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Performance Plans for FY 2002 and 2003 and Performance Report for FY 2001

Agency for Healthcare Research and Quality

Following is the Fiscal Year 2002 Revised Final Plan (and 2001 Performance Report) of the Agency for Healthcare Research and Quality (AHRQ). The Fiscal Year 2003 President's budget request for AHRQ incorporates the annual performance plan required under the Government Performance and Results Act (GPRA). The Fiscal Year 2003 performance goals and measures are detailed in AHRQ's performance plan and are linked to both the budget and to the Strategic Plan of the Department of Health and Human Services (HHS). Performance targets in the plan depend partly on resource levels requested in the President's budget and could change based on congressional appropriation action.

GPRA requires that HHS plans and budgets be accountable for program results. The intent of the Act is to improve program performance by considering performance information in decisionmaking and by involving our partners and stakeholders in accomplishing program results.

Select for a summary of AHRQ's Fiscal Year 2003 performance plan.

Part 2. Program Planning and Assessment

"What we really want to get at 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?"

—Congressman John Porter, 1998
Chairman, House Appropriations
Subcommittee on Labor, HHS, and Education

Introduction and Rationale:

The purpose of research is to produce information and knowledge that can inform decisionmaking. There is increasing awareness among those who provide and receive health care services, those who pay for those services and those who are making policy decisions that health care should be research led and that the services which are provided should be evidence based. As a result, research agencies must find a way to demonstrate the benefits of the research produced, not only in terms of how many research finding are published in professional journals but how the investment in research results in practical everyday applications which can be used by people who need information to make decisions about health care.

Demonstrating that research has led to tangible effects in the care provided to individual patients is difficult. Impact is rarely immediate. For example, we may learn that a health care organization has adopted a policy based on research funded by AHRQ, however, it might be several years before we know what effect it has had on patient care overall. Knowing that some clinicians, or health systems are changing their practice is different from knowing how overall practice patterns are being influenced and what the effect is on clinical outcomes.

To address the need to demonstrate the impact of research on people's health, AHRQ staff and consultants developed a "pyramid of outcomes" (10 KB) model that includes four different levels of impact beginning at the base with impact on knowledge and further research development and progressing to the impact on health outcomes.

This model of assessing impact of AHRQ sponsored research forms the basis for the development of performance measures. Similarly, AHRQ must ensure that performance measures are developed to assess the impact of the research investment at all levels of the pyramid.

Performance measures aimed at the base of the pyramid focus on research that contributes to the health care knowledge base, leads to future research or both. Research at this level includes the development of tools and methods for research, instruments and techniques to assist clinical decision-making, and identify areas which do not have a sufficient evidence base. The process indicators that are developed to measure performance at this level of the pyramid assess the quantity or quality of activities that have the potential to contribute, at least indirectly, to helping AHRQ meet it's strategic goals, or to monitor the establishment of major new initiatives or implementation of improvements in core activities where significant resources are involved or the potential for significance of the ultimate impact is high.

Output indicators are developed aimed at capturing the impact at the second and third level of the pyramid. Research at the second level of impact is research that results in the creation of a policy or program by a professional organization, health plans, hospitals, legislative bodies, regulators or accrediting organizations. Similarly, impact at level three of the pyramid is defined as research that results in a change in what clinicians or patients do, or changes in a pattern of care.

AHRQ has developed outcome indicators to measure impact at the fourth level of the pyramid, that is impact on the quality of care, actual health outcomes, cost of treatment or access to health care. Often, however, the connection between a particular research project and health outcomes is indirect and can take years to emerge. As a result, AHRQ has developed measures that utilize a "convergence of evidence" approach to establish a connection between research and outcomes. This involves identifying bodies of research which, when considered together, establish a connection between research and outcomes.

AHRQ Performance Indicators

Indicator	Year 1	Years 3-5	Years 3-10
Phase of initiative	Research initiative starts	Results received	Results used in health care system
Indicator type	Process indicators	Output indicators	Outcome indicators
Indicator examples	Grants funded, creation of reports, partnerships formed	Publications, Web site, dissemination, research findings, reports, products available for use in health care system	Results of evaluation studies, users stories, analysis of trend/other data

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Budget and Program Aggregation:

The AHRQ GPRA annual performance report and plans are aligned with the Agency's three budget lines:

Research on Health Care Costs, Quality, and Outcomes,
Medical Expenditure Panel Survey, and
Program Support.

The first two budget lines are where Agency programs are funded. The goals associated with each of the budget lines represent core activities funded in each. The following two tables illustrate how the GPRA goals are aligned with the AHRQ budget lines.

