AHRQ Annual Highlights, 2007

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The Agency for Healthcare Research and Quality (AHRQ), is committed to helping the Nation improve our health care system. To fulfill its mission, AHRQ conducts and supports a wide range of health services research. This report presents key findings from AHRQ's research portfolio during 2007.

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Contents

Introduction
Comparative Effectiveness
Developing and Promoting the Use of Evidence
Improving the Safety and Quality of Health Care
Using Health Information Technology to Improve Patient Safety and Quality
Eliminating Disparities in Health Care
Getting Value for Money Spent on Health Care
Developing Tools and Data for Research and Policymaking
Preparing for Public Health Emergencies
Looking to the Future

Introduction

The U.S. health care system is considered by many to be the finest in the world. Americans are living longer, healthier lives, thanks to significant advances in biomedical and health services research, yet too many people still do not receive the quality of care that they expect and deserve. The quality of health care in this Nation continues to improve at a modest pace. However, the rate of improvement appears to be slowing. According to data from the National Healthcare Quality Report, the quality of health care improved by an average 2.3 percent a year between 1994 and 2005, a rate that reflects some important advances but points to an overall slowing in quality gains. The improvement rate is lower than the 3.1 percent average annual improvement rate reported in the 2006 reports. According to the National Healthcare Disparities Report, disparities in health care quality and access are not getting smaller. Progress is being made, but many of the biggest gaps in quality and access have not been reduced, and the problem of persistent uninsurance is a major barrier to reducing disparities.

Improving the quality and effectiveness of health care—providing the right care to the right patient at the right time, and getting it right the first time—remains a challenge in the United States. Our health care system faces many challenges including:

• Improving the quality and safety of health care.
• Ensuring access to care.
• Getting value for what we spend on health care.
• Eliminating disparities.
• Increasing the use of health information technology.
• Providing consumers, providers, and other stakeholders with evidence-based information that they can use to make informed health care decisions.

As 1 of 12 agencies within the Department of Health and Human Services (HHS), the Agency for Healthcare Research and Quality (AHRQ) has a mission to improve the quality, safety, efficiency, effectiveness, and cost-effectiveness of health care for all Americans. The Agency works to fulfill this mission by conducting and supporting health services research, both within AHRQ as well as in leading academic institutions, hospitals, physicians' offices, health care systems, and many other settings across the country, that:

• Reduces the risk of harm from health care services by using evidence-based research and technology to promote the delivery of the best possible care.
• Transforms research into practice to achieve wider access to effective health care services and reduce unnecessary health care costs.
• Improves health care outcomes by encouraging providers, consumers, and patients to use evidence-based information to make informed treatment choices/decisions.

The Agency's mission helps HHS achieve its strategic goals to improve the safety, quality, affordability, accessibility of health care; public health promotion and protection, disease prevention, and emergency preparedness; promote the economic and social well-being of individuals, families, and communities; and advance scientific and biomedical research and development related to health and human services. The Agency has a broad research portfolio that touches on nearly every aspect of health care including:

• Comparative effectiveness.
• Patient safety/medical errors.
• Health care quality.
• Health information technology.
• Evidence-based medicine.
• Clinical practice.
• Outcomes of care and effectiveness.
• Primary care and care for priority populations.
• Organization and delivery of care and use of health care resources.
• Health care costs and financing.
• Health care system and public health preparedness.

This report presents key accomplishments, initiatives, and research findings from AHRQ's research portfolio during 2007.

AHRQ's Customers

Ultimately, the Agency's goal is to improve the quality and safety of health care. It achieves this goal by translating research into improved health care practice and policy. Health care providers, patients, policymakers, payers, administrators, and others use AHRQ research findings to improve health care quality, accessibility, and outcomes of care:

