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Research Activities Newsletter. December 2009, No. 352 by rvk23499


                                               U.S. Department of Health and Human Services • No. 352, December 2009

Highlights                                       High blood pressure medicines show
                                                 promise for treating heart disease
                                                      wo medications typically

Chronic Disease . . . . . . . . . . . 2                                               the flow of oxygen-rich blood to
                                                      used to treat high blood        the heart is reduced because of
Patient Safety and Quality . . 4                      pressure appear to be           narrowed or blocked arteries.
                                               effective in treating a common type    Symptoms of stable ischemic heart
Pharmaceutical Research . . . 5                of heart disease known as stable       disease include decreased tolerance
                                               ischemic heart disease, according      of exercise and severe chest pain on
Disparities/Minority Health . . 7
                                               to a new comparative effectiveness     exertion (known as angina), which
Outcomes/Effectiveness                         review funded by the Agency for        afflicts about 9 million U.S. adults.
Research . . . . . . . . . . . . . . . . . 8
                                               Healthcare Research and Quality        Long-term risks of stable ischemic
                                               (AHRQ). Treatment featuring the        heart disease include heart failure
Men’s Health. . . . . . . . . . . . . 10       two medications—inhibitors of          and heart attack.
                                               angiotensin-converting enzyme, or         Standard treatment of stable
Women’s Health . . . . . . . . . . 11          ACE inhibitors, and angiotensin        ischemic heart disease consists of a
                                               receptor blockers, or ARBs—can         modification of diet, exercise, and
Child/Adolescent Health . . . 12               lead to a reduction in death, lower    medications that include aspirin,
                                               risk of heart attack and stroke, and   anticholesterol drugs, nitroglycerin,
Emergency Medicine . . . . . . 12              fewer hospitalizations for heart       and beta blockers. While standard
Health Information
                                               failure for patients suffering from    treatment usually alleviates chest
                                               stable ischemic heart disease,         pain, it is not universally successful
Technology . . . . . . . . . . . . . . 13
                                               researchers found.                     in reducing risk of heart failure or
Public Health                                     However, the drugs have risks of    heart attack.
Preparedness . . . . . . . . . . . . 15        their own. Risks associated with          The AHRQ report found that
                                               ACE inhibitors include a persistent    patients with stable ischemic heart
Primary Care. . . . . . . . . . . . . 16       cough, sudden fainting, too much       disease who take an ACE inhibitor
                                               potassium in the blood, and            in addition to standard treatment
HIV/AIDS Research . . . . . . . 17             dangerously low blood pressure         can reduce the likelihood of several
                                               (hypotension). Risks associated        negative outcomes, including death
                                               with ARBs include too much             from heart attack or heart failure,
Regular Features
                                               potassium in the blood and low         nonfatal heart attacks,
Agency News and Notes . . . 19                 blood pressure.                        hospitalization for heart failure, and
                                                  Knowing the risks and benefits      revascularization (surgeries that
Announcements . . . . . . . . . . 20           of these medications will help         reroute blood to the heart). Patients
                                               patients and their doctors decide      who take an ARB in addition to
Research Briefs . . . . . . . . . . 21         the optimal treatment. Stable          standard medications can reduce
                                               ischemic heart disease occurs when                    continued on page 2

                                                               Advancing Excellence in Health Care
Heart disease                              kidney problems. The report found          Standard Medical Therapy for
continued from page 1                      that existing studies provide few          Treating Stable Ischemic Heart
their risk of death from a heart-          data on the medications’ benefits or       Disease, is the newest research
related cause, heart attack, or stroke.    harms in specific populations such         review from the Agency’s Effective
   While some patients and                 as people of different genders,            Health Care Program. The report’s
clinicians pursue a course of              ethnicity, diabetic status, or those       findings will soon be available in
treatment using both ACE inhibitors        who have or do not have high blood         plain-language summary guides for
and ARBs, the report found that            pressure.                                  patients, clinicians, and
combined treatment does not show              AHRQ’s new report,                      policymakers. Summary guides
any benefit over an ACE inhibitor          Comparative Effectiveness of               and reports on numerous clinical
alone and that risks include fainting,     Angiotensin-Converting Enzyme              topics can be found at
diarrhea, low blood pressure, and          Inhibitors or Angiotensin II      I
                                           Receptor Blockers Added to

Chronic Disease

Lifestyle changes are needed in addition to drugs to prevent
heart attacks
          hen factors such as large        heart attack, largely because                Compared with the first period’s

W         waistlines, high
          triglyceride levels, high
cholesterol, high blood pressure,
                                           patients do not adopt healthy
                                           lifestyle changes. Researchers at the
                                           University of Alabama at
                                                                                     patients, those in the second period
                                                                                     took more medicines and,
                                                                                     subsequently, had lower triglyceride
and high blood sugar levels work in        Birmingham studied 1,125 patients         levels, cholesterol levels, and blood
concert (the so-called metabolic           with coronary artery disease who          pressure. While both groups had
syndrome), they become “perfect            underwent cardiac rehabilitation          similar diets and functional
storms” for heart attacks. Most of         during two periods, 1996 to 2001          capacities, the second group had
these conditions can be treated with       and 2002 to 2006, a period in             lower physical activity levels and
drugs. However, a new study finds          which guidelines recommended              larger waistbands than the earlier
that drugs alone do not                    providing medications to get              group, keeping members of both
substantially reduce the risk of a         cardiovascular risks under control.                      continued on page 3

 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          ADHD drugs and cardiac
 information in Research Activities is intended to contribute to the policymaking     problems, see page 5
 process, not to make policy. The views expressed herein do not necessarily
 represent the views or policies of the Agency for Healthcare Research and            Effects of hormone therapy for
 Quality, the Public Health Service, or the Department of Health and Human            prostate cancer, see page 10
 Services. For further information, contact:
                                                                                      Detecting concussion damage
 AHRQ                                     Gail Makulowich
                                                                                      in the ED, see page 13
 Office of Communications                 Assistant Managing Editor
   and Knowledge Transfer                 Mark Stanton, Karen Fleming-Michael,
                                                                                      Stress felt by primary care
 540 Gaither Road                         David Lewin, Kevin Blanchet
                                                                                      physicians, see page 17
 Rockville, MD 20850                      Contributing Editors
 (301) 427-1360                           Joel Boches
                                                                                      Doubling of care costs for
                                          Design and Production
 Barbara L. Kass, MPH, CHES                                                           middle-aged Americans, see
                                          Karen Migdail                               page 19
 Managing Editor                          Media Inquiries

Number 352, December 2009                                                                 
Heart attacks                            changes, such as increasing             intensive therapeutic lifestyle
continued from page 2                    exercise, to truly reduce a patient’s   change,” by Todd M. Brown, M.D.,
groups at the same risk levels for       risk of heart attack. This study was    Bonnie K. Sanderson, Ph.D., R.N.,
having heart attacks.                    funded in part by the Agency for        and Vera Bittner, M.D., M.S.P.H., in
   The authors suggest that while        Healthcare Research and Quality         the Winter 2009 Journal of
medication certainly does its part in    (HS13852).                              Cardiometabolic Syndrome 4(1),
modifying risk factors, clinicians          See “Drugs are not enough: The       pp. 20-25. I
need to emphasize lifestyle              metabolic syndrome—A call for

Best time to start statins in patients with diabetes depends on
the cardiovascular risk model used
       atients with type 2 diabetes often need to lower      gender, metabolic state of the patient, and the societal

P      their cholesterol levels with statin drugs.
       However, a new study finds that the best time to
start such therapy depends on the method used to
                                                             value associated with quality-adjusted life years. For a
                                                             selected base case, when the UKPDS model was used,
                                                             it recommended that all white males with diabetes
determine a patient’s risk for heart disease. Depending      should start statin therapy. However, for the other two
on which risk model is used, there are differences in        models it was never optimal to start statins in men who
age and gender when it comes to prescribing statins for      were at low risk for cardiovascular problems. Earliest
the first time.                                              optimal start times for women were 50 years of age for
   Using clinical data from medical records,                 UKPDS, 46 for Framingham, and 40 for Archimedes.
researchers identified 683 patients over the age of 40       In men, the earliest start time was 40 for all three
with at least 10 years of followup. Information was          models. According to the researchers, these observed
collected on age, gender, number of years with               differences in cardiovascular risk models, age, and
diabetes, different types of cholesterol levels, and blood   metabolic factors contribute to current disagreements
pressure. Three different cardiovascular risk models         as to the best time to start statin therapy in patients
were used to determine the optimal time to start statin      with type 2 diabetes. The study was supported in part
therapy. One model is based on patients in the United        by the Agency for Healthcare Research and Quality
Kingdom (UKPDS), while another is based on patients          (HS17628).
in the United States (Framingham). The third model,              See “Optimizing the start time of statin therapy for
Archimedes, uses a mathematical model to calculate           patients with diabetes,” by Brian T. Denton, Ph.D.,
cardiovascular complications based on several clinical       Murat Kurt, M.S., Nilay D. Shah, Ph.D., and others, in
study results.                                               the May-June 2009 Medical Decision Making 29, pp.
   The best time to start statin drugs depended on the       351-367. I
cardiovascular risk model used, as well as the age,

Care is poor for diabetic patients without insurance and no
regular care provider
        aving both health insurance

                                         information included whether or            More than 84 percent of the
        coverage and a usual source      not they received recommended           individuals had both full-year
        of care (USC) are critical to    diabetes-specific preventive            health insurance coverage and a
receiving proper care for diabetes,      services within the past year. These    USC. The 2.3 percent who had
concludes a new study. It found that     included screening for hemoglobin       neither benefit received the fewest
uninsured patients without a USC         A1c (a marker of glucose control),      services in all seven diabetes care
are not as likely to get diabetes care   blood pressure check, foot and eye      categories. They were only one-
services as their counterparts with      examinations, and routine medical       fifth as likely to have received A1c
health insurance coverage.               care. Various unmet needs (medical,     screening and one-tenth as likely to
   The researchers analyzed data on      dental, specialty care, delayed care)   have blood pressure checks
6,562 individuals with diabetes who      were also examined by the               compared with insured individuals
were 18 years of age and older. The      researchers.                                           continued on page 4

                                                                                                                      3                                                                      Number 352, December 2009
Diabetes care                           unmet health care needs in the last         See “Usual source of care as a
continued from page 3                   year. Those who were uninsured           health insurance substitute for U.S.
with a USC. They were also one-         with no USC had 5.5 times the odds       adults with diabetes?” by Jennifer E.
fourth as likely to have received a     of having an unmet medical need          DeVoe, M.D., D.Phil., Carrie J.
foot care checkup. The insured          and more than 3 times the odds of        Tillotson, M.P.H., and Lorraine S.
group with a USC also had               having delayed urgent care or unmet      Wallace, Ph.D., in the June 2009
significantly better access to most     prescription needs. The study was        Diabetes Care 32(6), pp. 983-989. I
of the care services. Such              supported in part by the Agency for
individuals had fewer reports of        Healthcare Research and Quality

Patient Safety and Quality

Specimens from multiple body sites are needed to accurately
test for MRSA
           hen it comes to accurately diagnosing            samples from the groin and perineum tested positive

W          methicillin-resistant Staphylococcus aureus
           (MRSA) colonization, taking swab samples
from the nose may not be enough. According to a new
                                                            for probable community-acquired MRSA significantly
                                                            more often (75 percent) than they did for hospital-
                                                            acquired MRSA (33 percent).
study, samples from at least two sites on the body need        The researchers found strong agreement between the
to be obtained in order to achieve a sensitivity of more    findings for patient-collected samples and provider-
than 90 percent for MRSA colonization.                      collected samples. As such, patient-collected sampling
   At the Center for Education and Research on              may be a way to improve the efficiency of community-
Therapeutics (CERT) at the University of Pennsylvania       based surveillance and research. This study was funded
School of Medicine, researchers identified 56               in part by a grant from the Agency for Healthcare
individuals who had swab samples positive for MRSA.         Research and Quality (HS10399) to the University of
Swab specimens were taken from the nose, under the          Pennsylvania School of Medicine CERT. For more
arm, throat, groin, and perineum. Immediately after         information on the CERTs program, please visit
these were taken, either the patient or the parent (for
pediatric patients) took swab samples from the same            See “Surveillance cultures for detection of
body sites.                                                 methicillin-resistant Staphylococcus aureus: Diagnostic
   For both provider- and patient-collected samples, the    yield of anatomic sites and comparison of provider- and
nose was the most common site where MRSA was                patient-collected samples,” by Ebbing Lautenbach,
present, followed by the throat. However, nearly a          M.D., M.P.H., M.S.C.E., Irving Nachamkin, Dr.P.H.,
quarter of individuals would not have been identified as    M.P.H., Baofeng Hu, M.D., and others, in the April
having MRSA if the nose had not been sampled.               2009 Infection Control and Hospital Epidemiology
Likewise, 5 percent of cases would have been missed if      30(4), pp. 380-382. I
samples were not obtained from the throat. Swab