Table I, representing the GPRA goals for FY 2001 and FY 2002 uses the cycle of research as a basic framework underpinning the development of goals and measures for AHRQ's budget line: Research on Health Care Costs, Quality and Outcomes.

Table 1: GPRA Framework FY 2001-2002

What the Indicators Address	GPRA Goal
Budget line 1: Research on Health Care Costs, Quality, and Outcomes
Cycle of Research Phase 1: Needs Assessment	GPRA Goal 1: Establish Future Research Agenda Based on User's Needs.
Cycle of Research Phase 2: Knowledge Creation	GPRA Goal 2: Make significant contributions to the effective functioning of the US health care system through the creation of new knowledge.
Cycle of Research Phase 3: Translation and Dissemination	GPRA Goal 3: Foster translation of new knowledge into practice by developing and providing information, products, and tools on outcomes, quality, access, cost and use of care.
Cycle of Research Phase 4: Evaluation	GPRA Goal 4: Evaluate the effectiveness and impact of AHRQ research and associated activities.
Lead role for quality initiative	GPRA Goal 5: Support Department-wide Initiative to Improve Health Care Quality through leadership and research.
Budget line 2: Medical Panel Expenditure Survey
Core MEPS activities	GPRA Goal 6: Collect current data and create data tapes and associated products on health care use and expenditures for use by public and private-sector decision makers and researchers.
Budget line 3: Program Support
Agency management activities: contracts management and the AHRQ Intranet.	Goal 7: Support the overall direction and management of AHRQ

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Beginning in FY 2003, AHRQ has redesigned our strategic management system and revised our GPRA goals to align more closely with the Agency's strategic plan. Table 2 shows this revision and realignment.

Table 2: FY 2003 GPRA Framework

What the Indicators Address	GPRA Goal
Budget line 1: Research on Health Care Costs, Quality, and Outcomes
Strategic Goal 1: Strengthen Quality Measurement and Improvement	To have measurable improvement in the quality and safety of healthcare for Americans.
Strategic Goal 2: Support Improvements in Health outcomes	To have measurable improvement in the type of delivery system or processes by which care is provided and their effects on health care outcomes.
Strategic Goal 3: Identify Strategies to Improve Access, Foster Appropriate Use and Reduce Unnecessary Expenditures	To develop the evidence base for policy makers and health systems to use in making decisions about what services to pay for, how to structure those services, and how those services are accessed.
Budget line 2: Medical Panel Expenditure Survey
Core MEPS activities	To provide comprehensive, relevant and timely data on health care use and expenditures for use by public and private sector decision makers and researchers.
Budget line 3: Program Support
Enhance the value of AHRQ as the leader in Healthcare Outcomes, Quality, Cost, Use and Access	Maximize the value of AHRQ by developing efficient and responsive business processes, aligning human capital policies and practices with AHRQ's mission, building an integrated and reliable information technology infrastructure

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We believe that this realignment will help us determine how well the basic knowledge which forms the core of AHRQ's work provides information which can be turned into actions by clinical decision makers; purchasers and providers who make decisions about what services to use and pay for and how to structure those services; as well as by policy makers.

Note: A complete FY 2001 performance report has been included in the Appendix.

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FY 2001 GPRA Performance Report Results: Executive Summary

The mission of the Agency for Healthcare Research and Quality is to conduct and sponsor research that will help improve the outcomes and quality of health care, reduce costs, address patient safety and medical errors, and broaden access to effective services. AHRQ's ability to sustain a high level of performance during fiscal year 2001 is evidenced by how its research has been used to provide better health care and the impact it has had on the delivery of health care services.

Among other activities, in Fiscal Year 2001, AHRQ:

