Special Issues for Nurses
Helen Burstin, M.D., M.P.H. | David I. Lewin,
M.Phil. | Heddy Hubbard, R.N., M.P.H.
The information presented in this article was originally published in Policy, Politics, and Nursing Practice (Volume 2, Number 2, May 2001).
Contents
Overview
Reauthorization
Quality of Care
Nurse Staffing
Primary Care
Practice-Based Research
Nurse Scholar
Nurse Grant Applicants
References
How treatments work in practice rather than in basic and clinical research studies
is the domain of the Agency for Healthcare Research and Quality (AHRQ). The
Agency conducts and funds research into health services research, especially
the effectiveness of treatments—including patient outcomes, treatment costs,
and accessibility. AHRQ also is concerned with the quality of care, including
major initiatives in patient safety and medical errors. The article outlines
the role of the Agency in primary care research, and particularly its role in
nursing research. The authors note the role of the Agency in developing a
research agenda for nurse staffing research and outline initiatives and programs
of interest to nursing researchers.
Although new treatments are studied under
controlled conditions—typically with support from the National Institutes of
Health (NIH)—to determine their efficacy, how these treatments work in the real
world of primary care is more difficult to assess. For example, a controlled
trial may show that a particular antibiotic is effective in reducing the
inflammation associated with childhood otitis media, but determination of
whether antibiotic treatment improves patient outcomes requires a different set
of research designs, generally with support from the Agency for Healthcare
Research and Quality (AHRQ).
The assessment of the effectiveness of
patient outcomes and of treatment cost and accessibility—as opposed to the
assessment of treatment efficacy alone—is not a new field of research. Its
modern roots go back at least to 1968, when the National Center for Health
Services Research was established within what was then the U.S. Department of
Health, Education, and Welfare. In 1989, this center became the Agency for
Health Care Policy and Research, which was reauthorized by Congress in 1999 as
AHRQ. The reauthorization affirms the Agency's existing goals and research
priorities:
- Support improvement in health outcomes.
- Strengthen quality measurement and improvement.
- Identify strategies to improve access, foster
appropriate use, and reduce unnecessary expenditures.
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The Center for Primary Care Research (CPCR)
at AHRQ was named in a statute as part of the 1999 reauthorization process.
CPCR was codified as the major Federal source of funding for primary care
practice research in the Department of Health and Human Services and the focal
point of research on access, quality, and cost of primary care services, as
well as patient-provider communication, generalist-specialist issues, and
workforce issues in primary care.
The legislation also codified the Medical
Expenditure Panel Survey (MEPS) and the U.S. Preventive Services Task Force
(USPSTF). It directed the Agency to advance the use of information technology
for coordinating patient care and for undertaking quality and outcomes
research. The legislation also directed the Agency to address the needs of
specific priority populations:
- Residents of inner-city, rural, and frontier areas.
- People with low incomes.
- Elderly, children, women, and minorities.
- People with special health care needs, including
disabilities, chronic care, and end-of-life health care.
At the end of last year, Congress passed the
fiscal year 2001 appropriations bill for the departments of Labor, Health and
Human Services, Education, and related agencies, which the President
subsequently signed. The bill recommended $270 million for AHRQ in fiscal
year (FY) 2001, which is approximately $70 million above the FY 2000 level and
$20 million above the president's request. The increase includes $50 million to
conduct and support research to enhance patient safety, initiatives that are
expected to involve the nursing community. The increase also provides $10
million to support research related to health care workers and the quality of
health care, especially to examine the relationship between the health care workplace
and its impact on medical errors and the quality of care provided to patients.
The remaining increase will go to activities such as the National Quality
Report, research on disparities in care, training, and early career
development, and other extramural research initiatives.
In many ways, AHRQ seeks to answer a
question put by Rep. John Porter (R-IL), retiring chairman of the House
Appropriations Subcommittee on Labor, Health and Human Services (HHS), and
Education. "What we really want to get at [in health care research] is not
how many reports have been done, but how many people's lives are being bettered
by what has been accomplished. In other words, is it being used, is it being
followed, is it actually being given to patients—... [W]hat effect is it
having on people—" The Agency seeks to assist the health care pipeline,
increasing resources for new research on priority health issues to develop tools and talent for a new century, and to translate research into practice.
The goals of these activities are improved outcomes for patients, better
quality of care, greater access to care, and delivery of care with appropriate
cost and use.
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In addition, a growing focus of the Agency
is on reducing medical errors and improving patient safety. Although actively
supporting research into these fields, the Agency also serves as part of the
Quality Interagency Task Force (QuIC), a group that brings together Federal
agencies working on patient safety and other quality issues. In response to an
Institute of Medicine (IOM) report, To Err Is Human (IOM, 1999), the QuIC
issued Doing What Counts for Patient Safety: Federal Actions to Reduce Medical
Errors and Their Impact (QuIC, 2000). This report, including more than 100
errors-related activities to be taken by various Federal agencies, was released
by former President Clinton in February 2000. Fulfilling one of the promised
actions, AHRQ organized a "National Summit on Medical Errors and Patient
Safety Research," held in September 2000. Bringing together a panel of 14
Federal agency and private sector funders to develop a national research agenda,
the meeting drew submissions from a variety of organizations and individuals,
including nursing organizations, on research needs in this field.
