Chapter 6. AHRQ Strategic Goals (continued)

Goal 3. Effectiveness

AHRQ helps assure that providers and consumers/patients use accurate and timely health care information to make informed decisions and choices about their health care. To this end, AHRQ translates and disseminates research findings that have the potential to improve health care outcomes. The Agency also works to develops methods to define and measure the effectiveness of health care.

United States Preventive Services Task Force (Task Force)

The Task Force is an independent panel of private-sector experts in prevention and primary care. It conducts rigorous scientific assessments of the effectiveness of a broad range of clinical preventive services, including screening tests, chemoprevention, immunizations, and counseling, and develops recommendations for clinical preventive services. These recommendations serve as the basis for the products produced within this portfolio. The Task Force's pioneering efforts culminated in the 1989 Guide to Clinical Preventive Services. The most recent edition, The Guide to Clinical Preventive Services, Third Edition: Periodic Updates, is updated with semi-annual installments of recommendations from the Task Force supplemented by an annual cumulative update of Task Force recommendations on CD-ROM.

In addition, AHRQ revised and improved its interactive clinical decision-support tool for personal digital assistants (PDAs) to include the Electronic Preventive Services Selector (ePSS) which is designed for clinicians to use at the bedside to deliver evidence-based care according to recommendations from the Task Force when they are with a patient. The Electronic Preventive Services Selector (ePSS) helps clinicians quickly and easily search for which preventive services to provide or not provide to patients based on their age and sex.

In 2004, the Task Force issued recommendations on the following topics:

• Alcohol Misuse: Screening and Behavioral Counseling.
• Back Pain, Lower: Counseling.
• Bacteriuria: Screening.
• Bladder Cancer: Screening.
• Coronary Heart Disease: Screening.
• Dental Caries in Preschool Children: Screening.
• Family Violence: Screening.
• Hepatitis B Virus Infection: Screening.
• Hepatitis C: Screening.
• Idiopathic Scoliosis in Adolescents: Screening.
• Lung Cancer: Screening.
• Oral Cancer: Screening.
• Pancreatic Cancer: Screening.
• Rh Incompatibility: Screening.
• Suicide Risk: Screening.
• Syphilis: Screening.
• Testicular Cancer: Screening.
• Thyroid Disease: Screening.
• Visual Impairment in Children Ages 0-5: Screening.

Prevention Dissemination and Implementation

Put Prevention Into Practice

Through the Put Prevention into Practice (PPIP) program, AHRQ disseminates evidence-based information to improve the delivery of appropriate clinical preventive services, such as those based on USPSTF recommendations. The tools and resources of this program support public and private health care organizations and engage the entire health care delivery system, including clinicians, health care provider organizations, employers, insurers, and consumers.

The PPIP program develops tools and resources that enable doctors and other health care professionals to determine what preventive services patients should receive as well as enable patients to more easily understand and keep track of their preventive care. Its purpose is to increase the appropriate use of clinical preventive services, such as screening tests, chemoprevention (the use of medications to prevent disease), and counseling.

VA Relies on PPIP Guide The Department of Veteran Affairs (VA) National Center for Health Promotion and Disease Prevention (NCP) has developed and will be promoting a new Prevention Program Manual to help each of the 162 VA clinical sites focus on and enhance disease prevention. The new program is a significant element in the NCP's overall mandate to promote wellness and disease prevention among veterans. The manual provides step-by-step instructions for the development and implementation of prevention programs and builds on the AHRQ's Put Prevention Into Practice (PIPP) Implementation Guide.

PPIP materials include:

• The Clinician's Handbook of Preventive Services, Third Edition. This is both a reference tool and a practical guide to delivering clinical preventive services in a variety of settings.
• Materials for clinical office staff, including preventive care flow sheets, reminder postcards, and prevention timeline posters.
• Pocket-sized guides for health care consumers, including the Pocket Guide to Good Health for Adults, Staying Healthy at 50+, and Pocket Guide to Good Health for Children (all available in English and Spanish).

Safe and Effective Use of Pharmaceuticals

Pharmaceuticals and other medical products improve the lives of many patients, yet underuse, overuse, adverse events, and medical errors may cause serious impairment to patient health. Since 1992, AHRQ has funded studies focused on patient outcomes associated with pharmaceutical therapy. These studies have addressed many important questions regarding the management of drug prescribing.

Centers for Education and Research on Therapeutics

The Centers for Education and Research on Therapeutics (CERTs) demonstration program is a national initiative to conduct research and provide education that advances the optimal use of therapeutics (i.e., drugs, medical devices, and biological products). The program consists of seven research centers and a Coordinating Center and is administered as a cooperative agreement by AHRQ in consultation with the Food and Drug Administration.

