Part 1. AHRQ Activities and Accomplishments, FY 2004

Chapter 1. Health Care in America

Health care in the United States continues to be the finest available anywhere in the world. Advancements in treatment for heart disease, diabetes, and cancer help people live longer, and with better quality of life. Americans are looking forward to an electronically linked health care system that can deliver more coordinated and higher quality care. Although there have been many advances, the U.S. health care system continues to face many challenges. For example:

• According to the most recent data from the Medical Expenditure Panel Survey (MEPS), health care costs continue to escalate. Total expenditures for health care services in 2002 were $810 billion compared with $726 billion in 2001—an increase of 11.6 percent.
• Health insurance premiums are also increasing. In 2002, the average annual total premium for single coverage was $3,189, a 10.4 percent increase over 2001. Family coverage averaged $8,469 in 2002, a 12.8 percent increase over 2001.
• During the first half of 2003, over 47 million people (18.8 percent of the U.S. population) under age 65 were uninsured.
• Expenditures for prescribed medicines reported as purchased by the elderly in the U.S. community population totaled $49.9 billion in 2002, an increase of 12.6 percent from the $44.3 billion total reported in 2001.
• In 2002, the top three prescribed medicines for the elderly in terms of expenditures were all cholesterol-lowering medicines. Lipitor® ranked first at $2.47 billion, Zocor® ranked second at $2.28 billion, and Pravachol® ranked third at $1.13 billion. Expenditures for just these three medicines totaled $5.9 billion in 2002, and represented 11.8 percent of total prescription medicine expenditures by the elderly that year.
• The percentage of the community adult population who reported having high cholesterol and having purchased a prescribed medicine to treat high cholesterol more than doubled from 1987 to 2001 (39.1 percent to 89.7 percent).
• In 2001, about 12.4 million Americans age 18 and older and not living in institutions had been told by a physician that they had diabetes. When comparing 1987 to 2001, the percentage of adults who reported having diabetes and purchasing a prescribed medicine to treat diabetes increased as well (83.3 percent to 92.9 percent).
• Roughly 60 million or one-third of the adults in the United States are obese, and 9 million adults are extremely obese. Obesity increases the risk of developing heart disease, diabetes, some cancers, osteoarthritis, and other disorders.
• Access to care continues to be a problem for many Americans. Less than half of America's small businesses (those with fewer than 50 employees) offer their employees health benefits.
• An estimated 90 million adults in America have lower-than-average reading skills. They are less likely than other Americans to get potentially life-saving screening tests such as mammograms and Pap smears, or to receive flu and pneumonia vaccines.

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AHRQ: Advancing Excellence in Health Care

As one of 12 agencies within the Department of Health and Human Services, the Agency for Healthcare Research and Quality (AHRQ) supports health services research initiatives that seek to improve the quality of health care in America. The Agency works to make sure that research findings make their way into practice and policy by designing, disseminating, and implementing tools and products. Consistent with the vision that led to the Agency's creation 15 years ago, AHRQ continues to focus on both supporting research and ensuring that findings and evidence are used to improve health care services and outcomes for all Americans. Thus, making sure that findings from AHRQ supported research are translated into everyday clinical practice. This step is a critical component of AHRQ's mission.

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Role and Mission of AHRQ

AHRQ's mission is to improve the quality, safety, 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.

The Agency has a broad research portfolio that touches on nearly every aspect of health care. AHRQ-supported researchers are working to answer questions about:

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

The ultimate goal is research translation—that is, making sure that findings from AHRQ research are widely disseminated and ready to be used in everyday health care decisionmaking. AHRQ research findings are used by providers, patients, policymakers, payers, health care administrators, and others to improve health care quality, accessibility, and outcomes of care.

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AHRQ's Customers

AHRQ provides assistance, often Web-based, for its customers who want to improve the quality of patient care. For example, AHRQ sponsors a Web-based clearinghouse (QualityTools.gov) that provides practical tools for assessing, measuring, promoting, and improving the quality of Americans' health care. The site's purpose is to provide clinicians, policymakers, purchasers, patients, and consumers an accessible mechanism to implement quality improvement recommendations and easily educate individuals regarding their own health care needs.

