November 2011 Research Activities - AHRQ Archive- … · · 2014-09-18conference theme of...

The Agency for HealthcareResearch and Quality (AHRQ)hosted its fifth annual conference,which some attendees refer to as“AHRQ-A-Palooza,” September19-21 in Bethesda, MD. Nearly1,800 individuals attended the eventin person or via the Webcastedplenary sessions to explore theconference theme of “LeadingThrough Innovation andCollaboration.” Choosing thattheme, said Carolyn Clancy, M.D.,AHRQ director, brings “attention tothe urgent need for addressing thechallenges that we face” and“points to the need forcollaboration with others, both in

and outside of the industry, toachieve the kind of improvementsthat will truly be transformational.”

Addressing Disparities

Panelists for the first plenary,“Addressing Health CareDisparities, Access, and Quality ofCare,” discussed approaches andconsiderations for reducingdisparities in health care. “This isone of those issues for which thereis almost universal agreement. Weall want to eliminate disparities incare,” Dr. Clancy said. “Mention itin a talk, and applause often breaksout spontaneously. Yet, in practice,the gap between that applause andtaking that first step sometimesfeels really, really big.”

Panelist Gary R. Gunderson,D.Min., M. Div., senior vice

president for the Faith & HealthDivision at Methodist Le BonheurHealthcare in Memphis, TN,provided an overview of hishospital’s “audacious” first step thatinvolved building a “web of trust”among 400 congregations to reducehealth care disparities in Memphis.With the help of a local chaplain,he began tackling themisperception that hospitals see thecommunity’s needs first. “Actually,we don’t. [Communities] are theones who know before we do, ingreater detail and further intricacy,what it is like to live on the groundin Memphis,” he said.

The congregational partners havetaught Gunderson’s hospital that thecritical issue the community facesis not communication but

continued on page 3

Highlights

AHRQ’s annual conference focuses on innovation andcollaboration

U.S. Department of Health and Human Services No. 375, November 2011

Topics

Disparities/Minority Health 5

Patient Safety and Quality 6

Primary Care 7

Prevention 8

Chronic Disease 9

Health Information Technology 10

Child/Adolescent Health 11

Regular Features

From the Director 2

Agency News and Notes 13

Announcements 16

Research Briefs 18

RESEARCHACTIVITIES

Dr. Gary Gunderson, Ms. Susan Vega, Dr. Carolyn Clancy, Dr. Rhonda Johnson, and Dr. HerbertSmitherman at the first plenary session.

AHRQ’s fifthannualconferencereminded meagain howexciting it is tobe surroundedby passionateand visionaryprofessionals

who are breaking new ground andadvancing the field of health care. Inthe months since the fourth annualconference, great progress has beenmade in our efforts to transform theU.S. health care system into aninformation-rich, patient-centeredenterprise that provides care forpeople when and where they need it.This year’s theme, “AHRQ: LeadingThrough Innovation &Collaboration,” focused on theurgency required to address today’schallenges in improving quality andaccess to care, and finding value forwhat we spend. It called forcollaboration with clinicians,patients, health care leaders andemployers, as well as community

partners, who are working to make adifference, and the development andsharing of new ideas.

It was exciting to unveil an originalseries of new “Questions Are theAnswer” videos at the first plenarysession. The videos, which featurereal patients and cliniciansdiscussing the importance of askingquestions and sharing information,underscore the importance ofpatient-centered care and goodcommunication to quality care in the21st century. The videos areavailable on the AHRQ Web site atwww.ahrq.gov/questions.

This year’s conference agenda wasaligned with the major aims outlinedin the National Quality Strategy:

• Better Care: Promote person-centered care that works forpatients, their families, and othercaregivers and providers.

• Healthy People/HealthyCommunities: Promote health andwellness at all levels for allpopulations.

• Affordable Care: Promotestrategies that reduce costs forindividual families, employers,and government, while improvingaccess and the quality of caredelivered to patients.

The plenary and other conferencesessions featured pioneers of healthcare describing their work, much ofwhich has the potential to affectcultural and system change on anational scale. We heard from fourleaders from Detroit, Memphis,Chicago, and western Pennsylvania,whose efforts are making adifference now in reducingdisparities in care in theircommunities. We also heard fromleaders from Los Angeles toBaltimore on innovations to improvecare, who noted that system changeand market forces were critical toimplementing innovations. Inaddition, we were challenged by onespeaker to envision and achieveexceptional outcomes across thehealth care system.

Multiple sessions showcased currentAHRQ-funded work in healthinformation technology, primarycare, preventing healthcare-associated infections and othersafety problems, reducingdisparities, as well as currentcollaborations with partners whoapply the results of our research toimprove health care. AHRQ’scollaboration and partnership withthese visionary individuals andorganizations, and their collaborationwith each other, have great potentialto improve the quality, safety,efficiency, and effectiveness ofhealth care for all Americans.

Carolyn M. Clancy, M.D.

www.ahrq.gov2 Number 375, November 2011

Research Activities is a digest of research findings that have been produced withsupport from the Agency for Healthcare Research and Quality. Research Activities ispublished by AHRQ’s Office of Communications and Knowledge Transfer. Theinformation in Research Activities is intended to contribute to the policymakingprocess, not to make policy. The views expressed herein do not necessarilyrepresent the views or policies of the Agency for Healthcare Research and Quality,the Public Health Service, or the Department of Health and Human Services. Forfurther information, contact:

AHRQOffice of Communications and Knowledge Transfer

540 Gaither RoadRockville, MD 20850(301) 427-1360

Gail MakulowichManaging Editor

Kevin BlanchetKaren Fleming-MichaelDavid I. LewinKathryn McKayMark W. StantonContributing Editors

Joel BochesDesign and Production

Farah EnglertMedia Inquiries

From the Director

www.ahrq.gov Number 375, November 2011 3

AHRQ conferencecontinued from page 1

navigation. To address that problem,his team mapped the health careassets available in the communityand found that a lot of what theythought they needed was alreadythere. Now “navigators” are in placein hospitals so hospital and primarycare partners can help people accessthe “extraordinary abundance ofassets,” Dr. Gunderson said.

Susan Vega, manager of seniorprograms at Alvio Medical Centerin Chicago, IL, is also a fan of thisasset-based community planningapproach. When patients visitingher center are eligible for publicassistance programs, she helps themcomplete the paperwork instead ofreferring them to another office.And she does not wait for people tocome through her door; she findsthem through school-based clinics,health fairs, and community events,and ensures that everyone whohears her speak has a name and aphone number to call if they needher help navigating the system.

Policy, unfortunately, can oftenworsen disparities, said Herb C.Smitherman, Jr., M.D., M.P.H.,assistant dean, Community andUrban Health at Wayne StateUniversity in Detroit, MI. Forexample, if individuals are onMedicaid, they lose that healthinsurance once they get a job. Then,because they can no longer afford tosee their doctor, they can’t get theirmedications, they get sick, and theylose their job. “This is social policyand it’s really driving our healthpolicy,” Dr. Smitherman said.

Innovative programs, though, canmake inroads in reducing disparitiesand cost while improving care. Dr.Smitherman cited a 5-year programthat helped Detroit’s privatehospitals reduce their

uncompensated care costs, whichwere totaling $400-$500 millioneach year. By putting communityhealth workers in every hospitalemergency room, they were able toidentify uninsured patients whowere relying on emergency roomcare for common colds or answersto medication questions and connect33,000 of these uninsured patientsto primary care providers. As aresult, today these patients get bettercare that costs less.

Ms. Vega also stressed the pressingneed for more bilingual clinicians toreduce disparities. Her group tracksthe number of bilingual individualsenrolled in nursing programs andhas found that if every slot weretaken by a bilingual individual, theneed for bilingual nurses would stilloutpace the demand.

Bridging language barriers is onepart of reducing disparities. But theproblem is larger than that, saidRhonda M. Johnson, M.D., M.P.H.,medical director of Health Equityand Quality Services at Highmark,Inc., in Pittsburgh, PA. “We have tohave a disparity lens on everythingwe do. I think sometimes it feelsoverwhelming, because theproblems are so large and they areso ingrained. There’s social, there’shealth care, there’s access, there’slanguage and communication, and

the list goes on and on. But thelesson I have learned is that youhave to start somewhere. You mustbuild a collective consciousness sothe efforts to address disparitieshave uptake and spread.”

Unveiling a New Campaign

Attendees at the first plenary alsogot a sneak peek of AHRQ’supdated “Questions are the Answer”initiative. The initiative includes anoriginal series of new videos on theAHRQ Web site,www.ahrq.gov/questions, thatfeatures real patients and cliniciansdiscussing the importance of askingquestions and sharing informationto get high-quality care and betterhealth outcomes.

Unfortunately, the reality is thatdecreased reimbursements areforcing doctors to see more patients,which reduces the amount of timedoctors have to talk with patients,noted Dr. Smitherman, a practicingphysician for 25 years. He spoke ofa woman he treated who had had atleast $30,000 worth of diagnostictests in three different emergencyrooms and was facing a cardiaccatheterization. His diagnosis, afterspending 20 minutes getting herhealth history,

continued on page 4

Dr. Arnold Milstein, Dr. Carolyn Clancy, Dr. Molly Coye, and Dr. Peter Pronovost at the second plenarysession.


AHRQ conferencecontinued from page 3

was that she had heartburn. “It tooktime, which we have less and lessand less of,” he said. “Commun-ication, communication: I can’toveremphasize it.”

