FY 2004: Research on Health Care Costs, Quality and Outcomes (HCQO) (continued)

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National Guideline Clearinghouse™

The National Guideline Clearinghouse™ (NGC), an Internet resource for evidence-based clinical practice guidelines at www.guideline.gov, has been operational for 5 years. The NGC was developed by AHRQ, in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP) to be a resource for physicians, nurses, educators, and other health care professionals.

The NGC is designed to promote quality health care by making the latest evidence-based clinical practice guidelines available, in one easy-to-access location. The NGC Web site is updated weekly with new and changed guidelines. In addition to its 24-hour access on the Internet, the clearinghouse has many useful features such as standardized abstracts containing information about each guideline and how it was developed, the ability to make guideline comparisons, access to the full text of guidelines or ordering information, and the capability to browse for guideline titles by organization, disease/condition, or treatment/intervention.

Undoubtedly, the NGC's capacity to make vast amounts of information quickly accessible to clinicians is its biggest asset. Before development of the NGC, clinicians and others who wanted to study or compare guidelines for any medical condition had to contact individual guideline developers to obtain a copy. Users then had to perform their own side-by-side analysis to determine which, if any, they wanted to follow. The usefulness of NGC is evidenced by the large number of visits every week by physicians and other health professionals.

Like all good tools, the NGC is designed to be used according to personal preference. For example, a cardiologist might check to see whether he or she should refer an arthritic patient to a rheumatologist by accessing the American College of Cardiology's guidelines to check compatibility with his or her own practice, or a nursing director of a large inner city clinic might check the childhood immunization guidelines so he or she can provide young mothers with more information about preventive care.

The NGC has more than 1,000 clinical practice guidelines submitted by over 180 health care organizations and other entities. New guidelines are added weekly. Over the past 5 years, NGC has had more than 6 million visitors, processed over 55 million requests, and received more than 120 million "hits" or visits. NGC receives over 60,000 visits each week.

AHRQ does not require users of the NGC to register in order to use the site; however, the third customer satisfaction survey of NGC indicates who uses the site. Physicians were the largest portion of survey respondents (40.6 percent), followed by nurses and/or nurse practitioners (20.5 percent). More than 93 percent of respondents rated their overall satisfaction with NGC as either "fairly satisfied" or "very satisfied" compared with 89 percent for the first annual survey. Respondents also provided many useful comments on how they were using the site in their clinical work. For instance, a number of respondents reported using NGC to identify guidelines for adaptation in their health system or institution and to find the best approach to treating their patients. The results from the third customer satisfaction survey reinforced the high level of satisfaction registered on earlier surveys.

Management of Chronic Asthma An estimated 14 to 15 million Americans have asthma. It is the most common chronic disease of childhood, affecting approximately 4.8 million children. More than 70,000 people are hospitalized each year for asthma-related conditions, and 5,000 people die annually of asthma. In early FY 2002, AHRQ published an evidence report on the management of chronic asthma. Subsequently, the National Heart, Lung, and Blood Institute's National Asthma Education and Prevention Program used the AHRQ evidence report in formulating and updating NAEPP guidelines for managing the care of adults and children who have this condition. The NAEPP Web site features a link to the AHRQ guideline and summary on management of chronic asthma.

Clinical Preventive Services: Keeping People Healthy

AHRQ links prevention research with clinical practice by sponsoring the U.S. Preventive Services Task Force (USPSTF) and the Put Prevention Into Practice (PPIP) program. The Task Force synthesizes the evidence-base and the PPIP program promotes the application of the Task Force results.

The U.S. Preventive Services Task Force (USPSTF). General acceptance of preventive screening as a part of routine medical care didn't occur until the 1960's. Despite this acceptance, there was little evidence that screening tests and other preventive interventions actually improved patient outcomes. To address these issues, the U.S. Preventive Services Task Force (USPSTF) was established. The Task Force is a critical source of information on what does and does not work in the health care system specific to clinical prevention. First convened in 1984, the Task Force is an independent panel of health care experts who evaluate scientific evidence for the effectiveness of a range of clinical preventive services—including common screening tests, counseling for health behavior change, and chemoprevention (the use of drugs to reduce the risk of a disease)—and producing age- and risk-factor-specific recommendations for these services. The Task Force published its first set of recommendations in the 1989 Guide to Clinical Preventive Services, which was revised in 1995.

