Strategic Plan

Center for Outcomes and Effectiveness Research, November 1998


To provide national leadership and direction for the development and use of outcomes and effectiveness research (OER) that supports improvements in patient outcomes.


To support improvements in health outcomes by conducting, supporting and facilitating research that is aligned with and informed by the needs of clinicians and patients in typical ("real world") practice settings.


Since the establishment of the Agency for Health Care Policy and Research (AHCPR) in late 1989, interest among all stakeholders in the outcomes or end results of health care delivery has intensified. AHCPR's extensive and diverse portfolio of research has resulted in over 1,800 peer-reviewed publications, textbooks, recently established institutes and curricula, and new activity in outcomes research sponsored by multiple private-sector organizations and medical professional organizations. In addition, public concern that overzealous efforts to contain costs may have compromised the quality of care have stimulated new interest in translating the products of outcomes research into strategies to assess and improve health care quality.

Outcomes research was developed to address pragmatic questions confronting clinicians and patients daily:

The program at AHCPR has consisted of three major foci, complemented by a rich portfolio of complementary investigator-initiated research:

More recently, both within the second generation of PORTs (PORT IIs) and as discrete initiatives funded both by AHCPR alone (e.g., three trials examining the effectiveness of alternatives to hysterectomy for women with noncancerous uterine conditions) and in partnership with the National Institutes of Health (NIH), COER's portfolio has expanded to include selected clinical trials.

Criteria for the first generation (1989-93) of PORTs included a focus on specific conditions that are common, costly, and for which there was known to be well-documented evidence on substantial variation in practice. The PORTs were required to follow a very specific sequence and approach over a 5-year period. The second phase of PORTs (PORTIIs) offered investigators more flexibility in selecting research designs and methods, in part due to increasing recognition that the science base was much better developed in some areas (e.g., coronary artery disease) than others (e.g., most surgical conditions). The initial work quickly confirmed that the evidence for the vast majority of clinical practices was extremely limited.

Accomplishments to date include:

Multiple studies have generated findings and measures that are now beginning to influence clinical practice on a large scale. Included in the current success stories that are just beginning to bear fruit are:

There is now almost a routine acceptance by clinicians of the premise that scientific information should be applied to health care decisionmaking.

Outcomes research has also expanded the dimensions by which clinicians and patients evaluate the success of interventions to include those that are most important to individuals. OER has extended the focus of inquiry that informs health care decisionmaking from the individual patient to populations, from biometric readings only to measures that incorporate patient responses and values, and most importantly, from judgment based on some science and much experience to decisions grounded in scientific evidence relevant to heterogeneous populations.

From the outset, the opportunities for outcomes research to improve the end results experienced by individual patients as well as the measures by which improvement can be assessed have vastly exceeded available resources. COER's accomplishments to date underscore a collective need for better evidence to inform clinical practice—and a mandate to develop strategies that enhance the probability that better evidence will lead to enhanced health outcomes. In recent years, AHCPR has been joined by multiple private-sector organizations in conducting and supporting OER. This offers AHCPR and COER new challenges and opportunities in providing leadership for a burgeoning field.

Evolution of the sponsorship of OER is occurring concurrently with rapid changes in health care delivery, as well as comparable changes in information and communications technology that have important implications for the use and conduct of OER. In relation to the Agency's Strategic Plan, COER's focus is on supporting and conducting research that supports improvements in health outcomes. The primary audience for OER are clinical policymakers, including both individual clinicians and those who influence the landscape for clinical decisionmaking.

An essential component of all COER activities is summarized by the term "Strategic Science Development," a dynamic and explicit process that undergirds our efforts to support high quality research to promote improvements in health outcomes. This process is linked with an ongoing evaluation of the impact of AHCPR-supported OER and systematic analysis of OER supported by the private sector to inform future research initiatives, with the aim of aligning the products of the research enterprise with the needs of clinicians and patients.

A central challenge now and in the future is aligning the research enterprise, which has historically focused on publications, with the information needs of decisionmakers. (Select to access Figure 1 [4 KB].)

Where evidence has successfully altered clinical behavior, it has been combined with strategies and incentives for change at a local level. The challenge for the next generation of OER is to shift from a descriptive, exploratory enterprise to one that has a problem-solving focus (i.e., to move from "Gee Whiz" to "So What?!").

Achieving the greatest possible good with limited resources will require new approaches to identify the "outcomes of outcomes research" on an ongoing basis. It will also require a new conceptual approach for setting priorities for OER to clarify AHCPR's unique niche and enhance the sustainability of the entire enterprise.

Strategic Environment: 1998

COER's future planning must recognize important changes in the health care delivery system and within AHCPR itself. When the OER program was first initiated, some underlying premises included:

Within AHCPR, COER's mission and work is most closely aligned with that of the Center for Organization and Delivery Studies (CODS), and the Center for Quality Measurement and Improvement (CQMI). Figure 2, labeled 'Key Focus of COER Research' depicts the interface between COER and CODS (16 KB). The interface and synergy between COER and CQMI is more challenging to articulate clearly. Better information regarding the relationship between the processes and outcomes of care can be used to expand the universe of available performance measures to assess—and improve—quality of care. However, this neglects the companion goal of OER to expand the metrics by which clinical interventions are assessed. To the extent that COER focuses its efforts on outcomes of care for individuals with multiple conditions, and can stimulate exploration of the relative benefits of using disease-specific vs. generic measures, COER and CQMI will have multiple opportunities for synergistic and complementary efforts. In addition, both COER and CQMI can benefit from joint understanding of factors that:

Goal 1. Needs Assessment

Identify knowledge gaps where OER is needed and can improve patient outcomes.


