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.

AHRQ 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 other organizations helps us meet our goals.

Most of the Agency's partnerships are related to the development of new research knowledge, tools, measures, and decision support mechanisms so that existing knowledge can easily be used. AHRQ works with various 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 clinical 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.

The following examples illustrate the many ways in which AHRQ works in collaboration and partnership to carry out the Agency's mission:

• We are developing new knowledge regarding effective health care services and efficient approaches to financing and delivering services by co-funding research projects with other public- and private-sector funding organizations and sponsoring 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.
• Collaborations are underway to synthesize existing scientific knowledge and develop tools, measures, and other decision-support mechanisms to assist physicians, patients, and others in using the evidence on what works best. A growing number of Federal agencies—(such as 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, a number of professional societies, providers, and other private-sector entities used the AHRQ evidence report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices, to develop evidence-based clinical care practices and related health policies.
• Creating partnerships to accelerate the pace with which research findings can be translated into improved quality of care and health system performance:
  • AHRQ established the AHRQ-VA Patient Safety Improvement Corps, a training program for State health officials and their selected hospital partners. During the first annual program, 50 participants completed coursework in three, 1-week sessions at AHRQ's offices in Rockville, MD. Participants analyzed adverse medical events and close calls—sometimes known as "near misses"—to identify the root causes of these events and correct and prevent them. Anticipating that the growing demand for patient safety expertise will exceed the capacity of this intensive program, one aspect of this initiative will be to develop Web-based training modules. These will be in the public domain and could be used independently or by private-sector training programs that would provide additional "hands on" experiences.
  • To accelerate the pace of quality improvement, AHRQ launched a program called Partnerships for Quality. The Partnerships for Quality program provides a mechanism for collaborations aimed at translating research findings on quality improvement into practice and policy. The unifying goal of this program is a strong commitment to the improvement of health care services and their security, safety, outcomes, quality, effectiveness, and cost-effectiveness. The projects are developing partnerships among researchers, health plans, medical and nursing facilities and services, employers, consumer groups, and professional societies. The aim is to test prototype activities aimed at accelerating the health system's adoption of research findings that have been shown to improve quality of care for patients. For example, AHRQ awarded a grant to The Leapfrog Group, which is a consortium of more than 135 large private and public health care purchasers buying health benefits for more than 33 million Americans. Leapfrog has devised a plan for conducting and rigorously evaluating financial incentive or reward-based pilot projects in up to six U.S. health care markets in two waves over the next 3 years.
  • The Surgical Care Improvement Project (SCIP) is a national partnership of organizations committed to improving the safety of surgical care through the reduction of postoperative complications. In summer 2005, the SCIP partnership will launch a multi-year national campaign to substantially reduce surgical mortality and morbidity in four target areas through collaborative efforts. The goal is to reduce nationally the incidence of surgical complications by 25 percent by the year 2010. The project is led by CMS and the Center for Disease Control and Prevention (CDC). AHRQ is a member of the SCIP Partnership's steering committee.

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Translating Research into Practice

Over 10 years may pass before the findings of original research become part of routine clinical practice, and often the findings are never implemented. Numerous evidence-based clinical practice guidelines recommend specific approaches to clinical care, but we do not know how many doctors and other clinicians follow these guidelines. We do know that passive guideline dissemination has rarely been effective in changing clinician behavior. Methods that have been shown to be effective in specific settings include use of peer-opinion leaders, clinical practice audit and feedback, educational interventions, small group consensus processes, more intensive academic detailing, prospective reminder systems, and computer-based guideline implementation.

AHRQ funded the first 14 projects of its TRIP initiative in 1999 to help close the gap between knowledge and practice to ensure continuing improvements in the quality of the Nation's health care. There are now 458 sites (hospitals, physician's offices, nursing homes, Head Start programs, outpatient clinics, and research network practices) involved in this initiative. AHRQ funded a second set of 13 projects (known as TRIP II) in 2000 to evaluate different strategies for translating research findings into clinical practice. The goal of 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.

A recent survey of principal investigators for the TRIP II projects revealed several barriers to implementing TRIP projects as well as some successful solutions. The survey was conducted 6 months and 18 months after project implementation. In the early months of TRIP implementation, challenges occurred often with the human subjects' application process and with introducing new TRIP responsibilities at the study sites. A year later, the most prevalent barriers were process (such as blocked access to data), behavioral (target audience not participating), and structural (skill or system limitations at the study site).

For example, implementation of an intervention to improve asthma management met with resistance from agency staff. The research team found that the staff appeared not to trust the intervention and were sometimes overwhelmed by the tasks required for asthma management. To address the problems, the researchers made several minor adjustments to the intervention and provided the staff with necessary training. Early evidence of the positive impact of the intervention on families was used to win staff acceptance. An incentive program, including small monetary rewards and social recognition, was implemented for "asthma champions."

