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Meyers D, Miller T, De La Mare J, Gerteis JS, Makulowich G, Weber GH, Zhan C, Genevro J. What AHRQ Learned While Working to Transform Primary Care. Ann Fam Med 2024; 22:161-166. [PMID: 38527822 DOI: 10.1370/afm.3090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 03/27/2024] Open
Abstract
Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.
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Affiliation(s)
- David Meyers
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Therese Miller
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Jan De La Mare
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Gail Makulowich
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Chunliu Zhan
- Agency for Healthcare Research and Quality, Rockville, Maryland
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Kim J, Choi EY, Lee W, Oh HM, Pyo J, Ock M, Kim SY, Lee SI. Feasibility of Capturing Adverse Events From Insurance Claims Data Using International Classification of Diseases, Tenth Revision, Codes Coupled to Present on Admission Indicators. J Patient Saf 2022; 18:404-409. [PMID: 35948289 PMCID: PMC9329045 DOI: 10.1097/pts.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the feasibility of using administrative data to screen adverse events in Korea. METHODS We used a diagnosis-related groups claims data set and the information of the checklist of healthcare quality improvement (a part of the value incentive program) to verify adverse events in fiscal year 2018. Adverse events were identified using patient safety indicator (PSI) clusters and a present on admission indicator (POA). The PSIs consisted of 19 clusters representing subcategories of adverse events, such as hospital-acquired infection. Among the adverse events identified using PSI clusters, "POA = N," which means not present at the time of admission, was only deemed as the case in the final stage. We compared the agreement on the occurrence of adverse events from claims data with a reference standard data set (i.e., checklist of healthcare quality improvement) and presented them by PSI cluster and institution. RESULTS The cases of global PSI for any adverse event numbered 27,320 (2.32%) among all diagnostic codes in 2018. In terms of institutional distribution, considerable variation was observed throughout the clusters. For example, only 13.2% of institutions (n = 387) reported any global PSI for any adverse event throughout the whole year. The agreement between the reference standard and the claims data was poor, in the range of 2.2% to 10.8%, in 3 types of adverse events. The current claims data system (i.e., diagnostic codes coupled to POA indicators) failed to capture a large majority of adverse events identified using the reference standard. CONCLUSIONS Our results imply that the coding status of International Classification of Diseases, Tenth Revision, codes and POA indicators should be refined before using them as quality indicators.
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Affiliation(s)
- Juyoung Kim
- From the Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul
| | - Eun Young Choi
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
- Department of Nursing, Graduate School of Chung-Ang University
| | - Won Lee
- Department of Nursing, Chung-Ang University
| | - Hae Mi Oh
- Asian Institute for Bioethics and Health Law, Yonsei University
| | - Jeehee Pyo
- From the Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - Minsu Ock
- From the Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul
- Department of Preventive Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan
| | - So Yoon Kim
- Division of Medical Law and Bioethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang-il Lee
- From the Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul
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Milliren CE, Bailey G, Graham DA, Ozonoff A. Relationships Between Pediatric Safety Indicators Across a National Sample of Pediatric Hospitals: Dispelling the Myth of the "Safest" Hospital. J Patient Saf 2022; 18:e741-e746. [PMID: 35617599 PMCID: PMC9136151 DOI: 10.1097/pts.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE There are many measures of healthcare quality, but no obvious summary measures to simplify ranking of hospital performance. With public reporting and accountability for hospital performance, the validity of composite measures for performance rankings has increased importance. This study aimed to explore the covariance of pediatric hospital quality indicators and evaluate the use of a single composite score. METHODS We performed an observational study of pediatric hospital performance across 13 safety indicators extracted from the Pediatric Health Information System, a comparative database of children's hospitals in the United States. We included patients discharged from 36 hospitals from January 1, 2016, to December 31, 2019. Using principal components analysis, we investigate relationships among patient safety measures from the Agency for Healthcare Research and Quality pediatric quality indicators and Center for Medicare and Medicaid Services hospital-acquired conditions. We compare and summarize rankings based on individual safety indicators and calculate alternative composite scores. RESULTS We identified 5 orthogonal variance components accounting for 68% of variation in pediatric hospital quality indicators. Rankings demonstrated greater within-hospital variation compared with between-hospital variation. We observed discordant rankings across commonly used summary measures and conclude that these pediatric safety measures demonstrate at least 2 underlying variance components. CONCLUSIONS This study demonstrates the multifactorial nature of patient safety. This implies no unique ordering of hospitals based on these measures, and thus, no pediatric hospital can claim to be "the safest." This raises further questions about appropriate methods to rank hospitals by safety.
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Affiliation(s)
- Carly E. Milliren
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, United States
| | | | - Dionne A. Graham
- Program for Patient Safety and Quality, Boston Children’s Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Al Ozonoff
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA, United States
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Katz MJ, Tamma PD, Cosgrove SE, Miller MA, Dullabh P, Rowe TA, Ahn R, Speck K, Gao Y, Shah S, Jump RLP. Implementation of an Antibiotic Stewardship Program in Long-term Care Facilities Across the US. JAMA Netw Open 2022; 5:e220181. [PMID: 35226084 PMCID: PMC8886516 DOI: 10.1001/jamanetworkopen.2022.0181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Antibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown. OBJECTIVES To determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was implemented to assist facilities in establishing ASPs and with antibiotic decision-making. Training was conducted between December 2018 and November 2019. Data were analyzed from January 2019 to December 2019. INTERVENTIONS Fifteen webinars occurred over 12 months (December 2018 to November 2019), accompanied by additional tools, activities, posters, and pocket cards. All clinical staff were encouraged to participate. MAIN OUTCOMES AND MEASURES The primary outcome was antibiotic starts per 1000 resident-days. Secondary outcomes included days of antibiotic therapy (DOT) per 1000 resident-days, the number of urine cultures per 1000 resident-days, and Clostridioides difficile laboratory-identified events per 10 000 resident-days. All outcomes compared data from the baseline (January-February 2019) to the completion of the program (November-December 2019). Generalized linear mixed models with random intercepts at the site level assessed changes over time. RESULTS Of a total 523 eligible LTC facilities, 439 (83.9%) completed the safety program. The mean difference for antibiotic starts from baseline to study completion per 1000 resident-days was -0.41 (95% CI, -0.76 to -0.07; P = .02), with fluoroquinolones showing the greatest decrease at -0.21 starts per 1000 resident-days (95% CI, -0.35 to -0.08; P = .002). The mean difference for antibiotic DOT per 1000 resident-days was not significant (-3.05; 95% CI, -6.34 to 0.23; P = .07). Reductions in antibiotic starts and use were greater in facilities with greater program engagement (as measured by webinar attendance). While antibiotic starts and DOT in these facilities decreased by 1.12 per 1000 resident-days (95% CI, -1.75 to -0.49; P < .001) and 9.97 per 1000 resident-days (95% CI, -15.4 to -4.6; P < .001), respectively, no significant reductions occurred in low engagement facilities. Urine cultures per 1000 resident-days decreased by 0.38 (95% CI, -0.61 to -0.15; P = .001). There was no significant change in facility-onset C difficile laboratory-identified events. CONCLUSIONS AND RELEVANCE Participation in the AHRQ safety program was associated with the development of ASPs that actively engaged clinical staff in the decision-making processes around antibiotic prescriptions in participating LTC facilities. The reduction in antibiotic DOT and starts, which was more pronounced in more engaged facilities, indicates that implementation of this multifaceted program may support successful ASPs in LTC settings.
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Affiliation(s)
- Morgan J. Katz
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranita D. Tamma
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sara E. Cosgrove
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa A. Miller
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | | | - Roy Ahn
- NORC at the University of Chicago, Chicago, Illinois
| | - Kathleen Speck
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yue Gao
- NORC at the University of Chicago, Bethesda, Maryland
| | | | - Robin L. P. Jump
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
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Bailie J, Peiris D, Cunningham FC, Laycock A, Bailie R, Matthews V, Conte KP, Bainbridge RG, Passey ME, Abimbola S. Utility of the AHRQ Learning Collaboratives Taxonomy for Analyzing Innovations from an Australian Collaborative. Jt Comm J Qual Patient Saf 2021; 47:711-722. [PMID: 34538583 DOI: 10.1016/j.jcjq.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite the proliferation of learning collaborations such as innovation platforms, the factors contributing to their success or failure are rarely documented. The Agency for Healthcare Research and Quality learning collaboratives taxonomy provides a framework for understanding how such collaborations work in different settings according to four primary elements: innovation, communication, time, and social systems. This study applied the taxonomy to assess an innovation platform and the utility of applying the taxonomy. METHODS The study focus was a five-year national research collaboration operating as an innovation platform to strengthen primary health care quality improvement efforts for Indigenous Australians. The study team analyzed project records, reports and publications, and interviews that were conducted with 35 stakeholders. Data were mapped retrospectively against the taxonomy domains and thematically analyzed. RESULTS The taxonomy proved useful in understanding how and why the innovation platform generated innovations. It revealed that time was particularly important, both to see innovations through and to establish a social system that enabled interconnectivity between members. However, the taxonomy did not provide useful guidance on identifying the types of innovations from the collaboration or the importance of a culture of continuous adaptation and learning. The study also found that the primary and secondary elements of the taxonomy were not discrete, which meant that it was difficult to align themes with only one element. CONCLUSION To improve the utility of the taxonomy, several elaborations are proposed, including reconfiguring it to a more dynamic form that recognizes the interconnections and links between the elements.