 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

Number 352, December 2009                                                             
Using trigger tools to review medical charts helps identify
adverse drug events among older adults
        hart review is one way to        treatments. The researchers then        Common triggers were medication

C       estimate adverse drug events
        (ADEs), which are common
among older adults. However, using
                                         added several new triggers,
                                         including emergency room visit,
                                         unplanned hospitalization, an abrupt
                                                                                 stops, hospitalizations, and
                                                                                 emergency room visits. Nine
                                                                                 triggers were identified as having
“trigger tools” can improve the          medication stop, and death for a        the highest positive predictive
identification of ADEs and make          total of 39 items.                      values for ADEs. These triggers
the chart review process more               Upon careful review, half of the     were responsible for detecting 94.4
efficient and standardized, suggests     charts (645) contained one or more      percent of all ADEs identified by
a new study. A trigger tool uses a set   triggers. From this group, a random     the full trigger tool instrument. This
of screening criteria that includes      sample of 383 charts was selected       suggests the possibility of a much
identifying certain words or medical     for additional review. This group of    briefer trigger tool. The study was
results in charts that may point to an   charts contained a total of 908         supported in part by the Agency for
ADE. Such charts are then pulled         triggers, 232 of which were             Healthcare Research and Quality
for additional study and analysis to     determined to represent ADEs.           (HS14867).
confirm that an ADE took place.          Among these identified ADEs, the           See “Experience with a trigger
   In this study, 1,289 charts were      researchers concluded that 92 of        tool for identifying adverse drug
reviewed at 6 ambulatory primary         them could have been prevented.         events among older adults in
care practices during a 1-year           These preventable ADEs most often       ambulatory primary care,” by Ranjit
period. A trigger tool, previously       occurred during the prescribing or      Singh, M.D., M.B.A., Elizabeth A.
used on ambulatory older adults,         administration of medications.          McLean-Plunckett, M.A., R. Kee,
was used. This included items under      Thirty percent of these were deemed     M.S., and others, in Quality and
such headings as drug levels,            severe, resulting in hospitalization,   Safety in Health Care 18, pp. 199-
diagnoses, laboratory results, and       permanent disability, or death.         204, 2009. I

Pharmaceutical Research
Common attention deficit-hyperactivity disorder drugs have
similar risk for emergency visits for cardiac problems
         mphetamines and methylphenidate are the two           The risk of a trip to the ED was similar for youth

A        most common stimulants used to treat attention
         deficit-hyperactivity disorder (ADHD). In 2007,
the U.S. Food and Drug Administration required that all
                                                            taking either ADHD drug. Youth who visited the ED
                                                            were more likely to use bronchodilators,
                                                            antidepressants, or antipsychotics; have a history of
patient medication guides for ADHD medicines contain        circulatory or cardiac symptoms or congenital
information about the risks of taking these medicines,      anomalies; or be 15 years or older. The authors suggest
including cardiac events. This requirement was sparked      that additional studies are needed that examine long-
in part because of reports linking ADHD drugs, most         term use and dosages to determine if ADHD drugs are
notably the amphetamine Adderall®, with cardiac             linked with heart disease. This study was funded in part
problems.                                                   by a grant from the Agency for Healthcare Research
   To determine if the two stimulants were associated       and Quality (HS16097) to the CERT at Rutgers
with cardiac events, researchers at the University of       University. For more information on the CERTs
Florida in collaboration with the Center for Education      program, visit
and Research on Therapeutics (CERT) at Rutgers                 See “Cardiac safety of methylphenidate versus
University studied data from Florida’s Medicaid             amphetamine salts in the treatment of ADHD,” by
program. Of 30,576 youth who were newly started on          Almut G. Winterstein, Ph.D., Tobias Gerhard, Ph.D.,
either amphetamines or methylphenidate for their            Jonathan Shuster, Ph.D., and Arwa Saidi, M.B.B.Ch., in
ADHD between January 1995 and June 2004, 456                the July 2009 Pediatrics 124(1), pp. e75-e80. I
visited the emergency department (ED) to seek care for
cardiac events.

                                                                                                                   5                                                                      Number 352, December 2009
 More antipsychotic medications are being prescribed for youth
 and nursing home residents, despite lack of evidence
         ntipsychotic medications        have increased fivefold. Currently,   2005 that antipsychotic use is

 A       are commonly being
         prescribed for children,
 adolescents, and nursing home
                                         the U.S. Food and Drug
                                         Administration (FDA) approves
                                         their use to treat schizophrenia,
                                                                               associated with an increased risk
                                                                               for death. Schizophrenia and
                                                                               bipolar disorder, FDA-approved
 residents for a variety of              autism, Tourette’s disorder, and      conditions for antipsychotics,
 conditions not originally intended,     bipolar episodes. However, more       accounted for only 20.7 percent of
 despite a dearth of good evidence       than three-quarters of Medicaid       resident antipsychotic use. The
 to warrant their use. The               youth are treated for non-FDA-        findings were based on several
 widespread use is due to the            approved conditions; the              market, State, and national
 availability of newer agents called     proportion is more than 70 percent    databases. The study was funded
 “atypical antipsychotics.”              for youth with private insurance.     in part by a grant from the Agency
 According to researchers from the       Such conditions include attention     for Healthcare Research and
 Center for Education and                deficit-hyperactivity disorder and    Quality (HS16097) to the Rutgers
 Research on Therapeutics (CERT)         aggressive behavior, conditions for   University CERT. For more
 at Rutgers University, atypical         which little evidence exists to       information on the CERTs
 antipsychotics are considered safer     validate antipsychotic use. A         program, please visit
 than older agents and have all but      major concern is the side effect of
 replaced them. They have also           significant weight gain, which           See “Broadened use of atypical
 become the most costly drug class       may result in obesity, type 2         antipsychotics: Safety,
 for Medicaid programs, far              diabetes, and other problems.         effectiveness, and policy
 surpassing antidepressants. For            Also, nearly 28 percent of         challenges,” by Stephen Crystal,
 Medicare, they are a major              nursing home residents took           Ph.D., Mark Olfson, M.D., M.P.H.,
 expenditure item for the Part D         antipsychotics in 2006, mostly to     Cecilia Huang, Ph.D., and others,
 drug program.                           manage behavioral symptoms of         in the July 2009 Health Affairs
    Most troubling is atypical           dementia, such as agitation,          28(5), pp. w770-w781. I
 antipsychotic use in children and       irritability, and aggression. This
 adolescents, where prescriptions        was despite an FDA warning in

Long-term use of beta blockers is associated with reduced
mortality in patients with heart failure
       ong-term use of beta blockers is significantly

                                                            (ARBs) persistently over the first 2 years after a cardiac
       associated with a lower risk of death in patients    catheterization compared with those who did not use
       with heart failure, according to a recent study by   ACEIs or ARBs in this same time period.
Nancy M. Allen LaPointe, Pharm.D, and her associates           The researchers used data from the Duke Databank
at Duke University Medical Center. They found a 27          for Cardiovascular Disease (DDCD), complemented by
percent lower risk of death for patients with heart         searches of the National Death Index, to study the use
failure and coronary artery disease using beta blockers     of beta blockers and ACEIs/ARBs in all patients who
persistently over the first 2 years after a cardiac         had undergone a cardiac procedure at Duke and were
catheterization when compared with patients who did         found to have significant coronary artery disease and a
not use beta blockers in this same time period. They        left ventricular ejection fraction of less than 40 percent
found no significant difference in death between            (fraction of blood pumped out of the heart’s ventricle).
persistent use of evidence-based beta blockers for          Patients with significant coronary artery disease—
chronic heart failure and other beta blockers in this       those with at least one diseased coronary artery, those
group of persistent users. In addition, they found no       who had undergone angioplasty, and/or those who had
significant difference in death between heart failure       undergone coronary artery bypass—were asked to
patients who received angiotensin-converting enzyme         participate in a clinical followup program that is part of
inhibitors (ACEIs) or angiotensin receptor blockers                                            continued on page 7

Number 352, December 2009                                                             
Beta blockers                                               the need to continually encourage and monitor beta
continued from page 6                                       blocker use as a key part of the management of chronic
the DDCD. Patients (or their families) were contacted       heart failure, note the researchers. However, they
by mail or telephone 6 months after their first entry       caution that because the data were collected at a single
into the database and approximately every year              medical center, the findings may not be generalizable
thereafter for the followup.                                to other health care systems. The study was funded in
   Of the 3,187 patients identified for beta blocker        part by the Agency for Healthcare Research and
analysis, 42 percent had persistent use of any beta         Quality (HS10548).
blocker for at least 2 years after the catheterization.        More details are in “Association between mortality
Among those surviving the 2 years, the risk of death        and persistent use of beta blockers and angiotensin-
was significantly lower in those who had persistent beta    converting enzyme inhibitors in patients with left
blocker use than those with no beta blocker use. Of the     ventricular systolic dysfunction and coronary artery
3,166 patients identified for ACEI/ARB analysis, 42.5       disease,” by Dr. Allen LaPointe, Yi Zhou, M.S., Judith
percent were considered persistent users during the 2       A. Stafford, M.S., and others, in the 2009 American
years after catheterization. These findings underscore      Journal of Cardiology 103, pp. 1518-1524, 2009. I

Disparities/Minority Health
High blood pressure control is often elusive for blacks and Mexican
Americans, despite adherence to treatment and lifestyle changes
        lacks and Mexican

                                        excretion among blacks). Both          differences in diet, and the lower
        Americans struggle with         blacks and Mexican Americans           responsiveness to certain blood
        uncontrolled blood pressure,    were twice as likely as whites to      pressure medications among blacks.
despite adherence to treatment and      report following advice to exercise,   These findings underscore the point
lifestyle modifications, concludes a    quit smoking, restrict alcohol, and    that adherence to treatment alone is
new study. Researchers studied          reduce stress. Also, blacks were 50    not sufficient to adequately control
ethnic differences in treatment,        percent more likely to report salt     hypertension among blacks and
adherence, and control among            restriction and 70 percent more        Mexican Americans and highlight
5,392 adults with hypertension who      likely to report weight loss           the need to monitor blood pressure
participated in the Third National      attempts. Despite adherence to         levels and escalate intensity of
Health and Nutrition Examination        medication (which was similar for      treatment in adherent persons to
Survey (NHANES III), conducted          all three groups) and lifestyle        achieve blood pressure control. The
between 1988 and 1994. During           modification, both blacks and          study was supported in part by the
their participation in NHANES over      Mexican Americans were 40              Agency for Healthcare Research
7 years, individuals received home-     percent and 50 percent,                and Quality (HS10871).
based interviews and received           respectively, more likely than            See “Effect of treatment and
physical examinations at mobile         whites to suffer from uncontrolled     adherence on ethnic differences in
examination centers.                    hypertension.                          blood pressure control among
    Blacks were 60 percent more            The researchers cite several        adults with hypertension,” by
likely than non-Hispanic whites to      reasons to explain these ethnic        Sundar Natarajan, M.D., M.Sc.,
be prescribed medication and 50         differences in blood pressure          Elizabeth J. Santa Ana, M.A.,
percent more likely to be advised to    control. These include higher rates    Youlian Liao, M.D., and others, in
restrict salt intake (probably due to   of obesity and diabetes in blacks      the March 2009 Annals of
evidence of impaired renal salt         and Mexican Americans,                 Epidemiology 19, pp. 172-179. 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.

