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

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

Budget Line 1—Research on Health Care Costs, Quality, and Outcomes

Funding Levels

Fiscal Year 1999: $139,314,000 (Actual).
Fiscal Year 2000: $165,293,000 (Enacted).
Fiscal Year 2001: $226,446,000 (Appropriation).
Fiscal Year 2002: $255,145,000 (President's Budget)

This budget line represents the bulk of the Agency's research (extramural and intramural) portfolio. Dissemination and evaluation activities as well as the Agency's lead role in the Quality Interagency Coordination Task Force (QuIC) are also included. The first five of the annual performance plan's six goals are used to track Agency performance in these areas.

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GPRA Goal 1: Establish Research Needs Based on User's Needs. (HCQO)

Strategy

Cycle of Research Phase 1: Needs Assessment

In the field of health services research, the user of the information plays a critical role. If health services research is to improve the quality of health care, it must provide answers to the questions and issues that represent the barriers to improvement. AHRQ emphasizes open communication with users of its research to ensure that it is addressing important questions. Through continued emphasis on the first phase of the cycle of research, needs assessment, AHRQ will continue to assure that the Agency's research begins and ends with the user.

Types of Indicators: Output

Use of results by AHRQ

Input received on specific topic areas and health care issues are used in the Agency's program and budget development activities. The result is inclusion of many identified research areas that will assist users.

Data Issues

To provide context for reviewing the advice received from users, and to determine the initiation of research, AHRQ reviews major articles in the research literature pertaining to a particular subject area. This allows the Agency to assess where the user input fits into the current body of research and how best to proceed. Through a 1999 study conducted by the Lewin Group, we learned that user input loses much of its critical meaning when aggregated. The Agency has created a data management system that will electronically store the source document and have word search capability so that staff can identify relevant documents and access them efficiently from their desk top computers when performing program and budget development activities. Additionally, to ensure that the input from users is incorporated into Agency activities, a number of check points have been integrated into the planning processes where user input is explicitly identified and assessed in relation to the proposed activities.

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GPRA Goal 1 - Fiscal Year 2000 Results

Objective 1.1: Define direction of Fiscal Year 2000 project funding priorities, in large part, by needs assessment activities.

Indicator 1

Agency research agenda covering three strategic research goals and the new Fiscal Year 2000 "Closing the Gap" initiatives are documented based on consultations with various groups.

Results

AHRQ strategic research goals include supporting improvements in health outcomes, strengthening quality measurement and improvement, and identifying strategies to improve access, foster appropriate use, and reduce unnecessary expenditures. Three of the Agency's Fiscal Year 2000 initiatives that focused on "Closing the Gap" between the knowledge resulting from funded research and the translation of research findings into practices that improve the health care Americans receive are:

Long-term Care. In Fiscal Year 2000, AHRQ held three meetings to obtain user input, developed the draft of a long-term care (LTC) research agenda and associated work plan for the Agency and the Department, prepared a report on the first expert meeting, and increased AHRQ-financed LTC research activities.

The draft plan is based on feedback collected at two expert meetings and one User Liaison Meeting sponsored by AHRQ in Fiscal Year 2000. The overall goal of AHRQ is to foster research on the LTC population that answers priority research and policy questions. Major goals identified by the users were to: 1) evaluate the quality of the overall system of care (including transitions in care) for persons requiring LTC, in both the community and residential settings, 2) monitor the variation in LTC programs and assess implications for access, outcomes of care and quality of life outcomes and 3) monitor the financial implications of the high cost of LTC care for consumers and payers. To accomplish these goals, the Agency developed in Fiscal Year 2000 a multi-year work plan that focused initially on the development of an integrated data system that in time would support the research agenda. This plan will be publicly available by January 2001.

Translating Research Into Practice II. An implicit premise underlying the establishment of AHRQ was that supporting studies using data from typical practice settings would be relevant to clinical practice and that the results would be translated into practice rapidly. In short, studies assessing the impact of clinical care on outcomes or end results would be expeditiously translated into improved outcomes. In 1998, AHRQ conducted an internal evaluation (The Outcome of Outcomes Research at AHCPR) to assess the impact of the first decade of its outcomes research program, and found that while some findings had resulted in improved patient outcomes, particularly for Medicare beneficiaries, many studies had not achieved the highest level of impact. At the same time, systematic reviews of the impact of research on clinical practice reported that knowledge of "what works" was necessary but not sufficient to effect change. Improved practice and outcomes also required incentives for change and a supportive practice environment.

