Chapter 2. AHRQ's Research Portfolio

AHRQ research priorities are user-driven, and the Agency actively responds to the needs of its customers. The Agency receives input and feedback through the National Advisory Council, meetings with stakeholder groups, Federal Register notices, and comments submitted by the public through AHRQ's Web site at http://www.ahrq.gov.

The Agency carries out a variety of activities to accomplish its research mission. Together, these activities build the infrastructure, tools, and knowledge for measurable improvements in America's health care system. Researchers—including grantees, contractors, and intramural investigators—build on the foundation laid by biomedical researchers who have determined which interventions can work under ideal circumstances. Knowing that these interventions work is only a first step. We also need to know if they are effective in everyday practice and in which circumstances they work, for whom they work and don't work, and other critical information to make sure that the interventions are used appropriately and efficiently to improve patients' health.

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Opportunities for Research

Almost 80 percent of AHRQ's funding supports research that is conducted at universities, in clinical settings such as hospitals and doctor's offices, and in health care organizations. AHRQ makes funding awards through targeted program announcements on particular research projects or to researchers with innovative ideas that propose to help improve health care in America.

In FY 2004, we implemented a new policy of inclusion of priority populations in the research we fund. Priority populations include low-income groups, minority groups, women, children, the elderly, and individuals with special health care needs, including individuals with disabilities, and individuals who need chronic care or end-of-life health care. New in 2004, prospective grantees are required to discuss plans to include priority populations within the context of their scientific objectives and research methods. The goal of this policy is to ensure that the Agency's overall research portfolio includes priority populations.

Innovative Research: Addressing Current and Emerging Challenges

The topics addressed by innovative research proposals reflect timely issues and ideas from top health services researchers. AHRQ uses Program Announcements (PAs) to invite applications and communicate the Agency's priorities for new and ongoing research topics. Examples of new and ongoing FY 2004 PAs include:

• AHRQ Health Services Research Grants. This program provides support for projects focused on improvements in health outcomes, and enhanced decisionmaking at all levels of the health care system. Findings from these projects will increase our understanding of what works, for whom, when, and at what cost. Research funded by this PA will strengthen quality measurement and improvement, and identify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures.
• Practice-based Research Networks (PBRNs) and the Translation of Research into Practice. Projects funded under this program are evaluating scientifically based strategies for translating evidence into sustainable improvements in clinical practice and developing, improving, and/or validating research dissemination methods applicable to cancer control in primary care practice. Researchers will assess the conditions under which the strategies being tested can be expected to be sustainable, can be rapidly transferred or adapted to other primary care settings, and can lead to demonstrable improvements in the quality of care and/or patient outcomes.
• Building the Evidence to Promote Bioterrorism and Other Public Health Emergency Preparedness in Health Care Systems. These grants are examining and promoting the health care system's readiness for a bioterrorist event and other public health emergencies through the development of new evidence, tools, and models. Specific focus is being given to emergency preparedness of hospitals and health care systems for bioterrorism and other public health emergencies, enhanced capacity needs of ambulatory care, home and long-term care, care of psychosocial consequences, and other related services. Researchers are also assessing information technology linkages and emerging communication networks to improve communication in the health care system, emergency response networks, and public health agencies. They are also exploring novel uses of health care system training strategies that can prepare community clinicians to recognize and manage bioterrorist events and other public health emergencies.
• Translating Research into Practice (TRIP). This is a collaborative effort between AHRQ and the Health Services Research and Development Service within the Department of Veterans Affairs. Researchers are implementing innovative and rigorous research and evaluation projects related to the translation of research findings into measurable improvements in quality; patient safety; health care outcomes; and cost, use, and access. Two specific priorities for these projects are to:
  1. Compare the use of interventions to translate research into practice across different health care systems.
  2. Measure the impact of translation activities and interventions that foster measurable and sustainable quality and patient safety improvement or consistent quality and patient safety at a lower cost.