                                                                                                                 7                                                                     Number 352, December 2009
Better educational materials are needed to boost the health
literacy of individuals who are deaf
        ven after achieving high education levels, people     test’s end. Further, the authors suggest that participants

E       who are deaf do not necessarily have high health
        literacy levels, a new study finds. Steven Barnett,
M.D., of the University of Rochester School of
                                                              were more likely to circle a word they did not actually
                                                              understand than to cross through a word they did not
                                                              comprehend, so the study’s results may actually
Medicine, and his colleague gave a modified version of        overestimate this group’s health literacy.
a test that measures health literacy to 57 individuals           Individuals who are unable to read and comprehend
who were deaf. Participants were asked to read 66             health-related words in English are at risk for health
health-related words, then circle the ones they               disparities, the authors state. For this reason, health
understood and cross through those with which they            care professionals should develop better, accessible
were unfamiliar. More than 68 percent of participants         health education materials to correct this knowledge
understood more than 90 percent of the words on the           gap and prevent adverse health outcomes for
test. However, although nearly 81 percent of                  individuals who are deaf. This study was funded in part
participants had college degrees, almost a third scored       by the Agency for Healthcare Research and Quality
below a ninth grade level on the test, indicating they        (HS15700).
had low health literacy.                                         See “Health-related vocabulary knowledge among
   Words on the test are arranged by increasing               deaf adults,” by Robert Q. Pollard Jr., Ph.D., and Dr.
difficulty. Surprisingly, the words that participants         Barnett in the May 2009 Rehabilitation Psychology
found the most difficult were not necessarily at the          54(2), pp. 182-185. I

Outcomes/Effectiveness Research

 Severity of small blood vessel damage predicts clinical
 outcome after stroke
         ommon among the elderly, leukoaraiosis is a

                                                              functional deficits after 6 months. They were also
         disease of the small blood vessels in the brain.     more likely to be discharged to a rehabilitation center
         It is an independent predictor of risk for           compared with patients with lower volumes. After the
 symptomatic stroke, recurrence, and poststroke               researchers adjusted for factors such as age, initial
 dementia. Now, a new study has found an association          stroke severity, and the amount of brain tissue
 between the severity of leukoaraiosis and the clinical       damaged, the volume of leukoaraiosis remained a
 outcome after a stroke.                                      predictor of clinical outcome. The researchers suggest
    Researchers calculated the volume of leukoaraiosis        that any therapies that may slow the progression of
 in 240 patients with stroke. All had magnetic                leukoaraiosis may also reduce how severe a stroke is
 resonance imaging (MRI) within 24 hours of the               and improve its clinical outcome. The study was
 onset of stroke symptoms such as weakness, blurred           supported in part by the Agency for Healthcare
 vision, confusion, and slurred speech. The average           Research and Quality (HS11392).
 time from symptom onset to MRI was 7.5 hours.                   See “Severity of leukoaraiosis correlates with
    Among the patients studied, the volume of                 clinical outcome after ischemic stroke,” by Ethem M.
 leukoaraiosis ranged from 0.1 to 57.4 mL. Those who          Arsava, M.D., Rosanna Rahman, Ph.D., Jonathan
 had a higher volume of diseased blood vessels at the         Rosand, M.D., M.Sc., and others, in the February
 time of their stroke ended up with more severe               2009 Neurology 72, pp. 1403-1410. I

Number 352, December 2009                                                               
Public reporting of hospital antibiotic timing for patients with
pneumonia is not linked to antibiotic overuse or overdiagnosis
       eleasing information to the      patients with pneumonia receiving       indiscriminate antibiotic use and an

R      public about how hospitals
       treat patients with
pneumonia does not produce any
                                        antibiotics within 4 hours. Rates of
                                        pneumonia diagnosis, antibiotic use,
                                        and physician wait times were
                                                                                overdiagnosis of pneumonia as a
                                                                                result of public reporting are
                                                                                unfounded. The study was
negative consequences for patients.     compared before and after public        supported in part by the Agency for
Specifically, reporting how quickly     reporting.                              Healthcare Research and Quality
patients receive antibiotics does not      No major difference was found        (HS14563).
lead to overdiagnosis or                in the rate of pneumonia diagnosis         See “Reporting hospitals’
inappropriate treatment of              before public reporting (10 percent)    antibiotic timing in pneumonia:
pneumonia, concludes a new study.       and after public reporting (11          Adverse consequences for
   Researchers looked at                percent). The same was true for         patients?” by Mark W. Friedberg,
information from 13,042 visits to       antibiotic timing scores (34 percent    M.D., M.P.P., Ateev Mehrotra, M.D.,
hospital emergency departments by       vs. 35 percent). Any variation in       M.P.H., and Jeffrey A. Linder, M.D.,
adults complaining of respiratory       hospital antibiotic timing was due to   M.P.H., in the February 2009
symptoms from 2001 to 2005. In          differences in wait times to see a      American Journal of Managed Care
2004, the majority of hospitals         doctor rather than differences in the   15(2), pp. 137-144. I
began publicly reporting                rates of pneumonia diagnosis or
information on 10 quality measures.     prescribing antibiotics. The study’s
This included the percentage of         results suggest that fears over

Mysterious skin infection is linked to World War II bomb craters
       hortly after the end of World War II, the first

                                                            to the island during World War II by the Japanese to
       cases of a mysterious skin affliction began to       decrease the mosquito population. The medaka fish is
       affect taro farmers on the Micronesian island of     known to tolerate chronic infection with M. marinum.
Satowan. In 2006, after a man from Satowan with a           This bacterium rarely affects humans except through
skin infection was diagnosed with Mycobacterium             aquatic exposure of a cut or sore. The second major
marinum at a clinic in Portland, Oregon, government         risk factor for the infection was engaging in taro
health authorities in Micronesia invited a team of          farming, which requires standing or walking around in
researchers led by Joseph V Lillis, M.D., of the Oregon     water-filled fields. All of those infected were taro
Health and Sciences University, to investigate. After       farmers and most (95 percent) reported a history of a
evaluation by team members, 39 patients with the            cut or abrasion near the site of their skin infection.
disfiguring skin infection were treated with the               The investigators were unable to definitively identify
antibiotic doxycycline for 3 months. Followup               M. marinum in the 19 tissue samples collected from
evaluation of a few patients showed dramatic                Satowan patients, possibly because of storage at
improvement among those with limited disease.               suboptimal temperatures and a 5-day interval between
   The Satowan islanders affected by the skin disease       collection of the tissue and plating the culture. Further
had suffered from symptoms for an average of 13             microbiological assessment is needed to definitively
years. Its principal symptoms were chronic,                 identify the mycobacterial organism causing this skin
progressive, large, warty plaques primarily affecting the   disease. With intervention and therapy, the researchers
upper and lower limbs. By 2004, the infection had           believe that mitigation of this significant public health
affected more than 10 percent of the island’s population    problem on Satowan is possible. The study was
of 650. Up until this point, surgical and other             supported by the Agency for Healthcare Research and
treatments had proved ineffective and there had never       Quality (HS17552).
been a formal investigation of the condition.                  See “”Sequelae of World War II: An outbreak of
   The team’s investigation showed that the principal       chronic cutaneous nontuberculous mycobacterial
risk factor for the disease was swimming or bathing in      infection among Satowanese islanders,” by Dr. Lillis,
the stagnant waters of craters left by Allied bombing in    Vernon E. Ansdell, M.D., Kino Ruben, M.D., and
World War II. The craters were filled with large            others, in Clinical Infectious Diseases 48, pp. 1541-
numbers of medaka fish that were originally introduced      1546, 2009. I

                                                                                                                  9                                                                      Number 352, December 2009
Men’s Health

Vigorous physical activity may reduce risk of diverticulitis and
diverticular bleeding among men
    t has been known for some time      diverticulitis and a 39 percent          2004, the researchers identified 800

I   that physical activity may
    reduce the risk of colon cancer
and a number of other
                                        reduction in the risk of diverticular
                                        bleeding when compared with men
                                        who did not exercise vigorously.
                                                                                 incident cases of diverticulitis and
                                                                                 383 cases of diverticular bleeding.
                                                                                 The patients’ physical activity
gastrointestinal disorders by           This reduction in risk occurred in a     levels were assessed on a biennial
decreasing colon transit time,          group who engaged in at least 28         basis. Average weekly time spent in
inflammation, and pressure. Now a       MET-h/week of vigorous physical          various recreational activities was
new study shows that vigorous           activity (equivalent to 3 hours of       measured according to 13 different
physical activity can reduce the risk   running).                                categories. The activities included
of diverticular bleeding and               One MET is defined as the             walking, jogging, running,
diverticulitis by more than a third.    energy expended by a 70 kg adult         bicycling, lap swimming, tennis,
Diverticulosis is the condition of      while at rest. Activities assigned a     squash or racquet ball, calisthenics,
having small pouches (diverticula)      MET score of 6 or greater were           rowing, and using a stair climber or
in the lining of the large intestine    classified as vigorous. The MET          ski machine. Each activity was
that bulge outward through weak         score was multiplied by the              assigned a MET score based on
spots, which can cause cramps or        duration of activity in hours and        energy expenditure. Other risk
discomfort in the lower abdomen,        expressed in MET-h/week.                 factors such as sedentary behavior,
bloating, and constipation.                Running was the only specific         diet, medication use, and body
Diverticulitis refers to inflammation   activity associated with a               mass index were also measured.
of the diverticula, which can cause     significantly decreased risk of          The study was supported by the
symptoms ranging from cramping,         diverticulitis. This finding contrasts   Agency for Healthcare Research
nausea, and vomiting to fever,          to many other medical disorders,         and Quality (HS14062).
diarrhea, or constipation.              for which walking and other                 See “Physical activity decreases
   A team led by Lisa L. Strate,        moderate activities help reduce          diverticular complications,” by Dr.
M.D., M.P.H., of the University of      risks.                                   Strate, Yan L. Liu, M.S., Walid H.
Washington, examined the physical          Study patients were participants      Aldoori, M.D., and Edward L.
activity of 48,000 men over an 18-      in the Health Professionals Follow       Giovannucci, M.D., Sc.D. in the
year period. Those engaging in          up Study, who were free of               American Journal of
vigorous physical activity had a 34     diverticulosis or its complications at   Gastroenterology 104, pp. 1221-
percent reduction in the risk of        baseline (1986). In the period 1986-     1230, 2009. I

Men with prostate cancer who receive androgen deprivation
therapy are at elevated risk of bone fractures, cardiovascular
mortality, and diabetes
        ndrogen-deprivation therapy (ADT) is a widely

                                                            1,000 person-years to between 10.5 and 11.7 deaths per
        used treatment for men with either localized or     1,000 person-years. The review scrutinized studies on
        advanced prostate cancer. A new review by           the major side effects of ADT published between 1966
researchers at the University of Texas Health Sciences      and 2008.
Center in Houston has found that the use of ADT                The goal of ADT is to reduce the level of male
increases the chances of bone fracture by 23 percent        hormones (androgens) produced mainly by the testicles,
and cardiovascular mortality by 17 percent. However, in     which stimulate prostate cancer cells to grow. ADT can
absolute terms, the risk for either remained low. Bone      take the form either of surgical castration (orchiectomy)
fracture risk rose only from 6.5 per 100 person-years to    or chemical castration with gonadotropin-releasing
7.2 per 100 person-years, while cardiovascular-related      hormone. It is used as either primary or
mortality risk rose from between 9 and 10 deaths per                                           continued on page 11

Number 352, December 2009                                                             
Prostate cancer                                              but nonsignificant increases in cardiovascular mortality
continued from page 10                                       related to ADT. The other two studies were
adjuvant therapy (in combination with radiation) and is      retrospective studies, both of which reported
effective in alleviating disease-specific symptoms and       significantly increased risks of cardiovascular-related
prolonging survival. Its side effects, in addition to        mortality. Also, two studies investigating the risk of
skeletal and cardiovascular complications, include           diabetes related to ADT found a significant 36 to 39
metabolic complications leading to diabetes. On the          percent increase in the risk of incident diabetes.
subject of ADT’s effects on bone and cardiovascular-         Although the absolute risks of fracture and
related outcomes, researchers found 683 articles             cardiovascular mortality are low among men treated
published during the review period, but only 14 were         with ADT, the researchers recommend consideration of
considered rigorous enough to meet the study’s               preventive treatments, such as the use of
inclusion criteria.                                          bisphosphonates to increase bone density. The study
   The five studies that investigated the risk of fracture   was supported by the Agency for Healthcare Research
as a major side effect of ADT all reported significantly     and Quality (HS16743).
increased risks of overall fracture in patients with            See “Review of major adverse effects of androgen-
prostate cancer who underwent ADT compared with              deprivation therapy in men with prostate cancer,” by
patients who did not undergo ADT. Of the four studies        Lockwood G. Taylor, M.P.H., Steven E. Canfield, M.D.,
investigating cardiovascular-related mortality, two were     and Xianglin L. Du, M.D., Ph.D., in the June 1, 2009
randomized clinical trials that reported slightly elevated   Cancer 115, pp. 2388-2399. I

