Health Services Research Training
At this time of rapid change and restructuring in the nation's
health care delivery system, the need for persons trained to
conduct research and perform analyses to assist decision makers
in both health policy and health care delivery settings is
critical. The Institute of Medicine's (IOM) Committee on Health
Outcomes for Older People recently noted that advances in
research methodology, data analysis, and interpretation hold the
promise for "significant breakthroughs" in addressing a variety
of research questions within the next decade.
However, the committee expressed reservations about the adequacy
of the current research infrastructure and, in particular, the
research workforce, to meet this challenge. Though some private
training support is available, it is highly targeted and has
decreased compared to past years. The ability of academic health
centers and other educational institutions to use internal
resources to support the career development of junior researchers
is dwindling because of more generalized cost pressures. Another
IOM group, specifically addressing health services research
workforce and educational issues, concluded: "Like research and
education in the biomedical and clinical sciences, generally,
health services research and research training are public goods
worthy of support by society as a whole."
In response to the needs outlined by the IOM, AHCPR developed
incentive awards for innovative approaches to health services
research training that are responsive to the research and
analytic needs of the evolving health care delivery system. The
intent of the awards is to support the design and implementation
of new models for training health services researchers to address
emerging issues in health care policy and delivery and to respond
to the changing analytic needs of health care providers, payers,
and policy makers. The awards represent seed money to support
developmental efforts not readily supported by existing training
mechanisms. They are aimed at developing and sustaining novel
and unique educational approaches geared to enhancing established
health services research training programs.
Priority Populations
Health services research has documented the marked variations in
health status and access to appropriate health care services for
certain groups, notably racial and ethnic minorities. Within the
context of increasing reliance on States and markets to address
enduring health care problems, the unique needs of minorities are
especially relevant to Medicaid policymakers. Health services
research must do a better job of bringing science-based
information to bear on these variations so that the health of
minorities, women, and children is enhanced.
AHCPR will build upon the findings of the Minority MEDTEP Centers
and lay the groundwork for Centers of Excellence that will
develop and test targeted intervention strategies designed to
improve the health outcomes of minority populations. These
interventions will target a number of the high-priority areas of
disparity identified in past research, such as:
1. Women's and children's health
- A larger proportion of white women with breast cancer undergo
biopsy compared to non-white women; non-white women have a
significant delay in diagnostic testing for breast cancer and
receive less intensive evaluations than white women.
- Black women undergoing hysterectomy had higher mortality rates,
higher complication rates, and longer hospital stays than white
women.
- Black children with asthma were much less likely to be
prescribed a nebulizer for home use than white children.
- Rates of low birth weight in Cambodian, Filipino, Indian,
Japanese, Laotian, and Thai women were higher than the U.S.
national goal.
- Latino and black women are much less likely to undergo
amniocentesis and chorionic villus sampling than white and Asian
women. Latinos over 35 years of age are three times more likely
to give birth to a Down Syndrome affected infant than white
women, and black women are nearly twice as likely to do so.
2. Heart disease and diabetes
- Black patients are less likely to undergo coronary artery bypass
grafting than white patients and are less likely to receive
cardiac revascularization.
- Most minority groups in the US have higher rates of adult-onset
diabetes as well as more complications and death from the disease
than do whites.
- Minority individual suffer from six times more cases of diabetic
kidney disease than whites.
3. Health insurance and health care access
- More than one-third of Mexican Americans lack health insurance.
Uninsured Mexican Americans are most in need of health care and
are least likely to receive it.
- One study revealed that black patients received fewer hospital
services than white patients.
- A study revealed that fewer black AIDS patients received
preventive drugs from AIDS-related pneumonia (PCP) than white
AIDS patients.
AHCPR supports a number of important women's health research
projects as part of its ongoing research agenda. Additional
research is needed, targeted to three broad issues of special
significance to women: reduction of disparities and improving
health outcomes among minority women; addressing issues related
to women and quality of care; and clinical studies of improving
the quality of life for women with multiple chronic illnesses.
By almost any standard, the health of African-American women is
worse than for white women: they are 50 percent more likely to
die of heart disease, four times more likely to die of stroke,
and one-third more like to die of breast cancer. There are gaps
in health status for most other racial and ethnic groups as well.
Some of these differences can be attribute to poverty and lack of
access to care and technologies, but, even when adjusted for
socioeconomic status, important differences remain. Increased
work is needed to synthesize scientific studies related to the
effectiveness of programs and services designed to raise the
health status of women of color, and to initiate a series of
clinical and cost-effectiveness studies to provide information
about which interventions make a difference in health outcomes
for minority women. In FY 1998, AHCPR will develop a targeted
solicitation to address these needs.
