Research Activities, November 2010: HIV/AIDS Research: Internet-based personal health records helpful to most HIV/AIDS patients who used them

HIV/AIDS Research
Internet-based personal health records helpful to most HIV/AIDS patients who used them

Public health records (PHRs) are a free, secure, Internet-based application that allows patients to retrieve comprehensive information such as laboratory test results and to share their health information with providers. Clinicians may use the application to document and verify demographics, diagnoses, medications, and laboratory data. A new study shows that the majority of HIV/AIDS patients who used the PHR at a San Francisco General Hospital HIV/AIDS clinic found it helped them manage their disease.

The researchers activated a session tracking tool in order to measure online PHR use and added a 25-item evaluation survey to the PHR. Session usage was tracked for 136 persons, with the median number of sessions being 7 and the median session length being 4 minutes. Thirty-eight percent of this group completed the 25-item survey. Of these, more than 80 percent agreed that the PHR helped them manage their medical problems, prepared them better for their visits, and helped them take charge of their health care.

The most popular page contained laboratory values, lists of medical conditions, medication lists, and links to information about health conditions. The finding that nearly a third of patients did not agree that the information in their PHR was confidential was surprising. It is not clear whether this concern impacted patients' PHR use. The PHR, known as "myHERO," was made available at the HIV/AIDS clinic between March 2007 and December 2008. In this period, 221 of 3,760 patients registered for their online PHR account. Compared with the entire clinic, these initial users were more likely to be white, male, non-Hispanic, on antiretroviral medications, and have better control of their HIV infection.

The researchers believe that this project demonstrated that HIV/AIDS patients receiving care in a safety-net setting will choose to create, activate, and use a PHR. The study was supported in part by the Agency for Healthcare Research and Quality (HS17787).

See "Personal health records in a public hospital: Experience at the HIV/AIDS clinic at San Francisco General Hospital," by James S. Kahn, M.D. Joan F. Hilton M.D., T. Van Nunnery, and others in the Journal of the American Medical Informatics Association 17, pp. 224-228, 2010.

Research Activities, November 2010: HIV/AIDS Research: Internet-based personal health records helpful to most HIV/AIDS patients who used them

Research Activities, November 2010: Women's Health: 9/11 attacks may have caused miscarriages of male fetuses

Women's Health
9/11 attacks may have caused miscarriages of male fetuses

The odds of having a male baby tend to fall after a natural or social disaster, research has shown. The communal bereavement hypothesis may be one explanation for this drop. It asserts that the widespread distress that occurs after a disaster can also affect individuals, like pregnant women, who have never met the victims of the disaster. For pregnant women, this stress can lead to production of corticosteroids that adversely affect male more than female fetuses, suggests a new study.

Researchers from the University of California at Irvine found that the events of September 11, 2001, led to a rise in miscarriages of male fetuses. Using 1996 to 2002 fetal death data files from the National Vital Statistics System, which records fetal deaths at 20 weeks or more, and birth certificate data from the National Vital Statistics System, the authors found that the odds of male fetal death increased unexpectedly in the United States (except for California) in September 2001. Further, the ratio of males expected to be born in December 2001 fell below expected values.

These findings suggest that the physiological response pregnant women experience after tragedies can threaten the gestation of male fetuses and serve as an indicator of how pregnant women react to societal stressors, the authors state. This study was funded in part by the Agency for Healthcare Research and Quality (T32 HS00086).

See "Male fetal loss in the U.S. following the terrorist attacks of September 11, 2001," by Tim A. Bruckner, Ph.D., Ralph Catalano, Ph.D., M.R.P., and Jennifer Ahern, Ph.D., M.P.H., in the May 25, 2010 BMC Public Health 10, pp. 273.

Research Activities, November 2010: Women's Health: 9/11 attacks may have caused miscarriages of male fetuses

Research Activities, November 2010: Outcomes/Effectiveness Research: Hospital report cards on coronary bypass surgery are more accurate when based on 2-year data

Outcomes/Effectiveness Research
Hospital report cards on coronary bypass surgery are more accurate when based on 2-year data

The public reporting of hospital outcomes data is becoming increasing popular, particularly with the availability of the Internet. Patients and their doctors can now find information on how hospitals do when it comes to various conditions and treatments. One area where these "mortality report cards" have become popular is for coronary artery bypass graft (CABG) surgery. However, these data may not be accurate for predicting subsequent hospital performance depending on how old the data are. A new study finds that patients and doctors can rely on risk-adjusted outcomes reports based on 2-year-old data for CABG surgery as a strong predictor of future hospital performance. However, mortality report cards based on 3-year-old data are not that useful when it comes to identifying low-performance hospitals.