In FY 2004, AHRQ joined with other sponsors to fund and support the following projects:

• Understanding and Promoting Health Literacy. The goal of these projects is to increase scientific understanding of the nature of health literacy and its relationship to healthy behaviors, illness prevention and treatment, chronic disease management, health disparities, risk assessment of environmental factors, and health outcomes, including mental and oral health. Researchers are focusing on interventions that can strengthen health literacy and improve communication between health care and public health professionals (including dentists, health care delivery organizations, and public health entities) and consumers and patients.
• Research Partnerships for Improving Functional Outcomes. These projects are focused on biological, behavioral, medical, and/or psychosocial problems related to the rehabilitation or health maintenance of individuals with acute or chronic disease. Researchers are developing and testing the efficacy of symptom-focused or holistic/integrated therapies for high-prevalence conditions causing disability, such as low back pain, stroke, hearing loss, vision loss, and congestive heart failure and for lower prevalence conditions with high levels of comorbidity, such as spinal cord injury and spina bifida.
• Colorectal Cancer Screening in Primary Care Practice. The purpose of these grants is to develop innovative research projects to increase the knowledge base for enhanced translation of effective colorectal cancer screening techniques into community practice. Researchers are developing interventions, mechanisms, and systems to monitor and improve compliance with recommendations for colorectal cancer screening and followup, including tracking procedures such as sigmoidoscopy or colonoscopy. Other projects are evaluating how the risk for colorectal cancer is assessed in the primary care setting and proposing strategies to improve informed and shared decisionmaking between physicians and patients regarding colorectal cancer screening options.
• Studies of the Economics of Cancer Prevention, Screening, and Care. The purpose of these grants is to increase our knowledge about the economic aspects of cancer prevention screening, and care, including the economic burden to the patient, family, and society resulting from cancer and cancer treatment. The overall goal of this initiative is to enhance the state-of-the-science on the quality of cancer care and inform Federal decisionmaking on care delivery, coverage, and regulation to help formulate effective health care policy related to cancer prevention and control.
• Cancer Surveillance Using Health Claims-Based Data Systems. Investigators are assessing patterns of care, quality and outcomes of care, and health disparities across the continuum of treatment. Researchers are also looking at the intensity and types of services provided at the end of life, short-term complications following cancer treatment, and long-term complications for cancer survivors that result from their cancer treatment.
• Screening and Intervention for Youth in Primary Care Settings. This research project is focused on expanding the role of primary care in the prevention and treatment of drug abuse and related health problems among youth in the predependency phase of drug use. Researchers are developing, testing, and refining screening/assessment instruments to be embedded into comprehensive behavioral health assessments for use in primary care settings to screen for and assess drug use. The emphasis is on tools that are simple, brief, easy-to-use, have optimum levels of sensitivity and specificity, and can be administered by a variety of health care providers. These projects are also evaluating the effect that drug abuse screening tools have on primary care providers' ability to recognize patient problems and intervene accordingly.
• Translational Research for the Prevention and Control of Diabetes. The goals of these projects are to translate recent advances in the prevention and treatment of type 1 or type 2 diabetes into clinical practice for individuals and communities at risk. Researchers are developing and testing improved methods of health care delivery to patients with or at risk of diabetes, improved methods of diabetes self-management especially among underserved and minority populations, and cost-effective, community-based strategies to promote healthy lifestyles that will reduce the risk of diabetes and obesity.

The following summaries are representative of new projects funded in FY 2004 that are focused on well-defined research areas or topics:

• Improving Diabetes Efforts Across Language and Literacy (IDEALL). The goal of this project is to expand exposure to self-management support strategies for patients and providers within the Community Health Network of San Francisco. Researchers will examine the extent of patient participation, engagement with the interventions, changes in diabetes indices, and relative resource use.
• Expanding Surge Capacity Through Use of Former (Shuttered or Converted) Hospitals. This project is assessing the required planning/preparedness needed for hospital use in the Boston area during a major man-made or natural disaster. The researchers will evaluate ways to augment hospital bed capacity, assure sufficient numbers of trained medical personnel and pharmaceutical supplies, expand national disaster medical systems capabilities, and test models to set surge requirements.
• Health Care System Preparedness and Surge Capacity for Bioterrorism and Public Health Emergencies. The goal of this project is to produce a planning guide for hospital and health system administrators to help them understand and operationalize regional preparedness plans for emergencies that result in large numbers of casualties.
• Hospital Adoption of the National Quality Forum Safe Practices. For this project, researchers will examine 30 health care safe practices in actual clinical environments and assess challenges to their implementation, costs and benefits, types of support and resources and tools necessary for successful implementation, and any association and/or correlation between the implementation of safe practices and improved clinical outcomes.
• Root Cause Analyses of Precursor Events Using an Electronic Reporting System. Researchers are testing existing assumptions that the underlying causes and contributing factors for three types of medical errors are the same, similar, or have no relationship by examining their root causes. They will further test whether this similarity is associated with the severity of potential or actual patient safety events and whether such associations vary by Structured Abstract.
• Translating Data to Information: Development of Reporting Template for the AHRQ Quality Indicators (QIs). This project provides support for development and testing of reporting templates for all QIs, Prevention QIs, Inpatient QIs, and the Patient Safety Indicators for consumers, purchasers, policymakers, and health care providers. Researchers also will evaluate an existing program that has used the AHRQ QIs for public reporting and pay for performance. Findings from this project will be incorporated into the QI software thus providing QI users with ready access to recommended reporting templates.
• Development of Curricula to Train Users in the Application of the Quality Indicators (QI) and the Interpretation of QI Output. This project will develop training curricula for use of AHRQ's QIs. These modules and related documentation are intended for use by stakeholder audiences including Federal and State agencies, hospital associations, health care systems, purchasers, and payers interested in applying these standardized, scientifically based quality indicators to their data.

