Chapter 4. Areas of Special Interest

System Capacity and Bioterrorism

AHRQ, through its bioterrorism and response activities, supports research in assessing and improving the U.S. health care system's capacity to respond to possible incidents of bioterrorism. These research projects examine an array of issues related to clinicians, hospitals, and health care systems, as well as linkages among these providers, local and State public health departments, emergency personnel, and others preparing to respond to terrorist events and other public health emergencies, along with regional planning and surge capacity issues. This work is also an essential component to CDC and HRSA investments.

System capacity and bioterrorism research spans nine key areas:

1. Models for medication/vaccine distribution.
2. Understanding the role of State and regional models for preparedness.
3. Defining, measuring, and demonstrating surge capacity within the health care system.
4. The unique issues related to pediatric care and bioterrorism.
5. The role of health information technology in detecting, tracking, and providing real-time decision support to clinicians.
6. Methods and best practices for clinician training.
7. Further development of health care system/public health linkages.
8. Translating research into practice.
9. Personal protective equipment, isolation/quarantine, and laboratories.

AHRQ recognizes that community clinicians, hospitals, and health care systems have essential roles to play in this infrastructure. To inform and assist these groups in meeting the health care needs of the U.S. population in the face of bioterrorist threats, AHRQ supports research that emphasizes the following research objectives:

• Emergency preparedness of hospitals and health care systems for bioterrorism.
• Need for enhanced capacity of ambulatory care, home and long-term care, care for psychosocial consequences, and other related services during and after a bioterrorist event.
• Information technology linkages and emerging communication networks to improve coordination between the personal health care system, emergency response networks, and public health agencies.
• Novel uses of health care system training strategies to prepare community clinicians to recognize and manage a bioterrorist event.

Disaster scenarios that once seemed merely theoretical have become a disturbing reality and represent a growing threat for a mass casualty incident. There is a clear need to determine the best ways to mitigate the potential impact of a mass casualty incident that could result in multiple victim that may overwhelm local resources and potentially could involve natural, biological, chemical, nuclear, or other agents.

In FY 2004, AHRQ sponsored a series of free Web-assisted bioterrorism audio conference calls on surge capacity and health system preparedness. Surge capacity is a health care system's ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care, and public health in the event of bioterrorism or other large-scale public health emergencies or disasters. These 90-minute audioconferences were designed to share the latest health services, research findings, promising practices, and other important information with State and local health officials and key health system decisionmakers.

Topics that were covered included:

• Education and training for a qualified workforce.
• Facilities and equipment.
• Surge capacity in a mass casualty event.
• The role of information/communication technology and monitoring/surveillance systems in bioterrorism preparedness.

Three regional and national conferences were held for State and regional bioterrorism decisionmakers and responders focusing on tools and models for planning and preparedness.

Bioterrorism Preparedness

Five new grants totaling nearly $5 million have been funded under AHRQ's grant program, "Building the Evidence to Promote Bioterrorism and Other Public Health Emergency Preparedness in Health Care Systems." Each of the five grants addresses surge capacity. The new awards were made to:

• Weill Medical College, Cornell University in New York, "Modeling the U.S. Health System's Epidemic Response Capacity" ($840,262).
• Johns Hopkins University School of Medicine in Baltimore, "Discharge Criteria for Creation of Hospital Surge Capacity" ($911,199).
• University of Florida in Gainesville, "Bioterrorism Preparedness in Rural and Urban Communities" ($889,072).
• Vanderbilt University Medical Center in Nashville, "Preparing Volunteer Nurses for Public Health Emergencies" ($1,090,145).
• Johns Hopkins University in Baltimore, "Evaluation of Bioterrorism Training for Clinicians" ($991,843).