Women’s Health

 Women in Michigan who suffer miscarriages may not be
 receiving patient-centered care
         woman who suffers a

                                         more likely to be treated with            The primary factor in
         miscarriage has several         surgery (35 percent) than the          determining treatment patterns for
         treatment options. She can      women enrolled in the university       miscarriages appears to be having
 wait to see if the miscarriage          plan (18 percent). In addition, just   access to providers who offer a
 progresses naturally (expectant         0.5 percent of the Medicaid            range of services, the authors
 management), take a drug called         enrollees had surgery in medical       suggest. Some providers may shy
 misoprostol to speed up the             offices, while nearly 31 percent of    away from in-office surgeries
 miscarriage, or have surgery            the university plan’s women            because the procedure is so
 (uterine evacuation) in a medical       underwent office procedures. This      similar to induced abortions.
 office or a hospital. In Michigan,      most likely occurred because the       Expanding treatment options for
 however, providers’ attitudes           latter women had access to a           miscarriage so that they reflect
 appear to be dictating treatment by     network of providers who offered       patient preferences will have the
 expectant management or surgery         this service while the Medicaid-       dual effect of improving patient
 in a hospital operating room, a         insured women did not.                 care and decreasing health care
 new study finds.                           Once the university plan offered    resource use, the authors suggest.
    Vanessa K. Dalton, M.D.,             office uterine evacuations,            This study was funded in part by
 M.P.H., of the University of            researchers saw a movement away        the Agency for Healthcare
 Michigan Medical School, and            from hospitals and toward medical      Research and Quality (HS15491).
 colleagues identified 21,311            offices. However, this option may         See “Treatment patterns for
 women enrolled in Michigan’s            have also led some women and           early pregnancy failure in
 Medicaid program and 1,493              providers to choose surgery in lieu    Michigan,” by Dr. Dalton, Lisa H.
 women from a university-affiliated      of expectant management or             Harris, M.D., Ph.D., Sarah J.
 health plan in Michigan who             misoprostol use, which was low         Clark, M.P.H, and others in the
 experienced miscarriages. The           for both the Medicaid group and        June 2009 Journal of Women’s
 women covered by Medicaid were          the university plan.                   Health 18(6), pp. 787-793. I

                                                                                                               11                                                                      Number 352, December 2009
Child/Adolescent Health

 New guidelines issued for nephrotic syndrome in children
          ew guidelines have been released on the          The guidelines offer definitions for these categories

 N        diagnosis and management of childhood
          nephrotic syndrome. The syndrome, which
 can lead to kidney failure, is characterized by large
                                                           of treatment response, which form the basis of
                                                           implementing appropriate therapy. Clinicians will
                                                           also find a section on complications, including
 amounts of protein in the urine, increased cholesterol    growth disturbances, lipid abnormalities, infection,
 levels, and fluid retention. Development of the           and blood clots.
 guidelines was prompted by changes in the incidence          For children who are responsive to steroids, the
 of different forms of the condition, with increases       guidelines recommend an initial, 12-week
 over the past decade in one type (focal segmental         glucocorticoid regimen in order to decrease the
 glomerulosclerosis). This type of nephrotic syndrome      chance of a relapse. The guidelines also note that
 is less responsive to glucocorticoid treatment (the       children who are overweight at the start of steroid
 gold standard initial treatment) and also has a greater   therapy are more likely to remain overweight after
 risk for progressive kidney failure.                      treatment. The use of glucocorticoids may impair
     In addition, the greater prevalence of obesity and    growth and increase body mass index. Both patients
 diabetes among U.S. children may be exacerbated by        and their caregivers need to be educated in the
 long-term glucocorticoid (steroid) therapy. The           complex treatment of this chronic condition. They
 current recommendations are based on an extensive         should receive specialized instruction in the proper
 literature search, analysis of the data, and expert       administration of medications, how to deal with
 opinion from a consensus study group on the topic.        dietary restrictions, and the need for ongoing medical
     The guidelines offer recommendations to               monitoring. The study was supported in part by the
 physicians for the initial evaluation of children with    Agency for Healthcare Research and Quality
 nephrotic syndrome who are aged 1 to 18 years old.        (HS10397).
 Important to its treatment and management are                See “Management of childhood onset nephrotic
 defining key descriptors of nephrotic syndrome            syndrome,” by Debbie S. Gipson, M.D., M.S., Susan
 management, including remission, relapse, frequently      F. Massengill, M.D., Lynne Yao, M.D., and others, in
 relapsing, steroid-dependent, and steroid-resistant.      the August 2009 Pediatrics 124(2), pp. 747-757. I

Emergency Medicine
Telemedicine reduces children’s emergency department visits for
nonemergency problems
          hen telemedicine is

                                       that provides pediatric care for       greater illness visits overall (i.e.,
          available in child care      acute illnesses through 10 primary     visits to any site).
          centers and schools for      care practices in Rochester, New          Based on observed differences in
urban children with acute illnesses,   York. In their study, researchers      use rates among children at
the use of emergency departments       from the University of Rochester       telemedicine access sites, the
(EDs) decreases substantially,         examined use of telemedicine           researchers calculated a break-even
according to a new study. In turn,     access at 22 child care and school     ratio, where the payment for ED
the decline in ED use for              sites, office visits, and ED care.     visits would be sufficiently greater
nonemergency problems reduces          Children at telemedicine access        than the payment for telemedicine
health care costs. This finding is     sites had 22.2 percent fewer visits    visits so that the cost decrease due
based on the experience of Health-     to EDs than those without access.      to fewer ED visits would equal the
e-Access, a telemedicine service       However, they had 23.5 percent                       continued on page 13

Number 352, December 2009                                                           
Telemedicine                             to 1 break-even ratio was exceeded      The study was supported in part by
continued from page 12                   by current reimbursement rates in       the Agency for Healthcare Research
cost increase due to more overall        the Rochester study community,          and Quality (HS15165).
visits. Based on this calculation, if    where the ED to telemedicine               See “Acute illness care patterns
the mean payment for ED visits is at     payment ratio was 7 to 1.               change with use of telemedicine,”
least fivefold greater than the mean        Thus, the study’s findings           by Kenneth M. McConnochie,
payment for telemedicine visits,         support reimbursing telemedicine        M.D., M.P.H., Nancy E. Wood,
then the health care system will at      providers for services with an          B.A., C.C.R.A., Neil E. Herendeen,
least break even with the                expected financial gain for             M.D., and others, in the June 2009
introduction of telemedicine. The 5      insurance companies and payers.         Pediatrics 123(6), pp. e989-e995. I

Laptop test in an emergency department can help detect subtle
cognitive deficits following concussions
          ild traumatic brain injury (MTBI), also known      memory were similar for both groups; however, the

M         as concussion, is one of the most common
          neurologic conditions. While some patients
bounce back with no complications in the days and
                                                             researchers indicate that these findings might have
                                                             been different if a larger group had been observed and
                                                             if trauma patients had been included.
weeks after suffering MTBI, studies show that up to 15           The authors believe that administering the
percent of patients can experience disability long after     Immediate Post-concussion Assessment and Cognitive
their injury. Thus, tests that help flag impairments early   Testing to detect cognitive deficits can be done
can lead to better treatments and outcomes for patients      effectively in the emergency department. The patients
with MTBI. After administering computer tests that           who took the test completed it without assistance in 25
detect concussions, researchers found that patients with     minutes or less, although some suggested that it could
MTBIs are not as quick at recognizing or reacting to         stand to be shortened. This study was funded in part by
visual objects as patients with no concussions.              the Agency for Healthcare Research and Quality
   Researchers gave the Immediate Post-concussion            (HS13628).
Assessment and Cognitive Testing battery to 23 patients          See “Neurocognitive function of emergency
with concussions and 31 patients with hand injuries          department patients with mild traumatic brain injury,”
over a 3-month period in 2007 at a university-affiliated     by Shane E. Peterson, B.S., Matthew J. Stull, B.S.,
hospital emergency department. Patients with MTBI            B.A., Michael W. Collins, Ph.D., and Henry E. Wang,
had slower visual motor speeds and reaction times than       M.D., M.S., in the June 2009 Annals of Emergency
patients with hand injuries. Scores for visual and verbal    Medicine 53(6), pp. 796-803. I

Health Information Technology

Electronic patient-provider messaging is linked to good diabetes
        ebate continues over the

                                        likely to have their diabetes well      Patients with diabetes had the
        value, usefulness, and          controlled than the group who           option to use electronic messaging
        privacy concerns of             chose not to e-mail their providers.    to communicate with their care
electronic patient-provider             The e-mailing patients also made        providers over a secure Web site. In
messaging. A recent study looked at     more in-person visits to their          addition to measuring message
what happens when patients with         providers.                              threads, the researchers also
diabetes are given the option to           Over a 15-month period,              measured three diabetes-related
communicate with their provider by      researchers analyzed electronic         quality-of-care indicators. These
e-mail. The patients who                patient-provider messaging at           were hemoglobin A1c (a marker of
established an e-mail relationship      Group Health Cooperative, which         glucose control), blood pressure,
with their care providers were more     operates in Washington and Idaho.                     continued on page 14

                                                                                                                13                                                                      Number 352, December 2009
Diabetes control                         was 36 percent higher in patients      be more proactive with providers
continued from page 13                   who had the highest rate of secure     both online and in person, suggest
and LDL-cholesterol (“bad”               messaging use (defined as 12 or        the researchers. Their study was
cholesterol).                            more threads per year) compared        supported in part by the Agency for
   A total of 2,924 patients (19         with nonmessaging patients.            Healthcare Research and Quality
percent) with diabetes used the          Electronic messaging, however, was     (HS14625).
secure messaging option on the           not strongly associated with              See “Diabetes quality of care
Web site. Each user participated in      adequate blood pressure control or     and outpatient utilization associated
an average of 5.3 message threads        lower LDL cholesterol.                 with electronic patient-provider
consisting of 11.8 individual               High messaging users also made      messaging: A cross-sectional
messages. The vast majority (86.9        32 percent more primary care visits    analysis,” by Lynne T. Harris,
percent) of message threads were         than nonusers, which was               Sebastien J. Haneuse, Ph.D., Diane
started by the patient. The rate of      surprising. High messaging users       P. Martin, M.A., Ph.D., and James
A1c at or below 7 percent (which         also had more outpatient specialty     D. Ralston, M.D., M.P.H., in the
indicates good glycemic control)         and emergency care visits. Patients    July 2009 Diabetes Care 32(7),
                                         who use electronic messaging may       1182-1187. I

Certain types of hospitals are more likely to use computerized
physician order entry
        ospitals across the country continue to adopt        CPOE, and urban teaching hospitals were nearly 4

H       computerized physician order entry (CPOE),
        although it is still not widespread. A study of
hospitals that care for children found that hospitals that
                                                             times more likely than rural hospitals to use CPOE.
                                                                The researchers also found geographic differences.
                                                             Hospitals located in the Northeast, Midwest, and the
became early adopters of CPOE had certain                    South were 11.2, 4.2, and 3.1 times respectively more
characteristics. Researchers from the Medical                likely to use CPOE than hospitals located out West. The
University of South Carolina in Charleston reviewed 2        researchers call for future studies to look at the
large databases to identify 2,145 hospitals that care for    financial benefits of CPOE use in children’s health
children that used CPOE in 2003. They analyzed               care. Their study was supported in part by the Agency
hospital characteristics, including hospital type, bed       for Healthcare Research and Quality (HS15679).
size, ownership, health system affiliation, rural/urban         See “Early adopters of computerized physician order
location, and U.S. region.                                   entry in hospitals that care for children: A picture of
   At the time of the study, only 6 percent of the           US health care shortly after the Institute of Medicine
hospitals were using CPOE. Dedicated children’s              reports on quality,” by Ronald J. Teufel II, M.D.,
hospitals were six times more likely to be early             M.S.C.R., Abby Swanson Kazley, Ph.D., and William T.
adopters of CPOE compared with general hospitals             Basco Jr., M.D., in the May 2009 Clinical Pediatrics
with pediatric units. Private for-profit hospitals were      48(4), pp. 389-396. I
26.5 times more likely than public hospitals to use

