Chapter 3. From Research to Results

Partnerships and Coordination

Forming partnerships allows organizations in both the public and private sectors to strengthen their capabilities in improving health care, stimulate new forms of integration among organizations, and contribute to ensuring better access to health services and better health outcomes.

The Agency for Healthcare Research and Quality has a long and successful history of developing partnerships and working in collaboration with various organizations within the Department of Health and Human Services, other components of the Federal Government, State and local governments, and private-sector entities. Working in partnership with these other organizations helps us meet our goals.

AHRQ's partnerships and collaborative efforts span the spectrum of our activities:

• Developing new knowledge.
• Developing tools, measures, and other decision-support mechanisms so that existing knowledge can be used easily.
• Working with the agencies and organizations in the public and private sectors to accelerate the adoption of effective health care interventions.

Because our authorizing statute provides the agency with a unique focus on improving the quality of the health care delivery system, AHRQ has developed several initiatives that place great emphasis on partnerships and collaboration.

In 1999, AHRQ developed the first initiative—Translating Research into Practice (TRIP)—a targeted research effort designed to assess the effectiveness of different strategies and methods for applying the often technical findings from research in daily practice. This was followed by the establishment of two "real world" research networks—the Integrated Delivery System Research Network (IDSRN) and the Practice-Based Research Network (PBRN)—that serve as ongoing, living laboratories, enabling us to quickly assess emerging trends in health care and evaluate the impact of new interventions.

With our recent initiative, Partnerships for Quality, AHRQ is now working with other public- and private-sector entities to ensure that AHRQ-supported research will be applied to achieve meaningful and lasting improvements in care.

Examples of the many ways in which AHRQ works in collaboration and partnership to carry out the Agency's mission