Cost-effectiveness Analysis
AHCPR plays a critical role in nurturing the development of the
scientific tools of health services research. Most of these
tools are developed through investigator-initiated work. One
method, however, warrants a targeted effort across the Agency
because of its increasing policy relevance: cost-effectiveness
analysis (CEA). Purchasers and consumers of health care services
are increasingly concerned with not just the effectiveness but
the value of the care being provided. By forcing an explicit
approach to the decision making process and providing a framework
for identifying and considering as many of the relevant costs and
benefits as is feasible, CEA can improve decision making in both
the private and public sectors. Yet, many questions remain about
the quality of CEAs; their comparability, impact, and potential
for bias; how they are used in managed care decision making; and
the effects of their use on health systems management and patient
care.
AHCPR is building on past Agency work in this field, as well as
the 1996 landmark report, "Cost Effectiveness in Health and
Medicine," to begin to address these questions. The Agency is
focusing on two areas: developing better basic tools for CEA;
and the applications of CEA, including the use of CEA in patient
decision making.
Dissemination Activities
AHCPR promotes widespread distribution and assimilation of its
information and research products through a variety of
dissemination methods including: publication in professional
journals; provider and consumer materials; press conferences;
interviews and story placement with the medical/trade press; and
articles in the popular press.
AHCPR's Home Page on the World Wide Web has allowed ready access
to our research findings, consumer publications, and information
for applicants. AHCPR has had well over 2 million hits on the
site in 1997, up from 1 million in 1996. The web site was
redesigned in 1997 to respond to customer suggestions and make it
more user friendly. AHCPR will continue to upgrade and revise
various sections of the site including, a "virtual newsroom" for
the press to help disseminate AHCPR's studies and products. The
site will be evaluated later this year to decide what other
upgrades/redesigns would be helpful.
The User Liaison Program (ULP) synthesizes and disseminates
research findings to state, Federal, and local policy makers in
easily understood and usable formats. The ULP plays a key role
in AHCPR's efforts to support capacity-building for public health
at the state and local level through policy-thematic workshops,
skill-building workshops, and technical assistance.
Specifically, two workshops that were conducted in 1997 and are
planned again in 1998 that focus on providing technical
assistance to local policy makers include:
- "Local Health Departments in a Managed Care Environment"—This workshop was designed to compliment the AHCPR publication
"Assessing Roles, Responsibilities, and Activities in a
Managed Care Environment: A Workbook for Local Health
Officials" by providing a forum for further examination and
discussion of the issues raised in it. This workshop was held
twice in FY 1997 and will be repeated in FY 1998.
- "What Do We Do About the Uninsured?"—The purpose of this
workshop was to examine the latest research findings on the
uninsured and what state governments have been doing to
ameliorate this persistent problem—focusing on programs and
policies that have been developed and implemented.
In addition, the ULP is planning a series of technical
assistance workshops in FY 1998 designed to help State
legislators and executive branch officials plan for and implement
the State Children's Health Insurance Program (SCHIP) recently
enacted by Congress. The workshops are being developed in
cooperation with ASPE, HCFA, HRSA, the National Governors
Association, and the National Conference of State Legislators.
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Prior Year Funding
Funding and full-time equivalent (FTE) staffing levels for the
Research on Health Costs, Quality and Outcomes program
over the five-year period prior to FY 1998 has been as follows:
| Year |
Amount | FTEs |
| 1994 | $141,968,000 | 227 |
| 1995 | $141,962,000 | 226 |
| 1996 | $107,939,000 | 222 |
| 1997 | $102,863,000 | 216 |
| 1998 Appropriation | $107,905,000 | 226 |
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FY 1999 Request
The FY 1999 Request includes funding for commitments and provides
for new extramural research in areas such as outcomes and
effectiveness; measuring quality; health care markets,
organization and delivery; and evidence-based practice. The
Request also includes continued funding for the Medical
Expenditures Panel Survey (MEPS) at $27,800,000, a reduction of
$8,500,000 from the FY 1998 level.
In fiscal years 1997 and 1998, the level of MEPS funding was over
twenty million dollars more than the base level in FY 1996,
without a concurrent increase in total funding. AHCPR's ability
to fund new research was severely curtailed and the area of
research on minority health care was particularly hard hit.
Funding for the Research Centers on Minority Populations ended in
FY 1997 and new research funds were not available to build on the
findings of those Centers or to initiate research in new areas.
