National Healthcare Quality and Disparities Report
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Search All Research Studies
Topics
- Adverse Drug Events (ADE) (3)
- Adverse Events (2)
- Antibiotics (3)
- Antimicrobial Stewardship (3)
- Asthma (1)
- Care Coordination (1)
- Care Management (1)
- Children/Adolescents (1)
- Chronic Conditions (1)
- Communication (1)
- Elderly (3)
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- Health Information Technology (HIT) (1)
- Home Healthcare (2)
- Hospital Discharge (7)
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- Long-Term Care (1)
- Medical Errors (3)
- (-) Medication (15)
- Medication: Safety (6)
- Nursing Homes (2)
- Opioids (2)
- Pain (2)
- Patient-Centered Outcomes Research (1)
- Patient Adherence/Compliance (1)
- Patient and Family Engagement (2)
- Patient Safety (7)
- Patient Self-Management (1)
- Practice Patterns (1)
- Provider: Pharmacist (1)
- Substance Abuse (1)
- Surgery (1)
- Teams (1)
- (-) Transitions of Care (15)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 15 of 15 Research Studies DisplayedXiao Y, Smith A, Abebe E
Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.
The purpose of this study was to utilize a systems approach to examine hazards to medication safety for older adults during care transitions. The researchers interviewed 38 hospital-based professionals (5 hospitalists, 24 nurses, 4 clinical pharmacists, 3 pharmacy technicians, and 2 social workers) from 4 hospitals about ADE risks after hospital discharge among older adults. For each concern the participants provided, the hazard for medication-related harms was coded and grouped by its sources utilizing a human factors and systems engineering model. The study found that the hazards fell into 6 groups: 1) medication tasks related at home, 2) patient and caregiver related, 3) hospital work system related, 4) home resource related, 5) hospital professional-patient collaborative work related, and 6) external environment related. The type of medications indicated most frequently when describing concerns included anticoagulants, insulins, and diuretics. The types of hazards coded the most were: complex dosing, patient and caregiver knowledge gaps in medication management, errors in discharge medications, unaffordable cost, inadequate understanding about changes in medications, and gaps in access to care or in sharing medication information.
AHRQ-funded; HS024436.
Citation: Xiao Y, Smith A, Abebe E .
Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.
J Patient Saf 2022 Dec 1;18(8):e1174-e80. doi: 10.1097/pts.0000000000001046..
Keywords: Elderly, Adverse Drug Events (ADE), Medication, Medication: Safety, Hospital Discharge, Hospitals, Transitions of Care
Vaughn VM, Ratz D, Greene MT
Antibiotic stewardship strategies and their association with antibiotic overuse after hospital discharge: an analysis of the Reducing Overuse of Antibiotics at Discharge (ROAD) home framework.
Researchers sought to understand strategies to optimize antibiotic prescribing at discharge. Surveying Michigan hospitals on their antibiotic stewardship strategies for community-acquired pneumonia (CAP) and urinary tract infection (UTI), they found that the more stewardship strategies a hospital reported, the lower its antibiotic overuse at discharge.
AHRQ-funded; HS026530.
Citation: Vaughn VM, Ratz D, Greene MT .
Antibiotic stewardship strategies and their association with antibiotic overuse after hospital discharge: an analysis of the Reducing Overuse of Antibiotics at Discharge (ROAD) home framework.
Clin Infect Dis 2022 Sep 29;75(6):1063-72. doi: 10.1093/cid/ciac104..
Keywords: Antimicrobial Stewardship, Antibiotics, Medication, Hospital Discharge, Transitions of Care
Giesler DL, Krein S, Brancaccio A
Reducing overuse of antibiotics at discharge home: a single-center mixed methods pilot study.
This article described a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to hospital discharge. The timeout addressed key elements of duration and was designed and implemented using iterative cycles with rapid feedback. The authors evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability. The pharmacists conducted 288 antibiotic timeouts with a mean duration of 2.5 minutes. Pharmacists recommended an antibiotic change in 25% of timeouts with 70% of recommended changes accepted by hospitalists. Barriers included unanticipated and weekend discharges. There were no differences in antibiotic use after discharge during the intervention compared to control services.
AHRQ-funded; HS026530.
Citation: Giesler DL, Krein S, Brancaccio A .
Reducing overuse of antibiotics at discharge home: a single-center mixed methods pilot study.
Am J Infect Control 2022 Jul;50(7):777-86. doi: 10.1016/j.ajic.2021.11.016..
Keywords: Antibiotics, Antimicrobial Stewardship, Medication, Hospital Discharge, Transitions of Care
Sharara SL, Arbaje AI, Cosgrove SE
The voice of the patient: patient roles in antibiotic management at the hospital-to-home transition.
