Chapter 2. AHRQ's Research Portfolio

Agency activities start and finish with the end-users of AHRQ research. Our research agenda is user- or customer-driven—the needs of AHRQ's customers determine our research priorities and are crucial to our success. AHRQ regularly solicits input from our public- and private-sector customers through a variety of mechanisms, such as the Agency's National Advisory Council, meetings with stakeholder groups, Federal Register notices, and through comments submitted by the public via the Agency's Web site at http://www.ahrq.gov/.

The Agency carries out a variety of activities to accomplish its research mission. Together, these activities build the infrastructure, tools, and knowledge for measurable improvements in America's health care system. Researchers—including grantees, contractors, and intramural investigators—build on the foundation laid by biomedical researchers who have determined which interventions can work under ideal circumstances.

But knowing that these interventions work is only a first step. We also need to know in which circumstances they work, for whom they work and don't work, and other critical information to make sure that the interventions are used appropriately and efficiently to improve patients' health and that they are effective in everyday practice.

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Opportunities for Research

Talented and imaginative health services researchers are a critical component of our work at AHRQ, and they are essential to our ability to pursue and fulfill the Agency's mission. These researchers are dedicated to excellence in their own work. In addition, they collaborate with other researchers and health care decisionmakers so they can address relevant research questions and ensure that the findings are translated as improvements in health care. In addition to the researchers on AHRQ's staff, about three-quarters of the Agency's budget is awarded as grants and contracts to support the work of researchers at universities, in clinical settings such as hospitals and doctor's offices, and in health care organizations.

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Unique AHRQ Research Investments

In 2003, research on pharmaceuticals and other therapeutics, practice-based research, infrastructure building, and disparities were priorities for new research. AHRQ issued solicitations in the following areas:

• Centers for Education and Research on Therapeutics (CERTs). Initiated in 1999, the CERTs program conducts research and provides education to advance the optimal use of drugs, medical devices, and biological products such as vaccines. The CERTs concept grew out of recognition that, while pharmaceuticals and other medical products improve the lives of many patients, underuse, overuse, adverse events, and medical errors may cause serious impairment to patient health. In 2003, existing CERTs competed for additional funds to allow grantees to build on and expand their current work. CERTs at the University of Alabama at Birmingham, HMO Research Network, and University of Pennsylvania received funding to perform research to develop and implement educational strategies focused on translating the most promising findings of current work into everyday practices, to address existing gaps within the overall CERTs program, and to enhance the work of the CERTs consistent with AHRQ's patient safety agenda.
• CERTs Coordination. The CERTs Coordinating Center is located at Duke University Medical Center. Its mission is to support the work of the research centers by enhancing cross-center synergy and disseminating findings from the research conducted by the centers. The coordinating center is currently organizing a series of workshops focused on the risks of therapeutics.
• Primary Care Practice-Based Research Networks (PBRNs). The goal of the seven small research grants awarded in 2003 is to allow existing PBRN research networks to conduct exploratory/pilot projects or feasibility studies. A PBRN is a group of ambulatory practices devoted principally to providing primary care to patients. The practices are affiliated with each other (and often with an academic or professional organization) in order to investigate questions related to community-based practice. These grants will address issues such as:
  • Network strategies for assuring that new research evidence is translated into actual practice and that its impact is assessed.
  • Innovative use of information technology in primary care practices.
  • Feasibility of implementing electronic health records in primary care and assessing the impact on safety, quality, effectiveness, and efficiency of care.
  • Optimal methods of delivering preventive services in primary care settings.
  • Methods for improving community-based detection and responses to emerging public health threats, including bioterrorism.
  • Clarification of primary care-based strategies for diminishing disparities in health care delivery and health outcomes for AHRQ priority populations.
• National Research Service Awards. Believing that tomorrow's health care quality is achieved through an investment in educational excellence today, AHRQ is firmly committed to building a strong, visible infrastructure for the conduct of future health services research through support of a network of NRSA institutional training programs located throughout the country. Funds are provided to support over 150 clinical and nonclinical predoctoral and postdoctoral students annually in order to equip them with the necessary knowledge, skills, and experience to conduct health services research that will meet the needs of patients, providers, plans, purchasers, and policymakers. These awards allow scholars to gain the necessary methodological and substantive multidisciplinary expertise required to address critical issues facing the Nation's health care system, including patient safety and the delivery of cost-effective care.
• Building Research Infrastructure and Capacity (BRIC). AHRQ's BRIC program was launched in FY 2001 to build research capacity in States that have not traditionally been involved in health services research. The primary goals of BRIC are to enhance the competitiveness of research institutions and organizations in the BRIC-eligible States for AHRQ-funded grants and to increase the probability of long-term growth of AHRQ competitive funding to investigators at institutions from these eligible States. In 2003, AHRQ funded new BRIC grants with institutions in Utah, Louisiana, New Jersey, Kentucky, and Mississippi.

