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Performance Budget Submission for Congressional Justification

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How AHRQ's Research Helps People


The Fiscal Year 2002 Budget Request continues and strengthens AHRQ's commitment to ensure that the knowledge gained through health care research is translated into measurable improvements in the American health care system. An important part of AHRQ's research is developing knowledge regarding what interventions and processes are most effective in health care.

The work of research is not completed with the publication of findings in a major research journal. The results of research must be placed in the hands of those who can put it to practical use in order to produce high quality health care. The following examples demonstrate how AHRQ's research is being translated into practice and highlights the kind of research that will be enhanced at the Fiscal Year 2002 request level .


Contents

Introduction
Medical Errors and Patient Safety
Prevention
Access
Evidence-based Health Care Practice
Health Care Outcomes
Cost and Utilization
Quality Measurement
Information Sharing and Dissemination
Priority Populations

Introduction

Across the Nation, people are making better-informed health care decisions and are receiving higher quality care thanks to AHRQ-supported research:

  • A senior citizen compares the benefits and quality of Medicare managed care plans in her area using the Consumer Assessment of Health Plans Survey.
  • A doctor visits www.guideline.gov to look at the latest research about which patients are best suited for a heart procedure he performs.
  • A hospital administrator decides to encourage her organization to reduce medical errors by patterning improvements after proven successes in Utah and Massachusetts hospital systems.
  • A Federal policymaker contemplates an options paper with data drawn from the Medical Expenditure Panel Survey (MEPS).

These are just a few of the ways in which AHRQ research is used to improve the day-to-day functioning of health care in the United States.

AHRQ believes that the work of research is not completed with the publication of findings in a research journal. The results of research must be placed in the hands of those who can put it to practical use and produce even safer, more effective, more accessible and more efficient health care. The following are just a few examples of the health services research AHRQ has sponsored and how the results of that research have been put into practice. These instances demonstrate how AHRQ's research helps people and highlight the kind of research that will be enhanced at the FY 2002 request level.

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Medical Errors and Patient Safety

Research. Tens of thousands of Americans die each year from errors in their care, and many more barely escape or suffer from nonfatal injuries that a truly high-quality health care system should prevent. In fact, AHRQ (then the Agency for Health Care Policy and Research) funded the landmark research by Professors Lucian Leape and David Bates that first brought national attention to the issue of medical errors. Since then, AHRQ has sponsored studies on:

  • The detection of medical errors.
  • Investigation of diagnostic inaccuracies.
  • The relationship between nurse staffing and adverse events.
  • Computerized adverse drug event monitoring.
  • Computer-assisted decisionmaking tools to mitigate errors and improve safety.

Practice. AHRQ synthesized its research and other research on medical errors to develop a short list of steps patients could take to improve the safety of their own care, "Five Steps for Patient Safety." This fact sheet is being used by Federal agencies:

  • The Office of Personnel Management included it in the materials sent out in open season for the Federal Employees Health Benefits Program.
  • The Department of Defense has used it for radio and television spots aired on the Armed Forces Radio and Television networks.

In addition, many large private-sector employers, such as International Business Machines (IBM) and General Motors (GM), have distributed the information to their beneficiaries.

Select for more information on medical errors.

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Prevention

Research. By studying patients' outcomes, AHRQ-funded researchers have been able to provide evidence on what preventive measures are most effective. For example, AHRQ funded a grant that enabled the Massachusetts General Hospital to study screening for prostate cancer. One of the tests used to screen men for prostate cancer is the prostate-specific antigen (PSA) test. The researchers evaluated patient outcomes to determine which patients and what frequency of PSA testing was most beneficial. The study concluded that establishing simple limits on patient age and frequency of testing would eliminate 74 percent of inappropriate PSA tests.

Practice. AHRQ oversees the operation of the U.S. Preventive Services Task Force (USPSTF), which is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. The pioneering efforts of the Task Force to develop evidence-based recommendations covering a broad range of clinical preventive care culminated in the 1989 (first edition) and 1996 (second edition) Guide to Clinical Preventive Services. This year, the Task Force will begin releasing the first new recommendations and updated chapters of the guide. As they are completed, these will be released through journals and on the AHRQ Web site and then will be compiled in the third edition of its guide.

