Fiscal Year 2002 Research on Health Care Costs, Quality and Outcomes (HCQO)

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Performance Budget Submission for Congressional Justification

Strengthen Quality Measurement and Improvement

AHRQ's second research goal includes developing and testing measures of quality, as well as studies of the best ways to collect, compare, and communicate these data, and identifying and widely disseminating effective strategies to improve quality of care. To facilitate the use of this information in the health care system, the Agency focuses on research that determines the most effective ways to improve health care quality, including promoting the use of information on quality through a variety of strategies, such as information dissemination and assessing the impact on health care organization and financing.

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Measuring and Improving the Quality of Health Care

Millions of Americans receive high-quality health care services. The United States has many of the world's finest health care professionals, academic health centers, and other research institutions. However, too often, patients receive excessive services that undermine the quality of care and needlessly increase costs. At other times, they do not receive services that have proven to be effective at improving health outcomes and even reducing costs.

For example, one study found that only 20 percent of eligible patients received beta blockers following a heart attack, despite the fact that they have been proven to be an effective intervention, reducing mortality by 43 percent. Another study found that antibiotics are frequently over-prescribed, contributing to microbial resistance to these drugs. Such resistance could cost as much as $7.5 billion a year for more expensive health care interventions.

An Institute of Medicine (IOM) report examining cancer care found that quality problems occur across all types of cancer care and in all aspects of the process of care. Crossing the Quality Chasm summarized problems with breast cancer care include "underuse of mammography for early cancer detection, lack of adherence to standards for diagnosis, inadequate patient counseling regarding treatment options, and underuse of radiation therapy and adjuvant chemotherapy following surgery."

IOM Report, Crossing the Quality Chasm, states:

"Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm."

Poor quality care leads to sicker patients, more disabilities, higher costs, and lower confidence in the health care industry. There is great potential to improve the quality of the Nation's health care system, and there is widespread interest among representatives in the health care system to make these improvements.

In Fiscal Year 2000, AHRQ funded new research to demonstrate and evaluate different strategies for translating research into practice and to ensure that improvements in quality continue.

Translating Research Into Practice II (TRIP II). Translating research into practice (TRIP) is the final step of the research pipeline. This step focuses on closing the gap between what we know and what we do. AHRQ has a growing agenda to accelerate the translation of research into clinical practice. The Agency is committed to informing practitioners, patients, consumers and other decisionmakers about needed health care changes as revealed by research. As we obtain the knowledge of what can be improved, the Agency must be able to promote the adoption and use of these research findings. By doing so, we will be better able to demonstrate that the benefits observed in research are achievable in daily practice and yield measurable and sustainable improvements in health care.

In Fiscal Year 2000, AHRQ published a second Request for Applications (RFA) for TRIP. TRIP II is aimed at applying some of the techniques and methods developed in idealized practice settings or based on theoretical constructs to community-based settings. AHRQ funded 13 grants for 3 years (summary). Select for a complete list of TRIP II projects.

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Selected Fiscal Year 2000 TRIP II Grants

Improving Quality with Outpatient Decision Support. This project will test physician compliance with paper-based and electronic guidelines, reminders, and alerts for outpatient settings (Brigham and Women's Hospital).

Improving Utilization of Ischemic Stroke Research. This study will assess the effectiveness of a model for accelerating the use of evidence-based treatment guidelines for acute ischemic stroke in 24 urban and rural hospitals in Minnesota (Minneapolis Medical Research Institute).

Diabetes Education Multimedia for Vulnerable Populations. This randomized controlled trial will compare usual care with patient education through th use of an interactive, multimedia computer program to improve diabetes-related knowledge, attitudes, self-efficacy and compliance with self-care recommendations (University of Illinois at Chicago).

Implementing Adolescent Preventive Guidelines. This study will analyze the value of implementing office-based clinical preventive services for adolescents. The study will use an experimental design, consisting of training and tools, looking at the outcome of delivery of preventive services during routine well care visits (University of California-San Francisco).