• Clinicians who provide direct care and services to patients use AHRQ's evidencebased research to deliver high-quality health care and to work with their patients as partners. AHRQ also provides clinicians with clinical decision-support tools as well as access to guidelines and quality measures.
• Policymakers, purchasers, and other health officials use AHRQ research to make better informed decisions on health care services, insurance, costs, access, and quality. Public policymakers use the information produced by AHRQ to expand their capability to monitor and evaluate changes in the health care system and to devise policies designed to improve its performance. Purchasers use the products of AHRQ-sponsored research to obtain high-quality health care services. Health plan and delivery system administrators use the findings and tools developed through AHRQ-sponsored research to make choices on how to improve the health care system's ability to provide access to and deliver high-quality, high-value care.
• AHRQ research helps consumers get and use objective, evidence-based information on how to choose health plans, doctors, or hospitals. In addition, AHRQ can help patients and their families play an active role in their health care and reduce the likelihood that they will be subject to a medical error. Personal health guides developed by AHRQ help people keep track of their preventive care and other health services they receive. AHRQ's goal is to help people become better informed consumers and to be partners in their own care.

Questions Are the Answer AHRQ joined with the Ad Council to launch a national public service advertising (PSA) campaign designed to encourage adults to take a more proactive role in their health care. The campaign entitled "Questions Are the Answer: Get More Involved With Your Health Care" was launched during national Patient Safety Awareness Week (March 4-10, 2007). The PSA campaign encouraged all patients and caregivers to become more active in their health care by asking questions. The campaign included television, radio, print, and Web advertising that directed audiences to call a toll-free number, 1-800- 931-AHRQ, and visit the Web site at www.ahrq.gov/questionsaretheanswer/, to obtain tips on how to help prevent medical mistakes and become a partner in their health care. The site also features an interactive "Question Builder" that allows consumers to generate a customized list of questions for their health care providers that they can bring to each medical appointment.

Healthcare 411 Healthcare 411 is a news series produced by AHRQ. These weekly audio and video programs feature news and information on current health care topics with synopses of AHRQ s latest research findings. The stories keep consumers, employers, health care providers, researchers, educators, and others informed about the findings of selected AHRQ-sponsored research. Also on this site are links to AHRQ's public service announcements on issues such as quitting smoking, taking medication safely, eating healthy, and the importance of regular visits to a doctor as well as messages encouraging patients to be involved in their health care and ask questions of all their health care providers. In 2007, newscasts released included: Health literacy: how well people understand and evaluate information about health and health care. Blood pressure medications: which medication is better at controlling high blood pressure. High quality health care: advice on getting the services that give the best results. Antidepressant medication: the effectiveness of common antidepressants and their side effects. Medication errors and children: ways to keep children safe from drug or other medical errors. Pediatric emergency departments: parents using information technology to help clinicians treat their child.

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Comparative Effectiveness

AHRQ was authorized to perform comparative effectiveness research under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. The MMA authorizes AHRQ to conduct and support research with a focus on outcomes, comparative clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. The focus of this research is based on the top conditions that are common and costly among those whose health care is funded by Medicare, Medicaid, and the State Children's Health Insurance Program such as arthritis, cancer, chronic obstructive pulmonary disease, dementia, depression, diabetes, heart disease, peptic ulcer disease, pneumonia, stroke, and hypertension.

This work is conducted under the Agency's Effective Health Care Program, which was launched in 2005, and it focuses strategically on comparing the outcomes, clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. The Effective Health Care Program's primary principle is that all stakeholders should have the best available evidence on which to make decisions about health care items and services.

The Effective Health Care Program has three approaches to research on the comparative effectiveness of different treatments and clinical practices:

• Research reviews: comprehensive reviews and syntheses of evidence prepared by the Evidence-based Practice Centers (EPCs).
• New research: reports that cover new evidence and analytical tools produced by AHRQ's Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network and the Centers for Education & Research on Therapeutics (CERTs).
• Summary guides: short, comprehensive summaries of research findings translated into a variety of useful formats by the John M. Eisenberg Clinical Decisions and Communications Science Center.