The Task Force conducts impartial assessments of scientific evidence for a broad range of clinical conditions to produce recommendations for the regular provision of clinical preventive services. The Task Force grades the strength of evidence as follows:

• A (strongly recommends).
• B (recommends).
• C (makes no recommendation for or against).
• D (recommends against).
• I (insufficient evidence to recommend for or against).

The Task Force is updating the 70 chapters in its 1996 report, and AHRQ is releasing the revised recommendations incrementally, as they are completed, on the Agency's Web site, through the National Guideline Clearinghouse™, and in medical journals.

The third Task Force, convened in 1999, began work on 12 initial topics selected by Task Force members based on preliminary work by two of the AHRQ's Evidence-based Practice Centers:

• The Research Triangle Institute/University of North Carolina at Chapel Hill.
• The Oregon Health & Science University.

The selection process included a preliminary literature search of new information on prevention and screening published since 1995; consultation with professional societies, health care organizations, and outside prevention experts; a review of current levels of controversy and variations in practice; and consideration of the potential for a change from the 1995 Task Force recommendations. A list of the topics selected by the third Task Force follows.

• Chemoprevention (heart disease and cancer).
• Vitamin supplementation to prevent cancer or coronary heart disease (vitamin E, folate, beta carotene, and vitamin C) (new topic).
• Screening for bacterial vaginosis in pregnancy (new topic).
• Developmental screening in children (new topic).
• Screening for diabetes mellitus (updated topic).
• Newborn hearing screening (updated topic).
• Screening for skin cancer (updated topic).
• Counseling to prevent unintended pregnancy (updated topic).
• Screening for high cholesterol (updated topic).
• Postmenopausal hormone therapy (updated topic).
• Screening for chlamydial infection (updated topic).
• Screening for depression (updated topic).

Also in 2002, the third Task Force issued the following recommendations covering colorectal cancer, osteoporosis, hormone replacement therapy, depression, chemoprevention, and breast cancer:

• Colorectal cancer. The Task Force in its strongest ever recommendation for colorectal cancer screening urges that all adults age 50 and over get screened for the disease, the nation's second leading cause of cancer deaths. Various screening tests are available, making it possible for patients and their doctors to decide which test is most appropriate for each individual. Although each of these tests is effective in diagnosing colorectal cancer at an early stage when it is treatable, the Task Force noted that there is no single best test for all patients. Options include at-home fecal occult blood test (FOBS); flexible sigmoidoscopy; a combine of home FOBT and flexible sigmoidoscopy; colonoscopy; and double-contrast barium enema. Screening can also lead to early detection of adenomatous polyps—precancerous growths that can be removed to prevent them from progressing to cancer.
• Osteoporosis. The Task Force recommends that women aged 65 and older be screened routinely for osteoporosis, and that women at high risk for fractures begin screening at age 60. Women are at greater risk for osteoporosis than men because women's bones are less dense than mens' bones. The Task Force found good evidence that the risk for osteoporosis and fracture increases with age and other factors, that bone density measurements accurately predict the risk for fractures in the short-term, and that treating women with no symptoms of osteoporosis reduces their risk for fracture. Other risk factors cited include lower body weight and no current use of estrogen. The Task Force concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors.
• Hormone replacement therapy. The Task Force recommends against the use of combined estrogen and progestin therapy for preventing cardiovascular disease and other chronic conditions in postmenopausal women. It also recommends that women considering whether to start or continue hormone therapy to relieve menopausal symptoms discuss their individual risks for specific chronic conditions and personal preferences with their clinician. Although the Task Force found evidence for both benefits and harms of combined estrogen and progestin therapy— one of the most commonly prescribed hormone regimens— they conclude that harmful effects of the combined therapy are likely to exceed the chronic disease prevention benefits for most women. The Task Force concludes that combined hormone therapy could increase bone mineral density and reduce the risk of fractures, and may reduce the risk of colorectal cancer. They also found equally strong evidence, however, that this therapy increases the risk for breast cancer, blood clots, stroke, and gallbladder disease, and that this therapy does not reduce the risk of heart disease but actually increases the risk of heart attacks. An estimated 14 million American women take hormone therapy.