Translating Prevention Research into Practice. As a collaboration between Meharry Medical College and the Center for Health Research at Tennessee State University, this project will conduct a randomized clinical trial comparing two methods of integrating preventive services in a group practice plan serving a low-income minority Medicaid population. Five of the six priority racial and ethnic health disparities will be addressed: infant mortality, cardiovascular disease, cancer screening, HIV/AIDS, and adult and children immunizations (Meharry Medical College).

Primary and Secondary Prevention of Coronary Heart Disease and Stroke. This project will study the impact of a quality improvement model using academic detailing and electronic medical records (EMR) on adherence with clinical practice guidelines for prevention of cardiovascular disease and stroke in primary care settings (Medical University of South Carolina).

Patient Safety and Reducing Errors in Medicine

The November 1999 report of the Institute of Medicine (IOM), entitled To Err Is Human: Building A Safer Health System, focused a great deal of attention on the issue of medical errors and patient safety. The report indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors. Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country—higher than motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). About 7,000 people per year are estimated to die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries.

Although this level of public attention on the issue is a recent phenomenon, AHRQ has recognized for some time that reducing medical errors is critically important for improving the quality of health care. In 1993, the Agency funded the initial research on medical errors, a landmark report which found that 78 percent of adverse drug reactions were due to system failures, such as the misreading of handwritten prescriptions.

Subsequent studies sponsored by the Agency have focused on:

The detection of medication errors.
Investigation of diagnostic inaccuracies.
The relationship between nurse staffing and adverse events.
Computerized adverse drug event monitoring.
Computer-assisted decisionmaking tools to mitigate errors and improve safety.

Research Findings. The results of an AHRQ/Kaiser Family Foundation survey showed that the recent attention to medical errors may have entered the public's consciousness. The survey indicated that people are more concerned about mistakes happening when they are in the hands of the health care system than when they are flying on an airplane.

More than 60 percent of the respondents believe there is a role for government in promoting, monitoring, and providing information about the quality of doctors, hospitals, and health plans.

Fiscal Year 2000 Activities. In Fiscal Year 2000, AHRQ provided $2 million to fund six new research projects to improve patient safety by identifying and preventing avoidable system errors. Funding for these projects builds on AHRQ's earlier investments in patient safety research (select for projects).

Fiscal Year 2000 Patient Safety Grants

Characterizing Medical Error: A Primary Care Study. This study seeks a new perspective on the definition of medical error by gathering the input of primary care patients and their providers (Virginia Commonwealth University).

Time-insensitive Predictive Instrument Information Systems (TIPI- IS) to Reduce Errors in Emergency Cardiac Care. This project addresses the prevention of medical errors in emergency department triage and treatment of acute cardiac ischemia (ACI) by computing the probability that a patient has ACI (New England Medical Center).

Brief Risky High Benefit Procedures: Best Practice Model. This project will study and evaluate the procedure of chest tube thoracostomy insertion at the Maryland Shock Trauma Center. Video and audio recordings will be used to demonstrate how medical errors can occur through deviations in processes, and to prompt discussion among the clinical team about improving practice guidelines to encourage appropriate clinical actions (University of Maryland/Shock Trauma Center).

Developing Best Practices for Patient Safety. This project will develop a public-private patient safety consortium between leading national organizations (e.g., Joint Commission for accreditation of Healthcare Organizations [JCAHO], Institute for Safe Medical Practices, California Healthcare Association) and 14 northern California hospitals serving diverse populations. The goal of this consortium is to improve the national evidence base for measuring and predicting patient safety problems and to develop cost-effective strategies for improving safety practices at individual hospitals (Stanford University).

Improving Safety by Computerizing Outpatient Prescribing. This project will study the impact of electronic medical records and computerized medication prescribing on adverse drug events in outpatient clinics associated with Partners HealthCare System and the Regenstrief Institute at Indiana University (Brigham and Women's Hospital).