In 1999 and 2000, Agency staff consulted with external stakeholders to obtain feedback on the critical question of how the Agency could support research that would accelerate the translation of research into practice. Consistent themes from these consultations included:

Many stakeholders, including those attempting to improve outcomes and quality in their institutions, perceive that outcomes research must include an explicit focus on evaluating alternative strategies for translating research findings into practice.
Increased demands for accountability from purchasers have stimulated enormous interest within health care delivery organizations to create change.
Published articles do not include sufficient details to help those attempting to replicate successful results to do so easily. For example, chart review forms and precise measure specifications are frequently not included in peer-reviewed articles.
There is far too little evidence about how research can be translated into improved quality and outcomes, and almost no information on the sustainability of improvements.

Based on this input, in Fiscal Year 2000 AHRQ developed a research initiative (Translating Research Into Practice II or TRIP II) with the dual goals of promoting sustainable improvements in the quality and outcomes of healthcare. Extending investments in Fiscal Year 1999 that evaluated strategies for translating research into practice under ideal conditions, and addressing stakeholders' concerns, the TRIP II initiative explicitly required partnerships between researchers and health care organizations to encourage collaboration at all phases of the research, with the expectation that this strategy would result in more rapid uptake of research results. Rather than providing direct support for improvement programs, AHRQ's support would provide an incentive for health care organizations to evaluate alternative improvement strategies. The initiative further specified that an important objective was to produce tools for improvement that could be made available for broad use through an electronic clearinghouse or toolbox, and that a program evaluation would focus explicitly on the sustainability of observed improvements in practice and outcomes.

Patient Safety Initiative. The Congress has instructed AHRQ to support the development of guidance on the collection of uniform data related to patient safety. AHRQ has initiated this work with an evaluation of existing state reporting systems which will be released in early February 2001. In addition, in Fiscal Year 2000, AHRQ funded the following six new research projects designed to improve patient safety by identifying and preventing avoidable system errors:

Characterizing Medical Error: A Primary Care Study. Principal investigator: Steven H. Woolf, M.D., Virginia Commonwealth University, Richmond, VA.

This study seeks a new perspective on the definition of medical error by gathering the input of primary care patients and their providers. In-depth interviews will be conducted with approximately 45 primary care patients from Virginia and Ohio from various demographic groups. Their perspective will be contrasted with that of 10-20 primary care physicians, who will participate in a telephone interview that explores their experience with errors and seeks their reaction to the patient's comments. The study seeks to find out what constitutes a medical error and the experiences the victims of error consider most common and most serious.
TIPI Systems to Reduce Errors in Emergency Cardiac Care. Principal investigator: Harry P. Selker, M.D., New England Medical Center, Boston, MA.

This project addresses the problem of medical errors in emergency department triage and treatment of acute cardiac ischemia by introducing a time-insensitive predictive instrument to provide concurrent, real-time decision support using tested and statistically based information. The intervention will be introduced in a stepwise fashion, and a before-after time-series design will be used to measure its impact.
Improving Safety by computerizing Outpatient Prescribing. Principal investigator: David W. Bates, M.D., M.Sc., Brigham and Women's Hospital, Boston, MA.

This project will study the impact of electronic medical records and computerized medication prescribing on adverse drug events (ADE) in outpatient clinics associated with Partners HealthCare System and the Regenstrief Institute at Indiana University. The study has three primary goals. The first is to develop improved methods for ADE detection by the use of an automated ADE monitor. The second goal is to study the impact of electronic prescribing on preventable ADE rates in the outpatient setting by examining whether a basic electronic prescribing system can influence the prescribing process. Finally, the applicants plan to disseminate the knowledge gained in ADE monitoring and prevention and potential cost savings to encourage other institutions.
Teamwork and Error in Neonatal Intensive Care. Principal investigator: Eric J. Thomas, University of Texas Medical School, Houston, TX.

This project will assess team-related, error-management behavior in the hospital neonatal intensive care unit (NICU). It will adapt the aviation model of teamwork and medical error management to NICU teams by conducting focus groups with NICU personnel and analyzing videotapes for a prospective cohort of preterm infants recorded during two critical periods: initial resuscitation and the first 90 minutes of admission to the NICU. The data derived from focus group sessions and videotape analysis, along with data from previous work, will aid in the design of an intervention to improve these behaviors and address elements of the organizational and professional culture that influence the frequency of error.
Brief Risky High Benefit Procedures: Best Practice Model. Principal investigator: Colin F. MacKenzie, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD.