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Fong A, Adams K, Samarth A, McQueen L, Trivedi M, Chappel T, Grace E, Terrillion S, Ratwani RM. Assessment of Automating Safety Surveillance From Electronic Health Records: Analysis for the Quality and Safety Review System. J Patient Saf 2021; 17:e524-e528. [PMID: 28671914 DOI: 10.1097/pts.0000000000000402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES In an effort to improve and standardize the collection of adverse event data, the Agency for Healthcare Research and Quality is developing and testing a patient safety surveillance system called the Quality and Safety Review System (QSRS). Its current abstraction from medical records is through manual human coders, taking an average of 75 minutes to complete the review and abstraction tasks for one patient record. With many healthcare systems across the country adopting electronic health record (EHR) technology, there is tremendous potential for more efficient abstraction by automatically populating QSRS. In the absence of real-world testing data and models, which require a substantial investment, we provide a heuristic assessment of the feasibility of automatically populating QSRS questions from EHR data. METHODS To provide an assessment of the automation feasibility for QSRS, we first developed a heuristic framework, the Relative Abstraction Complexity Framework, to assess relative complexity of data abstraction questions. This framework assesses the relative complexity of characteristics or features of abstraction questions that should be considered when determining the feasibility of automating QSRS. Questions are assigned a final relative complexity score (RCS) of low, medium, or high by a team of clinicians, human factors, and natural language processing researchers. RESULTS One hundred thirty-four QSRS questions were coded using this framework by a team of natural language processing and clinical experts. Fifty-five questions (41%) had high RCS and would be more difficult to automate, such as "Was use of a device associated with an adverse outcome(s)?" Forty-two questions (31%) had medium RCS, such as "Were there any injuries as a result of the fall(s)?" and 37 questions (28%) had low RCS, such as "Did the patient deliver during this stay?" These results suggest that Blood and Hospital Acquired Infections-Clostridium Difficile Infection (HAI-CDI) modules would be relatively easier to automate, whereas Surgery and HAI-Surgical Site Infection would be more difficult to automate. CONCLUSIONS Although EHRs contain a wealth of information, abstracting information from these records is still very challenging, particularly for complex questions, such as those concerning patient adverse events. In this work, we developed a heuristic framework, which can be applied to help guide conversations around the feasibility of automating QSRS data abstraction. This framework does not aim to replace testing with real data but complement the process by providing initial guidance and direction to subject matter experts to help prioritize, which abstraction questions to test for feasibility using real data.
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Affiliation(s)
- Allan Fong
- From the National Center for Human Factors in Healthcare, Medstar Health
| | - Katharine Adams
- From the National Center for Human Factors in Healthcare, Medstar Health
| | | | | | | | - Tahleah Chappel
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Washington, District of Columbia
| | - Erin Grace
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Washington, District of Columbia
| | - Susan Terrillion
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Washington, District of Columbia
| | - Raj M Ratwani
- From the National Center for Human Factors in Healthcare, Medstar Health
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Affiliation(s)
- Chelsea P Fischer
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois
- Division for Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amir A Ghaferi
- Department of Surgery, University of Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Tamma PD, Miller MA, Dullabh P, Ahn R, Speck K, Gao Y, Scherpf E, Cosgrove SE. Association of a Safety Program for Improving Antibiotic Use With Antibiotic Use and Hospital-Onset Clostridioides difficile Infection Rates Among US Hospitals. JAMA Netw Open 2021; 4:e210235. [PMID: 33635327 PMCID: PMC7910818 DOI: 10.1001/jamanetworkopen.2021.0235] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Regulatory agencies and professional organizations recommend antibiotic stewardship programs (ASPs) in US hospitals. The optimal approach to establish robust, sustainable ASPs across diverse hospitals is unknown. OBJECTIVE To assess whether the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use is associated with reductions in antibiotic use across US hospitals. DESIGN, SETTING, AND PARTICIPANTS A pragmatic quality improvement program was conducted and evaluated over a 1-year period in US hospitals. A total of 437 hospitals were enrolled. The study was conducted from December 1, 2017, to November 30, 2018. Data analysis was performed from March 1 to October 31, 2019. INTERVENTIONS The Safety Program assisted hospitals with establishing ASPs and worked with frontline clinicians to improve their antibiotic decision-making. All clinical staff (eg, clinicians, pharmacists, and nurses) were encouraged to participate. Seventeen webinars occurred over 12 months, accompanied by additional durable educational content. Topics focused on establishing ASPs, the science of safety, improving teamwork and communication, and best practices for the diagnosis and management of infectious processes. MAIN OUTCOMES AND MEASURES The primary outcome was overall antibiotic use (days of antibiotic therapy [DOT] per 1000 patient days [PD]) comparing the beginning (January-February 2018) and end (November-December 2018) of the Safety Program. Data analysis occurred using linear mixed models with random hospital unit effects. Antibiotic use from 614 hospitals in the Premier Healthcare Database from the same period was analyzed to evaluate contemporary US antibiotic trends. Quarterly hospital-onset Clostridioides difficile laboratory-identified events per 10 000 PD were a secondary outcome. RESULTS Of the 437 hospitals enrolled, 402 (92%) remained in the program until its completion, including 28 (7%) academic medical centers, 122 (30%) midlevel teaching hospitals, 167 (42%) community hospitals, and 85 (21%) critical access hospitals. Adherence to key components of ASPs (ie, interventions before and after prescription of antibiotics, availability of local antibiotic guidelines, ASP leads with dedicated salary support, and quarterly reporting of antibiotic use) improved from 8% to 74% over the 1-year period (P < .01). Antibiotic use decreased by 30.3 DOT per 1000 PD (95% CI, -52.6 to -8.0 DOT; P = .008). Similar changes in antibiotic use were not observed in the Premier Healthcare Database. The incidence rate of hospital-onset C difficile laboratory-identified events decreased by 19.5% (95% CI, -33.5% to -2.4%; P = .03). CONCLUSIONS AND RELEVANCE The Agency for Healthcare Research and Quality Safety Program appeared to enable diverse hospitals to establish ASPs and teach frontline clinicians to self-steward their antibiotic use. Safety Program content is publicly available.
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Affiliation(s)
- Pranita D. Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa A. Miller
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Roy Ahn
- NORC at the University of Chicago, Chicago, Illinois
| | - Kathleen Speck
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yue Gao
- NORC at the University of Chicago, Bethesda, Maryland
| | - Erik Scherpf
- NORC at the University of Chicago, Chicago, Illinois
| | - Sara E. Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Fiordalisi C, Borsky A, Chang S, Guise JM. AHRQ EPC Series on Improving Translation of Evidence into Practice for the Learning Health System: Introduction. Jt Comm J Qual Patient Saf 2020; 45:558-565. [PMID: 31378276 DOI: 10.1016/j.jcjq.2019.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/08/2019] [Accepted: 05/16/2019] [Indexed: 11/28/2022]
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BRACH C, BORSKY A. How the U.S. Agency for Healthcare Research and Quality Promotes Health Literate Health Care. Stud Health Technol Inform 2020; 269:313-323. [PMID: 32594006 PMCID: PMC7413323 DOI: 10.3233/shti200046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This report traces the U.S. Agency for Healthcare Research and Quality's (AHRQ) strategic approach to promote health literate health care delivery systems. For almost 15 years, the AHRQ Health Literacy Action Plan has served as the framework for the Agency's efforts to: 1) Develop Measures; 2) Improve the Evidence Base and Create Implementation Tools; 3) Create and Support Change; 4) Disseminate and Transfer Knowledge and Tools; and 5) Practice What We Preach. Drawing upon its core competencies in data and measurement, practice improvement, and health services research, AHRQ accelerated the uptake of evidence-based health literacy strategies by health care organizations.