Staff willingness to change and adapt is important when
implementing electronic pharmacy systems
       lectronic pharmacy systems

                                         and adapt to the system as factors     months prior to the system being
       can do much to improve            critical to success.                   introduced and then again at 3
       patient safety and reduce            These insights come from            months after implementation.
medication errors in hospitals.          Children’s Healthcare of Atlanta, a       While interviewed pharmacists
Implementing these systems               two-hospital pediatric health care     believed the system’s implemen-
requires putting into place a            system that began implementing an      tation would mainly affect
number of facilitators as well as        electronic pharmacy system in          pharmacists, clinical managers felt
overcoming identified barriers. A        2005. Information was gathered         that frontline nurses and respiratory
new study points to the willingness      from pharmacists and clinical          therapists would be most affected.
of hospital employees to change          managers at approximately 3                          continued on page 15

Number 352, December 2009                                                             
Electronic pharmacy                    identified facilitators included        electronic pharmacy system
systems                                having an effective implementation      consider training super users,
continued from page 14                 plan and having a user-friendly,        providing formal feedback
                                       flexible system. Pharmacists cited      mechanisms, and understanding
Both pharmacists and clinical
                                       the most important barrier as staff     how implementation may affect
managers generally agreed that the
                                       concerns with the usability of          various hospital staff groups
three main goals for
                                       information in the pediatric drug       differently. The study was
implementation were to improve
                                       file. Clinical managers, however,       supported in part by the Agency for
patient safety, increase job
                                       felt that adjusting to new work         Healthcare Research and Quality
efficiency, and update the existing
                                       processes was the biggest barrier.      (HS15236).
hospital system.
                                       Other barriers included staff              See “Implementing a pharmacy
   Staff readiness-to-change was
                                       apprehension and resistance,            system: Facilitators and barriers,”
the most significant facilitator of
                                       potential problems transferring         by Steven D. Culler, Ph.D., James
adoption, according to the
                                       active orders, and poor                 Jose, M.D., Susan Kohler, R.N.,
pharmacists. On the other hand,
                                       communication and feedback. The         M.P.H., and others, in the Journal
clinical managers identified system
                                       researchers recommend that              of Medical Systems 33, pp. 81-90,
training and education as their most
                                       hospitals implementing an               2009. I
significant facilitator. Other

Public Health Preparedness

 A substantial number of adults stockpiled drugs for the avian flu
 outbreak in 2005
         uring the fall of 2005, amidst media reports of

                                                            medicine practitioners (39.4 percent). Only 33
         a worldwide H5N1 influenza (bird flu)              percent of individuals received a prescription for an
         outbreak, a substantial number of adults           appropriate indication. Oseltamivir is appropriately
 stockpiled prescribed Tamiflu® (oseltamivir), reports      prescribed within 12 to 48 hours of initial flu
 a new study. Stockpilers were more often older and of      symptoms to be effective in alleviating duration and
 white race. They more often reported greater worry         severity of symptoms. It is also used to prevent the
 about the flu, felt more vulnerable to getting infected,   flu among persons exposed to infected individuals.
 and expected that it would spread to the United            Among those getting inappropriate prescriptions, 15.1
 States.                                                    percent specifically requested the drug for
    Researchers at the Center for Education and             stockpiling. Another 24.7 percent requested it without
 Research on Therapeutics (CERT) at the University          giving a reason. The study was funded in part by a
 of Pennsylvania School of Medicine identified 109          grant from the Agency for Healthcare Research and
 individuals who received prescriptions for the             Quality (HS10399) to the University of Pennsylvania
 influenza medication oseltamivir from 45 providers.        School of Medicine CERT. For more information on
    They examined medical records and supplemental          the CERTs program, please visit
 questionnaires to determine drug usage patterns. They         See “Stockpiling drugs for an avian influenza
 compared individuals who received oseltamivir              outbreak: Examining the surge in oseltamivir
 prescriptions with those who did not receive               prescriptions during heightened media coverage of
 oseltamivir prescriptions. The study period was            the potential for a worldwide pandemic,” by Leanne
 between September 1, 2005 and December 31, 2005,           B. Gasink, M.D., M.S.C.E., Darren R. Linkin, M.D.,
 when there was intense media coverage about avian          M.S.C.E., Neil O. Fishman, M.D., and others, in the
 flu outbreaks in certain regions.                          April 2009 Infection Control and Hospital
    The majority of oseltamivir prescriptions were          Epidemiology 30(4), pp. 370-376. I
 written by internists (47.7 percent) and family

                                                                                                              15                                                                     Number 352, December 2009
Primary Care

Majority of primary care physicians now recommend colonoscopy
         bout 95 percent of primary     effective at reducing mortality from   recommends, but does not

A        care physicians routinely
         recommend screening
colonoscopy to patients with
                                        CRC, 95 percent felt this way in the
                                        latest survey. In the older survey,
                                        the fecal occult blood test (FOBT)
                                                                               distinguish among, all three
                                                                               procedures. According to the latest
                                                                               survey, the majority of primary care
average risk for colorectal cancer      was the screening modality most        physicians recommend age 50 years
(CRC). Procedures once                  recommended (95 percent).              for the start of CRC screening, with
recommended in the past, such as        Colonoscopy was a distant third at     colonoscopy performed once every
sigmoidoscopy (where only a third       only 38 percent, behind                10 years. Close to two-thirds (61
of the colon is examined), are now      sigmoidoscopy (78 percent). Now,       percent) of physicians reported
only rarely suggested to patients,      95 percent of primary care             having implemented guidelines for
reveals a new study. Researchers        physicians routinely recommend         CRC screening..
analyzed responses from 1,266           colonoscopy, followed by FOBT             See “Colorectal cancer screening
primary care physicians who             (80 percent) and sigmoidoscopy (26     by primary care physicians:
responded to a 2006-2007 survey         percent). There has been a 25          Recommendations and practices,
on recommendations and practices        percent drop in the number of          2006-2007,” by Carrie N.
for colorectal and other commonly       primary care physicians who            Klabunde, Ph.D., David Lanier,
screened cancers. Results were then     perform flexible sigmoidoscopies.      M.D., Marion R. Nadel, Ph.D., and
compared with responses from an         While many have been trained in        others, in the July 2009 American
earlier nationwide survey               the procedure, they now only rarely    Journal of Preventive Medicine
conducted in 1999-2000.                 recommend or perform it, note the      37(1), pp. 8-16. Reprints (AHRQ
   Whereas 86 percent of                researchers.                           Publication No. 09-RA076) are
physicians in the earlier survey           The U.S. Preventive Services        available from AHRQ*. I
perceived colonoscopy to be very        Task Force on CRC screening

Primary care physicians do not always discuss the risks and
benefits of prostate cancer screening with patients
       here is insufficient evidence to recommend for or

                                                             lowest among PCPs who discussed testing with their
       against routine prostate cancer screening. Thus,      patients and let them decide. Patient risk factors also
       guidelines recommend that doctors discuss the         played a role in how likely physicians were to screen
risks and benefits of prostate cancer screening, so that     men. For example, 69 percent of nondiscussion
men can decide for themselves about prostate-specific        physicians and 50 percent of discussion physicians said
antigen (PSA) testing. However, one in five primary          they were more likely to screen black men (who have a
care physicians (PCPs) do not have this discussion with      higher risk for the disease). Also, 91 percent of
their patients, according to a new study. Primary care       nondiscussion physicians and 46 percent of discussion
physicians filled out a survey that included open-ended      physicians indicated they were more likely to screen
questions about their use of prostate cancer screening       patients with family histories of prostate cancer.
practices and patient discussions. Among the 63                 Among the nearly three-fourths of PCPs who used
physicians surveyed, 20.6 percent ordered a PSA test         prescreening discussions, the role of decisionmaker
without any discussion with the patient and 71.4 percent     varied. Some PCPs let patients decide, while others
ordered the test after a prescreening discussion. Three      recommended testing. Physicians who tried to persuade
physicians did not order a PSA test or discuss it with the   men to get tested believed in the efficacy of screening
patient.                                                     and PSA testing. Physicians who did not try to persuade
   Ordering a PSA test was highest among PCPs who            men to be tested questioned the lack of scientific
did not discuss screening with their patients, followed      evidence and efficacy of the PSA test and
by PCPs who engaged in discussions and recommended           some were concerned about treatment side effects
the PSA test for their patients. PSA test orders were                                         continued on page 17

Number 352, December 2009                                                           
Prostate cancer screening                                      See “Primary care physicians’ reported use of pre-
continued from page 16                                      screening discussions for prostate cancer screening: A
(e.g., incontinence and impotence from surgery or           cross-sectional survey,” by Suzanne K. Linder, M.D.,
radiation). None of the surveyed physicians reported        Sarah T. Hawley, Ph.D., Crystale P. Cooper, Ph.D., and
recommending against the test. The study was                others, in the March 18, 2009 online issue of BMC
supported in part by the Agency for Healthcare              Family Practice 10(19) at
Research and Quality (HS10612).                             articlerender.fcgi?artid=2666644. I

 More than half of primary care physicians report stressful
 working conditions
        rimary care physicians are      experiencing time pressures when        missing from care of all patients

 P      not having an easy time at
        work these days. According
 to a new study on working
                                        conducting physical examinations.
                                        Nearly a third (30.3 percent) felt
                                        they needed at least 50 percent
                                                                                across clinics) of only 33.5
                                                                                percent. According to the
                                                                                researchers, physicians may act as
 conditions, more than half report      more time than was allotted for         buffers between adverse work
 feeling stressed over time             this patient care function. In          conditions and patient care, as
 pressures during office visits. They   addition, 21.3 percent said they        their reactions do not appear to
 also report other stress-related       needed at least 50 percent more         translate into lower quality care.
 problems that affect their daily       time for followup appointments.         However, some direct relationships
 practice. However, the good news       Time pressure was strongly              were seen between adverse work
 is that while these physicians         associated with feelings of             conditions and some patient
 report stress, their reactions to it   dissatisfaction, stress, burnout, and   outcomes. These findings require
 do not affect the quality of care      intent to leave the practice. Nearly    further study, and could provide a
 they provide to patients.              half of the physicians (48.1            link between the primary care
     Researchers surveyed 422           percent) reported chaotic               work environment and quality of
 family physicians and general          environments. A minority (21.6          care. The study was supported by
 internists who worked in 119           percent) felt they had moderate         the Agency for Healthcare
 ambulatory care clinics located in     control over their work                 Research and Quality (HS11955).
 New York City, Chicago,                environment.                               See “Working conditions in
 Milwaukee, Madison, and rural             Despite these survey responses,      primary care: Physician reactions
 Wisconsin. They also surveyed          chart review data produced an           and care quality,” by Mark Linzer,
 1,795 patients from these clinics      average overall quality score           M.D., Linda Baier Manwell, M.S.,
 and reviewed their medical records     (average proportion of quality          Eric S. Williams, Ph.D., and
 for information on care quality and    outcomes for all patients across        others, in the July 7, 2009 Annals
 medical errors.                        clinics) of 57.8 percent and an         of Internal Medicine 151(1), pp.
     More than half (53.1 percent) of   average error score (average            28-36. I
 the physicians reported                proportion of processes of care

HIV/AIDS Research
Smoking is particularly hazardous for individuals with HIV infection
       veryone knows smoking is a leading cause of

                                                            former smoker), the number of pack-years (based on
       death and disease. But for persons living with       cigarettes smoked per day and years), coexisting
       HIV smoking is particularly hazardous,               diseases, respiratory symptoms, substance abuse, and
concludes a study of veterans. Researchers compared         quality of life. They were followed for a median of 5.3
overall mortality in 1,034 HIV-positive veterans and        years.
739 HIV-negative veterans. Both groups were matched            There were 200 deaths in the HIV-positive group,
according to age, race, sex, and demographics.              resulting in a mortality rate of 4.1 per 100 person-years
Information was obtained on smoking status (current or                                        continued on page 18

                                                                                                                17                                                                      Number 352, December 2009
Smoking                                                        Smoking was also linked to increased respiratory
continued from page 17                                      symptoms and coexisting diseases, as well as a
(PY). This was double the mortality rate of 2.0 per 100     decreased quality of life. The researchers recommend
PY (72 deaths) in the HIV-negative group. However,          that encouraging individuals with HIV infection to quit
HIV-positive current smokers had the highest mortality      smoking, regardless of pack-year history, should be an
rate of 5.48 per 100 PY, followed by 3.41 for HIV-          important part of their ongoing care. The study was
positive former smokers, and 2.45 for never smokers         supported in part by the Agency for Healthcare
infected with HIV When the researchers stratified
                  .                                         Research and Quality (HS16097).
patients by pack-years of smoking, there was a                 See “Impact of cigarette smoking on mortality in
decreased survival among HIV-positive veterans with         HIV-positive and HIV-negative veterans,” by Kristina
any degree of smoking exposure. Mortality rates were        Crothers, M.D., Joseph L. Goulet, Ph.D., M.S., Maria
significantly higher in HIV-positive smokers compared       C. Rodriguez-Barradas, M.D. and others, in the 2009
with HIV-positive veterans who never smoked for both        AIDS Education and Prevention 21(Suppl A), pp. 40-
less than 20 and greater than or equal to 20 pack-years     53. I
of exposure.