In FY 1999, some leveling off of MEPS requirements should occur
and those funds will be redirected to support new and enhanced
research on outcomes and effectiveness, and cost, use and
accessibility of health care services for minority populations.
A particular emphasis will be placed on research and
demonstrations to identify effective approaches to reduce or
eliminate the existing disparities in the quality, outcomes, and
access to care for minority populations for conditions including
cancer, diabetes, HIV/AIDS, infant mortality and cardiovascular
disease. AHCPR will also use these funds to build on past work
in the area of women's health, targeting three broad issues of
special significance to women: reduction of disparities and
improving health outcomes among minority women; addressing issues
related to women and quality of care; and clinical studies of
improving the quality of life for women with multiple chronic
illnesses. A modest effort to improve cost effectiveness
analysis (CEA), an important scientific tool of growing in
significance in health services research, will also be supported.
An increase of $25,000,000 over the FY 1998 Appropriation will
support the Secretarial Initiative to Improve Health Care Quality
($15,000,000) and new extramural research in key emphasis areas,
i.e., the elderly and chronically ill ($5,000,000), clinical
preventive services ($2,000,000), Centers for Education and
Research Therapeutics [CERTs] ($1,000,000), and children's health
($2,000,000).
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Improve Health Care Quality ($15,000,000)
The Government plays a number of key roles in improving health
care quality. As the major purchaser of health care services,
the Government has a responsibility to make effective use
of its purchasing power to assure that the individuals it serves
receive quality health care services at a reasonable price. As
a leading provider of health care services, the Government has
the responsibility to assure that its programs continuously
assess and improve the quality of care that they provide. As
the leading funder of health research, the Government has the
responsibility to provide the objective scientific information that
Americans need to make more informed health care choices.
The Department's Quality Initiative will:
- Facilitate Consumers' Use of Information on Quality.
Consumers seldom have the information they need to make
informed decisions about health plans, providers, and
treatments. In a market-driven health care system, informed
decisions will lead to better quality care. This initiative
will enable consumers to understand and use quality
information effectively.
- Strengthen Value-Based Purchasing by the Department. This
initiative will use the Department's power as a major health
care purchaser to ensure High quality care through prudent,
value-based purchasing decisions. The Department will use key
elements in purchasing, such as reimbursement criteria,
contract specifications, performance measures to assess health
care quality, and standards for access to culturally competent
providers and adequate provider networks. This initiative
will develop purchasing models, strategies and implementation
plans for strengthening purchasing power across the
Department.
- Improve the Quality of Health Care Services Delivered Directly
by HHS Programs. The Department provides direct care through
many programs, each of which has its own quality improvement
activities. This initiative will identify quality improvement
strategies that work and promote their adoption across these
programs.
- Expand Research that Improves Quality. The Department
has a substantial portfolio of research on quality of care, but
translating that knowledge base into concrete improvements in
health care is still a challenge. This initiative will support
research to develop and determine which quality improvement
methods work, and in which settings. It will also support
research to understand how to redesign the tasks of
delivering care, to eliminate unnecessary steps and minimize
the chances for error.
- Measure National Health Care Quality. Little objective
information currently exists to determine what is happening to
the overall quality of health care in America. Under this
initiative the Department will build upon existing data
reporting systems to provide an ongoing picture of the state
of health care quality, an early warning system for quality
problems, and opportunities for improvement.
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Improve Outcomes for the Elderly and Chronically Ill ($5,000,000)
In FY 1999, AHCPR will launch an initiative to improve health
outcomes for the elderly and chronically ill by providing
clinicians and health care systems with the knowledge they
need to identify and provide effective care in the most
cost-effective settings.
This initiative responds to the 1997 report by the Institute of
Medicine that called for increased research on health outcomes
for the elderly. Specifically, this initiative will:
- Develop a "toolbox" of well-defined and validated measurement
instruments, including a core set of outcomes measures to
address the top conditions paid for by Medicare, that have
been specifically tested for use in older individuals in
different health care settings, including managed care and fee
for services.
- Examine how various system characteristics, including how
physicians are compensated, which services are "carved-out"
and provided separately, and the degree of clinical
integration, affect the health outcomes for the elderly and
chronically ill including studies to identify the most cost-effective
solutions for both the Medicare and Medicaid populations.
- Include a specific focus on the health outcomes and needs of
racial and ethnic minorities and women, who represent a large
and growing proportion of this population.
Rationale for the Initiative. Along with longer life expectancy
and a boom in the elderly population has come an increase in
people whose elder years are complicated by substantial
functional disability from chronic diseases. In fact, a
substantial portion of the increase in the elderly will come from
a tripling in the number of those over 85 and nearly half of
these will suffer from Alzheimer's or other dementias. These
startling facts raise unique challenges for the health care
system of today and the future.