Addressing Innovations

Panelists for the second plenary,titled “Addressing Health SystemChange, Patient Safety, and Qualityof Care,” focused on innovation andimplementation. “With quality, thegood news is that the latest AHRQNational Healthcare Quality Reportshows statistically significantimprovement every year, across allpopulations and settings, since2003. The slightly less good newsis that the magnitude of thoseimprovements is very modest,usually in the 1 to 2 percentballpark. We’re moving in the rightdirection—I don’t want to discountthat—but it’s slow,” Dr. Clancysaid.

The panelists all agreed thatimplementing innovations quicklyis challenging. Arnie Milstein,M.D., M.P.H., professor ofmedicine at Stanford and Directorof the Stanford Clinical ExcellenceResearch Center, said that cost-lowering, health-improvinginnovations might have quickeruptake if they move large numbersof patients and their revenue toproviders who are willing to beaccountable, for example, byparticipating in outcome registriesthat can be used to measure carequality.

Market forces do influence howquickly innovations are adopted.

“There’s no question that untilpurchasers and payers really crackthe whip, this is not going to go asfast as we want it to go, said MollyJoel Coye, M.D., M.P.H., chiefinnovation officer for the Universityof California Los Angeles HealthSystem. “We know there is a lot ofmoney that can be savedeverywhere in the country if thesystems get really serious abouthow to do that.”

Appreciating that system change iscrucial for innovation adoption isalso essential if hospitals are to besuccessful adopters. “If they don’thave clear systems in place toactually be able to do it, and if theydon’t have the driving force and theclear steps that are needed, it’s veryeasy to go off track,” Dr. Coye said.She cited the VeteransAdministration’s (VA’s) success inmonitoring chronic disease in thecommunity, noting that if otherhealth systems tried to duplicate theVA’s work they might be misguidedby buying in-home monitoringtechnology, not realizing that theVA’s program is based on a system,not a technology.

One innovation that has achievednoteworthy spread is aComprehensive Unit-based SafetyProgram (CUSP) that virtuallyeliminated blood stream infectionsin Michigan, saving 1,500 lives and$100 million annually. The protocolis now being implemented acrossthe United States and has reducedblood stream infections by 60percent.

The father of CUSP is PeterPronovost, M.D., Ph.D., a practicinganesthesiologist and critical care

physician and senior vice presidentfor patient safety and quality atJohns Hopkins University inBaltimore, MD.

He attributes the success of theproject to the fact that the protocoluses a measure that cliniciansbelieve is valid, is guided byimplementation science, andinvolves a community of clinicians.“Clinicians saw this as a socialproblem that they were capable ofsolving,” he said. Dr. Pronovostadded that the biggest barrier wasovercoming the belief that youactually couldn’t take a solution toa problem and bring it to scaleacross the country.

He used the example of RogerBannister breaking the 4-minutemile in 1954, even after physicianssaid the human body wasn’t capableof this feat. Once Bannister brokethat record, many, many others—including 10 male high schoolrunners in a track meet inFalmouth, MA in August—accomplished that feat as well.

“I think the only thing that changedwas their belief,” he said. “RogerBannister freed up what waspossible and in doing so itempowered all these other people tosay, ‘Hey, we can do that too.’That’s what you and the people atAHRQ are trying to do.” n KFM

Editor’s note: The plenary sessionWebcasts and session speakerpresentations will be posted on theAHRQ Web site later this fall. The2012 AHRQ Annual Conferencewill be held September 9-12 at theBethesda North MarriottConvention Center in Maryland.

Note: Only items marked with a single (*) asterisk are available from the AHRQ Clearinghouse. See the backcover of Research Activities for ordering information. Consult a reference librarian for information on obtainingcopies of articles not marked with an asterisk.


Disparities/Minority Health

In a study of 100,000 Medicare patients hospitalized in3,648 hospitals, researchers found that blacks had ahigher risk than whites of suffering from a healthcare-associated infection or adverse drug event. Also,patients discharged from hospitals with the highestpercentage of black patients had a significantly higherrisk of hospital-acquired infection or adverse drugevent than patients discharged from hospitals with thelowest percentage of black patients.

On the other patient safety measures studied, there wasno difference between groups. The adverse eventsstudied included: adverse drug events associated withhypoglycemic agents, heparin, and warfarin; generaladverse events such as falls and pressure ulcers; fourtypes of infection-related adverse events; and seventypes of post-procedural adverse events.

Ernest Moy, M.D., M.P.H., of the Agency for Health-care Research and Quality, and fellow researchers

suggest that hospitalized blacks experience higher ratesof adverse drug events and hospital-acquired infectionsbecause they are independently at higher risk of theseevents. Also, blacks are more often cared for athospitals where these events are more likely to occur,independent of race. The researchers call for greaterattention to patient safety and quality improvement atthese hospitals.

See “Racial disparities in the frequency of patientsafety events. Results from the the National MedicarePatient Safety Monitoring System,” by Mark L.Metersky, M.D., David R. Hunt, M.D., RebeccaKliman, M.P.H., and others in the May 2011 MedicalCare 49(5), pp. 504-510. Reprints (AHRQ Pub. No.11-R050) are available from the Agency for HealthcareResearch and Quality.* n MWS

Blacks and patients at hospitals with a high percentage of black patientsmore likely to suffer adverse events

Discrimination has been suggestedas one of the potential explanationsfor the presence of racial/ethnichealth and health care disparities inthe United States. In a group ofalmost 18,000 patients withdiabetes enrolled in KaiserPermanente Northern California, 3 percent reported health carediscrimination from doctors orhealth care providers and 20percent reported generaldiscrimination in everyday life. Allracial and ethnic groups (Blacks,Latinos, East Asians, and Filipinos)reported discrimination morefrequently than whites. Blacksreported general discriminationmost frequently (52 percent) and

Filipinos reported health careprovider discrimination mostfrequently (8 percent). Individualswho reported generaldiscrimination were significantlymore likely to also report healthcare provider discrimination. Healthcare discrimination was more oftenreported not only by minorities, butalso by those with poorer healthliteracy, limited Englishproficiency, and depression.

These findings suggest thatperceived health care providerdiscrimination was uncommon,especially when compared withgeneral discrimination. Theresearchers conclude that aprovider’s careful attention to

patient factors such as limitedhealth literacy and languagebarriers may reduce perceptions ofhealth care discrimination. Thestudy was supported in part by theAgency for Healthcare Researchand Quality (HS13853).

See “Correlates of patient-reportedracial/ethnic health carediscrimination in the DiabetesStudy of Northern California(DISTANCE),” by Courtney R.Lyles, Ph.D., Andrew J. Karter,Ph.D., Bessie A. Young, M.D.,M.P.H., and others in the Journal ofHealth Care for the Poor andUnderserved 22, pp. 211-225,2011. n MWS

Among patients with diabetes, racial/ethnic discrimination by health careproviders is uncommon


Pituitary adenomas are normally benign tumors on thepituitary gland. Although they do not cause anysymptoms in many cases, some patients experiencehormonal and neurological problems. More than 30years have passed since a population-based study wasconducted on demographic differences in pituitaryadenoma. However, a recent study by University ofIowa researchers updates knowledge about itsincidence. It found that blacks have a higher incidenceof the condition than other ethnic groups.

Data for this study came from the SurveillanceEpidemiology and End Results (SEER) Program thatcovers nearly 26 percent of the U.S. population. Four-year’s worth of information on 8,276 cases of pituitaryadenoma (2004 to 2007) were gathered and analyzed.

Incidence rates were found to increase with age.Females had a higher incidence of pituitary adenoma inearly life, while males had a higher incidence in laterlife. Males also tended to be diagnosed with largertumors, indicating a possible delay in diagnosis. The

highest, age-adjusted incidence rate was found forblacks (4.4 cases per 100,000), with the lowest rateobserved in American Indians/Alaskan Natives (1.9cases per 100,00). In the case of blacks, they weremore likely to have their pituitary adenomas diagnosedthrough x-ray alone without microscopic confirmation.

Although their tumors were slightly larger than thosefound in whites, blacks had lower rates of surgicaltreatment than other ethnic groups. Future studies thatincorporate the SEER and Medicare databases may beable to clarify some of these findings, including thisracial/ethnic treatment disparity. The study wassupported in part by the Agency for HealthcareResearch and Quality (HS16094).

See “Demographic differences in incidence forpituitary adenoma,” by Bradley D. McDowell, Ph.D.,Robert B. Wallace, M.D., Ryan M. Carnahan,Pharm.D., and others in Pituitary 14, pp. 23-30, 2011.n KB

Blacks have higher rates of pituitary adenoma

Patient Safety and Quality

Electronic prescribing (e-prescribing) has helped reducemedication errors and adverse drugevents (ADEs) in a variety of healthcare settings, including theoutpatient environment. However,computer-generated prescriptionscan also introduce a new level oferrors. What’s more, they cannotprevent all of the errors normallymade with paper prescriptions. Anew study found that about 1 in 10computer-generated prescriptionshad at least 1 error. In addition, athird of these errors had thepotential for harm.

Massachusetts researchers reviewed3,850 computer-generatedprescriptions from a retailoutpatient pharmacy chain located

in three States. During a 4-weekperiod, the pharmacy sent allcomputer-generated prescriptions tothe study’s research group. Theywere then reviewed by anindependent clinical review panel.A total of 452 (11.7 percent)prescriptions were found to have466 errors in them. More than athird of these errors (35.0 percent)were classified as potential ADEs.None of the ADEs were consideredlife-threatening; they were deemedeither significant (58.3 percent) orserious (41.7 percent). The majorityof medication errors involved anti-infectives, while nervous-systemdrugs accounted for the mostADEs.

