Partnerships and Coordination

The Agency for Healthcare Research and Quality has a long history of developing partnerships and working in collaboration with various HHS organizations, 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 collaborative activities and partnerships span the spectrum of our activities: development of new knowledge; development of tools, measures, and other decision-support mechanisms so that existing knowledge can be easily used; and working with 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 to meet this responsibility. Each of these initiatives places great emphasis on partnerships and collaboration. In FY 1999, AHRQ developed the first of these initiatives, Translating Research into Practice, a targeted research effort designed to assess the effectiveness of different strategies and methods for applying the often technical findings of research in daily practice. This was followed by the establishment of two "real world" research networks—an Integrated Delivery System Research Network and Practice-Based Research Networks—that serve as ongoing, living laboratories, enabling us to quickly assess emerging trends in health care or evaluate the impact of new interventions. With the most recent initiative, Partnerships for Quality, AHRQ is now working with other public- and private-sector entities to use this entire spectrum of research to actually improve care.

There are a variety of ways in which AHRQ works in collaboration and partnership to carry out its mission:

• Develop new knowledge through research.
  • AHRQ's focus is 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 funders and sponsor joint research solicitations with other HHS agencies and research foundations. When we co-fund a project supported by other agencies, the goal is to ensure that the research addresses issues of great importance in daily practice, such as the comparative cost-effectiveness of alternative treatments, which would otherwise go unaddressed.
  • In FY 2002, for example, an ongoing partnership between AHRQ, the Health Resources and Services Administration (HRSA), CMS, and the National Institute for Nursing Research resulted in a published study on the relationship between nurse staffing levels and patient outcomes. The researchers found a direct link between nurse staffing levels and patient complications and deaths in hospitals. They demonstrated that low RN staffing is associated with rates of serious complications, such as pneumonia, cardiac arrest, shock, and gastrointestinal bleeding.
• 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 burgeoning medical literature, and it is even more challenging to determine how to apply research findings effectively. In response, 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, the Centers for Medicare & Medicaid Services, 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. For example, NIH has used literature reviews and evidence reports prepared by AHRQ-supported EPCs as the basis for consensus development conferences on several topics, including management of cancer pain, management of hepatitis C, and prevention of antisocial behavior. In addition, CMS uses technology assessments prepared by the EPCs to inform decisions about Medicare coverage of new and existing health technologies.
  • 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 in our EPC report on prostate cancer as part of its continuing medical education program.
• Working 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 (Translating Research into Practice) research and research conducted through AHRQ's Integrated Delivery System Research Networks (IDSRNs) and Practice-Based Research Networks can help identify the organizational, financial, and cultural barriers to implementation and help assess the effectiveness of alternative approaches to facilitate adoption. The Partnerships for Quality 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 Translating Research into Practice cooperative agreements is to identify sustainable and reproducible strategies to overcome the barriers to use of effective health care interventions and interventions that facilitate their adoption. Twenty-seven projects were funded in 1999 and 2000, involving 458 sites (hospitals, physician's offices, nursing homes, Head Start programs, outpatient clinics, and research network practices), more than 150,000 patients/participants, 1,547 physicians, and 4,276 nurses, pharmacists, and other health care providers.
  • AHRQ supports nine Integrated Delivery System Research Networks 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 health agencies, and 60 dental facilities are affiliated with these nine networks.
  • The Practice-Based Research 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. With awards made in September, 2002, AHRQ now supports 36 networks involving 10,000 providers, and 10 million patients.
  • The Partnerships for Quality funded in FY 2002 are designed to accelerate the pace with which research findings can be translated into improved quality of care and health care system performance. These 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.
  • In FY 2002, AHRQ continued to play a leadership role in the HHS Patient Safety Task Force, which includes the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the Centers for Medicare & Medicaid Services (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, has 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 cross-matching and electronic analysis of data, and facilitate more rapid responses to patient safety problems.
  • 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 long-term care data infrastructure. The Health Research Workgroup recommendations focused on improved coordination and gaining efficiencies in improving research translation, dissemination, and implementation, as well as gaining efficiencies in improving research translation, dissemination, implementation and better coordination of research related to health care. The Science workgroup recommendations are related to the Secretarial Initiative on Prevention.

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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. Accelerating the uptake of evidence-based practice is a top priority for AHRQ.

In September 2000, AHRQ funded 13 new projects to evaluate different strategies for translating research findings into clinical practice. The goal of these cooperative agreements is to identify sustainable and reproducible strategies 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. There are more than 150,000 patients/participants, 1,547 physicians, and 4,276 nurses, pharmacists, and other health care providers 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 that improves 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.