Clinicians and Other Health Care Providers

Clinicians who provide direct care and services to patients use AHRQ's evidence-based research to deliver high-quality health care and to work with their patients as partners. The evidence developed through AHRQ-sponsored research and analysis helps everyone involved in patient care make informed choices about what treatments work, for whom, when, and at what cost. AHRQ also provides clinicians with clinical decision-support tools and access to guidelines and quality measures.

• AHRQ partnered with Premier, Inc., the Department of Defense, and the American Hospital Association to develop a new tool to help hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units. The Hospital Survey on Patient Safety Culture addresses a critical aspect of patient safety improvement: measuring organizational conditions that can lead to adverse events and patient harm.
• Researchers at the University of North Carolina at Charlotte developed a critical pathway for clinicians to use when treating victims of intimate partner violence (IPV). Several guidelines for the screening and management of IPV have been published. The pathway helps to integrate care guidelines by providing a visual summary of care processes, their timing, and the roles of each provider.
• AHRQ released two interactive applications for Palm™ Pilots™ and other personal digital assistants (PDAs) that clinicians can download from the Agency's Web site:
  • The Pneumonia Severity Index Calculator, an interactive application to help doctors quickly and easily determine whether patients with community-acquired pneumonia should be treated at home or in a hospital. Developed by MDpda Design, Inc., the Pneumonia Severity Index Calculator is based on a clinical algorithm produced in 1997 by an AHRQ-funded research team.
  • The Electronic Preventive Services Selector (ePSS), a clinical decision-support tool, is designed to help clinicians deliver evidence-based medicine when they are with a patient. It helps clinicians quickly and easily search for which preventive services to provide—or not provide—to patients based on their age and sex.
• AHRQ's National Guidelines Clearinghouse™ (NGC) is a comprehensive database of evidence-based clinical practice guidelines and related documents. The NGC provides clinicians, health plans, integrated delivery systems, purchasers, and others with a Web-based mechanism for obtaining objective, detailed information on clinical practice guidelines.

Web M&M: Online Patient Safety Journal AHRQ encourages ongoing learning from experts in the field to expedite quality improvement. To help health care professionals benefit from insights beyond their home institutions, AHRQ continues to sponsor Web M&M, a monthly, online medical journal that showcases patient safety lessons drawn from actual cases. This unique online resource allows health care professionals to learn about avoidable errors made in other institutions, as well as effective strategies for preventing their recurrence. One case each month is expanded into a "Spotlight Case" that includes a downloadable set of slides and an interactive learning module that features readers' polls, quizzes, and other multimedia elements. Physicians may obtain continuing medical education credit and nurses are able to obtain continuing education credit by successfully completing the spotlight case and its questions. Trainees can receive certification credits in patient safety, thereby helping to meet new Accreditation Council on Graduate Medical Education requirements for systems-based learning. There are now 5,500 registrants viewing the journal regularly. Here are some examples of cases shared on Web M&M in 2004: A patient given an antipsychotic drug intravenously who then required a pacemaker. A patient who had heart surgery and had a suction tip inadvertently left inside his chest. A triage delay, which led parents to take their feverish child to a different emergency department—where, upon arrival, the child was in full arrest. A pregnant woman who arrived at the emergency department with severe abdominal pain, whose correct diagnosis was not considered until the OB resident arrived. A nurse who drew the privacy drapes for a child in the recovery room, not realizing the child was in distress until she nearly stopped breathing. A woman who died after 3 weeks of hospitalization for an undiagnosed respiratory infection, whose test results later revealed that she actually had tuberculosis. A patient who nearly had surgery intended for another patient with the same, unusual last name. A patient with vertigo who was handed off to multiple providers, and her true— and ultimately lethal—diagnosis was missed. A man sent for a Holter monitor to record heart rhythm who received a skin test instead. Signout flaws that caused a non-diabetic hospitalized woman to be given several rounds of insulin and concentrated dextrose after repeated blood tests showed her glucose to be dangerously high, then dangerously low. A parent who misunderstood the instructions on how to administer a medication, ultimately leading to an infant choking on a syringe cap. A man discharged from the emergency department who was found unresponsive at home the next morning and an autopsy revealed a diagnosis not even considered. A central line mistakenly placed in the carotid artery, causing permanent neurologic damage.

