller, independent primary care
screening, found this study. The
                                      promote colon cancer screening         practices and those composed of
researchers compared CRC
                                      through e-mail over the Internet:      large integrated health systems—
screening prevalence and type of
                                      Lessons learned from a pilot           and the types of CRC screening-
screening among Medicare
                                      study,” pp. S117-S122. (AHRQ           related questions that have been or
beneficiaries enrolled in Medicare
                                      grant HS11421).                        can be addressed by these networks.
managed care (MMC) plans,
                                         Physician e-mails recommending      For example, by probing the rich
Medicare fee-for-service (FFS)
                                      CRC screening to 97 patients in        clinical databases of HMOs, the
plans with supplemental insurance,
                                      their primary care practice were not   Cancer Research Network has been
and those with Medicare FFS
                                      feasible to implement, concluded       able to conduct population-based,
coverage only. Interval-appropriate
                                      this pilot study. However, reasons     longitudinal monitoring of the use
CRC screening was reported by
                                      for lack of success differed for       of CRC screening services within a
54.7 percent of those in Medicare
                                      patients with home or work e-mails     managed care population and study
FFS plans with supplemental
                                      and those using computers at the       the occurrence of rare events, such
insurance, 52.9 percent in MMC
                                      public library to access e-mail.       as complications of screening
                                                                             procedures. I
plans, and 36.3 percent in the FFS
                                      Patients with both types of Internet
group that did not have
                                      access were randomized to InterNet
supplemental insurance. Use of
                                      LETter (NetLET) or a control
fecal occult blood testing was a
                                      group. The NetLET was a
more common screening strategy
                                      personalized e-mail from the
among persons in MMC plans than
                                      physician reminding the patient to
those with FFS plans with or
                                      undergo CRC screening via a fecal
without supplemental insurance.



                                                                                                            15
 http://www.ahrq.gov/                                                                   Number 339, November 2008
Studies suggest that large-scale strategies may be needed to
reduce overuse of antibiotics in U.S. communities
         ntibiotic resistance among       tool for parent education. The          antibiotic use.” Medical Care

A        many community-acquired
         bacterial pathogens is a
growing public health problem.
                                          researchers surveyed 168
                                          physicians in 16 Massachusetts
                                          communities in a 3-year REACH
                                                                                  46(6), pp. 597-605.
                                                                                     A mass media campaign for
                                                                                  appropriate antibiotic use that
While recent studies suggest that         (Reducing Antibiotics in Children)      targeted mothers of young children
agriculture is the largest source of      trial to promote judicious antibiotic   in a large metropolitan community
exposure to antibiotics, the health       use for respiratory tract infections    reduced community-level antibiotic
care system is also viewed as a           that are caused by viruses, which       use in a cost-efficient manner,
contributor. Hence, most efforts to       cannot be treated by antibiotics.       according to this study. The
reduce unnecessary antibiotic use,            Physicians in intervention          researchers examined the impact of
which fuels this problem, have            communities received locally            a “Get Smart Colorado” campaign.
focused on office-level educational       endorsed guidelines, group              The campaign consisted of paid
programs for clinicians and patients.     educational sessions, and biweekly      outdoor advertising and media and
Two new studies, supported by the         newsletters on judicious antibiotic     physician advocacy and ran
Agency for Healthcare Research and        use. Parents simultaneously             between November 2002 and
Quality, suggest that community-          received materials in physicians’       February 2003. The researchers
level approaches may boost the            offices and by mail. The                measured antibiotics dispensed per
effectiveness of this approach. The       researchers mailed a physician          1,000 persons or managed care
first study (HS10247) found that an       survey and interviewed them after       enrollees, and the proportion of
office-based intervention to promote      the educational campaign to assess      office visits in which antibiotics
judicious antibiotic prescribing          its impact.                             were received during the 10 to 12
reached its intended audience, but            More intervention than control      months before and after the
physicians felt that reinforcement of     physicians (who received no             campaign.
the messages via mass media would         educational materials or training)         Following the mass media
enhance its effectiveness. A second       reported decreased antibiotic           campaign, there was a 3.8 percent
study (HS13001) linked a low-cost         prescribing from 2000 to 2003 (75       net decrease in retail pharmacy
mass media campaign with reduced          vs. 58 percent), but there were no      antibiotic dispensings per 1,000
antibiotic use in the community.          differences between groups in           persons and an 8.8 percent net
While these studies show declines in      knowledge, attitudes, or behaviors      decrease in managed care-
the prescribing of antibiotics, they do   favoring judicious antibiotic use.      associated antibiotic dispensings
not claim to affect rates of antibiotic   Both groups expressed concern           per 1,000 members in the mass
resistance. Both studies are briefly      about antibiotic resistance and         media community. Most of the
summarized here.                          reported room to reduce their own       decline was among children and
                                          prescribing. Interviewed                corresponded with a decline in the
Stille, C.J., Rifas-Shiman, S.L.,         intervention physicians believed        number of pediatric office visits in
Kleinman, K., and others. (2008,          that frequent repetition of short,      which patients received antibiotics.
May-June). “Physician responses           consistent messages to both parents        Finally, the campaign seemed to
to a community-level trial                and physicians, brief physician and     be cost-saving. The monetary
promoting judicious antibiotic            parent handouts on specific topics,     savings per 1,000 pediatric
use.” Annals of Family Medicine           and dissemination of the message        managed care members was over
6(3), pp. 206-212.                        by the mass media were the most         $5,500. Overall, the researchers
   This study found that the              effective way to improve judicious      estimated a savings of over $7 per
message to reduce unnecessary use         antibiotic use.                         managed care member per year.
of antibiotics, promoted through                                                  The “Get Smart Colorado”
multiple methods directed at both         Gonzales, R., Corbett, K.K.,            campaign is the first example of a
physicians and parents, reached           Wong, S., and others. (2008,            wide-scale mass media campaign to
physician audiences in those              June). “‘Get smart Colorado’:           affect office visit and antibiotic use
communities. These materials were         Impact of a mass media                  at the community level in the
also welcomed by physicians as a          campaign to improve community           United States. I



16
Number 339, November 2008                                                                         http://www.ahrq.gov/
Pharmaceutical Research

 Women are dispensed more drugs than men during their
 reproductive years
          new study finds that women in their                  to have migraines, and 73 percent of women with

 A        reproductive years are prescribed more
          medications than men, particularly for certain
 conditions. However, as they age, women don’t always
                                                               migraines see a doctor, while just 49 percent of men
                                                               do.
                                                                  Once women and men reached the 55 to 64 and 65
 receive the same medications as men with similar              to 74 age groups, prescription patterns changed. Men
 conditions.                                                   received more drugs than women for angina, to
    Researchers from the Arizona Center for                    prevent blood clots, to lower blood cholesterol, and to
 Education and Research on Therapeutics (CERT), at             treat heart failure, even though women in these age
 the Critical Path Institute, and colleagues reviewed          categories often have the same conditions. Further,
 prescriptions for 200 of the most common medicines            women were given certain pain relievers twice as
 that were filled by nearly 69 million patients at a           often as men thus putting women at higher risk for
 national drug store from 2002 to 2003.                        adverse drug reactions.
    Children of both sexes received equal numbers of              The study was supported by the Agency for
 common prescriptions. However, once women                     Healthcare Research and Quality by a grant
 reached their childbearing years, they received more          (HS17001) to the Arizona CERT. For more
 prescriptions than men in 48 of 53 drug classes. As           information on the CERTs program, go to
 expected, females received drugs commonly used to             www.ahrq.gov/clinic/certsovr.htm.
 treat urinary tract and vaginal infections. They also            See “Gender and age differences in medications
 received more prescriptions to treat mental health,           dispensed from a national chain drugstore,” by
 pain, and gastrointestinal ailments than men.                 Marietta Anthony, Ph.D., Kwan Y. Lee, Ph.D., Carl T.
    These prescription patterns may be in part because         Bertram, Pharm.D., and others in the June 2008
 women are more likely than men to suffer with                 Journal of Women’s Health 17(5), pp. 735-743. I
 certain ailments and seek care, the authors suggest.
 For example, women are three times as likely as men



Stool cultures are rarely used in diarrhea cases
        linical guidelines recommend that patients who         percent). However, antibiotics were prescribed for