The Task Force's guides have formed the basis of clinical guidelines developed by professional societies and have helped guide coverage policies of many health plans and insurers. Among the Task Force's 1996 guidelines was one on prostate-cancer screening that provided recommendations on PSA tests based on the AHRQ-sponsored study by the Massachusetts General Hospital.

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Access

Research. Collecting data on health services used, their cost, and how they are paid for, the Medical Expenditure Panel Survey (MEPS) provides timely data to a wide range of users. Providing unparalleled detail, MEPS is the only national survey that provides a foundation for estimating the impact of changes in payment sources and insurance coverage on different economic groups and special populations.

In one example of MEPS data usage, AHRQ researchers estimated that 4.7 million uninsured children were eligible for Medicaid in 1996.

In a separate paper, the same researchers projected that the new State Children's Health Insurance Program (SCHIP) would be less effective in enrolling all newly eligible uninsured, low-income children if States followed the same enrollment practices connected with the Medicaid poverty expansions.

Practice. As a result of this research and similar results by other researchers, State and Federal policymakers launched new efforts to establish simplified SCHIP enrollment procedures and to implement innovative outreach efforts for both Medicaid and SCHIP. MEPS is used by many other decisionmakers, as well. The Bureau of Economic Analysis (BEA) is now using MEPS data in its computation of the U.S. Gross Domestic Product. Identifying MEPS as being "far superior to any health insurance data source currently available," BEA also plans to use MEPS data to support State and regional estimates. The General Accounting Office is using MEPS to develop data on behalf of the Senate Committee on Small Business, and AHRQ has provided numerous special data tabulations for the staffs of the Joint Committee on Taxation and the Pension Welfare Benefits Administration, as well.

In addition, at the written request of 19 State government agencies, MEPS is being used to produce special tabulations in support of the States' studies of the uninsured. Three States have partnered with AHRQ, purchasing additional sample in MEPS to enhance survey estimates in their States. Other States have used MEPS data in various reports to governors and State legislatures (e.g., the Governor's Task Force on Accessibility and Affordability of Health Care in New Jersey).

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Evidence-based Health Care Practice

Research. For a several years, AHRQ has sponsored Evidence-based Practice Centers (EPCs), which provide evidence reports synthesizing research on a particular topic. For example, the University of California-San Francisco partnered with Stanford University to conduct a thorough, systematic review and synthesis of the literature on treatment of stable angina. The investigators studied the relative efficacy and safety of beta-blockers, calcium antagonists, and long-acting nitrates in patients who have stable angina. They also evaluated the efficacy of alternative therapies in patients who have stable angina. Among their findings was that beta-blockers were associated with fewer episodes of angina when compared with calcium antagonists in general and with nifedipine in particular. Select for summary.

Practice. Based on this evidence report, the American College of Cardiology and the American Heart Association developed guidelines, which were published in the Journal of the American College of Cardiology (September 2000). This is just one example among many of how the reports from the EPCs have been used and have made a difference in the day-to-day care that patients receive.

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Health Care Outcomes

Research. The Centers for Education and Research on Therapeutics (CERTs) program is a national effort to increase awareness of the benefits and risks of new, existing, or combined uses of therapeutics through education and research. The CERTs concept grew out of a recognition that physicians need more information about the therapies they prescribe. Although information is available through the pharmaceutical industry, continuing medical education programs, professional organizations, and peer-reviewed literature, comparative information about the risks and benefits of new and older agents and about drug interactions is limited.

There are seven CERTs presently performing research that each cover a broad category of health care therapeutics, such as Duke University's study of "approved drugs and therapeutic devices in cardiovascular medicine."

Practice. In May, the CERTs—along with the Center for Drug Evaluation and Research of the Food and Drug Administration (FDA) and the Pharmaceutical Research and Manufacturers of America (PhRMA)—will host a workshop entitled "Improving Communication of Drug Risk Information to Prevent Patient Injury." The workshop has two basic objectives:

  1. To gather new information on methods and strategies to improve the current state of communication about the risk of medical products.
  2. To create a research and education agenda on risk communication for drugs and other medical products.

These are ambitious goals, and in order to achieve them, a carefully selected and distinguished group of leaders representing industry, patients, professional practitioners, and academia has been invited. This will ensure that when the final results of the first round of CERTs have been issued that they can be implemented appropriately.