This project will study and evaluate the procedure of chest tube thoracostomy insertion at the Maryland Shock Trauma Center using video and audio recordings to demonstrate how medical errors can be reduced through the use of a practice guideline. The goals are to create a best practice model for chest tube insertion; examine diagnostic procedures, indications, and techniques under elective versus emergency conditions; and develop a best practice training guideline to reduce complications from chest thoracostomy insertion and improve patient safety.
Developing Best Practices for Patient Safety. Principal investigator: Mark B. McClellan, Stanford University, Stanford, CA. Total projected funding:

This project will develop a public-private patient safety consortium between leading national organizations and 14 northern California hospitals serving diverse populations. The goals of this consortium will be to conduct a collaborative study to build the national evidence base for measuring and predicting patient safety performance and to develop cost-effective strategies for improving safety practices in hospitals. The study will analyze data from event reporting systems using internal hospital surveys and a new database on medication safety procedures and a new instrument to be used is the patient safety culture survey.

Go to http://www.ahrq.gov/qual/errorsix.htm for more information on patient safety.

GPRA Goal 1—Fiscal Year 2001 and 2002 Indicators

Goal 1 Objectives
Objective 1.1: Define direction of Fiscal Year project funding priorities, in large part, by needs assessment activities.

Fiscal Year 2001 Indicator
Agency research agenda in strategic goal areas for Fiscal Year 2001 priorities (patient safety and informatics) is documented based on consultations with various groups.

Baseline: First reports produced in Fiscal Year 1999.
Budget: Commitment Base

Fiscal Year 2002 Indicator: Agency research agenda for the Fiscal Year 02 priorities (investigator-initiated research, national quality report, national disparities report) is documented based on consultation with various groups.

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GPRA Goal 2: Make significant contributions to the effective functioning of the U.S. health care system through the creation of new knowledge. (HCQO)

Strategy: Cycle of Research Phase 2: Knowledge Creation

There are many gaps in knowledge in all areas of health care. New questions emerge as new technologies are developed, the population's demographics change, areas of inquiry previously under-emphasized take on greater importance, and research previously undertaken identifies further areas that need attention. Therefore, AHRQ will continue to focus on creating new knowledge through its peer reviewed extramural and intramural research and assessing the findings that result from completed projects.

Type of Indicators

Process and Output

Use of Results by AHRQ

AHRQ uses three approaches to illustrate how it addresses its core activity of creating new knowledge. First, the Agency documents science advances that have resulted from its investment of funds, staff, and other resources. This enables the Agency to do the following:

Identify and highlight significant research findings from research funded or sponsored by AHRQ.
Focus its translation and dissemination activities to maximize the potential use of critical findings in the health care system.
Annually assess progress toward filling the gap between what we know and what we need to know about health care.

Second, AHRQ documents coverage in major journals and/or evidence of use of research findings. Coverage by popular and professional media is highly competitive. AHRQ's receiving coverage is an initial indication that its investment in research has the potential for significant impact when disseminated and implemented widely. The actual use of the finding by purchasers, professional associations, managed care organizations, and/or insurers also signals that the new knowledge has the potential to make a difference. The ultimate outcome or impact will be evaluated after the finding has been implemented over a period of time.

Third, the statistics on number of grants funded and dollars invested in particular areas are used to determine whether the AHRQ portfolio has a significant body of work underway to begin to inform the field. They are also used in gauging the investment in these areas vs. other programs as AHRQ allocates its resources.

Data Issues

AHRQ knows it cannot collect 100% of the available data on the publication and use of its research findings. Collecting data and/or anecdotes on the use of research results or tools is largely done through searches of the literature, media outlets, and Internet listings and tracking by project officers in consultation with grantees. Underscoring the commitment of the Agency to document and understand the use of its research, staff from the AHRQ Office of Health Care Information, Division of User Liaison and Research Translation have as a particular focus the tracking of documented evidence of the use. The information is captured through regular communications with partners, researchers, associations, and Federal, State, and local governments. Anecdotal information is used only when it can be verified with the actual user. Documentation of the use is sought whenever possible. AHRQ continues to look for ways to introduce efficiencies in this labor-intensive effort.

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GPRA Goal 2 - Fiscal Year 2000 Results

Objective 2.1: Determine the salient findings from research for three priority populations and develop plan for next steps in translation and dissemination.