• Develop new knowledge through research. AHRQ's focus is on developing new knowledge regarding effective health care services and efficient approaches to financing and delivering those services. We co-fund individual research projects with other public- and private-sector funding organizations and sponsor joint research solicitations with other HHS agencies and research foundations. When we co-fund a project supported by other agencies, our goal is to ensure that the research addresses issues that are significant and important in daily practice, such as the comparative cost-effectiveness of alternative treatments, which would otherwise go unaddressed.
• Develop tools, measures, and other decision-support mechanisms so that existing knowledge can be easily used.
  • It is becoming increasingly difficult to keep abreast of the rapidly increasing amount of medical literature. It is even more challenging to determine how to apply research findings effectively. To address these challenges, AHRQ supports the assessment and synthesis of existing scientific knowledge and the development of tools, measures, and decision-support mechanisms to assist physicians, patients, and others in using the evidence on what works best.
  • AHRQ increasingly is being seen as the source of definitive assessments of existing scientific evidence. A growing number of Federal agencies (e.g., the National Institutes of Health (NIH), the Centers for Medicare & Medicaid Services (CMS), the Social Security Administration, and the Department of Veterans Affairs) professional societies, and other health care providers are working closely with AHRQ's Evidence-based Practice Centers (EPCs) to develop syntheses of existing scientific evidence to guide their work. In addition, CMS uses technology assessments prepared by the EPCs to inform decisions about Medicare coverage of new and existing health technologies. For example, when Medicare asked AHRQ to evaluate the effectiveness of lung-volume reduction surgery, we concluded that there was insufficient evidence to reach a determination. However, we pointed out to Medicare the potential for developing the evidence through an innovative process of conditional coverage in which Medicare would pay for the procedure in selected institutions, provided the surgeons and patients agreed to the collection of outcomes data. This resulted in a partnership between Medicare, NIH's National Heart, Lung, and Blood Institute, and AHRQ to assess the procedure. As a result of this study, we now know which patients are likely to benefit, and even more importantly, the study identified a subgroup of patients who experienced increased mortality as a result of the procedure, which means that avoidable deaths can be reduced.
  • Evidence reports prepared by AHRQ-supported EPCs have been used in the development of clinical practice guidelines by a number of private-sector organizations, including the American Psychiatric Association, the American Academy of Pediatrics, the American Heart Association, and many others. For example, the American Academy of Pediatrics has developed a practice guideline based on the AHRQ evidence report on diagnosis of attention-deficit/hyperactivity disorder (ADHD). Also, the Department of Veterans Affairs is using the meta-analysis (i.e., a statistical method of combining the results of independent studies and synthesizing summaries and conclusions) in our EPC report on prostate cancer as part of its continuing medical education program.
• Working in concert with public- and private-sector efforts to accelerate the adoption of effective health care interventions.
  • Even when the scientific evidence is clear and clinicians, patients, and others have the tools to use existing knowledge, it may not be used. Findings from AHRQ-supported TRIP research and research conducted through AHRQ's IDSRNs and PBRNs can help identify the organizational, financial, and cultural barriers to implementation and help assess the effectiveness of alternative approaches to facilitate adoption. AHRQ's Partnerships for Quality vehicle can then use this research to speed the adoption of effective practices and, in turn, further assess and refine these implementation strategies.
  • The goal of the TRIP cooperative agreements is to identify sustainable and reproducible strategies to overcome the barriers to using effective health care interventions and identify ways to facilitate adoption of effective interventions.
  • AHRQ supports nine IDSRNs that conduct fast-track, cutting-edge research on health policy and delivery system issues. More than 700,000 physicians, a majority of hospitals, more than 2,000 outpatient clinics, 450 long-term care facilities, 50 rehabilitation facilities, 30 home heath agencies, and 60 dental facilities are affiliated with these networks.
  • PBRNs are groups of practices devoted principally to patient care that work together with researchers and/or professional organizations to study and improve the delivery and quality of primary care. AHRQ supported 33 networks involving 10,000 providers and 10 million patients in 2003.
  • The Partnerships for Quality grants originally funded in 2002 are designed to accelerate the pace with which research findings can be translated into improved quality of care and health care system performance. The 22 projects span much of the Nation and involve more than 88,000 medical providers; 5,800 hospitals, nursing homes, and other health care facilities; and 180 health plans.
• Coordination with other HHS agencies.
  • AHRQ continues to play a leadership role in the HHS Patient Safety Task Force, which includes CDC, the Food and Drug Administration (FDA), and CMS. The goal is to work closely with the States and the private sector to improve existing systems to collect and analyze patient safety data. AHRQ, on behalf of the Patient Safety Task Force, awarded a contract to develop and implement a user-friendly, Internet-based patient safety reporting format that will greatly simplify the burden on those required to report patient safety events, enable faster crossmatching and electronic analysis of data, and facilitate more rapid responses to patient safety problems. In 2003, AHRQ and the Patient Safety Task Force supported 13 grants to assess risks to patients and devise ways to prevent them, as well as implement safety practices that show evidence of eliminating or reducing known hazards to patient safety.
  • AHRQ has been a very active participant in the Research Coordination Council (RCC). We have received valuable input from the RCC workgroups that will help us strengthen coordination and collaboration in several areas of the Agency's research. For example, the Disability, Aging, and Long-term Care Workgroup made recommendations related to AHRQ's research agenda on nursing home quality, disability measurement, and efforts to improve the longterm care data infrastructure. Recommendations from the Health Research Workgroup focused on improving coordination and efficiency in research translation, dissemination, and implementation, as well as improving coordination of research related to health care. The Science Workgroup recommendations are related to an HHS Secretarial Initiative on Prevention.

Use Of AHRQ Technology Assessments AHRQ serves as a science partner with the Centers for Medicare & Medicaid Services (CMS) by preparing technology assessments that CMS can use to inform coverage decisions for the Medicare program and to provide guidance to Medicare carriers. The following technology assessments were developed by AHRQ in FY 2003: Acupuncture for Fibromyalgia. Acupuncture for Osteoarthritis. Electrical Bioimpedance for Cardiac Output Monitoring. Magnetic Resonance Spectroscopy for Brain Tumors (MRS). Obesity in the Elderly. Positron Emission Tomography for Brain, Cervical, Ovarian, Pancreatic, Small Cell Lung, and Testicular Cancers. Screening Immunoassay Fecal Occult Blood Testing. Knee Arthroscopy. Wound Care Technologies. To find these and other technology assessments, go to the Technology Assessments section of the AHRQ Web site.