Teamwork and Error in Neonatal Intensive Care. This project will assess team-related, error-management behavior in the hospital neonatal intensive care unit (NICU). Some researchers and influential groups, like the Institute of Medicine, believe that team functioning should be improved as one method of decreasing errors and improving patient safety. However, fundamental questions exist about the relationships among teamwork and error in healthcare.

Many of these questions have been answered for the aviation industry, and the research group that led that effort is a critical element of the research team assembled for this project. This project will adapt the aviation model of teamwork and medical error management to NICU teams by conducting focus groups with NICU personnel and analyzing videotapes for a prospective cohort of preterm infants recorded during two critical periods:

Initial resuscitation.
The first 90 minutes of admission to the NICU (University of Texas Medical School).

Fiscal Year 2001 Activities. In Fiscal Year 2001, AHRQ will spend $50 million on patient safety activities. The Agency believes the best way to approach improving patient safety is through an integrated set of activities to:

Design and test best practices for reducing errors in multiple settings of care.
Develop the science base to inform these efforts, as well as to improve provider training in the reduction of errors.
Capitalize on the advances in information technology to translate proven effective strategies into widespread practice.
Build the capacity to further reduce errors in the future.

These activities will be carried out using five activities, as summarized below.

Fiscal Year 2001 Patient Safety Activities

Health System and Network Demonstrations ($26.5 million). These demonstrations will be targeted to test interventions in sectors where evidence already exists about the basic epidemiology and etiology of errors. AHRQ will provide grants and contracts to fund States, health care systems, and networks of providers in rural and urban areas, to work in partnership with experts in the causes of medical errors.

The demonstrations will use technology, staff training, and other methods to reduce errors. They will develop and test replicable models that minimize the frequency and severity of medical errors, as well as develop methods to minimize any additional paperwork burden on health care professionals. Finally, the demonstrations will evaluate the impact of these efforts on patient health, quality of care, and costs.

Projects will be solicited to examine any one of three types of error reporting parameters:

Voluntary reporting to the Director by participating health care providers of any adverse or sentinel events, health care-related errors, or medication-related errors.
Required reporting to the Director by participating health care providers of any adverse or sentinel events, health care-related errors, or medication-related errors.
Required reporting to the Director and to the affected patient or family member by participating health care providers of any adverse or sentinel events, health care-related errors, or medication-related errors.

Clinical Informatics to Promote Patient Safety (CLIPS) ($6.35 million). As part of the demonstration program, AHRQ will solicit grants and contracts to develop and test appropriate technologies to reduce medical errors which can then be implemented by the demonstration sites. Examples include:

Hand-held electronic medication and specimen management systems and prescription pads.
Training simulators for medical education.
Bar-coding of prescription drugs.
Patient bracelets.
Automated dispensing of medication in a hospital setting.

Research in Patient Safety ($8.70 million). Teams of researchers and health care facilities and organizations in geographically diverse locations will be assembled to determine the causes of medical errors. This new information and knowledge will support the work of the demonstrations.

The key feature of this research is bringing together experts from the fields of aviation safety, human factors research and other disciplines new to health services research, but critical to addressing the errors challenge. These experts will be charged with developing strategies (including needs assessment, design and implementation of curriculum and content) to improve provider training in the reduction of medical errors. The results will be used by the health systems demonstrations. Since the primary focus of these centers will be to determine the correctable causes of medical errors, they will also work with the demonstrations to conduct research on the data generated by different reporting strategies, and identify strengths and weaknesses of the various implementation options.

Patient safety, provider training, and working conditions ($3.00 million). Understanding how the environment of care affects patient safety is critical to improvement. AHRQ will support research to examine how the work environment for health care providers relates to error rates, how these conditions can be improved, and what impact that has on error reduction.

This research will include projects on organizational options in staff deployment and qualifications affect errors. Knowledge gained from these short-term projects will enable the development of improved provider training in the reduction of medical errors, including the examination of curriculum development, technology training, and continuing medical education.

In addition, stakeholder groups have been requesting research that will provide knowledge about working conditions (including staffing ratios, hours, and skill mix) and patient safety. That information will improve the training of hospital managers, an important group with a central role in creating an organizational environment supporting a culture of safety.