C       are suffering from diarrhea provide stool samples
        for culture. The test results can help pinpoint
which, if any, antibiotics can aid the patient. Cultures can
                                                               32,949 patients (10.4 percent). Of the diarrheal
                                                               episodes for which antibiotics were prescribed, 3,504
                                                               (10.6 percent) had stool cultures performed.
also provide valuable clues during a diarrheal disease            Stool cultures were most often provided for whites
outbreak, such as the one that occurred earlier this year      who lived in urban areas, suggesting this group had
with Salmonella in tomatoes and peppers. Nevertheless, a       better access to health care. Whites were also more
new study finds that when patients with diarrhea receive       likely than blacks to receive prescriptions for antibiotics
prescriptions for antibiotics, more than likely no stool       for their diarrhea.
culture was performed.                                            Although some clinicians see stool cultures as
   Researchers scoured the outpatient and pharmacy             expensive tests that do not yield valuable results, the
records of TennCare, Tennessee’s Medicaid program,             authors state that the lack of stool cultures for diarrhea
for visits for diarrhea and antibiotic prescriptions from      cases indicates that antibiotics are possibly being used
1995 to 2004. For the 315,828 visits for diarrhea, stool       inappropriately. This can lead to adverse events, high
culture was performed for just 15,820 patients (5              costs, and antibiotic resistance. This study was funded
                                                                                                  continued on page 18




                                                                                                                    17
 http://www.ahrq.gov/                                                                          Number 339, November 2008
Diarrhea                                                    D.V.M., Stephen J. Pont, M.D., M.P.H., William O.
continued from page 17                                      Cooper, M.D., M.P.H., and others in the June 15, 2008
in part by the Agency for Healthcare Research and           Journal of Infectious Diseases 197, pp. 1709-1712. I
Quality (HS13833).
   See “Stool cultures and antimicrobial prescriptions
related to infectious diarrhea,” by L. Rand Carpenter,



Health Care Costs and Financing

Quality partnerships yield advances in collaboration
    n November 2005, users,             hospitals. Evaluations could be         elsewhere opt to stay with

I   researchers, funders, and
    developers of health care market
data converged at a conference
                                        bettered by tracking care utilization
                                        of all patients instead of just the
                                        Medicare population (commonly
                                                                                companies simply because of health
                                                                                benefits. The answers to these
                                                                                queries have public policy
hosted by the Agency for Healthcare     done because data are readily           implications because initiatives,
Research and Quality (AHRQ). A          available), and by creating             such as subsidizing premiums and
long-time supporter of research on      physician identifiers to link them      mandating insurance coverage, can
health care costs, productivity,        with the care they provide to get a     be complicated in light of limited
market forces, and organization, the    clearer picture of their role in        data. The authors would like to
Agency hosted the event to present      hospital quality. The AHRQ-             have better measures on workers’
recent research on health care and      sponsored Healthcare Cost and           and their families’ health status and
health insurance markets and to chart   Utilization Project databases could     expenses to determine the value
a course for future research            also serve as clearinghouses for        they place on employer-sponsored
endeavors. Further, the attendees       data on care measures for heart         insurance. The article lists ways
were to adapt current or craft new      attacks, heart failure, pneumonia,      AHRQ can better organize data to
measures of activities in the health    and surgery to aid research on          assist researchers interested in
care market. Five papers from the       consumer choice. Another useful         examining the link between the
conference appear in the Spring 2008    measure for researching hospital        labor and health insurance market,
Inquiry, Volume 45, introduced by a     choice is to collect distance data      such as promoting standardized
conference overview from Michael        from a patient’s ZIP code to the        data collection and improving the
Hagan and William Encinosa,             hospital.                               Medical Expenditure Panel Survey
senior economists at AHRQ, on                                                   Household Component/Insurance
pages 15-18. Each paper puts forth      Garrett, B. and Chernew, M.             Component files.
recommendations on how AHRQ             “Health insurance and labor
can assist researchers interested in    markets: Concepts, open                 Grabowski, D.C. “The market for
health care markets. The papers are     questions, and data needs,” pp.         long-term care services,” pp. 58-
briefly summarized here.                30-57.                                  74.
                                           By conducting literature reviews,        Addressing the lack of good
Lindrooth, R.C. “Research on the        the authors attempt to answer           measures to evaluate the long-term
hospital market: Recent advances        questions on the relationship           care market, the author states that
and continuing data needs,” pp.         between health insurance and the        good measures reflect market
19-29. (AHRQ grant HS10730)             labor force. They examined the          competition, consider the fact that
  The author uses papers published      implications of employer-sponsored      patient choice is linked to facility
on health economics to show how         health insurance, including how         quality, and can be linked to other
measures, data, and models of           premium costs affect wages and          market-level data (such as
hospital services, locations, and       influence employees to elect or         population) measures. The article’s
competition are used to evaluate        decline it, and whether employees       list of policy questions that could
what drives consumers to choose         who might be more productive                          continued on page 19




18
Number 339, November 2008                                                                      http://www.ahrq.gov/
Partnerships                             “Retail pharmacy market                     States appear to be leading the
continued from page 18                   structure and performance,” pp.          way in health care transformation
benefit from better measures and         75-88.                                   through initiatives such as
data include whether increased              The authors explore current           expanding Medicaid eligibility and
competition among nursing homes          methods of research and data             small group insurance reform.
lowers costs, if nursing homes and       available to examine the retail          However, to assist States in making
home health care agencies compete        pharmacy market and its effect on        informed policy decisions,
with one another, and how assisted       use, pricing, and service levels.        researchers need annual data on
living influences the nursing home       Though vendors collect a wealth of       Medicaid enrollment, drug and
market. The author suggests that         data on payer prescription               service use, payments, policies, and
AHRQ can improve long-term care          utilization, payment, and costs,         spending. They also need economic
research by defining market              researchers do not have access to        measures on premiums,
boundaries, collecting market and        this information. One remedy is to       reimbursement rates, and health
regulatory data, providing de-           have AHRQ develop agreements             insurance plan characteristics.
identified data, standardizing           with vendors to gain access to this      Ideally, this information would be
Medicaid cost data, and                  data.                                    stored in a central database. As a
encouraging research outside of                                                   starting point, AHRQ can assist in
                                         Simon, K. “Data needs for policy         the data compiling effort by
nursing home settings.
                                         research on State-level health           creating a Web site that points
Brooks, J.M., Doucette, W.R.,            insurance markets,” pp. 89-97.           researchers to existing data
Wan, S., and Klepser, D.G.                                                        collection efforts or puts all


Introduction of a multitiered formulary decreases antidepressant use
       he great majority of U.S. health plans use              some antidepressants were placed on a nonpreferred

T      multitiered formularies because they offer a means
       to contain prescription drug costs. With this
business model, health plans sort drugs by price into tiers,
                                                               tier). However, prescriptions per enrollee increased 5
                                                               percent in the comparison group. Though their higher
                                                               copayments apparently caused a shift away from
and patients’ copayments are linked to the tier their drug     nonpreferred drugs, some patients continued to use
falls within. For example, if a patient is prescribed a        those antidepressants. This may be in part because their
medication that falls within the “nonpreferred” tier, the      physicians believed those nonpreferred drugs worked
patient must either pay more out of pocket to get the drug     better and were unwilling to switch patients to preferred
or request the physician write a prescription for a            antidepressants or patients refused to settle for any drug
medication that falls in a preferred, more affordable tier.    but the one initially prescribed.
   Dominic Hodgkin, Ph.D., of Brandeis University, and            Certain antidepressants work better than others for
colleagues examined how a managed care organization’s          some patients, which may be one reason the response to
introduction of a three-tiered formulary in 2000 affected      the three-tier formularies is more muted for
enrollee copayments and drug use for antidepressant            antidepressants than has been shown for other drug
prescriptions. The plan’s copayment for generics was $5,       classes, such as statins, explain the researchers. Their
for preferred brand drugs was $10, and for nonpreferred        study was funded in part by the Agency for Healthcare
drugs was $25. Because the new formulary was phased            Research and Quality (HS13092).
in during the year, researchers were able to compare              See “The effect of a three-tier formulary on
costs and use for 45,197 members who were subject to           antidepressant utilization and expenditures,” by Dr.
the new formulary with 64,489 members who were not.            Hodgkin, Cindy Parks Thomas, Ph.D., Linda Simoni-
   The three-tier program reduced both the probability         Wastila, Ph.D., and others in the June 2008 Journal of
of using an antidepressant and the spending per user.          Mental Health Policy and Economics 11(2), pp. 67-77. I
Prescriptions per enrollee declined 11 percent for
enrollees who were in the experimental group (where




