Purpose
Achievements
Goal 1. Supporting Improvements in Health Outcomes
Goal 2. Strengthening Quality Mesurement and Improvement
Goal 3. Identifying Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures
Improving the Health of Priority Populations
Training and Dissemination
Funding Summary
Funding History
Rationale for AHRQ's FY 2004 Request
The purpose of the activities funded under the Research on Health Costs, Quality and Outcomes (HCQO) budget line is to support, conduct and disseminate research to improve the outcomes, quality, cost, use and accessibility of health care. Accordingly, the Agency has three main goals:
In addition to these goals, improving the health of priority populations is another focus of HCQO. The commitment to funding new research, translating research into practice and disseminating new knowledge underlies all HCQO activity.
AHRQ has made important strides toward meeting its strategic goals. This report reviews achievements of the Agency's established programs as well as activities initiated under the Agency's FY 2003 budget.
The first section of this report, Supporting Improvements in Health Outcomes, reviews the Agency's progress in the following research areas:
The second section, Strengthening Quality Measurement and Improvement, provides updates on activities in the following areas:
The third section, Identifying Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures, reports on AHRQ projects that address critical policy issues as well as develop data and information for policymakers:
The fourth section, Improving the Health of Priority Populations, outlines AHRQ's efforts and findings on the following issues:
The final section, Training and Dissemination, includes a discussion of AHRQ's efforts to maintain and nurture a cadre of well-trained and talented health services researchers and AHRQ's activities to put the knowledge gained through research into the hands of health care providers.
Rapidly rising health care costs, questions about effective medical treatments, and the need for efficient delivery of health care services are the reasons why outcomes research has been one of AHRQ's core activities for over a decade. Patient outcomes research provides evidence about the benefits, risks, and results of treatments that take place in "real world" setting so clinicians and patients can make more informed health care choices. Outcomes research answers a number of very fundamental questions about health care services:
The answers to these questions form a solid foundation for efforts to improve health care quality and patient safety, enhance access to care, and improve the cost-effectiveness of care.
Outcomes research also looks at differences in care from one part of the country to another and from one population group to another. Repeatedly, studies have documented that therapies as commonplace as hysterectomy and hernia repair are performed much more frequently in some regions than in others, even when there is no difference in the rates of disease.
The results of AHRQ-funded outcomes research—such as the effectiveness of given treatments or clinical intervention strategies—and patient health outcomes measures often serve as the evidences and foundations for the development of various quality indicators and other tools, which are increasingly are being integrated into "report cards" that purchasers and consumers can use to assess the quality of care provided in health plans. For public programs such as Medicaid and Medicare, outcomes research provides policymakers with the tools to evaluate, monitor, and improve the delivery of effective health care services in the most efficient manner. By linking the care people get to the outcomes they experience, outcomes research has become the key to developing cost-effective ways to improve the quality of care.
In 2002, AHRQ's outcomes research portfolio included more than 100 projects that:
Below are examples of findings from recent AHRQ-supported outcomes studies and projects currently underway.
Women's Health. An AHRQ-sponsored study found that among women with mild to moderate pelvic inflammatory disease (PID), rates of pregnancy, recurrent PID, and chronic pelvic pain were no different for inpatient versus outpatient treatment. Inpatient treatment is 10 times as expensive as outpatient treatment.
Prescription Drugs. An AHRQ study published in the New England Journal of Medicine found that a carefully designed and implemented prescription drug reference-pricing policy reduced overall drug expenditures without any obvious adverse clinical outcomes for the beneficiaries. Reference drug pricing programs work on the principle that if several drugs work equally well for a certain condition, the program will fully fund the drug that costs the least. Patients may choose the more expensive drug but the program will only reimburse people for the cost of the lowest cost reference drug(s). This study, which examined data 2 years before and 1 year after implementation of reference-based pricing policy in the province of British Columbia, focused specifically on a large group of elderly Canadian Pharmacare beneficiaries who took drugs to treat hypertension. These findings are relevant to health care systems' and payors' efforts to use pharmaceuticals cost-effectively.
Heart Disease. AHRQ-supported research found that patients who take beta-blockers (drugs to slow the heart rate and reduce contractions of the heart muscle) prior to bypass surgery appear to have improved survival and fewer complications during and after the procedure. Researchers indicate that up to 1,000 lives potentially could be saved each year by giving patients beta-blockers before bypass surgery.
