AHRQ Annual Highlights, 2006

Promoting the Use of Evidence

AHRQ supports research in areas that enhance clinical practice by building on the potential for evidence-based approaches to improve health care. Patients, providers, and payers all need information on which treatments work most effectively, whom these treatments work for, under what circumstances, and the risks involved. This information needs to be objective, reliable, understandable, and easily accessible. AHRQ has implemented several initiates to help synthesize and translate evidence-based information on health care effectiveness.

The American Heart Association Uses an AHRQ Evidence Report To Create Preventive Care Recommendations The American Heart Association (AHA) used AHRQ's Evidence Report/Technology Assessment No. 80, Results of Systematic Review of Research on Diagnosis and Treatment of Coronary Heart Disease in Women, to help inform the recent update of AHA's Scientific Statement, Evidence-based Guidelines for the Prevention of Cardiovascular Disease in Women. The evidence report had a direct and substantial impact in formulating recommendations for improving the prevention of women's heart disease in primary care settings and increasing research on cardiovascular disease in women.

Evidence-based Practice Centers

Under the Evidence-based Practice Centers (EPC) program, AHRQ awards 5-year contracts to institutions in the United States and Canada to serve as EPCs. The EPCs review all relevant scientific literature on clinical, behavioral, and organization and financing topics to produce evidence reports and technology assessments. These reports are used for informing and developing coverage decisions, quality measures, educational materials and tools, guidelines, and research agendas. The EPCs also conduct research on methodology of systematic reviews. With this program, AHRQ became a "science partner" with private and public organizations such as the Center for Medicare & Medicaid Services and the U.S. Preventive Services Task Force.

Beginning in 2005, the EPCs began researching and preparing new evidence and technology reports as well as Comparative Effectiveness Reviews (CERs) on medications, devices, and other relevant intervention for AHRQ's Effective Health Care Program.

In 2006, the EPCs released 22 new evidence and technology reports. Examples include:

• Genomic Tests for Ovarian Cancer Detection and Management. This report found that many genomic tests that are currently used to diagnose and guide treatment of ovarian cancer are not shown to decrease the number of women who die from the disease or improve their quality of life.
• Management of Adnexal Mass. Adnexal masses are enlargements in the area of the ovaries and fallopian tubes that are sometimes a sign of ovarian cancer. The report concludes that it is not possible to estimate how well different diagnostic strategies will work. In particular, the common bimanual pelvic exam is not accurate in detecting adnexal masses or distinguishing benign from malignant masses.
• Telemedicine for the Medicare Population. This update of the 2001 report finds increased evidence in favor of telemedicine, though significant gaps still remain in the research. Larger and more comprehensive clinical trials are needed to further determine the benefits of telemedicine in the Medicare population, especially in the promising areas of dermatology, psychiatry, neurology, and home health care.
• Management of Eating Disorders. The report concludes that no medications are available that effectively treat patients suffering from anorexia nervosa, but a few behavioral therapies may help prevent a relapse and offer other limited benefits. The review also found evidence that several medications and behavioral therapies can help patients suffering from bulimia nervosa and binge eating disorder.
• Cesarean Delivery on Maternal Request. This report examined the use of cesarean delivery in situations where there are no factors, either for mother or child that would make such a procedure medically advisable. The report finds no major differences in the results of a first-time cesarean delivery at the mother's request and a planned vaginal delivery but cautions that the evidence is too weak to warrant a firm conclusion that there are, in fact, no differences.

For more information on the EPCs and the reports available, go to http://www.ahrq.gov/clinic/epcix.htm.

The Social Security Administration Uses AHRQ Evidence Reports To Revise its Policies The Social Security Administration (SSA) used AHRQ's Evidence Report Series, Criteria for Determining Disability in Infants and Children (Nos. 70, 72, and 73), to inform their policies on the evaluation of low birth weight in premature infants and linear and weight-related growth impairments in children. These policies have a direct impact on the process for determining both initial and continuing eligibility for Supplemental Security Income (SSI) benefits and, therefore, eligibility for Medicaid in many States. The SSA used the criteria from the report Criteria for Determining Disability in Infants and Children: Low Birth Weight in considering revisions to the policy for determining the most appropriate time at which to evaluate a low birth weight infant's continuing eligibility for SSI benefits.