Innovative Research: Addressing Current and Emerging Challenges

The topics addressed by innovative research proposals reflect timely issues and ideas from the top health services researchers. In 2003, close to half of the grants and cooperative agreements funded by AHRQ were initiated by individual investigators who developed research proposals within an area of interest to the Agency. AHRQ uses Program Announcements (PAs) to invite applications and communicate the Agency's priorities for new and ongoing research topics. Examples of new and ongoing FY 2003 PAs include:

• Building the Evidence to Promote Bioterrorism and Other Public Health Emergency Preparedness in Health Care Systems. Projects funded under this PA are examining and promoting the health care system's readiness for a bioterrorist event and other public health emergencies. Emphasis is focused on a vital area of bioterrorism preparedness concern know as "surge capacity," which is a health care system's ability to rapidly expand beyond normal services to meet the increased demand for qualified personnel, medical care, and public health in the event of a large-scale public health emergency or disaster.
• Translating Research Into Practice. Projects funded under this PA, which was issued jointly by AHRQ, the Department of Veterans Affairs, and the National Institutes of Health, are conducting innovative and rigorous research and evaluation projects related to the translation of research findings into measurable improvements in quality, patient safety, health care outcomes, and costs, use of services, and access to care. Specific priorities are to: (1) compare the use of interventions to translate research into practice across different health care systems, and (2) measure the impact of translation activities, including the testing of interventions that foster measurable and sustainable improvements in quality and safety or consistent quality and patient safety at a lower cost.
• Patient-Centered Care: Customizing Care to Meet Patients' Needs. These projects focus on design and evaluation of care processes to empower patients, improve patient-provider interaction, help patients and clinicians navigate through complicated health care systems, and improve access, quality, and outcomes.
• Impact of Payment and Organization on Cost, Quality, and Equity. Many health care leaders have concluded that the gap between the level of quality that could be provided and that which is provided to most people is attributable to a lack of incentives and rewards, as well as inattention to organizational factors that make doing the right thing the easy thing to do. These projects focus on the effects of payment and organizational structures and processes on the cost, quality, and equity of health care.

The following summaries are representative of new projects funded in FY 2003 that are focused on well-defined research areas or topics:

• Using barcode technology may help to improve medication safety. Medications are the most commonly used form of medical therapy and are the single most frequent cause of adverse events. Many of these adverse events are caused by medication errors, which often occur in the dispensing, transcribing, and administration stages of the medication use process. This project focuses on using barcode technology in conjunction with an electronic medication administration record system to reduce medication errors. Specifically, the researchers are examining how effective barcode and electronic medication administration record technology is at reducing medication errors in hospitalized patients, what the impact is of this technology on nursing and pharmacy efficiency and satisfaction, and whether the cost of this technology can be justified by its benefits.
• Drug cost-sharing may affect the safety and affordability of drugs. Drug cost-sharing between the consumer and the provider is a commonly used method to control prescription drug costs. This study is addressing the safety and economic effects of drug cost-sharing. It includes a broad sample of Medicare beneficiaries. The researchers are evaluating how drug cost-sharing affects clinical outcomes and total medical costs, which is a particular concern given that the most extreme version of cost-sharing—no provider coverage—is associated with poor health. Also, poor drug adherence may lead to higher downstream medical costs.

