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Performance Budget Submission for Congressional Justification

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Significant Items

FY 2005 House Appropriations Committee Report Language (House Report 109-143)

Item

Study to assess risk for mothers and babies of cesarean versus vaginal births—Despite the Healthy People 2010 recommendations to decrease primary cesarean section rates to 15 percent and repeat cesarean section rates to 63 percent, the Committee is aware that rates of primary elective cesarean section are progressively increasing and that vaginal birth after cesarean rates are steadily decreasing. The Committee encourages AHRQ to conduct a comprehensive meta-analysis of the best available research studies comparing short and long term risks for mothers and babies of cesarean versus vaginal birth and requests that AHRQ report back to the Committee with this information by next year (House Report, p. 121).

Action taken or to be taken—Hospitalization for the delivery of a child is the most common reason for hospitalization in the United States and thus, labor and delivery is an important public health issue. AHRQ has recognized that trends in cesarean delivery are changing and has recently published an analysis showing a rising rate of pre-labor primary cesarean delivery, which can also be called maternal choice cesarean delivery. The risks and benefits of maternal choice cesarean delivery will be explored at a state of the science conference titled "Cesarean Delivery on Maternal Request" sponsored by the Office of Medical Applications Research at NIH to be held March 27-29, 2006. For this conference, AHRQ will prepare a systematic review that will address trends, maternal outcomes and neonatal outcomes of cesarean delivery compared to vaginal delivery as well as outlining important future research areas. A panel selected by the OMAR office at NIH will prepare a consensus statement based on presentations at the conference and the AHRQ evidence report. A final report on the topic and the panel statement will be available to the public on the AHRQ and OMAR Web sites March 29, 2006.

Item

Medical Errors—Within the total for research on health costs, quality, and outcomes, the Committee provides $84,000,000 for reducing medical errors, which is the same as the fiscal year 2005 comparable level and the budget request. This amount includes $50,000,000 for grants to support the health information technology initiative. The Committee urges AHRQ to play a key role in the initiative being developed in the Office of the National Coordinator for Health Information Technology. The Committee encourages AHRQ to conduct pilot projects to demonstrate the feasibility and value of standards-based electronic health care data interchange (House Report, p. 120).

Action taken or to be taken—AHRQ remains committed to demonstrating the impact of health IT, including health information exchange (HIE), on the quality and safety of care. AHRQ currently sponsors demonstration projects and research programs with an emphasis on HIEs' contribution to improving care. These programs, ranging from State-wide HIE efforts to local exchanges, directly support ONC initiatives. To date, AHRQ supports 6 state contracts in addition to multiple regional efforts supported through AHRQ's grant program. AHRQ has provided technical assistance and meeting support for emerging states (e.g., Florida, Montana) as they plan standards-based health care data exchange. AHRQ has also worked closely with the Office of the National Coordinator in other areas. AHRQ, in conjunction with the National Coordinator recently awarded the Health Information Security and Privacy Project an 18-month contract that will help us better understand and define the legal, regulatory and business issues surrounding HIE in up to 40 states. AHRQ and ONC staff jointly manage the project whose deliverables will be critical to HIE efforts. In addition, AHRQ sponsored a number of health IT projects in Louisiana that are providing an "on the ground" resource for the ONC sponsored Louisiana regional health information exchange.

Item

Use of high-tech patient simulators for training—The Committee is aware that a number of medical schools and medical centers in the U.S. are using high-tech patient simulators or medical simulators to improve doctor training, especially surgical and emergency room training. The Committee is also aware that AHRQ has a series of projects underway to evaluate the use of such simulators. The Committee strongly encourages AHRQ to continue these efforts and to expand them if necessary in order to evaluate effectively the utility of simulators in improving patient care and medical training, and decreasing medical mistakes (p. 120).

