Role and Mission of the Agency for Healthcare Research and Quality

The mission of the Agency for Healthcare Research and quality is to improve the quality, safety, and efficiency of health care for all Americans through research and partnerships. As the Nation's lead Federal agency for research on health care quality, costs, outcomes, and patient safety, AHRQ develops the evidence about what works in health care practice that enables providers, patients and consumers, system managers, purchasers, and policymakers to obtain real value for their health care dollar. For more information about AHRQ's organizational structure, see appendixes A and B at the back of this report.

The data gathered for AHRQ-funded health services research come from:

• People receiving the care and the clinicians and systems providing the care.
• Employees enrolled in health plans (to help measure and improve patients' experiences with care).
• Hospital records and administrative data provided by States working together to obtain detailed information about the health care people receive.
• Clinicians who meticulously examine and evaluate hundreds of research articles to synthesize the information for providers and patients. The results enhance access to relevant evidence for making effective clinical decisions.

Health services research completes the work begun in the laboratory. Health services researchers strive to answer the central question: "Does this work in daily practice with real people whose characteristics, needs, and local communities are different?"

Health care in America is changing rapidly. These changes are occurring in the way we organize and pay for care and in the characteristics and health care needs of the U.S. population. Each year, many new health care services and sophisticated technologies become available. This ever-changing health care landscape underscores the importance of high-quality health services research.

The Agency for Healthcare Research and Quality advances private and public efforts to improve the quality, safety, and efficiency of health care. AHRQ supports research that addresses concerns of very high public priority, such as health disparities, safe and effective use of drugs and other therapeutics, primary care practice, and integrated health care delivery systems. In addition, AHRQ supports projects that test and evaluate successful ways to translate research into practice to improve care for patients in diverse health care settings; Evidence-based Practice Centers that review and synthesize scientific evidence for conditions that are costly, common, or important to the Medicare or Medicaid programs; and translates the recommendations of the U.S. Preventive Services Task Force into resources for clinicians, patients, and health care systems.

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AHRQ's Customers

AHRQ's customers are decisionmakers who need objective, evidence-based, and timely information to make informed choices about the health care they provide, receive, and purchase. These customers include clinical decisionmakers, health care system decisionmakers, policymakers, and patients.

• Clinical Decisionmakers. The evidence uncovered through AHRQ-sponsored research and tools developed from those findings help clinicians, consumers, patients, and health care institutions make informed choices about which treatments work, for whom, when, and at what cost.
• Health Care System Decisionmakers. Health plan and health care system managers use the findings and tools developed through AHRQ-sponsored research to make choices on how to improve the health care system's ability to increase access to care and deliver high-quality, high-value care. Purchasers use the products of AHRQ-sponsored research to obtain high-quality health care services.
• Policymakers. Public- and private-sector policymakers use the information produced by AHRQ to expand their ability to monitor and evaluate the impact of system changes on outcomes, quality, access, cost, and use of health care and to devise policies designed to improve the performance of the system.
• Patients/Consumers. AHRQ's research findings provide patients and families with objective information on how to choose health plans, doctors, or hospitals based on their performance. Consumer materials, including personal health guides, help patients navigate the health care system and get the best and safest care possible.

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How AHRQ's Research Helps People

Across the Nation, policymakers, clinicians, patients, and consumers are making better-informed, more cost-effective health care decisions, and they are providing and receiving higher quality care thanks to AHRQ-supported research. The following are just a few examples of the research AHRQ has sponsored and how the results of that research have been put into practice by policymakers, those who make purchasing decisions, clinicians, patients, and consumers.

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Policymakers Use AHRQ's Research in Many Ways

In FY 2002, AHRQ responded to thousands of requests for information from Federal, State, and local government officials searching for evidence to inform their decisions. As a scientific research agency, AHRQ's role in responding to these requests is a simple one: to ensure that policymakers have the benefit of our existing knowledge and past experience so that they can make informed decisions.

AHRQ uses a number of approaches in responding to these requests, including:

• Rigorous analyses of the scientific and medical literature.
• Short-term research on the impact of past policy interventions at the Federal and State levels.
• Simulations of the potential impacts of new policy options.
• Customer-driven workshops on topics that include ways to improve care delivered to people served by public programs and strategies to reduce health care disparities.
• Other forms of technical assistance.

The following examples represent selected instances in which AHRQ's tools and research have been used by policymakers to improve the functioning of the entire U.S. health care system.

Online resources for research and policymaking. AHRQ has made available three online resources that provide invaluable data and statistics for use by policymakers, researchers, and others.