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Improving Primary Care Through Practice-Based Research

In FY 2002, AHRQ awarded $1.5 million to 18 primary care Practice-Based Research Networks (PBRNs). The 18 funded networks directly involved 4,275 primary care providers (family physicians, pediatricians, general internists, and nurse practitioners) whose practices are spread across all 50 States and provide care for about 6.2 million patients. Subsequently, in September, 2002, AHRQ made PBRN awards under a new initiative that doubles (to 36) the number of funded networks and greatly increases the number of providers (about 10,000) and patients (about 10 million) who will be affected by AHRQ's efforts.

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. Through cooperative agreements, AHRQ supported 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 made up of mostly inner-city practices or community health centers, serve large minority and low-income patient populations. In addition to several regional networks, the group included 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 wanted to improve 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 has partnered with the Robert Wood Johnson Foundation in the development of a new PBRN-targeted initiative that will focus on identifying successful methods of promoting healthy behaviors (smoking cessation, avoidance of risky drinking, increased activity, and healthy diets) in primary care practices. The agency also partnered in FY 2002 with the National Cancer Institute in issuing a program announcement supporting research by PBRNs aimed at improving rates of screening for colorectal cancer in primary care practice. We expect the initial awards to PBRNs from both the AHRQ/Robert Wood Johnson Foundation and the AHRQ/National Cancer Institute initiatives will be made in early 2003.

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Fast-Track Research Through Integrated Systems

AHRQ's Integrated Delivery System Research Network (IDSRN) facilitates fast-track, cutting-edge research on health policy and delivery system issues. The research is carried out by top scientists in clinical settings and leads to results that are timely and immediately useful. 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 the Centers for Medicare & Medicaid Services (CMS), the Office of Minority Health/Office of the Secretary of Health and Human Services, and the Office of Public Health Preparedness.

The IDSRN includes nine practice-based research consortia and their collaborators, who 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, those who are uninsured, racial/ethnic minorities, and urban and rural residents.

With access to linked private-sector data about care in ambulatory 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.

The IDSRN was initiated in FY 2000. In its first 3 years of operation, awards totaling more than $11 million have been 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 the studies include analyses of financial incentives, payment policies, and/or the impact of costs on care.

Network Participation
Provider type	Number participating in IDSRN
Physicians	More than 700,000
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

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, and fact sheets and other publications.

Examples of recent findings from IDSRN projects include:

• Guides on Cultural Competency: AHRQ and CMS cofunded the development of two guides to help Medicare+Choice organizations improve the delivery of culturally competent care. The guides are published on the CMS and AHRQ Web sites, print copies have been sent to CMS's Medicare+Choice organizations, and copies also are available from the AHRQ Clearinghouse. Medicare+Choice organizations are mandated by CMS to implement either clinical or cultural competency interventions, and the majority are expected to opt for a cultural competency intervention using the guides to achieve this goal.
• Uniform Collection of Race/Ethnicity Data. Following their study on the impact of race/ethnicity on access, use, and outcomes of health care, Denver Health implemented a new process throughout its health system to collect race/ethnicity information from patients in a uniform manner. This study was cofunded by AHRQ and the Office of Minority Health/Office of the Secretary, U.S. Department of Health and Human Services.
• 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.
• Tri-POD Drill. Following the development and use of the POD model described above, the simulation model of mass antibiotic prophylaxis was tested in May 2002 in a large-scale, live exercise in New York City. The drill succeeded in triaging and providing simulated antibiotics to over 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.
• Community Health Access (CHA) Initiative. Marshfield researchers presented results from their Community Health Access (CHA) Initiative Evaluation to Marshfield Clinic's President and other senior staff, describing CHA evaluation findings and recommended changes. Following the meeting, Marshfield leadership agreed to extend funding and support to the CHA program for a minimum of an additional year.
• Coumadin Clinic Evaluation. In June 2002, the Director of Marshfield Clinic ProActive Health Department presented findings to senior staff from the recently completed coumadin clinic evaluation conducted at Marshfield Clinic. A central focus was the opportunity to improve anticoagulation management services and reduce adverse health outcomes—primarily hospitalizations—by expanding coumadin clinic services throughout the clinic system. It is expected that anticoagulation management services will be extended systematically to the remainder of the Marshfield Clinic system. Findings from this initiative strongly suggest that disease state management such as this could save Medicare an estimated $236,000 per 100 person years.
• Reducing Medication Errors. In a study of integrated delivery system solutions for transferring medication data across patient care settings, Research Triangle Institute developed a model showing that use of an electronic medication list at hospital admission and discharge may reduce by 50 percent the risks and errors associated with poor information transfer. Examples of these risks are medication omissions, wrong doses, and allergic reactions. Providence Hospital in Portland, OR, is using the study findings to reduce medication errors.

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Partnerships for Quality

Research and experience have taught us that new scientific knowledge does not automatically translate into practice and 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.

