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Performance Budget Submission for Congressional Justification

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Justification of Budget Estimates for Appropriations Committees, Fiscal Year 2001

Mission Statement

The mission of the Agency for Healthcare Research and Quality is to support, conduct, and disseminate research that improves the outcomes, quality, access to, and cost and use of health care services. This mission, which focuses on the effectiveness and value of health care in daily practice, is unique and complements the biomedical and behavioral research responsibilities of the National Institutes of Health. The products of the Agency include knowledge that supports decisionmaking to improve health care, as well as tools that can help improve quality and reduce costs.

To fulfill this mission, AHRQ works to foster health care research that helps the American health care system provide access to high-quality, cost-effective services; be accountable and responsive to patients, consumers, and purchasers; and improve health status and quality of life. There are three overarching goals that the Agency uses to frame its activities.

  • Support Improvements in Health Outcomes.
  • Strengthen Quality Measurement and Improvement.
  • Identify Strategies To Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures.

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Research That Begins and Ends with the User

After an extensive planning process, the Agency's strategic plan was released in December 1998 and made widely available for comment. The Agency identified three main audiences for its work and products. These include consumers and patients, clinicians and other providers, institutions, plans, purchasers, and policymakers in all sectors (e.g., Federal, State, and local governments; voluntary associations; international organizations; and foundations). All of these customers require evidence-based information to inform health policy decisions. Health policy choices in this context represent three general levels of decisionmaking:

  1. Clinical Policy Decisions. Information is used every day by clinicians, consumers, patients, and health care institutions to make choices about what works, for whom, when, and at what cost.
  2. Health Care System Policy Decisions. Health plan and system administrators and policymakers, purchasers, and leaders of other organizations are confronted daily by choices on how to improve the health care system's ability to provide access to and deliver high-quality, high-value care.
  3. Public Policy Decisions. Information is used by policymakers to expand their capability 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.

The development of information and tools for these customers is dependent on a robust partnership between the Agency and the investigator community. Ongoing dialogue with researchers is essential to ensuring the highest quality and most relevant research.

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Cycle of Research

Producing meaningful contributions to the Nation and to research on health care requires continuous activity focused on iterative improvement in priority setting, on developing research initiatives, and on research products and processes. There are four processes used in AHRQ's research cycle which ensure the most productive use of resources:

  1. Needs Assessment. Agency activities begin and end with the end-users of our research. Through a continuing dialogue, staff identify major issues and decisions for which information on quality, outcomes, cost, access, and use is needed. The research agenda is based on an assessment of gaps in the knowledge base and on the needs of patients, clinicians, institutions, plans, purchasers, and State and Federal policymakers for evidence-based information.
  2. Knowledge Creation. AHRQ will support and conduct research to produce the next generation of knowledge needed to improve the health care system. Building on the last decade of investment in outcomes and health care research, AHRQ will focus on national priority areas for which much remains unknown.
  3. Translation and Dissemination. Simply producing knowledge is not sufficient; findings must be useful and made widely available to practitioners, patients, and other decision makers. The Agency systematically identifies priority areas for improving care through integrating findings into practice, and determines the most effective ways of doing this. Additionally, AHRQ will continue to synthesize and translate knowledge into products and tools, and disseminate these to appropriate audiences.
  4. Evaluation. Knowledge development is a continuous process. It includes a feedback loop that depends on evaluation of the research's utility to the end user and impact on health care. In order to assess the ultimate outcomes of AHRQ research, the Agency will place increased emphasis on evaluation of the impact and usefulness of Agency-supported work in health care settings and policymaking.

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The AHRQ Portfolio: A Pipeline of Investment

As described in fiscal year 2000, the pipeline (select for Figure 1, 27 KB) begins with the funding of new research that answers important questions about what works in American health care (New Knowledge on Priority Health Issues). This is the essential knowledge base that investigators create and which enables us to understand the determinants of the outcomes, quality, and costs of care, as well as to identify instances when care falls short of achieving its intended outcomes.