Differentcomputerizedsystems generateddifferent typesof medicationerrors.Omittedinformationsuch as dose,frequency, and duration, was themost common reason for error.Omitting a dose was responsible for35 percent of all potential ADEs.Based on their findings, theresearchers offer several strategiesto reduce errors associated withcomputer-generated prescriptions.These include designing functionsto prevent omitted information

continued on page 7

Nearly 1 in 10 outpatient computerized prescriptions contains errors


Primary Care

Computerized prescriptionscontinued from page 6

(called forcing functions),incorporating maximum dosechecking in drug-decision supportfeatures, and using systemcalculators to resolve quantity

errors. The study was supported inpart by the Agency for HealthcareResearch and Quality (HS16970).

See “Errors associated withoutpatient computerized prescribingsystems,” by Karen C. Nanji, M.D.,

M.P.H., Jeffrey M. Rothschild,M.D., M.P.H., Claudia Salzberg,M.S., and others in the June 29,2011 online edition of the Journalof the American MedicalInformatics Association. n KB

Hospitalized patients typically use call lights to requestpain medication, personal assistance, or bathroomassistance. Delays in responding to these calls canresult in patient discomfort or even falls. A new studyfound that nurses took longer to respond to call lightswhen patient call-light use on the unit was higher andthe average length of patient stay was shorter. Nurseresponse time was not affected by total nursing hoursor registered nurse (R.N.) hours.

A shorter length of stay suggests the patients weregenerally less sick and should have presented fewerproblems to the nursing staff. Instead, the importantfactor seems to have been the number of admissionsand discharges to the unit, and more frequentprocedures, treatments, and instances of patienteducation per patient-day—all activities that consume asubstantial amount of nursing staff time, note theresearchers. They found that the mean call-lightresponse time in the five acute care community

hospital units in the study was about 3 minutes (181.99seconds), and that mean call-light use was nearly 5times per patient-day. The mean length of patient staywas 5.60 days, mean total nursing hours per patient-daywere 8.15, and mean R.N. hours per patient-day were4.76.

The researchers examined data from February 2007through June 2008 (17 months) from five adult acute-care inpatient units at a community hospital. Analysisincluded only normal calls made from the patient’s bedor bathroom. The study was funded in part by theAgency for Healthcare Research and Quality(HS18258).

More details are in “Exploring the relationship betweenpatient call-light use and nurse call-light response timein acute care settings,” by Huey-Ming Tzeng, Ph.D.,R.N., FAAN., and Janet L. Larson, Ph.D., R.N., in theMarch 2011 CIN:Computers, Informatics, Nursing29(3), pp. 138-143. n DIL

Nurses in hospital units with a higher proportion of short-term patientstake longer to respond to patient call lights

An estimated 3.2 millionAmericans live with chronichepatitis C virus (HCV) infectionthat can lead to cirrhosis and livercancer. Treatment is available,although its complex nature meansthat specialists usually provide care.Yet a new study shows that, withproper training and the use of videoconferencing, primary careproviders at community-based

health centers can extend thistreatment to underserved groups.

Called the Extension forCommunity Healthcare Outcomes(ECHO) model, the program takesadvantage of telehealth technologyto deliver training, advice, andsupport on optimal clinical care topatients with HCV infection.Clinicians at each community

provider site participate in weeklyHCV clinics in which they presenttheir cases to key specialists at amajor academic medical center.

Sanjeev Arora, M.D., of theUniversity of Mexico, andcolleagues looked at 21 ECHO sitesin rural areas and prisons in New

continued on page 8

Primary care model helps treat underserved patients with hepatitis C virusinfection


Prevention

Hepatitis C virus infectioncontinued from page 7

Mexico involving 407 patients withchronic HCV infection, who startedtreatment at these sites.Participating patients receivedstandard treatment consisting ofpeginterferon and ribavirin foreither 24 or 48 weeks depending onthe type of HCV infection they had.

More than half (58.2 percent) ofpatients at the ECHO sites had asustained response to treatment.

This rate was similar for patientsreceiving treatment at the HCVclinic at the academic medicalcenter (57.5 percent). However,patients at the ECHO sitesexperienced less serious adverseevents (6.9%) than at the academicHCV clinic (13.7 percent).According to the researchers, theECHO model can be replicatedelsewhere at other communityhealth centers with thecollaboration of local academic

specialists and the use of telehealthtechnology. The study wassupported in part by the Agency forHealthcare Research and Quality(HS16510).

See “Outcomes of treatment forhepatitis C virus infection byprimary care providers,” by SanjeevArora, M.D., Karla Thornton, M.D.,Glen Murata, M.D., and others inthe June 9, 2011 The New EnglandJournal of Medicine 364(23), pp.2199-2207. n KB

Studies of the clinical use of thefecal occult blood test (FOBT) forthe detection of colon cancersuggest that a person should havea life expectancy of at least 5years to derive survival benefitfrom screening. Otherwise theyare only subject to the potentialburdens of followup proceduresand treatments stemming from apositive result. Researchers whotracked over a 7-year period agroup of 211 male veterans and 1female veteran who had receivedFOBTs found that only 56 percentof patients received follow-upcolonoscopy.

Colonoscopy found 34 significantadenomas and 6 cancers. Tenpercent of patients experienced

complications from colonoscopyor cancer treatment (12 of 118).Forty-six percent of those withoutfollow-up colonoscopy died ofother causes within 5 years ofFOBT, while three died ofcolorectal cancer within 5 years.

Eighty-seven percent of patientswith the worst life expectancyexperienced a net burden fromscreening compared with 70percent with average lifeexpectancy and only 65 percentwith best life expectancy. Theresearchers concluded that olderpatients with the best predictedlife expectancy were less likely toexperience a net burden fromscreening than those with theworst. Their study supports

guidelines that recommend usinglife expectancy to guide colorectalcancer screening decisions inolder adults, and argues againstone-size-fits-all interventions thatsimply aim to increase overallscreening and followup rates. Thestudy was supported by theAgency for Healthcare Researchand Quality (HS19468).

See “Long-term outcomesfollowing positive fecal occultblood test results in older adults.Benefits and burdens,” byChristine E. Kistler, M.D.,Katharine A. Kirby, M.S., DeliaLee, B.S., and others in the May 9,2011 Archives of InternalMedicine 171(15), pp. 1344-1351.n MWS

Fecal occult blood tests and followup need to be better targeted tohealthy older adults


Chronic Disease

Patients with multiple sclerosis (MS) experience acomplex spectrum of symptoms such as fatigue, pain,reduced use of legs and arms, vision problems, andfunctional difficulties with their bowels and bladders,not to mention sexual problems. They also experiencehigher rates of insomnia—often linked to theirdepression and anxiety. A new study suggests thatshort-term psychotherapy can improve insomnia inthese individuals, which may also lower levels ofdepression and anxiety.

A total of 127 patients with MS and depression wererecruited from a large medical group in California andfrom regional chapters of the Multiple SclerosisSociety. Initial brief telephone interviews determinedtheir level of depressive symptoms. Following thisscreening, participants were randomized to receiveeither cognitive behavioral therapy or supportiveemotion-focused therapy, both delivered via telephonecalls. Each patient was evaluated for depression,insomnia, anxiety, and quality of life criteria beforetreatment and then again at 8 weeks (mid-treatment)and 16 weeks (post-treatment).

A majority of patients (78 percent) initially reportedinsomnia occurring at least three or more times perweek, which declined to 43 percent followingpsychotherapy. Insomnia symptoms, particularly sleep-

onset insomnia, improved with psychotherapy fordepression, with greatest improvement seen in thosewith greatest relief of depression and anxiety. However,a considerable proportion of individuals continued toexperience insomnia despite remission of majordepressive disorder and low symptoms of anxiety.These results suggest that treatment of depression andanxiety has the potential to greatly improve insomnia inpatients with MS, but may not be sufficient to addressthe multiple factors related to insomnia in thesepatients.

Following treatment, 27 percent of patients continuedto have major depressive disorder and 21 percentcontinued to experience elevated anxiety symptoms.The researchers suggest that patients with MS receivecomprehensive screening for all primary sleepdisorders as well as management for depression,anxiety, and pain. The study was supported in part bythe Agency for Healthcare Research and Quality (T32HS00078).

See “Impact of psychotherapy on insomnia symptomsin patients with depression and multiple sclerosis,” byKelly Glazer Baron, Ph.D., Marya Corden, B.S., LingJin, M.S., and David C. Mohr, Ph.D., in the Journal ofBehavioral Medicine 34, pp. 92-101, 2011. n KB

Brief psychotherapy helps multiple sclerosis patients with insomnia and depression

A new study reveals regionaldifferences in physicians’recommendations of implantablecardioverter-defibrillators (ICDs) forpatients considered eligible bycurrent guidelines. It found thatphysicians in regions with low ICDuse were no less likely torecommend ICDs to eligiblepatients. However, physicians inregions with high ICD use weremore likely to recommend thedevice for patients who may receivelimited benefit, such as frail andelderly patients with lifeexpectancies of less than 1 year.

Researchers surveyed activemembers of the American Collegeof Cardiology, with 1,210responding. Cardiologists wereasked to agree or disagree withstatements about ICD use and costs,ability to enable the patient to livelonger, improved/decreased qualityof life, and recommending ICDs toall eligible patients.

Regardless of region, respondentswere likely to agree that an ICDenables a patient to live longer. Theywere also likely to recommend anICD to patients who meet eligibility

guidelines. The study was supportedin part by the Agency for HealthcareResearch and Quality (HS16964).

