Quality Research for Quality Health Care (continued)

Opportunities for Research

The mission of AHRQ could not be achieved without talented health services researchers who are dedicated to excellence in research. They understand the importance of evidence to inform decisionmaking and improve health care quality. In addition to the researchers on AHRQ's staff, nearly two-thirds of the Agency's budget is awarded as grants and contracts to support the work of researchers at universities and research institutions around the country.

AHRQ's research funds are awarded either through targeted announcements that address specific research questions or in response to ideas generated by researchers on significant issues in the health care system. Both of these mechanisms—targeted research requests and unsolicited investigator-initiated research proposals—are important and complementary. The Agency's targeted research initiatives respond to the specific needs of individual customers or the needs of the health care system as a whole, although researchers have latitude to design their own projects within the scope of a targeted request.

Investigator-Initiated Research

The topics addressed by unsolicited investigator-initiated research proposals reflect cutting-edge issues and ideas from the top researchers in the field of health services research. About half of the grants and cooperative agreements funded by AHRQ in fiscal year 2000 were in response to program announcements and initiated by individual investigators who developed research proposals within an area of interest to the agency. These are some examples of recent AHRQ-supported investigator-initiated research. Examples from other investigator-initiated projects are scattered throughout this report.

• Researchers at the University of Alabama at Birmingham have found that one-third of all patients suffering a heart attack don't have chest pain and thus may delay seeking life-saving treatment. In this study, patients who were suffering a heart attack but did not have chest pain arrived at the hospital 3 hours later than patients with chest pain. They also were less likely to be diagnosed with a heart attack at hospital admission and were twice as likely to die while in the hospital.
• The same Alabama researchers have found that on average only 57 percent of all patients who are eligible for reperfusion therapy to reopen a clogged artery—either thrombolytic drugs or angioplasty—actually receive this lifesaving treatment. And, the likelihood of receiving reperfusion therapy varies substantially according to the patient's race. Black patients—particularly black women—are significantly less likely to receive reperfusion therapy than white men (44 percent vs. 59 percent, respectively).
• A recent study by researchers at the University of Colorado found that monthly recertification of Medicaid eligibility leads to frequent shifts on and off the program and may undermine delivery of quality health care for children. About one in five U.S. children is enrolled in a State Medicaid program. These researchers used children's access to care and treatment for middle ear infection to examine the effects of Medicaid recertification on quality of care. They found that children who are continuously enrolled in Medicaid throughout the year are much more likely to have an assigned primary care physician and receive better care for middle ear infections, less likely to visit a hospital emergency department for the condition, more likely to fill antibiotic prescriptions, and more likely to be referred for needed ear surgery, such as tube placement or adenoidectomy.
• Many studies have pointed to the link between nurse staffing levels and nursing home quality of care. However, researchers at the University of California, San Francisco, have found that nursing home characteristics and geographic location are more predictive of nursing home care deficiencies than staffing hours or resident characteristics. They examined the data reporting system for all U.S. certified nursing homes and found that fewer RN hours and nursing assistant hours were associated with total deficiencies and quality of care deficiencies. However, staffing hours alone predicted less than 1 percent of the total variance in deficiencies. Staffing and resident characteristics together explained 3 percent of the variance. Adding facility characteristics and region to the mix increased the proportion of variance explained to 21 percent. Facilities that were smaller and nonprofit or government-owned had fewer deficiencies, and facilities with a higher percentage of Medicaid residents had more deficiencies.
• In half of the cases of out-of-hospital cardiac arrest that occurred in Seattle over the past few decades and were witnessed by bystanders, the victims did not receive bystander-initiated CPR. In this study, the researchers randomly assigned 241 out-of-hospital cardiac arrest patients to receive chest compression alone and 279 to receive chest compression plus mouth-to-mouth ventilation. Emergency medical dispatchers gave bystanders instructions during 62 percent of episodes for chest compression plus mouth-to-mouth ventilation (about 2.4 minutes for instruction) and in 81 percent of episodes for chest compression alone (only 1 minute of instruction). The outcomes for people who were administered CPR according to instructions given by the emergency medical dispatcher were virtually the same after chest compression alone as after chest compression with mouth-to-mouth ventilation.

Targeted Research Requests

In fiscal year 1999, AHRQ announced six Requests for Applications (RFAs) on questions critical to the health care system. Another six RFAs were announced in fiscal year 2000.