• Depression. The Task Force indicates that clinicians can identify up to 90 percent of people who suffer from major depression by asking all patients they see two simple questions. The questions are:

  • "Over the past 2 weeks, have you felt down, depressed or hopeless?"
  • "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"

  This recommendation is the latest sign of the growing recognition that depression is one of the most common—and most commonly undiagnosed and untreated—chronic illnesses. About 19 million American adults suffer from depression, and estimates suggest that as many as two-thirds do not get treatment. This recommendation could bring many of these people into treatment and add millions to the numbers who are taking antidepressants such as Prozac. The Task Force adds that screening is only the first step—patients must have access to the right therapy and medicines, and health care systems must encourage patient followup care by clinicians.

• Chemoprevention—heart disease. The Task Force strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease. Discussion with patients should address both the potential benefits and harms of aspirin therapy.
• Chemoprevention of breast cancer. The Task Force recommends that clinicians discuss the potential benefits and risks of taking prescription medicines such as tamoxifen to reduce the risk of breast cancer with their female patients who are at high risk for the disease. Women are considered at high risk if they are over 40 and have a family history of breast cancer in a mother, sister, or daughter, or have a history of abnormal cells on a breast biopsy. The Task Force also recommends against the use of these drugs by women at low or average risk for breast cancer because the harmful side effects may outweigh the potential benefits. Those side effects can include hot flashes, increased risk for blood clots in the legs or lungs, and increased risk for endometrial cancer.
• Breast cancer. The Task Force recommends that women aged 40 and older have a mammogram with or without clinical beast examination every 1-2 years. They found fair evidence that mammography screening every 1-2 years could reduce breast cancer mortality by approximately 20 percent to 25 percent over 10 years. The evidence is strongest for women between the ages of 50 and 69, but the Task Force concludes benefits were likely to extend to women 40-49 as well. The Task Force published two earlier breast cancer screening recommendations, in 1989 and 1996, that both endorsed mammography for women over age 50. The Task Force is now extending that recommendation to all women over age 40, even though the strongest evidence of benefit and reduced mortality from breast cancer is among women ages 50-69. This recommendation acknowledges that there are some risks associated with mammography (e.g., false-positive results that lead to unnecessary biopsies or surgery), but that these risks lessen as women get older.

Two of the Task Force's 2002 assessments yielded insufficient evidence to make a recommendation:

• Does counseling in primary care settings to promote physical activity lead to sustained increases in physical activity among adult patients?
• Does routine screening of newborns for hearing loss and earlier treatment resulting from screening lead to long-term improvements in language skills?

Putting Prevention Into Practice. AHRQ's Put Prevention Into Practice (PPIP) program helps keep people healthy by translating the recommendations of the U.S. Preventive Services Task Force into practice. PPIP provides clinicians, office staff, and patients with various tools and resources to increase the delivery and use of recommended clinical preventive services. PPIP facilitates the delivery of services that can prevent some of the leading causes of death and disability, and it helps to combat barriers to the effective delivery of preventive care such as time constraints, lack of training, and patient anxiety about procedures and results.

The PPIP program emphasizes that:

• Clinical prevention works and is important,.
• Different people need different services.
• An extensive system-wide team approach is necessary to ensure that prevention is a routine part of every patient experience.

AHRQ works closely with public and private partners to disseminate PPIP tools and resources, which include information on preventive services recommendations, an implementation guide, as well as personal health guides for children, adults, and people over 50.

In December 2001, AHRQ released A Step-by-Step Guide to Delivering Clinical Preventive Services—A System Approach designed for use by physicians, nurses, health educators, and office staff. The guide, which has been found effective in many clinical settings, explains how to deliver routine preventive care to every patient, tells what services to provide, describes how to involve all staff, and explains how to evaluate and refine systems. The guide breaks the process into small, manageable tasks, and provides tools for tracking the delivery of preventive care, such as flow sheets (a simple form that gathers all the important data regarding a patient's condition) and health risk profiles. Other materials provided include questionnaires, presentation materials for use in introducing the system to administrators and office staff, and worksheets to identify staff interests and concerns.