                                                                                                                  19
 http://www.ahrq.gov/                                                                        Number 339, November 2008
Public Health Preparedness

 Most Federal health centers are not integrated in their
 community’s emergency preparedness plans
            ore than 15 million            community responders on a hazard       tended to have high patient

 M          Americans receive care
            from 890 federally funded
 health centers across the United
                                           vulnerability assessment (HVA), the
                                           center was included in the
                                           community emergency response
                                                                                  volumes and past experience with
                                                                                  emergencies or disasters.
                                                                                     Health centers offered several
 States. Despite their prevalence in       plan, and the center participated in   reasons why they were not
 both rural and urban areas and            community exercises.                   incorporated in community
 potential contributions in a disaster,       Of the 307 health centers that      disaster plans. They include staff
 these centers often do not have a         responded, just 25 (8.1 percent)       and time limitations, insufficient
 designated role to play in                answered positively to all three       funding for training and
 community emergency response              items. Those centers tended to be      equipment, poor leadership and
 plans, a new study finds. Jerod M.        rural (and typically the only health   coordination, insufficient
 Loeb, Ph.D., of The Joint                 care providers in a community),        reimbursement for services, and
 Commission, and colleagues mailed         have past experience in                lack of community understanding
 60-item questionnaires to the health      responding to a disaster or public     of the center’s potential role. This
 centers, covering experience with         health emergency, perceived a          study was funded in part by the
 prior emergencies or disasters,           threat of hazards, and were            Agency for Healthcare Research
 community emergency                       accredited by The Joint                and Quality (HS13728).
 preparedness planning, the health         Commission. Breaking down                 See “Assessing the integration
 center’s role in a community              responses to the three items, 27       of health center and community
 response, communication,                  percent of the centers had             emergency preparedness and
 surveillance, reporting and lab           completed an HVA, with rural           response planning,” by Nicole V   .
 testing, and training and exercises.      centers more likely than urban         Wineman, M.A., M.P.H., M.B.A.,
 The research team focused the             centers to complete the                Barbara I. Braun, Ph.D., Joseph A.
 analysis on three items selected to       assessment. Thirty percent said        Barbera, M.D., and Dr. Loeb in
 best represent the health center’s        their centers were included in         the November 2007 Disaster
 links to community preparedness           community emergency response           Medicine and Health
 efforts. These items included             plans. The 24 percent of centers       Preparedness 1(2), pp. 96-105. I
 whether the center worked with            that participated in exercises




Complementary/Alternative Medicine

Skeptical patients with arthritis and fibromyalgia are likely to use
alternative medicine
           edical skeptics are individuals who doubt           their subsequent use of complementary and alternative

M          conventional medicine’s ability to significantly
           improve their health status. Their skepticism can
often lead them to seek additional care from massage
                                                               medicine (CAM).
                                                                  Of the 721 individuals who returned the survey, 106
                                                               (15 percent) used CAM providers. When church
therapists, church leaders, chiropractors, herbalists, and     leaders were excluded, the number fell to 75 (10
acupuncturists. In a recent study, researchers at the          percent). Of the 106, 54 percent had rheumatoid
University of North Carolina at Chapel Hill surveyed           arthritis, 23 percent had osteoarthritis, and 23 percent
1,759 patients with arthritis and fibromyalgia to              had fibromyalgia. Most were female (78 percent) and
determine the strength of their medical skepticism and                                           continued on page 21



20
Number 339, November 2008                                                                         http://www.ahrq.gov/
Arhtritis and fibromyalgia                                    communicating what conventional medicine offers as
continued from page 20                                        well as which alternative therapies may be useful in
white (86 percent) and had spent some time in college.        treating their conditions. This study was funded in part
   Researchers measured medical skepticism using the          by the Agency for Healthcare Research and Quality
Medical Skepticism Scale. This consists of four               (T32 HS00032).
questions to which respondents answer using a five-              See “Medical skepticism and the use of
point Likert scale (disagree strongly to agree strongly).     complementary and alternative health care providers by
In this study, medical skepticism was associated with         patients followed by rheumatologists,” by Leigh F.
CAM provider use. In fact, a one-point increase in the        Callahan, Ph.D., Janet K. Freburger, P.T., Ph.D., Thelma
skepticism scale increased the probability of using a         J. Mielenz, P.T., Ph.D., O.C.S., and Elizabeth K. Wiley-
                                                              Exley, M.P.H., in the June 2008 Journal of Clinical
                                                              Rheumatology 14(3), pp. 143-147. I
CAM provider by 70 percent.
   The authors note that providers who treat medical
skeptics can better assist these patients by thoroughly


Agency News and Notes

Patients’ hospital bills jumped $70 billion in just one year
        ospital charges—what             and 2006, hospital charges               Statistical Brief #59 (www.hcup-

H       patients are billed for their
        rooms, nursing care,
diagnostic tests, and other services—
                                         increased by:
                                         • $38 billion to $44 billion—15
                                           percent for people with no
                                                                                  us.ahrq.gov/ reports/statbriefs.jsp).
                                                                                  The report uses statistics from the
                                                                                  2006 Nationwide Inpatient Sample,
jumped from $873 billion in 2005 to        insurance                              a database of hospital inpatient
$943 billion in 2006, according to                                                stays that is nationally
data from the Agency for Healthcare      • $124 billion to $135 billion—9         representative of inpatient stays in
Research and Quality.                      percent for Medicaid patients          all short-term, non-Federal
   The steep increase occurred even      • $411 billion to $444 billion—8         hospitals. The data are drawn from
though hospital admissions                 percent for Medicare patients          hospitals that comprise 90 percent
increased only slightly, from 39.2       • $272 billion to $287 billion—6         of all discharges in the United
million to 39.5 million. Insured           percent for patients with private      States and include all patients,
patients and their health plans pay        insurance.                             regardless of insurance type, as well
less than the full charge, but              For more information, see The         as the uninsured. I
uninsured patients are expected to       National Bill: The Most Expensive
pay the full amount. Between 2005        Conditions by Payer, 2006, HCUP


Modified insulin is most effective for controlling postmeal blood
sugar levels
       remixed insulin analogues, a modified form of          type 2 diabetes tripled from 5.6 million in 1980 to 15.8

P      conventional premixed human insulin, are more
       effective than long-acting analogues for controlling
high blood sugar levels after meals in patients with type 2
                                                              million in 2005. Obesity increases the risks of
                                                              developing type 2 diabetes. Diabetes can cause serious
                                                              problems with the heart, kidneys, eyes, and nerves.
diabetes, according to a report funded by the Agency for      Many patients with type 2 diabetes control their blood
Healthcare Research and Quality (AHRQ). Conventional          sugar through diet and use of oral medications. Recent
premixed human insulin, however, appears to be equally        research suggests that good blood glucose control can
as effective as premixed insulin analogues for lowering       reduce loss of sight, kidney failure, and heart disease.
blood sugar levels when patients go 8 or more hours              The new report was compiled by the Johns Hopkins
without eating, according to the report.                      University Evidence-based Practice Center in
   Type 2 diabetes accounts for more than 90 percent of       Baltimore, 1 of 14 such centers funded by AHRQ
diabetes. The number of Americans diagnosed with                                                continued on page 22



                                                                                                                  21
 http://www.ahrq.gov/                                                                       Number 339, November 2008
Blood sugar levels                                                Although noninsulin oral medications are used as a
continued from page 21                                         first-line treatment for patients with type 2 diabetes,
through its Effective Health Care program. The report          insulin is frequently required at some stage during the
represents a systematic review of 45 research studies          course of the disease. Under such circumstances, some
and is intended to provide unbiased, evidence-based            patients are controlled with long-acting insulin alone
information so that patients, clinicians, and others can       while others need a combination of long-acting and
make the best possible treatment decisions.                    rapid-acting insulins to control blood sugar levels after
   Premixed insulin analogues are a modified form of           meals, especially meals with high sugar content.
conventional premixed human insulin. AHRQ’s report                The report, Comparative Effectiveness, Safety and
compared premixed insulin analogues with                       Indications of Pre-mixed Insulin Analogues for Adults
                                                               With Type 2 Diabetes, is available at
                                                               http://effectivehealthcare.ahrq.gov. I
conventional premixed human insulin, oral diabetes
drugs, and two other kinds of insulin analogues—long-
acting (or “basal”) analogues, and rapid-acting (or
“bolus”) analogues.