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Increasingly, nurse staffing is becoming an
issue of concern to both the nursing community and the broader community of
providers, patients, and policymakers. For example, an October 2000 meeting on
working conditions, jointly sponsored by the National Institute of Occupational
Safety and Health and AHRQ, included nurse staffing as an issue on the agenda.
As cost containment efforts over the past 18 years have led to more selective
use of hospital services, hospital organizations have sought to reduce
financial concerns by changing nursing services. Because of the financial
issues and changes in health care technology, research into the impact of nurse
staffing on health outcomes has become of greater importance. Addressing this
concern, the Agency has supported research on this topic and has been a
cosponsor of a research contract supported by the Health Resources and Services
Administration's Division of Nursing, "Nurse Staffing and Quality of Care
in Inpatient Units in Acute Care Hospitals." In response to an IOM report
on nurse staffing (Wunderlich, Sloan, & Davis, 1996), AHRQ, the American
Nurses Association, and the American Association of Nurse Executives sponsored a
meeting held by the American Academy of Nursing (AAN) on "Outcome Measures
and Care Delivery Systems." The results of that conference was a research
agenda (AHRQ, 1997) published in the November 13, 1996, Federal Register and
revised in response to public comment. A key need to come out of the meeting
was that of refining and standardizing conceptual and operational definitions
of such factors as nursing staff level and nursing skill mix. An upcoming
solicitation for research grants and conferences will support research on the
impact of working conditions on the safety and quality of care.
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A number of research projects related to
primary care nursing issues are supported by CPCR, the only one of the
AHRQ's six centers and four offices that focuses on understanding the quality
effectiveness, cost, and outcomes of primary care; other types of nursing
research are considered by the Agency's remaining centers. CPCR investigates
issues surrounding:
- Patient-provider communication.
- The relationship between
medical generalists and specialists.
- The health care workforce.
- Access to
care, including racial and ethnic disparities.
All of these are issues of strong interest to the nursing community.
The center is also playing a lead role
within AHRQ on initiatives concerning ambulatory patient safety. In cooperation
with the Health Care Financing Administration (HCFA), AHRQ has begun working
toward understanding patient safety and medical errors in the outpatient
setting. A recent conference sponsored by AHRQ and HCFA addressed the
epidemiology of medical errors in the ambulatory setting and began to develop a
research agenda and demonstration programs to address this issue. In
particular, researchers need to understand how primary care providers can help
to reduce the high-risk errors, such as medication errors and missed followup
of laboratory and radiology tests.
CPCR has been designated as the lead for
the Agency on clinical informatics. As part of our reauthorization, AHRQ was
directed to support the use of information technology (IT) to improve patient
coordination, quality of care, and patient outcomes. AHRQ's unique role in IT
will focus primarily on those applications that can improve care and patient
safety. An upcoming grant solicitation will support work in this area.
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Recently, AHRQ awarded planning grants to 19
primary care Practice-Based Research Networks (PBRNs), a program administered
by the center. These networks are groups of practices—devoted principally to
the care of patients—that have affiliated with each other (and often with an
academic or professional organization) to investigate questions related to
community-based practice. Nurses will be an important component of these
networks, which are expected to be ongoing structures designed to function over
more than a single study. Together, the PBRNs will be able to engage in research
with more than 5,000 primary care practice settings and almost 7 million
patients across the United States. One of the networks, directed by Margaret
Grey, Ph.D., B.S.N., at Yale, will focus on nurse-practitioner practice.
For FY 2000, the selected PBRNs recently
received $75,000 in planning grants. During this fiscal year, the networks will
be expected to:
- Implement the computer-based collection of research data from
the participating practices.
- Expand the scope of the networks and include
larger numbers of minority or underserved patients.
- Plan how to translate
new research findings into clinical practice.
AHRQ, in partnership with other
Federal funding agencies and foundations, will also provide funds to conduct
research in the context of the primary care PBRNs. These directed funds will
likely support work in the area of patient safety, working conditions, mental
health, and health care disparities.
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Of direct interest to the nursing community,
AHRQ and the AAN have joined forces since 1995 to put a senior nurse scholar in
place at the Agency to help AHRQ develop areas of investigation that integrate
clinical nursing care questions with critical issues of quality, effectiveness,
cost, and access to health care.