Action taken or to be taken—AHRQ is aware of recent developments in a number of U.S. medical schools and centers that are using patient simulators and advanced technology to improve the training of physicians and other providers. Over the past five years we have funded several simulation projects in such areas as paramedic performance, cardiac catheter lab, endoscopic sinus surgery, the delivery room, team crises management, and the next generation simulation, among others). In FY 2004, AHRQ researchers edited a special supplement on simulation and team training for Quality and Safety in Health Care, one of the BMJ journals. New simulation projects were added to our patient safety portfolio in FY 2005. Currently, AHRQ is planning to release a Request for Proposals (RFP) in FY 2006 to further examine critical issues in this promising technology.

Item

Duchenne muscular dystrophy—The Committee is pleased AHRQ is studying standards of care issues associated with patients diagnosed with Duchenne Muscular Dystrophy. The Committee urges AHRQ to build on this work by partnering with CDC to convene a consensus conference to develop these standards (House Report, p. 120).

Action taken or to be taken—Duchenne muscular dystrophy is part of a group of genetic, degenerative diseases primarily affecting voluntary muscles. As DMD eventually affects all voluntary muscles, including the heart and breathing muscles, the care of individuals with the disease often requires the close collaboration of a clinical team with various specialties and patient families. The national advocacy organizations have provided an invaluable service to both the patient and the provider communities in raising the awareness of the diseases and patient needs, and in the calls to support more research. In response to these efforts, AHRQ provided input to CDC to help them plan a conference, now scheduled for Fall 2006. This conference involves a wide range of stakeholders and will discuss the evidence regarding best practices for the diagnosis, treatment, and ongoing management of DMD. We look forward to continuing to consult with CDC to help their efforts to clarify what we know and what we still need to know to improve the care of DMD.

Item

Elderly Mental Health—The Committee is concerned about the prevalence of undiagnosed and untreated mental illness among older Americans. Affective disorders, including depression, anxiety, dementia, and substance abuse and dependence, are often misdiagnosed or not recognized at all by primary and specialty care physicians in their elderly patients. Research has shown that the treatment of mental illness can improve health outcomes for those with other chronic diseases. While effective treatments for these conditions are available, there is an urgent need to translate advancements from biomedical and behavioral research to clinical practice. The Committee encourages AHRQ to support evidence-based research projects focused on the diagnosis and treatment of mental illnesses in the geriatric population, and to disseminate evidence-based reports to physicians and other health care professionals (House Report, p. 121).

Action taken or to be taken—AHRQ recognizes that mental health conditions have a substantial burden on the elderly, and we are actively engaged in developing and disseminating evidence-based information to assist with the identification and management of such conditions. Regarding screening, the U.S. Preventive Services Task Force, an independent panel of experts in primary care and prevention that is supported by AHRQ, has released recommendations on screening for dementia, screening for alcohol misuse, and screening for depression. AHRQ's Put Prevention Into Practice Program works to facilitate incorporation of these recommendations into clinical practice. AHRQ's Evidence-based Practice Centers Program has released reports on pharmacotherapy for alcohol dependence, post-myocardial infarction depression, and pharmacologic treatment of dementia. In addition, through our new Effective Health Care (EHC) Program, we are currently conducting reports on Evidence for Off-Label Use of Atypical Anti-psychotic Medications and on Comparative Effectiveness of Pharmacotherapeutics for Depression. As part of the EHC Program, the John M. Eisenberg Clinical Decisions and Communications Science Center was created to translate knowledge about effective health care into understandable, actionable language for all decisionmakers. An important function of the Center is to present the often complex scientific information in a format that stakeholders and the public can easily understand. In 2006, AHRQ will award a cooperative agreement to establish a Center for Education and Research on Therapeutics (CERT) that will specialize on mental health. AHRQ also supports a breadth of research to develop new knowledge about effective care for mental health in the elderly.*

*Recent/Ongoing Grants on Mental Health Related Projects

A program of collaborative care for Alzheimer Disease (2001-2006)
The study will test the efficacy of an Integrated Program of Collaborative Care (IPCP) as compared to usual care in improving the outcomes of care for older adults with Alzheimer Disease in a primary care setting.

