Other Quality, Effectiveness and Efficiency Research

Long-Term Objective 1: Reduce antibiotic inappropriate use in children between the ages of one and fourteen.

#	Key Outcomes	FY 2004 Actual	FY 2005 Actual	FY 2006  Target	FY 2006 Actual	FY 2007 Target	FY 2007 Actual	FY 2008 Target	FY 2009 Target	Out-Year Target
4.4.1	Reduce antibiotic inappropriate use in children between the ages of one and fourteen	Baseline 0.56	0.59	1.8% drop	0.60	1.8% drop	0.52	1.8% drop	1.8% drop	2014 reduce to 0.42

Long-Term Objective 2: Reduce congestive heart failure hospital readmission rates in those between 65 and 85 year of age.

#	Key Outcomes	FY 2004 Actual	FY 2005 Actual	FY 2006  Target	FY 2006 Actual	FY 2007 Target	FY 2007 Actual	FY 2008 Target	FY 2009 Target	Out-Year Target
4.4.2	Reduce congestive heart failure hospital readmission rates during the first six months in those between 65 and 85 years of age	Baseline 38%	36.99%	drop to 36%	36.74%	drop to 35.5%	36.51%	35%	34.5%	2014 reduce to 30%

Long-Term Objective 3: Reduce hospitalization for upper gastrointestinal bleeding in those between 65 and 85 year of age.

#	Key Outcomes	FY 2004 Actual	FY 2005 Actual	FY 2006  Target	FY 2006 Actual	FY 2007 Target	FY 2007 Actual	FY 2008 Target	FY 2009 Target	Out-Year Target
4.4.3	Reduce hospitalization for upper gastrointestinal bleeding due to the adverse effects of medication or inappropriate treatment of peptic ulcer disease, in those between 65 and 85 year of age	Baseline 55/10,000	55/10,000	2% drop	54.38/10,000	2.0 drop	51.56/10,000	1.8% drop	3% drop	2014 reduce to 45/10,000
4.4.4	The decreased number of admissions for upper gastrointestinal (GI) bleeding will generate a per year drop in per capita charges for GI bleeding. (Reductions are compared to baseline).	$96.54 Baseline	$93.20 per capita (3.4% drop)	$93.64 (3% drop)	$93.36 per capita (3.2% drop)	$92.68 (4% drop)	$91.81 per capita (4.9% drop)	$91.71 per capita (5% drop)	$90.75 per capita (6% drop)	2012

Long-Term Objective 1: Achieve wider access to effective health care services and reduce health care costs.

#	Key Outputs	FY 2004 Actual	FY 2005 Actual	FY 2006  Target/ Est.	FY 2006 Actual	FY 2007 Target/ Est.	FY 2007 Actual	FY 2008 Target/ Est.	FY 2009 Target/ Est.	Out-Year Target/ Est.
1.3.15	Increase # of partners	36 States	5 new out-patient data-sets	Increase # of partners	21 AS 17 ED	Increase # of partners	24 AS 22 ED	Increase # of partners	Increase # of partners	2010 5%
1.3.22	Inc # of organizations using Healthcare Cost and Utilization Project (HCUP) databases, products or tools to improve health care quality for their constituencies by 5%, as defined by AHRQ Quality Indicators (QIs)	2 new organizations 1 implementation	2 organizations	3 organizations and 1 implementation will use HCUP/QIs to assess QI Impact in at least 1 organization	3 new organizations— Organization for Economic Cooperation & Development CT Office of Health Care Access Dallas-Fort Worth Hospital Council Canada's Public Reports Impact—CO Health & Hospital Assoc	3 organizations and 1 implementation will use HCUP/QIs to assess QI Impact in at least 1 organization	3 new organizations— CO Health Institute OH Department of Health Harvard Vanguard Medical Assoc & Atrias Health Impact—University Health-system Consortium	Impact will be observed in 1 new organization after the development and implementation of an intervention based on the QIs	3 new organizations will use HCUP/QIs to assess potential areas of quality improvement, and at least of them will develop and implement an intervention based on the QIs Impact will be observed in 1 new organization after the development and implementation of an intervention based on the QIs	2010 5 organizations

Long-Term Objective 2: Assure that providers and consumers/patients use beneficial and timely health care information to make informed decisions/choices.

