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Performance Budget Submission for Congressional Justification

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FY 2005: Research on Health Costs, Quality and Outcomes (HCQO) (continued)


Informatics Portfolio

Despite promises of reduced costs and improved quality, physicians, hospitals and other health care facilities have lagged behind other industries in their adoption of information technologies (IT). Among other factors, the implementation of health care information technologies has been hindered by:

  • Payment systems that fail to reward information technology investments and associated quality improvements.
  • The fragmentation of the health care industry.
  • The absence of industry standards.
  • Resistance by clinicians to change practice patterns.
  • The failure of many technology companies to perform at promised levels and appreciable upfront IT investment costs.

There are however a number of encouraging signs. Pressure on providers to respond to external forces and to invest in, e.g., computerized prescription order entry (CPOE) systems in response to State legislative mandates and employer activities should result in broader adoption of technologies that improve patient safety and health care industry efficiency. Studies of providers' findings regarding integrating clinical IT into their practices and analyses of emerging Internet disease management and other applications will also bring the health care industry closer to an understanding of IT's benefits; this evidence is critical to overcome inertia and resistance to change in a highly fragmented sector of the economy.

To encourage the health care industry's progress, health services research is needed to understand both the factors that influence adoption of emerging health care information technologies among various types of providers and health care systems as well as the costs and organizational and system challenges associated with implementing new applications. Most generally, the Agency is therefore working to understand better IT application in the health care delivery setting as well as uptake and performance trends related to health care providers' use of emerging information technology.

Sample of Information Technology Projects
Improving Primary Care Patient Safety with Handheld DSS

We are currently funding two projects that are studying the use of handheld Computerized Physician Order Entry (CPOE) systems with decision support in primary care clinics. The studies are evaluating the impact of these systems on reducing medical errors and improving clinical care. They are also assessing the barriers to use of these systems and the cost-effectiveness of using this technology.

Using Handheld Technology to Reduce Errors in ADHD Care

This project is using a handheld CPOE system with decision support to reduce medical errors and improve the management of attention-deficit/hyperactivity disorder (ADHD) in children.

Impact of EpicCare on the Management of Diabetes in the Geisinger Health System

This project is using an electronic medical record system with CPOE and automated clinical reminders to improve the quality of diabetes care.

The Effect of Using Rules Technology with Provider Order Entry in Medication Error Reduction

This project is evaluating the impact of a CPOE with decision support on reducing medication errors and preventing adverse drug events. The CPOE system will trigger automatic warnings that assist providers in detecting and preventing potential adverse drug events when they are ordering medications in both the inpatient and outpatient setting. Potential problems will be identified using algorithms that link information from the laboratory, pharmacy, and medical records. They are also assessing barriers to use of CPOE, physician adherence to the recommendations, and physician satisfaction with the system.

Improving Quality with Outpatient Decision Support

This project is studying the impact of an electronic medical record system with CPOE and automated reminders on quality of care in outpatient clinics setting and assessing physician compliance with guidelines, reminders, and alerts. Areas being studied include chronic disease management, medication management, and the use of ancillary tests.

Impact of Electronic Prescribing on Medication Errors

This project is studying the impact of a handheld CPOE system on prescribing practices and medication error rates in an urban pediatric clinic and in the emergency department.

HIV Treatment Error Reduction Using a Genotype Database

This project is evaluating an electronic medical record system with CPOE and automated decision support that integrates an individual patient's HIV genotype information with the patient's medication information. The study will evaluate the impact of the system on the selection of antiretroviral drug medications, prescribing errors, the development of drug resistance, and overall quality of care.

The Use of Encoded Guidelines in an Electronic Medical Record System for Targeted Tuberculin Testing and Treatment of Latent Tuberculosis

This project is studying the use of a CPOE system to identify patients at increased risk for tuberculosis infection and the effectiveness of the rules and alerts in improving adherence to the screening guidelines.

FY 2004 Patient Safety Health Care IT Program

In FY 2005, AHRQ will continue funding of $49,886,000 for the Patient Safety Health Care IT program begun in FY 2004. The program will support a variety of activities aimed at improving health care quality and patient safety by promoting and accelerating the development, adoption and diffusion of interoperable information technology in a range of health care settings. This program will include a special focus on small and rural hospitals and other providers, which will help assure that these hospitals can implement and use interoperable IT to support improvements in health care quality and patient safety. Funds also will be used to support innovative research and demonstration projects that will improve health care quality and patient safety in a wide variety of health care settings, as well as State or regional implementation grants to begin demonstrating and testing the feasibility of interoperable information exchange among health care settings. Funding for the Patient Safety Health Care IT program will continue into FY 2005.