Different Approaches to Information Dissemination (2002-2006)
This is a four-year project aimed at dissemination of evidence-based practices in nursing homes and adult care facilities through provision of training modules for chronic health and mental disorder.

Expert system diagnosis of depression and dementia (1998-1999)
The study will develop and compare an expert decision system and neural network classification system designed to diagnose and differentiate depression and dementia in the elderly. This neural network classification system has the potential to assist non-specialist clinicians or allied health professionals in the preliminary evaluation and diagnosis of common disorders in the elderly.

Pilot—Provide AHRQ guidelines to African Americans with diabetes and depression (2000-2005)
The Diabetes Nurse Educator (DNE) model of diabetes care was designed to address problems in the provision of American Diabetes Association minimum levels of diabetes care. This study will train the DNA to collaborate with primary care providers to provide AHRQ guidelines concordant depression treatment for African-Americans (AA) with both diabetes and depression (primary care setting).

Accelerating TRIP in a Practice-Based Research Network (2002-2006)
This is a demonstration project to expand PPRNet's successful approach to quality improvement in the primary care setting. The project will address practice guidelines for priority conditions and improvement approaches advocated in the IOM report and Healthy People 2010 activities. Target conditions include mental health.

Depression Care Using Computerized Decision Support (1996-2002)
This study develops and implements a computerized decision support system (CDSS) to assist board-certified primary care physicians (PCPs) in caring for patients experiencing major depression in an outpatient setting. Few investigators have explored the use of a CDSS to enhance PCPs' adherence to a treatment guideline and none have examined either clinicians' or patients' adherence to a mental health treatment guideline. Major depression is an appropriate condition to study as it is: (1) prevalent in primary care; (2) responsible for significant amounts of excess morbidity and costs; (3) poorly recognized and managed by PCPs; (4) effective treatments are available; and (5) expert panel guidelines are available for local modification and conversion into a CDSS algorithm. The clinical content of the CDSS is based on the AHCPR clinical practice guidelines for major depression and modified for local use. The CDSS is programmed into the electronic medical record (EMR) in use at our study site running on a Windows®-PC platform.

Item

Heart disease research and prevention action plan—Concerned that heart disease remains a major cause of permanent disability, the Committee encourages NIH to consider convening an inter-agency conference on heart disease to develop a comprehensive, long range research and prevention action plan. Participants should include representatives from all Federal agencies involved in heart disease research and prevention, including the NIH, CDC, AHRQ, DOD, and pertinent voluntary nonprofit organizations and experts in the field. The conference would be the basis for a long-range, strategic heart disease research and prevention action plan which would include quantifiable goals and benchmarks to measure progress in the battle against heart disease (p. 169).

Action taken or to be taken—Heart disease represents an example where advances in research have led to important gains in reducing the toll of preventable chronic disease. At the same time heart disease remains the leading single cause of mortality and morbidity and AHRQ's National Healthcare Quality Report and National Healthcare Disparities Report illustrates the substantial room for improvement in the prevention and management of heart disease. Improving heart disease outcomes will require a long-range research agenda to: improve our medical interventions to prevent and treat heart disease; improve our ability to address behavioral risk factors such as poor diet, lack of exercise, obesity and tobacco use; and improvements in our ability to deliver coordinated, high quality care for chronic diseases. The Agency currently tracks 20 measures of the quality of prevention and treatment of heart disease that help track progress in quality of heart disease care. In addition, the AHRQ supported U.S. Preventive Services Task Force has issued a series of recommendations on effective behavioral and screening interventions for prevention of heart disease in the primary care setting. AHRQ looks forward to working with NIH, CDC, DOD, CMS and non-federal partners to develop a long-range action plan and quantifiable benchmarks for improving the prevention and treatment of heart disease.

