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Performance Plans for Fiscal Year 2001 and 2002 and Performance Report for Fiscal Year 2000

Agency for Healthcare Research and Quality

Performance Plans for Fiscal Year 2001 and 2002 and Performance Report for Fiscal Year 2000

Following is the Fiscal Year 2001 and 2002 Performance Plan (and 2000 Performance Report) of the Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research). The Fiscal Year 2002 President's budget request for AHRQ incorporates the annual performance plan required under the Government Performance and Results Act (GPRA). The Fiscal Year 2002 performance goals and measures are detailed in AHRQ's performance plan and are linked to both the budget and to the Strategic Plan of the Department of Health and Human Services (HHS). Performance targets in the plan depend partly on resource levels requested in the President's budget and could change based on congressional appropriation action.

GPRA requires that HHS plans and budgets be accountable for program results. The intent of the Act is to improve program performance by considering performance information in decisionmaking and by involving our partners and stakeholders in accomplishing program results.

Select for a summary of AHRQ's Fiscal Year 2002 performance plan.

Introduction
Fiscal Year 2000 GPRA Performance Report Results: Summary
Budget Line 1—Research on Health Care Costs, Quality, and Outcomes
          Goal 1: Establish Future Research Agenda Based on User's Needs
          Fiscal Year 2000 Performance Results
          Goal 2: Make significant contributions to the effective functioning of the U.S. health care system through the creation of new knowledge
          Fiscal Year 2000 Performance Results
          Goal 3: Foster translation of new knowledge into practice by developing and providing information, products, and tools on outcomes, quality, access, cost and use of care
          Fiscal Year 2000 Performance Results
          Goal 4: Evaluate the effectiveness and impact of AHRQ research and associated activities
          Fiscal Year 2000 Performance Results
          Goal 5: Support Department-wide Initiative to Improve Health Care Quality through leadership and research
          Fiscal Year 2000 Performance Results
Budget Line 2—Medical Panel Expenditure Survey
          Goal 6: Collect current data and create data tapes and associated products on health care use and expenditures for use by public and private-sector decisionmakers and researchers
          Fiscal Year 2000 Performance Results
Budget Line 3—Program Support
          Goal 7: Support the overall direction and management of AHRQ
          Fiscal Year 2000 Performance Results
Appendix 1. Approach to Performance Measurement
Appendix 2. Changes and Improvements Over Previous Year
Appendix 3. Linkage to HHS Strategic Plan
Appendix 4. Performance Measurement Linkages with Budget, Cost Accounting, Information Technology Planning, Capital Planning and Program Evaluation

Part 2. Program Planning and Assessment

Introduction—Structure of the AHRQ GPRA Fiscal Year 2000 Performance Report, Fiscal Year 2001 Revised Performance Plan, and Fiscal Year 2002 Annual Performance Plan

The AHRQ GPRA annual performance report and plans are aligned with the Agency's three budget lines:

Research on Health Care Costs, Quality, and Outcomes.
Medical Expenditure Panel Survey.
Program Support.

The first two budget lines are where Agency programs are funded. The cycle of research, used to structure the first four goals, is the basic framework from the Agency's strategic plan that is used when designing and implementing research projects.

What the Indicators Address	GPRA Goal
Budget Line 1: Research on Health Care Costs, Quality, and Outcomes—Subtotal for Fiscal Year 2002 = $255,145,000
Cycle of Research Phase 1: Needs Assessment	GPRA Goal 1: Establish Research Agenda Based on User's Needs
Cycle of Research Phase 2: Knowledge Creation	GPRA Goal 2: Make significant contributions to the effective functioning of the U.S. health care system through the creation of new knowledge
Cycle of Research Phase 3: Translation and Dissemination	GPRA Goal 3: Foster translation of new knowledge into practice by developing and providing information, products, and tools on outcomes, quality, access, cost and use of care
Cycle of Research Phase 4: Evaluation	GPRA Goal 4: Evaluate the effectiveness and impact of AHRQ research and associated activities
Lead role for quality initiative	GPRA Goal 5: Support Department-wide Initiative to Improve Health Care Quality through leadership and research
Budget Line 2: Medical Expenditure Panel Survey—Subtotal for Fiscal Year 2002 = $48,500,000
Core MEPS activities	GPRA Goal 6: Collect current data and create data tapes and associated products on health care use and expenditures for use by public and private-sector decisionmakers and researchers
Budget Line 3: Program Support—Subtotal = $2,600,000
Agency management activities: contracts management and the AHRQ Intranet.	Goal 7: Support the overall direction and management of AHRQ