CERTs Organization and Focus Duke University Medical Center Therapies for disorders of the heart and blood vessels. HMO Research Network Drug use; safety and effectiveness studies in health maintenance organization populations. University of Alabama at Birmingham Therapies for musculoskeletal disorders. University of Arizona Health Sciences Center Reduction of drug interactions that result in harm to women. University of North Carolina at Chapel Hill Therapies for children. University of Pennsylvania School of Medicine Therapies for infection; antibiotic drug resistance. Vanderbilt University Medical Center Prescription drug use in a Medicaid population.

The CERTs receive funds from both public and private sources, with AHRQ providing core financial support. The research conducted by the CERTs program has three major aims:

1. To increase awareness of both the uses and risks of new drugs and drug combinations, biological products, and devices, as well as of mechanisms to improve their safe and effective use.
2. To provide clinical information to patients and consumers; health care providers; pharmacists, pharmacy HMOs, and health care delivery systems; insurers; and government agencies.
3. To improve quality while reducing the cost of care by increasing the appropriate use of drugs, biological products, and devices and by preventing their adverse drug events and their sequence (such as unnecessary hospitalizations).

The CERTs Coordinating Center is located at Duke University Medical Center. Directed by Robert M. Califf, M.D., the Coordinating Center helps support the work of the research centers by enhancing cross-center synergy and disseminating findings from the research conducted by the centers.

Partnerships and Collaboration

A core tenet of the CERTs program is the belief that collaboration among groups with different perspectives and resources is critical if the results are to be applicable in "real world" settings. The centers work with public and private collaborators on projects, which allows each center to expand the number of its projects and extend their potential impact.

The CERTs are committed to creating a collaborative environment with other organizations interested in advancing the best use of therapeutics. For that purpose, a "Partnerships to Advance Therapeutics" (PATHs) program was established as an integral part of the CERTs initiative. Each year, the CERTs host a PATHs meeting of leaders from public and private organizations concerned about the quality and safety of health care. Partners and participants include organizations representing patients, health care providers, government, academia, delivery systems, payers, purchasers, and manufacturers of medical products.

CERTs Research Findings in Action Wayne Ray, Ph.D., Vanderbilt University Medical Center CERT, and Brian Strom, M.D., University of Pennsylvania CERT, were featured in the October 4 Wall Street Journal, among other publications, and Robert Califf, M.D., Duke University Medical Center CERT appeared on the October 7 Today Show—on the worldwide withdrawal of the arthritis medication Vioxx. Merck & Co. withdrew the drug because of increased risk of heart attack and stroke in people using the medication, as well as drug safety processes. These stories referred to earlier CERTs research that found potential problems with Vioxx. Dr. Ray was also in the news recently regarding his study of oral erythromycin (an older and widely used antibiotic) when used together with newer drugs such as those that inhibit CYP3A drug enzymes, i.e., certain calcium-channel blockers, certain antifungal drugs, and some antidepressants.

Findings from AHRQ pharmaceutical research have yielded important insights for the health care system. Some key issues and recent findings from AHRQ's CERTs initiative include:

• A new study by the HMO Research Network CERT of postmenopausal women in seven health maintenance organizations across the United States found that only 24 percent of women who had suffered an osteoporosis-related fracture received drug treatment for osteoporosis within a year following the fracture. Women who suffered a fracture of the vertebra were twice as likely to receive medication to treat osteoporosis (44 percent) as those with a hip fracture (21 percent) or wrist fracture (23 percent). Also, older women were less likely than younger women to receive osteoporosis treatment, even though aging increases the risk of fracture.
• Monitoring blood concentration of protease inhibitors (PIs) may improve the care of both HIV-infected adults and children. Researchers at Ohio State University and the Columbus Children's Hospital through the CERTs' program examined laboratory data on 10 adults and 15 children with HIV disease. Nondetectable concentrations were found in 33 percent of adult samples and 24 percent of pediatric samples. The clinicians were able to identify and correct important clinical problems, including drug-drug interactions, drug administration problems, and noncompliance. Routine PI monitoring and interpretation could improve the care of adult and pediatric HIV patients, especially patients who do not respond as expected to treatment, develop viral resistance or toxicity, or have questionable compliance.
• Patients who undergo surgery for gastroesophageal reflux disease (GERD) use fewer GERD-related medications and outpatient visits than those who are treated only with medication, according to a study conducted by the Vanderbilt University CERT. In 1996, all patients in the surgical group underwent fundoplication (which creates a one-way valve in the esophagus to allow food into the stomach and prevent backflow of stomach acid, thus preventing GERD). Patients in the medical group were treated without fundoplication. During the 4-year followup period, the surgical group had fewer GERD-related outpatient physician visits (5.5 vs. 6.7 visits). During each year of followup, the proportion of patients using GERD medications was lower in the surgical group than in the medication only group (0.67 vs. 0.93 in year 1; 0.67 vs. 0.91 in year 2; 0.72 vs. 0.85 in year 3; and 0.74 vs. 0.90 in year 4, respectively).
• Use of higher dose tricyclic and other cyclic antidepressants (TCAs) increases the risk of sudden cardiac death, indicating such TCA doses should be used cautiously, particularly in patients with preexisting cardiovascular disease or the elderly, according to a study by the Vanderbilt University CERT. Compared with nonusers of antidepressants, users of high- or low-dose selective serotonin reuptake inhibitors sudden cardiac and current users of low-dose TCAs had similar rates of sudden cardiac death. However, patients taking TCA doses of 100 mg or greater had a 41 percent greater rate of sudden cardiac death, and those taking TCA doses of 300 mg or greater had a 2.5-fold greater rate of death than patients not taking antidepressants. There was no evidence that TCA doses lower than 100 mg increased the risk of sudden cardiac death in subgroups who already had elevated risk, such as the elderly or those with preexisting cardiovascular disease.