The FY 2005 request also continues $10,000,000 in contracts for the joint ASPE—AHRQ program begun in FY 2004 to accelerate and promote the development, adoption and availability of interoperable clinical data standards and technology, including message format and vocabulary standards, to support interoperable data exchange in health care.

Accomplishments—Web-based Patient Safety Indicators

AHRQ has developed the Patient Safety Indicators (PSIs), a new Web-based tool that can help hospitals enhance their patient safety performance by quickly detecting potential medical errors in patients who have undergone medical or surgical care. Hospitals then investigate to determine whether the problems detected were caused by potentially preventable medical errors or have some other explanations. The PSIs were used to analyze the occurrence of errors during hospitalization.

Performance Goals

Select to access Table 9 for performance goals of the Informatics Portfolio.

Return to Accomplishments and Performance Analysis

Prevention Portfolio

Clinical prevention is the focus of the Agency's disease prevention research portfolio. Namely, those preventions interventions and services provided in a clinical setting between physician and patient, such as screening tests and/or counseling. AHRQ's clinical prevention program is based primarily on the activities of the U.S. Preventive Services Task Force (USPSTF) and its implementation arm, the Put Prevention Into Practice (PPIP) program.

The Task Force is an independent panel of private-sector experts in prevention and primary care. It conducts rigorous scientific assessments of the effectiveness of a broad range of clinical preventive services, including screening tests, chemoprevention, immunizations, and counseling. The PPIP program targets providers and patients using tools and resources that enable doctors and other health care professionals to determine what preventive services patients should receive as well as enable patients to more easily understand and keep track of their preventive care.

Accomplishments—USPSTF

In 2002, the third Task Force issued the following recommendations covering colorectal cancer, osteoporosis, hormone replacement therapy, depression, chemoprevention, and breast cancer.

Colorectal Cancer. The Task Force in its strongest ever recommendation for colorectal cancer screening urges that all adults age 50 and over get screened for the disease, the Nation's second leading cause of cancer deaths. Various screening tests are available, making it possible for patients and their doctors to decide which test is most appropriate for each individual. Although each of these tests is effective in diagnosing colorectal cancer at an early stage when it is treatable, the Task Force noted that there is no single best test for all patients. Options include at-home fecal occult blood test (FOBS); flexible sigmoidoscopy; a combine of home FOBT and flexible sigmoidoscopy; colonoscopy; and double-contrast barium enema. Screening can also lead to early detection of adenomatous polyps—precancerous growths that can be removed to prevent them from progressing to cancer.

Osteoporosis. The Task Force recommends that women aged 65 and older be screened routinely for osteoporosis, and that women at high risk for fractures begin screening at age 60. Women are at greater risk for osteoporosis than men because women's bones are less dense than mens' bones. The Task Force found good evidence that:

  • The risk for osteoporosis and fracture increases with age and other factors.
  • Bone density measurements accurately predict the risk for fractures in the short-term.
  • Treating women with no symptoms of osteoporosis reduces their risk for fracture.

Other risk factors cited include lower body weight and no current use of estrogen. The Task Force concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors.

Hormone Replacement Therapy. The Task Force recommends against the use of combined estrogen and progestin therapy for preventing cardiovascular disease and other chronic conditions in postmenopausal women. They also recommend that women considering whether to start or continue hormone therapy to relieve menopausal symptoms discuss their individual risks for specific chronic conditions and personal preferences with their clinician. Although the Task Force found evidence for both benefits and harms of combined estrogen and progestin therapy—one of the most commonly prescribed hormone regimens—they conclude that harmful effects of the combined therapy are likely to exceed the chronic disease prevention benefits for most women. The Task Force concludes that combined hormone therapy could increase bone mineral density and reduce the risk of fractures, and may reduce the risk of colorectal cancer. They also found equally strong evidence, however, that this therapy increases the risk for breast cancer, blood clots, stroke, and gallbladder disease, and that this therapy does not reduce the risk of heart disease but actually increases the risk of heart attacks. An estimated 14 million American women take hormone therapy.

Depression. The Task Force indicates that clinicians can identify up to 90 percent of people who suffer from major depression by asking all patients they see two simple questions. The questions are:

  • "Over the past 2 weeks, have you felt down, depressed or hopeless?"
  • "Over the past 2 weeks, have you felt little interest or pleasure in doing things?"