Capacity Building, Coordination, and Dissemination ($5.45 million). Other components will be brought together by a set of activities to maximize coordination across sites and projects, to transfer learning, and to speed up the diffusion of effective practices to additional sites other than those explicitly funded under the demonstration program. These activities include:

Develop tools for the infrastructure of a national patient safety system, including guidance and data standards. The guidance should address issues surrounding how providers may report and how States may collect data. The guidance should also address issues surrounding how States may collect, analyze, and disseminate such data, including guidance to States on appropriate confidentiality rules.
Work to ensure explicit translation of the new knowledge from research on patient safety to the demonstration sites and transfer from the demonstration sites to the Centers of information on patterns of errors identified by various reporting strategies, and processing of reporting data for transmittal to AHRQ.
Support testing feasibility of standardizing, merging and using data currently collected by AHRQ, HCFA, CDC, and the FDA to support medical error reporting, research, and reduction.
Develop, demonstrate, and evaluate new ways to improve provider training in order to reduce errors including taking new knowledge on patient safety and rapidly integrating it into curricula, continuing education, and other provider training strategies.
Disseminate findings and effective strategies from the demonstration sites to diverse audiences and support implementation of these approaches.

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Progress Toward a National Report on Quality

Since Fiscal Year 2000, AHRQ has been developing the first-ever annual report on the quality of health care in the United States, as called for in AHRQ's reauthorization legislation, which became law in December 1999. The goal of the report is to provide a clear, easily understood picture of the quality of health care in America and to highlight areas where improvement is needed. The development of a national report on health care quality is an important step in improving the quality of the Nation's health care system.

In March of 2001, the Institute of Medicine (IOM) released, Crossing the Quality Chasm. In this report, the IOM proposes 13 recommendations to build a stronger health system over the next decade. This report recommended that a national report be developed to track the quality of care in the nation. AHRQ's National Quality Report is mentioned as a tool to "raise the awareness of the American public about the quality-of-care challenges facing the health care system."

IOM Report, Crossing the Quality Chasm, March 2001:

"The National Quality Report has the potential to play an important role in continuing to raise the awareness of the American public about the quality-of-care challenges facing the health care system. Public awareness of short-comings in quality is critical to securing public support for the steps that must be taken to address these [quality of care] concerns."

The project is being led by AHRQ with collaboration from the National Center for Health Statistics. An interagency work group will develop the final content and design of the report. Other members of the work group include:

The Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services.
The Centers for Disease Control and Prevention.
The Health Care Financing Administration.
The National Institutes of Health.
The National Cancer Institute.
The Substance Abuse and Mental Health Services Administration.

Work on the National Quality Report (NQR) will proceed in five areas:

Developing a conceptual framework for reporting.
Identifying potential measures to populate the framework.
Identifying data sources for potential measures.
Conducting market research on format and design options for the report.
Coordination.

Framework for reporting. In November, 1999, AHRQ commissioned a study with the Institute of Medicine (IOM) to complement its existing efforts by working on a vision for the NQR. The IOM formed a 14-member committee of leading experts in quality and quality measurement, chaired by Dr. William Roper. The committee was charged with identifying:

The most important questions to answer in evaluating whether the health care delivery system is providing high quality health care and whether quality is improving over time.
The types of domains of information that should be produced.
Examples of specific measures that fall into each domain.

The committee completed its meetings in early Fiscal Year 2001, hearing testimony from a wide variety of groups, including:

The National Forum for Healthcare Quality Measurement and Reporting (the Forum).
Foundation for Accountability.
National Committee for Quality Assurance.
Joint Commission on Accreditation of Healthcare Organizations.
American Medical Accreditation Program.
Leading academic researchers.
International experts.

The IOM expects to complete work for the NQR conceptual framework by Spring 2001.