New Web Site Focuses On Medication Safety and Use The AHRQ-sponsored HMO Research Network CERT collaborated with the American Association of Health Plans-Health Insurance Association of America to develop content for a new Web site, "The Tools and Techniques of Improved Medication Use," for those in the health care community who design medication safety programs and/or seek information to enhance existing patient safety efforts. The site includes selected studies as well as resources needed to replicate strategies known to achieve important results in medication safety and use.

Promoting Evidence-Based Health Care

Health care decisionmakers need a synthesis of the best evidence that is understandable, objective, and places the ever-increasing number of scientific studies in context. AHRQ is committed to accelerating the adoption of science into practice so that all Americans benefit from advances in biomedical science.

Evidence-based Practice Centers

Since the creation of the Evidence-based Practice Center (EPC) program in 1997, AHRQ has published over 120 new evidence reports and technology reports. The goal is to inform health plans, providers, purchasers, and the health care system as a whole by providing essential science-based information to improve health care quality.

The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments. The 13 AHRQ-supported EPCs were awarded 5-year contacts in 2002:

• Blue Cross and Blue Shield Association, Technology Evaluation Center (TEC), Chicago, IL.
• Duke University, Durham, NC.
• ECRI, Plymouth Meeting, PA.
• Johns Hopkins University, Baltimore, MD.
• McMaster University, Hamilton, Ontario, Canada.
• Oregon Evidence-based Practice Center, Portland, OR.
• RTI International—University of North Carolina at Chapel Hill, NC.
• Southern California Evidence-based Practice Center—RAND, Santa Monica, CA.
• Stanford University, Stanford, and University of California, San Francisco, CA.
• Tufts University—New England Medical Center, Boston, MA.
• University of Alberta, Edmonton, Alberta, Canada.
• University of Minnesota, Minneapolis, MN.
• University of Ottawa, Ottawa, Canada.

Professional societies, providers, and other private-sector entities use AHRQ evidence reports to develop evidence-based clinical care practices and related health policies. Several of AHRQ's customers have used Evidence Report No. 43, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, to examine options and priorities in patient safety practices:

• Blue Cross Blue Shield (BCBS) of Michigan used the patient safety practices as part of its acute care hospital incentive program in 2004. Participating hospitals will select and comply with three of seven National Quality Forum-Endorsed Safe Practices, which are based on the AHRQ report. Six of the seven practices selected by BCBS of Michigan for inclusion in their incentive program are AHRQ-recommended practices.
• The Florida Hospital Association (FHA) developed a patient safety tool kit—a compendium of patient safety resources organized by general subject areas. Each reference consists of the title of the document and a Web link to it. For example, the resource on the FHA Web site is indexed under Surgical Safety and posted as follows: AHRQ Making Health Care Safer, http://www.ahrq.gov/clinic/ptsafety/chap43b.htm.
• Creighton University in Omaha, NE, used the evidence report to develop a new interprofessional patient safety course. The course will be offered as an elective to students of medicine, dentistry, law, nursing, pharmacy, occupational therapy, physical therapy, social work, and business. Approximately 70 students were enrolled for spring 2005. The goal of the course is to serve as a foundation for educating students on issues of patient safety by providing a theoretical and adaptable framework for future applications in each student's respective discipline. The Evidence Report provided appropriate critical analysis to define the breadth and scope of the course, as well as numerous evidence-based approaches and case-based applications that will be used in case examples throughout the course curriculum.
• Saint Vincent Health Center in Erie, PA, developed a new program that incorporates the postoperative use of beta-blockers for high-risk cardiac patients. After a successful 4-month pilot program, staff members are expanding the program to the entire hospital. Saint Vincent distributed 50 copies of Chapter 25, AHRQ's summary on the use of peri- and postoperative beta-blockers, half to anesthesia providers and half to surgeons and nursing leaders. The distribution of this information resulted in an increased awareness of research that beta-blockers can improve patient outcomes.