Recent Bioterrorism Research Findings and Products

• During FY 2004, AHRQ published the evidence report, Training of Hospital Staff to Respond to a Mass Casualty Incident. The report reviews the published evidence regarding the usefulness of the following approaches in training staff to respond to a mass casualty incident: hospital disaster drills, computer simulations, and tabletop or other exercises, as well as the methods and tools that have been used in evaluating these approaches. The review revealed that the evidence is limited. Enough studies were available to suggest that hospital disaster drills can help to identify problems with incident command, communications, triage, patient flow, security, and other issues. The evidence also indicated that computer simulations and tabletop and other exercises may help to train key decisionmakers in disaster response. However, the evidence was insufficient to support firm conclusions about specific training methods or the usefulness of reported evaluation methods. The report notes that future disaster preparedness efforts would benefit from increased reporting of hospitals' experiences in disaster response training.
• Denver Health, one of AHRQ's IDSRN partners, produced an alternate care site selection tool to help State and local officials quickly locate alternate health care sites if hospitals are overwhelmed by patients due to a bioterrorist attack or other public health emergency. A complete description of the tool is included in a new report entitled The Rocky Mountain Regional Care Model for Bioterrorist Events. The alternate care site selection tool was shared with emergency response planners at the 2004 Summer Olympics in Athens, Greece. In the aftermath of a bioterrorist event or other public health emergency, hospitals may be overwhelmed by a sudden influx of patients. The new alternate care site selection tool is designed to allow regional planners to locate and rank potential alternative sites—stadiums, schools, recreation centers, motels, and other venues—based on whether they have adequate ventilation, plumbing, food supply, and kitchen facilities, for example.
• A new planning guide from AHRQ was designed to help communities across the Nation make sure that appropriate drugs and vaccines are available to everyone who needs them in the event of a natural epidemic or bioterrorist attack. The guide was developed with AHRQ support by a team of researchers in the Department of Public Health at Weill Medical College of Cornell University and New York-Presbyterian Hospital. This new guide complements the Strategic National Stockpile Guidebook prepared by the CDC, which includes a chapter on dispensing medications and vaccines. It is designed to help State, county, and local officials comply with Federal requirements for public health emergency planning by:
  • Providing a framework for understanding the components of epidemic outbreak response (surveillance, stockpiling, distribution, dispensing, and followup care) and the planning and implementation of dispensing operations using specially designated dispensing clinics.
  • Applying these concepts to develop model pill-dispensing and vaccination clinics run on the Bioterrorism and Epidemic Outbreak Model (BERM), a computer staffing model (also developed by Weill Medical College of Cornell University under contract to AHRQ) that can be customized to meet local community needs.
  • Discussing implementation of a command and control framework for dispensing clinics based on the CDC's National Incident Management System.
• In FY 2004, AHRQ published a series of five issue briefs that summarize the Agency's Web-assisted conferences on bioterrorism and health system preparedness.

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HIV/AIDS in the United States

The impact of new drug therapies on the longevity and progression of HIV disease has been dramatic. As a result, today HIV disease may be thought of as a moderately expensive chronic disease rather than a catastrophically expensive fatal illness. Drugs such as protease inhibitors, in combination with other antiretroviral medications, have dramatically improved the lives of HIV-infected patients.

More than 950,000 people in the United States have been diagnosed with HIV or AIDS, and this number grows by 40,000 each year. However, a recent study by AHRQ showed a substantial decline in HIV-related hospitalizations in eight States from 1996 to 2000. In these States, where more than 52 percent of AIDS patients were living at the time, HIV-related hospitalizations declined from 114,885 in 1996 to 77,694 in 2000.

AHRQ's HIV/AIDS Research Agenda

The HIV Cost and Services Utilization Survey (HCSUS) was the first study to examine the health status and health care use of a nationally representative sample of adults infected with HIV. Data from HCSUS have been used to address a number of policy-relevant issues, such as variations in access to antiretroviral therapy.

Research supported by AHRQ and conducted under a cooperative agreement between RAND and AHRQ has helped the HRSA to examine the delivery of services offered under the Ryan White CARE Act.

Data from the HIV Cost and Services Utilization Study (HCSUS) provided information on a nationally representative sample of HIV-positive people in care and was useful in answering Congressional inquires. The research helped HRSA's HIV/AIDS Bureau to confirm that the CARE Act was reaching and serving the populations that the Ryan White funds were directed by Congress to serve. These vulnerable and underserved populations included people who had low incomes, or no income, and people who had little or no insurance or were on Medicaid.

HSCUS estimated the number of people who were treated for HIV disease. This is extremely important as it gives statisticians a basis for assumptions or estimates for predicting future needs and planning for services. Until recently, HIV was not a reportable disease. And some of the biggest states with the largest number of cases, such as California and New York, were just beginning to do it. This lack of reporting made predicting service needs more difficult.