At the same time, others remain active and in the workforce with
the expectation that their chronic illness will be adequately
managed by the health care system. The growing demands being
placed on long-term and home-care facilities have also raised
questions about the adequacy, cost, and quality of these
services. Chronic disease is the main cause of disability in
this country, the number one reason that people use health
services, and accounts for 70 percent of health care resources.
Yet the health care system is arranged largely for acute care.
There is growing evidence that this structure is neither
efficient nor particularly effective at meeting the needs of
persons with chronic and disabling conditions and is not
cost-effective. The challenge here is to determine what works best
in providing high-quality, cost-effective care, whether in the
acute, ambulatory setting, long term care, or home based
settings.
The elderly are more likely to have multiple clinical conditions,
use multiple medications, and suffer from a variety of
impairments (e.g., poor vision or hearing). In addition, this
older population is projected to be much more racially and
ethnically diverse than ever before: the number of elderly blacks
will more than triple and the Hispanic population will increase
11-fold by the middle of the next century. Finally, women are
likely to make up a substantial percentage of the elderly,
including over 70 percent of those over 85.
These changes in the burden of disease and the racial/ethnic and
gender make up of the elderly create new challenges for the
health care system. Health services research has amply
demonstrated that significant differences exist in the type and
quality of care received by racial/ethnic minorities and women.
Research must now identify effective strategies for overcoming
these differences where they reflect poor quality or lead to
worse outcomes.
At the same time, managed care is transforming how care is
provided to the chronically ill and disabled. It is not clear to
what extent coverage and payment policies provide for the range
of clinical and support services needed by the chronically ill.
For the most frail, systems of care developed over decades within
communities are being disrupted as the financing is shifted from
public or nonprofit entities to managed care organizations and
cross-subsidies are eliminated. Other aspects of care needs of
the chronically ill could benefit from the new incentives in
managed care. For example, self-management, long known to be a
key factor in maintaining function and reducing disability for
those with chronic illness, is being actively promoted by managed
care organizations.
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Clinical Preventive Services ($2,000,000)
There is great interest among providers and patients in the delivery
of the full range of appropriate preventive care—screening tests
for the early detection of disease, advice to help people change
their risky health-related behaviors, and immunizations to prevent
infections. These interventions have enormous potential to
improve the health of the American people, but without careful
assessment of what works and what doesn't, costs could be
astronomical. This initiative will support 2-4 major new
assessments of preventive services and updates of priority
topics, providing targeted, timely information to help providers
and patients make appropriate decisions on preventive services.
AHCPR also will sponsor the Put Prevention into Practice
(PPIP) initiative, which will develop and disseminate materials
for providers, health plans, consumers and purchasers. This
will help them choose and deliver appropriate preventive
care--ranging from screening tests to immunizations to
health-related behavior changes. It will also make consumers
aware of how they can improve their health through prevention
activities. Many of these recommendations derive from US
Preventive Services Task Force reports, and PPIP serves to
increase awareness of USPSTF conclusions, to facilitate
implementation of USPSTF recommendations, and to improve quality
of clinical preventive care. Products of PPIP will be directly
disseminated in a wide variety of ways, including public-private
partnerships to develop and disseminate new materials and to
evaluate impact of USPSTF recommendations and PPIP materials.
PPIP will maintain Website to provide access to USPSTF and PPIP
materials.
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Centers for Education and Research Therapeutics (CERTs) ($1,000,000)
The recently-passed Food and Drug Administration Modernization and
Accountability Act of 1997 includes new responsibilities for AHCPR.
A level of $1,000,000 will allow AHCPR to make grants to support
the establishment and operation of two Centers for Education and
Research Therapeutics (CERTs). The CERTs will increase the
awareness of new uses and risks of medical products; provide
information to health care participants to help them use new products
most effectively; improve the appropriate use of medical products by
health professionals; and prevent adverse effects of medical products
and the consequences of these effects.
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Children's Health ($2,000,000)
In FY 1999, AHCPR will enhance its existing portfolio of activities
related to key issues in child health. This initiative responds to the
focus on child health reflected in the Secretarial Initiative on Child
Health and the State State Child Health Insurance Program (SCHIP). With
the passage of SCHIP as part of the Balanced Budget Act of 1997,
the nation is once again focused on health care for children and
adolescents, especially those in low-income families. SCHIP
provides a landmark opportunity to develop and apply tools to
measure and improve the quality of care for children in this
country. This initiative will support:
- Applied research and demonstrations to develop a
toolbox of measures, instruments, and proven strategies
to improve quality and outcomes of care.