Hispanics are hospitalized at higher rates for potentially
preventable hospitalizations than whites in both wealthy and
poor communities
         ispanic adults from both poor      amputations, glaucoma and other           diabetes complications and nearly

H        and wealthy communities are
         much more likely than whites
to be hospitalized for health problems
                                            eye problems, and kidney failure.
                                          • Hispanic adults were almost 1.5
                                            times more likely than whites to
                                                                                      one-fifth more likely to be
                                                                                      admitted for heart ailments than
                                                                                      whites. The ratios were similar in
such as uncontrolled diabetes and           be hospitalized for congestive            the poorest communities.
heart ailments, according to data from      heart failure, high blood pressure,        The report uses statistics from a
the Agency for Healthcare Research          and heart pain known as angina.         special disparities analysis file
and Quality (AHRQ). Wealthy                                                         created from the Healthcare Cost
communities in this report have           • In contrast, hospitalization rates
                                            were about the same for                 and Utilization Project (HCUP)
average annual household incomes of                                                 2006 State Inpatient Databases
$62,000 or greater. AHRQ’s analysis         Hispanics and whites with
                                            chronic respiratory conditions          (SID). For details, see Potentially
found that in 2006:                                                                 Preventable Hospitalizations among
                                            (asthma and chronic obstructive
• Hispanic adults were more than            pulmonary disease).                     Hispanic Adults, 2006, HCUP
   two times as likely as white                                                     Statistical Brief #61 (www.hcup-
                                                                                    us.ahrq.gov/reports/statbriefs.jsp). I
   adults to be hospitalized for          • In wealthy communities,
   uncontrolled diabetes and its            Hispanics were 1.8 times more
   complications such as leg or foot        likely to be hospitalized for

Hospitalizations for osteoarthritis are rising sharply
        ospitalizations for osteoarthritis soared from about     percent in 1997. Women accounted for 63 percent of

H       322,000 in 1993 to 735,000 in 2006, according to
        data from the Agency for Healthcare Research and
Quality (AHRQ). Osteoarthritis is a painful disease
                                                                 hospitalizations for osteoarthritis in 2006, a number
                                                                 that is essentially unchanged since 1997.
                                                               • Most of the increase in osteoarthritis hospitalizations
resulting from deteriorating cartilage and bones rubbing         occurred beginning in 2000, when osteoarthritis stays
together. AHRQ’s analysis of arthritis hospitalizations          rose from 443,000 to 735,000, a 66 percent increase.
found:
                                                               • The large increase in osteoarthritis hospitalizations is
• In 2006, osteoarthritis was the principal diagnosis for        primarily related to the increase in knee replacement
   about 90 percent of 547,000 knee surgery                      surgery. From 2000 to 2006, knee replacement
   hospitalizations and about 50 percent of hip                  surgery increased 65 percent while hip replacement
   replacement hospitalizations.                                 surgery increased 21 percent.
• Also in 2006, 45-64 year olds accounted for 38
                                                                                                   continued on page 23
   percent of all osteoarthritis, compared with 25


22
Number 339, November 2008                                                                          http://www.ahrq.gov/
Osteoarthritis                                                factsandfigures/HAR_2006.pdf). The document
continued from page 22                                        highlights the latest data from the 2006 Nationwide
                                                              Inpatient Sample, a part of AHRQ’s Healthcare Cost
                                                              and Utilization Project. I
   This summary is based on data in HCUP Facts and
Figures, 2006 (www.hcup-us.ahrq.gov/reports/


 More U.S. children are getting government dental insurance
         bout 30 percent of U.S.          found that between 1996 and               dental insurance in 2006

 A       children and adolescents
         were covered by
 government-sponsored dental
                                          2006:
                                          • Enrollment in government
                                            dental insurance rose sharply
                                                                                    compared with 29 percent in
                                                                                    1996.
                                                                                    The data are taken from the
 insurance in 2006, a significant           among Hispanic and black             Medical Expenditure Panel
 increase from the 18 percent               adolescents and children, 48         Survey, a detailed source of
 covered in 1996, according to data         percent and 35 percent,              information on the health services
 from the Agency for Healthcare             respectively.                        used by Americans, the frequency
 Research and Quality (AHRQ).                                                    with which they are used, the cost
 Private dental insurance enrollment      • White children and adolescents
                                            were less likely than blacks and     of those services, and how they
 remained relatively unchanged                                                   are paid. For more information, go
 during the period.                         Hispanics to have public dental
                                            insurance, but their enrollment      to Dental Coverage of Children
    Much of the increase resulted                                                and Young Adults under Age 21,
 from the State Children’s Health           doubled, climbing from 10
                                            percent to 20 percent.               United States, 1996 and 2006,
 Insurance Program, which began                                                  MEPS Statistical Brief #221
                                                                                 (http://meps.ahrq.gov/). I
 in 1997, and extensions of               • Largely due to expanded
 Medicaid coverage for dental               government coverage, only 19
 services. AHRQ’s analysis also             percent of U.S. children had no



Announcements

HHS issues interim guidance for Patient Safety Organizations
         ew interim guidance that outlines how to become         The interim guidance describes how an organization

N        a Patient Safety Organization (PSO) is now
         available from the U.S. Department of Health and
Human Services. The Patient Safety and Quality
                                                              may become a PSO by submitting a certification form
                                                              that is available on AHRQ’s PSO Web site at
                                                              www.pso.ahrq.gov. The Web site includes more
Improvement Act (Patient Safety Act) authorized the           explanation of the certification process and instructions
creation of PSOs to improve safety through the collection     for submitting this form either electronically or via
and analysis of data on patient safety events. By providing   mail. When the organization’s certifications are
both privilege and confidentiality, PSOs will create a        accepted, AHRQ will list the entity as a PSO on the
secure environment where clinicians and health care           AHRQ PSO Web site.
organizations can voluntarily collect, aggregate, and            “Patient safety work product,” which is the data
analyze data that enable the identification and reduction     submitted by the health care provider to a listed PSO
of the risks and hazards associated with patient care.        and the data developed by the listed PSO during the
   The interim guidance allows the Agency for                 interim guidance period, is privileged and confidential
Healthcare Research and Quality (AHRQ) to begin               under the Patient Safety Act. This patient safety work
receiving applications from qualified entities that wish      product will remain privileged and confidential during
to become PSOs. This guidance will remain effective           and after the interim period. HHS’ Office for Civil
until HHS issues a final rule for PSOs, which will then       Rights will enforce the confidentiality provisions of the
supersede the interim guidance. A final rule is expected      Patient Safety Act. These data protection provisions are
to be released by the end of 2008.                            a significant component of the Patient Safety Act.
                                                                                                continued on page 24


                                                                                                                  23
 http://www.ahrq.gov/                                                                        Number 339, November 2008
Patient Safety Organizations                                 common definitions and reporting formats that health
continued from page 23                                       care professionals can use to collect and track patient
   To facilitate the collection and reporting of patient     safety information. These formats may be used by
safety information, AHRQ released Common Formats             providers and PSOs to report a range of patient safety
                                                             concerns, capturing both structured and narrative
                                                             information. I
on Aug. 29. The Common Formats, now available for
download through AHRQ’s PSO Web site, provide

Task Force finds several methods equally effective for colorectal
cancer screening
    n a change from its previous          colonography and fecal DNA             the scientific evidence for the