Indicator 1

Annual report on science advances in three research goal areas.

At least four major findings in each area that have potential to save significant amounts of money, improve quality, save lives or prevent physical suffering, or change the organization and delivery of health care.

Results

AHRQ investments in effective strategies for translation and dissemination have been successful, and are evidenced by the following examples:

Heart Disease. "Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain: The ERASE Chest Pain Trial" - Selker.

The ERASE Chest Pain clinical trial has shown that patients who receive the sestamibi scan as part of their ED care were significantly more likely to be discharged safely and directly home from the ED. This represents a 20% reduction in unnecessary admission rates for patients without true acute cardiac ischemia, possibly avoiding approximately 240,000 unnecessary hospitalizations per year.

Translation and Dissemination. Activities have included announcement at the annual American Heart Association meeting, a publication in preparation, an AHRQ press release, and presentation at the National Heart Attack Alert Program meeting.

Depression. Depression PORT intervention tool: "Improving Depression Outcomes in Primary Care: A User's Guide to Implementing the Partners in Care Approach"

The quality-improvement toolkit is a collection of components that provide information and specific materials needed to understand and implement the Partners in Care approach to improving care for depression. The components are comprised of introductory materials, training manuals, materials for primary care physicians and nurses, quick reference cards, a range of therapy manuals, materials for patients, and videotapes. All of these materials can be used by various provider and service plans to improve depressed patient outcomes. Impact analysis after one year disseminating a QI program for depression in primary care practices found that the QI interventions improved use of medications and psychotherapy, reduced symptoms, increased employment retention of depressed MCO patients, and that medical visits did not increase overall.

Translation and Dissemination. AHRQ is marketing via Web site notices and letters to professional organization members the "tool" kit for purchase directly from RAND as a total package or in pieces. In addition, the findings from a study using the tool was published in a peer-review journal: Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial [published erratum appears in JAMA 2000 Jun 28;283(24):3204] JAMA 2000 Jan 12;283(2):212-20.

Low Birthweight Babies. Robert L. Goldenberg, M.D., University of Alabama, "Low Birthweight in Minority and High-Risk Women"

One of the results of the Low Birthweight PORT was the identification of effective strategies for the management of Group B strep neonatal infections. This past year, an article was published documenting a decrease in group B strep neonatal infections in a population-based surveillance in 8 states following dissemination of CDC recommendations. If projected nationally, 3900 infections and 200 deaths would be prevented.

Translation and Dissemination. Publication in The New England Journal of Medicine.

Stroke. David B. Matchar, M.D., Duke University, "Secondary and Tertiary Prevention of Stroke Patient Outcomes Research Team"

The Stroke PORT released its phase I final report in June 2000. The investigators of the research team found that anticoagulation with warfarin though an effective therapy in preventing stroke related to atrial fibrillation is underprescribed by the clinical community. One particularly significant contribution of the Stroke PORT final report is the inclusion of programming codes, input data and algorithms used in a stroke policy model that can be utilized in clinical policy decision-making to estimate the impacts of different stroke prevention/treatment and quality improvement efforts.

Translation and Dissemination. The release and publication of the complete documentation specifications for the stroke policy model represent the first ever effort in facilitating and encouraging the use of the model in other studies of stroke interventions by the greater research and clinical policy making communities. To further disseminate this policy tool, we are currently exploring steps needed to develop a more user-friendly interface for the stroke policy model to be accessible via the Internet.

Schizophrenia. Anthony F. Lehman, M.D., University of Maryland, "Schizophrenia Patient Outcomes Research Team".

Translation and Dissemination. Through a study of the State Mental Health Agencies (SMHAs), it was determined that at least seven states have adopted the Treatment Recommendations developed through the PORT as official state policy for the treatment of persons with schizophrenia.

Indicator 2

Results

The following are published examples of AHRQ-sponsored studies that have the potential to impact the outcomes, quality and cost, access and use of healthcare:

Quality of Care. "New Imaging Test Helps ER Doctors Separate Out Faster Patients in Danger of Heart Attack," Harry Selker and others. Presented at the 72nd annual meeting of the American Heart Association, November 10, 1999.

"The Impact of Disseminating Quality Improvement Programs for Depression in Managed Care: A Randomized Controlled Trial," Kenneth Wells and others, Journal of the American Medical Association, January 11, 2000.

"Lack of Progress as a Reason for Cesarean," Deidre Spelliscy and others, Obstetrics and Gynecology, April 1, 2000.

