Research on Health Care Costs, Quality and
Outcomes (HCQO)
Purpose and Method of Operation
Improving Clinical Practice
Patient Outcomes Research Teams (PORTS)
Pharmaceutical Outcomes Research
Evidence-based Practice
Improving the Health Care System's Delivery of Care
Consumer Decision Making
Consumer Decision Making—Smoking Cessation Initiative in FY 1998
Consumer Decision Making—Small Business Innovation Research
(SBIR)
Impact of Market Forces
Managed Care
Primary Care
Quality Measurement and Improvement
Tracking the Nation's Progress
Activities in Support of All Goals
Prior Year Funding
FY 1999 Request
The purpose of the Research on Health Care Costs, Quality and
Outcomes (HCQO) program is to support and conduct research that
improves the outcomes, quality, and cost, use, and accessibility
of health care services. To achieve this purpose, the HCQO
budget activity has three main areas of focus: (1) Improving
clinical practice, (2) Improving the health care system's
capacity to deliver quality care, and (3) Tracking the Nation's
progress by providing policy makers with the capability to
monitor and evaluate the impact of system changes on cost, use,
and accessibility of health care.
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HCQO focuses on improving health outcomes—a diverse area that
reflects a convergence of multiple themes in research on health
care delivery:
- The existence of variations in practice.
- The increasing occurrence of chronic diseases, a result of
the successes of acute care medicine and demographic shifts
in the population.
- Growing interest in the impact of different modalities and
financing arrangements on outcomes.
- Continued interest in the evaluation and appropriate use of
medical technologies and clinical services, including
pharmaceuticals, primary and preventive care, and
specialized services.
Outcomes and effectiveness research continues to be a central
component of AHCPR's portfolio of extramural research. Outcomes
research as a field is also maturing, and in the Fall 1997, the
Agency sponsored a national conference to bring together key
leaders in research and practice to determine the "state of the
science" and chart the course for the next 10 years of investment
in outcomes research. This report will be published by early
Spring 1998, and available on the AHCPR Web site. Some recent
findings of AHCPR-supported outcomes research include:
- While cardiac disease remains the number one cause of
mortality in the United States and the most expensive
category of illness for the Medicare program, mortality from
cardiac disease has been decreasing for the past 15 years.
Investigators from Harvard developed a model to study which
interventions—prevention or acute treatment—have led
to the decline in mortality. Their results suggest that
more than 50 percent of the observed decline can be
attributed to improvements in treatment (e.g., diagnostic
and therapeutic advances).
- Many patients with heart attacks do not receive thrombolytic
therapy ("clot-busters"). Investigators from the New
England Medical Center have developed a tool that provides
for each individual the expected mortality at 30 days and
one year if treated with thrombolytics—and if NOT
treated. The results are printed on the patient's EKG when
they are first seen in the Emergency Room. A trial to
assess whether this will increase the proportion of eligible
patients receiving recommended treatment is in progress; the
investigators are also working with the major manufacturer
of EKG machines to make this tool widely available.
- Patients admitted to the hospital with a heart attack may be
cared for by a cardiologist, primary care physician or both.
Investigators at Harvard examined care provided to Medicare
beneficiaries in New York and Texas and found that:
cardiologists tended to provide care to younger and less ill
individuals, and were more likely to recommend invasive
testing and surgery than primary care physicians.
Cardiologists were also more likely to comply with some but
not all recommended medical treatments than primary care
physicians. There were no differences in mortality at one
year associated with physician specialty. The results
indicate areas for needed quality improvement by all
physicians, and emphasize the importance of hospital as well
as physician factors in mortality from heart attacks.
- Investigators from Dartmouth worked with cardiovascular
surgeons in Northern New England to improve quality of care
for patients having bypass surgery (CABG). The intervention
resulted in a significant 24 percent reduction in mortality.