See “Regional variations inphysicians’ attitudes andrecommendations surroundingimplantable cardioverter-defibrillators,” by Dan D. Matlock,M.D., Jean S. Kutner, M.D.,M.S.P.H., Caroline B. Emsermann,M.S., and others in the April 2011Journal of Cardiac Failure 17(4),pp. 318-324. n KB

Study finds regional differences in physicians’ recommendations ofimplantable cardioverter-defibrillators


Helping medical practices implement electronichealth records (EHRs) can give the members of thepractice greater ability to create patient lists (knownas registries) sorted by diagnosis, laboratory testresults, or medication use, a new study finds. Theability to create patient registries allows practitionersto quickly identify patients overdue for followup visitsor lab tests, those with abnormal lab results, or thosetaking a medication that requires frequent monitoring.

The researchers analyzed responses from 163physicians in 134 practices to surveys sent before andafter a State pilot program to assist practices inadoption and use of robust EHR software. They foundthat the physicians were equally able to generate adiagnosis registry before and after the intervention (89percent in 2005 and 88 percent in 2009). However, theability of the physicians to generate a laboratoryresults registry increased markedly (from 44 percentin 2005 to 78 percent in 2009), as did the ability togenerate a medication registry (from 33 percent in

2005 to 83 percent in 2009). The researchers suggestthat implementation of EHR had little effect ondiagnosis registries, because most billing software hadthis ability, even in 2005.

The study also found that high users of EHR weremore likely than low users to generate lists of diabetespatients with overdue tests (55 vs. 30 percent) orabnormal lab results (51 vs. 37 percent), but not listsof patients with overdue visits (60 vs. 51 percent).However, high and low EHR users did not differ ingenerating any of these three lists for patients withcoronary artery disease. The study was funded in partby the Agency for Healthcare Research and Quality(HS15397).

More details are in “Massachusetts E-health projectincreased physicians’ ability to use registries, andsignals progress toward better care,” by MarshallFleurant, M.D., Rachel Kell, M.P.H., Jennifer Love,M.D., and others in the July 2011 Health Affairs30(7), pp. 1256-1264. n DIL

Physicians who use electronic health records more intensively are morelikely to use patient registries to improve care

Health Information Technology

Rates of childhood obesity arerising, including in ruralcommunities. Obesity is a complexcondition requiring in-depthlifestyle and psychosocialinterventions that may be difficultto access in rural areas. A newstudy suggests that telemedicinehas potential to deliver childhoodobesity interventions to parents andtheir children. It found that parentswere as satisfied with telemedicinecare as they were with face-to-facemanagement of their child’s obesity.

California researchers comparedtwo groups of children who hadreceived consultation for obesity ata university-affiliated pediatric

weight-management clinic. Onegroup received traditional, face-to-face care from a pediatricianspecializing in weight managementand a dietician at the clinic. Theother group of children receivedtheir care from the clinic’spediatrician and dietitian viatelemedicine at rural and remoteclinics.

All parents then receivedquestionnaires that asked aboutvarious aspects of the care theirchildren received, such as providerlistening skills, parentalunderstanding of instructions, andhow comfortable parents were atdiscussing health concerns. The

study evaluated surveys of 10telemedicine visits and 15 face-to-face visits. Overall satisfactionscores were similar for both groupsof parents. This includedsatisfaction with the consultinghealth care provider. There was onenotable difference in thetelemedicine group. These parentsrated the telemedicine visits slightlylower than face-to-face parentswhen it came to providersexplaining things about their child’shealth in an easy-to-understandmanner. Parents who hadparticipated in telemedicine visitsin the past said they would be

continued on page 11

Parents are satisfied with telemedicine care for their child’s obesity


Child/Adolescent Health

Telemedicine carecontinued from page 10

happy to participate in futuretelemedicine consultations. Thestudy was supported in part by the

Agency for Healthcare Researchand Quality (HS18567).

See “Comparison of parentsatisfaction with care for childhoodobesity delivered face-to-face andby telemedicine,” by Kirk W.

Mulgrew, M.D., Ulfat Shaikh,M.D., M.P.H., M.S., and JasmineNettiksimmons, M.A., in the June2011 Telemedicine and e-Health17(5), pp. 383-387. n KB

Use of medical diagnostic imaging is not uncommonamong children under 18 years old. The highest ratesare in children older than 10, with frequent use ininfants younger than 2 years as well, reveals a newstudy. This is worrisome, note the researchers. That’sbecause infants and children exposed to ionizingradiation are at higher risk of developing cancers andother problems than adults, because their longerexpected lifespan means a longer time for adverseeffects to emerge, and their rapidly developing tissuesare more sensitive to radiation damage. The researchersfound that 42.5 percent of the 355,088 children studiedunderwent 436,711 imaging procedures during the 3-year study period. A fourth of the children underwenttwo or more such procedures, while 16 percentunderwent 3 or more procedures.

Children older than 10 years had the highest rate of allimaging procedures involving ionizing radiation(506–512 per 1,000 person-years), with high rates ofuse in infants younger than 2 years as well. Plain x-raysaccounted for 84.7 percent of imaging proceduresperformed. However, computed tomographic (CT)scans, which are linked to substantially higher doses ofradiation, were commonly used—accounting for 11.9percent of all imaging procedures during the studyperiod.

Overall, 7.9 percent of children received at least one CTscan and 3.5 percent received two or more. Childrenunder 2 years old accounted for 1,675 of the patientsundergoing CT imaging for 27 CT scans per 1,000person-years. Nearly 40 percent of children received atleast 1 plain x-ray, with children age 10 years and abovehaving the highest rates of use (395-441 x-rays per1,000 person-years). While the rate of plain x-rays washighest for the chest (68 procedures per 1,000 person-years), the CT imaging rate was highest for the head(15 procedures per 1,000 person-years).

The findings were based on inpatient and outpatientclaims data for 355,088 children enrolled in a largehealth care plan from the beginning of 2005 through theend of 2007. The study was funded in part by theAgency for Healthcare Research and Quality(HS18781).

More details are in “Use of medical imaging procedureswith ionizing radiation in children. A population-basedstudy,” by Adam L. Dorfman, M.D., Reza Fazel, M.D.,M.Sc. Andrew J. Einstein, M.D., Ph.D., and others inthe May 2011 Archives of Pediatrics and AdolescentMedicine 165(5), pp. 458-464. n DIL

Children are commonly exposed to ionizing radiation from medicaldiagnostic imaging procedures

During the peak of the April to July2009 H1N1 influenza pandemic,there was a substantial 29 percentincrease in the number of pediatricemergency department (ED) visitsand a 51 percent increase ininfluenza-related illness (IRI) visits,according to a new study. Overall,

61 percent—14 of 23 children’shospitals studied—experienced asurge in ED volume, with anaverage increase of 49 ED visits perED day. Surge patients with IRIwere less ill than expected. Forexample, the percentage of childrenadmitted from the ED to intensive

care unit (ICU) beds and non-ICUbeds were 56 percent and 30percent lower than expected.Overall patient acuity alsoremained low, with only 5 percentof children hospitalized, and only


Pediatric emergency department visits surged during the 2009 H1N1 flupandemic, but few children were hospitalized


Pediatric emergency visitscontinued from page 11

0.01 percent requiring mechanicalventilation.

Higher-than-expected ED IRI visitswere seen for children 2 to 17 yearsold (highest for ages 9 to 17),females, Hispanics, the insured, andthose with asthma. Lower-than-expected ED-IRI visits were seenfor children under age 2, theuninsured, those with immunedeficiencies or cardiovasculardisease, and those in the MiddleAtlantic region.

Marion R. Sills, M.D., M.P.H., ofthe University of Colorado Schoolof Medicine, and colleagues useddata from the Pediatric HealthInformation System, whichcontains demographic and healthcare resource utilization data for 41nonprofit children’s hospitals acrossthe U.S. Twenty-three of thehospitals had ED data availablecontinuously from 2004 through2009, permitting calculation ofexpected utilization prior to thepandemic. Overall, the 23 hospitalsreported 390,983 ED visits and

88,885 ED-IRI visits during the 14-week study period (April–July2009). The study was funded in partby the Agency for HealthcareResearch and Quality (HS16418).

More details are in “Resourceburden at children’s hospitalsexperiencing surge volumes duringthe Spring 2009 H1N1 influenzapandemic,” by Dr. Sills, MatthewHall, Ph.D., Harold K. Simon,M.D., M.B.A., and others in theFebruary 2011 AcademicEmergency Medicine 18(2), pp.158-166. n DIL

An annual report of trends in children’s health carebetween 2000 and 2007 reveals that the rate ofhospital discharges for children 15 to 17 years olddeclined by 7.8 percent. This was primarily due to a15.8 percent decline in the rate of pregnancy anddelivery discharges for girls of that age. Yet the rate ofhospitalizations for skin infections doubled to 9 per10,000 children during this period, which coincidedwith the first reports of community-acquired,methicillin-resistant Staphylococcus aureus (MRSA).

The composite rate for hospital discharges for asthmaand short-term complications of diabetes amongchildren 5 to 17 years declined by 18.5 percent duringthe period. Children in the lowest-income ZIP codeshad persistently higher rates of admission for theseconditions. Hospital cost per discharge grew by anannual average of 4.5 percent, and Medicaid becamean increasingly important payer for children’s hospitalcare relative to private insurance. Nevertheless, trendswere not the same in all types of hospitals, all regions,or income categories.

The report was compiled by the Agency forHealthcare Research and Quality (AHRQ)researchers, Bernard Friedman, Ph.D., TerceiraBerdahl, Ph.D., and Roxanne Andrews, Ph.D., and

colleagues. Their findings were based on data fromAHRQ’s Medical Expenditure Panel Survey andHealthcare Cost and Utilization Project, whichincluded 9 indicators of patient safety for children inhospital care. Several measures of patient safetyimproved—the rates of postoperative sepsis,iatrogenic (care-caused) pneumothorax, and selectedinfections due to medical care declined by 14.2percent, 17.8 percent, and 23.5 percent, respectively.These and other safety indicators are some of themany Quality Indicators (QIs) developed by AHRQ,which measure health care quality using readilyavailable hospital inpatient administrative data. TheQIs can be used to highlight potential qualityconcerns, identify areas that need further study andinvestigation, and track changes over time. For moreinformation on AHRQ’s QIs, go towww.qualityindicators.ahrq.gov.