1. MEPSnet is a collection of analytical tools that operate on data from the Medical Expenditure Panel Survey (MEPS). MEPSnet is free and publicly available on the AHRQ Web site. MEPSnet/IC (Insurance Component) has been used to help policymakers at the State level produce reports for legislators and governors on the status of employer-sponsored health insurance in their State. It also has been used to generate cost estimates and otherwise inform new health insurance proposals in States and to track the effects of past changes in State health insurance policy. MEPSnet/HC (Household Component) has been used to answer questions about health care use and spending among various population groups, health insurance coverage and who is uninsured, and how health care use varies by type of health insurance. Go to http://www.meps.ahrq.gov/mepsweb/data_stats/meps_query.jsp to access this resource.
2. HCUPnet is an easy-to-use online tool (http://hcupnet.ahrq.gov/) that permits easy access to statistics and trends about hospital stays for the Nation as a whole, as well as for selected States. Users can select specific conditions or procedures of interest, rank order conditions or procedures (according to length of stay, total charges, or death rates), or examine all discharges in general. Users also can compare types of patients (by age, sex, primary payer, and/or income) and types of hospitals (by ownership, teaching status, location, bedsize, and/or region).
3. HIVnet presents selected statistics (such as type of insurance coverage) based on medical resource use data collected by the HIV Research Network, a group of 18 large medical practices treating over 14,000 people with HIV disease. HIVnet provides information on inpatient and outpatient use of services and is focused on health services delivery. It provides easy access to selected data for use by service providers, those who plan resource allocation, policymakers, and health services researchers. HIVnet is cosponsored by AHRQ and three other HHS agencies. Go to http://www.ahrq.gov/data/HIVnet.htm to access HIVnet. HIVnet is a collaborative project between AHRQ and other components of the Department of Health and Human Services. Through HIVnet, AHRQ and the Department's Assistant Secretary for Policy and Evaluation (ASPE), the Substance Abuse and Metal Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the National Institute of Health's Office of AIDS Research work closely together on this project.

Anticoagulation therapy for Medicare patients. Based on findings from AHRQ's research, Medicare's Peer Review Organizations (now called Quality Improvement Organizations, QIOs) have implemented 73 projects in 42 States to increase anticoagulation therapy for Medicare beneficiaries who have suffered a stroke. The percentage of Medicare patients discharged from the hospital on anticoagulation therapy has increased from 58.4 to 71.1 percent. The Centers for Medicare & Medicaid Services (CMS) estimates that as of spring 2002, this intervention had prevented up to 1,300 strokes.

Making coverage decisions. AHRQ's state-of-the-art assessments of the effectiveness of clinical services and technologies assist policymakers in making health insurance coverage decisions. For example, a technology assessment produced by an AHRQ-supported Evidence-based Practice Center (EPC) helped inform CMS's February 2002 decision regarding Medicare coverage of positron emission tomography (PET) for patients with breast cancer. Specifically, CMS announced it would revise its Medicare coverage issues manual to include coverage of PET as an adjunct to standard imaging modalities for two types of patients: one, staging patients with distant metastasis or restaging patients with locoregional recurrence of metastasis and two, monitoring tumor response to treatment in women with locally advanced and metastatic breast cancer.

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AHRQ's Research Findings Help Clinicians and Patients

The pace of medical discovery and innovation has never been greater. But experience has repeatedly demonstrated that great opportunities for improving health, developed through biomedical research, are easily lost if physicians and patients are unable to make the best use of the knowledge in everyday care. These wasted opportunities result in the underuse of effective interventions, continued reliance on outmoded approaches to patient care, and inappropriate use of new and often more expensive interventions. A critical portion of AHRQ's mission is to develop useful information for clinicians and patients – and to assure that it is broadly accessible.

Failure to understand which services work best, under what circumstances, and for which types of patients contributes to the ever-increasing cost of care, low quality and ineffective care, threats to patient safety, and avoidable loss of lives. AHRQ's objective is to close that gap by focusing on the effectiveness and cost-effectiveness of health care services and the organization, management, and financing of the health care systems through which these services are delivered. AHRQ's research ultimately assures that patients and society reap the full rewards of basic research and biomedical innovation.

The following examples illustrate how AHRQ-sponsored research has helped clinicians and patients make informed, evidence-based health care decisions.

Computerized diagnostic tools help ED clinicians make important treatment and triage decisions. Two computerized diagnostic aids are helping emergency department staff make faster and more appropriate decisions about care for the 6 million people with chest pain who go to hospital emergency departments each year. These tools also may lead to lower health care costs for these patients. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) and the related Thrombolytic Predictive Instrument (TPI) are programmed into conventional computerized electrocardiographs (ECGs), which automatically compute and print out a patient's predicted outcomes based on characteristics of the ECG when the patient arrives at the ED. The ACI-TIPI predicts a patient's probability of heart attack based on seven risk factors that range from pain in the chest or left arm to peaking or inversion of ECG T waves. The TPI, based on records from 13 major clinical trials and registries, is used to calculate 30-day and 1-year mortality and cardiac arrest probability within 48 hours with and without thrombolytic (clot-busting) therapy. Both instruments were developed, tested, and refined by researchers at Boston University with AHRQ support. Use of ACI-TIPI in a 10-hospital trial led to a decline from 15 to 12 percent in coronary care unit (CCU) admission rates and an increase from 49 to 52 percent in discharges to home among patients without cardiac ischemia. Appropriate hospitalization and CCU admission remained about the same for patients with AMI or unstable angina. If these results were reproduced nationally, it is estimated that use of the ACI-TIPI could result in savings of $728 million by avoiding unnecessary CCU admissions and hospitalizations.

