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Performance Budget Submission for Congressional Justification

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Long-term Care

Long-term Goal: To develop processes and tools supported by evidence-based research and to foster the integration of those processes and tools into the practice of long-term care so that providers can improve quality and safety while reducing costs, and so that consumers of long-term care have tools available to make informed decisions.

Measure FY Target Result
Improve quality and safety in all long-term care settings and during transitions across settings

Outcome

2007 Develop annual nursing home injurious falls measure in partnership with CMS; quantify baseline measure December 2007
2007 Develop partnerships, and access needs and barriers to the adoption of a 2nd generation injurious falls program in nursing homes December 2007
2007 Initiate dissemination activities for adoption of 2nd generation pressure ulcer intervention December 2007
2007 Implement and evaluate, in at least 30 nursing homes and in partnership with the State's Quality Improvement Organizations (QIO's), 2nd generation nursing home pressure ulcer intervention December 2007
2006 Synthesize recent research findings on what aspects of nursing home care prevents inappropriate hospitalizations December 2006
2006 Distribute report on implementation of evidence-based protocols for pressure ulcers prevention in nursing homes December 2006
2006 Disseminate findings from AHRQ nursing home fall prevention program December 2006
Improve coordination of formal long-term care with hospital care, primary care, and informal caregivers to facilitate clinical decision making and assure timely transfer of clinical data

Outcome

2007 Draft contractual award materials for 2007 multiple provider implementation of 2nd generation e-communication tool in diverse geographic settings December 2007
2007 Complete initial identification of user needs and barriers associated with 2nd generation e-communication tool use December 2007
2007 Disseminate e-communication user aids and expand network of provider partnerships to jump-start use of e-communication tools by multiple provider organizations December 2007
2006 Initiate dissemination of e-communication tool (i.e., a Web- based tool to improve coordination between hospital, primary care, and home care clinicians and patients and their informal care providers to improve care planning and self-care) December 2006
Improve community-based care to maximize function and community participation, and prevent inappropriate institutionalization and hospitalizations

Outcome

2007 In partnership with CMS, develop annual measure of re-hospitalization from long-term care settings; quantify baseline measure December 2007
2006 New Freedom Initiative: Initiate evaluation plan to assess findings from youth in transition (from pediatric to adult services) projects December 2006
2006 Synthesize recent research findings on what aspects of community-based services and care in assisted living can prevent inappropriate institutionalization and hospitalizations December 2006
Improve information about services and quality so that consumers can make informed choices about the care they receive

Outcome

2007 Complete cognitive testing on 1st generation of assisted living/residential care consumer instruments December 2007
2006 Produce report on the state-of-the art instruments and tools available to profile assisted living/residential care December 2006
2006 Publish report on how States monitor assisted living/residential care facilities and how States report to consumers December 2006
2006 Determine final sampling methodology and plan of implementation to enhance measurement on the long-term care population December 2006

Data Source: National Health Care Quality Report based on CMS's Minimum Data Set and OASIS data.

Data Validation: AHRQ products undergo extensive peer review for merit and relevance.

Cross Reference: Strategic goals 1/3/5; Healthy People 2010 goal 1

An Institute of Medicine (IOM) report entitled Improving the Quality of Long-term Care (2001) states that "concerns about problems in the quality of long-term care persist despite some improvements in recent years, and are reflected in, and spurred by, recent government reports, congressional hearings, newspaper stories, and criminal and civil court cases." Examples of high priority quality and safety concerns are the high prevalence of pressure ulcers, the large number of residents having serious falls, medical and drug errors, preventable hospitalizations caused by inadequate care management at transitions from hospital to long-term care, and the difficulty consumers of assisted living and residential care have evaluating the quality and services provided in those settings.

The purpose of AHRQ's Long-term Care Portfolio is to develop processes and tools supported by evidence-based research and to foster the integration of those processes and tools into the practice of long-term care so that providers can improve quality and safety while reducing costs, and consumers of long-term care have tools available to make informed decisions.

To meet these goals the Long-term Care Portfolio funds research to develop evidence to support tool development and test the impact on quality of integrating evidence-based tools into everyday practice. It partners with stakeholders to disseminate evidence-based tools, and evaluates approaches to implementing these practices into the day-to-day practice of care received by long-term care users. The portfolio is currently focusing on preventing pressure ulcers and injurious falls in nursing homes, improving care management of person discharged from hospital to home health, and improving tools to help consumers of assisted living make informed choices. The 2007 projects build on early small studies of pressure ulcer and falls prevention in nursing homes that have shown to improve quality and our part of a strategy to bring these interventions to scale. It also builds on assisted living development work and partnership with other Federal partners.

