Chapter 6. AHRQ Program Objectives (continued)

Goal 2: Effectiveness

Prevention Research: Keeping People Healthy

Thousands of Americans die prematurely each year as a result of diseases that often are preventable, such as heart disease, diabetes, some cancers, and HIV/AIDS. Individual behaviors often contribute to these diseases and to other causes of death. These behaviors include tobacco use, lack of physical activity, poor eating habits, substance abuse, and violence.

Individuals, communities, clinicians, health systems, policymakers, and businesses can contribute to preventing disease and to improving the health of the Nation. Involving such a broad constituency in prevention requires the coordinated, widespread dissemination of science-based information about which prevention efforts are effective in improving health and the quality of life.

To address these issues, AHRQ convenes the U.S. Preventive Services Task Force, an independent panel of experts in primary health care and prevention. The first Task Force was convened in 1984; the third Task Force began work in 1998 to update recommendations formulated by the first two Task Forces and to address new topics. Task Force recommendations are considered the gold standard for clinical preventive services.

The mission of the Task Force is to conduct comprehensive assessments of a wide range of preventive services—including screening tests, counseling activities, immunizations, and preventive therapies—and to make recommendations about which services should be provided routinely as part of primary health care. The evidence-based recommendations developed by the Task Force have been used by a diverse audience interested in clinical prevention, including:

• Clinicians and professional societies.
• Health plans, insurers, and policymakers.
• Students, trainees, health educators, and researchers.

In 2003, the Task Force issued recommendations on the following topics:

• Screening for obesity in adults.
• Counseling to prevent tobacco use.
• Counseling for skin cancer.
• Counseling to promote breastfeeding.
• Screening for high blood pressure.
• Counseling for vitamin supplementation to prevent cardiovascular disease and cancer.
• Screening for dementia.
• Screening for diabetes in adults.
• Screening for gestational diabetes mellitus.
• Screening for cervical cancer.
• Counseling to promote a healthy diet.

More information on the U.S. Preventive Services Task Force, including recommendations and materials for clinicians and others, is available at: http://www.ahrq.gov/clinic/uspstfix.htm

Task Force Recommendations Released in Early 2004 Recommendations on the following topics were released in early 2004, as this report was being finalized. Screening for family and intimate partner violence. Screening for hepatitis C. Primary care interventions to prevent low-back pain. Screening for asymptomatic bacteriuria. Screening for hepatitis B virus infection. Screening for oral cancer. Screening for Rh (D) incompatibility. Screening for coronary heart disease. Screening for thyroid disease. More information is available in the Preventive Services section of the AHRQ Web site.

Put Prevention Into Practice

Put Prevention Into Practice (PPIP) is the implementation arm of the U.S. Preventive Services Task Force. It is a national program to improve delivery of appropriate clinical preventive services on the one hand, and to improve the general public's awareness of what we all can do to stay healthy on the other. PPIP was launched in 1994 by the Department of Health and Human Services' Office of Disease Prevention and Health Promotion. Management of PPIP was transferred to AHRQ in 1998, and it has been integrated into the Agency's overall program in clinical prevention.

PPIP materials are derived from the evidence-based recommendations of the U.S. Preventive Services Task Force. PPIP tools and materials enable doctors, nurses, other clinicians, and patients to determine which services patients should receive, facilitate the delivery of clinical preventive services, and make it easier for patients to understand and keep track of their preventive care.

An important goal for the PPIP program is to reduce barriers to the effective delivery of clinical preventive services. These barriers include:

• Clinician barriers: Lack of prevention training, lack of confidence that the preventive interventions can make a difference, lack of time, confusion due to conflicting recommendations, lack of knowledge about new tests, inadequate reimbursement for prevention, and liability concerns or patient demand.
• Office barriers: Lack of knowledge, motivation, readiness for change, or support among office staff; clinical settings focused on illness rather than prevention; and inadequate office systems for tracking delivery and followup of preventive services.
• Patient barriers: Lack of knowledge or motivation, anxiety about procedures and possible results, inconvenience, costs, and unrealistic expectations about the benefits of some services.

PPIP in Action Since 1994, the Texas Department of Health has used Put Prevention Into Practice to develop systems for the delivery of preventive care services. The TDH provided start-up funds to primary care sites, including local health departments and community health centers, to build an infrastructure to effectively deliver preventive care. TDH has developed customized materials such as risk assessment profiles and has trained public health nurses to implement PPIP.