#	Key Outputs	FY 2004 Actual	FY 2005 Actual	FY 2006  Target/Est.	FY 2006 Actual	FY 2007 Target/Est.	FY 2007 Actual	FY 2008 Target/Est.	FY 2009 Target/Est.	Out-Year Target/Est.
1.3.23	# of consumers who have accessed Consumer Assessment of Healthcare Providers and Systems (CAHPS®) information to make health care choices will	130 Million Completed H-CAHPS	135 Million Completed ICH-CAHPS survey	Increase over baseline	138 Million Completed surveys	Inc 40% over baseline	41% (141 Million)	42%	44%	2012 Inc to 50%
	Appropriated Amount ($ Million)	$159M	$143M	$143M	$153M	$153M	$144M	$151M	$157M

AHRQ's research related to quality, effectiveness and efficiency touches on nearly every aspect of health care. AHRQ supports research grants, contracts and Interagency Agreements (IAAs) related to:

• Effectiveness Research: Assure that providers and consumers/patients use beneficial and timely health care information to make informed decisions/choices. To assure the effectiveness of health care research and information is to assure that it leads to the intended and expected desirable outcomes. Supporting activities that improve the effectiveness of American health care is one of AHRQ's strategic goals. Assuring that providers and consumers get appropriate and timely health care information and treatment choices are key activities supporting that goal.
• Efficiency Research: Achieve wider access to effective health care services and reduce health care costs. American health care should provide services of the highest quality, with the best possible outcomes, at the lowest possible cost. Striving to reach this ideal is a primary emphasis of AHRQ's mission with many of its activities directed at improving efficiency through the design of systems that assure safe and effective treatment and reduce waste and cost. The driving force of AHRQ research is to promote the best possible medical outcomes for every patient at the lowest possible cost.
• Quality Research: Reduce the risk of harm from health care services by promoting the delivery of appropriate care that achieves the best quality outcome. Quality problems are reflected today in the wide variation in use of health care services, the underuse and overuse of some services, and misuse of others. Improving the quality of health care and reducing medical errors are priorities for the AHRQ.

Research and Training Grants

AHRQ-supported grantees in this portfolio are working to answer questions about: cost, organization and socio-economics; long-term care; pharmaceutical outcomes; training; quality of care; and system capacity and bioterrorism. AHRQ will highlight two grant programs related to Quality, Effectiveness and Efficiency research: CAHPS® and the Centers for Education & Research on Therapeutics (CERTs).

CAHPS®. CAHPS® is a multi-year initiative of AHRQ. Originally, "CAHPS" referred to AHRQ's "Consumer Assessment of Health Plans Study." However, in 2005, AHRQ changed this to "Consumer Assessment of Health Providers and Systems." This name better reflects the evolution of CAHPS® from its initial focus on enrollees' experiences with health plans to a broader focus on consumer experience with health care providers and facilities. AHRQ first launched the program in October 1995 in response to concerns about the lack of reliable information about the quality of health plans from the enrollees' perspective. The survey was adopted by the Centers for Medicare & Medicaid Services (CMS), U.S. Office of Personnel Management and the National Committee for Quality Assurance for public reporting and accreditation purposes. As of 2007, 138,000,000 Americans are enrolled in health plans for which CAHPS® data are collected. Over time, the program has expanded beyond its original focus on health plans to address a range of health care services and meet the various needs of health care consumers, purchasers, health plans, providers, and policymakers. The program was been through two stages, CAHPS I and CAHPS II. Grants for CAHPS III have just been awarded. These grants will focus on quality improvement strategies and strengthening approaches to the reporting of CAHPS® data.