Combine expert opinion and empirical analysis (intramural assessments, synthesis of extramural research, and literature reviews) to determine where knowledge gaps and opportunities for improvement converge.


  1. Consult periodically with researchers and intermediate customers to establish an ongoing process for priority setting and identify opportunities for research and collaboration (Select to access Figure 3 [17 KB]).
  2. Identify (on an ongoing basis) unique opportunities for AHCPR support and involvement, alone and in partnership with other funders.
  3. Develop an empirical and conceptual assessment to inform priority setting.
  4. Identify and followup unanswered questions from prior research investments. Questions to be answered include: Was the question worth answering? If so, have we or others supported needed follow-up studies? (If not, should we have funded the original study?) How can translation of findings be accelerated?
  5. Develop specific strategies for use of convening function to provide leadership for OER with other funders. In addition to periodic meetings, develop plan for establishing an organizational structure to reinforce (e.g., Inter-Agency Committee on OER; Foundation for Health Outcomes Research)


Goal 2. Knowledge Development (What and How)

Conduct, support, and facilitate the production of scientific knowledge that supports improvements in health outcomes.


Conduct and support research that develops and validates the application of health outcomes measures and condition-specific information relevant to health care decisionmakers.


  1. Develop initiative for fiscal year 1999 that focuses on outcomes of care for older patients with chronic conditions, with a specific emphasis on vulnerable populations. (PORT III or "Vintage PORTs")
  2. Support initiatives (as part of and separate from the above initiative) to develop innovative OER methodologies, including new health status measures, decision modeling, severity-of-illness measures, cost-effectiveness analysis, and statistical methods for effectiveness trials.
  3. Support conferences and other activities that enhance synergy across individual projects (e.g., researchers focused on chronic care for older patients share information on methods and challenges).
  4. Continue to refine emerging agenda for intramural research in COER, now including chronic illness and older women, cardiovascular OER, ethics, and cost-effectiveness analyses (CEA).



  1. Support the identification of mutual areas of cooperation and opportunity with the Food and Drug Administration (FDA), Health Care Financing Administration (HCFA) , the Office of the Assistant Secretary for Planning and Evaluation (OASPE), the pharmaceutical industry, and other interested parties.
  2. Design and implement the Centers for Education and Research Therapeutics (CERTs) program.
  3. Support OER to produce new, innovative methods for determining the outcomes, appropriateness, and effectiveness of therapeutics.


Goal 3. Specific Emphasis: Clinical Economics/Ethics

Conduct, support and facilitate the production of knowledge that informs the efficient allocation of health care resources.


A. Support development of tools to facilitate the conduct and comparability of CEAs.
B. Develop strategic assessment for performing CEA ("the CE of CEA").
C. Conduct and support research that promotes the use of CEA as a framework for decisionmaking.
D. Conduct and support research that examines the ethical implications of alternative criteria for health care resource allocation.


  1. Develop formal needs and opportunities assessment as per Goals 1 and 2, with a specific focus on tools needed for performing CEAs (e.g., development of a database for researchers' use for common cost inputs to CEAs).
  2. Develop intramural capacity for targeting clinical decisions uniquely suitable for CEA.
  3. Build capacity for studying ethical issues related to changes in the locus of decisionmaking for resource allocation.
  4. Support CEA component of the National Emphysema Treatment Trial.
  5. Work with CQMI to evaluate opportunities for applying CEA to quality improvement (QI) programs.
  6. Identify the "right" opportunities to support CEA components of large trials funded by NIH and others.


Goal 4. Translation

Support and facilitate the translation of scientific knowledge that leads to the optimal use of effective health care interventions.


Promote the dissemination of OER to and uptake by "change agents," educational institutions, and clinicians.


  1. Develop internal system for frequent periodic assessment of key findings from extramural and intramural projects.
  2. Disseminate OER findings at conferences, workshops, presentations, and briefings.
  3. Explore strategies for inclusion of OER in educational curricula for health care professionals, including Continuing Medical Education (CME)/CE.
  4. Develop and publish syntheses of findings and evidence of impact (both peer-reviewed papers and AHCPR documents or substrate for same).
  5. Ongoing collaboration with Office of Health Care Information (OHCI) to identify and exploit opportunities for dissemination.


Goal 5. Evaluation


Develop strategies for evaluating the impact of AHCPR-supported OER.


  1. Develop plan (with assistance of the Evaluation Officer) to assess:
  2. Identify mechanisms for capturing translation of AHCPR-supported OER and impact of same.


Goal 6. Team Development

Recruit and develop staff with the requisite knowledge, skills, and abilities to accomplish COER's vision.


Build an interdisciplinary team that complement each other's abilities and who, together, can accomplish the Center's goals.


  1. Formalize Deputy position.
  2. Recruit staff with appropriate knowledge, skills, and abilities.
  3. Provide staff with appropriate educational and training opportunities to increase/improve their knowledge of OER and related knowledge, skills, and abilities.
  4. Encourage staff to pursue activities of interest to them that are consistent with COER's mission.
  5. Develop systematic internal approach for synthesizing results of previously and currently funded projects.


Goal 7. Agency and Department Priorities

Contribute to and advance Agency and Departmental Initiatives, including Agency cross-cuts and special populations emphases.


Develop work plans for meeting/contributing to cross-cut and special population initiatives.


  1. Actively participate in working group meetings and specific plans for contributions and feedback to COER.
  2. Provide prompt and useful responses to requests from cross-cut coordinators for minority health, children's health, and women's health.


Current as of November 1998

Internet Citation:

Strategic Plan, November 1998: Center for Outcomes and Effectiveness Research. Agency for Healthcare Research and Quality, Rockville, MD.

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