PPIP works to overcome barriers to prevention and promotes the use of appropriate preventive services—such as screening tests, immunizations, and counseling. The PPIP program develops and disseminates tools to help clinicians deliver preventive services and materials for patients to help them understand what they can do to stay healthy and to help them keep track of their preventive care.

PPIP materials include:

• What's New from the U.S. Preventive Services Task Force. This series of fact sheets summarizes individual USPSTF recommendations in a one-page, easy-to-read format.
• A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach describes easy-to-follow, logical steps through the process of implementing a formal system for delivering clinical preventive services.
• Materials for clinical office staff, including preventive care flow sheets, reminder postcards, and prevention timeline posters.
• Pocket-sized guides and pamphlets for patients and the general public, including the Pocket Guide to Good Health for Adults, the Pocket Guide to Good Health for Children, and Pocket Guide to Staying Healthy at 50+ (all guides are available in English and Spanish), as well as Women Stay Healthy at Any Age: Checklist for Your Next Checkup and Men Stay Healthy at Any Age: Checklist for Your Next Checkup.
• Clinician's Handbook of Preventive Services, Second Edition. This publication is both a reference guide and a practical tool to delivering clinical preventive services in a variety of settings. It includes information on more than 200 preventive services, including cancer screening tests, blood and urine tests, x-rays and other radiologic screening tests, prenatal and newborn screening, and counseling interventions related to behavioral change (e.g., smoking, diet, and exercise).
• A PDA tool has been developed that allows clinicians to search the AHRQ Web site for USPSTF recommended preventive services by patient age and sex.
• A Web chart for consumers will be available in the near future. This chart will allow health care consumers to search by age and sex for the preventive care they need.

PPIP materials are based on research-tested interventions for improving the delivery of preventive services in primary care settings and on focus group testing with clinicians, office staff, and patients. These materials have been developed with the cooperation of many public and private institutions, including Federal agency experts and contributors from academic institutions, State departments of health, professional groups, and voluntary organizations. PPIP materials are available online through the AHRQ Web site and in print from AHRQ's Publications Clearinghouse.

Promoting Safe and Effective Use of Pharmaceuticals

Since 1992, AHRQ has funded pharmaceutical research. AHRQ funded studies have focused on patient outcomes related to medications, medication safety, strategies intended to improve the efficiency of drug use, and ways to control medication costs.

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

• ACE inhibitors and beta-blockers reduce deaths in a broad range of patients with heart disease. However, the value of using ACE inhibitors in women with asymptomatic left ventricular systolic dysfunction is uncertain, and the beta-blocker bucindolol may be associated with increased mortality in blacks.
• After decades of being on the rise, antibiotic use by U.S. children fell by almost 25 percent from 1996 to 2000, and more than half of the decrease came from decreased use of antibiotics for ear infections. Awareness by public health and professional groups, as well as attention by the news media to antibiotic overprescribing, may have contributed to this change in prescribing practices.
• Counterdetailing—using pharmacists to work with physicians to help control medication costs—can save money and improve outcomes. This approach developed from AHRQ research helped Partners Community Healthcare, Inc., (PCHI) in Boston save more than $5 million in pharmacy costs. PCHI comprises 1,200 primary care physicians and 3,000 specialists serving about 1.5 million patients. In counterdetailing, pharmacists use an educational approach to work with physicians in an approach adapted from the pharmaceutical industry's practice of "detailing" physicians about new drugs.

Use of Antidepressants Among Elderly Primary Care Patients According to a recent study by researchers at Rutgers University, primary care prescribing of antidepressants for elderly patients increased markedly between 1985 and 1999. This increase was probably due to a combination of factors, including the introduction of a new class of antidepressants in 1988—the selective serotonin reuptake inhibitors (SSRIs)—which have fewer side effects than earlier antidepressants, increased recognition of depression in the elderly by primary care physicians, and financial incentives leading to more reliance on antidepressants instead of more costly psychotherapy. As many as one-sixth of elderly Americans suffer from clinical depression. Elderly patients are more likely than younger ones to feel the stigma of depression, report fatigue and other somatic symptoms instead of psychological symptoms, and prefer treatment by their primary care physicians.