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Affiliation(s)
- Cindy BRACH
- Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
| | - Amanda BORSKY
- Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
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Marcial LH, Blumenfeld B, Harle C, Jing X, Keller MS, Lee V, Lin Z, Dover A, Midboe AM, Al-Showk S, Bradley V, Breen J, Fadden M, Lomotan E, Marco-Ruiz L, Mohamed R, O'Connor P, Rosendale D, Solomon H, Kawamoto K. Barriers, Facilitators, and Potential Solutions to Advancing Interoperable Clinical Decision Support: Multi-Stakeholder Consensus Recommendations for the Opioid Use Case. AMIA Annu Symp Proc 2020; 2019:637-646. [PMID: 32308858 PMCID: PMC7153100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
With the advent of interoperability standards such as FHIR, SMART, CDS Hooks, and CQL, interoperable clinical decision support (CDS) holds great promise for improving healthcare. In 2018, the Agency for Healthcare Research and Quality (AHRQ)-sponsored Patient-Centered CDS Learning Network (PCCDS LN) chartered a Technical Framework Working Group (TechFWG) to identify barriers, facilitators, and potential solutions for interoperable CDS, with a specific focus on addressing the opioid epidemic. Through an open, multi-stakeholder process that engaged 54 representatives from healthcare, industry, and academia, the TechFWG identified barriers in 6 categories: regulatory environment, data integration, scalability, business case, effective and useful CDS, and care planning and coordination. Facilitators and key recommendations were also identified for overcoming these barriers. The key insights were also extrapolated to CDS-facilitated care improvement outside of the specific opioid use case. If applied broadly, the recommendations should help advance the availability and impact of interoperable CDS delivered at scale.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Amanda M Midboe
- VA Palo Alto Health Care System, Stanford University, San Francisco, CA
| | - Shafa Al-Showk
- Agency for Healthcare Research and Quality, Rockville, MD
| | | | | | | | - Edwin Lomotan
- Agency for Healthcare Research and Quality, Rockville, MD
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Adam GP, Balk EM, Jap J, Senturk B, Sanders-Schmidler G, Lallinger K, Butler M, Brasure M, Trikalinos TA. AHRQ EPC Series on Improving Translation of Evidence: Web-Based Interactive Presentation of Systematic Review Reports. Jt Comm J Qual Patient Saf 2019; 45:629-638. [PMID: 31488251 DOI: 10.1016/j.jcjq.2019.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/24/2019] [Accepted: 05/07/2019] [Indexed: 11/29/2022]
Abstract
Systematic reviews are used by a diverse range of users to address an ever-expanding set of questions and needs. It is unlikely that a single static report will efficiently satisfy the different needs of diverse users. METHODS An open-source Web-based interactive report presentation of a systematic review was developed to allow users to generate their own "reports" from the information produced by the review. Data from a broad-scope systematic review were used with network meta-analysis conducted on nonsurgical treatments of urinary incontinence (UI) in women. Stakeholders informed and piloted the tool and assessed its usefulness. RESULTS The final tool allows users to obtain descriptive and analytic results for a network of treatment categories and various outcomes (cure, improvement, satisfaction, quality of life, adverse events) across several subgroups (all women, older women, or those with stress or urgency UI), along with study-level information, and overall conclusions. The stakeholders were satisfied with the functionality of the tool and proposed a number of improvements regarding presentation (for example, present information on numbers of trials in figures), analyses (for example, allow on-the-fly subgroup analyses, explore trade-offs between several outcomes), and information sharing (for example, provide ability to import/export data from/to other software). CONCLUSION A prototype tool to present customized analyses from broad-scope systematic reviews is presented. Further improvements are suggested to develop a scalable tool to make systematic reviews useful to increasingly diverse user groups.
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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Coombs LA, Stephens C. Identifying the Contribution of Nurse Practitioners in the Care of Older Adults With Cancer. Oncol Nurs Forum 2019; 46:277-282. [PMID: 31007255 PMCID: PMC7105278 DOI: 10.1188/19.onf.277-282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify the best available dataset that measured the number of nurse practitioners (NPs) and the type of care they provided; patient information, including malignancy type, age, and insurance status; and volume of procedures performed by NPs. SAMPLE & SETTING All available national datasets that included patients with cancer and provider types. METHODS & VARIABLES Using prespecified consensus-driven criteria, all available administrative datasets were reviewed. The authors evaluated four that met the inclusion criteria. RESULTS The authors' analysis identified the Surveillance, Epidemiology, and End Results (SEER) Program linked with Medicare claims dataset as the most appropriate to measure the contribution of NP-provided cancer care to older adults. The Chronic Conditions Data Warehouse was excluded because of the limited number of malignancies included in the data; the SEER-Medicare dataset included all malignancies. IMPLICATIONS FOR NURSING Evidence demonstrates that NPs provide an unknown amount of cancer care to older adults. Further research using the SEER-Medicare dataset may yield a solution to the health issue of insufficient oncologists to care for the growing older adult population. Workforce research informs future training needs and influences policymakers' decisions, making secondary data analyses in nursing particularly important.
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Borsky AE, Flores EJ, Berliner E, Chang C, Umscheid CA, Chang SM. Next Steps in Improving Healthcare Value: AHRQ Evidence-based Practice Center Program-Applying the Knowledge to Practice to Data Cycle to Strengthen the Value of Patient Care. J Hosp Med 2019; 14:311-314. [PMID: 30794140 PMCID: PMC6609136 DOI: 10.12788/jhm.3157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 12/27/2018] [Indexed: 12/22/2022]
Abstract
For more than 20 years, the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program has been identifying and synthesizing evidence to inform evidence-based healthcare. Recognizing that many healthcare settings continue to face challenges in disseminating and implementing evidence into practice, AHRQ's EPC program has also embarked on initiatives to facilitate the translation of evidence into practice and to measure and monitor how practice changes impact health outcomes. The program has structured its efforts around the three phases of the Learning Healthcare System cycle: knowledge, practice, and data. Here, we use a topic relevant to the field of hospital medicine-Clostridium difficile colitis prevention and treatment-as an exemplar of how the EPC program has used this framework to move evidence into practice and develop systems to facilitate continuous learning in healthcare systems.
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Affiliation(s)
- Amanda E Borsky
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
- Corresponding Author: Amanda E. Borsky, DrPH, MPP; E-mail: ; Telephone: 301-427-1602
| | - Emilia J Flores
- University of Pennsylvania Health System, Center for Evidence-based Practice, Philadelphia, Philadelphia
| | - Elise Berliner
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
| | - Christine Chang
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
| | - Craig A Umscheid
- University of Chicago Medicine, Center for Healthcare Delivery Science and Innovation, Chicago, Illinois
| | - Stephanie M Chang
- Agency for Healthcare Research and Quality, Center for Evidence and Practice Improvement, Rockville, Maryland
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Almalki ZS, Karami NA, Almsoudi IA, Alhasoun RK, Mahdi AT, Alabsi EA, Alshahrani SM, Alkhdhran ND, Alotaib TM. Patient-centered medical home care access among adults with chronic conditions: National Estimates from the medical expenditure panel survey. BMC Health Serv Res 2018; 18:744. [PMID: 30261881 PMCID: PMC6161358 DOI: 10.1186/s12913-018-3554-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Patient-Centered Medical Home (PCMH) model is a coordinated-care model that has served as a means to improve several chronic disease outcomes and reduce management costs. However, access to PCMH has not been explored among adults suffering from chronic conditions in the United States. Therefore, the aim of this study was to describe the changes in receiving PCMH among adults suffering from chronic conditions that occurred from 2010 through 2015 and to identify predisposing, enabling, and need factors associated with receiving a PCMH. METHODS A cross-sectional analysis was conducted for adults with chronic conditions, using data from the 2010-2015 Medical Expenditure Panel Surveys (MEPS). Most common chronic conditions in the United States were identified by using the most recent data published by the Agency for Healthcare Research and Quality (AHRQ). The definition established by the AHRQ was used as the basis to determine whether respondents had access to PCMH. Multivariate logistic regression analyses were conducted to detect the association between the different variables and access to PCMH care. RESULTS A total of 20,403 patients with chronic conditions were identified, representing 213.7 million U.S. lives. Approximately 19.7% of the patients were categorized as the PCMH group at baseline who met all the PCMH criteria defined in this paper. Overall, the percentage of adults with chronic conditions who received a PCMH decreased from 22.3% in 2010 to 17.8% in 2015. The multivariate analyses revealed that several subgroups, including individuals aged 66 and older, separated, insured by public insurance or uninsured, from low-income families, residing in the South or the West, and with poor health, were less likely to have access to PCMH. CONCLUSION Our findings showed strong insufficiencies in access to a PCMH between 2010 and 2015, potentially driven by many factors. Thus, more resources and efforts need to be devoted to reducing the barriers to PCMH care which may improve the overall health of Americans with chronic conditions.