Pharmaceutical Outcomes

Long-term Goal: By 2014 inappropriate antibiotic use in children between the ages of 1 and 14 years of age should be such that use is reduced from 0.56 prescription per year to 0.42 per child (25%).

Measure FY Target Result
By 2014, antibiotic inappropriate use in children between the ages of one and fourteen should be such that use is reduced from 0.56 prescription per year to 0.42 per child (25%)

Outcome

2007 1.8% drop December 2007
2006 1.8% drop December 2006
2005 1.8% drop 0.59
2004 Establish baseline rates 0.56

Data Source: The data source for trends in children's use of antibiotics is the Medical Expenditure Panel Survey (MEPS). The MEPS is one of the core national sentinel data resources for tracking trends in health care use and expenditures. The MEPS is widely used by researchers in academia, government, and other research institutions and is recognized as a premier source of nationally representative data on medical use and expenditures.

Data Validation: The MEPS family of surveys includes a Medical Provider Survey and a Pharmacy Verification Survey to allow data validation studies in addition to serving as the primary source of medical expenditure data for the survey. The MEPS survey has been cleared by OMB and meets OMB standards for adequate response rates, and timely release of public use data files.

Cross Reference: Strategic goals 1/5; Healthy People 2010 goals 14/17.

Long-term Goal: Reduce congestive heart failure hospital readmission rates in those between 65 and 85 years of age.

Measure FY Target Result
By 2014, reduce congestive heart failure hospital readmission rates during the first 6 months, from 38% to 20% in those between 65 and 85 years of age

Outcome

2007 drop to 34% December 2007
2006 drop to 36% December 2006
2005 drop to 37% 36.99%
2004 Establish baseline rates 38%

Data Source: HCUP.
The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of 37 State data organizations, hospital associations, private data organizations, and the Federal Government to create a national information resource of patient-level health care data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988.

Data Validation: The validity of the data is verified several times a year by 37 State data organizations and then at the Federal level by AHRQ.

Cross Reference: Strategic goals 1/5; Healthy People 2010 goals 14/17.

Long-term Goal: Reduce hospitalization for upper gastrointestinal bleeding in those between 65 and 85 years of age.

Measure FY Target Result
Reduce hospitalization for upper gastrointestinal bleeding due to the adverse effects of medication or inappropriate treatment of peptic ulcer disease in those between 65 and 85 year of age from 55 per 10,000 population to 45 per 10,000

Outcome

2007 2.0% drop December 2007
2006 2.0% drop December 2006
2005 2.0% drop 55 per 10,000 (no change from baseline)
2004 Establish baseline rates (55 per 10,000)
The decreased number of admissions for upper gastrointestinal (GI) bleeding will generate a per-year drop in per capita charges for GI bleeding

Efficiency Outcome

2007 0.4% drop December 2007
2006 0.3% drop December 2006
2005 0.2% drop $93.20 per capita (3.4% drop)
2004 Establish baseline $96.50 per capita

Data Source: Congestive heart failure (CHF) goal.

Data Validation: Congestive heart failure (CHF) goal.

Cross Reference: Strategic goals 1/5; Healthy People 2010 goals 14/17.

Reduction in antibiotic use should be associated with improvement in the rates of resistant organisms and reduction of adverse reactions to medication use. A two-fold approach to this reduction is needed, through both the clinician and the caretaker. This goal includes children, a priority population for AHRQ. Antibiotic resistance is an important public health problem.

In FY 2006, efforts will continue to reduce congestive heart failure hospital readmission rates in those between 65 and 85 years of age. A recent study of patients undergoing home health care highlighted some issues related to hospitalization. Recent study findings showed minimal follow-up by hospital clinicians discharging patients, with follow-up in the community post-hospitalization occurring, on average, 16 days post-hospitalization. Transition of care may well be one of the major causes of re-hospitalizations. We will follow up with standard-setting organizations to see whether improvements can be identified.

The third major long-term goal of the portfolio is to reduce hospitalizations for upper gastrointestinal bleeding in those between 65 and 85 years of age. There are a number of studies and projects underway within the portfolio that relate to appropriate use of products that can cause abnormal bleeding. These include interventions to improve laboratory surveillance of the use of anticoagulants and ongoing studies of the use of non-steroidal anti-inflammatory drug products that cause drug-induced gastrointestinal bleeding. Studies on the use of drugs, such as VioxxR, a cox-2 inhibitor were completed this year.

Prevention

Long-term Goal: By 2010, an evidence-based model for health care organizations to minimize multi-risk behaviors among patients will be in use.