The CAHPS Hospital Survey, developed at CMS request, is a standardized survey of the experiences of adult inpatients with hospital care and services. Before public release of the survey in January 2006, CMS conducted two "dry runs" of survey implementation to give hospitals and vendors first-hand experience in collecting and transmitting survey data (without public reporting of results). MS began voluntary national implementation of the CAHPS Hospital Survey in Fall 2006. CMS plans to initiate public reporting of survey results in early 2008.

In Spring 2007, AHRQ released the CAHPS Clinician and Group Survey to the public. This survey asks patients about their recent experiences with physicians and other office staff. Other CAHPS® surveys available for public use at no charge include:

• CAHPS People with Mobility Impairments Survey.
• CAHPS American Indian Survey.
• CAHPS In-Center Hemodialysis Survey.
• CAHPS Dental Survey.
• CAHPS Prescription Drug Program (developed for CMS).

Surveys under development are the CAHPS Nursing Home Resident Survey, CAHPS Nursing Home Family Survey, CAHPS Home Health Survey and modules for Health Literacy, Cultural Competence and Health Information Technology.

The long-term goal is to ensure that providers and consumers/patients use beneficial and timely health care information to make informed choices/decisions. CAHPS® has set a goal of ensuring that CAHPS® data will be more easily available to the user community and the number of consumers who have accessed CAHPS® information to make health care choices will increase by over 50 percent from the FY 2002 baseline of 100 million. By moving to create surveys for a range of providers beyond the widely used CAHPS® health plan surveys, including clinicians, hospitals, nursing homes, and dialysis facilities, CAHPS® is rapidly expanding the capacity to collect data that can be utilized to make more informed choices by the purchasers who contract with and the consumers who visit these providers. In FY 2007, CAHPS® met the performance target (go to performance table 1.3.23) to increase 40 percent over the baseline of the user community. In FY 2007 AHRQ increased this usage to 41 percent over the baseline of 100 million users—141 million users of CAHPS® information.

CERTs. The Centers for Education & Research on Therapeutics (CERTs) demonstration program is a national initiative to conduct research and provide education that advances the optimal use of therapeutics (i.e., drugs, medical devices, and biological products). The program consists of 14 research centers and a Coordinating Center and is funded and run as a cooperative agreement by the Agency for Healthcare Research and Quality (AHRQ), in consultation with the U.S. Food and Drug Administration (FDA). The CERTs receive funds from both public and private sources, with AHRQ providing core financial support — $10.5 million in FY 2009. The research conducted by the CERTs program has three major aims:

• To increase awareness of both the uses and risks of new drugs and drug combinations, biological products, and devices, as well as of mechanisms to improve their safe and effective use.
• To provide clinical information to patients and consumers; health care providers; pharmacists, pharmacy benefit managers, and purchasers; health maintenance organizations (HMOs) and health care delivery systems; insurers; and government agencies.
• To improve quality while reducing cost of care by increasing the appropriate use of drugs, biological products, and devices and by preventing their adverse effects and consequences of these effects (such as unnecessary hospitalizations).

The CERTs program recently completed a study on the effects of co-prescribing proton-pump inhibitor medications (PPIs) with drugs used to treat arthritis. Study results found that this method reduces GI bleeding and yet is not currently done in many patients. Preliminary investigations in one State Medicaid agency suggest this may be due to formulary policies. As a result, AHRQ is working to disseminate these findings of improved outcomes with PPIs to health care policy decisionmakers and to pursue additional research and policy studies. The research has a direct impact on AHRQ's performance measures 4.4.3: reduce the financial cost (or burden) of upper gastrointestinal (GI) hospital admissions by implementing known research findings.

Results show that from FY 2004 through FY 2006, the number of admissions for GI bleeding have generated a per year drop in per capita charges for GI bleeding and our targets have consistently been met. In FY 2004, baselines rates were established ($96.54 per capita). In FY 2005, the target was a 2% drop and the actual result was a 3.4% drop ($93.20 per capita). In FY 2006, the target was a 3% drop and the actual result was a 3.2% drop ($93.36 per capita).