Questions and Answers about Health Insurance AHRQ and America's Health Insurance Plans released Questions and Answers about Health Insurance, a new guide designed to help consumers make important health insurance decisions. The guide explains how different types of health insurance work, including network-based plans, non-network based coverage, and consumer-directed health plans. It also provides a glossary of health insurance terms as well as additional resources to obtain more information. This guide is a critically important resource because today's more complex health care system requires consumers and employers to be more informed about their choices. Choosing and understanding how to use a health plan may be the key to helping consumers get the care they need when they need it. Copies can be downloaded at www.ahrq.gov/consumer/insuranceqa/.

Comparative Effectiveness Reviews (CERs)

Seven new comparative effectiveness reviews (CERs) were published in 2007. The reviews use a research methodology that systematically and critically appraises existing research to synthesize knowledge on a particular topic. They also identify research gaps and make recommendations for studies and approaches to fill those gaps. The CERs are briefly summarized here:

• Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics. The report indicates that some newer antipsychotic medications approved to treat schizophrenia and bipolar disorder are being prescribed to millions of Americans for depression, dementia, and other psychiatric disorders without strong evidence that such off-label uses are effective. They also found strong evidence that atypical antipsychotics can increase chances of adverse events.
• Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression. This report found that today's most commonly prescribed antidepressants are similar in effectiveness to each other but differ when it comes to possible side effects. The findings show that about 6 in 10 adult patients get some relief from the drugs.
• Comparative Effectiveness and Safety of Oral Diabetes Medications for Adults with Type 2 Diabetes. This report found that most oral medications prescribed for type 2 diabetes are similarly effective for reducing blood glucose, but the drug metformin is less likely to cause weight gain and may be more likely than other treatments to decrease "bad" cholesterol. The report summarizes the effectiveness, risks, and estimated costs for 10 drugs.
• Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Antagonists (ARBs) for Treating Essential Hypertension. This report found that two common classes of blood pressure medications—angiotensinconverting enzyme inhibitors and angiotensin receptor blockers—are equally effective at controlling high blood pressure. There are no consistently apparent differences between them when it comes to impacting lipids, managing or slowing the progression of diabetes, controlling renal disease, or impacting heart function.
• Comparative Effectiveness of Drug Therapy for Rheumatoid Arthritis and Psoriatic Arthritis in Adults. This report concluded that for patients with rheumatoid arthritis, combining one well-known, lower cost synthetic drug with one of six biologic medications often works best to reduce joint swelling or tenderness. The report concluded that combining methotrexate, a synthetic disease-modifying antirheumatic drug (DMARD), with one of the biologic DMARDs works better than using methotrexate or a biologic DMARD alone.
• Comparative Effectiveness of Treatments To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis. This report indicates that bisphosphonates, medications commonly used to reduce the risk of bone fractures in people with osteoporosis, have not been proven more effective than alternatives. Researchers compared the effectiveness and risks of six bisphosphonates and also looked at estrogen, calcitonin, calcium, vitamin D, testosterone, parathyroid hormone, and selective estrogen receptor modulators.
• Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Grafting for Coronary Artery Disease. Patients with mid-range coronary artery disease are more likely to get relief from painful angina and less likely to have repeat procedures if they get bypass surgery rather than balloon angioplasty with or without a stent. Bypass surgery and angioplasty patients had about the same survival rates and similar numbers of heart attacks, and bypass surgery presents a slightly higher risk of stroke within 30 days of the procedure. Studies that measured patients' quality of life 6 months to 3 years after undergoing the procedures found significantly more improvement for bypass surgery patients than for balloon angioplasty patients.

New Research Reports

• Survey of Medicare Part D Plans' Medication Therapy Management Programs, Effective Health Care Research Report No. 1. This report reflects that Medication Therapy Management (MTM) programs currently offered by Medicare Advantage Drug Plans and Prescription Drug Plans are highly variable. Once enrolled in an MTM program, the benefits were equally variable with some programs offering mailings or limited phone support services and others offering a range of services depending on patient needs.
• Comparative Safety of Conventional and Atypical Antipsychotic Medications: Risk of Death in British Columbia Seniors, Effective Health Care Research Report No. 2. This report indicates that elderly patients using conventional antipsychotic medications (APMs) are at no lower risk of mortality than those using atypical APMs.
• Comparative Effectiveness of Beta-Adrenergic Antagonists on the Risk of Rehospitalization in Adults with Heart Failure, Effective Health Care Research Report No. 3. Researchers found that among high-risk patients hospitalized with heart failure, the adjusted risks of rehospitalization for heart failure within 12 months were not significantly different among patients receiving atenolol, shorteracting metoprolol tartrate, or carvedilol.