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Performance Measures/Indicators

AHRQ uses a combination of process, output, and outcome indicators to present its performance information.

Process measures: To monitor the establishment of major new initiatives or implementation of improvements in core activities where significant resources are involved or the potential for significance of the ultimate impact is high.
Output measures: To record the results of research initiatives and dissemination activities essential to moving to the next step of implementation.
Outcome measures: To show the impact (or potential for impact) in affecting the outcomes, quality, access, cost, or use of health care.

AHRQ Performance Indicators

Performance Indicator	Year One	Years 3-5	Years 3-10
Phase of initiative	Research initiative starts	Results received	Results used in health care system
Indicator type	Process indicators	Output indicators	Outcome indicators
Indicator examples	Grants funded, creation of reports, partnerships formed	Publications, Web site, dissemination, research findings, reports, products available for use in health care system	Results of evaluation studies, users stories, analysis of trend/other data

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Crosswalk to the Budget Document

Where appropriate, links to the budget request are listed with the corresponding GPRA objective. In many cases the funding for activities, such as evaluation studies or dissemination activities, are captured in the base and there will not be a corresponding description in the text.

Fiscal Year 2000 GPRA Performance Report Results Executive Summary

The mission of the Agency for Healthcare Research and Quality is to conduct and sponsor research that will help improve the outcomes and quality of health care, reduce costs, address patient safety and medical errors, and broaden access to effective services. AHRQ's ability to sustain a high level of performance during fiscal year 2000 is evidenced by how its research has been used to provide better health care and the impact it has had on the delivery of health care services.

In fiscal year 2000, AHRQ:

Awarded 348 research grants (competing and non-competing), over 100 more than were awarded in the previous fiscal year.
Capitalized upon the research capacity of, and opportunities provided by, integrated delivery systems through the creation of an integrated delivery systems research network (IDSRN).
Established the foundation for a new data center where approved users can work in a secured data center to gain access to a broader range of data from the Medical Expenditure Panel Survey (MEPS) than is available publicly.
Awarded 80 training and career development awards.
Saw continued growth in the number of health plans (now over 500) submitting data to its Consumer Assessment Health Plan (CAHPS), a survey and reporting program that helps employees choose among survey health plans.
Established 19 primary care practice-based research networks (PBRNs).
Reached 853 in the number of evidence-based clinical practice guidelines that can be accessed through its National Guideline Clearinghouse™ (NGC).
Documented over 18,207,000 requests for NGC information during the course of over 1,665,000 visits to the NGC Web site from nearly 59,000 organizations.
Developed a draft of a long-term care (LTC) research agenda for the agency and the Department that is driven by user input collected at AHRQ- sponsored expert and User Liaison meetings.

The above listing, however only begins to capture the nature of AHRQ research and the Agency's role within the federal health care infrastructure. As the only federal agency specifically charged with providing information to the people who make decisions about health care, the research AHRQ sponsors and conducts undergirds the work of several federal agencies such as: Food and Drug Administration (FDA), National Institute of Health (NIH), Centers for Disease Control & Prevention (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA) and others. These agencies, and the decisionmakers who run them, are a key consumer group for AHRQ.

User Input

Key to the Agency's success in carrying out its mission is its user-driven agenda. AHRQ regularly requests input from its customers (public and private sector) through a variety of vehicles, including: the National Advisory Council, expert meetings, Federal Register notices, and public comments submitted through its Web site, www.ahrq.gov.

This user-driven research agenda may be thought of as a three-part research pipeline which:

Supports new research on priority health care issues.
Develops the tools and talent for knowledge creation.
Translates research into practice.