Tool helps determine treatment preferences. The shift toward patient-centered care has meant that a broader range of outcomes from the patient's perspective needs to be measured in order to understand the true benefits and risks of health care interventions. A tool developed through AHRQ research has helped patients with cataracts and their clinicians make important treatment decisions. The Visual Function-14 Index (VF-14) helps patients and physicians assess the need for and outcome of cataract surgery. It supplements the standard eye chart and other clinical measures. The VF-14 measures the degree of difficulty patients have in performing 14 vision-dependent everyday activities, such as driving and reading small print. Many insurers (including Medicare) now require that the results of the VF-14 be reported as a condition of claims payment, and it has been adapted for use in at least a dozen other countries.

ER nurses ability to recognize risk of suicide in children. AHRQ-supported researchers found that after attending educational sessions on psychiatric issues and learning about the Suicide Risk Questionnaire, nurses were better equipped to manage potentially suicidal children in the hospital emergency department. Four simple questions based on a standard 30-item Suicide Ideation Questionnaire helped the ER triage nurses identify 98 percent of children at risk of suicide.

Pain scale can be used in nursing homes. AHRQ researchers have developed a new pain scale that can help identify untreated pain in nursing home residents. The researchers found that more than two-thirds of nursing home residents reported being in pain. One-fourth of the residents reported their pain as "horrible." The researchers developed a Minimum Data Set (MDS) Pain Scale, which is similar to the Visual Analog Scale (the gold standard for assessing pain) but easier to administer. The scale is intended for use with routinely collected nursing home data to help indicate the presence and intensity of residents' pain.

Outpatient treatment of women with PID produces similar outcomes to hospital care and is much less expensive. Women who have mild to moderate pelvic inflammatory disease (PID) who are treated as outpatients have recovery and reproductive outcomes similar to those of women treated in hospitals, according to a recent AHRQ study. If left untreated, PID can result in chronic pelvic pain, infertility, and ectopic pregnancy. The PID Evaluation and Clinical Health (PEACH) study was a randomized clinical trial that compared the effectiveness of inpatient and outpatient treatment strategies in preserving fertility and preventing PID recurrence, chronic pelvic pain, and ectopic pregnancy for women with mild to moderate PID. Women treated as outpatients received a single injection of cefoxitin and an oral dose of probenecid, followed by a 14-day supply of oral doxycycline. Those treated in a hospital were given multiple intravenous doses of cefoxitin plus doxycycline during a minimum inpatient stay of 48 hours. The women's care was followed for 35 months to document long-term outcomes. The short-term clinical improvements were similar for women treated in inpatient and outpatient settings. After 35 months of followup, pregnancy rates were nearly equal between the groups, as was the amount of time it took to become pregnant. There also were no statistically significant differences between the proportion of women with ectopic pregnancy, chronic pelvic pain, or PID recurrence. It is estimated that approximately 85,000 women with mild or moderate PID currently are being hospitalized. Treating these women as outpatients would cause less disruption to their lives and could save as much as $500 million each year.

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AHRQ's Research Findings Help Health Systems Managers, Consumers, and Purchasers of Care

AHRQ, in conjunction with both public- and private-sector partners, supports a variety of projects to enhance quality and inform health care decisionmaking by consumers, purchasers, payers, and health care systems managers. For example:

AHRQ's CAHPS® helps patients choose health plans and obtain good health care. Consumers can now access comparative information about health plans based on other consumers' experiences with the health care they received from plans and providers. This information is available through CAHPS, a survey sponsored by AHRQ and the Centers for Medicare & Medicaid Services. CAHPS® results can help to inform consumers about their choices among health care plans and allow health plans, employers, and others to obtain consumers' views of the care they are receiving. CAHPS® users include purchasers (employers, Federal agencies, State Medicaid programs, and other groups), quality measurement organizations (for example, accrediting organizations and State associations of HMOs), and health plans. The surveys are in the public domain and are available free of charge from the AHRQ Web site (http://www.ahrq.gov).

Improving the system for delivery of emergency medical services for children. As a result of a clinical trial sponsored by AHRQ and the Health Resources and Services Administration's Maternal and Child Health Bureau, the Los Angeles and Orange County EMS ordered their paramedics to begin using bag-valve-mask ventilation alone on children needing artificial respiration. The researchers found that bag-valve-mask ventilation had comparable survival rates for young children who have stopped breathing without the risk of an intubation procedure. Based on the results of this study, the American Academy of Pediatrics modeled their Pediatric Education for Prehospital Professionals (PEPP) program to encourage the appropriate use of this technique.

Helping employers and other purchasers of health care evaluate their efforts to improve quality. As purchasers of much of the health care in the United States, employers could be a powerful force in closing the gap between the quality of care that we have and the quality of care that we should have. Although many employers are developing strategies to improve health care quality, there is little evidence on the impact of such efforts. Prompted by feedback from the employer community, AHRQ has published Evaluating the Impact of Value-Based Purchasing Initiatives. This new tool combines the formality of scientific research principles with real world examples and illustrations. It can be used by employers and other purchasers of health care to evaluate their efforts to measure, monitor, and improve the quality they are receiving for the health care dollars they spend.

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