Researchers looked at hospital mortality measures at 37 hospitals in New York State that perform CABG surgery. Patients and doctors can access such data from the State's health department Web site. At the moment, CABG mortality report cards are based either on 2- or 3-year old data. An observed-to-expected mortality rate (O-to-E ratio) was used to determine the association between a hospital's past quality ranking and its future performance. The subsequent performance of hospitals classified as low-performance in their 3-year-old report cards was no different than that of hospitals classified as average hospitals. Hospitals identified as high-quality using 3-year-old data had a subsequent O-to-E ratio that was 19.4 percent lower than intermediate-quality hospitals. At the same time, hospitals identified as low-quality hospitals based on 3-year-old data had subsequent O-to-E ratios nearly identical to intermediate-quality hospitals. On the other hand, high-quality hospitals identified by using 2-year-old data had O-to-E ratios that were 16.8 percent lower than intermediate-quality hospitals. Also, there was a 31.8 percent higher O-to-E ratio for low-quality hospitals compared with intermediate-quality hospitals.

Based on these findings, the researchers recommend that New York State base its CABG surgery mortality rates on 2-year-old data. The study was supported in part by the Agency for Healthcare Research and Quality (HS16737).

See "How well do hospital mortality rates reported in the New York State CABG report card predict subsequent hospital performance?" by Laurent G. Glance, M.D., Andrew W. Dick, Ph.D., Dana B. Mukamel, Ph.D., and others in the May 2010 Medical Care 48(5), pp. 466-471.

Research Activities, November 2010: Outcomes/Effectiveness Research: Hospital report cards on coronary bypass surgery are more accurate when based on 2-year data

Research Activities, November 2010: Safety and Quality of Care: Cesarean delivery rates may not be a useful measure of obstetric quality

Safety and Quality of Care
Cesarean delivery rates may not be a useful measure of obstetric quality

There are currently no uniformly accepted measures of obstetrical quality. The risk-adjusted cesarean delivery rate historically has been a proposed quality measure. Earlier studies have suggested that both higher-than-expected and lower-than-expected rates may be associated with adverse maternal and neonatal outcomes. However, a new study suggests that risk-adjusted cesarean delivery rates may not be a useful measure of obstetric quality.

The researchers correlated risk-adjusted cesarean delivery rates with important maternal and neonatal outcomes in a study of 845,000 women from 401 hospitals in California and Pennsylvania. Their study found that 60 percent of 107 hospitals with lower-than-expected risk-adjusted cesarean delivery rates had a higher-than-expected rate of at least one of six adverse outcomes. This compared with 36.1 percent of the as-expected group and 19.6 percent of hospitals with higher-than-expected risk-adjusted cesarean delivery rates. On the other hand, hospitals with higher-than-expected cesarean delivery rates had similar rates of adverse outcomes as the as-expected hospitals on the other six delivery outcome measures.

The researchers stress that the lack of a correlation between a higher-than-expected cesarean delivery rate and adverse outcomes should not suggest that a higher-than-expected rate is desirable. Instead, it likely reflects an overuse of medical care and the performance of unnecessary procedures. What's more, the higher rate of c-sections did not result in improved outcomes. The study evaluated all the women from the hospitals and a smaller subset of women delivering single babies for the first time with no history of prior cesarean delivery. The results for the smaller group were similar to those of the larger group.

The outcome measures were a composite maternal outcome measure, a composite neonatal outcome measure, and four patient safety indicators from the Agency for Healthcare Research and Quality (AHRQ): birth trauma, injury with instrumented vaginal delivery, injury with noninstrumented vaginal delivery, and injury with cesarean delivery. This study was supported in part by the Agency for Healthcare Research and Quality (HS15696).

See "Evaluating risk-adjusted cesarean delivery rate as a measure of obstetric quality," by Sindhu K. Srinivas, M.D., Corinne Fager, M.S., and Scott A. Lorch, M.D. in the May 2010 Obstetrics and Gynecology 115(5), pp. 1007-1013.

Research Activities, November 2010: Safety and Quality of Care: Cesarean delivery rates may not be a useful measure of obstetric quality

Research Activities, November 2010: Safety and Quality of Care: AHRQ patient safety indicator can be used to identify cases of hospital-acquired collapsed lung

Safety and Quality of Care
AHRQ patient safety indicator can be used to identify cases of hospital-acquired collapsed lung

Pneumothorax (collapsed lung) is a relatively frequent and potentially serious complication of hospital procedures performed near the lung. The complication is most commonly associated with central vein catheter (CVC) placement, nasogastric tube insertion, and other procedures involving the neck or chest wall that introduce air into the space between the pleural membrane and the lung. Symptoms include sudden chest pains, shortness of breath, and rapid heart beat. A new study shows that the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) 6, Iatrogenic (hospital-acquired) Pneumothorax, can identify this complication from administrative data. It also suggests that many of these complications could have been prevented with use of real-time ultrasound guidance when performing CVC insertion and other procedures.

AHRQ has developed PSIs of potentially preventable complications using readily available administrative data. The indicators are based on diagnostic codes and have become a widely used tool to assess, monitor, and compare safety-related aspects of hospital performance. The study found that PSI 6 software, used to analyze hospital administrative data for 200 randomly selected cases of suspected pneumothorax from 28 hospitals, correctly identified 78 percent of cases that were confirmed on the basis of chart-abstracted data. CVC placement was found to be associated with 44 percent of the pneumothorax events (59 events). However, only five of these procedures used ultrasound guidance, which is known to reduce the risk of pneumothorax by more than half.