An important contribution of this fundamental investment is the advancement of the methods used in research, for example methods to quantify costs and benefits, strategies to reliably synthesize existing literature, and new approaches to capture health information from children and adolescents. Examples of this type of research are the Centers for Education and Research on Therapeutics, which conduct studies to reduce adverse drug events and boost the positive impact of medical products on patient care.

The second section of the pipeline, New Tools and Talent for a New Century, is the creation of tools to apply the knowledge gained in the first investment. Here, the work of researchers is more applied and translates new knowledge into instruments for measurement, databases, informatics, and other applications that can be used to improve care. An example of this area is research to develop new quality measures for vulnerable populations including measures of segregation and quality of care in nursing homes, measures for the seriously mentally ill, and measures of care quality for very low birth weight babies.

The final section of the pipeline (Translating Research Into Practice—TRIP) is where these two investments come together to enable research and demonstrations which translate the knowledge and tools into measurable improvements in the care Americans receive. The Agency initiated steps in Fiscal Year 1999 to accomplish this long-term goal. Examples of activities include a set of studies in which investigators are testing new ways to promote the use of evidence, for example in improving diabetic care in community health centers and increasing the use of a life-saving drug for premature infants. In another effort, investigators are required to work with the end user of research, in this case State and local programs, and a national users group of State and local programs is being formed to advise the funded investigators.

Select for examples of How AHRQ's Research Helps People.

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The Fiscal Year 2001 Request

The fiscal year 2001 Request continues and strengthens the commitment articulated in the fiscal year 2000 request to "ensure that the knowledge gained through health care research is translated into measurable improvements in the American health system."

The Healthcare Research and Quality Act of 1999 reinforces this commitment, specifying that AHRQ will be responsible for promoting evidence-based medicine, detecting and preventing errors in health care, developing a report to the nation on quality, supporting primary care research, and applying the power and potential of information technology.

The Agency has embraced the principles and philosophy inherent in a commitment to promote the adoption and use of research findings. The organizing principle first articulated in the fiscal year 2000 request for a pipeline of investment is now a central planning tool for the Agency and the way we communicate with our customers and partners (including researchers).

The fiscal year 2001 request:

  • Supports activities along the full continuum of research—the pipeline of research.
  • Continues the fiscal year 2000 commitment to Translating Research Into Practice (TRIP).
  • Begin to provide the resources needed for the Agency to lead national efforts to improve patient safety and reduce medical errors.
  • Capitalizes on the advances in informatics and private sector investment to foster technological innovation in the translation of research into practice.
  • Supports research to improve employee health through the role of purchasers and healthcare systems.
  • Responds to the Congress, the Administration, and key national organizations by investing in the production of a Report to the Nation on the Quality of Health Care.
  • Supports research to improve the quality of preventive services particularly for populations receiving too few or low quality services.
  • Promotes the development of researchers and research centers in places other than those traditionally most successful at competing for research grants.

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Fiscal Year 2001 Priorities: A Summary

For fiscal year 2001, the Agency has established three new priorities and enhanced three continuing priorities that together represent a balanced investment in each section of the pipeline. This balance is critical to enable the Agency to meet its strategic goals. While the final segment of the pipeline, Translating Research Into Practice, is of paramount importance, the Agency also recognizes that renewed investment in the underlying research in the first two segments is also essential to ensuring that in 3 to 5 years, additional knowledge and tools will have been developed which can then be translated into practice. The following outlines AHRQ's three new and three ongoing priorities by type of research.

Fiscal Year 2001 Budget PrioritiesNew Knowledge on Priority Health IssuesNew Tools and Talent for a New CenturyTranslating Research Into Practice
Enhancing Patient Safety $5,000,000 $4,000,000 $11,000,000
Informatics   $2,000,000 $3,000,000
Improving Worker Health $6,000,000 $1,000,000 $3,000,000
The National Healthcare Quality Report  $7,145,000  
Improving Clinical Prevention $2,000,000   
Building Capacity for Health Services Research  $2,000,000 
Total $13,000,000 $16,145,000 $17,000,000
Investigator-Initiated Research   $8,400,000 
New Full-Time Equivalents (FTEs)   $850,000 

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Priority I: Enhancing Patient Safety—$20,000,000