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Integrated Delivery System Research Network

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. However, many delivery systems—even some very large ones—do not have these capacities.

In 2000, AHRQ created the Integrated Delivery System Research Network (IDSRN), a field-based research network that tests ways to improve quality within some of the most sophisticated health plans, systems, hospitals, nursing homes, and other provider sites in the country. 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.

In the past year, provider-researcher teams have been working on ways to reduce falls in nursing homes and ways to limit medication errors. Often we partner with others in the Department on these efforts. For example, CMS asked AHRQ to develop a handbook on ways to improve cultural competency of health care providers. CMS is now using this handbook as a key part of their training for Medicare and Medicaid providers. One IDSRN developed a tool to help hospitals prepare for bioterrorist events and other emergencies. The American Hospital Association has since shared this tool with all of their members and now provides technical assistance on how to use it.

A new tool produced by Denver Health, another of AHRQ's IDSRN partners, helps State and local officials quickly locate alternate health care sites if hospitals are overwhelmed by patients due to a bioterrorism attack or other public health emergency. The alternate care site selection tool was shared with emergency response planners at the 2004 Summer Olympics in Athens, Greece, and it is included in a new report, The Rocky Mountain Regional Care Model for Bioterrorist Events.

IDSRN Partners and Their Collaborators Partner: Abt Associates, Inc., Cambridge, MA Collaborator: Geisinger Health System Partner: Center for Health Care Policy and Evaluation, UnitedHealth Group, Minneapolis, MN Collaborators: Allina Health System, RAND, Health Systems Innovations Partner: Denver Health, Denver, CO Collaborators: University of Colorado Health Sciences Center, Colorado Prevention Program Partner: Emory Center on Health Outcomes and Quality (formerly USQA Center for Health Care Research), Atlanta, GA Collaborator: Aetna Partner: Kaiser Foundation Research Institute, Kaiser Permanente of Northern California, Oakland, CA Collaborators: Kaiser Permanente—Northwest, Southern California, Colorado, Georgia, Hawaii, Group Health Cooperative of Puget Sound; Harvard Pilgrim Health Care; Health Partners Research Foundation; Henry Ford Health System; Lovelace Health Systems; Fallon Health Care System Partner: Marshfield Medical Research and Education Foundation, Marshfield, WI Collaborators: Project HOPE Center for Health Affairs, CODA, Inc. Partner: Research Triangle Institute-UNC, Research Triangle, NC Collaborators: Intermountain Health Care; University of North Carolina at Chapel Hill; UNC Health Care; CareOregon; Summa Health System; Providence Health System; MayaTech Corp.; University of Pittsburgh Medical Center Partner: University of Minnesota, Division of Health Services Research and Policy, Minneapolis, MN Collaborators: Blue Cross Blue Shield of Minnesota; Institute for Clinical Systems Improvement; Medical Group Management Association; Allina Health System; Institute for Research and Education, HealthSystem Minnesota; Delta Rural Health Consulting Partner: Weill Medical College of Cornell University, New York, NY Collaborators: New York Presbyterian Healthcare System; Joseph L. Mailman School of Public Health of Columbia University; North Shore University Hospital; Memorial Sloan-Kettering Cancer Center; Health Watch

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Improving Primary Care through Practice-Based Research Networks

AHRQ began supporting 36 practice-based research networks (PBRNs) in 2003. 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.

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 practice or community health centers, serve large minority and low-income patient populations. In addition to several regional networks, the group includes four national networks managed by major primary care professional organizations: the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the Ambulatory Pediatric Association.

In 2003, AHRQ had 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.

In 2003 AHRQ also worked collaboratively with the Robert Wood Johnson Foundation (RWJF) to develop the Prescription for Health initiative, a two-phase $9 million 5-year national program. Under this initiative, primary care PBRNs are funded to develop creative, practical strategies for promoting healthy behaviors among patients. The program targets four health-risk behaviors that are the nation's leading causes of preventable disease and premature death: lack of physical activity, poor diet, tobacco use, and risky use of alcohol. The 17 PBRNs funded for Phase I of the program completed a diverse set of projects including the redesign of practices, implementation of effective interventions, and the development of tools to link practices with community resources.