In 2003, AHRQ staff participated in the RCC workgroups, which reviewed the FY 2005 research budget requests submitted by the agencies and assisted in the development of findings and recommendations for consideration by the Secretary's Budget Council. The purpose of these workgroups is to identify ways to increase the efficient use of existing resources by identifying opportunities to collaborate with other agencies. Some examples of how AHRQ contributed to the RCC follow.

• Identifying the potential for overlapping areas of focus or gaps in research efforts. The health care information technology (HIT) program efforts include improvements in the Indian Health Service's electronic health record and joint programming with CMS.
• Increasing collaboration and coordination with other HHS agencies. AHRQ, FDA, CDC, and CMS will join together to develop a National Patient Safety Network.
• Improved RD&E programs or efficiencies related to the FY 2005 planning process:
  • AHRQ, the HHS Assistant Secretary for Planning and Evaluation, CMS, the National Center for Health Statistics, and the National Institute on Aging are working to improve the Department's long-term care data systems.
  • AHRQ, CDC, the Health Resources and Services Administration, the Indian Health Service, and the Administration on Aging will work collaboratively to implement the prevention funding CDC received.

Working in partnership AHRQ worked collaboratively with the American Medical Association and the American Association of Health Plans (now America's Health Insurance Plans) to develop the National Guideline Clearinghouse™ (NGC), an internet resource for evidence-based clinical practice guidelines. Currently, the NGC includes more than 1,000 guidelines that have been submitted by over 165 health care organizations and other entities. The Healthcare Cost and Utilization Project (HCUP) is a long-standing public-private partnership between AHRQ and more than 33 partner States to build and maintain a multi-State data system. AHRQ and the Centers for Medicare & Medicaid Services (CMS) are working together to develop a module of the CAHPS® survey that will report consumer satisfaction with regard to hospital care. AHRQ staff are also working to develop messages CMS can use to target information to Medicare beneficiaries.

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Translating Research into Practice

It may take as long as several decades for findings from original research to be incorporated into routine clinical practice. Thus, the translation of research findings into sustainable improvements in everyday practice and patient outcomes remains one of the most significant challenges to be met in improving the quality of health care received by patients. Accelerating the uptake of evidence-based practice is a top priority for AHRQ.

In 2000, AHRQ funded 13 new projects to evaluate different strategies for translating research findings into clinical practice. The goal of these cooperative agreements, known collectively as TRIP-II, is to identify strategies that can be validated and replicated to help accelerate the impact of health services research on direct patient care and improve the outcomes, quality, effectiveness, and efficiency of care through partnerships between health care organizations and researchers.

The projects funded in 2000 joined 14 others that were funded in 1999 as part of a major initiative by AHRQ to close the gap between knowledge and practice to ensure continuing improvements in the quality of the Nation's health care. There now are 458 sites (hospitals, physician's offices, nursing homes, Head Start programs, outpatient clinics, and research network practices) involved in this initiative. More than 150,000 patients/participants; 1,547 physicians; and 4,276 nurses, pharmacists, and other health care providers are taking part in AHRQ's TRIP-II initiative.

Two areas of particular importance to the TRIP-II initiative are improving the health care provided to priority populations and using information technology to translate research findings into health care improvements and health policy. Collaboration is the key to realizing these goals. A number of partnerships have been formed between researchers and health care organizations such as integrated service delivery systems, practice-based networks, academic health centers, managed care organizations, and others. The structural and organizational diversity of these health systems may help to facilitate the evaluation of models and tools for research translation to actual care settings that might not otherwise occur.

These partnerships are helping to accelerate and magnify the impact of research on health care practice by:

• Disseminating evidence-based knowledge to audiences that include practitioners, patients, and administrators.
• Identifying information important to the efforts of organizations to improve the quality of health care.
• Providing practical assistance to physicians and other providers in implementing research in direct patient care.
• Supporting the further development and refinement of successful and sustainable strategies to translate research into practice and thereby improve outcomes.

A steering committee made up of grantees and AHRQ staff is working to strengthen individual studies and facilitate collaboration and synergism between the studies. Several work groups have been formed to discuss common issues, data elements, methods, tools, and outcomes. The goal is to advance the scientific base for clinical research implementation.