The Federal Ryan White CARE Act provides primary health care and support services for people with HIV disease. Enacted in 1990, it fills gaps in care faced by those with low-incomes and little or no insurance. HRSA's HIV/AIDS Bureau administers the program through hundreds of grantees, which serve an estimated 533,000 people each year.

HIV Research Network

The HIV Research Network (HIVRN) comprises 17 HIV care providers around the country who share information and data so that they can learn from each other on ways to improve quality of care for patients with HIV. The network provides timely aggregate information to policymakers and other providers interested in improving quality and answering other questions about access and cost of care for people with HIV. Through the work of this network and other large HIV care providers, AHRQ is looking to identify and remedy major causes of prescribing errors for patients with HIV. Data collection for HCSUS ended in early 1998. Data from the HIV Research Network cover the period of 2000 through 2002, with more recent data currently being collected. Thus, although not nationally representative, HIV data provide a more recent view of HIV-related service delivery.

The goal of the HIVRN is to obtain, analyze, and disseminate current information on the delivery of services to people with HIV infection. Treatment of HIV infection is complex. New drugs are being developed rapidly, and treatment guidelines change frequently. Policymakers, service providers, and patients need to know how often people with HIV infection receive specific services, and what factors are related to receiving more or fewer services. The HIVRN was designed to disseminate this information widely, using the most recent available data.

The HIVRN is sponsored by several Federal agencies: AHRQ, the Center for Substance Abuse Treatment in the Substance Abuse and Mental Health Services Administration (SAMHSA), the HIV/AIDS Bureau in HRSA, and the Office of AIDS Research in the Office of the Director of the National Institutes of Health (OAR/NIH).

HIVnet

Health officials and others can access HIV data online through AHRQ's HIVnet at http://www.ahrq.gov/data/hivnet.htm. HIVnet is a tool that provides information on inpatient and outpatient utilization by people with HIV disease. This information is valuable for service providers, program planners, policymakers, and health services researchers. HIVnet is focused on health services delivery. It does not contain information on outcomes of treatment for HIV infection or on how to access HIV-related services in the community. HIVnet provides easy access to selected statistics on patterns of HIV-related care.

At present, statistics displayed on the HIVnet are derived from the 12 medical practices that provided comprehensive resource utilization data for the year 2000. The statistics combine data from the 12 sites. HIVnet enables users to examine resource utilization for specific demographic and clinical subgroups. However, to ensure confidentiality, HIVnet does not contain any information that could be used to identify individual patients or practices or a particular geographic region of the country.

Recent Research Findings

• According to a study supported by AHRQ, 67 percent of patients with HIV disease reported suffering from pain. Patients reporting or developing more pain and those in poorer health used more outpatient services. Individuals who did not report pain at first or second followup after the outpatient visit were predicted to have 5.20 outpatient visits; those who had no pain at first followup but developed maximum pain by the second followup were predicted to have 6.94 visits; and those with maximum pain at first and second followups were predicted to have 7.24 visits. Improved pain management in these patients and identification of those at risk for developing pain could reduce their use of outpatient care, lead to substantial cost savings, and improve quality of life for affected individuals.
• AHRQ researchers found that women with HIV disease are much less likely than men with HIV to receive potentially life-prolonging drugs even though they have private health insurance that would help pay for the drugs. Only 39 percent of women with HIV disease enrolled in the health insurance plans of 24 large employers across the country were provided antiretroviral drugs for HIV disease in 2000, compared with 71 percent of men with HIV enrolled in the same plans. The researchers further found that among adults treated with antiretroviral therapy, women (31 percent) were only half as likely as men (63 percent) to be prescribed the newer, more effective, and more costly protease inhibitor and/or non-nucleotide reverse transcriptase inhibitor drugs. This disparity in prescribing for men and women was reflected in prescription drug expenditures. The average annual drug expenditure for men, $9,037, was more than twice the $3,893 spent for women's medications. Women, on average, had total health care expenditures of $10,397 in 2000, while total health care expenditures for men averaged $16,405 that year. Almost all of this difference resulted from lower payments for drugs for women with HIV disease.