Fiscal Year 1999 RFAs

1. Health Care Access, Quality, and Insurance for Low-Income Children. AHRQ teamed with the David and Lucile Packard Foundation and the Health Resources and Services Administration to fund studies that will help public health insurance programs and delivery systems improve the quality of and access to care for low-income children. Researchers funded under this RFA are focusing on minority children and those with special needs.
2. Development of Quality of Care Measures for Vulnerable Populations. This RFA focused on the development and testing of measures that can be used in the purchase or improvement of health care services for populations identified as vulnerable under the definition outlined by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. According to this definition, a person may be vulnerable because of financial status or place of residence, health, age, functional or development status, ability to communicate effectively, chronic or terminal illness, disability, or personal characteristics.
3. Translating Research into Practice. This RFA supported projects that explore strategies for implementing research findings and evidence-based tools in everyday clinical practice. Evidence-based tools include clinical practice guidelines, practice parameters, quality indicators, and continuous quality improvement initiatives developed using a systematic approach to evidence synthesis.
4. Quality Improvement. The goal of this initiative was to strengthen the evidence base underlying the choice of strategies to improve the quality of health care, particularly in areas where the greatest improvement in health and functional status can occur. Studies funded under this RFA are evaluating strategies for improving health care quality that currently are being used widely by organized quality improvement systems.
5. Centers for Education and Research in Therapeutics. This RFA announced the Agency's intention to establish Centers for Education and Research in Therapeutics (CERTs) to develop, translate, and disseminate objective information on therapeutics to health care providers and other decisionmakers to improve practice. These Centers are conducting state-of-the-art research to increase awareness of new uses of drugs, biological products, and devices; identify ways to improve their effective use; and examine the risks associated with new uses and combinations of drugs and biological products. The Centers also will help improve heath care quality while reducing costs by increasing the appropriate use of drugs, biological products, and devices and identifying ways to prevent potential adverse effects. (Select for a listing of CERTs funded under this RFA.)
6. Market Forces. Through this RFA, AHRQ provided support for Centers of Excellence that conduct research on how health care market forces are affecting the quality of health care, access to health care services, and the cost of care. Findings from studies conducted by these centers will help public policymakers understand, monitor, and anticipate changes in the Nation's market-driven health care system. The projects include special emphasis on market effects on rural and minority populations and the influence of purchasers in local markets.

Fiscal Year 2000 RFAs

1. Quality information for consumers and patients. This RFA was issued jointly by AHRQ and the National Cancer Institute. It announced support for demonstration projects to (1) identify and test methods and models for developing information on quality for use by consumers and patients in making health care decisions and (2) evaluate the impact of providing consumers and patients with quality information. Special emphasis was placed on populations made vulnerable by personal characteristics (e.g., race or sex), low income, place of residence (i.e., rural), poor health status, age, problems in communicating, or functional status.
2. Minority health disparities. This RFA announced AHRQ's interest in funding projects to analyze the causes and contributing factors associated with racial/ethnic disparities in burden of illness, death, and health care access, use, quality, and outcomes. The projects also will identify and implement strategies to eliminate such disparities in six clinical areas: infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV, and immunizations for children and adults.
3. Primary care practice-based research networks. This RFA announced funding for a series of 1-year exploratory grants to assist new or established practice-based research networks. The goal is to help them enhance their capacity to conduct research in primary care settings and translate research findings into practice.
4. Violence against women. This initiative called for research on the outcomes, effectiveness, and cost-effectiveness of programs for early identification and treatment of domestic violence against women. Goals are to develop new knowledge on the prevention of domestic violence, find better ways to identify female patients at risk, and evaluate outcomes and effectiveness of health care interventions to treat violence victims.
5. Improving patient safety. This RFA announced AHRQ's interest in funding cooperative agreements to test the effectiveness of "best practices" to improve patient safety by reducing preventable, systems-related medical errors that have a high prevalence and severe consequences.
6. Translating Research Into Practice II. This RFA invited applications for cooperative agreement demonstration projects to evaluate strategies for translating research into practice through the development of partnerships between researchers and health care systems and organizations. Such systems and organizations include purchaser groups, integrated health service delivery systems, academic health systems, HMOs and other managed care programs, practice networks, and worksite clinics. The goal is to accelerate and magnify the impact of research on clinical practice and patient outcomes in applied settings.

Nurturing Research Career Development

AHRQ contributes to excellence in health care delivery through research conducted by a cadre of well-trained and talented health services researchers. To maintain and nurture this vital resource, the Agency supports a variety of training and career development opportunities through individual and institutional grant programs. These include:

• Dissertation research support.
• Predoctoral fellowships for minority students.
• National Research Service Awards (pre- and postdoctoral fellowships).
• Independent Scientist Awards (K awards).