The recent Institute of Medicine (IOM) report, To Err is Human, alerted the nation that errors occur too frequently in the care of patients. It estimated that between 44,000 and 98,000 people die each year due to medical errors, and that more are harmed. The report notes that this means errors cause more deaths annually than breast cancer and auto accidents. The IOM recognized that errors are part of the larger health care quality agenda, which includes efforts to ensure that people are given the care that has been shown to be most effective in addressing their health problems. The IOM also recognized that safety does not reside in a person, device or department but emerges from the interactions of components of a system. Errors are systems problems, which cannot be resolved by eliminating "bad" clinicians. The IOM report concluded that many errors can be avoided, or their potentially harmful effects on patients minimized, if we can learn enough from the errors that occur to understand how to redesign the processes and systems of care to be safer.

In the fiscal year 2001 Request, AHRQ proposes a broad research initiative spanning the full pipeline of research that will further our understanding of when, how and under what circumstances errors occur, identify the causes of errors, develop the tools, data and researchers needed to foster a national strategy to improve patient safety, and work with public and private partners to apply evidence-based approaches to the improvement of patient safety.

Information technology holds the potential to dramatically reduce the rate of medical errors. For example, physician order entry systems have been shown to be effective in reducing mistakes due to misinterpretation of handwriting and have allowed clinicians to receive immediate feedback about potential drug interactions. Past Agency research has shown that computer applications can reduce the occurrence of adverse drug events, assist the appropriate timing of medications, provide automated reminders to alert providers in real time to medication interactions, and, through embedded decision support systems, can improve compliance with evidence based protocols. As part of this priority, $5 million will be dedicated to the role of computers in improving patient safety (also see Priority II—Informatics).

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Priority II: Informatics—$5,000,000 (and an additional $5,000,000 in Priority I)

The Agency's fiscal year 2001 request is designed to build on past Agency successes in identifying fruitful areas for applying information technology to health care and to renew Agency and Federal leadership in health informatics. Information technology applications are a critical element to the future improvement of the health care system, its outcomes, and efficiency. Most of the emphasis to date has been on their use in the improvement of the delivery of evidence-based information to decision makers, and this must continue. Equally important is the use of information technology applications to enhance the collection of patient and practitioner data, including quality and outcomes data, as an integral part of patient care.

The fiscal year 2001 request begins to rectify this by proposing investments in both types of traffic on the information superhighway, as well as using computer systems to collect and analyze data and to guide decisionmaking:

  • First, data and applications, especially Web-based applications and decision support tools, to assist providers and patients in providing and choosing high quality care and promoting patient safety will be tested to determine their impact on health care quality, outcomes and cost.
  • Second, innovations to improve the quality, privacy, and confidentiality of data collected from providers and health care systems will be fostered and evaluated to maximize the use of patient data for research and analysis that advances our understanding of care today.

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Priority III:Improving Worker Health—$10,000,000

The health of American workers has traditionally been addressed through initiatives designed to prevent acute injury in the workplace. This research initiative will complement those efforts by addressing very different dimensions of worker health. It begins with the recognition that the health and quality of workers' lives, workplace productivity, and the incidence of long-term disability are influenced by health conditions or injuries that occur outside as well as inside the workplace and by the availability of appropriate, timely, and quality medical treatment for these conditions. In addition, recent efforts to restructure the health care workplace, often in response to pressures to reduce costs, suggest that the resulting work environment and processes can affect, both positively and negatively, the health and quality of workers' lives as well as the patients for whom they care.

Employers and labor unions can play important roles in addressing these aspects of worker health by choosing and promoting high quality health care for employees and managers, by ensuring that the most effective evidence-based treatments are available to those in need of medical care, and by carefully assessing the implications of alternative approaches to restructuring the health care workplace and the processes by which care is delivered for their impact on both employee and patient health. This initiative will develop and extend the evidence base for decision making by workers and their employers, and by the clinicians and health care systems to which they turn for medical treatment.

This research initiative is made up of three parts:

  • Research on improving the quality of the healthcare delivery systems through which workers receive health care services.
  • Research on the quality of the health care workplace and its impact on patient quality and outcomes.
  • Research on the outcomes and effectiveness of the clinical interventions that workers receive.