The findings were based on a retrospective study of a cross-section of records that met criteria for PSI 6 from a voluntary group of 47 hospitals in 29 States. However, only 28 of the hospitals had pneumothorax cases involving a hospital discharge between October 2005 and March 2007. The study was funded in part by the Agency for Healthcare Research and Quality (Contract No. 290-04-0020).

More details are in "Cases of iatrogenic pneumothorax can be identified from ICD-9-CM coded data," by Banafsheh Sadeghi, M.D., Ph.D., Ruth Baron, R.N., Patricia Zrelak, Ph.D., and others in the March 2010 American Journal of Medical Quality 25(3), pp. 218-224.

Research Activities, November 2010: Safety and Quality of Care: AHRQ patient safety indicator can be used to identify cases of hospital-acquired collapsed lung

Research Activities, November 2010: Safety and Quality of Care: Various factors affect providers' ability to identify spoken drug names

Safety and Quality of Care
Various factors affect providers' ability to identify spoken drug names

A number of drugs have similar sounding names. This can create confusion among health care providers, particularly when using the telephone for medication orders. In a new study, researchers found several factors that can affect how a provider hears, understands, and identifies drug names. These include voice signal-to-background noise ratios, familiarity with the drug name, prescribing frequency, and the similarity of drug names.

A total of 62 pharmacists, 74 family physicians, and 70 nurses were recruited for this study from annual meetings held during 2005. In addition, 43 nonmedical consumers from the general public also participated. The researchers selected 99 brand and 99 generic drug names to be used in the study. These names were then recorded using correct, clinical pronunciation. Participants sat at a computer with headphones. They were asked to repeat back the name of the drug they had heard. These were presented against a background of multitalker noise at three different signal-to-noise conditions. The responses were recorded. In a second step, they went to a different computer where they read aloud all of the drug names from words presented on the screen. They were also asked to rate how familiar they were with each drug name.

The ability of providers to accurately identify spoken drug names increased significantly as the signal-to-noise ratio increased (i.e., as the noise decreased). A provider's subjective familiarity with a name also increased their accuracy in identifying the correct drug name. If a drug was frequently prescribed at the national level, participants were more often able to identify it. In the case of clinicians but not lay people, the existence of similar sounding drug names decreased their ability to accurately identify a particular target drug name.

The researchers recommend that providers receiving telephone orders have the ability to increase the voice signal volume to minimize errors. Using noise-cancelling headphones or being in a quiet area can also help. Other strategies, such as reading back the name, spelling it out, and using both brand and generic names can assist in reducing confusion over spoken drug names. The study was supported in part by the Agency for Healthcare Research and Quality (HS11609).

See "Listen carefully: The risk of error in spoken medication orders," by Bruce L. Lambert, Ph.D., Laura Walsh Dickey, Ph.D., William M. Fisher, Ph.D., and others in the 2010 Social Science & Medicine 79, pp. 1599-1608.

Research Activities, November 2010: Safety and Quality of Care: Various factors affect providers' ability to identify spoken drug names

Research Activities, November 2010: Safety and Quality of Care: Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup

Safety and Quality of Care
Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup

The electronic medical record (EMR) can do a great deal to improve office-based care, including reducing medical errors. However, while physicians believe that the EMR will greatly impact test result procedures, this is not always the case. A recent study found that while the EMR does increase the documentation of patient test results, it still falls short when it comes to notifying patients, documenting the interpretation of results, and following up on abnormal test results.

Researchers examined patient charts from eight primary care offices in Ohio. They reviewed a total of 461 test results in 200 charts. Of these, 274 were managed by EMR at 4 offices, with the others managed by standard paper-based procedures. There were significant differences between EMR vs. paper charts in the way test results were documented. Both did well at ensuring that the results were in the proper location in the chart. However, while 86 percent of paper test results had a clinician signature, all of the EMR results did. Also the EMR was better at documentation of test result interpretation and patient notifications. However, the success rate declined greatly for both EMR and paper charting when it came to writing a results interpretation in the chart and documenting patient notification. There were also low rates of documentation regarding needed followup of abnormal test results for both the EMR and paper systems.

The researchers concluded that the EMR is not being used to its fullest potential when it comes to steps involving the active input of staff and clinicians. They note that an important unresolved issue is whether an EMR really increases test result management quality or just documentation. The study was supported in part by the Agency for Healthcare Research and Quality (HS13914).

See "The management of test results in primary care: Does an electronic medical record make a difference?" by Nancy C. Elder, M.D., M.S.P.H., Timothy R. McEwen, M.S., John Flach, Ph.D., and others in the May 2010 Family Medicine 42(5), pp. 327-333.

Research Activities, November 2010: Safety and Quality of Care: Electronic medical record boosts documentation of test results, but still falls short for patient notification and test followup