To close the gap between the level of quality that is possible and that which is achieved, AHRQ is supporting a newly funded initiative called Partnerships for Quality (briefly described earlier in the "Research Portfolio" section of this report). 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 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 a focus on priority health conditions, such as diabetes and heart disease, and priority health issues, such as long-term care, bioterrorism, and children's mental health. First year funding for this initiative totals approximately $2.4 million, and funding in subsequent years could reach $19.5 million.

Following are some examples of the funded partnership projects:

• Partnership to Improve Children's Health Care Quality. The partners for this project are the National Initiative for Children's Healthcare Quality (NICHQ), the American Academy of Pediatrics (AAP), a certifying body (the American Board of Pediatrics, ABP), and Children and Adults with Attention Deficit Disorder (CHADD). The project will build on NICHQ's success in improving care for children with ADHD by engaging five State AAP chapters in systems- and evidence-based collaborative learning sessions along with an interactive Web-based CME quality improvement tool (eQUIPP). ABP will collaborate by including eQUIPP as a vehicle for satisfaction of new certification requirements. Efforts in subsequent years will focus on supporting these local improvement networks, spreading these efforts to additional AAP chapters, and beginning work with pediatric residency training programs.
• Partnership for Achieving Quality Home Care. This project, awarded to the Visiting Nurse Service of New York, will launch a national partnership among home health care providers to improve care for a priority population, elderly home care recipients, by creating a model and establishing an infrastructure through which collaborating organizations can identify and prioritize goals for improvement and gain access to methods, tools, and materials that will enable them to reach beyond what they could do as individual organizations to conduct more sophisticated, evidence-based quality improvement activities. A learning collaborative model, adapted from the successful Breakthrough Series approach developed by the Institute for Healthcare Improvement (IHI), will be created to serve as a central mechanism of the partnership. Activities will include 14 home health agencies, up to two national home health industry associations, two accrediting bodies, and the National Academy of Home Care Physicians.
• Measurement of Quality and Bioterrorism Preparedness: An Impact Study. This project, which was awarded to the Joint Commission on Accreditation of Healthcare Organizations, consists of two distinct but complementary components. The first element relates to performance measurement using an indicator-based approach to measuring quality of care that will demonstrate the impact of evidence-based measurement on health care quality across U.S. hospitals. Areas of focus will be congestive heart failure, acute myocardial infarction, community-acquired pneumonia, and pregnancy. The second element will address an essential element of overall preparedness of health care organizations for a bioterrorism event. The goal is to assess improvements in linkages between health care organizations, the public health infrastructure, and emergency response in the wake of multiple influences such as implementation of the revised Joint Commission emergency management standards, occurrence of national events, and availability of Federal funding for bioterrorism preparedness.

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Monitoring the Nation's Health Care Safety Net

In FY 2000, the Institute of Medicine released a report describing the health care safety net in the United States as "intact but endangered." In particular, the report emphasizes the precarious financial situation of many institutions that provide care to Medicaid, uninsured, and other vulnerable patients; the changing financial, economic, and social environment in which these institutions operate; and the highly localized, "patchwork" structure of the safety net. One of the five key recommendations in the report concerns 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, in consultation with the Office of the Assistant Secretary for Planning and Evaluation and the National Center for Health Statistics, have begun a joint safety net monitoring initiative. An expert meeting on November 9, 2000 provided an overview of the issues involved in establishing a monitoring system. Those attending the meeting recommended a monitoring system that would have four main goals:

1. Provide baseline information and an assessment of policymakers' information needs for the safety net system and its environment.
2. Establish an early warning system to alert policymakers to changes in safety net capacity and stability.
3. 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.
4. Develop and implement a research agenda on safety net and access-related issues for low-income populations.

To accomplish these goals, we need to develop more precise knowledge of what should be measured, identify data and measures that are currently available, identify opportunities and strategies to develop data capacity, and assess the feasibility of monitoring these areas. AHRQ and HRSA have agreed to a three-part strategy focusing on both safety net providers and the populations they serve.

• Develop a databook to describe baseline information. A project is now underway to describe the current status of the safety net in more than 90 metropolitan areas, as well as in more than 1,800 counties across 30 States. Core information for the databook is being drawn from a wide variety of existing data sources and covers demand for services, financial support, the structure of the safety net, and a wide variety of community contextual characteristics.
• Identify a core set of key tools to enable State and local health officials to measure key indicators of safety net status for their service areas. This book will include chapters on how to measure the size of the safety net population in a local area, guidance on data collection, a case study of building a State data system, information on how to assess the financial status of hospitals and community health centers, suggestions for monitoring the status of rural safety nets, and the use of emergency departments as a window on access to care.
• Make longer term recommendations on the data elements needed. The book will include recommendations on the data elements needed in the future to effectively monitor the capacity and performance of safety nets at the Federal, State, and local levels.

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