Quality Research for Quality Health Care

A Report from AHRQ on Recent Activities and Future Directions

Contents

Message from the Director
Introduction
   Organizational Structure
   National Advisory Council
   AHRQ's Customers
   How AHRQ's Research Helps People
AHRQ's Research Portfolio
   AHRQ Cycle of Research
   Opportunities for Research
   Nurturing Research Career Development
   Partnerships and Coordination
Strategic Plan and Goals
   Goal 1: Support Improvements in Health Outcomes
     Outcomes Research Portfolio
     U.S. Preventive Services Task Force
     Put Prevention Into Practice
     Evidence-based Practice Centers
     Centers for Education and Research on Therapeutics
     Translating Research into Practice
     Integrated Delivery System Research Network
     National Guideline Clearinghouse™
     Primary Care Research
   Goal 2: Strengthen Quality Measurement and Improvement
     CAHPS®
     CONQUEST
     Research on Quality Improvement
     Healthcare Cost and Utilization Project (HCUP) Quality Indicators
     AHRQ's Leadership in the QuIC
     Research on Patient Safety and Medical Errors
   Goal 3: Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce
   Unnecessary Expenditures
     Research on Priority Populations
     Medical Expenditure Panel Survey
     Healthcare Cost and Utilization Project
     Markets and Managed Care Research
     User Liaison Program
Future Directions

Message from the Director

I am very pleased to release this report on the goals, accomplishments, and future of the Agency for Healthcare Research and Quality. This report covers fiscal years 1999-2000. Our last year as the Agency for Health Care Policy and Research was 1999. The Agency was reauthorized in December 1999, a few days before its 10th anniversary and renamed as the Agency for Healthcare Research and Quality. While we fell a few days short of that milestone, we are celebrating the birth of a new Agency that builds on the strong foundation of high quality research laid by its predecessors—AHCPR and the National Center for Health Services Research and Health Care Technology Assessment.

With our reorganization comes an increased focus on quality and patient safety and ways to reduce medical errors. We are also emphasizing ways to accelerate and magnify the impact of research on clinical practice and patient outcomes.

AHCPR accomplished much during its decade. AHRQ will build on that success in the months and years to come and continue to make a difference in the quality of health care for Americans.

John M. Eisenberg, M.D.
Director
Agency for Healthcare Research and Quality

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Introduction

As we begin the 21st century, people in the United States are living longer, healthier lives. In 1998, life expectancy at birth increased to an all-time high of 76.7 years for men and women, and life expectancy for black males increased for the fifth year in a row. Death rates for heart disease, cancer, and stroke decreased.

Heart disease continues to be the leading cause of death for men and women of all races. The good news is that in 1998, the age-adjusted death rate for heart disease was about one-half of what it was in 1970. Deaths from cancer—the second leading cause of death—are also falling, continuing a trend that began in 1990. Between 1970 and 1990, age-adjusted cancer death rates had steadily increased. And finally, stroke deaths are continuing a steady decline that began in 1992.

Despite these encouraging gains in life expectancy and substantial progress on other health care fronts—such as increased use of early prenatal care and preventive services and rapid advances in new treatment regimens for HIV and AIDS—there are incredible challenges ahead for the U.S. health care system. These include rising health care costs, concerns about patient safety and medical errors, variations in clinical practice and patient outcomes, and barriers to care for our most vulnerable populations.

Disparities are substantial among racial and ethnic groups for many causes of death. Disparities also occur between men and women and among people with different education levels. Men and women with less than a high school education have death rates at least double those of people who have education beyond high school.

Research on these and other pressing issues forms the core mission of the Agency for Healthcare Research and Quality. Our goal at AHRQ is to work toward high quality, accessible, and affordable health care for all Americans. AHRQ conducts and supports health services research on clinical outcomes, quality, cost, use of resources, and access to care. Findings from AHRQ-supported health services research are used by clinicians, patients, health system leaders, and others to help them make more informed health care decisions.

Making sure that AHRQ's research helps to improve the health and health care of the American people is a touchstone for the Agency that is evident in all aspects of our operations: from our strategic planning process, to the consideration of the research we fund, to our partnerships with other groups. We work closely with our sister agencies within the Department of Health and Human Services, with other Federal, State, and local agencies, and with private-sector organizations.

AHRQ supports and conducts research that evaluates the effectiveness, quality, and value of health care in everyday settings, uncovering the evidence and developing the knowledge and tools that yield measurable improvements in quality. A key to the success of this mission is the Agency's TRIP agenda, or "Translating Research Into Practice," which helps to ensure that the impact of AHRQ's research is felt by more people in a timely manner. Through the TRIP initiative, findings from AHRQ research are put directly to work to improve the quality and value of health care provided in the Nation. (Select for more information about our TRIP research agenda.)