In 2002, AHRQ and the Department of Veterans Affairs (VA) supported grants addressing the translation of research findings into clinical practice to improve quality, patient safety, and health care outcomes. Because the challenge of translating research into practice confronts all health care organizations, this effort is an unprecedented collaboration between AHRQ and the VA to encourage evaluation of improvement strategies that can be broadly replicated.

For instance, one of the studies is looking at whether headache management programs (i.e., diagnosis, patient education and activation, clinical treatment, and regular monitoring and followup), should be promoted as an effective and cost-effective strategy for managing patients with chronic disabling headache. Though headache in its many forms is common and sometimes debilitating, consultation rates for it are low, training on how to manage it is insufficient, and effective diagnostic tests to help evaluate patients with headache are lacking. The study's foundations are AHRQ technical reviews on the state-of-the-science in headache management and the practice guidelines developed by the Headache Guideline Consortium.

AHRQ's Technology Partnerships AHRQ works in partnership with other public- and private sector entities to advance the use of health technologies to improve health care quality. AHRQ's first technology partnership began in 2003, when ePocrates, a market leader in providing clinical information to physicians and other health care professionals, agreed to publish ePocrates DocAlert® messages featuring recommendations from the AHRQ-supported U.S. Preventative Services Task Force and other AHRQ research findings. DocAlert® messages deliver clinical news such as medication safety alerts, customized information on medical specialties, and Task Force recommendations directly to clinicians' personal digital assistants (PDAs). AHRQ partners with Clinical Content Consultants, LLC, to incorporate the latest Task Force recommendations in its Prevention Encounter Form software, which provides clinical decision support prompts that automatically alert providers when preventive services are due and allow for easy documentation and tracking. AHRQ partners with InfoPOEMs®, Inc. (Patient-Oriented Evidence that Matters), to produce daily E-mails, called DailyPOEMs®, to health care providers alerting them to the latest developments in clinical research. These InfoPOEMs® can also be accessed through InfoRetriever®, an online database system that provides a full range of information from decision support tools to diagnostic calculators, and from clinical practice guidelines to Cochrane Systematic Review abstracts (reviews of health care interventions).

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Improving Primary Care Through Practice-Based Research

In 2003, AHRQ supported 33 primary care practice based research networks (PBRNs) at a total cost of $3.5 million. These networks directly involve about 10,000 family physicians, pediatricians, general internists, and nurse practitioners, whose practices are spread across all 50 States, and who provide care for about 10 million patients. Also, AHRQ awarded eight small research grants to existing PBRNs to conduct exploratory/pilot projects or feasibility studies for a range of issues including prevention of adolescent smoking and childhood obesity, use of electronic medical records to improve care, and the application of tools for translating research into practice.

PBRNs are groups of practices devoted principally to patient care that work together with academic researchers and/or professional organizations to study and improve the delivery and quality of primary care. These networks facilitate the sharing of ideas, questions, observations and resource information with greater frequency than a single practice normally would be able to maintain. Through cooperative agreements, AHRQ supports network efforts to define the practice base of each PBRN and to improve network methods of managing data and translating research into practice.

Several of the networks are made up entirely of rural practices. Others, especially those comprising mostly inner-city practices or community health centers, serve large minority and low-income patient populations. In addition to several regional networks, the group includes two national networks managed by major primary care professional organizations: the American Academy of Family Physicians and the American Academy of Pediatrics.

In particular, AHRQ is interested in improving in-office systems designed to assure that the primary care delivered in practice is consistent with current medical evidence. In addition to collecting survey data about their provider and patient populations, the networks have tested the use by practitioners of various electronic information technologies, including handheld devices, notebook computers, and Web-based applications. Two networks conducted qualitative studies on patient and provider concerns about the privacy and confidentiality of patient-related data collected in primary care practices.

AHRQ partnered with the Robert Wood Johnson Foundation to develop the Prescription for Health Initiative, a new PBRN-targeted project designed to develop effective, practical strategies that primary care providers can use to help Americans change their unhealthy behaviors. Seventeen PBRNs received grants to design and test innovative projects to assist primary care providers in helping patients become more physically active, eat healthier foods, avoid or quit smoking, and moderate use of alcohol.