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Selected Examples of Recent Findings from AHRQ-Funded Research

• Rates of antibiotic-resistant bacteria. An AHRQ study of 16 Massachusetts communities found that 8 percent of children under age 7 carry antibiotic-resistant Streptococcus pneumoniae, a bacterium commonly found in healthy children but which presents a low risk of illness to them. Although this rate is much higher than a decade ago, a new vaccine is reducing the presence of strains of the bacterium that can cause significant infection. This study is the first of its kind performed after introduction of a new vaccine to protect children from the seven most invasive strains of S. pneumoniae.
• Outpatient prescription drug-related injuries in older patients. In a new study sponsored by AHRQ and NIH's National Institute on Aging, medical researchers found that Medicare patients treated in an outpatient setting may suffer as many as 1.9 million drug-related injuries a year because of medical errors or adverse drug reactions not caused by errors. About 180,000 of these injuries are life-threatening or fatal, and more than half are preventable, say the researchers, who based the estimates on a study of over 30,000 Medicare enrollees.
• Risk factors for retained instruments and sponges after surgery. A study funded by AHRQ estimates that a surgical instrument or sponge is left in more than 1,500 patients during surgery each year. In this study, patients who had emergency surgery were nine times more likely to have a sponge or surgical instrument left in their body than patients undergoing scheduled surgery. In addition, the risk increased four-fold for patients who had unplanned changes in their procedure. Patients who had a higher body mass index (i.e., measure of body fat based on height and weight) were found to be more likely to have a foreign body left after surgery. Researchers concluded that a number of techniques are available to reduce the incidence of foreign bodies left in patients after surgery, including counting instruments and sponges before and after the procedures and x-raying patients for instruments that may inadvertently have been left behind.

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Building the Research Infrastructure

Health services researchers focus on some of the most complex and challenging issues currently affecting health care in the United States, and training new investigators is fundamental to producing the next generation of health services researchers. AHRQ believes that future improvements in health care depend in large part on the investments we make today in the research infrastructure. These investments also return a more immediate payoff in the form of high-quality research findings that accumulate naturally as a result of the training process.

The products and lessons learned from such research are useful to regional, State, and national decisionmakers in assessing the effectiveness of current programs and planning for future policies that address the costs and financing of health care, the use of health care services, and access to care across diverse regions and populations.

One way AHRQ contributes to excellence in health care delivery is by providing support to maintain and nurture health services researchers. The agency supports a variety of training and career development opportunities through individual and institutional grant programs. In FY 2003, AHRQ provided support for approximately 240 trainees and new investigators through these programs:

• Dissertation research support.
• Kerr White Visiting Scholars Program.
• National Research Service Awards (pre- and postdoctoral fellowships), including both individual and institutional programs.
• Career Development Awards (K awards).
• Building Research Infrastructure and Capacity (BRIC) awards.
• Minority Research Infrastructure Support Program (M-RISP) awards.

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Investments in Training

In 2003, AHRQ continued its mission to increase the geographic and demographic diversity in the pool of researchers through its BRIC and M-RISP programs, which respectively are designed to broaden the national capacity to conduct health services research across a wide range of States and in institutions that traditionally have served minorities. The following examples illustrate the types of projects AHRQ has funded recently under the BRIC and M-RISP initiatives.