This report presents information on the programs and activities undertaken by AHRQ in fiscal years 1999-2000 and provides some examples of accomplishments during that time. It also includes some of the research priorities that AHRQ will pursue in the coming months. To set the stage for this discussion, the report presents the organizational structure of the Agency and key responsibilities of its functional components, describes the Agency's National Advisory Council for Health Care Policy, Research, and Evaluation, and identifies the various audiences and customers who use the findings from Agency-supported research.

AHCPR/AHRQ in Fiscal Years 1999-2000

Budget: The agency's fiscal year 1999 budget was $171.055 million. AHRQ's budget in fiscal year 2000 was $203.8 million. Nearly two-thirds of the budget was awarded as grants and contracts to researchers across the country. AHRQ's budget for 2001 is $266.9 million.
Staff: 270
Director: John M. Eisenberg, M.D.
Deputy Director: Lisa Simpson, M.B., B.Ch., M.P.H.

Organizational Structure

AHRQ has nine major components. They are:

• Center for Practice and Technology Assessment. CPTA directs the evidence-based practice program, consisting of: (1) the Evidence-based Practice Centers that develop evidence reports and technology assessments; (2) the Internet-based National Guideline Clearinghouse®; (3) the U.S. Preventive Services Task Force; and (4) intramural and extramural research and evaluation on translating evidence-based findings into clinical practice. CPTA also is responsible for research on the assessment of medical technologies, including conducting and sponsoring technology assessments to assist decisionmaking in other agencies. Director: Douglas B. Kamerow, M.D., M.P.H.
• Center for Outcomes and Effectiveness Research. COER conducts and supports studies of the outcomes and effectiveness of diagnostic, therapeutic, and preventive health care services and procedures. Director: Carolyn M. Clancy, M.D.
• Center for Primary Care Research. CPCR conducts and supports studies of primary care and clinical, preventive, and public health policies and systems, including the effective application of information technology in health care. Director: Helen Burstin, M.D.
• Center for Organization and Delivery Studies. CODS conducts and manages studies of the structure, financing, organization, behavior, and performance of the health care system and providers within it. Director: Irene Fraser, Ph.D.
• Center for Cost and Financing Studies. CCFS conducts and supports studies of the cost and financing of health care and develops data sets to support policy and behavioral research and analyses. Director: Steven B. Cohen, Ph.D.
• Center for Quality Measurement and Improvement. CQMI conducts and supports research on the measurement and improvement of health care quality, including surveys regarding people's experiences with health care services and systems and research related to patient safety and medical errors. Director: Gregg Meyer, M.D., M.Sc.
• Office of Management. OM directs and coordinates Agency-wide administrative activities, including human resources, financial management, information resources management, and other support services. Director: Willard B. Evans, Jr.
• Office of Research Review, Education, and Policy. ORREP directs the scientific peer review process for grants and Small Business Innovation Research (SBIR) contracts, assigns projects to Agency components, plans and manages Agency health services research training and career development programs, develops and implements Agency policies and procedures regarding extramural research programs, and evaluates the scientific contribution of proposed and ongoing research, demonstrations, and evaluations. Director: Francis D. Chesley, Jr., M.D.
• Office of Health Care Information. OHCI designs, develops, implements, and manages programs for disseminating the results of Agency activities, including public affairs, print and electronic publishing and dissemination, reference services, research translation and synthesis, and liaison activities with State and local health policy officials. Director: Christine G. Williams.

Chart 1 (61 KB, text version) shows the agency's organizational structure during fiscal year 1999 and fiscal year 2000. Chart 2 (72 KB, text version) reflects our organizational structure as it is today. Chart 2 shows several changes to our organization that occurred in the first few months of fiscal year 2001 (e.g., renaming of the Center for Quality Measurement and Improvement as the Center for Quality Improvement and Patient Safety to reflect new responsibilities).

National Advisory Council for Health Care Policy, Research, and Evaluation

The National Advisory Council for Healthcare Research and Quality provides advice and recommendations to AHRQ's Director and to the Secretary of the Department of Health and Human Services, on priorities for a national health services research agenda. The 24-member panel comprises 17 private-sector experts who contribute a varied perspective on the health care system and the most important questions that AHRQ's research should address in order to promote improvements in the quality, outcomes, and cost-effectiveness of clinical practice. The private-sector members represent health care plans, providers, purchasers, consumers, and researchers.