Measure FY Target Result

Increase the quality and quantity of preventive services that are delivered in the clinical setting, focusing especially on priority populations

Outcome

2007 Develop tools to facilitate the implementation of clinical preventive services among multiple users  December 2007
2006 Establish baseline for reach of evidence-based preventive services through use of products and tools  December 2006
2005 Establish baseline quality and quantity of preventative services delivered Completed
—% of women (18+) who report having had a Pap smear within the past 3 years—81.3%
—% of men & women (50+) report they ever had a flexible sigmoidoscopy/colonoscopy—38.9%
—% of men & women (50+) who report they had a fecal occult blood test (FOBT) within the past 2 years—33%
—% of people (18+) who have had blood pressure measured within preceding 2 years and can state whether their blood pressure is normal or high—90.1%
—% of adults (18+) receiving cholesterol measurement within 5 years—67.0%
—% of smokers receiving advice to quit smoking—60.9%
2004 Benchmark best practices for delivering clinical preventive services Completed
Expert opinions regarding best practices for delivering clinical preventive services obtained through stakeholder meetings and focus groups
Increase continuing medical education (CME) activities by developing a Train the Trainer program for implementing a system to increase delivery of clinical preventive services Completed
Developed Train the Trainer program

Improve the timeliness and responsiveness of the USPSTF to emerging needs in clinical prevention

Outcome

2007 Decrease by 10% the number of USPSTF recommendations that are 5 years old or older December 2007
2006 Decrease the median time from topic assignment to recommendation release December 2006
2005 Establish baseline measures for timeliness and responsiveness Completed
9 recommendations released
78% current within National Guideline Clearinghouse standards (reviewed within 5 years)
100% of guidelines related to IOM priority areas for preventive care current within National Guideline Clearinghouse standards
Developed new topic criteria, submission, review, and prioritization processes with new USPSTF topic prioritization workgroup

Increase the number of partnerships that will adopt and promote evidence-based clinical prevention

Outcome

2007 Three new partners will adopt and/or promote USPSTF-based tools  December 2007
2006 Increase the number of partnerships promoting evidence-based clinical prevention by 5%  December 2006
2005 Establish baseline of partnerships within the Prevention Portfolio promoting clinical prevention Completed Federall partners—8
Non-Federal partners
—10 Primary Care Orgs
—2 Health Care Delivery Orgs
—1 Consumer Org
—3 Employer Orgs
—3 Other Orgs
2004 Produce fact sheets for adolescents, seniors, and children. Partner with appropriate professional societies and advocacy groups Completed
Pocket Guide to Staying Healthy at 50+—revised Nov. 2003 (English and Spanish)
—AARP Partnership
Adult Health Timeline (for clinicians/patients)—revised Jan. 2004
Women: Stay Healthy at Any Age—printed Jan. 2004 (English and Spanish)
Men: Stay Healthy at Any Age—printed Feb. 2004 (English and Spanish)
Pocket Guide to Good Health for Children—revised May 2004 (English and Spanish)

Data Source: USPSTF AHRQ Web Site.

Data Validation: Two Stakeholders meetings, an expert panel, and four clinician focus groups were conducted. The outcomes of these meetings identified what types of preventive services are being implemented and current barriers to further implementation. Established a database to monitor the time it takes from the nomination of a topic to recommendation release, and to monitor the age of current recommendations.

Cross Reference: Strategic goals 1/5; Healthy People 2010 goals 13/14/15/16/18/19/21/22/24/25/27.

Each of the measures supports the improved delivery of clinical preventive services in the primary care setting. The prevention portfolio focuses on increasing the quality and quantity of preventive services with the goal of improving health and health care quality. In FY 2005, stakeholders' meetings were held to identify which recommendations were being used effectively and what tools are needed to improve their quality and use by others. Stakeholders recommended that the portfolio develop both printed and electronic forms of the recommendations. As a result, a pocket-size version of the Guide to Clinical Preventive Services was developed and released in July 2005. A PDA application that provides clinical decisionmaking support at the point of care was developed and made available for downloading from the AHRQ Web site. The development of a significantly improved version of the PDA application is underway and will be available in FY 2007. Partnership development continues with the National Business Group on Health, with products targeted to a new audience, the employer, identified by stakeholders in FY 2005. The prevention portfolio partnered with the National Business Group on Health to develop and release Improving Health, Improving Business: An Employer's Guide to Health Improvement and Preventive Services (available at http://www.wbgh.org/services/index.cfm).

Providing evidence-based recommendations relevant to primary care providers is essential to improving the quality of clinical preventive services and is an important goal of the USPSTF and the prevention portfolio. Producing recommendations that are timely and responsive to the needs of clinicians is a critical element in achieving this goal. The prevention portfolio has worked with the USPSTF to develop a system to review and update recommendations to meet the National Guideline Clearinghouse standard of review within 5 years. As part of this process, a Task Force work group on topic prioritization was formed that establishes a schedule for the review of new topics and the reconsideration of topics for which recommendations have previously been released. The topic prioritization process is integral to producing evidence-based recommendations that are current and useful for implementation in health care systems.