FY 2005 Senate Appropriations Committee Report Language (Senate Report 109-103)

Item

Heart Disease Research and Prevention Action Plan—Advances have been made in the identification and treatment of risk factors for heart disease. The Committee encourages the NIH to convene a transagency national conference on heart disease to assess progress and opportunities and to develop a comprehensive, long range research and prevention action plan. Participants should include representatives from all Federal agencies involved in heart disease research and prevention, including the NIH and all relevant institutes and centers, CDC, AHRQ, DOD, and pertinent voluntary nonprofit organizations, foundations, and experts in the field. The Committee encourages the Director to develop a long-range, strategic Heart Disease Research and Prevention Action Plan and submit a report to the Committee by May 1, 2006. The plan should include quantifiable goals and benchmarks to measure progress in the battle against heart disease, and a professional judgment budget for each year as well as for the entire plan (p. 169).

Action taken or to be taken—Heart disease represents an example where advances in research have led to important gains in reducing the toll of preventable chronic disease. At the same time, heart disease remains the leading single cause of mortality and morbidity and AHRQ's National Healthcare Quality Report and National Healthcare Disparities Report illustrates the substantial opportunity for improvement in the prevention and management of heart disease. Improving heart disease outcomes will require a long-range research agenda to: improve our medical interventions to prevent and treat heart disease; improve our ability to address behavioral risk factors such as poor diet, lack of exercise, obesity and tobacco use; and improvements in our ability to deliver coordinated, high quality care for chronic diseases. The Agency currently tracks 20 measures of the quality of prevention and treatment of heart disease that help track progress in quality of heart disease care. In addition, the AHRQ supported U.S. Preventive Services Task Force has issued a series of recommendations on effective behavioral and screening interventions for prevention of heart disease in the primary care setting. AHRQ looks forward to working with NIH, CDC, DOD, CMS and non-federal partners to develop a long-range action plan and quantifiable benchmarks for improving the prevention and treatment of heart disease.

Item

Autoimmune Disease—In order to support continued HHS-wide implementation of the HHS Autoimmune Diseases Research Plan, the Committee encourages AHRQ to estimate the annual treatment and societal costs of autoimmune diseases in the United States, in order to project their future impact and burden on the healthcare system (Senate Report, p. 186).

Action taken or to be taken—The Medical Expenditure Panel Survey (MEPS), which is supported and conducted by AHRQ, is a primary source of information on the utilization and costs of health services in the United States. Each year MEPS obtains data from a nationally representative sample of households. A new cohort is inducted each year and followed for two years. In addition to collecting information on medical expenditures, MEPS also obtains data on the medical conditions for which people have received treatment. MEPS data can thus be used to develop estimates of the direct costs of treating autoimmune diseases. Information on clinical conditions will be used to identify members of the MEPS sample who have autoimmune diseases. For this subpopulation, estimates of costs of medical care will be derived. If sample sizes permit, annual estimates will be developed; otherwise, data from several years can be combined to obtain more stable estimates, and moving averages calculated to assess trends in expenditures over time.

Item

Duchenne Muscular Dystrophy—The Committee is pleased AHRQ is studying standards of care issues associated with patients diagnosed with Duchenne Muscular Dystrophy. The Committee urges AHRQ to build on this work by partnering with CDC to convene a consensus conference to develop these standards (Senate Report, pp. 186/187).

Action taken or to be taken—Duchenne muscular dystrophy is part of a group of genetic, degenerative diseases primarily affecting voluntary muscles. As DMD eventually affects all voluntary muscles, including the heart and breathing muscles, the care of individuals with the disease often requires the close collaboration of a clinical team with various specialties and patient families. The national advocacy organizations have provided an invaluable service to both the patient and the provider communities in raising the awareness of the diseases and patient needs, and in the calls to support more research. In response to these efforts, AHRQ provided input to CDC to help them plan a conference, now scheduled for Fall 2006. This conference involves a wide range of stakeholders and will discuss the evidence regarding best practices for the diagnosis, treatment, and ongoing management of DMD. We look forward to continuing to consult with CDC to help there efforts to clarify what we know and what we still need to know to improve the care of DMD.