Selected Examples of Recent Findings from AHRQ-Funded Research

• More widespread use of beta-blockers to treat patients with heart failure would result in lower costs to Medicare. A decision model developed by the Duke Center for Education and Research on Therapeutics estimated the costs to Medicare of treating heart failure per-person over a 5-year period were:
  • Without beta-blocker $39,739.
  • With beta-blocker $33,675 a savings of $6,000 per patient.
• Concurrent use of erythromycin with antifungal agents, certain calcium-channel blockers, and some antidepressant drugs (which inhibit CYP3A—a substance that helps the body metabolize erythromycin) should be avoided. AHRQ-funded researchers found that patients who took erythromycin with drugs that strongly inhibit the action of CYP3A had a substantially elevated risk of sudden death from cardiac causes.
• About two-thirds of chronically ill adults never tell their doctors that they don't take their medications because of high costs. Study results indicate that patients were most likely to find their clinicians helpful if the clinicians provided free samples, asked about problems paying for prescriptions, and offered advice about how to pay for current regimens.
• Nearly half of pregnant women who receive medications other than vitamins may be taking drugs that the Food and Drug Administration classifies as having no human evidence of safety for use during pregnancy or that evidence has shown can harm a developing fetus. A study conducted by researchers at AHRQ's HMO Research Network CERT found that 64 percent of women were dispensed a medication other than a vitamin or mineral supplement within the 270 days prior to delivery. Of those, nearly 40 percent of women were dispensed a drug for which human safety has not been established (Category C on the FDA's list). Nearly 5 percent were dispensed drugs from Category D, which the FDA classifies as having positive evidence of fetal risk but also having benefits of use that may be acceptable despite the risk. An additional 5 percent of women were dispensed a drug from Category X, for which the evidence indicates definite fetal risks based on human or animal studies or based on human experience, and the risk of using the drugs clearly outweighs any possible benefit.

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Building the Research Infrastructure

AHRQ believes that future improvements in health care depend in large part on the investments we make today in the research infrastructure. Health services researchers focus on some of the most complex and challenging issues currently affecting health care in the United States, and training new investigators is fundamental to producing the next generation of health services researchers. AHRQ supports an array of intramural and extramural predoctoral and postdoctoral educational, research infrastructure, and career development grants and opportunities in health services research. In addition, the Agency supports the development of health services research infrastructure in emerging centers of excellence and works with Federal and academic partners to develop innovative curricula and educational models.

The following is a list of training programs and support mechanisms for new health services research investigators:

Health Services Research Dissertation Awards

AHRQ supports research undertaken as part of an academic program to qualify for a doctorate. The AHRQ dissertation award supports dissertation research costs of students in accredited research doctoral programs in the United States (including Puerto Rico and other U.S. Territories or possessions). The dissertation will focus on areas relevant to health services research, with emphasis placed on methodological and research topics that address the mission of AHRQ.

Independent Scientist Awards

AHRQ sponsors Independent Scientist Awards in health services research, which are "Research Career Awards" intended to foster the development of promising new investigators in the field. Individual awards support newly independent scientists who can demonstrate a need for a period of intensive research focus.

Mentored Clinical Scientist Development Awards (K08)

AHRQ sponsors the Mentored Clinical Scientist Development Award in health services research. Support is provided for the development of outstanding clinician research scientists who are committed to a career in health services research, with a focus on development as an independent scientist.