This initiative will use AHRQ's extensive expertise in the outcomes, effectiveness, and quality of clinical care after the onset of disease or injury to target common health conditions experienced by workers. To ensure that this initiative appropriately complements the extensive research contributions of the National Institute for Occupational Safety and Health (NIOSH) on the causes and prevention of workplace injury.

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Priority IV: The National Healthcare Quality Report—$7,145,000

The Agency's reauthorization calls for the development of a national report on the quality of healthcare in the United States. In developing this report, the Agency is called on to expand the Medical Expenditure Panel Survey (MEPS) to collect information on quality (select for description of these activities). In addition, the Agency is charged with assuring coordination with the private sector in the development of the report.

When fully realized, the Report will include information on:

  • Consumer and patient assessments of healthcare quality, for example, the degree to which health plans and providers treat them with respect or how well people judge the health care system to be meeting the needs of their chronically ill family members, including children.
  • Clinical quality measures for common health care services, for instance, the amount and appropriateness of preventive services or the appropriate use of drugs such as first line antibiotics for ear infections or aspirin after heart attacks.
  • Performance measures related to management and outcomes of acute and chronic conditions, for example, complication rates after common medical procedures, blood glucose control of patients with diabetes or the outcomes of errors in the delivery of care across a variety of settings and populations, such as surgical complication rates and readmission following procedures.

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Priority V: Improving Clinical Prevention—$2,000,000

Improvements in the delivery of clinical preventive services have paved the way for an expanded focus, not just on the number of people who receive the service, but also on improvements in the quality of those services. Advances in early detection of selected conditions now mean that millions of Americans are treated earlier and more effectively than in the past.

The next frontier in clinical prevention health care research is to improve the quality of preventive services, to focus on populations who get not only fewer but also lower quality services, to study the cost-effectiveness and delivery of these clinical services, as well as to identify and address patient-related barriers to the use of clinical preventive services.

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Priority VI: Building Capacity for Health Services Research—$2,000,000

The Agency is committed to the Department's Initiative to Eliminate Racial and Ethnic Disparities in Health and the complementary Healthy People 2010 Goal to Eliminate Disparities in Health. A critical component in achieving these goals is to expand the Nation's health workforce to be more diverse and representative of racial and ethnic populations. This includes bringing needed diversity to the health services research workforce. AHRQ intends to enhance the knowledge base regarding health care for these populations by increasing the number of trained minority health service researchers, and by building the capacity for institutions to conduct health services research intended to benefit Hispanics and African-Americans.

To address geographic and disciplinary gaps in research capacity, the Institutional Training Innovative Incentive Award Program will be funded to pilot-test the feasibility of developing a program to broaden the geographic distribution of AHRQ funding and enhance the competitiveness for research funding of institutions located in states that have a low success rate for grant applications from AHRQ.

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The Medical Expenditure Panel Survey (MEPS)

The fiscal year 2001 Request for the Medical Expenditure Panel Survey (MEPS) totals $40,850,000 in one percent evaluation funds. The total reflects an increase of $4,850,000 from the fiscal year 2000 level of $36,000,000. This request consists of:

  • Ongoing data collection efforts and related survey activities for MEPS ($31,500,000).
  • Enhancements for the Report to the Nation on the Quality of Health Care ($9,350,000).

In fiscal year 2001, data collection will be ongoing for the MEPS Household Survey, the MEPS Medical Provider Survey, and the MEPS Insurance Component. All of the MEPS components will be heavily engaged in survey-related activities directed to the following tasks: data editing, imputation, data preparation and data processing, development of estimation weights and variance estimation capabilities for the component surveys, preparation of public use tapes, and development of analytical and methodological reports.

Select for details on MEPS.

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Budget Policy

The fiscal year 2001 Request of $249,943,000 reflects an increase of $46,144,000 or 22.6 percent, over the fiscal year 2000 appropriation. The Request provides a significant increase in research on reducing medical errors and improving patient safety, and strengthens our investment to close the gap between what we know and what we do in health care.