Item

Elderly Mental Health—The Committee is seriously concerned about the prevalence of undiagnosed and untreated mental illness among older Americans. Affective disorders, including depression, anxiety, dementia, and substance abuse and dependence, are often misdiagnosed or not recognized at all by primary and specialty care physicians in their elderly patients. While effective treatments for these conditions are available, there is an urgent need to translate advancements from biomedical and behavioral research to clinical practice. The Committee urges AHRQ to support evidence-based research projects focused on the diagnosis and treatment of mental illnesses in the geriatric population, and to disseminate evidence-based reports to physicians and other health care professionals (Senate Report, p. 187).

Action taken or to be taken—AHRQ recognizes that mental health conditions have a substantial burden on the elderly, and we are actively engaged in developing and disseminating evidence-based information to assist with the identification and management of such conditions. Regarding screening, the U.S. Preventive Services Task Force, an independent panel of experts in primary care an prevention that is supported by AHRQ, has released recommendations on screening for dementia, screening for alcohol misuse, and screening for depression. AHRQ's Put Prevention Into Practice Program works to facilitate incorporation of these recommendations into clinical practice. AHRQ's Evidence-based Practice Centers Program has released reports on pharmacotherapy for alcohol dependence, post-myocardial infarction depression, and pharmacologic treatment of dementia. In addition, through our new Effective Health Care (EHC) Program, we are currently conducting reports on Evidence for Off-Label Use of Atypical Anti-psychotic Medications and on Comparative Effectiveness of Pharmacotherapeutics for Depression. As part of the EHC Program, the John M. Eisenberg Clinical Decisions and Communications Science Center was created to translate knowledge about effective health care into understandable, actionable language for all decisionmakers. An important function of the Center is to present the often complex scientific information in a format that stakeholders and the public can easily understand. In 2006, AHRQ will award a cooperative agreement to establish a Center for Education and Research on Therapeutics (CERT) that will specialize on mental health. AHRQ also support a breadth of research to develop new knowledge about effective care for mental health in the elderly.*

*Recent/Ongoing Grants on Mental Health Related Projects

A program of collaborative care for Alzheimer Disease (2001-2006)
The study will test the efficacy of an Integrated Program of Collaborative Care (IPCP) as compared to usual care in improving the outcomes of care for older adults with Alzheimer Disease in a primary care setting.

Different Approaches to Information Dissemination (2002-2006)
This is a four-year project aimed at dissemination of evidence-based practices in nursing homes and adult care facilities through provision of training modules for chronic health and mental disorder.

Expert system diagnosis of depression and dementia (1998-1999)
The study will develop and compare an expert decision system and neural network classification system designed to diagnose and differentiate depression and dementia in the elderly. This neural network classification system has the potential to assist non-specialist clinicians or allied health professionals in the preliminary evaluation and diagnosis of common disorders in the elderly.

Pilot—Provide AHRQ guidelines to African Americans with diabetes and depression (2000-2005)
The Diabetes Nurse Educator (DNE) model of diabetes care was designed to address problems in the provision of American Diabetes Association minimum levels of diabetes care. This study will train the DNA to collaborate with primary care providers to provide AHRQ guidelines concordant depression treatment for African-Americans (AA) with both diabetes and depression (primary care setting).

Accelerating TRIP in a Practice-Based Research Network (2002-2006)
This is a demonstration project to expand PPRNet's successful approach to quality improvement in the primary care setting. The project will address practice guidelines for priority conditions and improvement approaches advocated in the IOM report and Healthy People 2010 activities. Target conditions include mental health.