Diabetes. An AHRQ study found that patients with both adult-onset (type 2) diabetes and other chronic conditions can still achieve good blood sugar control if they receive intensive therapy at a specialty diabetes clinic. Therapy included adding or changing oral medications or adding insulin to the treatment regimen.
Hip Fracture. An AHRQ-supported study found that medical staff in hospital, rehabilitation facilities, and nursing homes could improve patient outcomes for the approximately 350,000 hip fractures that occur annually in the United States by focusing efforts on reducing the risk of complications that often leave patients unable to work or lead to death. Currently, 4 of every 10 patients are unable to walk without total assistance by 6 months after the fracture, and one-fourth of patients die within a year. In addition to pain and suffering, hip fracture and its consequences have a large economic impact, with hospital charges alone totaling roughly $6 billion a year.
Lower respiratory infection. Lower respiratory infection (LRI) is one of the most common causes of death and hospitalization among nursing home residents. Although hospitalization can be lifesaving for the sickest patients, for those who are less ill there is considerable risk of incurring avoidable expense and harm from needless hospitalization. AHRQ-sponsored research studied nursing home residents with LRI and developed a strategy to predict which patients are at highest risk of hospitalization and which could be more effectively treated in the nursing home. Their findings demonstrate that up to 52 percent of nursing home residents with lower respiratory infection are at low risk of mortality and may not require hospital admission (i.e., can be safely treated in the nursing home.)
Organ Donation. Prior to the 1980's, kidney transplants from living donors offered the only hope of recovery for end-stage renal disease patients. However, improved surgical techniques, organ matching, rejection treatment, and organ preservation made kidney transplants from cadaver donors possible in the late 1970's. Although organ donor rates have increased the last 10 years, the supply of cadaver donors remains far short of the demand, and transplant centers are returning to living donations. The goal of this AHRQ-sponsored study is to design a model living-donor transplant program based on an evaluation of transplant center and individual barriers as well as facilitators of living donations.
Stroke. Based on AHRQ's research, Medicare's Peer Review Organizations (PROs) have implemented 73 projects in 42 States to increase anti-clotting therapy for Medicare beneficiaries who have suffered from a stroke. The percentage of Medicare patients discharged on this therapy has increased from 58.4 to 71.1 percent.
It is widely acknowledged that patients should be active in decisionmaking regarding their care and research has shown that this approach yields better outcomes. To empower patients as decisionmakers, both technical care and interpersonal interactions must be centered on the needs and preferences of individual patients. As the recent Institute of Medicine (IOM) report, Bridging the Quality Chasm, stated, we must "modify the care to respond to the person, not the person to the care."
In FY 2002, AHRQ requested applications that focus creating an ideal environment for and tools to promote patient-centered care. This program announcement (PA), cosponsored by the National Institute of Mental Health, focuses on design and evaluation of care processes that empower patients, improve patient-provider interaction, help patients and clinicians navigate through complicated health care systems, and improve access, quality, and outcomes. Below are two examples of research grants funded under this program announcement.
Patients and caregivers should not have to guess which therapies are best or fear treatment mistakes. This is the basis of AHRQ's Centers for Education and Research on Therapeutics (CERTs) program, which conducts research and provides education to advance the optimal use of drugs, medical devices, and biological products such as vaccines. AHRQ was given authority to support the CERTs initiative under the Food and Drug Modernization Act of 1997. Between 1999 and 2000, AHRQ established seven CERTs centers, each of which focuses on therapies used in a particular population or therapeutic area. In FY 2001 AHRQ's support of the seven CERTs was approximately $4.9 million. In FY 2002 support for CERTs is approximately $5.0 million.
What is the focus of each CERTs Center?
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Although drugs, medical devices, and biological products improve health for thousands of people, side effects, misuse, and overuse of products can seriously impair the health of many others. The facts are:
The CERTs program aims to fill these information gaps by answering important questions that have not been addressed and implementing effective educational interventions for caregivers. The program is also a critical complement to FDA's post-marketing studies. Participants in the CERTs—Federal government agencies, academic organizations, managed are organizations, drug and device companies, practitioners, commercial research groups, and consumer groups, among others—are committed to seeking answers together.