This recommendation is the latest sign of the growing recognition that depression is one of the most common—and most commonly undiagnosed and untreated—chronic illnesses. About 19 million American adults suffer from depression, and estimates suggest that as many as two-thirds do not get treatment. This recommendation could bring many of these people into treatment and add millions to the numbers who are taking antidepressants such as Prozac®. The Task Force adds that screening is only the first step—patients must have access to the right therapy and medicines, and health care systems must encourage patient followup care by clinicians.

Chemoprevention for Heart Disease. The Task Force strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease. Discussion with patients should address both the potential benefits and harms of aspirin therapy.

Chemoprevention of Breast Cancer. The Task Force recommends that clinicians discuss the potential benefits and risks of taking prescription medicines such as tamoxifen to reduce the risk of breast cancer with their female patients who are at high risk for the disease. Women are considered at high risk if they are over 40 and have a family history of breast cancer in a mother, sister, or daughter, or have a history of abnormal cells on a breast biopsy. The Task Force also recommends against the use of these drugs by women at low or average risk for breast cancer because the harmful side effects may outweigh the potential benefits. Those side effects can include hot flashes, increased risk for blood clots in the legs or lungs, and increased risk for endometrial cancer.

Breast Cancer. The Task Force recommends that women aged 40 and older have a mammogram with or without clinical beast examination every 1-2 years. They found fair evidence that mammography screening every 1-2 years could reduce breast cancer mortality by approximately 20 percent to 25 percent over 10 years. The evidence is strongest for women between the ages of 50 and 69, but the Task Force concludes benefits were likely to extend to women 40-49 as well. The Task Force published two earlier breast cancer screening recommendations, in 1989 and 1996, that both endorsed mammography for women over age 50. The Task Force is now extending that recommendation to all women over age 40, even though the strongest evidence of benefit and reduced mortality from breast cancer is among women ages 50-69. This recommendation acknowledges that there are some risks associated with mammography (e.g., false-positive results that lead to unnecessary biopsies or surgery), but that these risks lessen as women get older.

Accomplishments—Prevention Quality Indicators

AHRQ launched a new Quality Indicator module, the Prevention Quality Indicators, a software tool for detecting potentially avoidable hospital admissions for illnesses (e.g., diabetes) which can be effectively treated with high-quality, community-based primary care. The AHRQ Prevention Quality Indicators allows users to measure and track hospital admissions for 16 conditions using their own hospital discharge data and will provide the information needed to improve the quality of primary care for these illnesses in a community or State.

The Dallas-Fort Worth Hospital Council (DFWHC) is a metropolitan hospital association representing hospitals in north Texas. The DFWHC Data effort was established in 1997 to answer the growing need in the health care community for high quality, standardized data which could be used to measure value, facilitate evaluation of health care quality, and promote quality improvements. In an evaluation of hospital discharge data collected from 63 hospitals in north Texas, diabetes was found to be one of the top 10 reasons for hospitalization. The Data effort used the AHRQ Prevention Quality Indicators (PQIs) to identify potential variances across geographic regions. Select for Figure 2 (24 KB), a visual representation of county-by-county variances found for admission rates specific to diabetes (long-term complications.)

Performance Goals

Select to access Table 10 for performance goals of the Prevention Portfolio.

Return to Accomplishments and Performance Analysis

Socio-economics of Health Care Portfolio

The program on financing, access, cost and coverage conducts, supports and manages studies of the cost and financing of health care, the access to health care services and related trends. These studies and data development activities are designed to provide health care leaders and policymakers with the information and tools they need to improve decisions on health care financing, access, coverage, and cost. The program is responsible for understanding the dynamics of consumer, employer, and provider behavior as well as the factors underlying trends in the areas of health care costs, use and access. To fulfill this mission, the program conducts and sponsors descriptive and behavioral analyses of the U.S. health care system including:

  • The population's access to, use of, and expenditures and sources of payment for health care.
  • The availability and costs of private health insurance in the employment-related and non-group markets.
  • The population enrolled in public health insurance coverage and those without health care coverage.
  • The role of health status in health care use, expenditures, and household decisionmaking, and in health insurance and employment choices.

Much of this research is informed by the development of analytical databases from the Medical Expenditure Panel Survey (MEPS). In addition, the program conducts and sponsors research and the development of models and data bases to support micro-simulation analyses of the impact on individuals and households of current and proposed changes in health care policy. Analyses focus on the impacts of health policies embodied in current law and on health care policies embodied in generic versions of proposed reforms. The end goal of the program is to provide health care leaders and policymakers with the information and tools they need to improve the health care system by improving their decisions on issues related to health care financing, access, coverage and cost.