Public Policymakers, Purchasers, and Other Health Officials

Policymakers, purchasers, and other health officials use AHRQ research to make well-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 sponsors free, interactive Web conferences and workshops that help facilitate understanding of the evidence base for quality-based purchasing and public reporting, encourage the use of tools to assist with evaluations of health care quality, and help policymakers, purchasers, and other health officials make well-informed decisions. These Web conferences and workshops are detailed in the User Liaison section in Chapter 4.
• AHRQ has several major initiatives that help policymakers and others stay informed on health care services, insurance, costs, access, and quality. The Medical Expenditure Panel Survey (MEPS) is a vital resource designed to continually provide policymakers, health care administrators, businesses, and others with timely, comprehensive information about health care use and costs in the United States. The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and software tools to enhance the use of administrative data developed through a Federal-State-Industry partnership and sponsored by AHRQ. Data from HCUP have been used to produce reports that answer questions on reasons why Americans are hospitalized, length of stay, charges, and outcomes. The HIV Cost and Services Utilization Study (HCSUS) was the first major research effort to collect information on a nationally representative sample of people in care for HIV infection. It continues to provide policymakers with reliable information about the type and costs of the health care services that people with HIV disease are receiving so that informed resource-allocation decisions can be made. MEPS, HCUP, and HCSUS are discussed in more detail in Chapter 6.

Consumers and Patients

Findings from AHRQ research can help consumers and patients make informed choices about treatments, providers, hospitals and long-term care facilities, and health plans. The goal is to educate and empower patients to play an active role in their own health care and to work in partnership with their clinicians to achieve the best outcomes possible. AHRQ produces personal health guides to help people keep track of preventive health care (such as immunizations and screening tests), brochures presenting the latest findings on a variety of health conditions, checklists to help patients identify good quality care and decrease the likelihood of a medical error, and tools to help patients make wise health care choices.

• Improving the patient experience of care is a widely recognized component of overall quality. Results from the CAHPS® surveys include reporting tools that provide reliable information to help consumers and purchasers assess and choose among health plans, providers, and other health facilities. The first CAHPS® surveys, which assessed consumers' perceptions of the quality of health plans, are used by more than 100 million Americans, including those in Medicare managed care plans, enrollees in the Federal Employees Health Benefits Program, and participants in health programs of the Department of Defense.
• AHRQ published a booklet for older adults called The Pocket Guide to Staying Healthy at 50+, an update to the original published in 2000. This guide, which incorporates new research-based recommendations from the U.S. Preventive Services Task Force, was developed in partnership with AARP. The Pocket Guide, available in English and Spanish, includes tips and recommendations on good health habits, screening tests, and immunizations. It provides easy-to-use charts to help track personal health information and includes questions to ask health care providers, as well as resources for additional information.
• AHRQ released a new consumer tool for Palm™ and Pocket PCs to help smokers who want to quit. Quit Smoking: Consumer Interactive Tool is drawn from the evidence-based recommendations of the Public Health Service guideline, Treating Tobacco Use and Dependence. It helps smokers set up a program tailored to their individual needs. To use the application, the smoker plugs in the date he or she wants to quit, and the program counts back 5 days leading up to the quit date. It then offers a 5-day countdown of daily practical steps to help the smoker quit, such as identifying reasons to quit smoking; talking to the doctor about medications, including the nicotine patch or gum; and getting support from family and friends. The AHRQ Palm™ and Pocket PC applications are free and can be downloaded from the Agency's Web site.

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