New Research

The first pipeline segment is about fundamental research that address important questions about what worked in American health care. Further, it is about moving from using conventional practices in medicine (organizational and financial, as well as clinical) to using the most valid scientific information available. It is about outcomes, about links between processes and outcome, how to measure quality, and about health expenditures, among other topics.

It is knowledge creation in the most literal sense of that term.

In Fiscal Year 2000, AHRQ provided $39.9 million to fund more than 120 new grants that were investigator initiated. The topics cover the gamut of health services research and allow AHRQ to fund important research which often may not fit within an RFA. The Agency funded an additional 106 small conference, conference and dissertation grants ($4.3 million). Some examples of these grants include the following:

Develop measures of the activities of managed care organizations (MCOs) and collect data to create the largest dataset in the country with information relevant to understanding growth of MCOs. These data will then be used to evaluate the impact of MCO growth on costs, utilization, and patient outcomes, and the impact of legislation and regulations on MCO growth.
Assess the reliability and efficacy of telemedicine for common, acute complaints of children presenting to the emergency department or primary care office setting.
Identify reasons for variability in the interpretation of mammograms in various communities.

Developing Tools and Talent

The second segment of AHRQ's pipeline is about the instruments used and the people mobilized to translate this new knowledge into practice. Among AHRQ's "tool-chest" in this regard are CAHPS and its Computerized Needs-Oriented Quality Measurement Evaluation System (CONQUEST), the quality measures derived from the Healthcare Cost and Utilization Project (HCUP) and Q-SPAN, and the quality improvement tools created from use of Evidence Reports (ERs) and Technology Assessments (Tas). In the area of preventive care, AHRQ provides technical support for the U.S. Preventive Services Task Force (USPSTF), an independent panel of preventive health experts charged with evaluating the scientific evidence for the effectiveness of a range of clinical preventive services.

AHRQ has been very successful in its partnerships with a wide variety of Federal agencies, academic institutions and health care organizations. Decisionmakers use the evidence developed through AHRQ-sponsored research, and the tools developed from those findings, to help make informed decisions about what works, for whom, when and at what cost.

Among the most visible examples of AHRQ's partnerships are its Evidence-Based Practice Centers (EPCs). For the past four years, AHRQ has been a science partner with leading public and private research institutions nationwide in conducting scientific reviews and syntheses of scientific literature. Each EPC has a five year contract to review assigned specific topics in clinical care. Nominations for these topics are routinely solicited from professional organizations, delivery systems, and others as well as accepted on an ongoing basis. Among the prime criteria for topic selection are whether these clinical care topics are common, expensive, and/or significant for Medicare and Medicaid populations.

With regard to talent, in fiscal year 2000 AHRQ funds ($3.6 million) supported 218 scholars, a 25% increase over the number of pre- and postdoctoral trainees and fellows supported in Fiscal Year 1999. In addition, fiscal year 2000 saw the launch of two career development programs, (the Independent Scientist Award (K02) and the Mentored Clinical Scientist Development (K08) programs), making it the first time the agency has invested in both intramural and extramural career development activities. These latter two programs supported an additional 16 scholars. Along with the National Institutes of Health, AHRQ also expanded opportunities available under the National Research Service Award program to include sponsorship of individual pre-doctoral fellowships for underrepresented minority students.

Translating Research

The final pipeline segment brings together the investment to achieve measurable improvements in health care. It combines the knowledge from the first pipeline segment with the tools and talent developed in the second to close the gap between what we know and what we can do to improve health care quality.

During an initial round of Translating Research into Practice (TRIP) grants in fiscal year 1999, the Agency sponsored work on a wide range of topics. Through its Translating Research into Practice II (TRIP II) initiative, in fiscal year 2000 AHRQ funded a second round of grants ($5.7 million) that more than doubled the number of projects funded in the first round. TRIP II focuses on seven specific areas: the six found in the race and disparities initiative (infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection/AIDS, immunizations) and pediatric asthma. Each of these TRIP II grants requires partnerships among researchers, health care systems and organizations to evaluate strategies for improving the quality of care. The expectation of the Agency is that this strategy will result in more rapid uptake of research results by providing an incentive for health care organizations to evaluate alternative improvement strategies.