Using PPIP Tools PPIP tools are part of the STEP-UP (Study to Enhance Prevention by Understanding Practice) clinical trial. STEP-UP involves 80 family practices and clinics across Northeast Ohio in urban, rural, and suburban areas, including large Amish populations. The STEP-UP study evaluates a preventive related delivery intervention that is tailored to the unique characteristics of each practice. A nurse facilitator is assigned to each practice to identify special prevention-oriented needs of the practice population, such as immunizations, screenings, and counseling. The STEP-up manual provides tools for clinicians to use as-is or modify. PPIP materials included in this manual are adult and child preventive care flow sheets, child immunization flow sheets, posters, and patient reminder postcards. The STEP-UP trial plans to continue using PPIP tools because they can easily be adapted to clinicians' needs as they work to enhance the delivery of preventive services to local patient populations.

Bioterrorism

Following the attacks of September 11, 2001, public attention has increasingly focused on the realization that the Nation=s health care system is ill prepared to respond to mass casualty incidents. This concern was heightened by the anthrax cases that followed in October 2001, which drew attention to bioterrorism and the various aspects of preparedness planning as it relates to mass casualty care due to infectious disease outbreaks.

AHRQ's bioterrorism initiative, which started before the attacks in 2000, is a critical component of the larger U.S. Department of Health and Human Services initiative to develop public health programs to combat bioterrorism. The Agency recognizes the need for a strong health infrastructure to coordinate, prepare for and respond to acts of terrorism.

To inform and assist primary care doctors and practices, community health centers, managed care organizations, emergency departments, and hospitals meet the health care needs of the U.S. population in the face of bioterrorist threats, AHRQ-supported research focuses on the following:

• Emergency preparedness of hospitals and health care systems for bioterrorism and other rare public health events.
• Technologies and methods to improve the links between the personal health care system, emergency response networks, and public health agencies.
• Training and information to prepare community clinicians to recognize the manifestations of bioterrorist agents and manage patients appropriately.

AHRQ's bioterrorism research is a natural outgrowth of the agency=s ongoing efforts to develop evidence-based information to improve the quality of the health care in the United States. Examples of products and tools that are currently or soon will be available include:

• Web-based training modules to teach health professionals how to address varied biological agents. Separate modules exist for emergency room doctors, radiologists, pathologists, nurses and infection control specialists. Clinicians can obtain continuing medical education (CME) credit at http://www.bioterrorism.uab.edu.
• A Real-time Outbreak and Disease Surveillance (RODS) System for bioterrorist events. The purpose of RODS is to provide early warning of infectious disease outbreaks, possibly caused by an act of bioterrorism, so that treatment and control measures can be initiated to protect and save large numbers of people.
• Use of a city-wide electronic medical records system as a model for surveillance and detection of potential bioterrorism events across a wide range of health care facilities, including primary care practices, public health clinics, emergency rooms, and hospitals.
• A new online survey that hospitals can use to assess their capacity to handle potential victims of bioterrorism attacks or for evaluating existing emergency plans. The survey covers subjects such as biological weapons training for personnel, procedures to permit rapid recognition of credentialed staff from other facilities, on-call nursing policies, and designated areas of emergency overflow for patients.

In 2002, AHRQ received over $10 million from other agencies to assist them and to continue efforts to support the national preparedness for a bioterrorist event. AHRQ's current bioterrorism activities continue to support departmental initiatives in the 3 broad areas stated previously. Through various contract mechanisms, AHRQ-funded researchers are preparing tools and models that can be exported to States and interested entities for use in their bioterrorism preparedness planning initiatives. Examples of projects currently underway include:

• Development of national guidelines for dispensing medications and/or vaccinating large populations in the event of a bioterrorist event.
• A Web-based data tool and manual that facilitates health care systems' ability to monitor and track resources that would be needed to respond to a bioterrorist event. This work will be developed with rural hospitals as a model.
• A Regional Health Emergency Assistance Line and Triage Hub (HEALTH) Model addressing the integration and communication with public health agencies and other facilities for efficient management of patient care during and after a public health emergency such as a bioterrorist event.
• Development of a report that provides an overview of current knowledge on how disaster drills and training are conducted and evaluated for bioterrorism preparedness and a tool for evaluating disaster drills and training that can be disseminated to States and other interested groups.
• Development of information technologies available in practice-based settings for surveillance of signs and symptoms of diseases that suggest bioterrorism in pediatric and adult primary care practices.
• Convening of an AHRQ-sponsored conference focused on preparedness and disaster responses for pediatric patients.