The program on delivery/organization/markets conducts, supports and manages studies designed to give health care leaders and policymakers the information and tools they need to improve health system performance. Performance in this context includes quality, safety, effectiveness, and efficiency. Through qualitative and quantitative research, delivery-based research networks and other partnerships, this program provides system and policy leaders with evidence on how changes in health care delivery affect performance across acute, community-based and long-term care settings. Delivery and organizational variables of special interest include structure, function, workforce, leadership, governance and culture. The mission of this program extends to capture how market forces such as payment methods, financial and non-financial incentives, funding of safety net providers, employer purchasing strategies, regulations, legislation and judicial actions and other aspects of the competitive environment influence health care delivery, organization, and ultimately provider performance. The end goal of this program is to improve health care by advancing the use of evidence by health care leaders and policymakers.

Accomplishments—Integrated Delivery System Research Network (IDSRN)

Accomplishments in the past year include the development of a simulation model of mass antibiotic prophylaxis for bioterrorism response developed by Weill Medical College of Cornell University in conjunction with New York City health and emergency preparedness agencies. The model was used in May 2002 in a large-scale live exercise that evaluated the city's ability to respond to a large bioterrorist attack. Called Operation TriPOD, for "Trial Point of Dispensing," it involved tracking simulated patients using bar-code technology that allowed the organizers to measure both the time required to process each patient and the accuracy with which the correct antibiotic was given to the right "patient." National, regional and municipal officials are using the results of this exercise to develop a template for bioterrorism response that can be adapted by other cities in the United States and around the world.

In another IDSRN project, Marshfield Health Clinic assessed the impact of its Coumadin Clinic on health care utilization, including urgent care, emergency department and inpatient events. While the estimates are still preliminary, testimony by Marshfield Clinic before the Way and Means Committee's Subcommittee on Health strongly suggests that disease State management projects like Marshfield's Coumadin Clinic offer potential for significant cost reductions by averting hospital inpatient and emergency department visits. Medicare, for example, would save an estimated $235,943 per 100 person years. Moreover, failure to manage patients on Coumadin appropriately is a leading cause of avoidable medical errors in older patients.

Select for IDSRN Fact Sheet.

Payment and Organizational Structures and Processes

AHRQ developed a Program Announcement (PA) on the effects of payment and organizational structures and processes on the cost, quality, and equity of health care. Important areas to be addressed by this research include:

  • The effects of different payment mechanisms and financial incentives on health care quality, costs, and access.
  • The impact of purchaser and public-sector projects on quality, costs, and access to care and to health insurance.
  • The organizational structures most likely to sustain high-quality, accessible health care.
  • The impact of different patterns and levels of market competition on health care quality and costs.

Below are three examples of grants funded under this program announcement.

  • Hospital Finances and the Quality of Hospital Care. This grant will look at the relationship between a hospital's financial condition, its operational and resource allocation decisions, and the quality of clinical care at that hospital. Since many hospitals and provider organizations in the United States are facing significant financial constraints, it is important to understand the impact of financial conditions on operational decisions.
  • Purchaser/Provider Evaluation: Hospital Quality Data. This project will compare and contrast the perceptions of health care purchasers and hospital administrators regarding the relative importance of hospital quality measures. It will also determine how health care purchasers use the comparative reports of hospital performance among their employees and for negotiating health coverage. Thus, the study will address key public policy questions such as: the impact and utility of public disclosure of hospital patient safety measures on purchasers/employers and on hospital administrators, the possible pathways for improving hospital performance, and how to increase the impact of future hospital comparative reports.
  • Physician Networks and Children with Chronic Conditions. The aim of this grant is to study the effect of offering out-of-network benefits for children with two chronic conditions: asthma and diabetes. The grant will determine the associations between the out-of-network benefits and cost-sharing of health plans and children's likelihood of seeing and out-of-network physician. The grant will also determine whether quality of care and expenditures are significantly different among children seeing in-network versus out-of-network physicians.
Performance Goals

Select to access Table 11 for performance goals of the Socio-economics of Health Care Portfolio.

Return to Accomplishments and Performance Analysis

Long-term Care Portfolio

Persons who need assistance with basic activities of daily living, homemaker activities and other normal role activities (e.g., work, school) comprise the long-term care (LTC) population. This population lives both in the community and in residential settings. Long-term care services are diverse; some of the most important include institutional/residential care, home care, personal assistance services, supportive housing, assistive technologies, services to promote education for children with special needs, services to foster employment for the disabled, rehabilitation and transportation services, and other associated health care services. These services are provided by agencies, family and friends, and institutions, and are paid and unpaid. There are many gaps in our knowledge about this population and the services received.