To complement this initiative and further foster partnerships, in Fiscal Year 2000, AHRQ awarded planning grants ($2.0 million) to 19 primary care practice-based research networks (PBRNs), groups of ambulatory practices devoted principally to the care of patients, affiliated with each other in order to investigate questions related to community-based practice. This funding supports the efforts of the PBRNs to design systems that will facilitate the translation of research into practice and to assess the impact of these systems on care delivered.

In addition, AHRQ has partnered with nine Integrated Delivery System Networks (IDSRN) to link the nation's top researchers with the some of the country's largest health care systems. As a group, the networks provide health services to over 34 million Americans, including the privately insured, Medicare and Medicaid patients, and the uninsured. This new model of field-based research will enable AHRQ to accelerate the pace of its research on key concerns such as medical care quality and safety, access to services and costs.

Additionally, AHRQ oversees the Put Prevention Into Practice (PIPP) initiative, which serves as the implementation vehicle for USPSTF's age-specific and risk factor-specific recommendations on preventive care.

Evaluations

To understand and report on the impact of AHRQ programs on health care, additional emphasis is being placed on evaluation activities. As a result, AHRQ was able to report on process, output, and interim outcome goals for its major initiatives. The Fiscal Year 2000 evaluation portfolio included a number of evaluations that assessed the impact of research products used to inform customers, measure quality, and make policy decisions. For example:

Evaluations of existing programs which are helping to shape their future development

Evaluation of the National Guideline Clearinghouse™.
Evaluation of Performance of the Medical Expenditure Panel Survey (MEPS).
Evaluation of CONQUEST.
Development and Implementation of the Evidence-Based Practice Center (EPC) Program.

Evaluations to assist in the design of new initiatives

Review of Existing Reporting Systems to Inform the Development of the National Quality Report.
Development of Priority Populations Report to Congress (Design Phase).

Evaluations in response to specific Congressional requests

Study of the Per-Patient Cost and Efficacy of Treatment for Temporomandibular Joint (TMJ) Disorders.
Vision Rehabilitation within Models of Care and Benefit Plans.

Leadership on Health Care Quality

Shortly after the agency's renaming, it adopted a new slogan, "Quality Research for Quality Healthcare." This phrase underscores the agency's commitment to research on quality measurement as well as quality improvement.

In this area, over 80 AHRQ-funded investigators are now studying issues as far ranging as:

Quality improvement in caring for newborns with jaundice.
The comprehensiveness of prescription drug coverage as a measure of quality care among elderly beneficiaries with chronic health conditions.
Identification of hospital-based quality improvement interventions that are most effective in increasing use of beta-blockers after acute myocardial infarction.

AHRQ has taken a lead role in the QuIC Task Force efforts to address medical errors and patientsafety in the U.S. Medical error and patient safety aren't well understood by most Americans. When the need for vital or risky health services occurs, patients want to believe that someone else has made sure the care they receive is safe. Sadly, every hour, 10 Americans die in a hospital due to avoidable errors; another 50 are disabled. As part of its efforts to improve patient safety and reduce medical errors, the QuIC Task Force has published Five Steps to Safer Health Care. The five steps were distilled from an earlier AHRQ publication, "20 Tips to Reduce Medical Errors." Those evidence based recommendations provide patients with guidance on how to improve their safety and have been widely adopted across the government through the QuIC. As an example, the OPM has included them in this years health benefits brochure.

As lead agency of the QuIC, AHRQ coordinated publication of a landmark report, Doing What Counts for Patient Safety—Federal Actions to Reduce Medical Errors and Their Impact, a response to the 1999 Institute of Medicine (IOM) report, To Err is Human.

As the Department's leader on healthcare quality, AHRQ has continued funding patient safety research. The agency awarded six grants ($2.1 million) covering topics as diverse as medical errors in primary care, use of decision support to reduce errors in emergency cardiac care, and development of a public-private patient safety consortium to study building a national evidence base for developing best practices for patient safety.