Many external factors could have affected this performance trend.  For example, upper GI bleeding is common in people taking certain drugs like anticoagulants, those affecting platelet functions, and those affecting mucosal defenses. Increased or more appropriate monitoring of these drugs could have affected the number of hospitalizations for upper GI bleeding due to adverse events of medication.  An increased use of pharmacologic agents such as proton pump inhibitors to prevent gastric irritation in patients could also have affected this performance trend.

The most recent results from FY 2007 did meet the corresponding target. In FY 2007, the target was a 4% drop and the actual result was a 4.9% drop ($91.81 per capita). Given the past trend, we believe it is reasonable to expect that hospitalization for upper GI bleeding due to adverse events of medication or inappropriate treatment of peptic ulcer disease in those between 65 and 85 years of age will decrease and the decreased number of admissions will continue to generate a per year drop in per capita charges for GI bleeding. The target selected for FY 2008 is a 5% drop. The target selected for FY 2009 is a 6% drop.

CERTs is part of the Pharmaceutical Outcomes program that received a PART review in 2004. The Pharmaceutical Outcome program received a Moderately Effective rating. The review cited research to be conducted by AHRQ's CERTS program to reduce antibiotic inappropriate use in children, congestive heart failure hospital readmission rates, and hospitalizations for upper gastrointestinal bleeding due to the adverse effects of medication or inappropriate treatment of peptic ulcer disease. The program continues to monitor the trends associated with antibiotic use in children and continues to support research for the CERTS in the areas of cardiology and the use of products that can cause bleeding. For more information on programs that have been evaluated based on the PART process, go to http://www.whitehouse.gov/omb/expectmore/.

Research Contracts and IAAs

Examples of types of research contracts and IAAs AHRQ has supported related to Quality, Effectiveness and Efficiency research includes the following:

• Contracts and IAAs support the development and release of the annual National Healthcare Quality Report and its companion document, the National Healthcare Disparities Report. These reports measure quality and disparities in four key areas of health care: effectiveness, patient safety, timeliness, and patient centeredness. In addition, AHRQ provides a State Snapshots Web tool was launched in 2005. It is an application that helps State health leaders, researchers, consumers, and others understand the status of health care quality in individual States, including each State's strengths and weaknesses. The 51 State Snapshots—every State plus Washington, D.C.—are based on 129 quality measures, each of which evaluates a different segment of health care performance. While the measures are the products of complex statistical formulas, they are expressed on the Web site as simple, five-color "performance meter" illustrations.

• The National Quality Measures Clearinghouse (NQMC) and its companion the National Guideline Clearinghouse™ (NGC) provide open access to thousands of quality measures and clinical practice guidelines to clinicians and health care providers. The NQMC and NGC receive close to 2 million visits each month. They can be found at http://www.qualitymeasures.ahrq.gov and http://www.guideline.gov.

• Contract support for HCUP. HCUP is a family of health care databases and related software tools and products developed through a partnership with State data organizations, hospital associations, and private data organizations. HCUP includes the largest collection of all-payer, encounter-level data in the United States, beginning in 1988. For more information, go to http://www.hcup-us.ahrq.gov/overview.jsp. HCUP provides critical information on the U.S. healthcare system such as:
  
  
  • Nearly 10 percent of all hospital admissions—2.9 million stays—were related to depression. Although the number of stays principally for depression remained relatively stable between 1995 and 2005, the number of stays with depression as a secondary diagnosis rose by 166 percent over the same time period.
  • In 2005, there were about 368,600 hospital stays for infections with MRSA (an antibiotic-resistant infection). In that year, hospital stays for these infections were more than three times higher than in 2000 and nearly 10 times higher than in 1995.
  • In 2004, traumatic brain injuries were the cause of 6.9 hospital stays per 10,000 persons and totaled $3.2 billion in hospital costs. Hospitalizations for the most serious type of brain injury had declined 21 percent between 1994-2001, but increased about 38 percent by 2004, reaching the previous high in 1995 and 1996.