Effective Health Care Program

The Agency's Effective Health Care Program, launched in 2005, focuses strategically on comparing the outcomes, clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. The Effective Health Care Program's primary principle is that all stakeholders should have the best available evidence on which to make decisions about health care items and services.

The Effective Health Care Program has three approaches to research on the comparative effectiveness of different treatments and clinical practices:

• Review and synthesize knowledge through reports prepared by the EPCs.
• Promote and generate knowledge through AHRQ's Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network.
• Compile the findings and translate knowledge through the John M. Eisenberg Clinical Decisions and Communications Science Center.

Four new CERs were published in 2006. The reviews use a research methodology that systematically and critically appraises existing research to synthesize knowledge on a particular topic. They also identify research gaps and make recommendations for studies and approaches to fill those gaps. The four CERs are briefly summarized here:

• Comparative Effectiveness Review, Effectiveness of Noninvasive Diagnostic Tests for Breast Abnormalities. Four common tests would miss about 4 to 9 percent of cancer cases among women testing negative who have average risk for the disease, with potentially more missed cancers among women at higher risk. The four tests—magnetic resonance imaging, ultrasonography, positron emission tomography scanning, and scintimammography—would miss a significant number of cases of cancer, compared with immediate biopsy for women at high-enough risk to warrant evaluation for breast cancer.
• Comparative Effectiveness of Epoetin and Darbepoetin for Managing Anemia in Patients Undergoing Cancer Treatment. This report found that these drugs show no clinically significant differences between improving hemoglobin concentration or reducing the need for transfusion. Studies directly comparing epoetin and darbepoetin showed no statistically significant difference in the rates of thromboembolic events (blood clotting).
• Comparative Effectiveness and Safety of Analgesics for Osteoarthritis. Two classes of drugs commonly used to treat osteoarthritis—NSAIDs and COX-2 inhibitors—present similar, increased risks of heart attack while offering about the same level of pain relief. The exception is the drug naproxen, commonly sold as Aleve® or Naprosyn®, a medication that scientific evidence suggests presents a lower risk of heart attack for some patients than other NSAIDs or COX-2 inhibitors.
• Comparative Effectiveness of Management Strategies for Renal Artery Stenosis. The available evidence on renal artery stenosis (RAS) treatments is inadequate to clearly support angioplasty, with or without a stent, over drug therapy. The published literature did confirm that drug therapy and angioplasty both improve blood pressure, and they have similar impacts on slowing down the worsening of kidney function, but actual improvements in kidney function have only been reported in angioplasty studies that lacked direct comparisons with other therapies.

For more information on the Effective Health Care Program, go to http://effectivehealthcare.ahrq.gov.

Developing Evidence to Inform Decisions about Effectiveness

The Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network is a network of research centers that AHRQ created as part of its Effective Health Care Program in 2005 to generate new knowledge. The DEcIDE Network conducts accelerated practical studies about the outcomes, comparative clinical effectiveness, safety, and appropriateness of health care items and services.

The Network comprises research-based health organizations with access to electronic health information databases and the capacity to conduct rapid turnaround research. Initial research focuses on the outcomes of prescription drug use and other interventions for which randomized controlled trials would not be feasible or timely or would raise ethical concerns that are difficult to address. Other DEcIDE network projects may focus on electronic registries, methods for analyzing health databases, and prospective observational or interventional studies.

DEcIDE: Registries for Evaluating Patient Outcomes

The purpose of the Registries for Evaluating Patient Outcomes project is to produce a reference for the design and use of successful registries. The project will produce a Web-based reference document defining standards and best practices. The draft outline, based on the stakeholder comments received in 2006, has been prepared and is scheduled for release in 2007. A draft report is in preparation and will include case studies to illustrate issues and challenges in implementing registries.

DEcIDE Projects in Progress

At the close of 2006, DEcIDE had over 20 research projects in progress. The priority conditions and topics being studied include:

• Arthritis and non-traumatic joint disorders.
• Cancer: quality measures for end-of-life care.
• Chronic obstructive pulmonary disease.
• Dementia including Alzheimer's disease.
• Depression and other mood disorders.
• Diabetes mellitus.
• Ischemic heart disease.
• Stroke and hypertension.
• Methodology for using administrative data, methods to improve safety of medication therapy, and establishing patient registries for evaluating patient outcomes.