Use of Corticosteroids Following Acute Asthma Episodes Disadvantaged inner-city adults with poorly controlled asthma often end up in the ER or are hospitalized for acute asthma episodes. They also are prone to relapse for weeks following acute asthma treatment, which can lead to another hospital stay. According to researchers at the University of Texas Southwestern Medical Center, a short course of oral corticosteroids (for example, prednisone) following ER treatment for acute asthma may prevent relapse. The researchers followed a group of 309 adults—most of whom were black or Hispanic—who had been discharged from a public hospital ER following acute asthma care between 1997 and 1999. They identified which care processes were effective in improving lung function and found that although there was a positive association between improved lung function and appropriate use of all processes of acute asthma care, only the appropriate use of systemic corticosteroids had a significant effect.

Centers for Education and Research on Therapeutics

The Centers for Education and Research on Therapeutics (CERTs) program, which is administered by AHRQ, is a unique network of seven research centers and a coordinating center focused on improving the use of medical therapies. A key feature of the CERTs program is collaboration across all sectors—public and private, industry and government, academia and business—to improve the use of medicines and medical devices.

There have been more than 130 CERTs projects to date that run the gamut from clinical studies to evaluation of teaching methods to policy-changing outcomes research. Reducing risk to patients is integral to the CERTs mission, and more than 70 projects have focused on ensuring the safe use of therapeutics.

Examples of recent findings from CERTs research include:

• Researchers at the Vanderbilt CERT found that adults who use high-dose (more than 25 mg) rofecoxib, a nonsteroidal antiinflammatory drug (NSAID), are nearly twice as likely to be hospitalized with a heart attack or die from serious coronary heart disease than users of other NSAIDs, such as ibuprofen, naproxen, or celecoxib. Adults typically take NSAIDs to alleviate the pain and inflammation associated with conditions such as rheumatoid arthritis. The study involved nearly 400,000 noninstitutionalized adults aged 50 to 84 who were enrolled in Tennessee's Medicaid program.
• Researchers at the University of Pennsylvania CERT used data on dispensed prescriptions from Medicaid programs in six States that used the same retrospective drug utilization review software vendor. For each State and each month, they calculated the rate of potential prescribing errors per thousand prescriptions and compared the rate before and after implementation of drug utilization review. The researchers found no reduction in the rate of potential prescribing errors coincident with the onset of drug utilization review. They also found no effect of this review on two clinical outcomes: the incidence of all-cause hospitalization or cause-specific hospitalization. Results were consistent across subgroups, including high-dose subgroups where one would expect to find the largest effect. Given the lack of evidence for effectiveness and suggestions of potential harm found in previous research, the CERT researchers suggest that policymakers reconsider the impact of drug utilization review programs.
• Prolongation of the QT interval on the electrocardiogram can predispose a person to torsades de pointes, a potentially fatal ventricular arrhythmia. The use of QT-prolonging medications—such as certain antiarrhythmics, antipsychotics, antibiotics, and antidepressants—can put patients at risk for torsades de pointes. Researchers at the Duke University CERT surveyed a group of experts on the QT interval. The majority of experts said they would always check an ECG before and after starting certain antiarrhythmics, one-third to one-half would always check an ECG before and after starting certain antipsychotics, and less than one-third said they would always check an ECG before and after starting certain antibiotics or antidepressants. The researchers cited a list of medications that experts consider likely to cause QT-prolongation, propose ways to enhance risk management of these medications, and suggest proper monitoring of the QT interval in patients receiving them. They note that in addition to certain medications, other factors that predispose a person to QT prolongation include older age, female gender, low left ventricular ejection fraction, left ventricular hypertrophy, ischemia, slow heart rate, and electrolyte abnormalities.
• Fluoroquinolone (FQ) antibiotics are highly potent, target a broad spectrum of bacteria, and are tolerated well by most patients. However, increasing FQ use in recent years has resulted in FQ resistance by several types of bacteria, including the bacteria that cause pneumonia. Strategies to limit this emerging resistance should target the frequently inappropriate use of FQ in hospital emergency departments, according to researchers at the University of Pennsylvania CERT. They found that 80 percent of FQ use among ED patients was inappropriate. The study involved 100 ED patients at two hospitals; 81 of the patients received FQ for an inappropriate indication. Of these, 53 percent were judged inappropriate because another medication was judged to be first-line treatment, 33 percent because there was no evidence of infection, and 14 percent because of insufficient evaluation. Of the 19 patients who received an FQ for an appropriate indication, only one patient received both the correct dose and duration of therapy.