In fiscal year 1999 and fiscal year 2000, AHRQ:

• Supported 167 pre- and postdoctoral students through institutional and individual National Research Service Awards and dissertation grants.
• Increased support by about 25 percent for pre- and postdoctoral trainees and fellows.
• Provided support for 218 scholars in fiscal year 2000.
• Launched two new career development programs: the Independent Scientist Award and the Mentored Clinical Scientist Development Award, which supported 16 additional scholars.
• Initiated a variety of activities to increase cohesiveness and build an infrastructure among AHRQ training programs, including annual meetings of students and faculty and enhanced Web-based information and links.
• Instituted the Kerr White Visiting Scholar program through which health services researchers work in residence at AHRQ and collaborate with Agency research staff.

Additional information on all of the Agency's funding opportunities—including an ongoing program announcement that describes the priorities for investigator-initiated research, targeted initiatives, and career-related grant programs—is available at www.ahrq.gov/fund.

Partnerships and Coordination

AHRQ works in partnership with many other agencies and organizations. These include the various HHS agencies, other components of the Federal Government, State and local governments, and private-sector organizations, all of whom help the agency achieve its goals.

Most of the agency's partnerships are related to the development of new knowledge, development of tools and other decision-support mechanisms, and/or the translation of research findings into practice. Examples of this collaboration include efforts to:

1. Develop new knowledge through research.
   • AHRQ co-funds individual research projects and sponsors joint research solicitations with other HHS agencies.
   • AHRQ recently co-funded research with the David and Lucile Packard Foundation and HRSA on the impact of public insurance programs and delivery systems on access to care and quality of care for low-income children.
2. Develop tools, measures, and decision-support mechanisms.
   • The Health Resources and Services Administration (HRSA) and AARP worked in partnership with AHRQ to develop Staying Healthy at 50+, the newest resource in the Put Prevention into Practice program.
   • Many agencies (e.g., the National Institutes of Health, the Health Care Financing Administration, and the Department of Veterans Affairs) are working closely with AHRQ's Evidence-based Practice Centers (EPCs) to develop assessments of existing scientific evidence to guide their work.
   • Evidence reports prepared by AHRQ-supported EPCs are being used in the development of clinical practice guidelines by a number of organizations, including the American Psychiatric Association, the American Academy of Pediatrics, the American Heart Association, and many others.
   • The Healthcare Cost and Utilization Project (HCUP) is a long-standing partnership between AHRQ and 22 States to build a multi-State data system.
3. Translate research into practice.
   • AHRQ has joined with 14 companies and organizations to disseminate a tool to help individuals apply research findings on quality measures and make major decisions about health plans, doctors, treatments, hospitals, and long-term care. Some of AHRQ's partners in this endeavor are IBM, United Parcel Service, and the Midwest Business Group on Health.
   • A number of companies and organizations have joined AHRQ in disseminating smoking cessation materials. These include the American Cancer Society, the American Academy of Pediatrics, and the Michigan Department of Community Health.
4. Update the Public Health Service smoking cessation guideline.
   • In fiscal year 2000, a consortium of seven Federal Government and nonprofit organizations, including AHRQ, joined together to sponsor the development and release of a clinical practice guideline and related materials on smoking cessation. Treating Tobacco Use and Dependence presents evidence about new, effective clinical treatments for tobacco dependence, including cigarettes, cigars, and other forms of tobacco. It includes recommendations for health care providers with brief supporting information, tables and figures, and pertinent references. In addition to the Public Health Service guideline itself, a quick reference guide presents summary information for day-to-day use by clinicians, and a consumer guide provides information for the general public.

Strategic Plan and Goals

For the last several years, the Agency has been engaged in a comprehensive process which culminated in the development of a strategic plan that will serve as a road map as we carry out our mission. This process involved an extensive review of AHRQ's activities and input from major stakeholders in the health care system: AHRQ's customers, the agency's National Advisory Council, Congress, and the Department of Health and Human Services. AHRQ staff members were heavily invested in the planning process from developing personal strategic and performance plans to contributing to the development of the strategic plan for their Offices and Centers.