Centers for Education and Research on Therapeutics

The Centers for Education and Research on Therapeutics (CERTs) program is a national initiative to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research. The program consists of 11 research centers and a Coordinating Center and is administered as a cooperative agreement by AHRQ, in consultation with the U.S. Food and Drug Administration (FDA).

In 2006, AHRQ awarded $16 million over the next 5 years to establish four new CERTs:

• Rutgers, the State University of New Jersey in New Brunswick, will work on improving the safe and effective use of treatments for mental health problems.
• University of Iowa in Iowa City will focus on improving the safety and effectiveness of medication use among the elderly.
• University of Texas M.D. Anderson Cancer Center and Baylor College of Medicine in Houston will focus on consumers and strategies to help English- and Spanish-speaking patients take prescription medications appropriately.
• Weill Medical College of Cornell University in New York City will focus on medical devices to help clinicians, regulators, and payers make decisions about how best to use prosthetic orthopedic devices, including total hip, total knee, and shoulder replacement.

Examples of recent research findings from the CERTs program include:

• The chances of a major congenital malformation among infants born to mothers who took angiotensin converting enzyme (ACE) inhibitors during the first trimester of pregnancy were nearly three times as high as in infants whose mothers did not use any hypertension medications. Researchers at the Vanderbilt University CERT in Nashville found that major congenital malformations were diagnosed in 856 (2.9 percent) of infants, and that 203 infants had more than one malformation. Among infants exposed to ACE inhibitors in the first trimester, the proportion born with major congenital malformations was 7.1 percent, compared with 1.7 percent among infants exposed to other antihypertensive medications. AHRQ is sponsoring followup studies on the effects of drug exposures during pregnancy. The research on ACE inhibitors and other related classes of medications, such as the angiotensin receptor blockers, will be conducted through its DEcIDE research network, in consultation with scientists from the Food and Drug Administration.
• The HMO Research Network CERT found that nearly a third of outpatients taking the anticoagulant warfarin were also prescribed another drug that dangerously increased its blood-thinning effect. Yet, when primary care doctors received computer alerts to such drug-drug interactions at the time of prescribing, the warfarin-interacting medication prescription rate was reduced by 15 percent. Coinciding with the alerts, there was an immediate and continued reduction in the warfarin-interacting medication prescription rate from 3,294 to 2,804 per 10,000 warfarin users per month.
• Pharmacists surveyed by researchers at the Arizona CERT reported an average volume of 1,340 prescriptions per week processed at a rate of nearly 17 prescriptions per hour. Over 85 percent of pharmacies possessed at least one type of technology, with the most predominant type being the countertop tablet/capsule-counting device (62 percent of pharmacies). About 55 percent of community pharmacists surveyed in this study believed that more than 70 percent of the computerized drug-drug interaction (DDI) alerts encountered in the previous week were clinically insignificant. Community pharmacy managers who could customize DDI alerts on their computer system and whose system provided detailed DDI information were more likely to express confidence in the pharmacy's computer system to provide meaningful alerts. Yet half of pharmacists surveyed stated that their computer software did not allow customization of DDI alerts.

More information on the CERTs and their research is available at: http://www.ahrq.gov/clinic/certsovr.htm.

National Guideline Clearinghouse™

The National Guideline Clearinghouse™ (NGC) is a Web-based resource for information on over 2,000 evidence-based clinical practice guidelines. Since becoming fully operational in early 1999, the NGC has had over 30 million visits and now receives over 900,000 visits each month. The NGC helps physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers, and others obtain objective, detailed information on clinical practice guidelines.

For more information about the NGC, go to: http://www.guideline.gov.

United States Preventive Services Task Force

The U.S. Preventive Services Task Force (Task Force) was first convened by the U.S. Public Health Service in 1984. Sponsored by AHRQ since 1998, the Task Force is the leading independent panel of private-sector experts in prevention and primary care. The Task Force conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services. AHRQ provides technical and administrative support, but the recommendations of the panel are its own.

The mission of the Task Force is to:

• Evaluate the benefits of individual services based on age, gender, and risk factors for disease.
• Make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations.
• Identify a research agenda for clinical preventive care.