The first senior nurse scholar was Christine
Kovner, Ph.D., R.N., F.A.A.N., of the New York University Division of Nursing, selected
in 1995. While at AHRQ, Dr. Kovner focused on the impact of nurse staffing on
quality of care. She was succeeded in 1997 by Lorraine Tulman, D.N.Sc., R.N., F.A.A.N.,
of the University of Pennsylvania School of Nursing. During her stay at AHRQ,
Dr. Tulman looked at the literature on controlled clinical trials in women that
use functional status as an outcome measure. Subsequently, Linda Moody, Ph.D.,
F.A.A.N., of the University of South Florida served as the senior nurse scholar.
While at AHRQ, she focused on avoidable adverse outcomes in cognitively
impaired nursing home residents. Our most recent senior nurse scholar, Sally
Lusk, Ph.D., R.N., F.A.A.N., of the University of Michigan, focused on issues related
to primary care services and occupational health, particularly the prevention
of noise-induced hearing loss. She also worked closely with the USPSTF and
helped to develop a research agenda on worker health.
In addition, nursing is represented on the
Agency's National Advisory Council by Marita Titler, Ph.D., R.N., F.A.A.N., Mary
Katherine Wakefield, R.N., Ph.D., F.A.A.N., and Colleen Conway-Welch, Ph.D., C.N.M, F.A.A.N.
To help improve the communications between AHRQ and the nursing community, the
Agency is developing a nursing page for its Web site
(http://www.ahrq.gov/about/nrsrscix.htm).
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The Agency is actively encouraging more
grant applications from nurses as principal investigators. Since 1994, nurse
principal investigators have accounted for 4 percent to 7 percent of the total pool of AHRQ
research grant applicants, and 2 percent to 9 percent of all funded grants during this
period. Many of AHRQ's priority areas are especially relevant to nurse
researchers—disease prevention, health promotion, primary care, quality of
care delivery, and service delivery—and the opportunities for nurse principal
investigators are good. However, although the Agency's funding has been
increasing the past several years, much of the increase has been in specific
program areas designated by Congress, such as medical errors and patient
safety; in consequence, the amount of funds available for general
investigator-initiated grants has been limited.
Despite this, there has been an
approximately 27 percent funding rate for grant applications from nursing principal
investigators in recent years (select Figure 1, 28 KB). This suggests that it is the low
rate of nursing applicants, rather than the funding level, that has produced
the paucity of nursing research projects at AHRQ. To combat this, we need more
nurse investigators applying to the Agency for support. Details of funding
opportunities with the Agency are available at the AHRQ Web site (http://www.ahrq.gov/fund/), including both
program announcements (PAs) and requests for applications (RFAs).
AHRQ's slogan is "quality research for
quality healthcare." To accurately assess health care cost, access, and quality,
it is imperative that we increase the voice of major providers of care in the
United States—nurses—in research in these critical areas. With growing
nurse-specific concerns, including the worsening nursing shortage and concern
regarding the relationship between nurse staffing and quality of care, it is
imperative that we increase the role of nurse investigators in health care
research.
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Agency for Health Care Policy and Research (1997, August 25). Nurse Staffing and Quality of Care in Health Care
Organizations Research Agenda.
Institute of Medicine (1999). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press. Available online: http://books.nap.edu/books/0309068371/html/index.html
Quality Interagency Task Force (2000). Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Rockville, MD: Quality Interagency Task Force. Available online: http://www.quic.gov/report/
Wunderlich GS, Sloan FA, and Davis, CK (1996). Nursing Staff in Hospitals and Nursing Homes: Is
It Adequate? Washington, DC: National Academy Press. Available online: http://www.nap.edu/books/0309053986/html/index.html
Helen Burstin, M.D., M.P.H., is the director of the Center for Primary Care Research (CPCR) at the Agency for
Healthcare Research and Quality. Prior to her appointment at AHRQ, Dr. Burstin was an assistant professor at Harvard Medical School and director of
quality measurement at Brigham and Women's Hospital. Her research has focused on such primary care topics as access, patient-provider communication, quality, screening, and patient satisfaction.
David I. Lewin, M.Phil., received degrees in developmental biology and genetics from Caltech and Yale before turning to science writing and editing. Before joining AHRQ in 1999 as a technical publications writer-editor, he served as senior editor of The Journal of the National Cancer Institute. Previously, he was a staff writer for The Journal of NIH Research and Washington editor of Mechanical Engineering magazine.
Heddy Hubbard, R.N., M.P.H., is a graduate of the Presbyterian Hospital/Bloomfield College School of Nursing, the University of Maryland School of Nursing, and the Johns Hopkins School of Public Health. She is the supervisory health scientist administrator and special assistant to the director, Center for Outcomes and Effectiveness Research with AHRQ, and serves as the Agency's senior advisor for nursing.
Current as of September 2001
Internet Citation:
Future Directions in Primary Care Research: Special
Issues for Nurses. May 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/nursing/nrsfutur.htm