Also serving in an ex-officio capacity are principal representatives of seven Federal agencies that address health care issues:

• The National Institutes of Health (NIH).
• The Department of Defense (Health Affairs) (DoD).
• The Centers for Disease Control and Prevention (CDC).
• The Department of Veterans Affairs (VA).
• The Substance Abuse and Mental Health Services Administration (SAMHSA).
• The Food and Drug Administration (FDA).
• The Health Care Financing Administration (HCFA).

AHRQ's Customers

AHRQ's customers are decisionmakers who need objective, evidence-based, and timely information to make informed decisions about the health care they provide, receive, and purchase. These customers include clinical decisionmakers, health care system decisionmakers, policymakers, and patients.

• Clinical Decisionmakers. The evidence uncovered through AHRQ-sponsored research and tools developed from those findings help clinicians, consumers, patients, and health care institutions make informed choices about which treatments work, for whom, when, and at what cost.
• Health Care System Decisionmakers. Health plan and health care system managers use the findings and tools developed through AHRQ-sponsored research to make choices on how to improve the health care system's ability to increase access to care and deliver high-quality, high-value care. Purchasers use the products of AHRQ-sponsored research to obtain high-quality health care services.
• Policymakers. Public-and private-sector policymakers use the information produced by AHRQ to expand their ability to monitor and evaluate the impact of system changes on outcomes, quality, access, cost, and use of health care and to devise policies designed to improve the performance of the system.

How AHRQ's Research Helps People

An important goal for AHRQ is that the Agency's research result in significant improvements in the health of the American people and in the delivery of health care services in the Nation. Following are examples of some of the ways AHRQ's research is making a difference.

• Improved diagnosis for people with heart attack symptoms. Three-fourths of the 7 million Americans who come to the hospital with symptoms of a heart attack turn out not to have one. Nonetheless, many of these people are admitted to the hospital because emergency room physicians are unable to determine with sufficient certainty that no heart attack occurred. New results from an AHRQ-sponsored clinical trial show that the use of a special imaging test on people who have a normal EKG reading and symptoms consistent with a heart attack can reduce by up to 20 percent the number of such people who must spend time in the hospital unnecessarily. If the data from this trial were applied nationally, savings from unnecessary admissions could be $85 million per year.
• Improved screening for pregnant women. AHRQ-funded research demonstrating the cost-effectiveness of screening for group B streptococcal bacteria infection in pregnant women—a condition associated with illness and death in newborn infants—was the basis for CDC recommendations on screening and treatment for this disease. The CDC recommendations have had a major impact on maternal and infant health. Recent research shows that the incidence of early-onset strep infection in infants has decreased by 65 percent since implementation of the recommendations. In addition, the excess incidence of disease in black infants compared with whites decreased by 75 percent, and the incidence of invasive group B strep infections in pregnant women decreased by 21 percent.
• Improved quality in Federal health programs. AHRQ research supports health care quality improvement and efficiency efforts in every Federal health agency, either directly or indirectly. For example:
  • The Department's QuIC (Quality Interagency Coordination) Task Force is a working group of representatives of Federal agencies with responsibility for health care programs. Through the QuIC, AHRQ research on the outcomes and effectiveness of diabetes care is contributing to quality improvement government wide. As one of its initiatives, QuIC member agencies are using a uniform set of diabetes measures, some of which are based on research on diabetes outcomes produced by AHRQ's Diabetes Patient Outcomes Research Team.
  • A "Patient Pointer" guide developed by the Memphis Veterans Affairs Medical Center, which outlines the pros and cons of prostate-specific antigen (PSA) testing for prostate cancer, is based on the findings of AHRQ research on the outcomes of treatment for prostate diseases.
  • AHRQ research provides data that Federal agencies use to make estimates of health care use and expenditures for many purposes. Data from AHRQ's Medical Expenditure Panel Survey (MEPS) and Healthcare Cost and Utilization Project (HCUP) are used by agencies ranging from the Congressional Budget Office and the Council of Economic Advisors to the Health Care Financing Administration and the Department of the Treasury. AHRQ analyses (based on MEPS data) of the number of children who potentially are eligible for public insurance programs but are not yet enrolled have catalyzed Federal efforts to encourage more effective State outreach to uninsured, low-income families with children.

AHRQ Research Findings at Work

• A new add-on to a standard electrocardiograph, originally developed with funding from AHRQ, helps hospitals reduce inappropriate admissions to cardiac care units while maintaining the quality of care for patients. This tool helps emergency room doctors decide on hospitalization or discharge and treatment options.