CERTs Organization and Focus University of Arizona Improve therapeutic outcomes and reduce adverse events caused by drug interactions, especially those affecting women. Also, identify and describe mechanisms for drug-induced arrhythmias. Duke University Advance the optimal use of cardiovascular drugs, medical devices, and biological products. University of North Carolina Improve the use of therapeutics in the pediatric population (neonates, infants, toddlers, children, and adolescents). University of Pennsylvania Optimize drug prescribing and improve the risk/benefit balance from drugs, particularly for anti-infectives. The focus is on antibiotic drug resistance, drug use, and intervention studies. University of Alabama at Birmingham Evaluate the effectiveness, safety, and impact on health-related quality of life of therapeutics for musculoskeletal disorders, and guide and evaluate changes in the practice community based on new therapeutic knowledge. Vanderbilt University Focus on observational studies of medication effects, evaluation of the effects of policy changes, and improving medication use. HMO Research Network Emphasizes studies of the use and outcomes of therapeutics in large, defined populations and of methods for changing provider and patient behavior with regard to prescribing and adherence to therapy. This CERT comprises 10 HMOs across the country, and studies usually involve multiple HMOs to achieve a large, diverse population and range of delivery systems. CERTs Coordinating Center Provides overall CERTs support through strategic planning, program development, and outreach. The coordinating center is housed at Duke University. Steering Committee The steering committee comprises the principal investigators from each CERT and representatives of government agencies, leaders in private industry, and consumer representatives.

Promoting Evidence-Based Health Care

Since the Agency established the Evidence-based Practice Center (EPC) program in 1997, evidence-based reports and technology assessments have been produced on more than 90 topics. In 2002, AHRQ awarded 13 new 5-year contracts to continue and expand the work performed by the first group of EPCs begun in 1997. The EPCs support technology assessment for the Centers for Medicare & Medicaid Services, provide evidence reports for the U.S. Preventive Services Task Force, and develop evidence reports for use by Federal and non-Federal partners to improve health and health care.

Over the past several years, the EPC portfolio has expanded from a primarily clinical focus to encompass studies of health policy issues and special economic studies. The availability of clinical and methodological expertise within the EPCs has drawn an increasing number and variety of professional societies, providers, payers, and policymakers to work in partnership with AHRQ and the EPCs. Beginning in FY 2002, the EPCs moved more fully into the health policy arena as providers and purchasers asked that the EPC expertise also be channeled into production of evidence-based information to help employers make purchasing decisions that will lead to quality health care for their employees.

In AHRQ's reauthorization legislation, the Congress directed the Agency to provide widespread guidance on systems or methods to rate the strength of scientific evidence. As a first step in developing such guidance, AHRQ commissioned the EPC report, Systems to Rate the Strength of Scientific Evidence. This important report is an essential teaching tool not only for researchers but also for purchasers and providers, educating them on how to assess the scientific strength or credibility of health care studies.

Two years ago, AHRQ formed a partnership with the Office of Medical Applications of Research (OMAR) at the National Institutes of Health to include EPC systematic reviews on each clinical condition presented at OMAR's Consensus Development Conferences. Providing OMAR with topic-specific, evidence-based reports will ensure that the NIH Consensus Development Conferences have the latest scientific evidence available to support their deliberations.

Today, the 13 EPCs are providing systematic reviews and analyses in evidence reports for a variety of professional societies, providers, and other private-sector entities that will use the reports to develop evidence-based clinical care practices and related health policies. Examples of ongoing EPC report topics include:

• Perinatal depression.
• Effectiveness of soy in health care.
• Electronic health information technology systems: Costs and benefits.
• Payment strategies to support quality-based purchasing.
• Best practices for providing quality care (for conditions included among the Institute of Medicine's priority conditions).

The EPCs also review and summarize evidence that is relevant to HHS priorities, such as the validation of tools to improve quality of care for hospitalized Medicare beneficiaries. Improvement in the quality and effectiveness of health care can occur only through establishing the evidence for such care and translating that evidence into practical tools that are easily understood and used by the various sectors and individuals involved in health care.