Depression Care Using Computerized Decision Support (1996-2002)
This study develops and implements a computerized decision support system (CDSS) to assist board-certified primary care physicians (PCPs) in caring for patients experiencing major depression in an outpatient setting. Few investigators have explored the use of a CDSS to enhance PCPs' adherence to a treatment guideline and none have examined either clinicians' or patients' adherence to a mental health treatment guideline. Major depression is an appropriate condition to study as it is: (1) prevalent in primary care; (2) responsible for significant amounts of excess morbidity and costs; (3) poorly recognized and managed by PCPs; (4) effective treatments are available; and (5) expert panel guidelines are available for local modification and conversion into a CDSS algorithm. The clinical content of the CDSS is based on the AHCPR clinical practice guidelines for major depression and modified for local use. The CDSS is programmed into the electronic medical record (EMR) in use at our study site running on a Windows®-PC platform.

Item

Health Disparities—The Committee remains disturbed by the March 2002 Institute of Medicine report regarding the disparities of medical care delivery to minorities. The Committee encourages AHRQ to carefully evaluate the analysis, findings, and recommendations of this study in order to pursue creative ways to improve health care delivery for all minority populations, including African-Americans, those of Hispanic and Asian origin, Native Americans, Alaskans and Native Hawaiians (Senate Report, p. 187).

Action taken or to be taken—First released in 2003, the annual National Healthcare Disparities Report (NHDR) provides a comprehensive national overview of disparities in health care among racial, ethnic, and socioeconomic groups in the general U.S. population and among priority populations. The NHDR tracks the Nation's progress towards the elimination of health care disparities, and targets policymakers, clinicians, health system administrators, and community leaders who seek information to improve health care services for all Americans. The NHDR tracks disparities in both quality of health care and access to health care. Measures of health care quality encompass four dimensions of quality—effectiveness, patient safety, timeliness, and patient centeredness.

The NHDR complies with the following Institute of Medicine (IOM) Report, "Unequal Treatment" recommendations: 2.1.-2.2., "Increase awareness of racial and ethnic disparities in healthcare among the general public, key stakeholders, and health care providers;" 7.2, "Include measures of racial and ethnic disparities in performance measurement;" 7.3, "Monitor progress toward the elimination of healthcare disparities;" and 7.4 "Report racial and ethnic data by OMB categories, but use subpopulation groups where possible." Based on results from the NHDR that have shown a lack of data on health care quality and health care access in some racial and ethnic minority communities, the Medical Expenditure Panel Survey (MEPS) and Healthcare Cost and Utilization Project (HCUP) have improved data collection for these communities through the expansion of sample sizes and the introduction of pioneering ways to make better estimates for patient quality and patient safety. HCUP also identifies states and hospitals with high quality racial and ethnic data and directly works with the states and hospitals on ways to improve their data collection for racial and ethnic minorities. The research conducted through MEPS and HCUP complies with the IOM Report "Unequal Treatment" recommendation 7.1, " Collect and report data on health care access and utilization by patient's race, ethnicity, socio economic status, and where possible, primary language." As part of AHRQ's Health Information Technology Program, community-based grants across the country are bringing the power of Health IT to underserved and minority communities that were previously on the other side of the "digital divide." AHRQ also supports Primary Care Practice Based Research Networks (PBRNs) by awarding planning grants to networks across the United States. Several grants support the development of a PBRN-specific plan to increase the network's capacity to study the health care of racial and ethnic minority and/or underserved populations. This plan complies with the IOM Report "Unequal Treatment" recommendations: 8-1: "Conduct further research to identify sources of racial and ethnic disparities and assess promising intervention strategies;" and 8-2: "Conduct research on ethical issues and other barriers eliminating disparities."

AHRQ is also a member of Commission to End Healthcare Disparities, chaired by the American Medical Association. The Commission to End Health Care Disparities, inspired by the IOM Report, "Unequal Treatment," recognizes that health care disparities exist due to multiple factors, including race and ethnicity. The commission seeks to collaborate proactively to increase awareness among physicians and health professionals; use evidence-based and other strategies; and advocate for action, including governmental, to eliminate disparities in health care and strengthen the health care system.

Item

Hospital-based Initiative—The Committee urges AHRQ to work with multi-site academic medical centers to identify and implement programs to improve patient safety in a hospital setting. The Committee is interested in patient safety improvements that are designed for rapid turnaround and for developing practical and replicable projects in the future (Senate Report, p. 187).