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Affiliation(s)
- Ziyad S Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia.
| | - Nedaa A Karami
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Imtinan A Almsoudi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Roaa K Alhasoun
- College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Alaa T Mahdi
- Department of Pharmaceutical Science, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Entesar A Alabsi
- Department of Clinical Pharmacy, College of Pharmacy, Jazan University, Jazan, Saudi Arabia
| | - Saad M Alshahrani
- Department of Pharmaceutics, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Nourah D Alkhdhran
- College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
| | - Tahani M Alotaib
- College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Riyadh, Saudi Arabia
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Lorch SA. Regarding "Implicit Review Instrument to Evaluate Quality of Care Delivered by Physicians to Children in Emergency Departments". Health Serv Res 2018; 53:1303-1307. [PMID: 29143323 PMCID: PMC5980172 DOI: 10.1111/1475-6773.12798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Scott A. Lorch
- Department of PediatricsDivision of NeonatologyThe Children's Hospital of PhiladelphiaPhiladelphiaPA
- Center for Pediatric and Perinatal Health Disparities Research and PolicyLabThe Children's Hospital of PhiladelphiaPhiladelphiaPA
- Leonard Davis InstituteUniversity of PennsylvaniaPhiladelphiaPA
- Center for Clinical Epidemiology and BiostatisticsPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
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Couture B, Fagan M, Gershanik E, Yoon C, Benneyan J, Bates DW, Collins SA. Towards Analytics of the Patient and Family Perspective: A Case Study and Recommendations for Data Capture of Safety and Quality Concerns. AMIA Annu Symp Proc 2018; 2017:615-624. [PMID: 29854126 PMCID: PMC5977637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Safety reporting systems are improving our current understanding of safety in hospital settings, although mostly from the clinician perspective. Patient Family Relations (PFR) programs provide the opportunity to capture patient/family concerns in the hospital. Descriptive statistics were completed of PFR concern submissions over a 20 month period, as well as a comparison of structured data fields to those of the AHRQ Common Format. We identified statistically significant differences in rates of concern submissions, methods of submission, and role of submitter across patient populations. Overall, the most frequent concerns submitted to PFR were care/treatment and communication concerns. There was very little overlap of the PFR data elements with those of the AHRQ Common Format (overall rate of mismatch approached 80%). These results emphasize both the unique information that PFR data provides, as well as the need for enhancement and continuity of reporting systems for more effective analysis of safety data.
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Affiliation(s)
- Brittany Couture
- Division of General Internal Medicine and Primary Care, Brigham Health, Boston, MA
| | - Maureen Fagan
- Center for Patients and Families, Brigham Health, Boston, MA
| | - Esteban Gershanik
- Division of General Internal Medicine and Primary Care, Brigham Health, Boston, MA
- Harvard Medical School, Boston, MA
| | - Cathy Yoon
- Division of General Internal Medicine and Primary Care, Brigham Health, Boston, MA
| | - James Benneyan
- Healthcare Systems Engineering Institute, Northeastern University, Boston, MA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham Health, Boston, MA
- Harvard Medical School, Boston, MA
| | - Sarah A Collins
- Division of General Internal Medicine and Primary Care, Brigham Health, Boston, MA
- Harvard Medical School, Boston, MA
- Clinical Informatics, Partners eCare, Partners Healthcare Systems, Boston, MA
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19
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Shin MH, Rivard PE, Shwartz M, Borzecki A, Yaksic E, Stolzmann K, Zubkoff L, Rosen AK. Tailoring an educational program on the AHRQ Patient Safety Indicators to meet stakeholder needs: lessons learned in the VA. BMC Health Serv Res 2018; 18:114. [PMID: 29444671 PMCID: PMC5813330 DOI: 10.1186/s12913-018-2904-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/31/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Given that patient safety measures are increasingly used for public reporting and pay-for performance, it is important for stakeholders to understand how to use these measures for improvement. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are one particularly visible set of measures that are now used primarily for public reporting and pay-for-performance among both private sector and Veterans Health Administration (VA) hospitals. This trend generates a strong need for stakeholders to understand how to interpret and use the PSIs for quality improvement (QI). The goal of this study was to develop an educational program and tailor it to stakeholders' needs. In this paper, we share what we learned from this program development process. METHODS Our study population included key VA stakeholders involved in reviewing performance reports and prioritizing and initiating quality/safety initiatives. A pre-program formative evaluation through telephone interviews and web-based surveys assessed stakeholders' educational needs/interests. Findings from the formative evaluation led to development and implementation of a cyberseminar-based program, which we tailored to stakeholders' needs/interests. A post-program survey evaluated program participants' perceptions about the PSI educational program. RESULTS Interview data confirmed that the concepts we had developed for the interviews could be used for the survey. Survey results informed us on what program delivery mode and content topics were of high interest. Six cyberseminars were developed-three of which focused on two content areas that were noted of greatest interest: learning how to use PSIs for monitoring trends and understanding how to interpret PSIs. We also used snapshots of VA PSI reports so that participants could directly apply learnings. Although initial interest in the program was high, actual attendance was low. However, post-program survey results indicated that perceptions about the program were positive. CONCLUSIONS Conducting a formative evaluation was a highly important process in program development. The useful information that we collected through the interviews and surveys allowed us to tailor the program to stakeholders' needs and interests. Our experiences, particularly with the formative evaluation process, yielded valuable lessons that can guide others when developing and implementing similar educational programs.
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Affiliation(s)
- Marlena H. Shin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
| | - Peter E. Rivard
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
- Sawyer Business School, Suffolk University, Boston, MA USA
| | - Michael Shwartz
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
- Questrom School of Business, Boston University, Boston, MA USA
| | - Ann Borzecki
- Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Medical Center, Bedford, MA USA
- Department of Internal Medicine, Boston University School of Medicine, Boston, MA USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA USA
| | - Enzo Yaksic
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA USA
| | - Kelly Stolzmann
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
| | - Lisa Zubkoff
- VA National Center for Patient Safety, Field Office, White River Junction, VT USA
- White River Junction VA Medical Center, White River Junction, VT USA
- Geisel School of Medicine, Dartmouth College, Hanover, NH USA
| | - Amy K. Rosen
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA USA
- Department of Surgery, Boston University School of Medicine, Boston, MA USA
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Abstract
IMPORTANCE Publicly available data sets hold much potential, but their unique design may require specific analytic approaches. OBJECTIVE To determine adherence to appropriate research practices for a frequently used large public database, the National Inpatient Sample (NIS) of the Agency for Healthcare Research and Quality (AHRQ). DESIGN, SETTING, AND PARTICIPANTS In this observational study of the 1082 studies published using the NIS from January 2015 through December 2016, a representative sample of 120 studies was systematically evaluated for adherence to practices required by AHRQ for the design and conduct of research using the NIS. EXPOSURES None. MAIN OUTCOMES AND MEASURES All studies were evaluated on 7 required research practices based on AHRQ's recommendations and compiled under 3 domains: (1) data interpretation (interpreting data as hospitalization records rather than unique patients); (2) research design (avoiding use in performing state-, hospital-, and physician-level assessments where inappropriate; not using nonspecific administrative secondary diagnosis codes to study in-hospital events); and (3) data analysis (accounting for complex survey design of the NIS and changes in data structure over time). RESULTS Of 120 published studies, 85% (n = 102) did not adhere to 1 or more required practices and 62% (n = 74) did not adhere to 2 or more required practices. An estimated 925 (95% CI, 852-998) NIS publications did not adhere to 1 or more required practices and 696 (95% CI, 596-796) NIS publications did not adhere to 2 or more required practices. A total of 79 sampled studies (68.3% [95% CI, 59.3%-77.3%]) among the 1082 NIS studies screened for eligibility did not account for the effects of sampling error, clustering, and stratification; 62 (54.4% [95% CI, 44.7%-64.0%]) extrapolated nonspecific secondary diagnoses to infer in-hospital events; 45 (40.4% [95% CI, 30.9%-50.0%]) miscategorized hospitalizations as individual patients; 10 (7.1% [95% CI, 2.1%-12.1%]) performed state-level analyses; and 3 (2.9% [95% CI, 0.0%-6.2%]) reported physician-level volume estimates. Of 27 studies (weighted; 218 studies [95% CI, 134-303]) spanning periods of major changes in the data structure of the NIS, 21 (79.7% [95% CI, 62.5%-97.0%]) did not account for the changes. Among the 24 studies published in journals with an impact factor of 10 or greater, 16 (67%) did not adhere to 1 or more practices, and 9 (38%) did not adhere to 2 or more practices. CONCLUSIONS AND RELEVANCE In this study of 120 recent publications that used data from the NIS, the majority did not adhere to required practices. Further research is needed to identify strategies to improve the quality of research using the NIS and assess whether there are similar problems with use of other publicly available data sets.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Suveen Angraal
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Tyler Couch
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - John W. Welsh
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Brahmajee K. Nallamothu
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Paul S. Chan
- Saint Luke's Mid America Heart and Vascular Institute and the University of Missouri-Kansas City, Kansas City, Missouri
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine and the Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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21
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Ganiats TG, Bierman AS. AHRQ's Tools for Better Practice: Helping Family Physicians Manage Today's Challenges. Am Fam Physician 2017; 96:569-570. [PMID: 29094872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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22
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Balk EM, Lichtenstein AH. Omega-3 Fatty Acids and Cardiovascular Disease: Summary of the 2016 Agency of Healthcare Research and Quality Evidence Review. Nutrients 2017; 9:E865. [PMID: 28800093 PMCID: PMC5579658 DOI: 10.3390/nu9080865] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/03/2017] [Accepted: 08/04/2017] [Indexed: 01/03/2023] Open
Abstract
We summarize the 2016 update of the 2004 Agency of Healthcare Research and Quality's evidence review of omega-3 fatty acids and cardiovascular disease (CVD). The overall findings for the effects of marine oil supplements on intermediate CVD outcomes remain largely unchanged. There is high strength of evidence, based on numerous trials, of no significant effects of marine oils on systolic or diastolic blood pressures, but there are small, yet statistically significant increases in high density lipoprotein and low density lipoprotein cholesterol concentrations. The clinical significance of these small changes, particularly in combination, is unclear. The strongest effect of marine oils is on triglyceride concentrations. Across studies, this effect was dose-dependent and related to studies' mean baseline triglyceride concentration. In observational studies, there is low strength of evidence that increased marine oil intake lowers ischemic stroke risk. Among randomized controlled trials and observational studies, there is evidence of variable strength of no association with increased marine oil intake and lower CVD event risk. Evidence regarding alpha-linolenic acid intake is sparser. There is moderate strength of evidence of no effect on blood pressure or lipoprotein concentrations and low strength of evidence of no association with coronary heart disease, atrial fibrillation and congestive heart failure.