Other new PBRN projects funded by AHRQ in 2004 include:

• Delivery of Preventive Services in Primary Care. The Center for Family Medicine Research at the University of Oklahoma and the Oklahoma Physicians Resource/Research Network, in collaboration with Medical Data Solutions, Inc., (a software development company) are studying the effectiveness of a multicomponent intervention to translate three office system strategies known to increase delivery of immunizations and other preventive services. The translational intervention includes medical record audits with feedback and benchmarking, academic detailing, a practice enhancement assistant, and a computer application designed to help the practice incorporate and maintain the office system strategies.
• QuitLink: A leveraging solution to tobacco counseling. The Virginia Ambulatory Care Outcomes Research Network is partnering with the American Cancer Society to test a three-part intervention strategy to offer counseling and pharmacotherapy to patients who use tobacco at 16 primary care practices in Virginia. The intervention includes:
  1. Using vital signs to prompt nurses or medical assistants to determine the patient's use of tobacco, offer brief advice, and assess readiness to quit as vital signs are obtained.
  2. Inviting tobacco users who are prepared to quit to get proactive counseling provided by the American Cancer Society through three, 30-minute telephone sessions.
  3. Feedback from the American Cancer Society, requests for prescription aids in support tobacco users attempts to quit, progress reports, and quarterly analyses of practice and clinician team referral outcomes.
• Improving Diabetes Efforts Across Language and Literacy. The UCSF Collaborative Research Network (CRN) is implementing the Improving Diabetes Efforts Across Language and Literacy (IDEALL) Project. This intervention uses both an automated telephone diabetes management program and group medical visits to introduce self-management support strategies to patients with diabetes and their providers. Researchers are comparing the effects of both interventions with respect to each other as well as to usual primary care as well as patient outcomes, the success of implementation, and maintenance of the programs.
• Evaluating a Patient-Centered Diabetes Registry. Researchers are implementing a patient-centered registry for improving diabetes care using a registry where both patients and practices can enter data and receive information tailored to their needs about diabetes care and self-management. The effectiveness, adoption, and implementation during all phases of developing and testing will also be evaluated.

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Monitoring the Nation's Health Care Safety Net

The health care safety net—the Nation's system of providing health care to low-income and other vulnerable populations—has been described as "intact but endangered." AHRQ and the Health Resources and Services Administration (HRSA) are leading a joint initiative to monitor it. The goal of this joint initiative is to help local policymakers, planners, and analysts monitor the status of their local safety nets and the populations they serve. Strategies include providing baseline data and a set of tools that enable monitoring of the capacity and performance of local safety nets with four main goals:

• Provide baseline information and an assessment of policymakers' information needs for the safety net system and its environment.
• Establish an early warning system to alert policymakers to changes in safety net capacity and stability.
• Provide information to policymakers about the status of safety net providers and the populations they serve that can help in designing interventions and strategies to achieve policy objectives.
• Develop and implement a research agenda on safety net and access-related issues for low-income populations.

"Enhancing the Safety Net Through Data-Driven Policy" is an intensive technical assistance project that is part of the safety net monitoring initiative. It is designed to help policymakers in three States develop a series of data-driven recommendations to enhance the strength and stability of their health care safety net(s). As part of the project, interdisciplinary State teams will:

• Demonstrate the practical application of the safety net monitoring initiative data and tools.
• Use the data and tools as the basis for crafting their own policy initiatives to strengthen and sustain the health care safety net.
• Receive technical assistance to build on the innovative practices others have used to address similar challenges.

This project gives States the opportunity to learn about new data and current research from Federal officials and nationally recognized experts, as well as promising State practices from peers in other States.

Two data books were published in 2003 that describe the current status of the safety net. The first, Monitoring the Health Care Safety Net—Book I: 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 II: A Data Book for States and Counties, shows data from over 1,800 counties across 30 States and the District of Columbia, including both metropolitan and nonmetropolitan counties.

The third and last product from the initiative, Monitoring the Health Care Safety Net—Book III: Tools for Monitoring the Health Care Safety Net, was published in 2004 and offers strategies and concrete tools for assessing local health care safety nets.

The information presented in these books can assist State and local health officials, planners, and analysts in assessing the capacity and viability of their existing safety net providers, and it can help them understand the characteristics and health outcomes for the populations served.

Recent Findings on Safety Net Projects A survey of more than 2,000 medical school faculty involved in direct patient care found large gaps exist between nonpaying and paying patients in referrals to specialists, access to technologically advanced care, outpatient mental health and substance abuse treatment, and even routine inpatient care. Nearly one-fourth of clinical faculty reported that they were rarely or never able to obtain nonemergency hospital admissions for uninsured patients. Nearly one in five clinical faculty felt that they were discouraged by their group practice or hospital from seeing too many indigent patients, and more than one in ten reported that their group practice placed formal limits on the number of patients or the amount of care they could provide. At teaching hospitals, faculty practices must finance their charity care through revenues from paying patients. However, they do so without the subsidies from Medicare and Medicaid that are available to hospitals serving a disproportionate number of poor and uninsured patients. The second most common reason given for limiting care to the uninsured was inadequate reimbursement.

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