AHRQ's Evidence-Based Practice Centers (EPCs) researched 28 new topics. These included research into: seasonal allergies; diabetes; venous thrombosis; hyperbaric oxygen therapy treatment for brain injury and stroke; the management of bronchiolitis and coronary heart disease in women; vaginal birth following Caesarian sections; and, the diagnosis and treatment of Attention Deficit/Hyperactivity Disorder(ADHD) in children;
The Integrated Delivery System Research Network (IDSRN) was charged with 16 projects focusing moreover on improving patient safety and working conditions for healthcare workers and reducing disparities in health care delivery;
State participation in the Healthcare Cost and Utilization Project (HCUP) increased by 15 percent this past fiscal year or to 25 states in sum. HCUP was also expanded to include hospital-based ambulatory surgery databases. The pilot of emergency department databases was expanded from one to five states. AHRQ also announced the availability of the Kids' Inpatient Database (KID), the first comprehensive research database exclusively concerned with inpatient care of children and adolescents in the nation's community hospitals. Finally, HCUP data was made more available to the public through HCUPnet;
AHRQ established nine Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED). This 5-year effort will bring together teams of new and experienced investigators to analyze the factors that contribute to ethnic and racial inequities in health care and to identify practical tools and strategies to eliminate disparities;
In 2001, AHRQ invested funds to evaluate health system responses to domestic violence. These studies are the first of their kind that will move beyond studying prevalence, screening, and training to take a rigorous look at health care interventions for domestic violence and their effectiveness. Victims will be evaluated over time to identify interventions that improve their health and safety, predict and improve health care use, prevent and reduce the occurrence of domestic violence, and develop better techniques to identify those at risk for domestic violence;
In 2001, AHRQ supported child-relevant studies focused on outcomes, quality and patient safety, cost use and access;
Concerning bioterrorism, this past year AHRQ funded, for example, research at the University of Alabama at Birmingham and the Research Triangle Institute that yielded the development of Web-based training modules to teach health professionals how to address varied biological agents. Separate modules were created for emergency room practitioners, radiologists, pathologists, and infection control specialists. Clinicians can obtain continuing medical education (CME) credit via: http://www.bioterrorism.uab.edu;
Based on the promising results from a pilot project, in 2001 AHRQ initiated a contract to continue funding the collaborative HIV Research Network project through 2005. Also, using AHRQ's Comprehensive Health Enhancement Support System (CHESS), an online services model for people facing major life crises, the University of Wisconsin at Madison showed that HIV-positive patients who are provided with CHESS software on home-based computer systems are more efficient users of health care. Having access to information, decision support, and connections to experts and other patients enabled 465 study patients to better monitor their health and alert their doctors when signs of serious illness appeared. These patients had lower health care costs, fewer hospitalizations, and shorter hospital stays than patients without access to CHESS. Treatment costs in one study were reduced by $400 per month and patients spent 15 percent less time in the doctor's office because their self-management improved.
The U.S. Preventive Services Task Force (USPSTF) this past year issued four recommendations covering chlamydia screening, lipid (high cholesterol) screening, skin cancer, and bacterial vaginosis in pregnancy. These are the first of 12 recommendations the Third USPSTF will release. The remainder are: chemoprevention (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); developmental screening in children (new topic); screening for diabetes mellitus (updated topic); newborn hearing screening (updated topic); counseling to prevent unintended pregnancy (updated topic); postmenopausal hormone therapy (updated topic); and, screening for depression (updated topic).
As of 2001 year end, work on the National Quality Report (NQR) continues. A 14-member Institute of Medicine (IOM) committee of leading experts in quality and quality measurement was formed and recommended that the NQR quality monitoring system be based on a conceptual framework that addresses both dimensions of patient care (e.g., safety, effectiveness, patient centeredness, timeliness, equity) and patient needs (e.g., staying healthy, getting better, living with illness, coping with end of life issues). AHRQ initiated a call for measures to relevant federal agencies to identify candidate measures to populate the conceptual framework. The IOM issued a complementary call for measures to the private sector. Over 400 measures were submitted. An interagency workgroup is evaluating the candidate measures for inclusion in the first report using criteria suggested by the IOM (e.g., significance, scientific soundness, feasibility).
Funded $50 million in 94 new research grants, contracts and other projects to reduce medical errors and improve patient safety;
Funded over 30 projects that will examine the effect of working conditions on health care workers' ability to provide safe, high-quality care in ambulatory, inpatient (both hospital and long term care institutions) and in home care settings.

The above listing only begins to capture the nature of AHRQ research and the Agency's role within the federal health care infrastructure. As the only federal agency specifically charged to provide information to those whom make decisions about health care, the research AHRQ sponsors and conducts supports the work of several federal agencies such as: the Food and Drug Administration (FDA); the National Institutes of Health (NIH); the Centers for Disease Control & Prevention (CDC); the Substance Abuse and Mental Health Services Administration (SAMHSA); the Center for Medicaid and Medicare Services; and, others. Leaders in these agencies and other federal and state government, private and not for profit leaders decision-makers are AHRQ's key constituent members.

Constituent or User Input is Key

Key to the Agency's success in carrying out its mission is its constituent or user-driven agenda. AHRQ regularly requests input from its users or stakeholders through a variety of vehicles, including: the National Advisory Council; expert meetings; Federal Register notices; and, public comments submitted through its web site, www.ahrq.gov. This user-driven research agenda may be thought of as a three-part research pipeline that:

Identifies and supports new research on priority health care issues;
Develops the tools and talent for knowledge creation; and,
Translates and disseminates research into practice.