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Cost and Utilization

Research. The Healthcare Cost and Utilization Project (HCUP) is a Federal-State-industry partnership to build a standardized, multi-State health data system. HCUP comprises a family of administrative longitudinal databases that include State-specific hospital-discharge databases and a national sample of discharges from community hospitals. Besides designing and managing HCUP, AHRQ has also taken the lead in developing HCUP databases, Web-based products, and other software tools.

Practice. The Oklahoma Department of Health's Healthcare Information Division used the HCUP Nationwide Inpatient Sample (NIS) along with AHRQ's Clinical Classification Software to develop a comprehensive annual report of hospitalizations in the State and to make comparisons with national figures. The HCUP products provided the Department with:

  • A systematic way of looking at hospitalizations (e.g., what keeps patients in the hospital the longest and at what cost).
  • A method of looking at chronic and preventable diseases as compared to national rates.
  • A means of seeing where proactive education and intervention efforts are of greatest benefit.

The data have prompted the development of several prevention campaigns aimed at encouraging seniors to get their flu and pneumonia vaccines.


"Anyone who needs to look at complete hospitalization information can use this to not only identify correctable trends, but to understand where you stand in comparison to other regions and the nation. I found the folks at AHRQ quite responsive to my suggestions and the next time I pulled up the file on the Web the program had been changed. The HCUPnet Web interface makes it easy to generate national rates."

—Betty Harris
Associate Director for Science
National Center for Health Statistics
Oklahoma Department of Health


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Quality Measurement

Research. In the mid-1990s, AHRQ sponsored three cooperative agreements for the development of a research-based Consumer Assessment of Health Plans Survey (CAHPS). The purpose of these agreements was to identify the best measures for judging the quality of a health plan from the consumer or patient perspective. These measures were tested thoroughly with respondents to be certain that they were reliable and valid. In addition, the CAHPS researchers developed and tested methods and formats for communicating the results of these measures to consumers to assist them in making health plan choices. The measures and the reports were then evaluated to assess their impact on consumers' decisions.

Practice. The knowledge that emerged from this and other research was used in the development of the CAHPS tools now used by 90 million Americans who compare the benefits and quality of health plans in their area. The Federal Government (for the Medicare program and the Federal Employees Health Benefit program), and many States also use CAHPS to provide their beneficiaries with information regarding the quality and benefits of the health plans available to them. For example, the State of Washington's Medical Assistance Administration has been using CAHPS since 1997 to report quality measures back to clients and assess health plan access and quality from the patient's perspective. In order to reach minority populations, the State translated the survey results into brochures in seven languages, including Spanish, Vietnamese, and Russian. The survey findings have also helped State administrators in assigning people to one of the States' nine health care plans.

In Madison, WI, The Alliance, an employer health care purchasing cooperative, recently used CAHPS to produce the consumer report "QualityCounts, Medical Group Report." The report is part of The Alliance's ongoing effort to bring quality health care information to 106,000 employees and family members who receive health care coverage through member companies.


"AHRQ plays a vital role in empowering consumers with the objective information they need to make informed health care purchasing decisions. Informed consumers are what drives the private market to provide quality services and products. The role of AHRQ as a nonpartisan agency able to provide evidence-based science to the market place is an invaluable resource from which all Americans will benefit."

—Representative Thomas Bliley,
House Subcommittee on Health and Environment


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Information Sharing and Dissemination

Research. Another example of AHRQ research that has informed decisionmakers and policymakers was a grant to the RAND Corporation to identify variation in quality and outcomes of care for depressed adults who either were outpatients in prepaid or fee-for-service plans or were elderly hospitalized patients in acute care general hospitals. The study found that quality of care was highly variable and associated with provider, patient, and system characteristics. The specific findings were published in numerous scientific and clinical journal articles.

Practice. The results of this RAND study were also used in AHRQ's User Liaison Program (ULP). About a dozen times a year, AHRQ holds a ULP workshop tailored to State policymakers, for them to learn about and to discuss the latest issues affecting health services. These workshops each focus on a theme salient in health policy and are held in different parts of the country to enable more State policymakers to attend. The ULP also disseminates research findings in easily understandable and usable formats through technical assistance for policymakers and other health services research users.