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Promoting Evidence-Based Policy and Practice

Outreach to Health Care Providers, Purchasers, and Health Officials

AHRQ's Division of User Liaison and Research Translation (ULRT) works closely with health care administrators, purchasers, and State and local policymakers so that they will find it easier to use evidence when making decisions about health care services and policy. In FY 2004, AHRQ began transitioning its program from a primary focus on dissemination of research findings to an emphasis on putting evidence into practice. ULRT worked on developing strategies that would help identify stakeholders who would be successful as they implement care management programs, develop programs to decrease health care disparities among disadvantaged children with asthma or diabetes, improve patient safety, and enhance purchaser-provider synergies. Several of these strategies are taking the shape of learning networks—people engaging in a process of collective learning facilitated by in-person meetings, Web-assisted events, and on site technical assistance.

In addition to providing information and tools to make informed decisions and implement successful practices and policy, ULRT serves as a bridge between the program's stakeholders and the health services research community by bringing back to the Agency the research questions being asked by key policymakers and decisionmakers. While ULRT was planning its new strategies, it continued its efforts to inform AHRQ stakeholders about important research and practice developments. A series of audio conferences focused on quality-based purchasing to help plans and providers prepare for and participate in quality-based purchasing and public reporting initiatives. These conferences included:

• "Paying for Performance," which featured a look at the current evidence base for quality-based purchasing with an emphasis on practical implications for purchasers and providers.
• "Using Quality Indicators for Hospital-Level Public Reporting and Payment," which provided guidance on the benefits and limitations of using AHRQ's Quality Indicators for public reporting of quality or to inform purchasing decisions.

ULRT also sponsored a Web conference: "Obesity: Latest Evidence on Prevention and Treatment." Objectives of the Web conference included helping participants better understand coverage issues related to obesity and the process used by CMS to make coverage decisions; differentiating among various approaches for the prevention and treatment of obesity and identifying their strengths and limitations; and understanding the value of the emerging evidence base for the pharmacological and surgical treatment of obesity and its use in policy development.

ULRT supported the Agency's bioterrorism and health system preparedness efforts by sponsoring regional and national workshops in FY2004, including:

• Three regional workshops for State and regional bioterrorism decisionmakers.
• Five Web conferences.
• A special expert meeting on mass casualty medical care.

Research Translation for Health Care Policymaking

AHRQ's research translation team produces research syntheses targeted to AHRQ stakeholders—the Research in Action series. The purpose of these syntheses is to share research findings and the impact the findings have had so that other stakeholders can learn from these experiences and related research from the field. Reports published in FY 2004 include:

• Hospital Nurse Staffing and Quality of Care. This report indicates that hospitals with lower nurse staffing levels, nurses who spend less time with patients, or have fewer registered nurses compared with licensed practical nurses or nurses' aides tend to have higher rates of poor patient outcomes, including pneumonia, shock, cardiac arrest, and urinary tract infections.
• Programs and Tools to Improve the Quality of Mental Health Services. This report highlights AHRQ-funded research that has led to the development of programs, methods, and tools for evaluating and improving the quality of mental health services and improving the education of mental health professionals. It details quality improvement programs for care and outcomes in treating depression, a screening tool that helps identify children and adolescents at risk for suicide, a consumer ratings assessment that can improve behavioral health services, and a conference that provided solutions to improve provider training and continuing education.
• Employer-Sponsored Health Insurance: Trends in Cost and Access. This report highlights data from AHRQ's Medical Expenditure Panel Survey about health insurance obtained through an employer for the period 1996 through the first half of 2003. U.S. employers provide health insurance to nearly two-thirds of the population under age 65. In general, the higher the employee contribution is, the less likely employees are to enroll. Employment-related insurance coverage among Hispanic men declined 13 percent between 1987 and 1996, and by 2003, 38.5 percent of Hispanic men under age 65 were uninsured, compared with 16.2 percent of white men. The percentage of full-time employees who worked where health insurance was offered to retirees fell between 1998 and 2000.
• Women and Domestic Violence: Programs and Tools that Improve Care for Victims. This report describes training programs and tools that health care providers, social workers, and facilities and their staff can use to provide better care for victims of domestic violence. It identifies gaps in research on domestic violence indicating a need to build a stronger evidence base for screening, detecting, and treating victims, and describes methods that health care providers can use to screen for and identify victims of domestic abuse, as well as tools that help providers counsel and treat victims and evaluate the quality of domestic violence programs.