More details are in “Annual Report on Health Carefor Children and Youth in the United States: Focus ontrends in hospital use and quality,” by Dr. Friedman,Dr. Berdahl, Lisa A. Simpson, M.D., B.Ch., M.P.H.,and others in the July/August 2011 AcademicPediatrics 11(4), pp. 263–279. Reprints (PublicationNo. 11-R061) are available from the AHRQPublications Clearinghouse.* n DIL

Recent trends in hospital use by children and youths are a mixed bag—lower for teen pregnancies, much higher for skin infections


Agency News and Notes

Septicemia, an illness caused byblood infections with bacteria suchas E. coli and methicillin-resistantStaphylococcus aureus, was thesingle most expensive conditiontreated in U.S. hospitals at nearly$15.4 billion in 2009, according tothe latest News and Numbers fromthe Agency for Healthcare Researchand Quality (AHRQ). Data includecases of septicemia acquired withinthe community and during hospitalstays. The Federal agency alsofound that:

• The number of hospital staysprincipally for septicemia morethan doubled between 2000 and2009 (337,100 admissions and836,000 admissions,respectively), making it the sixth

most common principal reasonfor hospitalization in 2009.

• Complication resulting from adevice, implant, or graft was themost common reason for thesehospitalizations, representing oneof every five septicemia-relatedstays.

• The in-hospital death rate forsepticemia was 16 percent in2009—more than eight times ashigh as for all other hospitalstays.

• More than half of all patientshospitalized for septicemia wereelderly; about 14 percent were 85and older and nearly 40 percentwere 65 to 84. Some 27 percentof cases were in patients age 45

to 64, nearly 11 percent were inpatients age 18 to 44, and only1.6 percent were in children age1 to 17.

This AHRQ News and Numberssummary is based on data fromStatistical Brief #122, Septicemia inU.S. Hospitals, 2009 (www.hcup-us.ahrq.gov/reports/statbriefs/sb122.pdf). The report uses data from theNationwide Inpatient Sample. Forinformation about this AHRQdatabase, go to www.ahrq.gov/data/hcup/datahcup.htm. For otherinformation, or to speak with anAHRQ data expert, please contactLinwood Norman [email protected] orcall (301) 427-1248. n

Blood infections most costly hospital care in 2009

The Agency for Healthcare Research and Qualityreleased a second report that highlights the progressthat has been achieved by hospitals taking part in anational effort to reduce the incidence of central line-associated bloodstream infections (CLABSIs) byimplementing a Comprehensive Unit-based SafetyProgram (CUSP). Eliminating CLABSI: A NationalPatient Safety Imperative-Second Progress Report onthe National On the CUSP: Stop BSI Project providesan update on the impact of the project and the numberof State hospital associations, hospitals, and hospitalteams that are implementing the clinical and safety

culture changes proven to reduce CLABSI. Adultintensive care units included in this report are drawnfrom 32 States and territories and more than 75hospitals. This is an increase to 10 States and 400hospitals since November 2010. These units havereduced their CLABSI rates by an average of 33percent. As of November 2010, CLABSI rates haddecreased by an average of 35 percent, indicating ratesare continuing to decrease but at a marginally slowerrate. You can access the report atwww.ahrq.gov/qual/clabsiupdate. n

Updated report highlights hospitals’ progress in reducing bloodstreaminfections


“Questions are the Answer,” a newinitiative from the U.S.Department of Health and HumanServices’ Agency for HealthcareResearch and Quality (AHRQ) andthe Ad Council, encouragesclinicians and patients to engage ineffective two-way communicationto ensure safer care and betterhealth outcomes.

An original series of new videoson the AHRQ Web site,www.ahrq.gov/questions, featuresreal patients and cliniciansdiscussing the importance of

asking questions and sharinginformation.

The Web site also features newresources to help patients beprepared before, during, and aftertheir medical appointments. Theresources include:

• An interactive “QuestionBuilder” tool that enablespatients to create, prioritize, andprint a personalized list ofquestions based on their healthcondition.

• A brochure, titled “Be MoreInvolved in Your Health Care:

Tips for Patients,” that offershelpful suggestions to followbefore, during, and after amedical visit.

• Notepads to help patientsprioritize the top three questionsthey wish to address during theirappointment.

For more information, go towww.ahrq.gov/questions. Torequest free copies of the brochureand notepad, please call 1-800-358-9295 or [email protected]. n

AHRQ initiative encourages better two-way communication betweenclinicians and patients

There is little evidence to support the use of atypicalantipsychotic drugs for some treatments other thantheir officially approved purposes, even though manyclinicians continue to commonly prescribe these drugsfor so-called “off label” uses, according to a new reportfrom the Effective Health Care Program of the Agencyfor Healthcare Research and Quality (AHRQ). Atypicalantipsychotic medications, which are approved by theU.S. Food and Drug Administration for treatment ofschizophrenia, bipolar disorder and, in some cases,depression, are commonly prescribed to treat otherbehavioral conditions.

The report, which is an update of a 2007 report, foundlimited evidence to support the off-label use of certainatypical antipsychotic medications. Evidence wasstrongest, for example, for the off-label use ofrisperidone, olanzapine, and aripiprazole to treatsymptoms of dementia; quetiapine to treat generalizedanxiety disorder; and risperidone to treat obsessive-compulsive disorder. However, evidence was lacking to

justify the use of these and other atypical antipsychoticdrugs to treat substance abuse problems, eatingdisorders, or insomnia. Atypical antipsychoticmedications have been linked to some harms, includinga small increased risk of death in elderly patients withdementia, the report said.

Off-Label Use of Atypical Antipsychotics: An Updatefound further research is needed on the efficacy,effectiveness, and harms of off-label use of atypicalantipsychotics to determine which population subsets,stratified by age, gender, or race, could benefit fromsuch treatment. Additional research examining differingmedication dosages within populations and treatmentlength will also better guide clinician prescribingpractice.

You can read and download the full review and otherpublications from AHRQ’s Effective Health CareProgram Web site, www.effectivehealthcare.ahrq.gov. n

Off-label use of atypical antipsychotics not supported by evidence forsome conditions


For patients age 40 and over withchronic obstructive pulmonarydisease (COPD), hospitalreadmissions within 30 days ofinitial treatment were 30 percenthigher among blacks thanHispanics or Asians and PacificIslanders and about 9 percenthigher than whites in 2008,according to the latest News andNumbers from the Agency forHealthcare Research and Quality.

Based on data for patients whowere hospitalized with COPD in 15States during 2008:

• About 7 percent of patients werereadmitted within 30 daysprincipally for COPD, but 21percent were readmitted for anyhealth condition (all-causereadmission). There were

190,700 initial hospitaladmissions specifically to treatCOPD at an average cost of$7,100. The average readmissioncost principally for COPD was18 percent higher, at $8,400 perstay, but all-cause readmissionswere 50 percent more expensivethan the initial stay—$11,100.

• Readmissions were 22 percenthigher among patients from thepoorest communities than amongthose from the highest incomeareas.

• Readmissions were about 13percent higher among malepatients compared to females.

This AHRQ News and Numberssummary is based on data fromStatistical Brief #121:

Readmissions for ChronicObstructive Pulmonary Disease,2008 (www.hcup-us.ahrq.gov/reports/statbriefs/sb121.pdf). The report uses data from theState Inpatient Databases for 15States: Arkansas, California,Florida, Hawaii, Louisiana,Massachusetts, Missouri, Nebraska,New Hampshire, New York, SouthCarolina, Tennessee, Utah, Virginia,and Washington. For informationabout these AHRQ databases, go tohttp://www.ahrq.gov/data/hcup/datahcup.htm.

For additional information, or tospeak with an AHRQ data expert,please contact Linwood Norman [email protected] orcall (301) 427-1248. n

Hospital readmissions for COPD highest among black patients

A new research report from the Agency forHealthcare Research and Quality (AHRQ) concludesthat not enough evidence is available to determinewhether terbutaline administered by a subcutaneousinfusion pump can effectively and safely preventrepeat episodes of preterm labor. The report,produced by AHRQ’s Effective Health Care Program,also concludes that the adverse effects of terbutalinepump therapy for mothers or their children, in boththe short term and long term, are not fullyunderstood.

Terbutaline is approved by the Food and DrugAdministration for treatment of asthmaticbronchospasm, but is sometimes used “off-label” formaintenance tocolysis—the prevention of uterinecontractions to delay preterm labor. Earlier this year,

the Food and Drug Administration warned doctorsand consumers about safety risks from long-term useof terbutaline. This was based on reports from womenwho experienced serious side effects while using thedrug, although not from formal research trials.

AHRQ’s review found some evidence suggesting thatterbutaline pump therapy may prevent preterm labor,particularly for some populations, but the overallbenefit on the neonate and the safety for mother andchild is unclear. AHRQ’s full report, TerbutalinePump for the Prevention of Preterm Birth, includesresearch findings and identifies needs for futureresearch. You can read and download the full reviewand other publications from AHRQ’s Effective HealthCare Program Web site,www.effectivehealthcare.ahrq.gov. n

Uncertainty surrounds use of terbutaline to prevent preterm birth


Announcements

Medications known as disease-modifying anti-rheumaticdrugs, or DMARDs, appear to be more effective thanother treatments for children with arthritis, but there isnot enough evidence to support one kind of DMARDover another, according to a new report from the Agencyfor Healthcare Research and Quality (AHRQ).