Examples from the Prescription for Health Initiative Create new types of staff positions, such as community health advisors, who link patients to specific local opportunities. Recommend Web sites that offer patients ways to access information, local resources, and assistance from their doctor. Develop a personal digital assistant (PDA) tool to help clinicians tailor counseling to individual patients. Establish links to community resources that provide regularly scheduled counseling by phone matched to each patient's stage of adaptation. Perform a PDA-based assessment of health risks for adolescents with E-mail followup.

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Fast-Track Research Through Integrated Systems

Most health care in the United States is delivered through complex health systems such as managed care organizations, hospitals and hospital networks, large physician groups, and nursing homes. As a result, these organizations have become increasingly important as both creators and users of information. Many of these organizations have considerable research capacity, including sophisticated data systems that follow patients over time and across different health systems; ties between research and operations staff; and strong teams of researchers. Then again, many delivery systems—even some very large ones—do not have these capacities.

AHRQ created the Integrated Delivery System Research Network (IDSRN) in 2000 to expand the capacity for research and facilitate fast-track, cutting-edge research on health policy and delivery system issues. The IDSRN is a creative agency-private-sector partnership that links AHRQ with the Nation's top researchers and some of the largest health care systems in the country. The Network is being tapped for research by a number of AHRQ's sister agencies, including CMS and HHS's Office of Minority Health and Office of Public Health Preparedness.

The rapid-turnaround nature of these contracts permits the Agency to quickly generate findings to answer priority policy questions. For example, an Institute of Medicine roundtable meeting examined the policy implications of studies linking good outcomes with large volume hospitals—hospitals that treat or perform procedures such as coronary artery bypass surgery on a large number of patients. This study found that little is known about what causes this association or what lies behind some of the outliers (i.e., small-volume hospitals with good outcomes and large-volume hospitals with poor outcomes). To find the answer, one of AHRQ's IDSRNs is doing a qualitative study focusing on the processes of care at high- and low-volume hospitals with good and bad outcomes.

Network partners The IDSRN includes the following nine practice-based research consortia and their collaborators: HMO Research Network. Abt Associates, Inc. Center for Health Care Policy and Evaluation (UnitedHealth Group). Research Triangle Institute-University of North Carolina Network. Emory Center on Health Outcomes and Quality. Denver Health. University of Minnesota Consortium. Marshfield Medical Research and Education Foundation. Weill Medical College of Cornell University.

The IDSRN includes nine practice-based research consortia and their collaborators that provide care to more than 55 million Americans across the United States. Many of those who receive care in participating facilities represent hard-to-reach populations, such as those covered by Medicare or Medicaid, uninsured individuals, racial/ethnic minorities, and rural residents.

With access to linked private-sector data about care in outpatient and inpatient settings, the IDSRN is uniquely situated to develop, disseminate, and implement scientific evidence about what works in a variety of health care settings. The partners and collaborators collect and maintain administrative, claims, encounter, and other health care data on large populations that are clinically, demographically, and geographically diverse. The IDSRN represents a real-world laboratory for organization- and system-level demonstrations, and it serves as a dissemination medium for putting evidence-based findings into practice.

In its first 3 years of operation, awards totaling more than $11 million were made to support research on a variety of topics, including patient safety, health care quality, information technology, the organization and financing of care, bioterrorism preparedness, and disparities in health care. Many of these studies include analyses of financial incentives, payment policies, and/or the impact of costs on care. FY 2003 IDSRN awards total about $2.9 million and include studies that address long-term care, quality and cost performance, patient safety/patient care, and disparities in health care.

Findings from IDSRN projects are of interest to a broad range of stakeholders, including policymakers, employers, public purchasers, health information organizations, clinicians, and patients. The network and the pool of providers and patients it represents are key dissemination vehicles for research findings from IDSRN studies. Findings are also disseminated through more traditional channels, such as conferences, Web sites, training programs, press briefings, fact sheets, and other publications.

Network Participation Provider type Number participating in IDSRN Physicians Majority of U.S. physicians Hospitals Majority of U.S. acute care facilities Outpatient clinics More than 2,000 Long-term care facilities 450 Rehabilitation facilities 50 Home health agencies 30 Dental facilities 60

Examples of recent findings from IDSRN projects follow.