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Much has been learned from the investments in the 14 original
Patient Outcomes Research Team (PORT) and 11 PORT II projects,
both in terms of effective care (for costly and common conditions
such as diabetes, coronary heart disease, and complications of
childbirth) as well as new ways to evaluate outcomes
appropriately. Select for a complete listing of PORT and
PORT II projects. Findings and publications continue to
be generated from the original 14 PORTS, as well as translation
of research findings into practice. To cite the most
recent example, in November 1997, four managed care organizations
in the Washington, D.C. area released a major education and
quality improvement program for community acquired pneumonia, and
explicitly stated that their program is based on outcomes
research funded by AHCPR. Specifically, investigators working on
the community-acquired pneumonia PORT, an illness that is one of
the most common reasons for hospital admission for Medicare
beneficiaries and one of the top 10 most costly diagnoses for the
Medicare program, have examined factors associated with hospital
admission from the perspective of physicians and patients,
factors that influence length of stay, and factors associated
with quality of care for hospitalized patients. Findings
published in medical journals include:
- Development of a risk-stratification index to predict those
individuals with very low risk of mortality who can safely
be treated at home (New England Journal of Medicine).
- Identification of specific factors (intravenous antibiotics
and nursing support at home) that would permit more than 50
percent of low-risk patients to be treated at home (Archives
of Internal Medicine).
- In conjunction with the American Thoracic Society,
demonstrated that less costly antibiotics are also more
effective for treating community-acquired pneumonia (Journal
of the American Medical Association).
In addition, the Diabetes PORT has examined treatment patterns
for patients with Type 2 diabetes, the more common type of
diabetes in the United States. Their recently published work has
demonstrated that insulin treatment is significantly more costly
and not always more effective than oral agents. They have worked
closely with leading professional organizations to assure that
these results are disseminated widely.
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The purpose of AHCPR's pharmaceutical outcomes research is to
determine what practices, with regard to such issues as
prescribing, patient education, reimbursement, and drug
utilization review, are associated with the best outcomes for
patients (including cost) with common conditions, in
uncontrolled, real world situations. This research is clearly
distinct from the kind of pharmaceutical research done by the Food
and Drug Administration and other Federal agencies, because
this research goes beyond questions of drug safety and efficacy.
One recent AHCPR-funded study at the University of Colorado
Health Science Center looked at more than 12,000 children, 13
years of age and younger, enrolled in Colorado's fee-for-service
Medicaid program, and treated for a new episode of acute otitis
media (ear infection). This study discovered that treatment of
common ear infections in children with antibiotics, such as
amoxicillin instead of more costly choices, could save millions
of dollars a year without changing recovery rates. Middle ear
infection is the most frequent reason for giving antibiotics to
children in the United States. No single antibiotic has been
found to be superior in treating this condition. However, costs
vary widely, from less than $3 to more than $62 for a course of
treatment. If, in one year, only half the prescriptions written
used a lower cost antibiotic, Colorado's Medicaid program would
have saved approximately $400,000.
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In 1997, the Agency successfully launched its initiative to
promote the use of evidence in everyday care through the funding
of National Evidence-based Practice Centers (EPCs) and
establishing a National Guideline Clearinghouse™. The latter is a
joint effort by AHCPR, the American Association of Health Plans,
and the American Medical Association, developed over an 18
month-period in 1996 and 1997.
In October 1997 AHCPR announced the first set of topics
assigned to the 12 EPCs. Select for EPC topics and centers.
The EPCs will make important contributions to promoting
evidence-based practice in two ways. First, they will
conduct rigorous and systematic reviews of all of the relevant
scientific literature about these topics. Unlike mere syntheses
of the literature, they will assess the appropriateness of the
research design of each study, the extent to which the study
adequately controlled for threats to the validity of the study's
findings, and the appropriateness of the statistical tests and
how they were applied. Where appropriate, they will conduct
additional analyses. This will provide clinicians and other
health care professionals with a clear understanding of the
strengths and weaknesses of the available scientific literature.
Second, to assure that the work of the EPCs is translated into
practice quickly, AHCPR will only assign a topic to an EPC when
one or more organizations (such as managed care organizations,
medical specialty societies, federal purchasers, and others) have
made a commitment to use the EPC report to develop their own
quality improvement strategies. In addition, the EPC findings
(evidence reports or technology assessments) will be broadly
disseminated.
AHCPR will also conduct evaluation studies on EPCs, to be
reported in the fiscal year (FY) 1999 Performance Report. These
evaluation studies will review the quality and usefulness of the
evidence reports and technology assessments produced by the
Evidence-based Practice Centers and the impact of the use of
these products on the health care system.