The report compared DMARDs with conventionaltreatments such as ibuprofen and steroids. It found thatDMARDs are more effective than other treatments forimproving symptoms of juvenile idiopathic arthritis, butthe evidence was unclear about their long-termeffectiveness and safety.

The new comparative effectiveness review was preparedfor AHRQ’s Effective Health Care Program by the DukeEvidence-based Practice Center. To accompany the newreport, AHRQ also released summary publications forconsumers and clinicians explaining juvenile arthritis andoptions for treatment. The report and the companionguides are available at www.effectivehealthcare.ahrq.gov.

“The pain associated with juvenile arthritis can bedebilitating and even excruciating for young patients andis a major concern for both patients and their families,”said AHRQ Director Carolyn M. Clancy, M.D. “Until acure for juvenile arthritis is found, patients want the best,safest treatment to relieve that pain. This report will helppatients choose the right treatment together with theirclinician.”

Juvenile idiopathic arthritis, sometimes called juvenilerheumatoid arthritis, is a common childhood disease thataffects up to 400 out of every 100,000 children in theUnited States. Juvenile idiopathic (meaning it has noknown cause) arthritis is the most common form ofpersistent arthritis in children. It is marked by severe jointpain that is sometimes accompanied by a fever and rashand may cause long-term joint damage. There is no cure,

but the development of DMARDs over the past 25 yearshas significantly advanced treatment and control ofsymptoms.

The AHRQ review compared traditional treatments—which include ibuprofen and other nonsteroidal anti-inflammatory drugs and corticosteroids—withDMARDs. The report also compared different types ofDMARDs with each other. DMARDs work by interferingwith immune cells that cause joint inflammation. Theyare typically classified as either biologic drugs, whichtarget specific proteins in the immune system, ornonbiologic drugs, which act through a variety ofdifferent ways. In general, nonbiologic DMARDs areolder. The nonbiologic DMARD methotrexate, which hasbeen approved for treating arthritis since 1988, is oftenconsidered part of conventional treatment.

Researchers have hoped that the development of newerbiologic DMARDs might put arthritis into long-termremission for more patients. But there are manyunanswered questions about the safety of these drugs,especially for long-term use in children. The AHRQreport did not find evidence supporting the use ofbiologic DMARDs over nonbiologic DMARDs.

The report, Disease-Modifying Antirheumatic Drugs(DMARDs) in Children with Juvenile Idiopathic Arthritis(JIA), is a recent comparative effectiveness review fromAHRQ’s Effective Health Care Program. The EffectiveHealth Care Program helps patients, doctors, nurses,pharmacists and others choose the most effectivetreatments by sponsoring the development of evidencereports and technology assessments. These reports assistpublic- and private-sector organizations in their efforts toimprove the quality of health care in the United States.More information about the program can be found atwww.effectivehealthcare.ahrq.gov. n

Report finds DMARDs effective in treating juvenile arthritis

AHRQ Director Carolyn M. Clancy, M.D., offers advice to consumers in brief, easy-to-understand columns.The columns help consumers better navigate the health care system. To read Dr. Clancy’s advice column aboutresearch on women’s health issues to help you make more informed treatment choices, go towww.ahrq.gov/consumer/cc/cc090611.htm. n

AHRQ director helps consumers navigate the health care system in a newadvice column on the Web


A new technical brief,Multidisciplinary Pain Programs forChronic Noncancer Pain, isavailable from the Effective HealthCare Program of the Agency forHealthcare Research and Quality.This technical brief adds to theliterature on Multidisciplinary PainPrograms (MPPs) by describing thecurrent evidence base on thistreatment modality, highlightinggaps in the evidence, and outliningthe key issues facing patients andpractitioners considering treatment

options for chronic, noncancer pain.

The brief finds the most pressingproblems facing MPPs are decliningaccess to MPP services andproviders receiving inadequatereimbursement from third-partypayers. The brief also outlines thepossible role of MPPs as alternativesto widespread opioid therapy. Ithighlights the need for moreresearch related to these programs,including more detailed informationaddressing cost-effectiveness,options for patients who are refused

MPP treatment or who do notexperience relief, information on thedecrease in the number of availableprograms, the structural supportsneeded to increase access to MPPs,and more randomized studies withinthe United States.

To access this brief and learn moreabout the AHRQ’s Effective HealthCare Program and treatment optionsfor other health conditions visitwww.effectivehealthcare.ahrq.gov. n

Brief on multidisciplinary pain programs for chronic noncancer pain available

A new review, Comparative Effectiveness ofManagement Strategies for Gastroesophageal RefluxDisease: Update, updates the Agency for HealthcareResearch and Quality’s 2005 review that compared theeffectiveness of different treatment options for adultswith gastroesophageal reflux disease (GERD). Theupdate finds proton pump inhibitors to be superior tohistamine type 2 receptor antagonists for the treatmentof chronic GERD. Also, laparoscopic fundoplication

appears to be as effective as medication in improvingGERD symptoms, but serious adverse effects are morecommon after surgery. Despite the availability ofmedical, surgical, and endoscopic options, optimalmanagement strategies remain unsettled.

You can read and download the full review update,summaries, and other publications from AHRQ’sEffective Health Care Program Web site,www.effectivehealthcare.ahrq.gov. n

Updated GERD research reviews and summaries available

AHRQ’s new white paper, MethodologicalConsiderations in Generating Provider PerformanceScores, is intended to help Chartered Value Exchanges(CVEs) and other organizations involved in publicreporting of health care provider performanceinformation. The paper offers guidance on identifyingthe sequence of decisions involved in public reportingand the range of options for each of these decisions.The paper addresses decisions encountered whenworking on six key tasks: negotiating consensus ongoals and value judgments of performance reporting;selecting the measures for evaluating providerperformance; identifying data sources and aggregatingperformance data; checking data quality andcompleteness; computing provider-level performancescores; and creating reports.

The paper also helps organizations involved in publicreporting of health care provider performanceinformation avoid the problem of inconsistent reports

based on the same data. Variances in methodologicaldecisions by different organizations using the sameexact data can produce divergent performance reports,thereby sending conflicting messages to patients andproviders. AHRQ’s new white paper helps usersunderstand different types of measurement error, howsources of error may enter into the construction ofprovider performance scores, and how to mitigate orminimize the risk of misclassifying a provider. Thepaper also includes a summary of methodologicaldecisions made by a sample of CVE stakeholders.

Developed for AHRQ by Mark W. Friedberg, M.D., andCheryl L. Damberg, Ph.D., of RAND Corporation, thewhite paper is intended to support ongoing dialogue ondata and measurement decisions as the Nationcontemplates the future of public reporting forconsumers. For details, go to http://www.ahrq.gov/qual/value/perfscoresmethods. n

New AHRQ white paper helps decisionmaking and consistency in publicreporting


Carson, A.P., DaJuanicia, N.H.,and Howard, D.L. (2010).“Weight change and functionallimitations among older adults inNorth Carolina.” (AHRQ grantHS13353). Journal of CommunityHealth 35, pp. 586-591.This study of adults age 65 andolder in North Carolina finds thatchanges in weight are associatedwith a number of functionallimitations that affect activities ofdaily living. Both weight gain (>8percent increase in weight from age50) and loss (>8 percent decrease)were associated with severe (4 ormore) functional limitationscompared with weight maintainers(<8 percent change).

Chetty, V.K., Culpepper, L.,Phillips, R.L. (2011, May). “FPslower hospital readmission ratesand costs.” Graham CenterPolicy One-Pager. AmericanFamily Physician 83(9), pp.1053A.A new study finds that 30-dayreadmission rates for pneumonia,heart attack, and heart failuredecrease as the number of familyphysicians increase. The study isbased on data from the MedicareCompare Hospital Database thatincludes readmission rates for 4,459hospitals and on data from the AreaResource File that shows thenumber of physicians perpopulation at the county level.

Chin, M.H., Goldmann, D. (2011,January).“Meaningful disparitiesreduction through research andtranslation programs.” (AHRQgrant T32 HS00063). Journal of

the American Medical Association305(4), pp. 404-405. The authors describe an approachfor making equity an integralcomponent and explicit requirementof funding announcements aimed atimproving quality of care andoutcomes. The approach makesdisparities a key goal in thedevelopment and rollout of a grantinitiative and requires applicants toprovide a detailed description ofhow they will address the equity intheir conceptual, intervention, andanalytical models.

Clancy, C.M. (2011). “Kidney-related diseases and qualityimprovement: AHRQ’s role.”Clinical Journal of the AmericanSociety of Nephrology 6, pp. 1-3.Reprints (AHRQ Publication No.11-R077) are available fromAHRQ.*The author, director of the Agencyfor Healthcare Research andQuality (AHRQ), stresses thatAHRQ has done work relevant tothe broad area of clinicalnephrology by pinpointing wherequality problems lie, advancing theevidence base to do somethingabout them, and promoting patient-centered outcomes research to givepatients and clinicians tools tomake decisions about their care. Anumber of specific programs, tools,and products are described.

Cresswell, K.M., Bates, D.W.,Phansalkar, S., and Sheikh, A.(2011). “Opportunities andchallenges in creating aninternational centralizedknowledge base for clinical

decision support systems inePrescribing.” (AHRQ grantHS16970). BMJ Quality andSafety 20, pp. 625-630. Given the redundancies in local andnational developments related toclinical decision support systems(CDSSs) for ePrescribing, theauthors consider some of theopportunities and challenges inmoving towards a more concertedcollaborative international effort indeveloping and maintaining theknowledge base for these systems.They hope that their ideas willstimulate debate, since a centrallyshared resource could potentiallyresult in significant cost savingsfacilitating increased adoption andpenetration of CDSSinternationally.