Health plans use software to identify disparities. RAND and the Center for Health Care Policy and Evaluation have developed a spreadsheet tool to help health plans identify disparities in performance between different racial/ethnic and/or socioeconomic-status subgroups of enrollees on a given HEDIS (Health Plan Employer Data and Information Set) measure or discern patterns of disparities across a set of measures. HEDIS, sponsored by the National Committee for Quality Assurance, is a set of standardized performance measures related to many significant public health issues such as cancer, heart disease, smoking, asthma, and diabetes.

These measures are designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. To date, two different plans within UnitedHealth and Molina Health Care are using this remarkably flexible tool to assess disparities, and other plans have expressed interest in obtaining the tool. AHRQ also expects that this tool will be used by plans participating in a new AHRQ and Robert Wood Johnson collaboration to reduce disparities in healthcare.

Hospital improves discharge processes to decrease medication errors. A Seattle hospital is now supporting discharge planning and transitions through extensive information sharing—ensuring that hospitals have accurate information about all active prescriptions a patient should have been taking when they were admitted and that all of the ambulatory physicians who have active prescriptions associated with a patient know their patient is being discharged. This change in practice is directly attributable to study findings from a Research Triangle Institute IDSRN project that examined how integrated delivery systems manage information transfer, a potential cause of medical errors.

Improving transitions and outcomes for heart failure patients. A joint study by Weill Medical College of Cornell University and the Visiting Nurse Services of New York to improve transitions and outcomes for heart failure patients through a hospital-home health care information exchange has resulted in the development of an electronic tool to replace a paper-based information exchange. This tool, which will shorten processing time and improve information flow between care settings and providers, has been very well received by operational leadership, clinicians, and informatics personnel at the two institutions. Cornell University plans to implement use of the electronic system in its geriatrics and general medicine facilities.

Leadership training for physicians. An IDSRN study conducted by Weill Medical College of Cornell University on the impact of leadership in enhancing patient safety resulted in the New York Presbyterian Healthcare System deciding to implement General Electric's Six Sigma program to train a cadre of its physicians to improve patient safety in a variety of hospital units.

Six Sigma is a highly disciplined process that focuses on delivering near-perfect products and services. The central idea behind this process is that if you can measure how many "defects" there are in a process, you can systematically figure out how to eliminate the defects and get as close to "zero defects" as possible.

Bioterrorism antibiotic prophylaxis model. Recent bioterrorism events have intensified the need for communities to develop concrete response plans. Weill Medical College of Cornell University produced a simulation model for outpatient antibiotic distribution in the event of a bioterrorist attack. This point-of-dispensing (POD) model has been used as a template by the Office of Emergency Management and the Department of Health in New York City to set up and run a number of POD sites.

For example, Presbyterian Hospital implemented a POD in its hospital cafeteria to brief, triage, and distribute antibiotics as necessary to employees and patients. In 2003, this model was refined to provide a field-tested, scalable, scenario-appropriate template for combined medical and public health responses to bioterrorism attacks.

Tri-POD drill. Following the development and use of the POD model described above, the simulation model of mass antibiotic prevention of disease was tested last year in a large-scale, live exercise in New York City. The drill succeeded in triaging and providing simulated antibiotics to more than 1,250 "patients" per hour.

The mock patients, who had been trained to present with or without various symptoms of illness, were tracked using bar-code technology that allowed the organizers to measure both processing time and accuracy. Officials hope to use the results of this exercise to develop a template for bioterrorism response that can be adapted by other U.S. cities and around the world. Subsequently, Weill researchers were invited by the CDC's National Pharmaceutical Stockpile Program and the U.S. Public Health Service Commissioned Corps Readiness Force to train personnel responsible for distribution and dispensing of pharmaceuticals in the event of a catastrophic incident in the United States.

First evidence-based anthrax triage protocol to distinguish anthrax from flu and flu-like illness. Researchers from Weill Medical College of Cornell University developed a four-step triage and screening protocol to distinguish anthrax from flu and flu-like illness for use in the prehospital setting in the aftermath of any future anthrax attack.

A comparison of clinical data from the 2001 anthrax attacks and historical accounts of inhalation anthrax cases with published accounts of the presenting signs and symptoms of flu and influenza-like illness were used to develop the protocol. This is the first evidence-based approach to the critical patient care and resource allocation issues that will accompany any large-scale mass prevention of disease effort in response to suspected or confirmed anthrax exposure.