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Affiliation(s)
- Ethan M Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI 02912, USA.
| | - Alice H Lichtenstein
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA 02111, USA.
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23
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Guise JM, Chang C, Butler M, Viswanathan M, Tugwell P. AHRQ series on complex intervention systematic reviews-paper 1: an introduction to a series of articles that provide guidance and tools for reviews of complex interventions. J Clin Epidemiol 2017; 90:6-10. [PMID: 28720511 DOI: 10.1016/j.jclinepi.2017.06.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 05/03/2017] [Accepted: 06/08/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Jeanne-Marie Guise
- Department of Obstetrics & Gynecology, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Department of Medical Informatics & Outcomes Research School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Department of Emergency Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA; Oregon Health & Science University, Portland State University School of Public Health, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
| | - Christine Chang
- Agency for Healthcare Research & Quality, 5600 Fishers Lane, Mailstop 06E53A, Rockville, MD 20857, USA
| | - Mary Butler
- University of Minnesota School of Public Health, 420 Delaware Street SE, Minneapolis, MN 55455, USA
| | - Meera Viswanathan
- RTI International, 3040 East Cornwallis Road, Research Triangle-Park, NC 27709, USA
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, 43 Bruyère Street, Annex E, Room 304, Ottawa, Ontario, Canada K1N 5C8
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Rubio GA, Koru-Sengul T, Vaghaiwalla TM, Parikh PP, Farra JC, Lew JI. Postoperative Outcomes in Graves' Disease Patients: Results from the Nationwide Inpatient Sample Database. Thyroid 2017; 27:825-831. [PMID: 28457178 DOI: 10.1089/thy.2016.0500] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current surgical indications for Graves' disease include intractability to medical and/or radioablative therapy, compressive symptoms, and worsening ophthalmopathy. Total thyroidectomy for Graves' disease may be technically challenging and lead to untoward perioperative outcomes. This study examines outcomes in patients with Graves' disease who underwent total thyroidectomy and assesses its safety for this patient population. METHODS A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample database from 2006 to 2011. Total thyroidectomy performed in patients with Graves' disease, benign multinodular goiter (MNG), and thyroid cancer was identified. Demographic factors, comorbidities, and postoperative complications were evaluated. Chi-square, one-way analysis of variance, and risk-adjusted multivariable logistic regression were performed. RESULTS Of 215,068 patients who underwent total thyroidectomy during the study period, 11,205 (5.2%) had Graves' disease, 110,124 (51.2%) MNG, and 93,739 (43.6%) thyroid malignancy. Patients with Graves' disease were younger than MNG and thyroid cancer patients (Mage = 42.8 years vs. 55.5 and 51.0 years; p < 0.01). The Graves' disease group included a higher proportion of women (p < 0.01) and nonwhites (p < 0.01). Postoperatively, Graves' patients had significantly higher rates of hypocalcemia (12.4% vs. 7.3% and 10.3%; p < 0.01), hematomas requiring reoperation (0.7% vs. 0.4% and 0.4%; p < 0.01), and longer mean hospital stay (2.7 days vs. 2.4 and 2.2 days; p < 0.01) compared to MNG and thyroid cancer patients, respectively. On risk-adjusted multivariate logistic regression, Graves' disease was independently associated with a higher risk of vocal-cord paralysis (odds ratio [OR] = 1.36 [confidence interval (CI) 1.08-1.69]), tracheostomy (OR = 1.35 [CI 1.1-1.67]), postoperative hypocalcemia (OR = 1.65 [CI 1.54-1.77]), and hematoma requiring reoperation (OR = 2.79 [CI 2.16-3.62]) compared to MNG patients. High-volume centers for total thyroidectomy were independently associated with lower risk of postoperative complications, including in patients with Graves' disease. CONCLUSIONS Despite low overall morbidity following total thyroidectomy, Graves' disease patients are at increased risk of postoperative complications, including bleeding, vocal-cord paralysis, tracheostomy, and hypocalcemia. These risks appear to be lower when performed at high-volume centers, and thus referral to these centers should be considered. Total thyroidectomy may therefore be a safe treatment option for appropriately selected patients with Graves' disease when performed by experienced surgeons.
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Affiliation(s)
- Gustavo A Rubio
- 1 Division of Endocrine Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
| | - Tulay Koru-Sengul
- 2 Division of Biostatistics, Department of Public Health Sciences, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
- 3 Sylvester Comprehensive Cancer Center, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
| | - Tanaz M Vaghaiwalla
- 1 Division of Endocrine Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
| | - Punam P Parikh
- 1 Division of Endocrine Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
| | - Josefina C Farra
- 1 Division of Endocrine Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
- 3 Sylvester Comprehensive Cancer Center, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
| | - John I Lew
- 1 Division of Endocrine Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
- 3 Sylvester Comprehensive Cancer Center, University of Miami Leonard M. Miller School of Medicine , Miami, Florida
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Whitlock EP, Eder M, Thompson JH, Jonas DE, Evans CV, Guirguis-Blake JM, Lin JS. An approach to addressing subpopulation considerations in systematic reviews: the experience of reviewers supporting the U.S. Preventive Services Task Force. Syst Rev 2017; 6:41. [PMID: 28253915 PMCID: PMC5335853 DOI: 10.1186/s13643-017-0437-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/17/2017] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Guideline developers and other users of systematic reviews need information about whether a medical or preventive intervention is likely to benefit or harm some patients more (or less) than the average in order to make clinical practice recommendations tailored to these populations. However, guidance is lacking on how to include patient subpopulation considerations into the systematic reviews upon which guidelines are often based. In this article, we describe methods developed to consistently consider the evidence for relevant subpopulations in systematic reviews conducted to support primary care clinical preventive service recommendations made by the U.S. Preventive Services Task Force (USPSTF). PROPOSED APPROACH Our approach is grounded in our experience conducting systematic reviews for the USPSTF and informed by a review of existing guidance on subgroup analysis and subpopulation issues. We developed and refined our approach based on feedback from the Subpopulation Workgroup of the USPSTF and pilot testing on reviews being conducted for the USPSTF. This paper provides processes and tools for incorporating evidence-based identification of important sources of potential heterogeneity of intervention effects into all phases of systematic reviews. Key components of our proposed approach include targeted literature searches and key informant interviews to identify the most important subpopulations a priori during topic scoping, a framework for assessing the credibility of subgroup analyses reported in studies, and structured investigation of sources of heterogeneity of intervention effects. CONCLUSIONS Further testing and evaluation are necessary to refine this proposed approach and demonstrate its utility to the producers and users of systematic reviews beyond the context of the USPSTF. Gaps in the evidence on important subpopulations identified by routinely applying this process in systematic reviews will also inform future research needs.
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Affiliation(s)
- Evelyn P. Whitlock
- Patient-Centered Outcomes Research Institute, 1919 M Street NW 2nd Floor, Washington DC, 20036 USA
| | - Michelle Eder
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Jamie H. Thompson
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Daniel E. Jonas
- Department of Medicine, University of North Carolina Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC 27599 USA
| | - Corinne V. Evans
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
| | - Janelle M. Guirguis-Blake
- Department of Family Medicine, Tacoma Family Medicine Residency Program, University of Washington, 521 Martin Luther King Jr. Way, Tacoma, WA 98405 USA
| | - Jennifer S. Lin
- Kaiser Permanente Research Affiliates Evidence-based Practice Center, Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR 97227 USA
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Shen W, Aguilar R, Montero AR, Fernandez SJ, Taylor AJ, Wilcox CS, Lipkowitz MS, Umans JG. Acute Kidney Injury and In-Hospital Mortality after Coronary Artery Bypass Graft versus Percutaneous Coronary Intervention: A Nationwide Study. Am J Nephrol 2017; 45:217-225. [PMID: 28135709 DOI: 10.1159/000455906] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/03/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Post-procedural acute kidney injury (AKI) is associated with significantly increased short- and long-term mortalities, and renal loss. Few studies have compared the incidence of post-procedural AKI and in-hospital mortality between 2 major modalities of revascularization - coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) - and results have been inconsistent. METHODS We generated a propensity score-matched cohort that includes a total of 286,670 hospitalizations with multi-vessel coronary disease undergoing CABG or PCI (2004-2012) from the National Inpatient Sample database. We compared incidence of AKI, AKI requiring renal replacement therapy (RRT), in-hospital mortality, hospital stay, and charges between CABG and PCI groups. RESULTS The incidence of AKI after CABG was higher than PCI (8.9 vs. 4.5%, OR 2.05, 95% CI 1.99-2.12, p < 0.001). The incidence of AKI requiring RRT was also higher after CABG (1.1 vs. 0.5%, OR 2.14, 95% CI 1.96-2.34, p < 0.001). Likewise, in-hospital mortality was higher after CABG than PCI (2.0 vs. 1.4%, OR 1.44, 95% CI 1.35-1.52, p < 0.001). Among patients with pre-existing chronic kidney disease (stages I-IV), those undergoing CABG was associated with 2.0-2.3-fold higher odds of developing AKI than those undergoing PCI. The patients treated with CABG had a significantly longer hospital stay and higher hospital charges. CONCLUSIONS Patients undergoing CABG are associated with (1) increased risk of developing post-procedural AKI, (2) higher likelihood of receiving RRT, and (3) worse short-term survival. Long-term renal outcome remains to be studied.