Evidence Report Topics Published in FY 2004 Literacy and Health Outcomes. Pharmacological Treatment of Dementia. Pharmacological and Surgical Treatment of Obesity. Use of Glycated Hemoglobin and Microalbuminuria in the Monitoring of Diabetes Mellitus. Total Knee Replacement. Strategies for Improving Minority Healthcare Quality. Effectiveness of Antimicrobial Adjuncts to Scaling and Root-Planing Therapy for Periodontitis. Regionalization of Bioterrorism Preparedness and Response. Training of Hospital Staff to Respond to a Mass Casualty Incident. Effects of Omega-3 Fatty Acids on Cardiovascular Disease. Effects of Omega-3 Fatty Acids on Cardiovascular Risk Factors and Intermediate Markers for Cardiovascular Disease. Effects of Omega-3 Fatty Acids on Arrhythmogenic Mechanisms in Animal and Isolated Organ/Cell Culture Studies. Health Effects of Omega-3 Fatty Acids on Asthma. Health Effects of Omega-3 Fatty Acids on Lipids and Glycemic Control in Type II Diabetes and the Metabolic Syndrome, and on Inflammatory Bowel Disease, Rheumatoid Arthritis, Renal Disease, Systemic Lupus Erythematosus, and Osteoporosis. Celiac Disease. Community-Based Participatory Research Assessing the Evidence. Criteria to Determine Disability Related to Multiple Sclerosis. Economic Incentives for Preventive Care. Islet Transplantation in Patients with Type 1 Diabetes Mellitus. Measuring the Quality of Breast Cancer Care in Women. Preventing Violence and Related Health-Risking Social Behaviors in Adolescents. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review No. 9.      Volume 1. Series Overview and Methodology.      Volume 2. Diabetes Mellitus Care. Strategies to Support Quality-Based Purchasing.

National Guidelines Clearinghouse™

The National Guidelines Clearinghouse™ (NGC) was developed in partnership with the American Medical Association and the American Association of Health Plans. The NGC is a Web-based resource for information on over 1,300 evidence-based clinical practice guidelines. Since becoming fully operational in early 1999, the NGC has had over 2 million visits and now receives over 135,000 visits each month. The NGC helps health care professionals and health system leaders select appropriate treatment recommendations by providing full text or an abstract of the recommendations, comparing and evaluating different recommendations, and describing how they were developed.

In response to user feedback, enhancements were added to the NGC and its Web site in 2004:

• A new CD-ROM tutorial walks users through a series of informative demonstrations and scenarios on how to use the enhanced site.
• A new MS Word® download feature allows users to download and view the complete summary for each guideline represented in the NGC database. The new feature works on all computers that use Microsoft Word. NGC content may also be downloaded to Personal Digital Assistants that can read Microsoft Word documents.
• NGC syntheses became available in PDF format, a printer-friendly version. NGC syntheses are analyses of guidelines that cover similar topic areas. Key elements of each synthesis include the scope of the guidelines, the interventions and practices considered, the major recommendations along with the corresponding rating schemes for quality of the evidence and strength of the recommendation, the areas of agreement, and the areas of difference.
• A new "Guidelines in Progress" page lists the guidelines submitted to NGC, accepted for inclusion, and for which copyright has been obtained. This page allows users to see if guidelines of interest to them are being abstracted and prepared for inclusion on the NGC site. The page will change as the status of guidelines in the work queue changes from "in progress" to "published" or "withdrawn."
• Enhanced summary content is now provided, such as methods used to formulate the recommendations, rating schemes for the strength of the recommendations, references supporting the major recommendations, contraindications, financial disclosures and the Institute of Medicine's National Healthcare Quality Report categories.
• An enhanced Detailed Search feature allows users to filter searches by the methodology and IOM categories.
• A glossary of all the controlled vocabulary terms utilized in the NGC has been added.
• Web developer tools, such as RSS feeds of the entire inventory of NGC content, and a new Search Form feature which offers Web developers the ability to create their own unique search interfaces with the NGC Web site are now operational.

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