Current Evidence-based Practice Centers (EPCs)
| Contract | Topic |
| Research Triangle Institute and University of North Carolina | Pharmacotherapy for alcohol
dependence |
| University of California and Stanford University | Management of stable angina |
| MetaWorks, Inc., Boston, MA | Diagnosis of sleep apnea |
| McMaster University | Treatment of attention deficit/ hyperactivity disorder |
| Oregon Health Sciences University | Rehabilitation of persons with traumatic brain injury |
| Blue Cross and Blue Shield Association Technical Evaluation Center (TEC) | Testosterone suppression treatment for prostatic cancer |
| Duke University | Evaluation of cervical cytology |
| University of Texas | Depression treatment with new drugs |
| Johns Hopkins University | Evaluation and treatment of new onset of a trial fibrillation in the elderly |
| RAND Corporation, Santa Monica, CA | Prevention and management of urinary complications in paralyzed persons |
| New England Medical Center | Diagnosis and treatment of acute sinusitis |
| ECRI, Plymouth Meeting, PA | Diagnosis and treatment of dysphagia/swallowing problems in the elderly |
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Clinical services are not delivered in isolation. Their
accessibility and quality are also affected by the settings in
which care is delivered, the processes and structures that
organizations put into place to manage those clinical services
and the clinical and support personnel that provide them, the
scope of (or lack of) insurance coverage patients have for
reimbursing those services, and the processes that organizations
put into place for measuring and improving the quality of the
care provided. In fact, the national policy debate on quality
has focused almost exclusively on non-clinical determinants of
quality, such as:
- Financing (limits on benefits/services/reimbursement).
- Management of services (limitations on length of stay
or referrals, the shift to outpatient care, the use of
financial incentives and cost-sharing).
- Limitations on the clinician's relationship with the
patient.
Despite the importance of these factors to the American public
and Federal and State policy makers, we have little scientific
evidence regarding their impact on quality. AHCPR supports
research in this area to improve the health care system's
capacity to deliver quality care.
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AHCPR has a strong commitment to improving the ability of
consumers to make informed choices in health care. The Agency
has identified three key choices that consumers face: choosing a
health plan, choosing a doctor or provider, and when confronted
by illness, choosing appropriate treatment. In each of these
areas, the Agency supports a diverse set of grant and contract
research.
AHCPR will continue to support a major initiative to assist
consumers in selecting high quality health plans and services.
The project, entitled the Consumer Assessments of Health Plans
(CAHPS®) study, consists of cooperative agreements totaling more
than $10 million over five years with three consortia headed by
the Research Triangle Institute, the RAND Corporation, and
Harvard Medical School. CAHPS® is a ground-breaking effort to
determine the factors that contribute most to consumer
assessments of health plans; find ways to measure those factors;
and determine if providing this information to consumers assists
them in choosing high quality health plans.
In phase 2 of the project, begun in Spring 1997, CAHPS® was
demonstrated and evaluated in a variety of settings that include
Medicaid programs, large employers, and health plan purchasing
coalitions. Select for a list of CAHPS® demonstration sites.
In these sites, CAHPS® survey instruments and reporting formats
will be used to collect and report information to the public.
Members of the CAHPS® teams provided technical assistance and
performed a systematic process and outcome evaluation of the
CAHPS® products. Using qualitative and quantitative methods, this
evaluation was aimed at improving the CAHPS® surveys and reports
and determining the usefulness of CAHPS® products to consumers and
purchasers in selecting health care plans and services.