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Affiliation(s)
- Wen Shen
- Division of Nephrology and Hypertension, MedStar Georgetown University Hospital, Washington, DC, USA
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Makrilakis K, Liatis S. Cardiovascular Screening for the Asymptomatic Patient with Diabetes: More Cons Than Pros. J Diabetes Res 2017; 2017:8927473. [PMID: 29387731 PMCID: PMC5745704 DOI: 10.1155/2017/8927473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/17/2017] [Accepted: 11/05/2017] [Indexed: 12/29/2022] Open
Abstract
Diabetes mellitus is associated with an increased risk of coronary heart disease (CHD) morbidity and mortality. Although it frequently coexists with other cardiovascular disease (CVD) risk factors, it confers an increased risk for CVD events on its own. Coronary atherosclerosis is generally more aggressive and widespread in people with diabetes (PWD) and is frequently asymptomatic. Screening for silent myocardial ischaemia can be applied in a wide variety of ways. In nearly all asymptomatic PWD, however, the results of screening will generally not change medical therapy, since aggressive preventive measures, such as control of blood pressure and lipids, would have been already indicated, and above all, invasive revascularization procedures (either with percutaneous coronary intervention or coronary artery bypass grafting) have not been shown in randomized clinical trials to confer any benefit on morbidity and mortality. Still, unresolved issues remain regarding the extent of the underlying ischaemia that might affect the risk and the benefit of revascularization (on top of optimal medical therapy) in ameliorating this risk in patients with moderate to severe ischaemia. The issues related to the detection of coronary atherosclerosis and ischaemia, as well as the studies related to management of CHD in asymptomatic PWD, will be reviewed here.
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Affiliation(s)
- Konstantinos Makrilakis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens Medical School, Laiko General Hospital, Athens, Greece
| | - Stavros Liatis
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University of Athens Medical School, Laiko General Hospital, Athens, Greece
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Zrelak PA, Utter GH, Tancredi DJ, Mayer LG, Cerese J, Cuny J, Romano PS. How Accurate is the AHRQ Patient Safety Indicator for Hospital-Acquired Pressure Ulcer in a National Sample of Records? J Healthc Qual 2016; 37:287-97. [PMID: 24118246 DOI: 10.1111/jhq.12052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In 2008, we conducted a retrospective cross-sectional study to determine the test characteristics of the Agency for Healthcare Research and Quality patient safety indicator (PSI) for hospital-acquired pressure ulcer (PU). We sampled 1,995 inpatient records that met PSI 3 criteria and 4,007 records assigned to 14 DRGs with the highest empirical rates of PSI 3, which did not meet PSI 3 criteria, from 32 U.S. academic hospitals. We estimated the positive predictive value (PPV), sensitivity, and specificity of PSI 3 using both the software version contemporary to the hospitalizations (v3.1) and an approximation of the current version (v4.4). Of records that met PSI 3 version 3.1 criteria, 572 (PPV 28.3%; 95% CI 23.6-32.9%) were true positive. PU that was present on admission (POA) accounted for 76% of the false-positive records. Estimated sensitivity was 48.2% (95% CI 41.0-55.3%) and specificity 71.4% (95% CI 68.3-74.5%). Reclassifying records based on reported POA information and PU stage to approximate version 4.4 of PSI 3 improved sensitivity (78.6%; 95% CI 62.7-94.5%) and specificity (98.0; 95% CI 97.1-98.9%). In conclusion, accounting for POA information and PU staging to approximate newer versions of the PSI software (v4.3) moderately improves validity.
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Tsou AY, Treadwell JR. Quality and clarity in systematic review abstracts: an empirical study. Res Synth Methods 2016; 7:447-458. [PMID: 27764903 DOI: 10.1002/jrsm.1221] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Systematic review (SR) abstracts are important for disseminating evidence syntheses to inform medical decision making. We assess reporting quality in SR abstracts using PRISMA for Abstracts (PRISMA-A), Cochrane Handbook, and Agency for Healthcare Research & Quality guidance. METHODS We evaluated a random sample of 200 SR abstracts (from 2014) comparing interventions in the general medical literature. We assessed adherence to PRISMA-A criteria, problematic wording in conclusions, and whether "positive" studies described clinical significance. RESULTS On average, abstracts reported 60% of PRISMA-A checklist items (mean 8.9 ± 1.7, range 4 to 12). Eighty percent of meta-analyses reported quantitative measures with a confidence interval. Only 49% described effects in terms meaningful to patients and clinicians (e.g., absolute measures), and only 43% mentioned strengths/limitations of the evidence base. Average abstract word count was 274 (SD 89). Word count explained only 13% of score variability. PRISMA-A scores did not differ between Cochrane and non-Cochrane abstracts (mean difference 0.08, 95% confidence interval -1.16 to 1.00). Of 275 primary outcomes, 48% were statistically significant, 32% were not statistically significant, and 19% did not report significance or results. Only one abstract described clinical significance for positive findings. For "negative" outcomes, we identified problematic simple restatements (20%), vague "no evidence of effect" wording (9%), and wishful wording (8%). CONCLUSIONS Improved SR abstract reporting is needed, particularly reporting of quantitative measures (for meta-analysis), easily interpretable units, strengths/limitations of evidence, clinical significance, and clarifying whether negative results reflect true equivalence between treatments. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Amy Y Tsou
- ECRI Institute, Health Technology Information Service and Evidence-based Practice Center, Plymouth Meeting, PA, USA
- Corporal Michael J. Crescenz Veterans Affairs Medical Center (VAMC), Philadelphia, PA, USA
| | - Jonathan R Treadwell
- ECRI Institute, Health Technology Information Service and Evidence-based Practice Center, Plymouth Meeting, PA, USA
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Goode V, Phillips E, DeGuzman P, Hinton I, Rovnyak V, Scully K, Merwin E. A Patient Safety Dilemma: Obesity in the Surgical Patient. AANA J 2016; 84:404-412. [PMID: 28235173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Patient safety and the delivery of quality care are major concerns for healthcare in the United States. Special populations (eg, obese patients) need study in order to support patient safety, quantify risks, advance education for healthcare-workers, and establish healthcare policy. Obesity is a complex chronic disease and is considered the second leading cause of preventable death in the United States with approximately 300,000 deaths per year. Obesity is recognized by the Agency for Healthcare Research and Quality (AHRQ) as a comorbid condition. These concerns emphasize the need to focus further research on the obese patient. Through the use of clinical and administrative data, this study examines the incidence of adverse outcomes in the obese surgical population through AHRQ Patient Safety Indicators (PSI) and allows for the engagement PSIs as measures to guide and improve performance. In this study, the surgical population was overwhelmingly positive for obesity. Body mass index (BMI) was also a significant positive predictor for 2 of 3 postoperative outcomes. This finding suggests that as BMI reaches the classification of obesity, the risk of these adverse outcomes increases. It further suggests there exists a threshold BMI that requires anticipation of alterations to systems and processes to revise outcomes.
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Affiliation(s)
- Victoria Goode
- Duke University School of Nursing, Durham, North Carolina
| | - Elayne Phillips
- University of Virginia School of Nursing, Charlottesville, Virginia
| | - Pamela DeGuzman
- University of Virginia School of Nursing, Charlottesville, Virginia
| | - Ivora Hinton
- University of Virginia School of Nursing, Charlottesville, Virginia
| | - Virginia Rovnyak
- University of Virginia School of Nursing, Charlottesville, Virginia
| | - Kenneth Scully
- University of Virginia School of Nursing, Charlottesville, Virginia
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Abstract
This study examines the utilization of hospital care by HIV patients in all hospitals in eight states (California, Colorado, Florida, Kansas, New Jersey, New York, Pennsylvania, and South Carolina), and examines the cost of hospital care for HIV patients in six of these states (California, Colorado, Kansas, New Jersey, New York, and South Carolina). The eight states in the sample account for more than 52% of all persons living with AIDS in the United States; the six states account for 39%. The unit of observation in both studies is a hospital admission by a patient with HIV. Hospital data were obtained from the Healthcare Cost and Utilization Project (HCUP), State Inpatient Database (SID), which is maintained by the Agency for Healthcare Research and Quality (AHRQ). The HCUP contains hospital discharge data and is a federal/state/industry partnership to build a multistate health care data system. Using multivariate analytic techniques and data from 2000, results indicate that cost and length of a hospital stay vary significantly across states after accounting for a patient's gender, insurance type, race, age, and number of diagnoses, as well as the teaching status and ownership category of the hospital.