Bioterrorism preparedness planning tool shared with the 2004 Olympic Planning Committee in Greece. A U.S. Northern Command participant in the Denver Health's Rocky Mountain Regional Care Model for Bioterrorist Events Working Group was interested in how to identify the "best" alternative care sites in the event of a bioterrorist threat. For example, what are the advantages versus disadvantages of using churches, schools, hotels, auditoriums, and other nontraditional facilities, depending on the type of bioterrorist attack?

In response to this need, Denver Health developed an "Alternative Care Site Selection Matrix Planning Tool," which assists with rating various facilities by comparing the facilities to a hospital. The U.S. Northern Command—established in 2002 by the Department of Defense to plan, organize, and execute homeland defense and civil support missions—was very pleased with the tool and shared it with the Athens 2004 Olympic Committee.

Characteristics of IDSRN facilities Top study settings: Outpatient clinics. Hospitals. Emergency rooms. Nursing homes. Top medical conditions: Diabetes. Pregnancy, labor, and delivery. Cardiovascular disease. Stroke. Top special populations: People with chronic conditions. Elderly. Medicaid/low socioeconomic status. Ethnic/racial minorities. Rural residents.

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Partnerships for Quality

Research and experience have taught us that new scientific knowledge does not automatically translate into practice to improve patient care. In order for research findings to make their way into everyday clinical practice, the new knowledge must be linked with supportive environments and incentives for change. Systematic approaches are required for changes to take place and services to be implemented that have the potential to improve care.

AHRQ's Partnerships for Quality initiative works to close the gap between the level of quality that is possible and that which is achieved. This initiative supports projects that are designed to accelerate the pace with which research findings can be translated into improved quality of care and improvements in the health care system's ability to deliver that care.

In response to AHRQ's 2002 call for research proposals, the Agency funded 22 cooperative agreements that are primarily focused on improvements in the delivery and outcomes of health care, with emphasis on priority health issues, such as longterm care, bioterrorism, and children's mental health. Second-year funding for this initiative totals about $6.5 million, an increase of over $4.0 million over first-year funding support.

For example, one of the partnerships looks to improve the quality of care and life in nursing homes. The partners for this project are the American Medical Directors Association (AMDA), the AMDA Foundation and its Long-term Care Research Network, the American Health Quality Association (representing State Quality Improvement Organizations), Quality Improvement Partners of Rhode Island, and the National Long-term Care Quality Coalition, consisting of representatives from more than 15 long-term care professional and provider groups.

The project's primary goal is to improve outcomes for the 1.6 million residents of long-term care facilities by: implementing community-based quality improvement programs for nursing homes that maximize knowledge and resources through collaboration; validating AMDA's pain and pressure ulcer clinical practice guidelines; and disseminating evidence-based clinical practice guideline implementation and training models that can be used in nursing homes throughout the country. The project will be rolled out in 50 facilities across California, Indiana, Florida, Ohio, Pennsylvania, and Texas.

Partnerships for Quality projects will: Test financial incentives and rewards to speed the adoption of recommended hospital patient safety practices. Test an innovative team-oriented, practice-based continuing medical education program to improve care for patients with type 2 diabetes. Build partnerships to promote cooperation in implementing quality improvement strategies in long-term care facilities. Incorporate validated quality measures into the recertification of family physicians. Test approaches to implementing tools and research findings into everyday health care. Help community-based primary care practices adopt quality improvement models for treating heart disease, stroke, diabetes, and other conditions. Create a national center for value-based purchasing methods. Test a bioterrorism simulation model with large health care networks.

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Monitoring the Nation's Health Care Safety Net

In 2000, the Institute of Medicine (IOM) released a report stating that the rising numbers of uninsured patients, together with changes in Medicaid policies and cutbacks in government subsidies, are putting unprecedented pressure on the United States' health care safety net. The health care safety net—the Nation's system of providing health care to low-income and other vulnerable populations—comprises public hospitals, community health centers, local health departments, rural health clinics, and special service providers such as AIDS clinics and school-based clinics. Many of these providers have either a legal mandate or an explicit policy to provide services regardless of a patient's ability to pay.