AHRQ has a long-standing role in supporting and conducting research to improve long-term care for the elderly, chronically ill and disabled. The goal of this research is to better understand how to foster independence, prevent unnecessary disability, provide services more efficiently, and improve the quality of care and the quality of life. In addition, this research identifies effective ways to integrate LTC and acute care services, , assure patient safety, develop tools to improve quality of care, and reduce disparities in the delivery of long-term care.

The Agency's long-term care portfolio of grants and contracts are divided into four substantive areas: safety, quality, effectiveness, and efficiency. About half of the grants in the LTC portfolio are concerned with quality issues. The remaining grants are evenly divided into the other three categories.

Safety/Quality

Safety is a major concern for the elderly and especially persons in residential settings such as assisted living and nursing homes. It is also a concern for the staff in these facilities. The Agency funds conferences and provides funding to initiate centers to focus on safety issues in long-term care and supports research to improve technology. One study will test whether a computer-based clinical decision support system can lower the rate of adverse drug events (ADEs) and potential ADEs in the long-term care setting. A new center on patient safety in long-term care at Emory University in Atlanta, GA will tell us how we can prevent falls and pressure ulcers in nursing homes and assisted living facilities. A center at New York University is focusing on safety in home care and a new center at the University of South Florida will tell us how to prevent falls for persons in the community. A study by AHRQ staff suggests that fractures in nursing homes can be prevented with increased aide staffing and adjustments to drug prescribing practices.

There are many quality concerns in the provision of long-term care services and caregiving. For example, a University of Colorado study will tell us the how well report cards and other varied information strategies help consumers make nursing home choices based on quality. Other studies:

  • Develop a nurse restorative care program for residential care.
  • Interventions to improve staff motivation, job design, work environment in nursing homes.
  • Improve assessment of pain and mobility in nursing homes.
  • Use electronic reminders to improve adherence to evidence based guidelines in home care.
  • Use a clinical algorithm to manage urinary tract infections and reduce antibiotic use in residential facilities.
  • Evaluate the use of nurse practitioners to improve urinary incontinence care in nursing homes.

In addition, the Agency is encouraging building partnerships between health care organizations. Helping home care agencies collaborate on evidence-based quality improvement activities is one example. Two of these partnerships are implementing improvements in clinical information in a number of nursing homes to improve pressure ulcer care and increase the use of nursing home care guidelines for pain and pressure ulcers.

Effectiveness

Another important part of the long-term care portfolio includes studies that assess the effectiveness of care. Generally, long-term care studies focus on outcomes such as the change in functioning, re-hospitalizations, and mortality. Some studies directly evaluate outcomes associated with interventions while others attempt to better understand the variation in outcomes associated with different heath conditions. For example, a training grant is funding outcome studies of persons in Program of All Inclusive Care for the Elderly (PACE) settings. Other studies include an evaluation of a geriatric nurse practitioner intervention is attempting to reduce behavioral problems for Alzheimer's patients and caregiver stress; tracking functional outcomes after trauma for adolescents; and assessing the impact of Medicare prospective payment on survival, discharge to community, and use of rehabilitation services.

Efficiency

Another important area in the AHRQ long-term care portfolio concerns the efficiency of provision of care across the continuum of care. Long-term care recipients often move between home care or residential care and hospitals. The high cost of hospital care makes it an important target for cost reduction. Hospital studies include the development of a model to assess factors that increase hospital admission rates for nursing home residents and an evaluation of the reasons for variation in hospitalization rates for pneumonia patients in Evercare-affiliated nursing homes. Evercare is a prospective payment model with incentives to reduce hospital care. Other studies include an assessment of the overall health care use of persons in assisted living facilities, and a study of access to care, preventive services and specialists for disabled adults. A study by AHRQ staff indicates that the decline in Medicare funding of home care after the Balanced Budget Amendment has been accompanied by increases in state and local expenditures.

Data Development

Two data development activities within MEPS are underway that will increase the ability to report on populations and services currently not being captured.

The first is a multi-year collaboration across HHS Agencies that has begun to develop data collection methodologies for the population in assisted living facilities, a group for which no national measures exist. Development of an instrument that would be used to identify characteristics and quality concerns of the assisted living population would then follow.

The second data effort is a project to measure the costs associated with informal care as measured with the time spent in caregiving. Development of an instrument is underway to design methods to measure the economic costs associated with providing care to the long-term care population. With these measures alternative policy options for the efficient delivery of services could be assessed.

Performance Goals

Select to access Table 12 for performance goals of the Long-term Care Portfolio.

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