National Research Service Award (NRSA) Program

The NRSA program, which supports the training of over 150 investigators annually, provides institutional training grants to academic institutions to develop health services research training opportunities across the Nation. The purpose of the NRSA program is to help ensure that adequate numbers of highly trained individuals are available to carry out the Nation's health services research agenda in order to improve quality of health care, assure value for health dollars spent, and enhance access to services. One goal is to equip students with the necessary knowledge, skills, and experiences to conduct future research which will meet the needs of patients, providers, health care plans, purchasers, and/or policymakers. NRSA institutional training grants assist these programmatically diverse domestic institutions in supporting predoctoral and postdoctoral academic training by providing support for student stipends and tuition.

Predoctoral Fellowship Awards For Minority Students

AHRQ sponsors predoctoral fellowship awards for minority students. Designed to enhance racial and ethnic diversity in the health services research sciences, this fellowship provides up to 5 years of support for research training leading to the Ph.D. or equivalent research degree; the combined M.D./Ph.D. degree; or other combined professional and research doctoral degrees. Support is not available for individuals enrolled in a medical or other professional school program unless it is a combined professional doctorate/Ph.D. degree program.

Building Research Infrastructure and Capacity (BRIC) Program

The Building Research Infrastructure and Capacity (BRIC) program is a merit-based, peer-reviewed program in response to Congressional intent to broaden geographic distribution of health services research funding among institutions located in States where the success rate for applications to the AHRQ has historically been low. BRIC-eligible States included all states that have received less than $3 million dollars in AHRQ support over the 5-year time span of 1999-2003.

AHRQ originally funded six Phase I BRIC awards in FY 2001. Ten States received over $1.7 million in 2-year planning grants: Kentucky, Louisiana, Mississippi, New Jersey, Utah, and a consortium involving Idaho, Montana, Nevada, Utah and Wyoming. Support for Phase 1 of the projects ended in FY 2002. The second phase of the BRIC program was limited to the original recipients of the initial BRIC planning grants. Phase II provided additional support for the refinement, expansion, and implementation of plans developed among grantees supported in Phase I, including resources to conduct pilot research projects.

Minority Research Infrastructure Support Program (M-RISP)

The M-RISP is designed to broaden the capacity of academic institutions predominantly or substantially serving minority racial and ethnic minority populations and the faculty at these institutions to conduct health services research. These awards provide grant support to strengthen the research environments of minority institutions and their ability to conduct research in health services that has the capacity to be disseminated, implemented, and translated into practice and policy.

The M-RISP provides support for two types of primary activities:

1. Institutional research development support to strengthen the institutional infrastructure and enhance the capability of individual faculty members to undertake health services research.
2. Individual investigator-initiated research project support for developing research scientists to conduct small grant research activities that can lead to successful applications for funding under regular health services research grant mechanisms.

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Ongoing Research

Examples of research grants funded in FY2004 under these training programs and support mechanisms include the following:

A Qualitative Description of Enrollment in PACE. The Program of All-Inclusive Care for the Elderly (PACE), a comprehensive community based long-term care programs, provides cost effective comprehensive care for elders with the goal of promoting independence and minimizing institutionalization. The purpose of this qualitative study is to describe enrollment in a PACE from the perspective of elders, families, informal caregivers, and providers, with specific focus on the following questions: What is enrollment in a PACE? When, how, and why do elders enroll in PACE? What events contribute or lead to enrollment in PACE from the perspectives of elders, families, informal caregivers, and providers of health and social services?

Using an EMR to Improve Urban Child Health. Researchers are using an electronic medical record (EMR) in a network of urban primary care centers to:

1. Describe the content and quality of EMR-based urban child and adolescent primary care.
2. Evaluate the efficacy of evidence-enhanced audit and feedback to improve the delivery of multiple primary care services.
3. Describe the perceptions of primary care clinicians and quality improvement strategies used after they receive practice-based audit and feedback.
4. Evaluate incremental improvements in quality following the addition of point-of-care decision support to improve the delivery of multiple primary care services.
5. Describe the perceptions of primary care clinicians following receipt of point-of-care decision support.

Capacity Building in Organizational Research. Researchers are investigating organizational/management science and its measurement and applying these results to the submission of a systems-directed intervention that seeks to improve patient safety and decrease medical errors. The practice-based research and organizational assessment products developed in this project will produce information that:

1. Is relevant and useful to health care policymakers, payers, providers, and consumers.
2. Can be applied in other health care organizational settings.
3. Will help address AHRQ's response to challenges of organizational research.

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