 Observing patients swallowing one HIV drug on weekdays has
 little impact on drug adherence
          irectly-observed therapy

                                        daily. Participants in the mDOT        evidence that the group originally
          (DOT), where providers        group received lopinavir/ritonavir     on mDOT did worse than the
          watch patients take their     under direct supervision by a care     group that started and stayed with
 medications every day, is often        provider during weekdays and           self-administered therapy. This
 used to improve adherence to a         self-administered the drug on          suggests that changing an
 drug regimen, including                weekends, holidays, and days in        individual’s adherence support
 medications used to treat HIV          which they could not reach the         may have detrimental effects.
 infection. A modified version of       site.                                  While participants did accept
 this technique (mDOT) only                Compared with self-                 mDOT and found it appealing, the
 observes patients during weekdays      administered therapy participants,     researchers concluded that mDOT
 and focuses on one drug in the         a higher proportion of those on        should not be incorporated
 regimen. The goal is to ensure that    mDOT remained on their dose            routinely into HIV care. However,
 patients just starting HIV therapy     schedule at week 24 (84 versus 78      they believe it may be useful in
 adhere to their regimen and            percent). By week 48, however,         patients with a high risk for
 continue to do so after mDOT is        the proportions had dropped to 73      nonadherence, particularly those
 stopped. A new study, however,         percent and 68 percent,                who have failed treatment. Their
 has found that such a strategy only    respectively. The difference in        study was supported in part by the
 produces marginal results. In          adherence level between the two        Agency for Healthcare Research
 addition, once mDOT is stopped         groups at this point was not           and Quality (HS16946).
 after 6 months, any benefits to        considered significant. Although          See “Modified directly
 adherence are not sustained.           the proportion of participants with    observed antiretroviral therapy
    Researchers randomized 243          adequate suppression of HIV at         compared with self-administered
 patients, who had never before         week 24 was higher in the mDOT         therapy in treatment-naive HIV-1-
 taken HIV medication, into two         group, the difference was once         infected patients,” by Robert
 groups. One group (161                 again not large enough to be           Gross, M.D., M.S.C.E., Camlin
 participants) took their HIV           deemed superior to self-               Tierney, Ph.D., Andriana Andrade,
 medications without any provider       administered therapy.                  M.D., M.P.H., and others, in
 supervision. The second group (82         Interestingly, after the mDOT       the July 13, 2009 Archives of
 participants) was given mDOT. As       was stopped and mDOT                   Internal Medicine 169(13), pp.
 part of their antiretroviral therapy   participants switched to fully self-   1224-1232. I
 regimen, all patients were             administered therapy for the final
 prescribed lopinavir/ritonavir once    24 weeks, there was some

Number 352, December 2009                                                            
Agency News and Notes
Care costs for middle-aged Americans have doubled in the past
        he $370 billion in health care expenses for          • The average expense per service rendered grew

T       Americans aged 45 to 64 in 2006 were about
        double the inflation-adjusted total for 1996 ($187
billion), according to the latest data from the Agency
                                                               significantly (in 2006 dollars):
                                                               – Physician office visit, $128 to $207
                                                               – Inpatient hospital day, $3,005 to $3,491
for Healthcare Research and Quality (AHRQ). The
Agency examined costs for all Americans aged 45 to             – Emergency room visit, $563 to $947
64 other than those residing in nursing homes and other        – Dental visit, $195 to $265
institutions.                                                  – Prescription medicines, $103 to $199
   AHRQ also found that during this period:
                                                                These findings were based on analysis of the
• The proportion of people aged 45 to 64 who incurred        Medical Expenditure Panel Survey (MEPS), a detailed
   medical expenses did not change (about 89 percent),       source of information on the health services used by
   but average annual health care expenses for those         Americans, the frequency of use, cost of services, and
   with expenses increased from $3,849 (after adjusting      how they are paid. For more information, see Trends in
   for inflation) to $5,455.                                 Health Care Expenditures for Adults Ages 45-64: 2006
• Prescribed medicines were a substantially higher           versus 1996 at
   proportion of total expenses in 2006 compared with        data_files/publications/st255/stat255.pdf. I
   1996 (25 percent and 15 percent, respectively).
• The proportion of total expenses for hospital
   inpatient care decreased (from 36 percent to 26

Patient deaths in hospitals cost nearly $20 billion
        ne of every three people

                                          and $12 billion in hospital costs,      of patients who died were
        who died in 2007 in the           while privately insured patients        admitted for accidents or
        United States were in the         accounted for 20 percent of             intentional injury and about 2
hospital for treatment at the time of     deaths and $4 billion. Medicaid         percent were newborn infants.
their deaths, according to the latest     patients accounted for 2 percent     • Septicemia, a life-threatening
data from the Agency for                  of deaths and $2.4 billion, and         blood infection, was the major
Healthcare Research and Quality           uninsured patients, 3 percent and       cause of death, accounting for 15
(AHRQ). The cost of their hospital        $630 million.                           percent of all deaths, followed by
stays was about $20 billion.            • The average cost for each               respiratory failure (8 percent);
AHRQ’s analysis of 765,651                Medicaid patient who died was           stroke (6 percent); pneumonia (5
hospital patient deaths in 2007           $38,939 – roughly $15,000 more          percent); heart attack (5
found that the average cost of            than the average cost of a              percent); and congestive heart
hospital stays in which patients          Medicare or uninsured patient           failure (4 percent). Other leading
died was $26,035, versus an               who died, and about $10,000             causes of death included cancer,
average of $9,447 for patients who        more than a privately insured           aspiration pneumonia, and
were discharged alive. The costs          patient who died.                       kidney failure.
were higher for patients who died,
because their hospital stays were       • About 12 percent of patients            These findings are based on data
longer than those of patients who         who died had been admitted for       in The Costs of End-of-Life
lived (8.8 days vs. 4.5 days).            an elective procedure or other       Hospitalizations, 2007, Statistical
   The study also found that:             non-urgent reason and 72             Brief #82. The report uses
                                          percent were emergency               statistics from the 2007 Nationwide
• Medicare patients accounted for         admissions. Roughly 7 percent                     continued on page 20
   67 percent of in-hospital deaths

                                                                                                                   19                                                                     Number 352, December 2009
Patient deaths                           hospitals that comprise 90 percent        uninsured. You can view the report
continued from page 19                   of all discharges in the United States    at
Inpatient Sample, a database of          and include all patients, regardless      statbriefs/sb82.pdf. I
hospital inpatient stays drawn from      of insurance type, as well as the

Georgians and Ohioans pay less for dental care than the national
      he annual amount spent by Georgians and                • Compared to the national average of 49 percent for

T     Ohioans or their insurers for dental care in 2006
      averaged about $150 less than the national
average of $607, according to the latest data from the
                                                                out-of-pocket payment for dental care, Floridians
                                                                paid more (62.5 percent) and Pennsylvanians paid
                                                                less (42 percent).
Agency for Healthcare Research and Quality (AHRQ).           • Nationally, private insurers paid 43 percent of all
The average annual dental expenditure for each                  dental expenditures.
Georgian who had dental care was $466, while for
Ohioans, it was $474.                                           These findings are taken from the Medical
  AHRQ’s analysis of average annual dental                   Expenditure Panel Survey (MEPS), a detailed source of
expenditures in the 10 States with the highest               information on the health services used by Americans,
populations in 2006 also found that:                         the frequency with which they are used, the cost of
                                                             those services, and how they are paid. For more
• Michigan had the highest proportion of residents           information, view Dental Expenditures in the 10
  with dental expenses (52.5 percent) and Texas had          Largest States, 2006 at
  the least (30 percent).                                    data_files/publications/st263/stat263.pdf. I


AHRQ awarded $17 million to fund projects to fight health care-
associated infections
       he Department of Health and

                                         The number of MRSA-associated            using a checklist of evidence-based
       Human Services (HHS) has          hospital stays has more than tripled     safety practices; staff training
       awarded the Agency for            since 2000, reaching 368,600 in          and other tools for preventing
Healthcare Research and Quality          2005, according to AHRQ’s                infections that can be
(AHRQ) $17 million to fund               Healthcare Cost and Utilization          implemented in hospital units;
projects to fight costly and             Project.                                 standard and consistent
dangerous health care-associated            Of the $17 million, $8 million        measurement of infection rates; and
infections (HAIs). These infections      will fund a national expansion of        tools to improve teamwork among
are one of the most common               the Keystone Project, which within       doctors, nurses, and hospital
complications of hospital care.          18 months successfully reduced the       leaders.
Nearly 2 million patients develop        rate of central-line blood stream           Last year, AHRQ funded an
HAIs, which contribute to 99,000         infections in more than 100              expansion of this project to 10
deaths each year and $28 billion to      Michigan intensive care units            States. With additional funding
$33 billion in health care costs.        (ICUs) and saved 1,500 lives and         from AHRQ and a private
HAIs are caused by different types       $200 million. The project was            foundation, the Keystone Project is
of bacteria that infect patients being   originally started by the Johns          now operating in all 50 States,
treated in a hospital or health care     Hopkins University in Baltimore          Puerto Rico, and the District of
setting for other conditions. The        and the Michigan Health &                Columbia. The new HHS funding
most common HAI-causing                  Hospital Association to implement        will expand the effort to more
bacteria is methicillin-resistant        a comprehensive unit-based safety        hospitals, extend it to other settings
Staphylococcus aureus, or MRSA.          program. The program involves                          continued on page 21

Number 352, December 2009                                                               
Health care-associated                  (CDC), AHRQ also identified             new ways to eliminate MRSA in
infections                              several high-priority areas to apply    ICUs. A complete list of institutions
continued from page 20                  the remaining $9 million toward         funded by the $17 million awarded
                                        reducing MRSA and other types of        to AHRQ is available at
in addition to ICUs, and broaden
                                        HAIs. These projects will range I
the focus to address other types of
                                        from reducing Clostridium difficile
                                        infections through a regional
   In collaboration with the Centers
                                        hospital collaborative to evaluating
for Disease Control and Prevention

 AHRQ introduces new Pharmacy Health Literacy Center
         HRQ recently announced the completion of its       Strategies to Improve Communication between Staff

 A       Pharmacy Health Literacy Center to help retail
         pharmacists meet the needs of customers with
 low or limited health literacy. Research shows that
                                                            and Patients: Training Program for Pharmacy Staff;
                                                            How to Create a Pill Card; and Telephone Reminders:
                                                            A Tool to Help Refill Medications on Time. The Web
 many people misread or misunderstand instructions          site,
 on how to take medications as prescribed. But              sites/PharmHealthLiteracy/default.aspx, also features
 effective communication can reduce medication errors       additional assistance for pharmacies interested in
 and the adverse outcomes they may cause.                   using the assessment tool; a list of resources to learn
    The AHRQ Pharmacy Health Literacy Center                more about health literacy; and a discussion board for
 features four tools for retail pharmacies: Is Our          visitors to post comments and questions to learn from
 Pharmacy Meeting Patients’ Needs: A Pharmacy               other pharmacists. I
 Health Literacy Assessment Tool User’s Guide;