The objective of this study was to characterize tasks required for patient-performed antibiotic medication management (MM) at the hospital-to-home transition, as well as barriers to and strategies for patient-led antibiotic MM. The overall goal was to understand patients' role in managing antibiotics at the hospital-to-home transition. The investigators concluded that there are many opportunities to improve patient-led antibiotic MM at the hospital-to-home transition.
AHRQ-funded; HS026995.
Citation: Sharara SL, Arbaje AI, Cosgrove SE .
The voice of the patient: patient roles in antibiotic management at the hospital-to-home transition.
J Patient Saf 2022 Apr 1;18(3):e633-e39. doi: 10.1097/pts.0000000000000899..
Keywords: Antibiotics, Antimicrobial Stewardship, Medication, Hospital Discharge, Transitions of Care, Patient Self-Management
De Oliveira GS, Castro-Alves LJ, Kendall MC
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
The main objective of the current investigation was to examine the effectiveness of pharmacist-based transition-of-care interventions on the reduction of medication errors after hospital discharge. Findings showed that pharmacist transition-of-care intervention is an effective strategy to reduce medication errors after hospital discharge and also reduces subsequent emergency room visits.
AHRQ-funded; HS024158.
Citation: De Oliveira GS, Castro-Alves LJ, Kendall MC .
Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.
J Patient Saf 2021 Aug 1;17(5):375-80. doi: 10.1097/pts.0000000000000283..
Keywords: Medication: Safety, Medication, Adverse Drug Events (ADE), Adverse Events, Medical Errors, Patient Safety, Provider: Pharmacist, Transitions of Care
Champion C, Sockolow PS, Bowles KH
Getting to complete and accurate medication lists during the transition to home health care.
This observational field study looked at the work that home health care (HHC) admissions nurses complete related to medication reconciliation tasks, explored the impact of shared electronic medication data (interoperability), and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies. Three diverse Pennsylvania HHC agencies participated, with each using different electronic health record systems. Six nurses per site admitted 2 patients each (36 patients total) and their tasks were examined in depth. Medication reconciliation tasks included changes in number of medications and change types and calls to the health provider (doctor or pharmacy) to resolve medication-related issues. A high percentage of patients used multiple medications (more than 12 medications on average), and were high-risk (on average more than 8 medications per patient). Medication reconciliation decreased the number of prescriptions between pre- and post-reconciliation for 91% of patients with 41% of the medications requiring changes. Two-thirds of the nurses called a provider to facilitate medication changes. Interoperability reduced the number of changes required but did not eliminate changes or calls to providers.
AHRQ-funded; R01 HS024537.
Citation: Champion C, Sockolow PS, Bowles KH .
Getting to complete and accurate medication lists during the transition to home health care.
J Am Med Dir Assoc 2021 May;22(5):1003-08. doi: 10.1016/j.jamda.2020.06.024..
Keywords: Medication, Medication: Safety, Transitions of Care, Home Healthcare, Patient Safety
Holden RJ, Abebe E
Medication transitions: vulnerable periods of change in need of human factors and ergonomics.
The authors present a novel view of transitions from the lens of patient ergonomics which posits that patients and other nonprofessionals experience many changes during patient work transitions toward health-related goals. Medication transitions are particularly vulnerable. Two cases of medication transitions; new and medication deprescribing are described in which the patient work lens reveals many accompanying changes, vulnerabilities, and opportunities for human factors and ergonomics.
AHRQ-funded; HS024384.
Citation: Holden RJ, Abebe E .
Medication transitions: vulnerable periods of change in need of human factors and ergonomics.
Appl Ergon 2021 Jan;90:103279. doi: 10.1016/j.apergo.2020.103279..
Keywords: Medication, Medication: Safety, Patient and Family Engagement, Transitions of Care, Patient Safety
Parikh K, Perry K, Pantor C
Multidisciplinary engagement increases medications in-hand for patients hospitalized with asthma.
Asthma exacerbations in children are a leading cause of missed school days and health care use. Patients discharged from the hospital often do not fill discharge prescriptions and are at risk for future exacerbations. In this study, a multidisciplinary team aimed to increase the percentage of patients discharged from the hospital after an asthma exacerbation with their medications in-hand from 15% to 80%.
AHRQ-funded; HS024554.
Citation: Parikh K, Perry K, Pantor C .
Multidisciplinary engagement increases medications in-hand for patients hospitalized with asthma.
Pediatrics 2019 Dec;144(6). doi: 10.1542/peds.2019-0674..
Keywords: Children/Adolescents, Asthma, Medication, Patient Adherence/Compliance, Teams, Hospital Discharge, Transitions of Care
Klueh MP, Sloss KR, Dossett LA
Postoperative opioid prescribing is not my job: a qualitative analysis of care transitions.