Curtis, J.R., and Levy, M.M.(2011). “Improving the scienceand politics of qualityimprovement.” (AHRQ grantHS17715). Journal of theAmerican Medical Association305(4), pp. 406-407. The authors discuss the results ofan important study designed toevaluate the effectiveness of qualityimprovement efforts in community-based critical care units in Ontario.The goal of the multifacetedknowledge-transfer interventionwas to increase adherence to sixquality measures that have beendocumented to improve patientoutcomes. Improvement wasrelatively modest, withimprovements seen in only two ofsix measures.


Research Briefs


Research briefscontinued from page 18

Edmonds, B.T., Fager, C.,Srinivas, S., and Lorch, S. (2011).“Predictors of cesarean deliveryfor periviable neonates.” (AHRQgrant HS05696). Obstetrics andGynecology 118(1), pp. 49-56.A study testing for racial or ethnicdisparities in periviable cesareandelivery has found that women ofAfrican American, Hispanic, andother racial or ethnic groups weresomewhat less likely to undergocesarean delivery. However, theodds were not statistically differentfrom those of white women.Ultimately, maternal coexistingmedical conditions and pregnancycomplications were found to be thestrongest predictors of cesareandelivery.

Gonzales, A.A., Ton, T.G.N.,Garroutte, E.M., and others.(2010, Autumn). “Perceivedcancer risk among AmericanIndians: Implications forintervention research.” (AHRQgrant HS108534). Ethnicity andDisease 20, pp. 458-462.The researchers conducted arandom survey of 182 AmericanIndians to assess whetherknowledge of cancer risk factors,attitudes about cancer prevention,and family history of cancer wereassociated with perception of risk.They found that neither knowledgeof cancer risk factors nor attitudestoward cancer prevention wereassociated with risk perception.Perceived cancer risk wassignificantly associated with self-reported family history of cancer.

Haywood, C., Beach, M.C.,Bediako, S., and others. (2011).“Examining the characteristics

and beliefs of hydroxyurea usersand nonusers among adults withsickle cell disease.” (AHRQ grantHS 13903). American Journal ofHematology, pp. 85-87.The researchers surveyed theattitudes and beliefs of 94 adultswith sickle cell disease to comparecurrent and previous users ofhydroxyurea (HU) therapy withthose who had never used it. Theyfound that half of the never-usershad received no information aboutHU from any source and 85 percentof never-users thought that HUwould provide no improvement intheir condition.

Hodge, J.G., Anderson, E.D.,Kirsch, T.D., and Kelen, G.D.(2011). “Facilitating hospitalemergency preparedness:Introduction of a modelmemorandum of understanding.”(AHRQ grant HS14533). DisasterMedicine and Public HealthPreparedness 5, pp. 54-61.The authors discuss a modelmemorandum of understanding(MOU) that seeks to align regionalhospitals through advanceagreements on procedures ofmutual aid that reflect modernprinciples of emergencypreparedness and changing legalnorms in declared emergencies. TheMOU outlines essential principleson how to allocate scarce resourcesamong providers across regions.The model MOU, which can bemodified by hospitals depending ontheir needs and preferences, createsoptions for collaboration withoutsignificant legal obligations.

Krumholz, H.M., Lin, Z., Drye,E.E., and others. (2011). “Anadministrative claims measuresuitable for profiling hospital

performance based on 30-day all-cause readmission rates amongpatients with acute myocardialinfarction.” (AHRQ grantHS16929). Circulation:Cardiovascular Quality andOutcomes 34, pp. 243-252.The researchers present a model toproduce hospital-specific risk-standardized estimates of 30-dayreadmission rates after dischargefor an acute myocardial infarction.The hierarchical logistic regressionclaims-based model producesestimates that are excellentsurrogates for those produced froma medical record model. This modelis being used to publicly report thevariation in readmission ratesamong U.S. hospitals.

Kuna, S.T., Badr, S., Kimoff, J.,and others. (2011). “An OfficialATS/AASM/ACCP/ERSworkshop report: Researchpriorities in ambulatorymanagement of adults withobstructive sleep apnea.” (AHRQgrant HS17402). Proceedings ofthe American Thoracic Society 8,pp. 1-16.This workshop identified barrierspreventing incorporation ofportable monitor testing intoclinical management pathways anddetermined the research anddevelopment needed to addressthese barriers. Recommendationswere developed concerningresearch study design andmethodology that include the needto standardize technology, identifythe patients most appropriate forambulatory management, ensurepatient safety, and identify sourcesof research funding.




Manfredi, C., Cho, Y.I.,Warnecke, R., and others. (2011).“Dissemination strategies toimprove implementation of thePHS smoking cessation guidelinein MCH public health clinics:Experimental evaluation resultsand contextual factors.” (AHRQgrant HS10544). HealthEducation Research 26(2), pp.348-360.Using three disseminationstrategies, researchers tested theeffectiveness of disseminationinterventions to improveimplementation of smokingcessation guidelines in 12 Illinoismaternal and child health clinics.The three strategies were: coredissemination (a tested smokingcessation program), coredissemination plus telephonecounseling, and core disseminationwith both telephone counseling andoutreach visits to clinics. The sevenclinics showing experimentaleffectiveness were distinguished byclinic type and absence ofdisruptive events from the otherclinics.

Meissner, H.I., Klabunde, C.N.,Han, P.K., and others. (2011,July). “Breast cancer screeningbeliefs, recommendations, andpractices.” (AHRQ interagencyagreement with the NationalInstitutes of Health). Cancer 117,pp. 3101-3111.This study represents the firstnational assessment of primary carephysicians’ (PCPs) breast cancerscreening beliefs,recommendations, and practicessince 1989. It found that virtuallyall 1,212 PCPs surveyed reportedroutinely recommendingmammography, clinical breast

examinations, and breast self-examinations to their patients age40 and over. Eighty percent of thePCPs reported that mammographyfor average-risk women age 50 andover was very effective in reducingcancer mortality.

Ovretveit, J.C., Shekelle, P.G., Dy,S.M., and others. (2011). “Howdoes context affect interventionsto improve patient safety? Anassessment of evidence fromstudies of five patient safetypractices and proposals.” (AHRQContract No. 290-2009-10001).BMJ Quality and Safety 20, pp.604-610. Experience suggests that context isimportant for understanding whysome patient safety practices areimplemented successfully and aremore effective in someorganizations and regions and notin others. In a review of theliterature on five patient safetyinterventions, researchers foundlittle strong evidence of theinfluence of different contextfactors. However, the researchreviewed was not specificallydesigned to investigate contextinfluence.

Polivka, B.J., Casavant, M., andBaker, S.D. (2010). “Factorsassociated with healthcare visitsby young children for nontoxicpoisoning exposures.” (AHRQgrant HS15713). Journal ofCommunity Health 35(6), pp. 572-578.Over a 4-year period, 2,494children up to 5 years old inColumbus, Ohio, and itssurrounding area made visits tolocal emergency departments orurgent care centers to treatpoisonings. Poisoning exposures inthe study were primarily to

medication (77 percent), which apoison control center can generallyhelp parents handle by telephone.

Pronovost, P.J., and Goeschel,C.A. (2011, July). “Time to takehealth delivery researchseriously.” (AHRQ Contract No.290-06-0221 and AHRQ grantHS19934). Journal of theAmerican Medical Association306(3), pp. 310-311.The authors argue for increasedemphasis on research to improvethe delivery of health care, inaddition to research to create newtreatments. Such changes wouldmean bringing human factors andsystems engineers, sociologists,psychologists, and health servicesresearchers into academic medicalcenters to use their skills inimplementing basic biomedicalresearch in clinical settings. Theauthors suggest that health carefunders and researchers shouldsupplement hypothesis-testingresearch with outcome-optimizingresearch.

Quest, T.E., Asplin, B.R., Cairns,C.B., and others. (2011).“Research priorities for palliativeand end-of-life care in theemergency setting.” (AHRQgrant HS18114). AcademicEmergency Medicine 18, pp. e70-e76.This article proposes a researchagenda for studying the integrationof palliative care in the emergencydepartment setting. The agenda wasdeveloped by the Palliative CareWorkgroup, part of a conferenceconvened by the American Collegeof Emergency Physicians. Thegroup concluded that theintegration of palliative care into




routine emergency practice willrequire a paradigm shift in caredelivery.

Rattanaumpawan, P., Tolomeo, P.,Bilker, W.B., and others. (2011).“Risk factors for fluoroquinoloneresistance in Enterococcusurinary tract infections inhospitalized patients.” (AHRQgrant 10399). Epidemiology ofInfection 139, pp. 955-961. This study is the first studyspecifically designed to identify riskfactors for fluoroquinolone (FQ)resistance in healthcare-acquiredurinary tract infections. It found thatindependent risk factors for FQresistance included cardiovasculardiseases; hospitalization within thepast 2 weeks; hospitalization on amedicine service; and recentexposure to beta-lactamaseinhibitors, extended spectrumcephalosporins, FQs, andclindamycin.

Rivera-Soto,W.T., Rodriguez-Figueroa, L., and Calderón, G.(2010, December). “Prevalence ofchildhood obesity in arepresentative sample ofelementary school children inPuerto Rico by socio-demographic characteristics,2008.” (AHRQ grant HS14060).Puerto Rico Health ScienceJournal 29(4); pp. 357-363.Elementary school children inPuerto Rico have higher rates ofoverweight and obesity than isobserved among Hispanic childrenin the United States, according to anew study. Overall, 27 percent ofthe students fit the criteria forobesity compared with 19 percentfor non-Hispanic whites or blacks inthe U.S., and 25 percent for allHispanic children in the U.S.