Action taken or to be taken—AHRQ has and continues to work with academic medical centers to improve patient safety in hospitals. Following are but a few examples of the work we have conducted or work that is currently underway.

The Patient Safety Improvement Corps (PSIC), which began in 2003 is designed to help teams of State health officials and their selected hospital partners as well as quality improvement organizations and their selected hospital partners. Team members are trained in analyzing reported medical errors, identifying root causes, and developing and implementing patient safety improvement processes. Some of the hospitals participating in the program represent academic medical centers (e.g., University of Massachusetts Memorial Medical Center, University of Missouri Health System, University of North Carolina Hospitals, Oregon Health and Science University, Jefferson Health System, University of Utah Hospitals and Clinics, University of Virginia Medical Center, Ohio State University Medical Center, University of Tennessee Medical Center, Cooper Hospital University Medical Center, and the University of Wisconsin Hospital and Clinics).

The Hospital Survey of Patient Safety Culture (HSOPS) is a tool developed with funding and direction from AHRQ which is now being used by many hospitals some of which are academic medical centers such as the University of Miami Hospital and Clinics in Miami, FL and Vanderbilt University Medical Center in Nashville, TN. This survey helps hospitals identify weaknesses in their culture of safety that can contribute to patient safety problems.

The Partnerships for Improving Patient Safety (PIPS) initiative launched in 2005 is focused on implementing patient safety solutions and the creation of toolkits that can be exported and used by others around the U.S. The PIPS projects include a number of academic medical centers (e.g., University of Nebraska Medical Center, University of Pittsburgh, Emory University, University of Washington, Vanderbilt University School of Medicine, Oregon Health and Science University, University of California-San Diego, University of Rochester Medical Center).

AHRQ has done, and will continue to do, systematic work to identify and implement rapid-cycle improvements in safety, quality, and effectiveness through the 2000-2005 Integrated Delivery System Research Network (IDSRN) and its expanded version, the ACTION (Accelerating Change and Transformation in Organizations and Networks) Network. Under the IDSRN, academic medical centers and other institutions have engaged in several large-scale efforts to improve patient safety. For example, AHRQ seeks to promote the development and deployment of a targeted injury detection system (TIDS) which combines both indicators from administrative data and record information with the use of specific triggers. This system must be able to deploy in multiple systems across the U.S., and it must operate within hospital and health systems with diverse electronic health record (EHR) systems including institution-specific (i.e., homegrown) and vendor-based (e.g., Cerner, Epic) EHRs as well as in systems where no EHR is used. This concept was developed by Brent James at Intermountain Health Care (IHC), a collaborator in the RTI consortium of the IDSRN, based on a chapter Dr. James wrote for an IOM patient safety report, Patient Safety: Achieving a New Standard for Care. RTI is working with a larger group of IDSRN hospital settings outside RTI on this task order. These additional hospital systems are sufficiently involved in and committed to the objectives of this study to make sure that the TIDS will be applicable to these additional settings, and that leaders in these additional settings regard the instrument as valid and useful for their systems.

In addition to the RTI IDSRN partnership mentioned above, which includes, the University of North Carolina at Chapel Hill, UNC Health Care, Providence Health System and the University of Pittsburgh Medical Center, the IDSRN included academic medical centers such as the University of Colorado Health Sciences Center (working with Denver Health), Emory Center on Health Outcomes and Quality, the University of Minnesota, and Weill Medical College of Cornell University. Under the soon-to-be-awarded contracts in the larger ACTION network, we expect representation from approximately two dozen academic medical centers and we expect to be able to implement more, and more wholesale, patient safety improvements.

AHRQ also supported a number of evaluations of medical error reporting systems, and some of these projects were conducted by academic medical centers (e.g., University of Pittsburgh, Johns Hopkins University, Emory University).