Measures. AHRQ will identify measures to complete the conceptual framework. The Agency has developed a multi-step "call for measures" to be sent to all relevant Federal agencies. The procedure is designed to identify a pool of measures that could be used for the report without placing undue burden on the agencies from which we will be requesting information. The IOM initiated a complementary call for measures to the private sector. Measures identified through our call to Federal agencies will be combined with measures identified by the IOM's call to the private sector to form the array of candidate measures for the report.

Data sources. AHRQ will continue efforts to identify, and in some cases modify, existing data sources that might be used to support the NQR. Potential sources fall into several categories, including:

Population-based data collection efforts.
Establishment/provider-based data collection efforts.
Administrative/regulatory data collection efforts.
Vital statistics and census data.
Surveillance activities.

The Agency is also modifying existing data sources to better support the NQR. For example, AHRQ is expanding the sample and quality-related content of the Medical Expenditure Panel Survey and the number of States in our Healthcare Cost and Utilization Project. It is expected that the first NQR will rely heavily on existing Federal databases. As time goes on, private data sources will likely take on added importance. In Fiscal Year 2001, AHRQ will be analyzing private-sector data sources that may be appropriate for future versions of the report.

Market research. AHRQ will be conducting research to identify the needs of potential audiences for the report and to develop a report design to meet those needs. The Agency plans to conduct two rounds of initial testing. The first round will take place in the spring of 2001 and will obtain input on general design options (e.g., text vs. tables vs. graphics, long vs. short). Based on this testing, AHRQ will prepare a more specific report prototype. In the second round of testing we will obtain audience input on the prototype. AHRQ has also initiated a project to review existing reporting systems to inform the development of the NQR.

Coordination. Coordination within the Department of Health and Human Services (HHS) will be maintained through the Secretary's Quality Improvement Initiative (SQII). The SQII is made up of six workgroups, one of which deals with the NQR. The workgroup is made up of representatives from across HHS.

Inter-departmental coordination will be maintained through the measurement workgroup of the Quality Interagency Coordination Task Force (QuIC). This group includes representatives from across the Federal Government.

AHRQ plans to maintain coordination with the private sector through relevant national quality measurement entities (e.g., the Forum). AHRQ has also started coordination of NQR activities with quality measurement efforts in other countries (e.g., the United Kingdom, Canada, Australia). The intent is to develop a set of indicators that are measured consistently across countries to facilitate international quality comparisons.

The first NQR is due to Congress in FY 2003 and annually thereafter.

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Healthcare Working Conditions on the Quality of Care

In Fiscal Year 2001, AHRQ was appropriated $10 million for research that investigates the relationship between the health care workplace and its impact on medical errors and the quality of care provided to patients. As a first step, AHRQ has developed an request for application (RFA) entitled The Effect of Healthcare Working Conditions on Quality of Care. It was released the week of March 5, 2001.

The RFA requests research proposals that will examine the effect of working conditions on health care workers' ability to provide safe, high-quality care. These grants are intended to identify, characterize, and directly measure the effect of the health care work environment on the safety and quality of care provided by health care workers. The Agency is seeking applications that will:

Explore the relationship between working conditions that affect health care workers and the safety and quality of care they provide.
Test innovative approaches to working conditions that have been effective in improving the quality of a product or service in industries other than health care.

This research will generate evidence to facilitate improvement of workplace practices that will lead to better outcomes for patients.

AHRQ's Evidence-Based Practice (EPC) centers will also perform a literature review on key workforce/safety issues, including comprehensive reviews of the nurse/physician/other health care workers' hours and fatigue on patient safety. This will explicitly include safety literature from non-health care related fields.

AHRQ will also support an Institute of Medicine (IOM) report on working conditions and patient safety. This report will focus on measures related to the health care workforce that could be undertaken by employers to improve patient safety. This report will be aimed at decisionmakers (including health care managers, educators, public policymakers).

Finally, AHRQ will also sponsor research on working conditions and quality through the Primary Care Practice Based Research Networks and the Integrated Delivery System Research Networks. To further work in this area, AHRQ will also sponsor a series of conferences on working conditions and quality of care.