Since its inception in September 1999, the CERTs have developed a portfolio of more than 120 completed and ongoing studies, the results of which address important issues to advance the best use of therapies. Following are examples of how the CERTs seek to improve the Nation's health through the best use of medical therapies:
Select for Figure 1: Use of Drugs to Treat ADHD and Depression in Youth (14 KB).
AHRQ has a long-standing role in supporting and conducting research to improve the quality of long-term care for the elderly, chronically ill and disabled. In FY 2002, AHRQ committed approximately $7 million in grants for long term care projects. A majority of projects were funded under patient safety solicitations.
Findings from many of these studies will be of direct use to HHS and private sector providers as they seek to improve patient safety and quality of care. Some of the studies are described below.
Coordination Across Federal Agencies. AHRQ, working with NCHS, ASPE and CMS, and input from a meeting of residential and community-based long-term care experts:
Based on this plan, the HHS Data Council determined that LTC should be a high HHS data priority. AHRQ is making several contributions to this data collection effort:
AHRQ's 13 Evidence-based Practice Centers (EPCs) produce evidence reports and technology assessments on clinical and behavioral therapies and technologies that are common, expensive, and significant for Medicare and Medicaid populations. The EPCs systematically review and analyze scientific evidence to develop the reports. During their reviews, the EPCs flag areas where the evidence base is sparse and suggest future research directions.
In 2002, AHRQ awarded 13 new 5-year contracts to continue and expand the work performed by the first group of EPCs initiated in 1997. During the past year AHRQ also formed a partnership with the Office of Medical Applications of Research (OMAR) at the National Institutes of Health (NIH), to include EPC systematic reviews on each clinical condition presented at a Consensus Development Conference. OMAR works closely with the NIH Institutes, Centers and Offices to assess, translate, and disseminate the results of biomedical research that can be used in the delivery of health services. The EPCs will present their topic-specific evidence-based reports to the NIH Consensus Development Conferences to ensure that they have the latest scientific evidence to support their deliberations. These conferences address complex issues of medical importance to health care providers, patients and the general public.
AHRQ funded 16 new evidence topics in 2002, of which 9 of the topics were nominated by private-sector professional societies and providers, and seven of the EPC reports were funded by other Federal agencies. In addition, AHRQ funded an EPC to continue to support the work of the U.S. Preventive Services Task Force, and several EPCs to continue to produce technology assessments requested by CMS.
FY 2002 EPC Evidence Reports and Technology
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Since the start of the program in 1997, the EPCs have conducted more than 90 systematic reviews and analyses of the literature on a wide spectrum of topics and published the results and conclusions as evidence reports and technology assessments. Some of these reviews are ongoing, and others have been published. Users include doctors, medical and professional associations, health system managers, researchers, consumer organizations, and policymakers. Public- and private-sector organizations employ the reports as the basis for developing their own clinical guidelines, performance measures, and other quality improvement tools and strategies. The reports and assessments often are used in formulating reimbursement and coverage policies. Examples include:
Nominations of topics are solicited routinely through notices in the Federal Register and are accepted on an ongoing basis. Professional organizations, health plans, providers, and others who nominate topics are considered partners and agree to use the evidence reports when they are completed. All EPCs collaborate with other medical and research organizations so that a broad range of experts are included in the development process. AHRQ invites comments from interested parties about the EPC program with respect to what has worked well, what has not worked well, and what changes and improvements could be made. AHRQ is also interested in suggestions about new opportunities, such as what steps the Agency can take to encourage more health care organizations and other relevant groups to translate EPC reports into clinical practice guidelines and related products.
EPC Technology Assessment: Actinic Keratoses CMS revised its Medicare Coverage Issues Manual to include a national coverage policy permitting coverage for the treatment of actinic keratoses (AK), a common skin condition that is often the precursor of skin cancer. The decision to cover the treatment of AKs was based largely on the AHRQ Technology Assessment for Actinic Keratoses Treatment. This assessment suggests that the presence of AKs is associated with the development of squamous cell carcinoma (SCC) more than other factors. SCC has the potential to metastasize and accounts for a large percentage of all non-melanoma skin cancer deaths in the Medicare population. |