I   recommendation, the U.S.
    Preventive Services Task Force
(Task Force) now recommends that
                                          testing as screening methods for the
                                          disease. Further, these Task Force
                                          recommendations do not apply to
                                                                                 effectiveness of a broad range of
                                                                                 clinical preventive services,
                                                                                 including screening, counseling,
adults age 50 to 75 be screened for       people with a personal history of      and preventive medications. Its
colorectal cancer using annual high-      certain types of polyps who are        recommendations are considered
sensitivity fecal occult blood testing,   being monitored regularly for the      the gold standard for clinical
sigmoidoscopy every 5 years with          condition or to those who have a       preventive services. The Task Force
fecal occult testing between              family history of rare syndromes       based its conclusions on a report
sigmoidoscopic exams, or                  that increase a person’s chances of    from a research team led by Evelyn
colonoscopy every 10 years.               getting colon cancer.                  Whitlock, M.D., at the Kaiser
According to the Task Force, good            This recommendation                 Permanente Center for Health
evidence exists that using these          strengthens the Task Force’s           Research, which is part of AHRQ’s
methods save lives.                       previous position in 2002, when it     Oregon Evidence-based Practice
    The Task Force recommends             recommended screening for              Center.
against routine colorectal cancer         colorectal cancer but noted that          The recommendation and the
screening in adults between the           evidence was insufficient to           accompanying summary of
ages of 76 and 85 because the             recommend one screening method         evidence are posted in the Annals of
benefits of regular screening were        over another. This is also the first   Internal Medicine online at
small compared with the risks. The        time that the Task Force has           http://www.annals.org/ and will
Task Force also recommends that           indicated an age that people should    appear in the November 4, 2008
adults over the age of 85 not be          stop being screened for colorectal     print edition of the journal. The
screened at all because the harms of      cancer.                                recommendations and materials for
screening may be significant, and            The Task Force is the leading       clinicians are also available on the
other conditions may be more likely       independent panel of experts in        AHRQ Web site at www.ahrq.gov/
to affect their health or well-being.     prevention and primary care. The       clinic/uspstf/uspscolo.htm. Previous
   For people of all ages, the Task       Task Force, which is supported by      Task Force recommendations,
Force found insufficient evidence to      the Agency for Healthcare Research     summaries of the evidence, and
assess the benefits and harms of          and Quality (AHRQ), conducts           related materials are available from
computed tomographic (CT)                 rigorous, impartial assessments of     AHRQ.* I


New Guide to Clinical Preventive Services 2008 is available
       he Guide to Clinical Preventive Services 2008,           In addition to previous recommendations, this year’s

T      which highlights recommendations of the U.S.
       Preventive Services Task Force (Task Force),
contains evidence-based recommendations that have
                                                             Guide provides new Task Force recommendations
                                                             released during 2007 on aspirin or nonsteroidal anti-
                                                             inflammatory drugs for the primary prevention of
been adapted for a pocket-size book, making it easier        colorectal cancer; screening for carotid artery
for clinicians to consult the recommendations in their       stenosis; screening for chronic obstructive pulmonary
daily practice. The Task Force is sponsored by the           disease using spirometry; counseling about proper
Agency for Healthcare Research and Quality (AHRQ).                                             continued on page 25




24
Number 339, November 2008                                                                       http://www.ahrq.gov/
New Guide                                                      Recommendations are presented in an indexed, easy-to-
continued from page 24                                         use format, with at-a-glance charts.
use of motor vehicle occupant restraints and avoidance            The pocket guide is available in several formats on
                                                               the Web at www.ahrq.gov/clinic/pocketgd.htm. Single
                                                               print copies are also available from AHRQ.* I
of alcohol use while driving; screening for illicit drug
use; screening for lipid disorders in children; and
screening for sickle cell disease in newborns.

Two new resources can help consumers and clinicians prevent
dangerous blood clots
       wo new guides to help              details how to start, implement,         Thromboembolism: A Guide for

T      consumers and clinicians
       prevent and treat deep vein
thrombosis have been released by the
                                          evaluate, and sustain a quality
                                          improvement strategy. It includes
                                          case studies, as well as examples of
                                                                                   Effective Quality Improvement
                                                                                   (publication no. 08-0075) is
                                                                                   available at www.ahrq.gov/qual/
Agency for Healthcare Research and        forms that clinicians in the field       vtguide. Copies are also available
Quality (AHRQ). AHRQ’s consumer           can use.                                 from AHRQ.*
booklet, Your Guide to Preventing            The AHRQ guides were                     Editor’s note: Treatment for
and Treating Blood Clots, is a 12-        developed from toolkits originally       blood clots often includes blood
page easy-to-read resource that           created by experts funded through        thinning medications such as
helps both patients and their             AHRQ’s Partnerships in                   Coumadin® (generic name:
families identify the causes and          Implementing Patient Safety grant        warfarin). AHRQ recently
symptoms of dangerous blood clots,        program (www.ahrq.gov/qual/              published Your Guide to
learn tips on how to prevent them,        pips). The consumer guide, Your          Coumadin®/Warfarin Therapy
and know what to expect during            Guide to Preventing and Treating         (publication no. 08-0028-A) to help
treatment. The clinician guide,           Blood Clots, is available in both        these patients better understand
Preventing Hospital-Acquired              English (publication no. 08-0058-        their treatment. This guide also
Venous Thromboembolism: A Guide           A, www.ahrq.gov/consumer/                originated from an AHRQ-funded
for Effective Quality Improvement,        bloodclots.htm) and Spanish              patient safety project. It is available
is a comprehensive tool to help           (publication no. 08-0058-B,              at www.ahrq.gov/consumer/
hospitals and clinicians implement        www.ahrq.gov/consumer/spblclots.h        coumadin.htm and from AHRQ.* I
processes to prevent dangerous            tm). The clinician guide, Preventing
blood clots. The 60-page guide            Hospital-Acquired Venous


New computer-based tools will help make best use of genetic
breast cancer tests
         new Federal project, funded by the Agency for         GEP test results can help evaluate which patients are at

A        Healthcare Research and Quality (AHRQ), will
         lead efforts to develop, implement, and evaluate
four computer-based decision-support tools that will help
                                                               a high risk of cancer recurrence and therefore are good
                                                               candidates for chemotherapy, in addition to other
                                                               appropriate treatments.
clinicians and patients better use genetic tests to evaluate      The $1 million project will be completed by RTI
and treat breast cancer.                                       International, an independent, nonprofit research
   The first pair of tools will assess whether a woman         institute in Research Triangle Park, NC. It is expected
with a family history of cancer should be tested for           to take about 16 months. Development of these tools
BRCA1 and BRCA2 gene mutations. Knowing                        will support AHRQ’s work of translating research into
whether a woman has inherited these gene mutations             clinical practice in the areas of genetic tests, health
may help determine her chances of developing certain           information technology, and patient care.
kinds of cancer, especially breast cancer. The second             The new project to create decision-support tools is
pair of tools, for women already diagnosed with breast         funded through AHRQ’s DEcIDE (Developing
cancer, will help determine which patients are                 Evidence to Inform Decisions about Effectiveness)
appropriate for a Gene Expression Profiling (GEP) test.                                          continued on page 26




                                                                                                                    25
 http://www.ahrq.gov/                                                                         Number 339, November 2008
Breast cancer tests                                          services. For more information about AHRQ’s Effective
continued from page 25                                       Health Care Program, the DEcIDE Network, and to
research network, part of the Effective Health Care          learn more about the project to create gene-based
Program. The Effective Health Care Program sponsors          clinical decision-support tools for breast cancer
                                                             patients, visit the Effective Health Care Web site at
                                                             http://effectivehealthcare.ahrq.gov. I
the development of new scientific knowledge through
studies on the outcomes of health care technologies and