- Outcomes research on the most important challenges in
children's health.
- Research and evaluations on the impact of various state
and local approaches to implementing the SCHIP
legislation to identify evidence-based practices.
- Dissemination of findings and technical assistance to
states, providers, and communities about what works in
improving child health.
In addition to passage of SCHIP, the first major expansion of
health insurance coverage for children since 1963, there are
other reasons why children merit an enhanced focus in health
services research. The Nation already spends an estimated $95
billion annually on so-called personal health services
(traditional health care) for children (AHCPR estimate). While
this was a mere 15 percent of total spending on personal health
services in 1995, there are other characteristics of children and
children's health care that require that children get special
attention in health services research. These include the
characteristics of childhood as a unique developmental stage of
life, the continuity between child and adult health, and the
distinctive organization and financing of children's health
services. Each aspect presents several unique conceptual and
methodological implications for quality, outcomes, cost, use, and
access.
Quality and children. Just as health care quality research will
be the Agency's highest priority, its child health portfolio will
also focus primarily on health care quality research as related
to children. The greatest need today is to develop and validate
better measures of the process and outcomes of care. Currently,
the National Committee on Quality Assurance has been able to
convince managed care organizations to report on only nine
quality measures specifically on children's health care. Only
one of these is directly on the effective treatment for childhood
disorders, when the primary interest of parents and children is
the ability of the health care system to get children better when
they get sick. Recent reviews make clear the lack of measures
for quality of care for children, relative to those for adults.
For example, a recent survey of Medicaid managed care directors
finds that State Medicaid directors are eager to get technical
assistance with the identification and development of quality
measures for children in the AFDC and disabled populations. As
the Balanced Budget Act of 1997 permits more States to use 1115
waivers to expand enrollment of poor in managed care
organizations, it also requires the Secretary to work with States
and an external quality measurement organization to develop
quality measures for Medicaid managed care (Public Law 105-33).
Measurement of quality for children is not an aim in itself.
States have also expressed a need for technical assistance in
using information on quality to guide consumer choice in
Medicaid, and to strengthen health plans' approaches to
measurement-based quality improvement. A landmark May 1997
conference on children and quality research--cosponsored by
AHCPR, seven other Federal agencies and several private
organizations--made clear the lack of attention that has been
paid to disseminating information on differential quality in
child health to parents, children, and others interested in
value-purchasing of children's health care (Halfon and McGlynn,
Health Services Research special supplement, in press). Quality
improvement strategies in child health are being implemented by
States and health plans (e.g., State of Vermont activity on
otitis media), but few are based on research-based evidence of
prior effectiveness, or are being subject to rigorous
evaluations.
Cost, Use, and Access. Within an overall context of system
change, the financing and delivery of health services to children
have evolved rapidly. Over the last five years, there has been a
steady erosion in employer-based insurance coverage for dependent
children at the same time as a rise in Medicaid financing.
Simultaneously, many States have embraced Medicaid managed care
insurance coverage. The Nation is now embarking on a major
State-specific expansion of health insurance for children as a
result of SCHIP. Renewed attention to cost, use, and access
research will help assess the impact of these unprecedented
changes in health care delivery on children.
The introduction of SCHIP has made the federal and State
governments newly aware that some basic questions about
children's coverage, access, and use of services have yet to be
resolved. The Medical Expenditures Panel Survey's continuous data
collection and other sources of data available to AHCPR will
provide a rich data source for examining some of these questions
at the national level. Under the Secretarial Initiative on Child
Health, AHCPR has the co-lead with the Office of the Assistant
Secretary for Planning and Evaluation (ASPE) on developing a
research and evaluation strategy to help answer SCHIP and
SCHIP-related questions.
Coordination with other agencies. Critical to the Agency's work
is close collaboration with other Federal components that have
unique authorities and responsibilities to sponsor and conduct
child health research, notably the National Institute for Child
Health and Human Development (NICHD/NIH), the Centers for Disease
Control and Prevention (CDC), and HRSA's Maternal and Child
Health Bureau (MCHB) and Bureau for Primary Health Care (BPHC).
As a co-lead on the Secretarial Child Health Initiative, AHCPR
also works closely with HCFA, ASPE, SAMHSA, IHS, and other
operating and staff divisions on issues related to children's
health and health care. The agency has lead or co-lead in areas
of research and evaluation and quality, as well as participation
in overall leadership for the initiative.
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Current as of February 1998
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