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Affiliation(s)
- Fred J Hellinger
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
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Bindman A. Researching the most important questions shaping quality and safety. Mod Healthc 2016; 46:30-31. [PMID: 30399273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
If you've never heard of AHRQ, you're not alone. But the Agency for Healthcare Research and Quality is quietly fueling research that's shaping the fundamentals. of the U.S. healthcare system. In October, Modern Healthcare reporter Elizabeth Whitman spoke with Dr. Andy Bindman, who became AHRQ's director in May, about the agency's work; its. influence, and the perks and perils of running a little-known federal agency (story, p. 14). A primary-care physician, Bindman spent nearly 30 years at San Francisco General Hospital-the city's safety net provider-and much of his own research has investigated barriers in access to care. The following is.an edited transcript.
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Abstract
Recent Medicare legislation calls on the Agency for Healthcare Research and Quality to conduct research related to the comparative effectiveness of health care items and services, including prescription drugs. This reinforces earlier calls for head-to-head comparative trials of clinically relevant treatment alternatives. Using a game-theoretic model, the authors explore the decision of pharmaceutical companies to conduct such trials. The model suggests that an important factor affecting this decision is the potential loss in market share and profits following a result of inferiority or comparability. This hidden cost is higher for the market leader than the market follower, making it less likely that the leader will choose to conduct a trial. The model also suggests that in a full-information environment, it will never be the case that both firms choose to conduct such a trial. Furthermore, if market shares and the probability of proving superiority are similar for both firms, it is quite possible that neither firm will choose to conduct a trial. Finally, the results indicate that incentives that offset the direct cost of a trial can prevent a no-trial equilibrium, even when both firms face the possibility of an inferior outcome.
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Affiliation(s)
- Edward C Mansley
- Outcomes Research & Management, Merck & Co. Inc., WP39-166, P.O. Box 4, West Point, PA 19486-000, USA.
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Affiliation(s)
- Carolyn M Clancy
- Agency for Healthcare Research and Quality, Rockville, Maryland, USA
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McNeill D, Moy E, Clancy CM. The Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Reports: Action Agendas for the Nation. Am J Med Qual 2016; 21:206-9. [PMID: 16679441 DOI: 10.1177/1062860606288003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Dwight McNeill
- Agency for Healthcare Research and Quality, Rockville, Maryland
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Jenkins KJ, Koch Kupiec J, Owens PL, Romano PS, Geppert JJ, Gauvreau K. Development and Validation of an Agency for Healthcare Research and Quality Indicator for Mortality After Congenital Heart Surgery Harmonized With Risk Adjustment for Congenital Heart Surgery (RACHS-1) Methodology. J Am Heart Assoc 2016; 5:e003028. [PMID: 27207997 PMCID: PMC4889177 DOI: 10.1161/jaha.115.003028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The National Quality Forum previously approved a quality indicator for mortality after congenital heart surgery developed by the Agency for Healthcare Research and Quality (AHRQ). Several parameters of the validated Risk Adjustment for Congenital Heart Surgery (RACHS-1) method were included, but others differed. As part of the National Quality Forum endorsement maintenance process, developers were asked to harmonize the 2 methodologies. METHODS AND RESULTS Parameters that were identical between the 2 methods were retained. AHRQ's Healthcare Cost and Utilization Project State Inpatient Databases (SID) 2008 were used to select optimal parameters where differences existed, with a goal to maximize model performance and face validity. Inclusion criteria were not changed and included all discharges for patients <18 years with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for congenital heart surgery or nonspecific heart surgery combined with congenital heart disease diagnosis codes. The final model includes procedure risk group, age (0-28 days, 29-90 days, 91-364 days, 1-17 years), low birth weight (500-2499 g), other congenital anomalies (Clinical Classifications Software 217, except for 758.xx), multiple procedures, and transfer-in status. Among 17 945 eligible cases in the SID 2008, the c statistic for model performance was 0.82. In the SID 2013 validation data set, the c statistic was 0.82. Risk-adjusted mortality rates by center ranged from 0.9% to 4.1% (5th-95th percentile). CONCLUSIONS Congenital heart surgery programs can now obtain national benchmarking reports by applying AHRQ Quality Indicator software to hospital administrative data, based on the harmonized RACHS-1 method, with high discrimination and face validity.
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Affiliation(s)
| | | | - Pamela L Owens
- Agency for Healthcare Research and Quality, Rockville, MD
| | - Patrick S Romano
- University of California Davis School of Medicine, Sacramento, CA
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Abstract
Medical education research suffers from a significant and persistent lack of funding. Although adequate funding has been shown to improve the quality of research, there are a number of factors that continue to limit it. The competitive environment for medical education research funding makes it essential to understand strategies for improving the search for funding sources and the preparation of proposals. This article offers a number of resources, strategies, and suggestions for finding funding. Investigators must be able to frame their research in the context of significant issues and principles in education. They must set their proposed work in the context of prior work and demonstrate its potential for significant new contributions. Because there are few funding sources earmarked for medical education research, researchers much also be creative, flexible, and adaptive as they seek to present their ideas in ways that are appealing and relevant to the goals of funders. Above all, the search for funding requires persistence and perseverance.
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Affiliation(s)
- Larry D Gruppen
- L.D. Gruppen is professor, Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan. S.J. Durning is professor, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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McCarthy M. Efforts to improve US hospital safety stalled in 2014, report finds. BMJ 2015; 351:h6571. [PMID: 26634275 DOI: 10.1136/bmj.h6571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Kronick R, Berkwits M. The Future of AHRQ's Health Services Research. JAMA 2015; 314:979-81. [PMID: 26287600 DOI: 10.1001/jama.2015.10260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
OBJECTIVES To provide an overview of statewide hospital discharge databases (HDD), including their uses in health services research and limitations, and to describe Agency for Healthcare Research and Quality (AHRQ) Enhanced State Data grants to address clinical and race-ethnicity data limitations. PRINCIPAL FINDINGS Almost all states have statewide HDD collected by public or private data organizations. Statewide HDD, based on the hospital claim with state variations, contain useful core variables and require minimal collection burden. AHRQ's Healthcare Cost and Utilization Project builds uniform state and national research files using statewide HDD. States, hospitals, and researchers use statewide HDD for many purposes. Illustrating researchers' use, during 2012-2014, HSR published 26 HDD-based articles on health policy, access, quality, clinical aspects of care, race-ethnicity and insurance impacts, economics, financing, and research methods. HDD have limitations affecting their use. Five AHRQ grants focused on enhancing clinical data and three grants aimed at improving race-ethnicity data. CONCLUSION ICD-10 implementation will significantly affect the HDD. The AHRQ grants, information technology advances, payment policy changes, and the need for outpatient information may stimulate other statewide HDD changes. To remain a mainstay of health services research, statewide HDD need to keep pace with changing user needs while minimizing collection burdens.
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Affiliation(s)
- Roxanne M Andrews
- Center for Delivery, Organization, and Markets, Agency for Healthcare Research and QualityRockville, MD
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Pine M, Kowlessar NM, Salemi JL, Miyamura J, Zingmond DS, Katz NE, Schindler J. Enhancing Clinical Content and Race/Ethnicity Data in Statewide Hospital Administrative Databases: Obstacles Encountered, Strategies Adopted, and Lessons Learned. Health Serv Res 2015; 50 Suppl 1:1300-21. [PMID: 26119470 PMCID: PMC4545333 DOI: 10.1111/1475-6773.12330] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Eight grant teams used Agency for Healthcare Research and Quality infrastructure development research grants to enhance the clinical content of and improve race/ethnicity identifiers in statewide all-payer hospital administrative databases. PRINCIPAL FINDINGS Grantees faced common challenges, including recruiting data partners and ensuring their continued effective participation, acquiring and validating the accuracy and utility of new data elements, and linking data from multiple sources to create internally consistent enhanced administrative databases. Successful strategies to overcome these challenges included aggressively engaging with providers of critical sources of data, emphasizing potential benefits to participants, revising requirements to lessen burdens associated with participation, maintaining continuous communication with participants, being flexible when responding to participants' difficulties in meeting program requirements, and paying scrupulous attention to preparing data specifications and creating and implementing protocols for data auditing, validation, cleaning, editing, and linking. In addition to common challenges, grantees also had to contend with unique challenges from local environmental factors that shaped the strategies they adopted. CONCLUSIONS The creation of enhanced administrative databases to support comparative effectiveness research is difficult, particularly in the face of numerous challenges with recruiting data partners such as competing demands on information technology resources. Excellent communication, flexibility, and attention to detail are essential ingredients in accomplishing this task. Additional research is needed to develop strategies for maintaining these databases when initial funding is exhausted.