Research Briefs
Clancy, C. (2009). “Building the        care quality improvement program.          This report describes how a
path to high-quality care.” HSR:        The work described in these studies     multidisciplinary medication
Health Services Research 44(1),         is far more challenging than some       education program was modified to
pp. 1-4. Reprints (AHRQ                 traditional research areas because it   include pharmacy students in
Publication No. 09-R090) are            requires effective engagement with      providing medication education to
available from AHRQ.*                   policymakers, clinicians, health        high-risk patients. The program,
   Recent assessments of health         care leaders, and patients, notes the   called the Enhanced Patient Safety
care quality consistently reflect a     author. She encourages investments      Intervention to Optimize
substantial and persistent gap          in improvement methods, new             Medication Education (EPITOME),
between high-quality evidence-          approaches to training, and             had already been implemented in a
based care and that which is            demonstrations.                         674-bed academic hospital but time
routinely delivered, according to the                                           constraints made it difficult for
director of the Agency for              Donihi, A. C., Weber, R. J., Sirio,     pharmacists to provide a
Healthcare Research and Quality.        C. A., and others. (2009).              meaningful education experience
She discusses two studies in this       “Instructional design and               for the patients. After consultation,
issue of the journal on the science     assessment. An advanced                 hospital and pharmacy school staff
of improvement. The first study         pharmacy practice experience in         proposed an Inpatient Medication
reported on the outcome of a            inpatient medication education.”        Education advanced pharmacy
multifaceted intervention to            (AHRQ grant HS15851).                   practice experience. Students were
improve pain management for             American Journal of                     trained to independently assess
elderly patients with hip fractures.    Pharmaceutical Education 73(1),         patients’ needs and identify drug-
The second study focused on the         pp. 1-6.                                related problems.
organizational costs of a depression                                                          continued on page 22

                                                                                                                21                                                                      Number 352, December 2009
Research briefs                         events increase readmission?”           errors are relatively common
continued from page 21                  Medical Care 47(5), pp. 1-8.            (approximately 3 per 1,000
Under supervision by clinical staff     Reprints (AHRQ Publication No.          prescription orders), wrong-site
pharmacists, they provided              09-R051) are available from             surgeries are relatively rare. A study
medication education and                AHRQ.*                                  published in 2006 of 2.8 million
performed medication therapy               The effects of patient safety        U.S. operations uncovered only 25
management. In the first 3 months       events in hospitals on readmissions     wrong-site surgeries, a rate of 1
of the program, more than twice as      have rarely been analyzed. The          error per 112,994 operations. Only
many patients were assessed than in     researchers examined nine types of      one of these errors was associated
the 3 months prior to the program.      patient safety events developed by      with permanent injury. The error
                                        AHRQ’s Healthcare Cost and              was apparent to the patient as soon
Facco, F., You, W., and Grobman,        Utilization Project. These safety       as she removed the bandages, and
W. (2009, June). “Genetic               problems ranged from postoperative      her doctor and the hospital
thrombophilias and intrauterine         sepsis to health care-associated        administration made themselves
growth restriction: A meta-             infections. The study included          available to apologize for the error
analysis.” (AHRQ grant T32              nearly 1.5 million surgery patients     and discuss possible compensation.
HS00078). Obstetrics and                from 1,088 short-stay hospitals.        The author reviews the state of
Gynecology 113(6), pp. 1206-1216.       Hospitalized patients who               error disclosure in U.S. hospitals,
   Pregnant women who suffer            experienced one or more events that     discussing studies that suggest that
from blood disorders that cause         jeopardized their safety had a 3-       error disclosure can reduce lawsuits
excessive clotting (thrombophilias)     month readmission rate of 25            and the amount of damages if a suit
are sometimes given blood thinning      percent (compared with 17 percent       goes to trial. He summarizes the
medication to prevent intrauterine      for patients with no safety events).    barriers to disclosure and potential
growth restriction (IUGR). IUGR is      The study also found that patients      solutions—as well as recent
a term used to describe a fetus that    experiencing a safety event had a       developments in disclosure
is smaller than normal (below the       higher in-hospital death rate (9.2      undertaken by Federal agencies,
10th percentile for a given             percent vs. 1.3 percent for patients    universities, and national quality
gestational age), a condition           with no safety events). Two safety      organizations.
associated with fetal death and         events, pulmonary embolism/deep
long-term illnesses, including          vein thrombosis and accidental          Gerhard, T., Chavez, B., Olfson,
cardiovascular disease. The authors     puncture or laceration, had the         M., and Crystal, S. (2009).
performed a literature review for       highest event rates, with large         “National patterns in the
three inherited thrombophilitic         patient populations at risk for these   outpatient pharmacological
mutations: homozygous or                events.                                 management of children and
heterozygous factor V Leiden,                                                   adolescents with autism
prothrombin G20210A mutations,          Gallagher, T.H. (August 2009).          spectrum disorder.” (AHRQ
and homozygous                          “Clinical Crossroads: A 62-year-        grant HS16097). Journal of
methylenetetrahydrofolate reductase     old woman with skin cancer who          Clinical Psychopharmacology 29
(MTHTR) C677T mutation. For the         experienced wrong-site surgery.”        (3), pp. 307-310.
19 studies that were included in the    (AHRQ grant HS16097).                      The authors characterize national
meta-analysis, they found no clear      Academic Medicine 84(8), pp.            trends and patterns in the outpatient
association between inherited           1135-1143.                              pharmacological management of
thrombophilias and IUGR. The               A case of wrong-site surgery for     children and adolescents with
findings of statistically significant   skin cancer served as the               autism spectrum disorder (ASD).
associations between IUGR and           framework for a discussion of           Ten years of data (1996-2000,
two of the mutations (MTHTR and         medical error and its disclosure to     2001-2005) from the National
Factor V Leiden) appeared to be         the patient by the surgeon and the      Ambulatory Medical Care Survey
influenced by publication bias in       hospital. The case, in which a          and the outpatient portion of the
case-control studies.                   woman had skin adjacent to her          National Hospital Ambulatory
                                        squamous cell carcinoma removed         Medical Care Survey were
Friedman, B., Encinosa, W.,             instead of the cancerous skin, is put   analyzed. During the study period,
Jiang, H. J., and Mutter, R.            into a larger context by the author.    annual nonadult ASD visits per
(2009, May). “Do patient safety         He notes that while medication                        continued on page 23

Number 352, December 2009                                                             
Research briefs                          models yields virtually identical        tax returns submitted. Other
continued from page 22                   observed-to-expected mortality           services, such as health promotion
100,000 people increased from 168        rates, irrespective of whether           and disease prevention programs,
in 1996-2000 to 543 in 2001-2005.        MPM-III or subgroup models based         are more difficult to quantify. In
During this latter period, visits were   on MPM-III are used to assess            order to keep their Federal tax
made by patients who were                overall ICU quality. Outside the         exemption, not-for-profit hospitals
overwhelmingly male, white, and          ICU, where the use of a single risk      will have to submit a detailed
non-Hispanic, with a mean age of         adjustment model for diverse             Schedule H as part of Form 990.
10.6 years. Over this same period,       surgical procedures may lack face        State officials will use these data to
the proportion of ASD visits with        validity, separate risk-adjustment       set guidelines for determining if
psychotropic prescriptions               models can be used to estimate the       community-benefit levels are large
significantly increased from 39          expected mortality rates for patients    enough to justify exclusion from
percent to 79 percent. Stimulants,       undergoing high-risk procedures.         State taxes.
antidepressants, and antipsychotics      The observed and expected
were the most commonly                   mortality rates could be aggregated      Ito, K., Hollenberg, J. P., and
prescribed medications. The mean         together to jointly produce a            Charlson, M. E. (2009). “Using
number of psychotropic medication        hospital quality metric for several      the osteoporosis self-assessment
classes prescribed at a given visit      high-risk procedures. The work of        tool for referring older men for
was 2.4. Almost one-half of visits       Nathanson, et al. suggests a simple      bone densitometry: A decision
reported a comorbid mental               solution to the problem caused by        analysis.” (AHRQ grant T32
disorder, often a disruptive             small sample sizes for patient           HS00066). Journal of the
behavioral disorder (30 percent). A      populations outside the ICU.             American Geriatric Society 57, pp.
limitation of this study is that it                                               218-224.
cannot determine to what extent          Hellinger, F. J. (2009, February).          As the U.S. population ages, men
psychotropic medications are being       “Tax-exempt hospitals and                are developing osteoporosis and
prescribed for ASDs or the               community benefits: A review of          related fractures, which cost an
codiagnosed mental disorders.            state reporting requirements.”           estimated $4.1 billion in 2005.
                                         Journal of Health Politics, Policy       Since osteoporosis in men is rarely
Glance, L. G., Osler, T. M.,             and Law 34(1), pp. 37-61.                identified and treated, the
Mukamel, D. B., and Dick, A. W.          Reprints (AHRQ Publication No.           researchers compared the health
(2009). “Grading intensive care          09-R048) are available from              benefits and costs of three
unit performance—Does one size           AHRQ.*                                   screening strategies for 70-year-old
fit all?” (AHRQ grant HS16737).              The Internal Revenue Service         community-dwelling white men
Critical Care Medicine 37(8), pp.        (IRS) has made major changes in          with no history of osteoporotic
2479-2480.                               its reporting requirements for tax-      fractures: no bone densitometry,
   It is impossible to compare the       exempt hospitals starting this year.     selective bone densitometry using
performance of intensive care units      Hospitals must now submit detailed       the Osteoporosis Self-Assessment
(ICUs) without accounting for            information on the percentage of         Tool (OST), and universal bone
differences in inpatient case mix,       total expenses attributable to charity   densitometry screening. They
assert these authors. They comment       care, unreimbursed Medicaid costs,       calculated that selective bone
on another article in the issue by       and community health improvement         densitometry using the OST would
Nathanson and colleagues that            programs. The researcher                 cost $100,000 per additional life
explored whether the quality             summarizes information from 16           year gained, compared with no
ranking of ICUs in the Project           States that already have laws            bone densitometry. Universal bone
IMPACT database changes when             requiring hospitals to place a           densitometry would cost $483,500
subgroup models based on the             monetary value on community              for additional life year gained,
Mortality Probability Models             benefits they provide. Under these       compared with selective bone
(MPM-III), but customized to             various State laws, hospitals appear     densitometry. They concluded that a
specific subgroups of patients (e.g.,    to have no trouble quantifying such      reasonably cost-effective strategy is
trauma, neurosurgical patients), are     things as charity and                    to stratify 70-year-old men for
used for risk adjustment instead of      uncompensated care. These should         osteoporosis risk using a
a single general MPM-III. They           be easily reportable on the newly        questionnaire (OST), perform bone
found that the use of subgroup           redesigned IRS Form 990 for 2009                       continued on page 24