The State of Texas and the Western Medicaid Pharmacy Administrators Association were recently considering options for containing Medicaid pharmaceutical spending without creating adverse effects on utilization and costs. The Texas Department of Health asked the ULP to conduct a State-specific seminar that would help them analyze their options with respect to mental health pharmaceuticals, which comprise a large portion of the Department's pharmaceutical budget. The results from the RAND study were included in the half-day seminar, which presented information on:

  • Prior authorization.
  • An automated Drug Utilization Review (DUR) system.
  • An online point-of-service delivery system to control drug spending.
  • DUR screens to identify and prevent prescribing errors based on the experiences of other States.

"Thanks for your presentation at the [User Liaison Program] workshop for senior State and local health officials on Expanding Long Term Care Choices for the Elderly. This workshop certainly was beneficial to me, as a State legislator, in helping to better understand the critical long-term health care issues involving the elderly."

—Merle Berman
Nevada State Assemblywoman
Assembly District 2


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Priority Populations

In AHRQ's 1999 reauthorization, Congress stressed the importance of studying priority populations, which the congressional language defines as:

  • Low-income groups.
  • Minority groups.
  • Women.
  • Children.
  • The elderly.
  • Those with special health care needs.

One target of this research at AHRQ is the reduction of disparities in health across ethnic and racial groups regardless of gender, age, and socioeconomic status. Research findings and examples of translating research into practice show how AHRQ is improving health and where more progress is needed.

AHRQ-sponsored research shows that implementing a program of comprehensive neonatal followup care after hospital discharge for inner city, high-risk infants reduces life-threatening illnesses and appears to reduce costs. When high-risk infants received comprehensive followup care, 47 percent fewer of them died or developed life-threatening illnesses that required admission for pediatric intensive care. During the first year of life, the estimated average cost per infant was $6,265 for comprehensive care compared to $9,913 for routine care.

Residents of the United States speak more than 300 languages. In some U.S. cities, less than 60 percent of the population speaks English. AHRQ-funded researchers have shown how culturally and linguistically appropriate techniques have the potential to improve the ability of health systems and clinicians to deliver appropriate services to their patients. Culturally competent health care could overcome barriers to care by improving clinician-patient communication, increasing trust between clinicians and patients, creating greater knowledge of differences among racial and ethnic groups, and enhancing understanding of patients' cultural behaviors and environment. For example, providing interpreter services could result in more accurate medical histories and lead to a reduction in diagnostic errors and unnecessary diagnostic testing.

Children dying of cancer often have substantial suffering during the last month of life. AHRQ research shows that earlier recognition by parents and physicians that these children had no realistic chances for a cure was associated with a stronger emphasis and integration of palliative care. This finding supports a consensus among providers that palliative care should be integrated concurrently with curative care in children with cancer.

AHRQ research shows that pediatric nurse practitioners who received free vaccine supplies for use in immunizing poor children through the Federal Vaccines for Children Program were less likely to refer children to public clinics for vaccinations. This eliminates a greater window of time when a child is not age-appropriately vaccinated and thus susceptible to diseases that can be prevented. In addition, this decreases fragmentation of care, parental burden and expense incurred when the child goes to one site for vaccines and another for well-child care and other services, and removes the necessity of transferring medical records from one site to another.

Concerns about the impact of short postpartum hospital stays on infants' health prompted the U.S. Congress and most State legislatures to mandate that insurers cover minimum 48-hour hospital stays following vaginal deliveries and 96-hour stays following cesarean deliveries. AHRQ research confirms that infants discharged home within 30 hours of birth were nearly four times more likely to die within 28 days of birth and nearly twice as likely to die during the first year of life than newborns sent home later. Newborns discharged early also were about four times more likely to die of heart-related problems or infection and twice as likely to die of other causes, such as Sudden Infant Death Syndrome, within a year of birth than newborns discharged later.


"I must congratulate the AHRQ for another excellent service which demonstrates a solid commitment by AHRQ to improve the health of our citizens."

—Angelo P. Creticos, M.D.
Director of the Union Health Service,
which covers 26,000 individuals,
Chicago, Illinois,
on the publication, Staying Healthy at 50+

 

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