Summary Guides

In 2007, the Eisenberg Center produced 12 summary guides for consumers, clinicians, and policymakers. Examples include:

• Antidepressant Medicines—A Guide for Adults With Depression, Consumer Summary Guide. This guide, based on a review of research about the medicines often used to treat adults with depression, can help consumers work with their doctor or nurse to choose medicines for depression. It covers common medicines for adults with depression, their side effects, and price.
• Choosing Non-Opioid Analgesics for Osteoarthritis, Clinician Summary Guide. This guide summarizes clinical evidence on the effectiveness and safety of non-opioid analgesics for osteoarthritis. It covers most available over-the-counter medications and prescription non-steroidal anti-inflammatory drugs.
• Off-Label Use of Atypical Antipsychotic Drugs, Policymaker Summary Guide. This guide reviews the benefits, risks, side effects, and price of five atypical antipsychotic drugs used for six conditions (dementia-related behavioral problems, depression, obsessivecompulsive disorder, post-traumatic stress disorder, personality disorders, and Tourette's syndrome in children and adolescents).

Developing Evidence to Inform Decisions about Effectiveness

The Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network is a network of research centers that AHRQ created as part of its Effective Health Care Program in 2005 to generate new knowledge. The DEcIDE Network conducts accelerated practical studies about the outcomes, comparative clinical effectiveness, safety, and appropriateness of health care items and services. The Network provides research-based health organizations with access to electronic health information databases and the capacity to conduct rapid turnaround research. Initial research focuses on the outcomes of prescription drug use and other interventions for which randomized controlled trials would not be feasible or timely or would raise ethical concerns that are difficult to address. Other DEcIDE Network projects may focus on electronic registries, methods for analyzing health databases, and prospective observational or interventional studies.

DEcIDE: Registries for Evaluating Patient Outcomes

In 2007, AHRQ released Registries for Evaluating Patient Outcomes: A User's Guide, the first government-supported handbook for establishing, managing, and analyzing patient registries. As part of the Effective Health Care Program, Outcome Sciences, Inc., a DEcIDE center, and the Duke Evidence-based Practice Center collaborated in a study of registries and the many elements involved in creating a registry. This handbook identifies the best scientific practices for operating registries.

DEcIDE Projects in Progress

At the close of 2007, DEcIDE had over 30 research projects in progress. The priority conditions and topics being studied include:

• Brain and nerve conditions.
• Breathing conditions.
• Cancer.
• Diabetes.
• Digestive system conditions.
• Heart and blood vessel conditions.
• Mental health.
• Muscle, bone, and joint conditions.
• Research methodology.

Information on the Effective Health Care program, including full reports, can be found at http://effectivehealthcare.ahrq.gov.

Use of Findings from the Effective Health Care Program Consumer Reports Best Buy Drugs, a public education project of Consumers Union, uses findings from AHRQ's Effective Health Care program to help clinicians and patients determine which drugs and other medical treatments work best for certain health conditions. For example, the Consumer s Unions used AHRQ's Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease to assist clinicians and patients in making informed decisions about which drugs to prescribe and use. The information is finalized into three final consumer products: a full report, a three-page summary, and a booklet that can be downloaded at no charge (www.crbestbuydrugs.org). The magnitude of the program's impact is evidenced by the fact that the Consumers Union drug class reviews are downloaded at a rate of 110,000 per month. Over the course of the two-year project, over 1 million reports have been downloaded. The National Business Group on Health uses this research to provide employers and their employees the best available evidence for designing benefits and making treatment choices. Medscape, an online medical information and education tool for specialists, primary care physicians, and other health professionals, uses the reports for clinicians to get continuing education. In addition, most of the reports are published concurrently in one of the Annals of Internal Medicine.

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