CAHPS® Demonstration Sites
| Harvard University | Population Surveyed | Comments |
|
Washington State Health Care Authority | Implemented CAHPS® with 21,500 State employees in 17 plans in Fall 1997 | Print guide was
disseminated Fall 1997;
some participants also have computer guide; Harvard producing plan-level and purchaser- level reports. |
|
Massachusetts Medicaid | Will implement CAHPS® with
Medicaid recipients in 1998. | |
|
State of Colorado | With NCQA, performed comparison study of NCQA's Member Satisfaction Survey with CAHPS® instrument with members of 6 managed care plans in Colorado. | |
| RAND
Site | Population Surveyed | Comments |
|
New Jersey Medicaid | Surveyed approximately 5,500 Medicaid recipients in 11 HMOs | Reports to be
disseminated to new Medicaid recipients in January 1998 |
| Florida Medicaid | Used an early version of CAHPS® in 1996 | Both print and computer
guide are being tested in Florida |
| Iowa Medicaid | Surveyed Medicaid recipients in 2 HMOs, 1 FFS and 1 PCCM plan | Will not send report or
conduct evaluation in 1997, but will do both in 1998 |
| Maryland Medicaid | Will implement CAHPS® with
Medicaid recipients in 1998 | |
| RTI Site | Population Surveyed | Comments |
|
Kansas Foundation for Medical Care | Surveyed state employees; employees of 2 private companies; Medicaid recipients in Kansas City; Medicare beneficiaries in Kansas City | Print guide distributed
to State employees in
October 1997; private companies are not reporting the results
|
|
Oregon | Will implement CAHPS® with State employees and Medicaid recipients in Spring 1998. | Developing report card
w/CAHPS® and other quality info
|
|
State of Iowa Employees Health Benefits | To Be Determined | Negotiations still underway; possible site for 1998 |
In addition to the AHCPR-supported demonstration projects, states
and other local governments are using CAHPS® to conduct their own
surveys. In November 1997, the State of New Jersey released a
report, New Jersey HMOs: Performance Results, which rates the
state's HMOs based upon interviews with 5,500 HMO members using
the CAHPS® instrument. This is just one of at least nine states
and various counties, in addition to Medicare, that has a
commitment to using CAHPS®.
In January 1998, the Quality Measurement Advisory Service (QMAS),
the Picker Institute, and Harvard University joined forces to
build the first national database of patient-derived assessments
of health plans using the results from CAHPS®. Fifteen groups,
including Medicaid agencies, business coalitions, and States,
have expressed interest in participating, according to QMAS.
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Consumer decisions about treatments are directly informed by the
results of outcomes research and the development of tools to
bring scientific findings to the lay public. The Agency's
activities in this area include the new Smoking Cessation
Two-Three Initiative that seeks to enlist the help of all
clinicians to get their patients who smoke to quit. The
Initiative highlights the AHCPR-sponsored smoking cessation
Clinical Practice Guideline released in 1996 recommending that
two questions: "Do You Smoke?" and "Do You Want To Quit?" be part
of every medical assessment by clinicians. This should be
followed by an intervention as brief as three minutes
recommending smoking cessation treatments proven to work.
Research shows that smokers have the best chance of quitting when
their health care providers get involved.
To aid clinicians in the intervention, AHCPR has developed a
Smoking Cessation Consumer Tools Kit, complete with four,
easy-to-read, write-ups that address particular concerns of
smokers, especially those in challenging situations such as First
Time Quitters, Multiple Quit Attempts, Pregnancy and Smoking, and
Smokers Facing Surgery.
The Initiative follows an AHCPR-funded report released in
December 1997 that found smoking cessation efforts to be
cost-effective. According to The Cost Effectiveness of AHCPR's
Smoking Cessation Guideline Report, while all types of cessation
treatment were found to be cost-effective, those involving more
intensive counseling and the nicotine patch proved to be
especially worthwhile. Smoking cessation interventions are less
costly than other preventive medical interventions such as the
treatment of high cholesterol. In fact, at an average cost of
about $2,600 per year of life saved, smoking cessation treatment
is especially cost-effective when compared with cholesterol
treatment, a routine intervention which costs nearly forty times
as much to treat a year.
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AHCPR supports a number of SBIR projects designed to tests
innovative strategies for assisting consumer decision making.
Several projects include:
- Elder Care—This contract will develop an interactive
CD-ROM program to assist families in deciding on the best
living/care arrangement for elderly relatives—home,
personal care homes, nursing homes. The decision model will
allow families to evaluate their elderly relatives' ability
to function in each setting, as well as the families'
ability to provide care. Decision factors address physical
and cognitive ability, psychosocial and financial issues.
This tool could be adapted for any number of public
programs, such as Medicare and Medicaid.
- How to Evaluate Information from Providers: Tools for Non-mainstream Populations—Under this project "low-barrier"
decision tools will be developed. That is, consumer
information will be developed to help low literate,
minimally English proficient, minority and low income
individuals better use health care services. The goal of the
project is to develop prototype print, video, and
interactive voice response (IVR) telephone systems to assist
consumers in communicating with plans and providers. The
IVR should help individuals to understand and evaluate the
information and advice they are given by providers with
respect to illnesses and treatments, so that there is more
shared decision making. These tools should be adaptable for
public programs.
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