Future research initiatives will address considerations relevant to rural preparedness, vulnerable populations, pediatric care issues, and public-private partnerships related to the use of information technology for surveillance, detection, notification alerts, and education of clinicians.

Physician Preparedness A survey taken shortly after September 11, 2001, showed that on the eve of last years' anthrax attack, three-quarters of the 614 primary care physicians surveyed said they felt unprepared to recognize bioterrorism-related illnesses in their own patients. This survey, sponsored by AHRQ and the American Academy of Family Physicians, found that 38 percent of these physicians rate their knowledge of the diagnosis and management of bioterrorism-related illnesses as poor, and only about 18 percent said that they had prior bioterrorism training. The survey also found that being familiar with the public health system did not prepare them for knowing what to do in case of a bioterrorist act—only 57 percent reported knowing who to call to report a suspected bioterrorism case. These findings underscore the importance of preparedness for family physicians. Because the symptoms caused by many bioterrorism agents mimic those of common illnesses, patients may seek care first from their family physicians.

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Goal 2. Strengthening Quality Measurement and Improvement

The United States has many of the world's finest health care professionals, academic health centers, and other research institutions. Every day, millions of Americans receive high-quality health care services that help to maintain or restore their health and ability to function. However, far too many do not. A shockingly high percentage of patients receive substandard care.

Quality problems may be reflected in a wide variation in the use of health care services, underuse of some services, overuse of other services, and even misuse of services, including an unacceptable level of errors. Sometimes patients receive more services than they need or they receive unnecessary services that undermine the quality of care and needlessly increase costs. At other times they do not receive needed services that have been proven to be effective.

The research that provided much of the basis for the 2001 report by the Institute of Medicine (IOM) report, Crossing the Quality Chasm, goes back several decades to early studies on quality of care, most of which were supported by AHRQ and its predecessor agencies. In its report, the IOM pointed out that quality problems occur across all types of cancer care and in all aspects of the process of care. For example, the IOM report described "underuse of mammography for early cancer detection, lack of adherence to standards for diagnosis, inadequate patient counseling regarding treatment options, and underuse of radiation therapy and adjuvant chemotherapy following surgery."

Poor quality care leads to patients who are sicker, have more disabilities, incur higher costs, and have lower confidence in the Nation's health care system. There is great potential to improve the quality of health care provided to Americans, and AHRQ is committed to this goal. We are working to maintain what is good about the existing health care system while focusing on the areas that need improvement.

Improving the quality of care and reducing medical errors are priority areas for the agency. AHRQ is working to:

• Develop and test measures of quality.
• Identify the best ways to collect, compare, and communicate data on quality.
• Widely disseminate information about effective strategies to improve the quality of care.

Research on Improving Health Care Quality

The following are examples of AHRQ-sponsored research now in progress that focuses on improving health care quality as well as recent findings from AHRQ-supported research on improving health quality.

Benefits of regionalizing surgery for Medicare patients. In this ongoing study, researchers at Dartmouth Medical school are using Medicare data and data from AHRQ's Nationwide Inpatient Sample (NIS) to investigate the potential benefits of regionalizing patients who have certain high-risk procedures. In a recent journal article, they reported a 12 percentage point difference in survival for patients being treated for cancer of the pancreas at high- and low-volume hospitals. Only 4 percent of patients treated at the highest volume hospital died, compared with 16 percent at the lowest volume hospitals. Indeed, they found that elderly patients undergoing treatment for any one of 14 high-risk cardiovascular or cancer operations were more likely to survive if they were treated in high-volume hospitals. Researchers are now testing the best methods to provide this information to beneficiaries.