Item

Investigator-initiated Research—The Committee notes that the Department reallocated $11,518,000 from AHRQ in fiscal year 2005 to fund the Department's health information technology initiative. While the Committee strongly supports this initiative, it notes that this reallocation delayed the start of several non-patient safety grant programs. Research outside of targeted areas such as patient safety, health IT and comparative effectiveness is a critical part of AHRQ's mission yet these grants are a diminishing portion of the agency's research portfolio. The Committee notes that important initiatives like the patient safety program were based on investigator-initiated research. The Committee strongly urges AHRQ to maximize investigator-initiated research (Senate Report, p. 187).

Action taken or to be taken—While targeted research investments comprise a large portion of our budget, AHRQ views investigator-initiated research as the backbone of our research portfolio. It is the basic research that provides the foundation for many of AHRQ's programs and activities, including patient safety, as the Committee notes. In FY 2006, the Agency plans to continue its investment in investigator-initiated type of research that supports studies to reduce health care costs, improve access to effective services, and translate research into practice. In FY 2007, the Agency looks forward to working with the Committee to develop ways to best leverage our resources so that we can most effectively meet the health care needs for all Americans.

Item

Nurse-Managed Health Centers—The Committee encourages AHRQ to include nurse managed health centers and advanced practice nurses in research and demonstration projects conducted by the agency (p. 187).

Action taken or to be taken—AHRQ is providing infrastructure support to two research networks composed of primary care advanced practice nurses (APNs). The Midwest Nursing Center Consortium Research Network (MNCCRN) includes 20 community nurse-managed centers that have been in operation from 3 to 17 years, representing 13 midwest universities with a total of 85 APNs. The Advanced Practice Registered Nurse Network (APRN), based at Yale University, is composed of 68 APNs who represent 57 primary care practices in New England (Maine to Connecticut). MNCCRN is currently involved in research aimed at reducing health disparities in vulnerable U.S. populations, and APRN is developing protocols to enhance APN-directed management of obesity in primary care. AHRQ anticipates that these (and perhaps other) APN networks will continue to be involved in agency-supported research and demonstration projects focused on the practice of primary care.

Significant Items for Inclusion in the FY 2007 Congressional Justification Conference Report No. 109-337

Item

Clinical effectiveness research—The conferees provide $15,000,000 within the total provided for AHRQ for clinical effectiveness research as proposed by the House. The Senate included $20,000,000 for this purpose. This type of research can help improve the quality, effectiveness and efficiency of health care, thereby reducing costs while still improving quality of care. The conferees urge AHRQ to ensure broad access to its findings in this research. In addition, the conferees encourage AHRQ to continue conducting high quality, comprehensive research studies in this area, building upon the priority list of conditions it identified in fiscal year 2005 and conducting research in additional areas such as organization, delivery and management of health care items and services (Conference Report, p. 82)

Action taken or to be taken—Patients, providers, and policymakers share an interest in making informed decisions about health care to promote good outcomes. One of the greatest challenges is finding reliable and practical data that can inform these decisions.

The AHRQ Effective Health Care Program has three approaches to research on the comparative effectiveness of different treatments and clinical practices:

  • Review and synthesize knowledge. The Evidence-based Practice Centers systematically review published and unpublished scientific evidence.
  • Promote and generate knowledge. The DEcIDE Research Network studies new scientific evidence and analytic tools in an accelerated and practical format.
  • Compile the findings and translate knowledge. The Clinical Decisions and Communications Scientific Center compiles the research results into a variety of useful formats for stakeholders.

AHRQ appreciates the importance of conducting clinical effectiveness research and released the first Comparative Effectiveness Review on December 14, 2005. The Effective Health Care Program offers broad access to study findings via http://www.effectivehealthcare.ahrq.gov and through ongoing broad dissemination efforts. The public is invited to nominate research topics and comment on ongoing studies at http://www.effectivehealthcare.ahrq.gov and to register to receive regular updates of program findings. AHRQ also will participate in a listening session on the Effective Health Care Program on January 11, 2006.

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