Research Briefs
Alexander, G.C. (2008, Spring).          Archives of Internal Medicine            improvement appears to be slowing.
“Commentary on the case of Mr.           168(11), pp. 1226-1227.                  Overall quality improved by an
A.B.: Dilemmas for a reason.”               The implementation of restricted      average of just 1.5 percent per year
(AHRQ grant HS15699). The                duty hours by the Accreditation          between the years 2000 and 2005.
Journal of Clinical Ethics, pp. 70-      Council for Graduate Medical             This represents a decline when
71.                                      Education (ACGME) has raised             compared with the 2.3 percent
   The author comments on the            concerns regarding possible              average annual rate over the longer
following ethical dilemma: should        negative effects not only on resident    reporting period of 1994 to 2005.
the staff not tell Mr. A.B. about the    education and patient care, but also     Some areas have improved, such as
tragic loss of his daughter prior to a   on teaching faculty. The researchers     counseling to quit smoking and
planned bypass surgery, as his           studied the effects of restricted duty   reduced disparities in childhood
family asks? The medical team            hours on inpatient attending             vaccinations, according to the 2007
must grapple with a classic tension      physician teaching and satisfaction      reports. However, measures of
between beneficence and patient          using data collected for 5 years         patient safety showed an average
autonomy. A complicating factor is       before and after implementation at       annual improvement of only 1
the difficulty of knowing how the        a single institution. After              percent. Part of improving health
timing of the message will affect        implementation of restricted duty        care quality is reducing the
Mr. A.B., because the physiologic        hours, attending physicians reported     variation in health care delivery
consequences of grief in the context     fewer hours of teaching more times       across the country, so that patients
of his critical illness are not clear.   per week when residents missed           in all States receive the same level
Given his comorbid conditions and        conferences due to rounds, and a         of high-quality, appropriate care.
clinical instability, Mr. A.B. is more   lower percentage of patients seen        On the average, since the year
likely than most patients to be at       on the day of admissions. They           2000, variation has decreased
increased risk of a poor outcome         were also less satisfied with time       across the measures for which State
triggered by acute grief. As with        for teaching, ability to determine       data is tracked, but this progress is
many cases of delivering bad news,       patient length of stay, and influence    not uniform.
the crux of the issue is how, not        on hospital policy. The researchers
whether, it should be told. The          caution that since the survey was        Bravata, D.M., Shojania, K.G.,
clinician shares with the family a       originally designed to test the          Olin, I., and Rave, A. (2008).
responsibility for the situation. In     effects of hospitalists, it may have     “CoPlot: A tool for visualizing
this case, the team reached a            missed other effects of duty hours.      multivariate data in medicine.”
decision through thoughtful                                                       (AHRQ Contract No. 290-02-
deliberation and careful                 Brady, J., Ho, K., and Clancy,           0017). Statistics in Medicine 27,
consultation with the affected           C.M. (2008). “Slowed progress in         pp. 2234-2247.
parties. Reasonable people, of           improving quality and                       Many research questions in
course, may differ about this or any     minimizing disparities.” AORN            medicine require the analysis of
such decision.                           Journal 87(5), pp. 1007-1009.            complex multivariate data.
                                            In its fifth annual National          Multidimensional scaling (MDS)
Arora, V. and Meltzer, D. (2008,         Healthcare Quality Report and the        facilitates the analysis of
June). “Effects of ACGME duty            National Healthcare Disparities          multivariate data by reducing the
hours on attending physician             Report, the Agency for Healthcare        multidimensional data into a two-
teaching and satisfaction.”              Research and Quality (AHRQ)              dimensional structure that attempts
(AHRQ grant HS10597).                    finds that the rate of quality                         continued on page 27



26
Number 339, November 2008                                                                        http://www.ahrq.gov/
Research briefs                         Clancy, C. (2008, June).                 growing urgency to identify
continued from page 26                  “AHRQ’s Effective Health Care            solutions to the challenges of
to uncover the hidden structure in a    Program: Accelerated access to           “unequal treatment.” Most studies
data set by creating a pictorial        decisive clinical information.”          confirm that disparities remain
representation of the data. CoPlot,     The Journal of Family Practice           pervasive, even though these
an adaptation of MDS, addresses         S20-S23.                                 differences vary by specific racial
two key limitations of MDS—the             To mine the potential of practice-    or ethnic group, specific disease
inability to simultaneously map the     based research networks and              condition, and specific region,
variables and observations and the      existing literature, the Agency for      health plan, or hospital. The author
lack of orientation of the MDS          Healthcare Research and Quality          of this paper, Carolyn M. Clancy,
map. CoPlot maps the observations       (AHRQ) has formed partnerships           M.D., director of the Agency for
and variables in a manner that          with major universities, health          Healthcare Research and Quality,
preserves their relationships,          maintenance organizations, and           discusses a research article focusing
allowing richer interpretation of the   independent office practices.            on the role of variation among
data. The authors describe CoPlot       According to Carolyn M. Clancy,          individual physicians in
and its methodology and present the     M.D., director of AHRQ, the goal         contributing to observed disparities
results of the application of CoPlot    of these efforts is to develop better,   in quality of care. That article
to multivariate data describing         more accessible clinical                 found that rates of achieving target
clinical presentations and treatment    information and to disseminate it        blood sugar and cholesterol levels
responses of children infected with     faster. One such partnership is          were significantly lower for black
anthrax. They also provide              Developing Evidence to Inform            patients than for white patients.
recommendations for the use of          Decisions about Effectiveness            Within-physician effects rather than
CoPlot for evaluating and               (DEcIDE), a consortium of health         patient sociodemographic or
interpreting other health care data     care organizations that conduct          clinical factors explained most of
sets.                                   rapid practical research in different    these observed differences. Since
                                        topic areas with existing patient        hypotheses differ as to why this is
Clancy, C.M. (2008, May/June).          databases. AHRQ has also                 the case, Dr. Clancy calls for more
“Evidence shows cost and patient        established 14 Evidence-based            research to better understand how
safety benefits of emergency            Practice Centers (EPCs) to compile       to close such gaps in disparities of
pharmacists.” American Journal          results of scientific literature,        care and for physician leadership to
of Medical Quality 23(3), pp. 231-      promote evidence-based practice on       assure that the care provided is
233.                                    various clinical topics, and conduct     evidence-based, patient-centered,
   Adverse drug events (ADEs)           comparative effectiveness reviews        effective, consistent, and equitable.
account for nearly 20 percent of        on medications, devices, and other
adverse events overall and hospital     interventions. In addition, AHRQ         Dalby, D.M. and Hirdes, J.P.
emergency departments (EDs) have        has established the Eisenberg            (2008). “The relationship
the highest rates of reportable         Clinical Decisions and                   between agency characteristics
errors, notes the author of this        Communications Science Center to         and quality of home care.”
commentary. There is some               translate the complex knowledge          (AHRQ grant HS09455). Home
evidence that use of ED                 gleaned by DEcIDE and the EPCs           Health Care Services Quarterly
pharmacists results in substantially    into practical tools for clinicians,     27(1), pp. 59-74.
lower rates of ADEs. One hospital       patients, and policymakers. Readers         To assess the relationship
found that within 6 months of           are invited to suggest topics for        between Canadian home health care
employing an emergency                  research in progress (visit              agency characteristics and the
pharmacist, medication errors in the    http://effectivehealthcare.ahrq.gov).    quality of care, the researchers
ED had dropped by 50 percent. A                                                  examined data from 12 agencies in
recent survey of pharmacy directors     Clancy, C. (2008, June).                 Ontario and the Winnipeg region of
found that 10.5 percent of level 1      “Improving care quality and              Manitoba and 11,767 of their adult
trauma centers employed an              reducing disparities: Physicians’        home care clients. These agencies
emergency pharmacist (EPh), while       roles.” Archives of Internal             used a set of home care quality
only 2.7 percent of hospitals           Medicine 168(11), pp. 1135-1136.         indicators (HCQIs) based on the
without a level 1 trauma center            As the U.S. population becomes        Resident Assessment Instrument for
employed an EPh.                        increasingly diverse, there is                         continued on page 28