Improving obesity and diabetes education in vulnerable populations. These researchers are examining the effectiveness of a multimedia, computer kiosk-based program to educate patients about prevention of obesity and diabetes and diabetes self-management. Programs have been designed to be culturally competent for Hispanic and black patients and are intended to improve their knowledge, self-care practices, and ultimately, glucose control for those with diabetes. The computer kiosks have been placed in clinics and churches in Chicago in order to reach patients both within and outside the health care system.

Bringing evidence-based medicine to the hospital bedside. Researchers at the University of Iowa are carrying out a 3-year randomized study at 12 hospitals in Iowa, Missouri, and Illinois to evaluate the effectiveness and cost-effectiveness of implementing and evidence-based acute pain management guideline for hospitalized elderly hip fracture patients. The intervention targets both nurses and prescribing physicians and includes training, computerized learning modules, the use of opinion leaders, the use of feedback and reminder cards, and system interventions for modifying chart forms and institutional policy. The goals are to determine whether a multidimensional organizational intervention alters nurse and physician behaviors and whether institutional barriers to change are reduced.

Effects of nurse staffing levels on postoperative outcomes. A study published in June, 2002, shows a relationship between fewer registered nurses in hospitals and an unusually high number of cases of postoperative pneumonia. AHRQ researchers linked discharge data from hospitals in 13 States with American Hospital Association data on hospital characteristics and nurse staffing. They used the data to examine the impact of nurse staffing on four postsurgical complications: venous thrombosis/pulmonary embolism, pulmonary compromise, urinary tract infection, and pneumonia among patients undergoing major surgery. After controlling for severity of illness and hospital characteristics, fewer RN hours per patient day were found to be significantly associated with more postsurgical pneumonia. This study used different data and different methods but reached the same conclusions as another recent AHRQ-funded study by researchers at the Harvard School of Public Health and Vanderbilt University, which was published in the May 30, 2002 issue of the New England Journal of Medicine.

Implementing evidence-based screening for chlamydia. Chlamydia infection is the most common sexually transmitted disease in the United States. These infections cause severe reproductive problems and account for billions of dollars in costs to the U.S. health care system. Nevertheless, only about 20 percent of eligible women aged 15-25 are screened for chlamydia infection. A team from the University of California, San Francisco, and Kaiser Permanente found that it was possible to dramatically increase chlamydia screening rates through a sustainable and reproducible intervention. By engaging leadership, identifying barriers and solutions, and monitoring progress, participating clinics were able to increase screening 13-fold and decrease the average infection rate compared with control sites. Successful treatment of chlamydia will decrease future infertility.

Calls for Research on Quality Measurement and Improvement

In FY 2002, AHRQ called for research to examine two aspects of quality. The first Program Announcement (PA) seeks to fund research to better understand the impact of payment and organization on quality. Select for details.

The second PA was issued through Translating Research into Practice (TRIP). One priority under this PA is to compare the use of interventions to translate research into practice across different health care systems. A second priority is to measure the impact of translation activities, including the testing of interventions that foster measurable and sustainable quality and patient safety improvement or consistent quality and patient safety at a lower cost. By translating research into practice, this part of AHRQ's portfolio will complete the research pipeline and yield more immediate improvements in Americans' health care. Two examples of research grants funded under this program announcement follow.

• Surgical Volume Matters: Helping Patients Pick Hospitals. This grant will conduct a nationwide phone survey of Medicare patients who have undergone 1 of 14 high risk operations in the last 2 years to determine how they chose the hospital to have surgery. Among the factors that will be assessed are whether hospital volume influenced the choice, how involved the patient was in the decision process, and what resources were used to find out about hospitals. Also, the study will develop and field test formats for presenting information about hospital volume ratings to Medicare beneficiaries.
• Evidence-Based 'Reminders' in Home Health Care. This project stems from recognizing the great need for tested, efficacious, affordable strategies to translate evidence-based practice guidelines into home health practice. A parent grant tested the relative effectiveness and cost effectiveness of two alternative information-based strategies intended to improve provider performance and promote adherence to evidence-based practice guidelines among home health care nurses. A basic and an augmented intervention were used in heart failure patients. This study will extend data collection activities to cancer pain patients with malignant (as opposed to post operative) pain.

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