New Research

The first pipeline segment is about health service delivery research that address important questions and/or inadequacies in the health care system. Further, it is about moving from the use of conventional practices in medicine to the use of the most valid or evidence-based scientific information available. The research is about outcomes, about links between processes and outcome, about how to measure quality and health expenditures.

In Fiscal Year 2001, AHRQ provided $136 million to fund more than 401 new grants that were investigator initiated. The topics cover a range of health services research and effectively allows AHRQ to fund important research that may not fit within the parameters of an AHRQ-issued RFA (requests for applications). Additionally, the Agency funded 45 small conference grants ($1.6 million) and 15 dissertation grants ($500,000) also covering an array of topics.

Developing Tools and Talent

The second segment of AHRQ's pipeline concerns developing instruments and human resources to translate new knowledge into practice. Among the tools AHRQ uses in this regard are CAHPS (Consumer Assessment of Health Plans) and its Computerized Needs-Oriented Quality Measurement Evaluation System (CONQUEST), the quality measures derived from the Healthcare Cost and Utilization Project (HCUP) and Q-SPAN (Expansion of Quality Measures) and the quality improvement tools created by the use of Evidence Reports (ERs) and Technology Assessments (TAs). In the area of preventive care, AHRQ provides technical support for the U.S. Preventive Services Task Force (USPSTF), an independent panel of preventive health experts charged with evaluating the scientific evidence for the effectiveness of a range of clinical preventive services.

AHRQ has partnered with a wide variety of Federal agencies, academic institutions and health care organizations. Decision-makers use the evidence developed through AHRQ-sponsored research and the tools developed from those findings to help make informed decisions about what works, for whom, when and at what cost.

Among the most visible examples of AHRQ's partnerships are its Evidence-Based Practice Centers (EPCs). For the past five years, AHRQ has been a science partner with leading public and private research institutions nationwide in conducting scientific reviews and syntheses of scientific literature. Each EPC has a five year contract to review assigned specific topics in clinical care. Nominations for these topics are routinely solicited from professional organizations, delivery systems and others as well as accepted on an on-going basis. Among the criteria for topic selection are whether these clinical care topics are common, expensive, and/or significantly relevant to Medicare and Medicaid populations.

With regard to talent, in fiscal year 2001 AHRQ created a new fellowship program in honor of Kerr White, a founder in the filed of health services research. Along with the National Institutes of Health, AHRQ also expanded opportunities available under the National Research Service Award program to include sponsorship of individual pre-doctoral fellowships for under-represented minority students.

Translating Research

The final pipeline segment translates research into measurable improvements in health care. New knowledge with improved tools and talent are used to close the gap between what we know and what we do to improve health care cost, outcomes and quality.

For example, Translating Research into Practice (TRIP) grants are now in their second round. TRIP II, amounting to $5.7 million and double the number of the first round of TRIP grants, focuses on seven specific areas: six found in the race and disparities initiative (infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection/AIDS and immunizations); and, pediatric asthma. Each of these TRIP II grants requires partnerships among researchers, health care systems and organizations to evaluate strategies for improving quality of care. The TRIP program will result in more rapid uptake of research results by providing an incentive for health care organizations to evaluate alternative improvement strategies.

To complement this initiative and further foster partnerships in Fiscal Year 2001, AHRQ awarded 18 planning grants equally $1.3 million. This funding supports the efforts of the PBRNs (Practice-Based Research Networks) to design systems that will facilitate the translation of research into practice and to assess the impact of these systems on care delivered.

Additionally, AHRQ has partnered with nine Integrated Delivery System Networks (IDSRN) to link the nation's top researchers with the some of the country's largest health care systems. As a group, the networks provide health services to over 34 million Americans, including the privately insured, Medicare and Medicaid patients and the uninsured. This new model of field-based research will enable AHRQ to accelerate the pace of its research regarding key concerns such as medical care quality and safety, access to services and costs.

Finally, AHRQ oversees the Put Prevention Into Practice (PIPP) initiative, which serves as the implementation vehicle for USPSTF's age-specific and risk factor-specific recommendations on preventive care.