                                                                                                                 27
 http://www.ahrq.gov/                                                                      Number 339, November 2008
Research briefs                          Edwards, J.C., Kang, J., and             homeless youths to consent to
continued from page 27                   Silenas, R. (2008, Summer).              participation in research and what
Home Care (RAI-HC), a                    “Promoting regional disaster             constitutes appropriate research
questionnaire to which their clients     preparedness.” (AHRQ grant               payments for homeless youths. The
responded. The agencies also             HS13715). Journal of Rural               authors used a 10-15 minute
responded to a mailed survey about       Health 24(3), pp. 321-325.               questionnaire to document
their characteristics. The                  Rural as well as urban areas need     researcher, health care provider, and
researchers found that agencies that     to be prepared for natural disasters.    program administrators’
served a larger population had           Rural hospitals face multiple            experiences with ethical issues of
lower quality of care with respect to    obstacles to preparedness. The           research with homeless youths in
11 of the HCQIs and the overall          authors created and implemented a        the U.S. and Canada. Of the 72
summary measure of quality. Home         simple and effective planning and        respondents to the questionnaire, 37
care case managers had between 90        training exercise to assist rural        respondents obtained written
and 130 clients and agencies with        hospitals to improve disaster            consent and 14 oral consent from
fewer clients per case manager had       preparedness and enhance regional        the youths. Overall, 27 of the
better performance.                      collaboration among these                researchers used money as an
                                         hospitals.                               incentive, while 26 used vouchers
Dougherty, D. and Conway, P.H.              The intervention selected for use     or gift cards, 16 used food, and 10
(2008, May). “The ‘3T’s’ road            was a tabletop exercise, one of the      used no incentive. Mental health
map to transform US health               training methods from the                and/or substance abuse researchers
care.” Journal of the American           discipline of emergency                  tended to use money as an
Medical Association 299(19), pp.         management. Tabletop exercises are       incentive, while health care
2319-2321.                               scripted scenarios depicting a           providers and program
   The authors outline a model or        public health emergency that are         administrators tended to use
“road map” to transform the U.S.         led by a facilitator who asks a          nonmonetary incentives.
health care system by accelerating       group of participants to respond to
the pace at which innovations are        a series of incidents in the scenario.   Fiscella, K. and Meldrum, K.
implemented in clinical settings and     The 3-hour exercise emphasizing          (2008). “Race and ethnicity
addressing the “how” of health care      regional issues in an avian flu          coding agreement between
delivery. Translation 1 (T1) is basic    pandemic was followed by a 1-hour        hospitals and between hospital
science and its translation into         debriefing. The exercise was             and death data.” (AHRQ grant
clinical research; Translation 2 (T2)    successful in identifying problems       HS10910). Medical Science
focuses on practice guidelines and       such as insufficient staff for           Monitor 14(3), pp. SR9-13.
tools for patients; Translation 3        incident command, facility                  Reliable coding of race and
(T3) activities address the “how” of     constraints, and the need to develop     ethnicity by hospitals represents a
health care delivery so that             more regional cooperation.               critical step toward assessing and
evidence-based treatment,                                                         addressing racial and ethnic
prevention, and other interventions      Ensign, J. and Ammerman, S.              disparities in acute inpatient care.
are delivered reliably to all patients   (2008). “Ethical issues in               The authors of this study used
in all settings of care. The 3T’s        research with homeless youths.”          California State Inpatient Data and
model of transformation has four         (AHRQ grant HS11414). Journal            matching vital data to examine the
main activities: 1) measurement and      of Advanced Nursing 62(3), 365-          reliability of race and ethnicity by
accountability, 2) implementation        372.                                     hospitals and death certificates for
and system redesign, 3) scaling and         As a vulnerable group, homeless       1998-2000. The analysis focused on
spread, and 4) research. For these       youths are the focus of an               the rates of agreement for race and
activities to truly transform the        increasing body of research              ethnicity coding among patients
health system to achieve the goal of     documenting their unique health          admitted to different hospitals, the
high-quality care and better health      and social needs. Unlike research        rates of agreement of coding
outcomes, the key facilitators of        with other adolescents, there are no     between hospital data and death
leadership, teamwork, tools, and         specific guidelines for the ethical      certificate data among 548,006
resources must be established and        conduct of research with homeless        persons, and the rates of agreement
integrated.                              youth. Specific ethical issues           for coding Asian and Hispanic
                                         concern the ability of minor                           continued on page 29



28
Number 339, November 2008                                                                        http://www.ahrq.gov/
Research briefs                        percent for a practice size of 50 or    informatics in its efforts to
continued from page 28                 less. Only with a practice size         understand and to improve
ethnicity between hospital and         larger than 100 children with           information processing in health
death data by country of origin        persistent asthma was                   care.
coded on death certificate data. The   reproducibility greater than 85
                                       percent for all measures. The           Henderson, G., Garret, J.,
rates of agreement were high for
                                       researchers concluded that only at      Bussey-Jones, J., and others.
most major racial and ethnic groups
                                       the level of the health care            (2008, March). “Great
both among hospitals and between
                                       organization can the asthma             expectations: Views of genetic
hospitals and death certificates but
                                       measures available within claims        research participants regarding
were too low for American Indians,
                                       data be used to reliably rank           current and future genetic
persons born in India, and selected
                                       physician/practice performance.         studies.” (AHRQ grant T32
Hispanic subgroups. Among
                                                                               HS00032). Genetics in Medicine
patients admitted to different
                                       Hazlehurst, B., Gorman, P.N.,           10(3), pp. 193-200.
hospitals, the rates of agreement
                                       and McMullen, C.K. (2008).                  People who have already
were 98 percent for Asians, 91
                                       “Distributed cognition: An              participated in genetic research
percent for Whites, 88 percent for
                                       alternative model of cognition for      represent an important resource for
Blacks, 19 percent for American
                                       medical informatics.” (AHRQ             future genetic research. However,
Indian, 26 percent for “Other” race,
                                       grant HS12003). International           few studies have investigated their
and 4 percent for unknown race.
                                       Journal of Medical Informatics          attitudes about their willingness to
Fuhlbrigge, A., Carey, V.J.,           77, pp. 226-234.                        participate in future genetic
Finkelstein, J.A., and others.            Cognitive science has provided       research. The researchers
(2008). “Are performance               medical informatics with theory,        interviewed 801 black and white
measures based on automated            methods, and findings for               individuals who had participated in
medical records valid for              understanding clinical knowledge,       a genetic epidemiology study of
physician/practice profiling of        problemsolving, decisionmaking,         colon cancer risk factors. Overall,
asthma care?” (AHRQ grant              and other cognitive phenomena in        63 percent felt “very positive” and
HS08368). Medical Care 46, pp.         health care. Classical cognitive        32 percent felt “positive” about
620-626.                               theory takes the individual person      research looking at whether genes
   The researchers sought to           as the relevant unit of cognitive       put people at risk for disease or
determine if physician practices in    analysis, and medical informatics       illness. Most reported being “very
treating children with asthma could    has largely inherited this approach     likely” (49 percent) or “somewhat
be reliably ranked using the Health    in its teaching, research, and design   likely” (40 percent) to participate in
Employers Data Information             of workplace technologies.              a genetic research study in the
System (HEDIS) performance             However, health care activities         future. When asked to list the good
measure plus three other measures.     include resources internal to           things about such research,
The research design was based on a     individuals as well as resources        respondents cited the potential for
simulation describing the              provided by workplace tools and         discovering the causes and cures of
relationship between practice size     technologies and the organization       various types of cancer, and
and precision of practice measures     of individuals into task-oriented and   increased awareness and preventive
to estimate performance. The study     role-based groups and collaborative     health activities that might reduce
group consisted of 39 practices        teams. The authors review               or eliminate the risk of disease.
with a total of 1,457 children         developments in cognitive science       When asked to list the “bad things,”
meeting the criteria for persistent    that have generated a theory of         over half of the subsample of 194
asthma. The main outcome was           distributed cognition, where the        said “none.” The most common
reproducibility of the HEDIS           unit of analysis is the activity        expressed concern was about the
measure and three other measures       system, which includes individual       implications of genetic information.
(proportion of children with           agents, their technologies and tools,
asthma-related hospitalization,        and their understandings, roles, and    Kuzniewicz, M.W., Vasilevskis,
emergency department visits, and       relationships defined by their          E.E., Lane, R., and others.
oral steroid dispensings for           history of interaction. They argue      (2008). “Variations in ICU risk-
asthma). Of the four measures          that the theory of distributed          adjusted mortality. Impact of
evaluated, none achieved a             cognition is relevant to medical                      continued on page 30
reproducibility of greater than 85