As part of this process, each year—during annual planning and budget development activities—AHRQ assesses the progress the Agency has made toward achieving each of the goals. To do this, measurable Agency-level evaluation parameters have been developed to determine whether AHRQ has achieved its objectives in knowledge development, translation, dissemination, and evaluation. These parameters are an integral part of AHRQ's compliance with the Government Performance and Results Act of 1993 (GPRA) and are detailed in the annual GPRA performance plans submitted with each annual budget request.

AHRQ's strategic plan supports the achievement of three goals, which together meet the challenge laid out by the Agency's mission. Activities supported under each goal meet the criteria of one or more segments of the research pipeline. The goals are:

1. Support improvements in health outcomes.
2. Strengthen quality measurement and improvement.
3. Identify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures.

Goal 1: Support Improvements in Health Outcomes

AHRQ has a 10-year tradition of supporting research that builds the fundamental evidence base on the outcomes and effectiveness of health care. A high priority for the Agency's outcomes research portfolio is the study of clinical conditions that are common, expensive, and/or for which there are significant variations in practice or opportunities for improvement. AHRQ also supports outcomes research on major organizational changes or innovations to the health care system and the processes by which health care services are delivered. An important component of this goal is that research supported must incorporate the patient's perspective in the assessment of effectiveness.

Outcomes research answers a number of very basic questions for the health care system: What works and doesn't work? Is it having the desired impact? Does it provide value for the money spent? The answers to these questions are the building blocks for the health care system's effort to improve access to health care and its cost, use, and quality.

Outcomes Research Portfolio

In fiscal year 1999, AHRQ focused its outcomes portfolio on health care for the chronically ill and elderly by publishing a special emphasis notice and by encouraging health services researchers to submit proposals in this area. Examples of funded projects include the following studies:

• Improving the quality of initial pneumonia care. This study is examining strategies guiding clinical decisions regarding which patients with community-acquired pneumonia require hospitalization and which can be safely treated at home. For patients who do require hospital admission, the researchers will evaluate and implement strategies to improve the quality of hospital care. (University of Pittsburgh, in collaboration with quality-improvement organizations in Pennsylvania and Connecticut).
• Identification of clinically relevant changes in health-related quality of life. This project is evaluating patient-reported outcome measures for three common chronic conditions (heart failure, chronic lung disease, and asthma) to determine their value for clinicians and patients. (St. Louis University).
• Automated assessments and the quality of diabetes care. This study is evaluating the variation in outcomes for patients with diabetes using an automated telephone disease-management system. Half of the patients primarily speak Spanish; the other half, primarily English. A rich array of information will be collected and assessed to predict adverse outcomes. (Palo Alto Institute for Research, Palo Alto, CA).
• Inguinal hernia management: Watchful waiting vs. operation. Inguinal hernia is one of the most common conditions affecting men around the world; approximately 700,000 herniorrhaphies are performed in the United States each year. The indications for surgical repair of a minimally symptomatic hernia are vague, and it is not known whether patients with inguinal hernias can safely delay surgical treatment. This study is testing the safety and outcomes of watchful waiting, which could change the management of many men with minimally symptomatic hernias. (American College of Surgeons, Northwestern University, and the VA Cooperative Studies).

In fiscal year 1999, AHRQ released an extensive evaluation of its past decade of outcomes research. This evaluation, The Outcomes of Outcomes Research, was developed with input from researchers and the users of outcomes research. It includes an evaluation of past projects funded by the Agency and a preliminary examination of their impact on the Nation's health care system. According to the report, outcomes research supported by the Agency has provided descriptive information that has challenged prevailing clinical ideas about the management of specific clinical conditions. In addition, AHRQ's outcomes research has resulted in tools, guidelines, and strategies that improve the treatment of common, costly medical conditions.

U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) is another critical source of information on what does and does not work in the health care system specific to prevention. First convened in 1984, the USPSTF is an independent panel of preventive health experts. The Task Force is charged with evaluating the scientific evidence for the effectiveness of a range of clinical preventive services—including common screening tests, immunizations, and counseling for health behavior change—and producing age- and risk-factor-specific recommendations for these services. The Task Force published its first set of recommendations in the 1989 Guide to Clinical Preventive Services, which was subsequently revised in 1995.

Many prescribers may be unaware of the evidence or how to monitor therapy properly. We are now tracking the use of dofetilide at one center, before examining compliance with the FDA's rigorous requirements for education and monitoring with dofetilide use.