"Many Heart Attack Patients Present Without Chest Pain," John Canto and others, Journal of the American Medical Association, June 28, 2000.

Outcomes of Care "Out-of-Hospital Pediatric Endotracheal Intubation—The Effect on Survival and Neurological Outcome: A Controlled Clinical Trial," Marianne Gausche and others, Journal of the American Medical Association, February 8, 2000.

"Comparison of Treatment Recommendations by Urologists and Radiation Oncologists for Men with Clinically Localized Prostate Cancer," Michael Barry and others, Journal of the American Medical Association, June 28, 2000.

"A Randomized Controlled Clinical Trial of Methods to Encourage the Use of Antenatal Corticosteroid Therapy for Fetal Maturation," Laura Leviton and Robert Goldenberg, Journal of the American Medical Association, January 5, 1999.

"Teaching Versus Non-Teaching Hospitals: Mortality and Quality of Care for Medicare Patients with Acute Myocardial Infarction," Jeroan Allison and others, Journal of the American Medical Association, September 12, 2000.

Access, Use And Costs of Care. "Organization and Financial Characteristics of Health Plans: Are They Related to Primary Care Performance?" Dana Gelb Safran and others, Archives of Internal Medicine, January 9, 2000.

"The Value of Medical Testing Before Cataract Surgery," Oliver Schein and others, New England Journal of Medicine, January 20, 2000.

"Relation of Race and Sex to the Use of Reperfusion Therapy in Medicare Beneficiaries with Acute Myocardial Infarction," John Canto and others, New England Journal of Medicine, April 13, 2000.

"Expenditures for Physician Services Under Alternative Models of Managed Care," Jose Escarce and others, Medical Care Research and Review, June 1, 2000.

Indicator 3

For each finding, specific steps in translation and dissemination are identified and initiated.

Results

AHRQ employs a range of strategies to disseminate extramural and intramural study findings through publications in the peer reviewed journals, as well as AHRQ generated and disseminated reports, statistics, software products, and patient and consumer education materials. Depending on subject and target audiences, the following are specific strategies AHRQ uses to publicize and disseminate new information:

Research Activities, a monthly periodical, summarizes AHRQ studies and announces all of the Agency's public information. It has about 50,000 subscribers from the research, policy, practitioner and other communities. Research Activities is also available online through AHRQ's Web site.
AHRQ Electronic Newsletter, an on-line newsletter, publishes short notices about on-going Agency-sponsored studies. The subscription list for this new information vehicle is 5,000 and growing.
Media Outreach is a core Agency strategy for marketing AHRQ-related information through press releases to mass media, including the trade press, and other specialized press, such as minority, business and consumer media. These releases can range from HHS- or AHRQ-letterhead press releases on issues of broad interest, to shorter "Research Bulletins" and other types of news announcements for more limited markets. In addition, AHRQ organizes and publicizes press conferences and briefings; establishes individual contact with reporters to alert them to the initiation, progress and findings of important studies; work with other Federal agencies and private-sector interest groups to produce video and audio news releases. Another approach by AHRQ is to send brief news announcements to editors of publications that target members of professional societies and trade associations.
Web Media is the AHRQ's most rapidly expanding strategy for disseminating information to professional and consumer audiences. The Agency encourages use of online news services such as Web MD and ReutersHealth. For health information that is timely and immediately newsworthy, the Agency has arranged online Web chats by Agency staff, grantees and other Agency related experts. In addition, AHRQ has contacted the Web site editors of other Federal agencies, State agencies, professional societies, and other entities, such as health advocacy groups, to request they announce AHRQ health information on their sites and/or link to the Agency's site. In addition to these and other proactive tactics, AHRQ includes press releases and other public information on the AHRQ Web site and periodically highlights particular information in the "Spotlight" section of the Agency's home page.
Targeted Mailings occur regularly. AHRQ routinely mails new AHRQ-sponsored publications and reports, press releases, and other new information to selected key audiences.
Exhibits at over 20 meetings of professional societies and trade associations annually provide AHRQ the opportunity for personal interaction with end-users of the Agency's tools and products such as HCUPnet and CONQUEST software.
AHRQ InstantFAX is a fax-on-demand system used by AHRQ to provide the public with quick access to documents such as research requests, evidence report summaries and press releases.
Special Outreach to Capital Hill is accomplished through our legislative liaisons who distribute selected and requested information to key Hill members.

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