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National Reports on Health Care Quality and Disparities

AHRQ produces two congressionally mandated annual reports on the state of the Nation's health care quality. By consolidating information on quality from a number of sources, the National Healthcare Quality Report (NHQR) provides a comprehensive picture of health care quality in the United States. Similarly, the National Healthcare Disparities Report (NHDR) documents differences in health care services for and among priority populations (women, children, racial and ethnic minorities, low-income, urban, rural, people with chronic disease and disability, and people at the end of life) specified in AHRQ's reauthorizing legislation. These reports provide a general picture of health care quality and discuss a number of selected conditions, including cancer, end-stage renal disease, diabetes, heart disease, HIV/AIDS, maternal and child health, mental illness, respiratory disease, nursing home care, and home health. Both reports provide a roadmap for improvement that communities can use to improve quality and reduce disparities in health care.

AHRQ completed work on the inaugural editions of the reports in FY 2003. The second annual reports released in 2004 find both evidence of improving quality as well as specific areas in which major improvements can be made, and they indicate that there are disparities related to race, ethnicity, and socioeconomic status in the American health care system. Both reports extend the baseline data on quality and disparities within health care delivery provided in AHRQ's 2003 reports.

National Healthcare Quality Report

The Quality Report identifies three key themes important to policymakers, clinicians, health system administrators, community leaders, and others who work in health care services. The report indicates that:

• Quality is improving in many areas, but change takes time.
• The gap between the best possible care and actual care remains large. Quality of care remains highly variable across the country.
• Further improvement in health care is possible. Best practices have been identified, and collaborative, focused efforts among key stakeholders have produced impressive and inspiring gains.

In comparison to data reported in the 2003 Quality Report, modest improvement has been noted in many of the report's quality measures. Across the entire set of Quality Report measures, quality has improved by approximately 3 percent versus data reported in the 2003 report. These include selected measures used by CMS, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, and others reporting on quality in hospitals, nursing homes, home health agencies, and other settings.

In addition, since the 2003 Quality Report, improvements have been made in specific measures related to health care delivery. The greatest changes were in the following:

• A decrease of 37 percent from 2002 to 2003 in the percentage of nursing home patients who have moderate or severe pain.
• A decrease of 34 percent from 1994 to 2001 in the hospital admission rate for uncontrolled diabetes.
• A decrease of 34 percent from 1996 to 2000 in the percentage of elderly patients who were given potentially inappropriate medications. Quality remains variable across the country. However, improvements were seen in many areas at the State level. Some of these notable improvements are:
• Minnesota—Largest improvement in State rank for mammogram testing rates.
• Alabama—Only State to significantly increase screening rates for two recommended tests for colorectal cancer.

National Healthcare Disparities Report

The 2004 National Healthcare Disparities Report presents data on the same clinical conditions and other measures as the Quality Report but focuses on priority populations, including women, children, the elderly, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with special health care needs, specifically children with special needs, people in need of long-term care, and people requiring end-of-life care.

The 2004 Disparities Report identifies three key themes:

• Disparities are pervasive.
• Improvement is possible.
• Gaps in information exist, especially for specific conditions and populations.

A subset of measures with the comparable data for 2000 and 2001 is highlighted in the 2004 Disparities Report. In both years:

• Blacks received poorer quality of care than whites for about two-thirds of quality measures, and they had worse access to care than whites for about 40 percent of access measures.
• Asians received poorer quality of care than whites for about 10 percent of quality measures, and they had worse access to care than whites for about a third of access measures.
• American Indians and Alaska Natives received poorer quality of care than whites for about a third of quality measures, and they had worse access to care than whites for about half of access measures.
• Hispanics received lower quality of care than non-Hispanic whites for half of quality measures, and they had worse access to care than non-Hispanic whites for about 90 percent of access measures.
• Poor people received lower quality of care for about 60 percent of quality measures and had worse access to care for about 80 percent of access measures than those with high incomes.

The 2004 Disparities Report found improvement in care provided to the Nation's poor, uninsured, and minorities through federally supported health centers. These centers, administered by HRSA, focus specifically on providing care to vulnerable populations. In 2004, over 3,600 health centers sites delivered primary and preventive care to 13.2 million people.

Availability of the Reports

The National Healthcare Quality Report and National Healthcare Disparities Report are available on AHRQ's QualityTools Web site at http://www.qualitytools.ahrq.gov. The site serves as a Web-based clearinghouse to make it easier for health care providers, policymakers, purchasers, patients, and consumers to take effective steps to improve quality.

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