In addition to describing the health care safety net in the United States as "intact but endangered," the IOM report emphasizes:

• The precarious financial situation of many of the institutions that provide care to Medicaid, uninsured, and other vulnerable patients.
• The changing financial, economic, and social environment in which these institutions operate.
• The highly localized, "patchwork" structure of the safety net.

One of the report's five key recommendations focuses on the need to improve data systems used to monitor the capacity and stability of the Nation's health care safety net to meet the health care needs of vulnerable populations. In response to this recommendation, AHRQ and the Health Resources and Services Administration (HRSA) began a joint safety net monitoring initiative. An expert meeting provided an overview of the issues involved in establishing a monitoring system. Attendees at the meeting recommended a monitoring system that would provide baseline information to policymakers about the status of safety net providers and the populations they serve to help in designing interventions and strategies to achieve policy objectives.

We need to develop more precise knowledge of what should be measured, identify data and measures that are currently available, determine opportunities and strategies to develop data capacity, and assess the feasibility of monitoring these areas. To that end, AHRQ and HRSA are producing a series of products to meet policymakers' needs.

In 2003, two data books that describe the current status of the safety net were published. Core information for these data books was drawn from a wide variety of existing data sources. The information covers demand for services, financial support, the structure of the safety net, and a wide variety of community contextual characteristics. A total of 118 different measures of the safety net are included.

The first book, Monitoring the Health Care Safety Net—Book 1: A Data Book for Metropolitan Areas, presents data from 90 metropolitan areas, including 355 counties and 172 cities in those areas. It provides extensive data tables as well as an overview of the findings from the measures included.

The second book, Monitoring the Health Care Safety Net—Book 2: A Data Book for States and Counties, shows data for over 1,800 counties across 30 States and the District of Columbia, including both metropolitan and nonmetropolitan counties.

In conjunction with these books, a Web-based safety net profile tool was developed. The Profile Tool provides easy access to all of the data included in the books and guides users step-by-step to obtain needed statistics. It can be used to generate reports that compare multiple measures for one or more geographic areas. In addition, a 3-day, Web-assisted audioconference series, broadcast in the fall of 2003, was designed to inform State and community officials about the data books and teach them to use the books and other tools for monitoring the health care safety net.

The third companion book, Monitoring the Health Care Safety Net—Book 3: Tools for Monitoring the Health Care Safety Net, will be published in 2004. This product provides "how to" manuals on a variety of topics, including estimating the size of local uninsured populations, conducting local surveys, using administrative data, assessing the financial health of safety net providers, and using geographic information systems to monitor the safety net.

This product can assist State and local health officials, planners, and analysts in assessing the capacity and viability of their existing safety net providers and help them understand the characteristics and health outcomes for the populations served.

To further assist State policymakers in using the information in these three books, HRSA has funded a grant through the National Governor's Association Center for Best Practices. The project is entitled "Enhancing the Safety Net Through Data-Driven Policy." This intensive technical assistance project is designed to help policymakers in four States develop a series of data-driven recommendations to enhance the strength, structure, and stability of their health care safety nets.

As part of the project, interdisciplinary State teams are using the two data books to access new information about their safety net systems, and they are using these data tools as the basis for crafting their own policy initiatives to strengthen and sustain the health care safety net. AHRQ staff are actively involved in providing technical assistance for this project, which began in 2003. Technical assistance will continue in 2004, and AHRQ will publish Developing Data-Driven Capabilities to Support Policymaking, the fourth publication in the Monitoring the Health Care Safety Net series.

Measures included in the safety net data books: Demand for safety net services. Includes measures of uninsurance, poverty, disability, and HIV/AIDS. Financial support for safety net services. Includes measures related to Medicaid, disproportionate share hospital payments (i.e., additional Medicare program payments that help hospitals finance care to low income and uninsured patients), and community health centers. Safety net structure and health system context. Includes a wide range of measures describing area hospitals, the distribution of uncompensated and Medicaid discharges, characteristics of the ambulatory care system, managed care penetration, and physician supply. Community context. Includes a wide range of measures on topics such as population size and growth, racial/ethnic distribution of the population, immigration, the economy, housing, education, and crime. Outcomes and safety net performance. Includes measures of preventable hospitalizations, birth outcomes, and barriers to accessing care.

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