                                                                                                               29
 http://www.ahrq.gov/                                                                     Number 339, November 2008
Research briefs                            Patient identification is the         2003-2004, 45 percent in 2006-
continued from page 29                  cornerstone of patient safety. The       2007) than in the two
methods of assessment and               use of barcode technology for            nonintervention seasons (28 percent
potential confounders.” (AHRQ           patient identification is a growing      in 2002-2003, 26 percent in 2005-
grant HS13919). Chest Journal           trend at many health care                2006). Of those vaccinated, two-
133, pp. 1319-1327.                     organizations. After deciding that a     thirds said they would not have
    The intensive care unit (ICU) has   radio-frequency identification           been vaccinated without the
become a focus of efforts to            system was too new and costly, a         intervention, with one-third stating
improve the quality of care because     small Vermont-based health system        that they would not have been
of the growing number of severely       explored barcode symbologies and         vaccinated if required to pay for it.
ill hospital patients and the           print options in light of the needs of
                                        patients, clinicians, and the hospital   Leonard, C.E., Haynes, K.,
increased complexity of care. In
                                        mission. The system switched from        Localio, A.R., and others. (2008).
order for Federal and State agencies
                                        using laser-generated labels, which      “Diagnostic E-codes for
to assess ICU performance, an
                                        were easily damaged, to using            commonly used, narrow
accurate method of measuring
                                        thermal printers specifically            therapeutic index medications
performance must be selected. The
                                        designed for barcoding that produce      poorly predict adverse drug
objectives of this study were to
                                        durable barcodes easily scanned at       events.” (AHRQ grant HS11530).
determine whether substantial
                                        the point of care. These wristbands      Journal of Clinical Epidemiology
variation in ICU mortality
                                        can survive a week of wear and           61, pp. 561-571.
performance still exists in modern
                                        temperatures up to 130 degrees. In          Adverse drug events (ADEs) are
ICUs and to compare the updated
                                        addition, there is not a significant     a common, major clinical problem
ICU risk-prediction models for
                                        cost difference between thermal and      resulting in patient morbidity and
predictive accuracy, reliability, and
                                        laser printers.                          mortality and increased cost of
data burden. The three models
                                                                                 care. The researchers sought to
compared in the study were the
                                        Lee, I., Thompson, S.,                   determine the validity of hospital
mortality probability model (MPM)
                                        Lautenbach, E., and others.              discharge E-codes (External-Cause-
III, the simplified acute physiology
                                        (2008). “Effect of accessibility of      of-Injury codes) in identifying drug
score (SAPS) III, and the acute
                                        influenza vaccination on the rate        toxicity precipitating hospitalization
physiology and chronic health
                                        of childcare staff vaccination.”         among elderly users of warfarin,
                           .
evaluation (APACHE) IV A total of
                                        (AHRQ grant HS10399).                    digoxin, or phenytoin. Included in
11,300 patients from 35 California
                                        Infection Control and Hospital           the study were 4,803 patients with
hospitals were used to compare the
                                        Epidemiology 29(5), pp.465-467.          11,409 person-years of experience
models. The researchers found
                                            In 2002, the Centers for Disease     with at least 1 of the 3 drug groups
substantial variation in ICU risk-
                                        Control and Prevention expanded          and with 8,756 hospitalizations of
adjusted mortality rates, regardless
                                        its influenza vaccination                which 304 were considered to be
of the risk adjustment model used.
                                        recommendations to include               ADEs related to the use of
Since there is no “gold standard”
                                        children aged 6-23 months and            warfarin, digoxin, or phenytoin. The
against which to judge the available
                                        their caregivers, and again in 2006      researchers found that the positive
models, there is no way to tell if
                                        to include children aged 6-59            predictive values of E-codes
variations in outcomes represent
                                        months and their caregivers. The         indicating toxicity were too low to
true differences in performance or
                                        researchers conducted a study to         confirm hospitalizations due to
merely the inability of the models
                                        evaluate the impact of free on-site      ADEs for any of the three drugs.
to account for unmeasured
                                        vaccination on childcare staff           They concluded that such rare
differences in case mix.
                                        vaccination rates. Included in the       events identified in studies based
Lanoue, E. and Still, C.J. (2008,       study were four influenza seasons:       solely on discharge coding should
May/June). “Patient                     2002-2003, 2003-2004, 2005-2006,         be confirmed by medical record
identification: Producing a better      and 2006-2007. Free on-site              review.
barcoded wristband.” (AHRQ              vaccinations were offered in the
                                        2003-2004 and the 2006-2007              Lieberthal, R.D. (2008, June).
grant HS15270). Patient Safety &
                                        seasons. Vaccination rates were          “Hospital quality: A PRIDIT
Quality Healthcare (available
                                        markedly higher in the two               approach.” (AHRQ grant T32
online at www.psqh.com).
                                        intervention seasons (51 percent in                    continued on page 31




30
Number 339, November 2008                                                                        http://www.ahrq.gov/
Research briefs                         There is some evidence to suggest         for an unsurvivable injury. Applied
continued from page 30                  that novel exposure to MRPs may           to a National Trauma Data Bank
HS00009). HSR: Health Services          elevate preeclampsia risk since first     containing information on 702,229
Research 43(3), pp. 988-1005.           pregnancies, teenage pregnancies,         patients, these continuous values
   Measuring hospital care quality      out-of-wedlock pregnancies,               provided much greater granularity
can be done by measuring inputs to      paternity change, and donor sperm         than the 6 integer values available
care (process measures) or              insemination are markers that             to the AIS. All three of the models
measuring outputs from care             increase the risk for preeclampsia.       discriminated survivors from
(patient outcomes). This study used     MRPs may also contribute to               nonsurvivors better than the ISS,
the PRIDIT method to retro-             spontaneous preterm birth. If novel       but the trauma mortality prediction
spectively analyze Medicare             MRPs influence reproductive               model had both better
hospital data to determine a relative   outcomes, donor insemination              discrimination and better
measure of hospital care quality for    might provide a useful framework          calibration than the ISS.
4,217 hospitals. The PRIDIT             to demonstrate this. The proposed
                                        link between MRPs and adverse             Quigley, D.D., Elliott, M.N., Hays,
approach uses 20 care process
                                        pregnancy outcomes in humans is           R.D., and others. (2008, July).
measures in 4 categories: heart
                                        speculative. Direct measures              “Bridging from the Picker
attack care, heart failure care,
                                        relating specific sperm and semen         hospital survey to the CAHPS®
pneumonia care, and surgical
                                        proteins to conception and birth          hospital survey.” (AHRQ grants
infection prevention and five
                                        outcomes will be needed to test the       HS09204 and HS16980). Medical
structural measures of hospital
                                        import of MRPs.                           Care 46, pp. 654-661.
type. The best indicators of hospital
                                                                                     The Consumer Assessment of
quality were heart failure patients
                                        Osler, T., Glance, L., Buzas, J.S.,       Healthcare Providers and System
given an assessment of left
                                        and others. (2008). “A trauma             (CAHPS®) Hospital Survey
ventricular function and heart
                                        mortality prediction model based          compares performance information
attack patients given a beta-blocker
                                        on the anatomic injury scale.”            on hospitals to inform consumer
at hospital arrival and at discharge.
                                        (AHRQ grant HS16737). Annals              choice and provide incentives to
Hospital teaching status was also an
                                        of Surgery 247, pp. 1041-1048.            hospitals to improve the care they
important indicator of higher
                                           Improving outcomes, whether            provide. With the introduction of
quality of care. The author
                                        through private comparisons among         the CAHPS® Hospital Survey in
concludes that the PRIDIT method
                                        trauma centers or public report           early 2007, hospitals that previously
is an alternative to the use of
                                        cards, depends on the ability to          used other surveys are faced with
clinical outcome measures in
                                        accurately compare performance            bridging and trending issues as they
measuring hospital quality.
                                        across trauma centers. This, in turn,     adopt the new survey. The authors
Ness, R. and Grainger, D.A.             depends on accurate statistical           of this paper illustrate an accessible
(2008). “Male reproductive              adjustment, especially for the            method of bridging data from
proteins and reproductive               severity of injury. Measuring this        earlier surveys to the CAHPS®
outcomes.” (AHRQ grant                  factor is difficult, because there are    Hospital Survey to support
HS08358). American Journal of           hundreds of possible individual           hospitals’ internal quality
Obstetrics and Gynecology 198,          injuries, and patients often have         improvement efforts. They
pp. 620.e1-620.e4.                      more than one injury. The                 administered 6 pairs of parallel
   Male reproductive proteins           researchers developed three new           items from the CAHPS® and
(MRPs) are among the most rapidly       models based on empiric estimates         Picker Hospital Surveys to the
evolving functional genes known.        of injury severity in the abbreviated     same 734 patients. Differences in
They play a central role in embryo      injury scale (AIS) and tested them        wording, response options, and cut
implantation and placentation by        against the injury severity score         points for “problem scores” yielded
inducing inflammation. No studies       (ISS). For each of the 1,322 AIS          large differences in problem score
to date have directly examined          coded injuries, the researchers           rates between the Picker and
whether and how MRPs have an            derived an empiric severity model-        CAHPS Hospital Surveys, which
                                        averaged regression coefficient           required bridging formulas that
                                                                                  they detail. I
impact on the efficacy and
outcomes of human reproduction.         (MARC) value ranging from -1.01
                                        for a trivial injury to a value of 4.03




                                                                                                                  31
 http://www.ahrq.gov/                                                                        Number 339, November 2008
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AHRQ Pub. No. 09-RA002
November 2008
ISSN 1537-0224