The third USPSTF was convened in early fiscal year 1999 and has begun work on 12 initial topics selected by Task Force members based on preliminary work by two of AHRQ's Evidence-based Practice Centers: the Research Triangle Institute/University of North Carolina at Chapel Hill and the Oregon Health Sciences University. The selection process included a preliminary literature search of new information on prevention and screening published since 1995; consultation with professional societies, health care organizations, and outside prevention experts; a review of current levels of controversy and variation in practice; and consideration of the potential for a change from the 1995 USPSTF recommendations.

The 12 topics are:

• Chemoprophylaxis (for example, tamoxifen and related drugs) to prevent breast cancer (new topic).
• Vitamin supplementation to prevent cancer or coronary heart disease (vitamin E, folate, beta carotene, and vitamin C) (new topic).
• Screening for bacterial vaginosis in pregnancy (new topic).
• Developmental screening in children (new topic).
• Screening for diabetes mellitus (updated topic).
• Newborn hearing screening (updated topic).
• Screening for skin cancer (updated topic).
• Counseling to prevent unintended pregnancy (updated topic).
• Screening for high cholesterol (updated topic).
• Postmenopausal hormone therapy (updated topic).
• Screening for chlamydial infection (updated topic).
• Screening for depression (updated topic).

Put Prevention Into Practice

AHRQ's Put Prevention Into Practice (PPIP) program helps translate the evidence-based recommendations of the U.S. Preventive Services Task Force into practice through the development and dissemination of resources for providers, patients, and office systems. PPIP emphasizes the importance of a comprehensive, system-wide, team approach to delivering effective preventive interventions. AHRQ works closely with public and private partners to disseminate PPIP resources. PPIP materials include information on preventive services recommendations, ideas for implementation, flowsheets, posters, and personal health guides.

During fiscal year 2000, work was completed on Staying Healthy at 50+. This new guide is available in English and Spanish. It contains tips and recommendations on health habits, screening tests, and immunizations to help people age 50 and older stay healthy. Staying Healthy at 50+ was developed by AHRQ in partnership with AARP and the Health Resources and Services Administration. Print copies of the guide are available from the AHRQ Clearinghouse (800-258-9295).

Evidence-based Practice Centers

AHRQ's 12 Evidence-based Practice Centers (EPCs) develop evidence reports and technology assessments on conditions and technologies that are costly, common, and/or significant for the Medicare and Medicaid populations. These reports and technology assessments are based on rigorous, comprehensive reviews of relevant scientific literature, and they emphasize explicit and detailed documentation of methods, rationale, and assumptions. The goal of these reports is to provide the scientific foundation that public and private organizations can use to develop their own clinical practice guidelines, quality measures, review criteria, and other tools to improve the quality and delivery of health care services. Professional organizations, health plans, providers, and others who nominate topics are considered partners, and they agree to use the evidence reports when they are completed. Eleven evidence reports were released in fiscal year 1999:

• Diagnosis of Sleep Apnea.
• Traumatic Brain Injury.
• Traumatic Brain Injury in Children and Adolescents.
• Pharmacotherapy for Alcohol Dependence.
• Advanced Prostate Cancer.
• Cervical Cytology.
• Urinary Tract Infections in Paralyzed Persons.
• Depression—New Pharmacotherapies.
• Swallowing Disorders in Stroke Patients.
• Acute Bacterial Rhinosinusitis.

Nineteen new evidence topics were announced in fiscal year 1999. For the first time, the EPCs began tackling some nonclinical topics in addition to high priority clinical questions. Examples of reports currently in development or in press include:

• Refinement of AHRQ's HCUP Clinical Quality Indicators, University of California, San Francisco (UCSF)-Stanford University, Palo Alto, CA.
• Medical Informatics and Telemedicine Coverage under Medicare, Oregon Health Sciences University, Portland OR.
• Complementary and Alternative Medicine, University of Texas Health Science Center, San Antonio, TX.
• Criteria for Referral of Patients with Epilepsy, Metaworks, Boston MA.
• Diagnosis and Management of Osteoporosis, Oregon Health Sciences University, Portland OR.
• Treatment of Pulmonary Disease Following Spinal Cord Injury, Duke University, Durham, NC.
• Management of Acute Chronic Obstructive Pulmonary Disease, Duke University, Durham, NC.
• Criteria for Determining Disability in Patients with End-Stage Renal Disease, ECRI, Plymouth Meeting, PA.
• Treatment of Acne, Johns Hopkins University, Baltimore, MD.
• Anesthesia Management During Cataract Surgery, Johns Hopkins University, Baltimore, MD.
• Management of Acute Otitis Media, Southern California EPC/RAND, Santa Monica, CA.

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