                                                                                                                   23                                                                        Number 352, December 2009
Research briefs                         Levtzion-Korach, O., Alcalai, H.,       consortium may be perfected and
continued from page 23                  Orav, E. J., and others (2009,          used effectively. The key principles
densitometry to diagnose                March). “Evaluation of the              discussed are the quality of
osteoporosis only for the high-risk     contributions of an electronic          datasets, the use of the data to
                                        web-based reporting system:             inform practice, and developing and
group (OST score of -2 or less),
                                        Enabling action.” (AHRQ grant           maintaining social capital. To
and then give men diagnosed with
                                        HS11046). Journal of Patient            ensure the quality of the dataset, the
osteoporosis generic alendronate,
                                        Safety 5(1), pp. 9-15.                  author emphasizes the importance
an antiosteoporotic medication.
                                           Incident reporting represents a      of involving frontline teams in
Kitahata, M. M., Gange, S. J.,          key tool in safety improvement. The     developing and defining variables.
Abraham, A. G., and others.             researchers sought to characterize a    To effectively use data to inform
(2009, April 20). “Effect of early      Web-based reporting system by           clinical practice, the registry
versus deferred antiretroviral          evaluating the rate and content of      consortium should focus on
therapy for HIV on survival.”           the incident reports and their          understanding the root cause of
(AHRQ Contract No. 290-01-              consequent actions and followup.        variability in key processes of care.
0012). New England Journal of           The system they studied was             To develop and maintain social
Medicine 360(18), pp. 1815-1826.        implemented at a large urban            capital, each of the units in every
   The availability of antiretroviral   hospital, where 14,179 reports were     medical center in the consortium
medications to treat HIV infection      submitted over a 31-month period.       should participate in all facets of
has done much to reduce disease         Researchers looked at the frequency     the consortium, including social
progression and death among             of reporting, severity of patient       events. Although the discussion
patients. Yet when to start treatment   harm, location in the hospital,         focuses on the structure and
remains uncertain. Current              followup actions, and ease of           function of the Perfusion Down
guidelines recommend starting           reporting. Most reports involved        Under Consortium to maximize the
therapy for asymptomatic patients       laboratory results (30.4 percent),      opportunity to improve the quality
with CD4+ cell counts (a marker of      followed by medications (17.2           of care delivered to a specific
how well the immune system is           percent), and falls (10.9 percent),     patient population, these principles
performing) of less than 350 cells      among others. Personnel found the       are applicable to any perfusion
per cubic millimeter.                   system easy to use and submitted        registry.
   The researchers studied a total of   most reports within 24 hours. The
17,517 asymptomatic patients with       majority of reports (70 percent)        Likosky, D. S. (2009). “An
HIV infection in the U.S. and           were reviewed by an average of          epidemiologist’s review of the
Canada. In the first analysis, among    four people within 72 hours. As a       case for pulsatile flow during
the 8,362 patients who had CD4+         result of the system, a number of       cardiopulmonary bypass.”
cell counts of 351 to 500 cells per     actions were implemented to             (AHRQ grant HS15663). The
cubic millimeter, those who             facilitate and improve patient safety   Journal of ExtraCorporeal
deferred therapy until their CD4+       hospital-wide. The researchers          Technology 41, pp. P30-P32.
cell count fell below the range had     concluded that this Web-based               During cardiopulmonary bypass
a 60 percent greater risk of death      hospital reporting system               (CPB), continuous rather than
than patients who began therapy         effectively captured patient safety     pulsatile flow has been used since it
while in the range. In a second         incidents, the actions taken in         is technologically easier to
analysis, the 76 percent of patients    response, and the followup.             accomplish. However, pulsatile flow
who deferred therapy until their                                                has many inherent and theoretical
                                        Likosky, D. S. (2009).                  advantages over continuous flow.
CD4+ cell counts fell below 500
                                        “Optimizing multi-center                Although ample reviews have
had a 94 percent greater risk of
                                        perfusion data.” (AHRQ grant            focused on addressing the efficacy
death than those who began therapy
                                        HS15663). The Journal of                and effectiveness of pulsatile flow
at a count above 500. The
                                        ExtraCorporeal Technology 41,           in the setting of CPB, few have
researchers suggest starting
                                        pp. P7-P10.                             focused their attention on critically
antiretroviral therapy even earlier
                                           This commentary provides some        appraising the methodology of the
(when CD4+ cell count is higher)
                                        insight on how to optimize the          literature. Using a previously
to improve survival in patients with
                                        quality of a multicenter registry and   published review article by
HIV infection.
                                        how to ensure that perfusion data
                                                                                              continued on page 25
                                        collected through such a

Number 352, December 2009                                                             
Research briefs                         sought to determine whether a           differ by race, ethnicity, and
continued from page 24                  survival benefit exists from the use    language?” (HS10599). HSR:
Alghamdi and Latter on pulsatility      of an intra-aortic balloon pump. His    Health Services Research 44(4),
with respect to patients undergoing     conclusion is that the model he         pp. 1326-1344.
elective coronary artery bypass         describes is generalizable and             This study sought to explore
grafting procedures, the author         applicable to the formulation and       whether patient satisfaction differed
focuses on sample size and              execution of sound observational        among blacks, English- and
statistical power as it relates to      studies.                                Spanish-speaking Latinos, and
pulsatile flow. The author mostly                                               whites. The researchers interviewed
agrees with the reviewers’ analysis     Miller, E. K., Edwards, K. M.,          1,664 adult general medicine
of the eight articles meeting the       Weinberg, G. A., and others.            patients from 9 university-based
review’s inclusion criteria.            (2009, January). “A novel group         practices in San Francisco staffed
However, he identifies either           of rhinoviruses is associated with      by general internists, family
inadequate sample size or               asthma hospitalizations.” (AHRQ         medicine physicians, and nurse
inadequate statistical power in these   grant HS13833). Journal of              practitioners. The survey related the
studies, which can prevent knowing      Allergy and Clinical Immunology         effects of seven interpersonal
whether the reported findings of the    123(1), pp. 98-104.                     processes of care (IPC) on three
relationship between pulsatile flow        Human rhinoviruses (HRVs) can        measures of patient satisfaction
and the outcomes of mortality,          cause a variety of respiratory tract    (satisfaction with health care,
myocardial infarction, stroke, and      infections in children and are linked   satisfaction with physician, and
renal failure are real or chance-       to asthma episodes in adults and        whether the patient would
related.                                children. A third group of HRVs,        recommend the physician to family
                                        called group C (HRVC), has been         or friends). Among Spanish-
Likosky, D. S. (2009). “Forming a       identified. Researchers sought to       speaking Latinos (but not for the
research question from a multi-         determine how HRVC affected             other three groups) lack of clarity
center database.” (AHRQ grant           disease among young hospitalized        was significantly and negatively
HS15663). The Journal of                children. They studied 1,123            related to satisfaction with
ExtraCorporeal Technology 41,           children admitted to hospitals          physicians and health care. The
pp. P33-P36.                            during a 2-year period. All had         association of four IPC scales (lack
   The author highlights the            either respiratory symptoms or          of clarity, explained results,
principles for formulating a            fever. Out of 1,052 viral samples       compassionate/respectful, and
research question from an existing      tested, 167 were positive for HRVs.     disrespectful staff) with the two
multicenter consortium, the             HRVC accounted for at least half of     global satisfaction measures
Northern New England                    all HRV-associated illnesses,           (satisfaction with health care and
Cardiovascular Disease Study            particularly asthma. Older children     satisfaction with physician) differed
Group (NNECDSG). The author             with HRVs were more likely to           by race/ethnicity, suggesting that
first describes the general process     have HRVCs. Children with Group         some interpersonal processes may
which the NNECDSG uses to               C strains tended to have underlying     be more important to patients from
translate ideas to research             high-risk conditions (41.6 percent)     some groups than others.
questions. This process includes the    compared with children with Group
sorts of questions that must be         A strains (23.4 percent). More          Selden, T. M. (2009, June). “The
addressed, the review of the peer-      HRVC strains were detected in           within-year concentration of
reviewed literature, and the series     October, compared with more             medical care: Implications for
of steps (meetings, conference          HRVA strains detected in April.         family out-of-pocket expenditure
calls) taken to solicit critique,       This may explain the seasonal peak      burdens.” Health Services
feedback, and general comments.         in asthma hospitalizations during       Research 44(3), pp. 1029-1051.
He also stresses the importance of      the month of September.                 Reprints (AHRQ Publication No.
considering questions of sample                                                 09-R070) are available from
size and statistical power during the   Napoles, A. M., Gregorich, S. E.,       AHRQ.*
development of the project, and not     Santoyo-Olsson, J., and others.            Researchers and policymakers
just at the end. The author then        (2009, August). “Interpersonal          often use annual out-of-pocket
describes the steps taken and the       processes of care and patient           expenses to describe the burden
results achieved when the group         satisfaction: Do associations
                                                                                              continued on page 26

                                                                                                                25                                                                      Number 352, December 2009
Research briefs                         increased for their children covered    were 18-65 years old, enrolled in a
continued from page 25                  by CHIP. This burden would force        staff-model HMO, with at least
U.S. families face in affording         many families to choose between         eight visits per year for the each of
health care. Using 2003 and 2004        pursuing medical care for their         the 2 years prior to the study. Of the
AHRQ Medical Expenditure Panel          children or facing financial            1,364 patients studied, 319 who
Survey data, the author found that      hardship. Cost-sharing                  were high utilizers (12.8 visits per
nearly half of all families’ medical    arrangements may seem attractive        year) met the criterion standard for
care occurred within a single           to policymakers grappling with          somatization. The somatizers
month, and 63 percent happened in       ways to reduce public spending.         differed in age, gender, total visits,
a single quarter.                       However, because half of the            and somatization potential.
   Accompanying the surge in care       publicly insured children in the
use was an upswell in expenses, so      study were poor, even modest            Tebb, K. P., Wibbelsman, C.,
that 27 percent of families had at      increases in cost-sharing               Neuhaus, J. M., and Shafer, M.
least 1 month in which their out-of-    arrangements would be burdensome        (2009, June). “Screening for
pocket expenses totaled more than       for their families. Implementing        asymptomatic chlamydia
20 percent of their incomes. Low-       caps on out-of-pocket spending,         infections among sexually active
income families were especially         which are generally set at 5 percent    adolescent girls during pediatric
vulnerable to these cost surges,        of family income, can help address      urgent care.” (AHRQ grant
because they were unlikely to have      the spending burden for low-            HS10537). Archives of Pediatric
ample savings or extra money each       income families without reducing        and Adolescent Medicine 163(6),
month to allot for a payment plan.      potential budgetary savings, the        pp. 559-564.
These findings suggest that viewing     authors suggest.                           Untreated Chlamydia
care use within the year, and not                                               trachomatis (CT) infections can
annually, gives a more realistic        Smith, R. C., Gardiner, J. C.,          lead to pelvic inflammatory
view of the financial pressures that    Luo, Z., and Rost, K. (2009,            disease, ectopic pregnancy, and
families face in paying for surges in   April). “The diagnostic accuracy        infertility. Since most of these
medical expenses.                       of predicting somatization from         infections have no symptoms,
                                        patients’ ICD diagnoses.”               routine screening is the only way to
Selden, T. M., Kenney, G. M.,           (AHRQ grant HS14206).                   detect the majority of CT cases.
Pantell, M. S., and Ruhter, J.          Psychosomatic Medicine 71(3), pp.       Despite recommendations for
(2009, July-August). “Cost              366-371.                                annual screenings, screening rates
sharing in Medicaid and CHIP:               Somatization is defined as          remain low among all sexually
How does it affect out-of-pocket        having physical symptoms with           active adolescents and young adults
spending?” Health Affairs 28(4),        little or no documented basis in        under 26 years of age. In a large
pp. w607-w619. Reprints (AHRQ           underlying organic disease; when        California HMO, a team of
Publication No. 09-R072) are            organic disease exists, the             providers and clinic staff redesigned
available from AHRQ.*                   symptoms are inconsistent with or       their clinic system to improve CT
   In 2007, many States increased       out of proportion to it. An earlier     screening during urgent care. As a
the premiums and copayments             study had shown that ICD-9              result of the intervention, the
charged for health care received by     diagnostic codes and other data         change in the proportions of
children insured by the Children’s      from the administrative database        adolescent girls screened for CT in
Health Insurance Program (CHIP).        (ADB) could identify somatization.      urgent care increased by almost 16
To determine the effect of increased    In this study, the researchers sought   percent in the five intervention
cost-sharing arrangements, the          to identify somatization in a new       clinics compared with a decrease of
researchers developed cost              population through ADB screening        over 2 percent in the comparison
scenarios using data from AHRQ’s        based on increasing numbers of          clinics. The intervention stressed
Medical Expenditure Panel Survey.       visits, female gender, and greater      patient confidentiality, education,
   They found that parents would        percent of ICD-9 primary diagnosis      and followup about the CT test
struggle with high out-of-pocket        codes in musculoskeletal, nervous,      results. It also addressed processes
costs and financial burdens if          gastrointestinal, and ill-defined       such as specimen collection,
premiums or copayments were             body systems. All patients selected     storage, and delivery. I

Number 352, December 2009                                                             
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                                                                                                         27                                                                  Number 352, December 2009
U.S. Department of
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AHRQ Pub. No. 10-RA003
December 2009
ISSN 1537-0224

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