In FY 2007 AHRQ met our performance target (go to performance table 1.3.15) to increase the number of partners contributing outpatient data to the HCUP databases. The number of State Ambulatory Surgery Databases (AS) increased by 3 partners (Kansas, Ohio, and South Dakota) and the number of State Emergency Department Databases (ED) increased by 5 partners (Arizona, Florida, Kansas, Ohio, and South Dakota). They were selected based on the diversity —in terms of geographic representation and population ethnicity—they bring to the project, along with data quality performance and their ability to facilitate timely processing of data.

• Another widely used HCUP tool is the AHRQ QIs which are a set of quality measures developed from HCUP data. This measure set is organized into four modules—Prevention, Inpatient, Patient Safety, and Pediatrics. The Prevention Quality Indictors (PQIs) focus on ambulatory care sensitive conditions that identify adult hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care. Inpatient Quality Indicators (IQIs) reflect quality of care for adults inside hospitals and include: Inpatient mortality for medical conditions; inpatient mortality for surgical procedures; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures maybe associated with lower mortality. Patient Safety Indicators (PSIs) also reflect quality of care for adults inside hospitals, but focus on potentially avoidable complications and iatrogenic events. Pediatric Quality Indicators (PDIs) both reflect quality of care for children below the age of 18 and neonates inside hospitals and identify potentially avoidable hospitalizations among children. These measures are publicly available as part of an AHRQ supported software package.

The AHRQ QIs are based upon a few guiding principles which make them unique:

• The QIs were developed using readily available administrative data (HCUP).
• The QIs use a transparent methodology.
• The QIs are risk adjusted and use a readily available, familiar methodology.
• The QIs are constantly refined based on user input.
• The QIs are updated and maintained by a trusted source.
• The QIs documentation and program software reside in the public domain.

The AHRQ QIs are widely used for quality improvement and public reporting initiatives. There are currently over 2,000 subscribers to the AHRQ QI listserv and approximately 150 inquiries being received monthly. Several States are using the QIs for public reporting on hospital quality. Most recently, Iowa became the 11th State to use the AHRQ Quality Indicators in a hospital level public report card. The Iowa Healthcare Collaborative used a subset of the Quality Indicators in its 2006 Iowa Report.  The report can be found at http://www.ihconline.org/iowareport/iowareport.cfm. Iowa's hospital level report presents each hospital's performance as being significantly better or worse than the State average. HCUP data was used to determine the State average.

• Previously, AHRQ has made several investments in systems research to help moderate infections with Methicillin Resistant Staphylococcus Aureus, or MRSA. MRSA and related bacteria in hospital settings as part of its patient safety portfolio. Two examples are: Testing Techniques to Radically Reduce Antibiotic Resistant Bacteria (Methicillin Resistant Staphylococcus aureus, or MRSA); and, Reducing Healthcare Associated Infections (HAI): Improving patient safety through implementing multi-disciplinary interventions. With the additional $5,000,000 provided in FY 2008, AHRQ will work closely with the Centers for Disease Control and Prevention (CDC) to identify gaps in the prevention, diagnosis, and treatment of MRSA and related infections across the healthcare system. In conjunction with CDC and other health care agencies within HHS and within the Federal government, AHRQ will use available mechanisms to fund research, implementation, measurement, and evaluation regarding practices that identify and mitigate these infections.

Research Management

Research management activities for the agency include items such as salaries and benefits, rent, supplies, travel, transportation, communications, printing and other reproduction costs, contractual services, taps and assessments, supplies, equipment, and furniture. In addition, the AHRQ request includes funding to support the President's Management Agenda e-GOV initiatives and Departmental enterprise information technology initiatives identified through the HHS strategic planning process, as well as the Unified Financial Management System (UFMS).

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