In collaboration with the National Center for Health Statistics and other agencies, AHRQ began the foundation work for the first annual report ever produced on U.S. healthcare quality, the National Quality Report (NQR). When completed, the NQR will show how the system is faring and where improvements may be needed.

Health Care Disparities

A similar agency effort is underway to produce a national disparity report. The National Disparities Report, targeted for release in 2003, will address prevailing disparities in health care delivery as it relates to racial and socioeconomic factors in the priority populations of rural, inner-city, low-income groups; minority groups; women; children; the elderly; and individuals with special health care needs. Life expectancy and overall health have improved for many Americans, but too many racial and ethnic minorities still suffer disproportionately from diabetes, cancer, and other diseases. We believe that through research partnerships, we can expand the magnitude of our efforts to ensure that all Americans receive high quality health care services.

In Fiscal Year 2000, AHRQ, in partnership with the Office of Research on Minority Health and the National Cancer Institute, funded ($4.8 million) a major new research initiative that will improve knowledge of the factors underlying ethnic and racial inequities in health care and help identify practical tools and strategies to eliminate such disparities, the EXCEED (Excellence Centers to Eliminate Ethnic/Racial Disparities) initiative. The studies also will help identify practical tools and strategies to eliminate these disparities. The themes of the projects include doctor-patient communication, racial health disparities in rural settings, under use of established and effective medical and surgical interventions, health issues of particular importance to elderly American Indians and Alaska Natives, health care access and quality for vulnerable African Americans, differences between white and minority elderly populations in health status, and factors that influence health care use and behavior.

MEPS

On the cost and utilization side, AHRQ conducts the Medical Expenditure Panel Survey (MEPS) that provides up-to-date, highly detailed information on how Americans as a whole, as well as different segments of the population, use and pay for health care. In fiscal year 2000, the impact of MEPS data and associated products on policymaking and research products was evaluated at a continuing high level, and the use of data and products from the MEPS databases increased dramatically. Users downloaded over 5,700 MEPS data files from the new MEPS Web-site, an additional 379 CD-ROM's containing MEPS data were distributed through the AHRQ clearinghouse, and AHRQ responded to 670 user requests for technical assistance.

The MEPS data was used to inform policy decisions in numerous public and private sector agencies around issues that included establishing a baseline measure for the Healthy People 2010 objective on oral health and preventive dental visits; comparing estimates of prices paid for drugs by elderly and nonelderly persons with and without health insurance for prescribed medications; validating an actuarial model; helping to create a profile of the population living with chronic illness; estimating national health expenditure rates for the elderly; and informing estimates of out-of-pocket expenditures by individuals not covered by the government or their own insurance policy. Customer satisfaction was rated high (90%), and feedback from recipients of MEPS data indicated that the data were timely and useful.

The data currently collected from MEPS will support quality of health care research directed to the following broad areas: access to care, patient/customer satisfaction, health insurance coverage, health status, health services utilization and expenditures. By August 2000, design enhancement decisions to modify the MEPS to facilitate collecting data to inform the National Healthcare Quality report were completed. The planned MEPS healthcare quality enhancements call for a significant household survey sample expansion of individuals with certain illnesses of national interest in terms of patient satisfaction with care received, the quality of the care and the burden of disease. The intent of this planned enhancement was to permit more focused analyses of the quality of care received for these special populations. It was recommended that the following medical conditions be given special attention for implementing MEPS healthcare quality enhancements: Diabetes, Asthma, Hypertension, Stroke, Ischemic Heart Disease, Arthritis, and COPD . It should be noted that the selection of diabetes and ischemic heart disease as targeted conditions also cover two clinical areas that are the focus of the disparities agenda ( i.e., diabetes, cardiovascular disease).

Conclusion

AHRQ's agenda has reflected, and continues to reflect, the most pressing issues in health care research. These issues have fueled the growth of outcome-centered research over the years. Building on the last 10 years of investment in outcomes and health care research, in fiscal year 2001 AHRQ will focus on national priority areas for which much remains unknown.

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