Another 11 percent of Puerto Ricanelementary school children wereoverweight.

Sarkar, I.N., Butte, A.J., Lussier,Y.A., and others. (2011).“Translational bioinformatics:Linking knowledge acrossbiological and clinical realms.”(AHRQ grant HS19913). Journalof the American MedicalInformatics Association 18, pp.354-357.The authors present translationalbioinformatics (TBI) as a disciplinethat builds on the successes ofbioinformatics and healthinformatics for the study ofcomplex diseases. A major goal ofTBI is to develop informaticsapproaches for linking acrosstraditionally disparate data andknowledge sources, enabling boththe generation and testing of newhypotheses. Projects involving TBIapproaches to integrating biologicaland clinical data are alreadyunderway.

Schiff, G.D., Galanter, W.L.,Duhig, J., and others. (2011,September). “Principles ofconservative prescribing.”(AHRQ grant HS16973). Archivesof Internal Medicine 171, pp.1433-1440.The authors, who are physicians,pharmacists, and educators, haveidentified principles for safer andmore evidence-based prescribing.These principles urge clinicians tothink beyond drugs; practice morestrategic prescribing; maintainheightened vigilance regardingadverse effects; and exercise cautionand skepticism regarding newdrugs. Taken together, theseprinciples represent a shift in theprescribing paradigm from “newerand more is better” to “fewer andmore time-tested” is better.

Schuur, J.D., Baugh, C.W., Hess,E.P., and others. (2011). “Criticalpathways for post-emergencyoutpatient diagnosis andtreatment: Tools to improve thevalue of emergency care.”(AHRQ grant HS181134).Academic Emergency Medicine 18,pp. e52-e63.This article reports the results of aworking group charged to addressmethods to improve value in post-emergency department (ED)transitions. The working group waspart of a conference convened bythe American College of EmergencyPhysicians. The authors describe amodel of post-ED pathways,describe the role of pathways inemergency care, list commondiagnoses that are amenable tocritical pathways in the outpatientsetting, and propose a researchagenda.

Seidling, H.M., Phansalkar, S.,Seger, D.L., and others. (2011).“Factors influencing alertacceptance: A novel approach forpredicting the success of clinicaldecision support.” (AHRQ grantHS11169). Journal of theAmerican Medical InformaticsAssociation 18, pp. 479-484. The researchers attempted toquantify the impact of some of themajor human factors issues thatmay affect computer alertacceptance by specification of threevariables—the display of the alert,the textual information, and theprioritization of the alerts. The alertdisplay most strongly correlatedwith alert acceptance. The textualinformation did not influence thefrequency of alert acceptance. Onlydrug-drug interaction alerts wereincluded in the study.




Sloane, P.D., Wroth, T., Halladay,J., and others. (2011,July/August). “How eightprimary care practices initiatedand maintained qualitymonitoring and reporting.”(AHRQ Contract No. 209-07-10014). Journal of the AmericanBoard of Family Medicine 24(4),pp. 360-369. To better understand the process bywhich practices initiate, support,and maintain performance datareporting, the researchers conducteda study of 8 diverse practices, eachof which was participatingsuccessfully in one or more of 34performance-data-reportingprograms. They found thatimplementing and sustaining qualityreporting requires a complex set ofmotivators, facilitators, andstrategies to overcome inherentbarriers that can present themselvesto practices seeking to implementchange.

Tarnutzer, A.A., Berkowitz, A.L.,Robinson, K.A., and others.(2011, June). “Does my dizzypatient have a stroke? Asystematic review of bedsidediagnosis in acute vestibularsyndrome.” (AHRQ grantHS17755). Canadian MedicalAssociation Journal 183(9), pp.E571-E592).The most common causes of acutevestibular syndrome are vestibularneuritis and ischemic stroke in thebrainstem or cerebellum, accordingto a review of 10 studies describing392 patients. These studies focusedlargely on bedside test of vestibularand oculomotor function, asassessed through care examinationof eye movements. Expert opinionsuggests a combination of focused

history and physical examination asthe initial approach to determiningif there is a stroke.

Taylor, S.L., Dy, S., Foy, R., andothers. (2011). “What contextfeatures might be importantdeterminants of the effectivenessof patient safety practiceinterventions?” (AHRQ ContractNo. 290-09-1001). BMJ Qualityand Safety 20, pp. 611-617.In order to identify whichcontextual factors are likely to havethe most relevance to and impact ona diverse range of patient safetypractices, the authors used aniterative process of formal groupdiscussions with a 22-membertechnical expert panel. The panelidentified four broad domains ofcontextual features important topatient safety practiceimplementations: safety culture,teamwork and leadershipinvolvement, structuralorganizational characteristics,external factors, and availability ofimplementation and managementtools.

Tschampi, C., Bernardo, J.,Garvey, T., and Garnick, D. (2011,July). “The need for performancemeasures on testing for latenttuberculosis infection in primarycare.” (AHRQ grant T32HS00062). The Joint CommissionJournal on Quality and PatientSafety 37(7), pp. 309-316.Using a National Quality Forum-endorsed measure that calculatesthe rate of tuberculosis screening inpersons with HIV as a model, theauthors propose a set ofperformance measures focused onthe rate of persons at high risk ofTB who are tested for latenttuberculosis infection and have thetest read. The proposed

performance measures will addressa neglected secondary preventionopportunity and will be consistentwith national priorities and healthreform.

Webb, J.R., Feinglass, J., Makoul,G., and others. (2010). “Canelectronic health records helpimprove patients’ understandingof medications?” (AHRQ grantHS17220). The American Journalof Managed Care 16(12), pp. 919-922.Researchers have come up with anovel approach that incorporates thebenefits of electronic health recordswith direct patient communication.Patients receive a computer-generated list of their medicationsto review in the waiting roombefore the physician visit. Aftertheir visit, patients were asked ifthey were still taking eachmedication in the mannerprescribed and if they had anyproblems or concerns with it.Nearly half of patients expressedproblems, concerns, or questionsabout their current medications. Useof the list was an opportunity toeducate them.

Welsh, C.A., Flanagan, M.E.,Hoke, S.C., and others. (2011).“Reducing health care-associatedinfections (HAIs): Lessonslearned from a nationalcollaborative of regional HAIprograms.” (AHRQ Contract No.290-06-0001). American Journalof Infection Control, pp. 1-8. In 2007, the Agency for HealthcareResearch and Quality (AHRQ)created the AHRQ Healthcare-Associated Infections (HAI)initiative, which funded fiveregional collaboratives. These




collaboratives consisted of 33hospitals with a range of hospitaltypes and geographic locations.This article summarizes thesuccesses, challenges, and lessonslearned that were common to thesecollaboratives.

Werner, R.M., Konezka, R.T.,Stuart, E.A., and others. (2011,April). “Changes in patientsorting to nursing homes underpublic reporting: Improvedpatient matching or providergaming?” (AHRQ grantHS16478). Health ServicesResearch 46(2), pp. 555-571.Public reporting of nursing homequality does appear to influence thetype of patient going to a skilled

nursing facility, the researchersfound—although they could notrule out that some providers aregaming the system by reducing thedegree of pain or delirium reportedat patient admission. The studycompared the percentages of short-stay patients at an SNF withoutmoderate to severe pain, withoutdelirium, and whose walkingremained independent or improved.n

Healthcare 411AHRQ’s Audio Podcast Series

Healthcare 411 is a free, online resource featuring AHRQ research incritical health care areas, such as:

• Comparative effectiveness

• Patient safety

• Preventive health care

One-minute consumer podcasts are available in both English and Spanish.

Listen online or subscribe to have podcasts sent directly to you.

For more information, visit healthcare411.ahrq.gov.

Follow AHRQ news on TwitterAHRQ uses Twitter to broadcast short health messages(“tweets”) that can be accessed by computer or mobile phone.You can follow AHRQ’s news releases on twitter athttp://twitter.com/AHRQNews.

To view all of AHRQ’s social media tools, including emailupdates, podcasts, and online videos, go towww.ahrq.gov/news/socialmedia.htm.

U.S. Department ofHealth and Human Services

Agency for Healthcare Research and QualityP.O. Box 8547Silver Spring, MD 20907-8547

Official BusinessPenalty for Private Use $300

Most AHRQ documents are available free of chargeand may be ordered online or through the Agency’sClearinghouse. Other documents are available fromthe National Technical Information Service (NTIS).To order AHRQ documents:

(*) Available from the AHRQ Clearinghouse:

Call or write:AHRQ Publications ClearinghouseAttn: (publication number)P.O. Box 8547Silver Spring, MD 20907800-358-9295703-437-2078 (callers outside theUnited States only)888-586-6340 (toll-free TDD service;hearing impaired only)

To order online, send an email to:[email protected]

For a print subscription to Research Activities:

Send an email to [email protected] with “Subscribe to Research Activities” in the subject line. Be sure to include your mailingaddress in the body of the email.

Access or subscribe to Research Activitiesonline at www.ahrq.gov/research/resact.htm.

AHRQ Pub. No. 12-RA002November 2011

ISSN 1537-0224

Ordering Information

Scan with your mobiledevice’s QR Code Readerto access or subscribe to AHRQ’s ResearchActivities.

November 2011 Research Activities - AHRQ Archive- … · · 2014-09-18conference theme of...

Documents

Transcript of November 2011 Research Activities - AHRQ Archive- … · · 2014-09-18conference theme of...