BRIC Projects

• A pilot study was conducted in which diabetes patients treated for foot ulcerations in Louisiana's State-wide public hospital system via telemedical consultation (advanced technology used to help geographically distant physicians consult with each other on patient cases) were compared with patients treated by a diabetes foot program. The management of foot ulcers by telemedical consultation was administered by a certified wound care nurse. The percent of wounds healed after 12 weeks was 81 percent in the telemedicine group and 85 percent in the diabetes foot program group. The results suggest that telemedicine, implemented via realtime interactive consultation, appears to be technically and logistically feasible to geographically extend the effectiveness of a currently existing diabetes foot program.
• Researchers conducted a retrospective analysis of indigent patients who participated in a comprehensive, interdisciplinary congestive heart failure disease management program from December 1996 to May 2002 at the Chabert Medical Center, one of nine public health care facilities in Louisiana. They found that the mortality rate was 19.6 percent for participants compared with 36 percent for nonparticipants.
• Enlisting the help of many organizations and collaborators, the Mississippi BRIC project was able to collect data on over 13,400 Mississippi Delta children enrolled in child care services. Most of the subjects were impoverished African American children. A significant number of these children were receiving no dental care. Pilot testing is underway to identify best practices for providing early dental care to those children at highest risk for dental disease.

M-RISP Projects

• Montana/Wyoming Tribal Leaders Council. The goal of this project is to address research on disparities in American Indian health care and to support the creation of a research infrastructure through the development of databases, research methodologies, and collaborative working relationships. Two studies concentrating on the significant health issues of American Indians in Montana and Wyoming are underway. The first study is focusing on research to identify factors affecting breast and cervical cancer screening, followup of abnormal findings, and development and implementation of a pilot program to increase the proportion of American Indian women who receive screening tests. The second study is designing and testing a methodology for reporting results from a survey that collects information on patient satisfaction from American Indians who receive care through the Indian Health Service.
• Puerto Rico Health Services Research Institute. The goal of this project is to develop the Puerto Rico Health Services Research Institute at the University of Puerto Rico Graduate School of Public Health. The Puerto Rico health care delivery system has experienced dramatic changes over the last 20 years. Amid different reforms implemented in the past, critical health disparities exist that are intertwined with cost, access, and quality issues affecting vulnerable populations. Puerto Ricans in the United States also exhibit the poorest health status profile of all Latino subpopulation groups. To assist decisionmakers in evaluating health policy options, this project is establishing an administrative structure that will support and foster the development of health services research capability with emphasis on health disparities. The resulting infrastructure will provide methodological and technical support to facilitate research projects and development of research proposals for external funding and dissemination of research findings. In addition, it will allow implementation of a faculty development and mentoring program to enhance the faculty's capabilities to undertake health services research. Finally, researchers will be able to conduct pilot projects in health services research that will lead toward more comprehensive projects supported by external funding.
• Morgan State University Health Research Enhancement Project. The goal of this project is to strengthen and expand the capacity at Morgan State University to conduct rigorous health services research. This interdisciplinary research project is focusing primarily on maternal and child health issues in the black community in inner city Baltimore. For example, the focal point of one undertaking is to assess the long-term impact of a school-based comprehensive program for pregnant adolescents on their health, education, and sociodemographic outcomes.

AHRQ also sponsors Research Career Awards, which are intended to foster the development of promising new scientists and clinicians who are committed to a career in health services research. Particular emphasis is placed on their development as independent scientists. Examples of the impact of the research produced by these grantees follow.

• Based on an evidence review of the safety of vaginal birth after cesarean, the American Academy of Family Physicians is formulating clinical guidelines for family medicine providers.
• Research findings on the needs of dying children have been used to motivate and guide the design of pediatric palliative, end-of-life, and bereavement services that were featured prominently in the IOM report When Children Die.
• Research from one project led to Washington State legal guidelines/advocacy for appropriate legal access to needed health care services for minors living on the streets.
• Research inspired the implementation of a policy to decrease the percentage of patients discharged early to post-acute care settings after major orthopedic procedures.
• Research findings, which will be included in an upcoming Centers for Disease Control and Prevention (CDC) report, have helped CDC prepare for optimal health care delivery in the event of a polio outbreak.

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