• The Consumer Assessment of Health Plans (CAHPS® ) is a survey-based tool to evaluate people's experiences with their health plans. It was developed by AHRQ to provide purchasers and others with information they can use to judge health care quality. Members of the Central Florida Health Care Coalition (CFHCC), a 128-member nonprofit business health care group, have been using CAHPS® for 3 years to improve the quality of the health care plans that serve their employees. After CAHPS® surveys are completed and the results are analyzed, CFHCC members focus on areas with low scores in patient satisfaction to identify and improve areas that scored poorly with employees.

• A new tool developed by AHRQ-supported researchers, the function-related groups (FRGs), can distinguish accurately between patients who need more complex and long-term services and those whose rehabilitation is likely to require less time.
• The Health Care Financing Administration has adopted a modified version of FRGs as the basis of Medicare payments to rehabilitation hospitals because FRGs can promote efficiency without giving hospitals an incentive to avoid or undertreat patients with complex needs.
• The Uniform Data System for Medical Rehabilitation (UDSMR) has incorporated FRGs into its data systems. Some 1,400 medical rehabilitation providers in the United States and other countries use this data system for continuous quality improvement, outcomes management, research, and other purposes.

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AHRQ's Research Portfolio: A Pipeline of Investment

The key to the success of AHRQ's program is that the research is driven by the needs of its customers. AHRQ seeks input from its customers in a variety of ways, including: the National Advisory Council, meetings with stakeholder groups, Federal Register notices, and through comments submitted by the public via the Agency's Web site.

AHRQ's research agenda is reflected in a "pipeline" of activities that together build the infrastructure, tools, and knowledge for measurable improvements in America's health care system. This pipeline builds on the foundation laid by biomedical science in determining which interventions can work under ideal circumstances. But knowing that these interventions work is only a first step. More work is needed to ensure that these treatments are used correctly to improve patients' health and that they are effective in everyday practice. AHRQ's pipeline has the following segments that provide the steps needed to achieve these goals.

1. New research on priority health issues. The first segment of the pipeline supports new research to answer important questions about what works in health care. The effort helps build the essential knowledge base that enables us to understand the determinants of the outcomes, quality, accessibility, and costs of care, as well as identify instances when care falls short of achieving its intended outcomes.
2. New tools and talent for a new century. The second segment of the pipeline is the development of tools to apply the knowledge gained through the investment in new research. Here, the work of researchers is applied, and the effort begins to translate this new knowledge into instruments for measurement, databases, informatics, and other applications that can be used to assess and improve care. In addition, the individuals who conduct this research and those who use it are educated to build an effective workforce of doers and users of health care research.
3. Translating Research into Practice. The final segment of the pipeline is where all the previous investment comes together. Research from the first segment of the pipeline and the tools developed in the second segment are translated into resources to close the gap between what we know and what we can do to improve health care quality. In this third segment of the pipeline, AHRQ funds research and demonstrations to translate the knowledge and tools into measurable improvements in the care Americans receive. The Agency also develops partnerships with public- and private-sector organizations to disseminate the knowledge and tools for use throughout the health care system. This third segment of the pipeline is a central focus of the Agency through its Translating Research Into Practice (TRIP) initiative aimed at implementing evidence-based tools and information in diverse health care settings among practitioners caring for diverse populations. The theme of translating research into practice is woven throughout all the initiatives undertaken by AHRQ in fiscal years 1999-2000.

AHRQ Cycle of Research

In order to produce meaningful contributions to health care, AHRQ must set and monitor priorities, develop research initiatives based on those priorities, and keep a close watch on the processes and products that result from agency-supported research. Four processes are involved in the AHRQ research cycle: needs assessment, knowledge creation, translation and dissemination, and evaluation.

Needs assessment. AHRQ's activities begin and end with the end-users of its research. Our research agenda is based on an assessment of gaps in the knowledge base and the needs of patients, clinicians, health care managers, institutions, plans, purchasers, and State and Federal policymakers for evidence-based information. Needs assessment helps us shape the research initiatives undertaken by the agency.

Knowledge creation. AHRQ continues to support and conduct research to produce the knowledge needed to improve the health care system in the coming years.

Translation and dissemination. Simply producing knowledge is not enough. Findings must be presented in ways that are useful and made widely available to clinicians, patients, health care managers, and other decisionmakers. AHRQ synthesizes and translates knowledge into products and tools that help our customers solve problems and make decisions. We are proactive in our dissemination of the knowledge, products, and tools to appropriate audiences, and we form partnerships with other organizations to leverage our resources.

Evaluation. To assess the ultimate outcomes of AHRQ research, we evaluate the impact and usefulness of agency-supported work in health care settings and policymaking. This involves a variety of evaluation activities, including smaller, short-term projects that assess processes, outputs, and interim outcomes to larger, retrospective projects that assess the ultimate outcomes and impact of AHRQ activities on the health care system.

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