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Help for Patients and Consumers of Health Care

Americans are demanding greater value and quality in their health care. To achieve these goals in today's rapidly changing health care environment, consumers need solid, reliable information to help them choose among health care plans, practitioners and facilities, and to participate more actively in their personal health care decisions. AHRQ plays a unique role in helping to provide the information consumers need and want.

Consumer Assessment of Health Plans (CAHPS). The Consumer Assessment of Health Plans (CAHPS) is an easy-to-use kit of survey and report tools that provides reliable information to help consumers and purchasers assess and choose among health plans. Information from CAHPS surveys was available to help more than 90 million Americans with their 2000 health care benefits decisions. There are CAHPS data available to nearly 40 million Medicare beneficiaries on 280 plans. These beneficiaries received the assessment of beneficiaries enrolled in managed care plans. Data were provided in the handbook sent to each beneficiary and were placed on the Medicare.gov Web site.

Building on previous CAHPS accomplishments:

AHRQ and HCFA collaborated with the CAHPS consortium to develop a Medicare CAHPS Disenrollee Survey of beneficiaries enrolled in managed care plans that was fielded by HCFA in Fiscal Year 2000. By obtaining the reason for disenrollment, it is possible to distinguish between those that are unrelated to quality (e.g., moving out of the area that the plan serves) and those that are related to quality (e.g., limited access to specialists).
Development has started on a CAHPS survey that would collect data at the group practice level. Research has shown that consumers are also very interested in assessments of doctors. AHRQ and the CAHPS consortium has been partnering with the California Health Care Foundation and the Pacific Group on Health in the development of the Group Practice Level CAHPS. By May 2001, a beta test version of the survey will be ready.
A partnership between the CAHPS consortium and the Foundation for Accountability, with support from the David and Lucille Packard Foundation, has led to the development of a CAHPS survey to identify children with special health care needs and collect additional information on the extent to which health plans are meeting their special health care needs. This tool is projected to be part of HEDIS requirement in 2002 and is already requested by numerous State Medicaid and SCHIP agencies to assist them in meeting the requirements set forth in the 1997 Balanced Budget Act.

Continuing to add to the family of CAHPS surveys, HCFA and AHRQ are also collaborating on the development of a CAHPS survey to obtain consumers' assessments of health and services received in nursing homes. The data, collected from nursing home residents and next of kin, will be used to help persons who are choosing a nursing home. The survey is going through development testing to identify the appropriate domains for the survey and prepare the questionnaire and sampling and data collection procedures. This phase will be completed in September 2001.

Making Quality Count for Consumers and Patients. Following release of the Fiscal Year 2000 RFA "Making Quality Count for Consumers and Patients," AHRQ funded four demonstration projects, for $3.4 million in total projected funding over 3 years, to enhance the health care system's ability to provide patients with information on health care quality. One of these projects received sole funding from the National Cancer Institute of the National Institutes of Health.

The demonstrations will develop and test methods and models for developing information on quality for consumer and patient use in health care decisions, as well as evaluate the impact of strategies to provide information about quality to consumers and patients. The newly funded projects are:

Information About Quality in a Randomized Evaluation. This project will identify factors associated with consumers' use of employer-disseminated information about health plan and medical group performance and determine if and how consumers use or do not use this information during open enrollment (University of California-Davis).
Helping Elders Include Quality in Health Plan Choice. This project will develop and evaluate an integrated information and decision support strategy for use by employee benefits staff in counseling employees aged 60 to 64 about their Medicare plan options. The study will examine how best to develop a system to integrate comparative quality, cost, and benefit information with motivational, educational, and decision support in a way that works for older persons with limited education. This project will develop and cognitively test two types of materials (paper and computer prototype) and will test the materials in a small-scale demonstration and evaluation (Research Triangle Institute).
Quality Factors in Nursing Home Choice. This project will develop and evaluate information strategies to help consumers use quality factors in making nursing home choices. The investigators will interview consumers and health care providers who help them make decisions about nursing home care to determine their information needs, uses, and values (University of Colorado Health Center).

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