This qualitative study aimed to describe transitions of care for postoperative opioid prescribing and to identify barriers and facilitators of ideal transitions for potential intervention targets. Results identified potential interventions aimed at changing physician behaviors regarding transitions of care for postoperative opioid prescribing. Implementation of these interventions could improve coordination of care for patients with persistent postoperative opioid use.
AHRQ-funded; HS026030.
Citation: Klueh MP, Sloss KR, Dossett LA .
Postoperative opioid prescribing is not my job: a qualitative analysis of care transitions.
Surgery 2019 Nov;166(5):744-51. doi: 10.1016/j.surg.2019.05.033..
Keywords: Opioids, Medication, Pain, Transitions of Care, Practice Patterns
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Xiao Y, Abebe E, Gurses AP
Engineering a foundation for partnership to improve medication safety during care transitions.
Current approaches to safe, self-medication management for patients and caregivers after hospital discharge tend to focus on adding isolated strategies. Positing the concept that medication safety during care transition and at patient homes is the property of a "work system," in which the patient and caregivers are in collaboration with health professionals, this article argues that system thinking can enable a fundamental transformation that redesigns professionals' interactions with patients and caregivers, with the explicit goal of developing patients and caregivers into true partners with targeted roles. The authors describe a set of recommendations based on human factors principles that creates an engineering partnership with patients and their caregivers at different stages during a care episode, to enable productive interactions.
AHRQ-funded; HS024436.
Citation: Xiao Y, Abebe E, Gurses AP .
Engineering a foundation for partnership to improve medication safety during care transitions.
J Patient Saf Risk Manag 2019 Feb 1;24(1):30-36. doi: 10.1177/2516043518821497..
Keywords: Medication, Medication: Safety, Patient and Family Engagement, Patient Safety, Transitions of Care
Klueh MP, Hu HM, Howard RA
Transitions of care for postoperative opioid prescribing in previously opioid-naive patients in the USA: a retrospective review.
The purpose of this study was to identify specialties prescribing opioids to surgical patients who develop new persistent opioid use. Results showed that, among surgical patients who developed new persistent opioid use, surgeons provided the majority of opioid prescriptions during the first 3 months after surgery, but by 9 to 12 months after surgery, the majority of opioid prescriptions were provided by primary care physicians. Recommendations included enhanced care coordination between surgeons and primary care physicians to allow earlier identification of patients at risk for new persistent opioid use in order to prevent misuse and dependence.
AHRQ-funded; HS023313.
Citation: Klueh MP, Hu HM, Howard RA .
Transitions of care for postoperative opioid prescribing in previously opioid-naive patients in the USA: a retrospective review.
J Gen Intern Med 2018 Oct;33(10):1685-91. doi: 10.1007/s11606-018-4463-1..
Keywords: Transitions of Care, Opioids, Substance Abuse, Surgery, Pain, Medication, Patient-Centered Outcomes Research
Kerstenetzky L, Birschbach MJ, Beach KF
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
The authors of this study report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to skilled nurse facilities and long term care pharmacy staff.
AHRQ-funded; HS021984.
Citation: Kerstenetzky L, Birschbach MJ, Beach KF .
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
Res Social Adm Pharm 2018 Feb;14(2):138-45. doi: 10.1016/j.sapharm.2016.12.013..
Keywords: Adverse Drug Events (ADE), Hospital Discharge, Hospitals, Long-Term Care, Medical Errors, Medication, Medication: Safety, Nursing Homes, Patient Safety, Transitions of Care
Werner NE, Malkana S, Gurses AP
Toward a process-level view of distributed healthcare tasks: medication management as a case study.
Researchers aimed to highlight the importance of using a process-level view in analyzing distributed healthcare tasks through a case study analysis of medication management (MM). Their findings identified key cross-system characteristics not observable at the task-level: (1) identification of emergent properties (e.g., role ambiguity, loosely-coupled teams performing MM) and associated barriers; and (2) examination of barrier propagation across system boundaries.
AHRQ-funded; HS022916.
Citation: Werner NE, Malkana S, Gurses AP .
Toward a process-level view of distributed healthcare tasks: medication management as a case study.
Appl Ergon 2017 Nov;65:255-68. doi: 10.1016/j.apergo.2017.06.020.
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Keywords: Care Management, Elderly, Home Healthcare, Medication, Transitions of Care
Marcum ZA, Hardy SE
Medication management skills in older skilled nursing facility residents transitioning home.
The objective of this pilot study was to describe potential medication management deficiencies of older SNF residents transitioning home. It found that medication management deficiencies were found to be common in a high-risk group of elderly adults making this important transition.
AHRQ-funded; HS020831.
Citation: Marcum ZA, Hardy SE .
Medication management skills in older skilled nursing facility residents transitioning home.
J Am Geriatr Soc 2015 Jun;63(6):1266-8. doi: 10.1111/jgs.13469..
Keywords: Patient Safety, Nursing Homes, Elderly, Medication, Transitions of Care