The fiscal year 2001 Request includes $8,400,000 for new investigator-initiated grants. Although these grants may support research in some of the fiscal year 2001 priority areas, the nature of investigator-initiated research will tend to yield studies that are more methodologic in focus, exploratory, and basic in nature. These types of studies build the foundation for investments 3 to 5 years from now. As such, they represent the Agency's "down payment" for future advances upon which the applied research of the 21st century will be built. These grants will be submitted in response to program announcements (PA's) or requests for applications (RFA's) and therefore will be less directed than most of the research supported through the three Priority areas.

We expect the studies submitted to be in response to the Agency's updated Health Services Research Program Announcement (PA), published in March 1998, which expresses AHRQ's priority interests in research, demonstration, dissemination, and evaluation projects to:

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

The fiscal year 2001 Request continues AHRQ's policy of working in partnership with other Federal entities as well as private organizations to leverage resources and, often more importantly, to promote rapid implementation of our research results. We will initiate new partnerships as well as continue to work with Federal partners such as the Health Care Financing Administration, the Office of Personnel Management, the Veterans Administration, and the Department of Defense as well as individual States; with private organizations such as the National Committee for Quality Assurance (NCQA), the Foundation for Accountability (FAcct), and the Joint Commission on the Accreditation of Health Care Organizations (JCAHO); and with health plans, provider organizations, purchasers, professional societies and practice networks.

AHRQ will continue to build capacity for health care research through its research training programs. These awards will be used to continue to develop scientists, committed to health care research, in need of basic and advanced training as well as additional experience. The fiscal year 2001 Request includes support for:

  • Small Grants.
  • Institutional Incentive Awards.
  • Career Development Awards.
  • Dissertation Grants.
  • Minority Access to Research Careers (MARC).
  • National Research Service Awards (1).

(1) AHRQ administers the National Research Service Awards using 1 percent funds appropriated to NIH.

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Budget Activities

All of AHRQ's funding is managed and appropriated in the following three budget activities:

  1. Health Care Costs, Quality, and Outcomes (HCQO).
  2. Medical Expenditure Panel Survey (MEPS).
  3. Program Support.

Health Care Costs, Quality, and Outcomes (HCQO)

The purpose of the Research on Health Care Costs, Quality and Outcomes activity is to support and conduct research that improves the outcomes, quality, cost, use and accessibility of health care. Accordingly, the Agency has identified three strategic plan goals that feed into this budget activity:

  1. Supporting improvements in health outcomes.
  2. Strengthening quality measurement and improvement.
  3. Identifying strategies to improve access, foster appropriate use, and reduce unnecessary expenditures.

The key themes throughout all three goals are to fund new research and to translate research into practice. In addition, AHRQ also has strengthened its commitment to support research that will improve health care for vulnerable populations. Lastly, AHRQ has enhanced specific activities that support all of our strategic goals.

For details from the justification, select Research on Health Costs, Quality, and Outcomes.

Medical Expenditure Panel Survey (MEPS)

The objectives of AHRQ's Medical Expenditure Panel Survey are to provide public and private sector decisionmakers with the ability to:

  • Obtain timely national estimates of health care use and expenditures, private and public health insurance coverage, and the availability, costs and scope of private health insurance benefits among the U.S. population.
  • Analyze changes in behavior as a result of market forces or policy changes (and the interaction of both) on health care use, expenditures, and insurance coverage.
  • Develop cost and savings estimates of proposed changes in policy.
  • Identify the impact of changes in policy for key subgroups of the population (i.e., who benefits and who pays more).

These objectives are accomplished through the fielding of the Medical Expenditure Panel Survey. MEPS is an interrelated series of surveys that replaces the National Medical Expenditure Survey (NMES). MEPS not only updates information that was last collected more than a decade ago in fiscal year 1987, but also provides more timely data, at a lower cost per year of data, through the move to an ongoing data collection effort.

For details on MEPS from the justification, select Medical Expenditure Panel Survey.

Program Support

Program Support provides support for the overall direction and management of the AHRQ. This includes the formulation of policies and program objectives; and administrative management and services activities.

For details from the justification, select Program Support.

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Current as of February 2000

 

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