Another key component to improving the delivery of clinical preventive services is working with partners to facilitate their promotion and adoption of USPSTF recommendations. In FY 2005 we have partnered with both Federal and private organizations with the mission of improving the quality and effectiveness of health care and the health of Americans. Work continues with the Centers for Disease Control (CDC) and Prevention on the Steps to a Healthier United States initiative. AHRQ serves as the lead for the health care sector and provides guidance on ways to incorporate USPSTF recommendations into program implementation. The prevention portfolio has continued to focus on priority populations. This work includes an active partnership with the Administration on Aging and the CDC to present an intensive workshop on evidence-based prevention of disability and disease in the elderly for state programs on aging. This partnership also provides staffing for work groups of the USPSTF considering new methods of evaluating evidence for clinical preventive services for the elderly and for children.

We continue to solidify partnerships with organizations such as C-Change and Partnership for Prevention that can facilitate and support the delivery of evidence-based clinical preventive services to improve the quality of life by promoting early detection and disease prevention. We also continue to work with internal AHRQ partners and external partners (including the National Cancer Institute (NCI) and the PBRNs) develop tools and educational resources to assist providers in the primary care setting.

Care Management

Long-term Goal: Increase the delivery of evidence-based treatments for acute and chronic conditions, through research and research syntheses; development of tools; identification of effective implementation strategies; and promotion of effective policies.

Measure FY Target Result
By 2010, we will:
  • Increase by 15% the proportion of patients with diabetes, coronary heart disease (including acute myocardial infarction) and asthma who receive effective treatments
  • Reduce disparities in effective care delivered to different populations
  • Increase the proportion of patients with chronic conditions such as diabetes and asthma who practice self-care
  • Increase the proportion of clinicians who have access to evidence-based tools to guide treatment decisions

Outcome

2007 Complete 2 reports under MMA Section 1013 to inform pharmacy benefits relevant to chronic disease. Establish survey measures for patient self-management of chronic disease December 2007
2006 Begin interventions through partnerships with Federal and State agencies, professional societies, plans, and purchasers December 2006
2005 Develop partnerships with 2-4 large delivery systems (States, health plans, purchasers) to improve outcomes and reduce disparities for 1 to 3 specific chronic diseases Completed
Synthesize evidence on interventions, burden of disease, gaps in care and costs; agree on outcome measures to be tracked. Completed
Establish trends in National Quality Report categories. Completed
2004 Report on progress in core measure set in National Quality Report and National Disparities Report Completed
Identify private sector data to be used in future reports Completed
Synthesize evidence on interventions for improving diabetes and hypertension care. Completed

Data Source: National Health Care Quality Report; National Healthcare Disparities Report; RFC Healthplan Disparities Collaboratives; EPC Reports.

Data Validation: Measures in the NHQR and NHDR are based on validated surveys conducted by HHS Agencies, including AHRQ and CDC and private partners such as the National Center for Quality Assurance (NCQA).

Cross Reference: Strategic goals 1/5; Healthy People 2010 goals 3/4/5/12/13/14/16/21/24.

The long-term goal of the Care Management Portfolio is to improve care and reduce disparities for common chronic conditions such as diabetes, asthma, and heart disease. In 2005, the AHRQ Portfolio Team supported information on effective interventions for practices and health systems to improve care; worked in partnership with health plans and States to improve the care they deliver; and identified changes in the health care system that will make it easier to deliver effective chronic illness care, such as evidence-based decision support, population data management, and support for patient self-management.

In 2005, the NHQR and NHDR reported that, although care for chronic diseases such as diabetes has improved, important disparities remain, especially for Hispanic patients. AHRQ launched the Health Disparities Collaboratives, involving 9 health plans serving over 73 million members, to help plans share the latest information on how to reduce disparities for racial and ethnic minorities related to diabetes and asthma outcomes. In September 2005, we began an initiative with six State Medicaid programs (with assistance of an additional two States as faulty) to assist them in their efforts to improve the quality of chronic care delivered under primary care case management. Both of these initiatives will help develop new data sources to track efforts to improve care for diabetes in health plans and public programs. We have completed reports and disseminated two Best Practices reports on interventions to improve care of diabetes and hypertension and will release a similar report on asthma in early summer 2006. Under section 1013 of the Medicare Modernization Act, we have released the first of a series of reports on the comparative effectiveness of different treatments for chronic conditions. These reports include diabetes, osteoporosis, arthritis, and high cholesterol. An additional three reports are scheduled for release by mid-2006.

The REACHES initiative was not launched due to insufficient Agency funds when money was reprogrammed to support the Department's initiatives in health care information technology.

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