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Affiliation(s)
- Michael Pine
- Michael Pine and Associates, 1 East Upper Wacker Drive #1210, Chicago, IL
| | | | - Jason L Salemi
- Baylor College of Medicine, 3701 Kirby Drive, Room LMPL-600, Mail Stop BCM700, Houston, TX, 77098
| | | | - David S Zingmond
- UCLA Division of General Internal Medicine and Health Services Research, Los Angeles, CA
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Salemi JL, Salinas-Miranda AA, Wilson RE, Salihu HM. Transformative Use of an Improved All-Payer Hospital Discharge Data Infrastructure for Community-Based Participatory Research: A Sustainability Pathway. Health Serv Res 2015; 50 Suppl 1:1322-38. [PMID: 25879276 PMCID: PMC4545334 DOI: 10.1111/1475-6773.12309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the use of a clinically enhanced maternal and child health (MCH) database to strengthen community-engaged research activities, and to support the sustainability of data infrastructure initiatives. DATA SOURCES/STUDY SETTING Population-based, longitudinal database covering over 2.3 million mother-infant dyads during a 12-year period (1998-2009) in Florida. SETTING A community-based participatory research (CBPR) project in a socioeconomically disadvantaged community in central Tampa, Florida. STUDY DESIGN Case study of the use of an enhanced state database for supporting CBPR activities. PRINCIPAL FINDINGS A federal data infrastructure award resulted in the creation of an MCH database in which over 92 percent of all birth certificate records for infants born between 1998 and 2009 were linked to maternal and infant hospital encounter-level data. The population-based, longitudinal database was used to supplement data collected from focus groups and community surveys with epidemiological and health care cost data on important MCH disparity issues in the target community. Data were used to facilitate a community-driven, decision-making process in which the most important priorities for intervention were identified. CONCLUSIONS Integrating statewide all-payer, hospital-based databases into CBPR can empower underserved communities with a reliable source of health data, and it can promote the sustainability of newly developed data systems.
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Affiliation(s)
- Jason L Salemi
- Address correspondence to Jason L. Salemi, Ph.D., Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600 (MS: BCM700), Houston, TX; e-mail:
| | - Abraham A Salinas-Miranda
- Abraham A. Salinas-Miranda, M.D., Ph.D., Roneé E. Wilson, Ph.D., and Hamisu M. Salihu, M.D., Ph.D., are with The Maternal and Child Health Comparative Effectiveness Research Group, Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
- Hamisu M. Salihu, M.D., Ph.D., is also with the, Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Roneé E Wilson
- Abraham A. Salinas-Miranda, M.D., Ph.D., Roneé E. Wilson, Ph.D., and Hamisu M. Salihu, M.D., Ph.D., are with The Maternal and Child Health Comparative Effectiveness Research Group, Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
- Hamisu M. Salihu, M.D., Ph.D., is also with the, Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
| | - Hamisu M Salihu
- Abraham A. Salinas-Miranda, M.D., Ph.D., Roneé E. Wilson, Ph.D., and Hamisu M. Salihu, M.D., Ph.D., are with The Maternal and Child Health Comparative Effectiveness Research Group, Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL
- Hamisu M. Salihu, M.D., Ph.D., is also with the, Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX
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Andrews RM, Schulman KA. Enhancing the Value of Statewide Hospital Discharge Data: Improving Clinical Content and Race-Ethnicity Data. Health Serv Res 2015; 50 Suppl 1:1265-72. [PMID: 26205563 PMCID: PMC4545331 DOI: 10.1111/1475-6773.12342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Hsu BS, Meyer BD, Lakhani S. Healthcare costs and outcomes for pediatric inpatients with bronchiolitis: comparison of urban versus rural hospitals. Rural Remote Health 2015; 15:3380. [PMID: 26108644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
MESH Headings
- Bronchiolitis/classification
- Bronchiolitis/epidemiology
- Diagnosis-Related Groups
- Female
- Health Care Costs/statistics & numerical data
- Hospitals, Pediatric/economics
- Hospitals, Pediatric/statistics & numerical data
- Hospitals, Private
- Hospitals, Rural/classification
- Hospitals, Rural/economics
- Hospitals, Rural/standards
- Hospitals, Teaching
- Hospitals, Urban/classification
- Hospitals, Urban/economics
- Hospitals, Urban/standards
- Humans
- Infant
- Inpatients/statistics & numerical data
- Length of Stay/statistics & numerical data
- Male
- Medical Staff, Hospital
- Mortality
- Outcome Assessment, Health Care
- Patient Discharge/statistics & numerical data
- Retrospective Studies
- Severity of Illness Index
- United States/epidemiology
- United States Agency for Healthcare Research and Quality
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Affiliation(s)
- Benson S Hsu
- Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA.
| | - Benjamin D Meyer
- Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA.
| | - Saquib Lakhani
- Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA.
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Affiliation(s)
- Ravi Rajaram
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Cynthia Barnard
- Department of Quality Strategies, Northwestern Memorial Hospital, Chicago, Illinois
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern Memorial Hospital and Northwestern University, Chicago, Illinois
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47
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Korbel L, Spencer JD. Diabetes mellitus and infection: an evaluation of hospital utilization and management costs in the United States. J Diabetes Complications 2015; 29:192-5. [PMID: 25488325 PMCID: PMC4333016 DOI: 10.1016/j.jdiacomp.2014.11.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 11/02/2014] [Accepted: 11/12/2014] [Indexed: 12/01/2022]
Abstract
AIMS The objective of this study is to evaluate the number of diabetics that seek medical treatment in emergency departments or require hospitalization for infection management in the United States. This study also assesses the socioeconomic impact of inpatient infection management among diabetics. METHODS We accessed the Healthcare Cost and Utilization Project's Nationwide Emergency Department Sample database and the Nationwide Inpatient Sample database to perform a retrospective analysis on diabetics presenting to the emergency department or hospitalized for infection management from 2006 to 2011. RESULTS Emergency Department: Since 2006, nearly 10 million diabetics were annually evaluated in the emergency department. Infection was the primary reason for presentation in 10% of these visits. Among those visits, urinary tract infection was the most common infection, accounting for over 30% of emergency department encounters for infections. Other common infections included sepsis, skin and soft tissue infections, and pneumonia. Diabetics were more than twice as likely to be hospitalized for infection management than patients without diabetes. Hospitalization: Since 2006, nearly 6 million diabetics were annually hospitalized. 8-12% of these patients were hospitalized for infection management. In 2011, the inpatient care provided to patients with DM, and infection was responsible for over $48 billion dollars in aggregate hospital charges. CONCLUSIONS Diabetics commonly present to the emergency department and require hospitalization for infection management. The care provided to diabetics for infection management has a large economic impact on the United States healthcare system. More efforts are needed to develop cost-effective strategies for the prevention of infection in patients with diabetes.
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Affiliation(s)
- Lindsey Korbel
- The Ohio State University College of Medicine, Center for Clinical and Translational Research
| | - John David Spencer
- The Research Institute at Nationwide Children's, Center for Clinical and Translational Research.
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Parisi LM, Gabbay RA. What providers want from the Primary Care Extension Service to facilitate practice transformation. Fam Med 2015; 47:210-216. [PMID: 25853532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND OBJECTIVES While several experts have shared their visions of the Primary Care Extension Service (PCES) as called for in the Affordable Care Act (ACA), little is known about providers' perspective. We aimed to identify the most and least desired resources that primary care providers want from the PCES. METHODS A 70-question survey was administered to primary care providers (n=556) in Pennsylvania, one of four initial states chosen to develop the PCES infrastructure. Analysis focused on the highest and lowest ranked questions. RESULTS The most desired PCES services include (1) identifying and coordinating mental health services, (2) improving office efficiency, (3) increasing overall revenues, and (4) strategies to help implement evidence-based clinical guidelines. The least desired PCES services include (1) implementing e-prescribing, (2) implementing an electronic medical record (EMR) system, (3) implementing group visits, (4) recruiting new patients, and (5) implementing open or advanced access scheduling. CONCLUSIONS Despite expert models presented for the PCES, there is a critical need to ask primary care providers what they need from such a service. Our findings identified some divergences from key patient-centered medical home (PCMH) components, including the low ranking of services related to EMRs and increasing patient access. With interest growing in developing a PCES that would help spread innovation as outlined in the ACA, it's important to take a demand-side approach to the services providers most desire versus the more traditional supply-side approach that assumes the assistance providers need.
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Less harm done in 2013, says AHRQ. Hosp Peer Rev 2015; 40:17-8. [PMID: 25668885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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50
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Stokowski LA. Coaching parents through the home stretch. Adv Neonatal Care 2014; 14:368. [PMID: 25574556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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