Evidence Report Topics and Partners, FY 2003 Evaluation and treatment of acute stroke—American Association of Health Plans. Closing the quality gap: A critical analysis of quality improvement strategies, Vol. 1. Diabetes mellitus and hypertension. Celiac disease—Office of Medical Applications Research (OMAR), NIH. Depression and postmyocardial infarction—American Academy of Family Physicians Effective payment strategies to support quality-based purchasing—Employer Health Care Alliance Cooperative Episiotomy—American College of Obstetricians and Gynecologists Food-related health claims—Food and Drug Administration Impaired glucose tolerance—American College of Physicians; American Academy of Family Physicians; American Academy of Pediatrics Multiple sclerosis: Criteria to determine disability—Social Security Administration Occupational asthma: Burden of illness/economic consequences—American College of Chest Physicians Perinatal depression—HHS Safe Motherhood Group Preventing violence and related health-risking behaviors in adolescents—OMAR Sexuality and reproductive health following spinal cord injury—Consortium for Spinal Cord Medicine Wound healing: Laser treatment and vacuum-assisted closure—American Association of Health Plans Recruitment of medically underserved populations to clinical trials: Knowledge and access to information—National Cancer Institute Spirometry—Chronic obstructive pulmonary disease—American Thoracic Society; American College of Physicians; American Academy of Family Physicians; American Academy of Pediatrics Health information technology—HHS, Office of the Assistant Secretary for Planning and Evaluation; Office of Disease Prevention and Health Promotion

National Guideline Clearinghouse

The National Guideline Clearinghouse™ (NGC) is an online, comprehensive database of evidence-based clinical practice guidelines and related documents. NGC was developed by AHRQ in partnership with the American Medical Association (AMA) and the American Association of Health Plans-Health Insurance Association of America (AAHP-HIAA).

NGC was launched in January 1999 and is updated weekly with new content. NGC has established a collection of over 1,100 evidence-based guidelines from more than 200 nationally and internationally known health care organizations and other entities. Over the past 5 years, NGC has had more than 8.5 million visitors.

The NGC mission is to provide physicians, nurses, and other health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further the dissemination, implementation, and use of guidelines.

The key components of NGC:

• Structured abstracts (summaries) about each guideline and its development.
• Links to full-text guidelines, where available, and/or ordering information for print copies.
• Palm-based PDA downloads and Microsoft Word® downloads of the Complete NGC summary for all guidelines represented in the database.
• A guideline comparison utility that gives users the ability to generate side-by-side comparisons for any combination of two or more guidelines.
• Guideline syntheses, which are unique guideline comparisons prepared by NGC staff. The syntheses compare guidelines covering similar topics, highlighting areas of similarity and difference. NGC guideline syntheses often provide a comparison of guidelines developed in different countries, providing insight into commonalities and differences in international health practices.
• An electronic forum, NGC-L for exchanging information on clinical practice guidelines and their development, implementation, and use.
• An annotated bibliography database where users can search for citations of publications and resources about guidelines, including guideline development and methodology, structure, evaluation, and implementation.

Other User-friendly Features:

• "What's New?" enables users to see what guidelines have been added each week and includes an index of all guidelines in NGC.
• NGC Update Service is a weekly electronic mailing of new and updated guidelines posted to the NGC Web site.
• Detailed Search enables users to create very specific search queries based on the various attributes found in the NGC Classification Scheme.
• NGC Browse permits users to scan for guidelines available on the NGC site by disease/condition, treatment/intervention, or developing organization.
• PDA/Palm List provides users with information regarding full-text guidelines and/or companion documents available through the guideline developer that can be downloaded for the handheld computer (Personal Digital Assistant [PDA], Palm, etc.).
• Guideline Resources page with links to many other Web sites with content that is complementary to NGC.
• List of AHRQ evidence reports/technology assessments provides users with links to the summaries and full-text reports for evidence reports and technology assessments produced through AHRQ's Evidence-based Practice Center (EPC) program.
• Glossary provides definitions of terms used in the standardized abstracts (summaries).

NGC also offers a new RSS feature that gives Web developers the ability to easily incorporate headline information from the NGC Web site into their own Web pages. This feature directs users of other health care Web sites back to the NGC site for access to detailed summaries and other features.

NGC promotes quality health care by making the latest evidence-based clinical practice guidelines available 24 hours a day in one easy-to-access location. Like all good tools, NGC is very versatile and can be used according to personal preference. Although AHRQ does not require NGC visitors to register in order to use the site, we know from customer satisfaction surveys who is using the site. Nearly half of NGC visitors are physicians, and about 20 percent are nurses and/or nurse practitioners. In the most recent survey of users, more than 93 percent of respondents reported that they were either "fairly" or "very" satisfied with the site.

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