Evaluations

To understand AHRQ's impact on health service delivery, additional emphasis is being placed on evaluation activities. As a result, AHRQ was able to report on both process, output and interim outcome goals for its major initiatives. The Fiscal Year 2001 evaluation portfolio included a number of evaluations that assessed the impact of research products used to inform customers, measure quality, and make policy decisions. Evaluations completed this year are:

Assessment of Past Agency Activities on Disabilities
Background Research in Support of the Development of an Institutional CAHPS Survey
Development and Analysis of HCUP—The Healthcare Cost and Utilization Project
Development of a Conceptual Framework for a Healthcare Disparities Report
Development of Point of Service Assessments for the Office of Management
Evaluation of Data Sources Used in Research on Health Care Markets
Evidence Report on the Efficacy of Behavioral Dietary Interventions to Reduce Cancer Risks
Health Services Research Education: Assessing Customer Satisfaction & Program Needs
Improving the Process for Tracking Research Impact
Study of the Per Patient Cost and Efficacy of Treatment for Temporomandibular Joint (TMJ) Disorders

Leadership on Health Care Quality

The Agency frequently uses the phrase, "quality research for quality healthcare." This underscores AHRQ's commitment to research on quality measurement as well as quality improvement. In this area, over 80 AHRQ-funded investigators are now studying issues as far ranging as:

Quality improvement in caring for newborns with jaundice;
The comprehensiveness of prescription drug coverage as a measure of quality care among elderly beneficiaries with chronic health conditions; and,
Identification of hospital-based quality improvement interventions that are most effective in increasing use of beta-blockers after acute myocardial infarction.

AHRQ has taken a lead role in the QuIC (Quality Inter-Agency Coordination) Task Force efforts to address medical errors and patient safety in the U.S. Sadly, every hour, 10 Americans die in a hospital due to avoidable errors and another 50 are disabled. As part of its efforts to improve patient safety and reduce medical errors, the QuIC Task Force has published Five Steps to Safer Health Care. The five steps were distilled from an earlier AHRQ publication, "20 Tips to Reduce Medical Errors." Those evidence based recommendations provide patients with guidance on how to improve their safety and have been widely adopted across the government through the QuIC. As an example, the OPM (Office of Personnel Management) has included them in this year's health benefits brochure. AHRQ also coordinated publication of the landmark report, Doing What Counts for Patient Safety—Federal Actions to Reduce Medical Errors and Their Impact, a response to the 1999 Institute of Medicine (IOM) report, To Err is Human.

As the Department's leader on healthcare quality, AHRQ has continued funding patient safety research. The agency in FY 2001 awarded 94 grants ($50 million) covering a diverse array of topics in the field.

In collaboration with the National Center for Health Statistics (NCHS) and other agencies, AHRQ continues its foundational work for the first annual report ever produced on U.S. health care quality, the National Quality Report (NQR). When completed in FY 2003, the NQR will show how the system is faring and where improvements will be needed.

Health Care Disparities

A similar agency effort is underway to produce a National Disparity Report. This work, also targeted for release in 2003, will address prevailing disparities in health care delivery as it relates to racial and socioeconomic factors in the priority populations of rural, inner-city, low-income and minority groups; women; children; the elderly; and individuals with special health care needs. Life expectancy and overall health have improved for many Americans but too many racial and ethnic minorities still suffer disproportionately from diabetes, cancer, and other diseases. We believe that through our research partnerships, we can expand the magnitude of our efforts to ensure that all Americans receive high quality and necessary health care services.

MEPS

Concerning cost and utilization, AHRQ continues to conduct the Medical Expenditure Panel Survey (MEPS) that provides up-to-date, highly detailed information on how Americans as a whole, as well as different segments of the population, use and pay for health care.

MEPS data has been used to inform policy decisions in numerous public and private sector agencies. For example, MEPS data was used to establish baseline measures for the Healthy People 2010 objective on oral health and preventive dental visits; to compare estimates of prices paid for drugs by elderly and nonelderly persons with and without health insurance for prescribed medications; to validate actuarial models; to help create a profile of the population living with chronic illness; to estimate national health expenditure rates for the elderly; and, to inform estimates of out-of-pocket expenditures by individuals not covered by the government or their own insurance policies. Customer satisfaction in using MEPS has been rated high (90 percent) and feedback from recipients of MEPS data indicated that the data were timely and useful.

More generally, the data currently collected from MEPS will support quality of health care research directed to the following broad areas: access to care; patient/customer satisfaction; health insurance coverage; health status; and, health services utilization and expenditures. The planned MEPS enhancements call for a significant household survey sample expansion of individuals with certain illnesses of national interest in terms of patient satisfaction with care received, the quality of the care and the burden of disease. The intent of this planned enhancement is to permit more focused analyses of the quality of care received for these special populations. It was recommended that the following medical conditions be given special attention for implementing MEPS healthcare quality enhancements: diabetes; asthma; hypertension; stroke; ischemic heart disease; arthritis; and, COPD (chronic obstructive pulmonary disease). Diabetes and ischemic heart were identified because these diseases are also priorities of the national health disparities research.

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