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Chronic Disease and Prevention—Examples of the Pipeline Approach
Two examples of the pipeline approach to improve care and yield important advances within the area of chronic disease prevention in AHCPR's budget request for fiscal year 2000 are provided below. The first example is the treatment of diabetes, with a $3.00 million investment, followed by the treatment of asthma, with a $1.50 million investment. The pipeline of activities begins with the funding of new research that answers important questions about what works in health care, followed by creating tools (such as instruments for measurement and databases) needed to apply that knowledge. Finally, the results of the activities come together to enable research and demonstrations to translate the knowledge and tools into measureable improvements in care.
Diabetes Care: Using the pipeline approach to substantially improve care
In AHCPR's fiscal year 2000 request, $3.00 million will support a comprehensive approach to diabetes mellitus. Constructing a disease-specific approach that encompasses all the research investments of the Agency is new for AHCPR, and this year will be a pilot year to determine the relative merit of constructing this type of strategy. The diabetes initiative was developed after consultation with experts in the field and colleagues at the Health Care Financing Administration (HCFA). This investment will fund activities under each of the three priorities of AHCPR's fiscal year 2000 budget request (select for details).
Diabetes costs the United States $98 billion each year. Diabetes affects nearly 6 percent of all Americans, 11 percent of African-Americans, and 12.2 percent of Native Americans. Children are also affected with the majority of the 500,000 to 1 million Americans with type 1 diabetes developing the disease prior to age 18. In addition, diabetes is now one of the six condition-focused Government Performance and Results Act (GPRA) goals of HCFA and will be the target of a major national push for improvement in the Medicare population in both managed care and fee-for-service settings. Twelve percent of Medicare patients have diabetes, but they account for a disproportionate amount of total Medicare expenditures. In fact, diabetes is the seventh most common diagnostic category for Medicare elderly and disabled. Despite significant progress in the science of treating diabetes and forestalling its complications, the application of this knowledge to the care of patients has lagged behind.
AHCPR began its research investment with the Diabetes Patient Outcomes Research Team (PORT) headed by Dr. Sheldon Greenfield at the New England Medical Center. This research team significantly advanced our ability to measure the quality and outcomes of care provided to diabetes patients. Research results include a measure to adjust for severity of illness and co-morbidities in diabetic patients, the development of several measures of diabetes-specific dysfunction, and ways to identify patients with low literacy skills who need different measurement approaches.
These methodologic advances have already been translated into a new tool for measuring the functional status of elderly patients, called the Health of Seniors measure. This measure was developed under the auspices of the National Committee for Quality Assurance's Committee on Performance Measurement for reporting by health plans on all Medicare patients over 65 years. Dr. Greenfield plays a leadership role in the National Diabetes Quality Improvement Project (DQIP), a partnership between the American Diabetes Association, the National Committee for Quality Assurance, the Veteran's Administration, and HCFA. The DQIP is intended to improve the quality and outcomes of care for diabetes through quality measurement and improvement efforts and is now being adopted throughout the Federal Government through the Quality Interagency Coordinating Task Force (QuIC).
In 1998, AHCPR funded three important studies to better understand care for diabetes in managed care plans. These studies will look at the use of different approaches to disease specific report cards in health plans, and assess the quality of care for diabetes and diabetic retinopathy in health plans across the country. These studies have set the stage for future investments to improve diabetic care that complement the activities planned (or currently underway) in the Department and the private sector.
In the fiscal year 2000 request, $3.0 million is targeted to partner with HCFA and the private sector to translate research into practice in this area. This investment will fund activities under each of the three priorities:
- Priority I—New Research on Priority Health Issues. This research will be in two main areas. First, we will emphasize studies of effective strategies for shared decisionmaking in diabetes treatment. Most of the focus to date in diabetes care has been on provider-driven strategies for quality improvement. Yet diabetes care requires a sustained partnership with an active patient. Thus, a better understanding of the values, utilities, and decisionmaking styles and needs of patients with this disease is required to develop and test approaches and tools to inform that decisionmaking and improve patient self care and compliance with treatment.
Second, we will fund studies of the quality, outcomes, and cost-effectiveness of carve outs, disease management, and other organizational interventions to enhance diabetic care. While these approaches are being applied increasingly in the market, there is little or no evidence on their effect on quality and costs for most diseases including diabetes.
- Priority II—New Tools and Talent for a New Century. This research will be focused on quality measures. We will first examine the performance of existing measures, including measures of quality, outcomes, functional status and quality of life in diabetic patients. Second, we will fund the testing and application of new measures of quality of care for diabetics, including indicators for vulnerable populations, including racial and ethnic minorities, who suffer a disproportionate burden of illness from this disease.
- Priority III—Translating Research into Practice. This research will complement the "real time" improvement work of the HCFA Quality Improvement Organizations by rigorously evaluating the many strategies currently being tested to improve quality and determine the relative effectiveness and cost-effectiveness of these interventions. HCFA is particularly interested in studies of provider education, patient education, financing strategies, and the applications of informatics to improve care. AHCPR will use the primary care and managed care networks funded as part of Priority III to drive improvements in care for diabetes in diverse settings, including a focus on vulnerable populations such as racial and ethnic minorities.
Treatment of Asthma: Using the pipeline approach to substantially improve care
Asthma is a major public health problem in the United States, with prevalence increasing rapidly, especially among children. More than 15 million Americans are affected, some 5 million of whom are under the age of 18.
Asthma is an important condition for which areas of AHCPR's pipeline of research are relevant. Currently, AHCPR's research on treatment of asthma includes the "Pediatric Asthma Patient Outcome Research Team (PORT) II," a randomized clinical trial co-funded by National Heart Lung and Blood Institute (NHLBI). This trial tests the cost-effectiveness of NHLBI's practice guidelines designed to reduce asthma morbidity among children. AHCPR also supports several other grants including one to develop and test asthma quality of care measures, a project on asthma care quality in varying managed Medicaid plans, and a grant begun in fiscal year 1998 on the impact of managed care organization policy on the quality of pediatric asthma care.
Private- and public-sector health care organizations are struggling to identify and implement best practices to reduce avoidable illness, functional burden (e.g. time lost from work and school), and expenditures. Efforts to date are limited by two key factors. The first is a lack of clear metrics for success (i.e. how can systems know which strategies are most effective?). The second is a lack of knowledge about effective and cost-effective treatments (i.e., which patients should be targeted for intensive quality improvement interventions and which patients require minimal reminders). Without a scientific basis on which to address these two issues, organizations and clinicians can't determine which disease management strategies for asthma will work for their population.
Although new research is needed, AHCPR's previous research already provides a scientific base from which to address both of these issues. For instance, the asthma PORT, being conducted in health plans in three cities, has determined that commonly used measures to assess the effectiveness of asthma treatment and interventions often are not sufficiently sensitive to guide organizational strategies. Based on the knowledge gained from current and previous investments, AHCPR will identify partners who can translate available research results into practice on the broadest possible scale.
In the Secretarial Initiative on Chronic Disease and Prevention, $1.50 million is targeted to activities which promote the translation of research on asthma treatment into improved practice, including the development of a user liaison program on asthma disease management.
Current as of February 1999