Examples of recent projects from the Task Force include:

• In 2006, AHRQ partnered with United Health Foundation to distribute more than 400,000 copies of the Guide to Clinical Preventive Services, 2006, a guide to clinical preventive services recommendations of the Task Force, to clinicians nationwide. The guide contains 53 new or revised recommendations on screenings, preventive medications, and behavioral counseling. The Guide to Clinical Preventive Services, 2006 is available online at http://www.ahrq.gov/clinic/pocketgd.htm.
• AHRQ launched the Electronic Preventive Services Selector (ePSS) tool for primary care clinicians to use when recommending preventive services for their patients. The interactive tool can be used on a PDA or desktop computer to allow clinicians to access the latest recommendations from the Task Force. The ePSS is designed to serve as an aid to clinical decisionmaking at the point of care and contains 110 recommendations for specific populations covering 59 separate preventive services topics. A clinician can enter patient characteristics and generate a report with the applicable Task Force recommendations specifically tailored for that patient. The tool is available for download from the AHRQ Web site at http://www.ePSS.ahrq.gov.
• AHRQ also released the Adult Preventive Services Timeline, a wall chart based on Task Force recommendations that illustrates who needs preventive services and when. The chart is available for downloading from the AHRQ Web site at http://www.ahrq.gov/ppip/timelinead.pdf (PDF Help).
• Collaborating with the Centers for Disease Control and Prevention and the National Business Group on Health, AHRQ provided scientific consultation and expertise to support the development of A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. A Purchaser's Guide provides large employers with information to select, define, and implement preventive medical benefits such as colorectal cancer screening and tobacco use treatment.
• The Task Force released the following new or updated recommendations in 2006:
  • Screening for Speech and Language Delay in Preschool Children—current evidence is insufficient to recommend for or against routine use of brief, formal screening instruments (those that can be used in less than 10 minutes) as a means to detect speech and language delay in children up to 5 years of age.
  • Screening for Developmental Dysplasia of the Hip—evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes.
  • Screening and Supplementation for Iron Deficiency Anemia—in children aged 6 to 12 months who have no symptoms, the Task Force found that there is insufficient evidence to recommend for or against routine screening for iron deficiency anemia; however, children in this age group who are at increased risk should receive routine iron supplements. The Task Force also recommended that pregnant women should undergo routine screening; however, there was insufficient evidence to recommend for or against routine iron supplementation in nonanemic pregnant women.
  • Screening for Hemochromatosis—the Task Force recommends against routine genetic screening for hereditary hemachromatosis in people who are asymptomatic.
  • Screening for Lead Levels in Childhood and Pregnancy—the evidence is insufficient to recommend for or against routine screening in children aged 1 to 5 who are at increased risk but have no symptoms. The Task Force recommends against routine screening for children aged 1 to 5 who are at average risk and have no symptoms and in pregnant women who have no symptoms.

More information on the Task Force is on the AHRQ Web site at: http://www.ahrq.gov/clinic/prevenix.htm.

Accelerating Change and Transformation in Organizations and Networks

In March 2006, AHRQ awarded contracts to 15 partnerships for the Agency's new Accelerating Change and Transformation in Organizations and Networks (ACTION) program, the successor to AHRQ's Integrated Delivery System Research Network. ACTION is a model of field-based research that fosters public-private collaboration in rapid-cycle, applied research. It links many of the Nation's largest healthcare systems with its top health services researchers. Each ACTION partnership has a demonstrated capacity to "turn research into practice" for proven interventions targeting those who manage, deliver or receive health care services. As a network, ACTION provides health services in a wide variety of organizational care settings to at least 100 million Americans.

The ACTION partnerships span all States and provide access to large numbers of providers, major health plans, hospitals, long-term care facilities, ambulatory care settings, and other care sites. Each partnership includes health care systems with large, robust databases, clinical and research expertise, and the authority to implement health care interventions. ACTION focuses on a wide variety of demand-driven, practical, applied topics that are broadly responsive to user needs and operational interests and which are expected to be generalizable across a number of settings.

More information on ACTION as well as the partnerships can be found on the AHRQ Web site at: http://www.ahrq.gov/research/action.htm.

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