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Center for Primary Care Research and Agency for Health Care Research and
Helen Burstin, M.D., M.P.H., and David Lanier, M.D.
This article originally appeared in Medical Care, April 2001, Volume 39, Number 4, pp. 309-11.
In 1990, the Agency for Healthcare Research and Quality (AHRQ), known then as the Agency for Health Care Policy and Research, established the first federal entity whose sole focus was the sponsorship of research to enhance the knowledge base for primary care practice and policy. After more than nine years of Agency-supported primary care research, AHRQ's 1999 re-authorization legislation codified the Center for Primary Care Research (CPCR) to "serve as the principal source of funding for primary care practice research in the Department of Health and Human Services." Status as a legislated entity assures that the Center will continue to exist even if there are changes, organizational or otherwise, within the Agency. It assures greater national visibility for the discipline of primary care and primary care research efforts.
The re-authorization also affirmed the Agency's existing goals and research priorities: support improvement in health outcomes; strengthen quality measurement and improvement; and identify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures. The re-authorization directed the Agency to advance the use of information technology (IT) for quality improvement in health care. The Agency was also directed to specifically address the needs of priority populations: elderly, children, women, and minorities; residents of inner city and rural areas; and people with special health care needs.
Federal Support of Primary Care Research
The Center for Primary Care Research is one of six Agency centers that work to achieve AHRQ's overall goals. Our Center's mission directs us to support and conduct primary care research the ‘focuses on the first contact when illness or health concerns arise, the diagnosis, treatment or referral to specialty care, preventive care, and the relationship between the clinician and the patient in the context of the family and the community.'1 CPCR's core research interests have been focused in the following areas:
- Characteristics of primary care practice that lead to improvements in outcomes and quality of care.
- Effective models of organizing, financing, and managing primary care services.
- Factors that influence access to primary care services, including socioeconomic, cultural, and geographic features.
- Clinical decision-making in primary care, including an emphasis on facilitating shared patient-clinical decision-making.
- Optimal delivery of health care, including primary care services in low-income, inner-city, and rural areas.
- Strategies for integrating quality measurement and improvement into primary care settings.
- Effective strategies in primary care settings for eliminating racial and ethnic disparities in health-related outcomes.
- Improved care for the elderly and those at end of life.
- Health care workforce organization, including communication and coordination of services among members of the health care team.
- Organizational and other factors affecting the cost and quality of transitions between ambulatory and other settings, including home, hospital, and long-term care.
- Strategies for facilitating the integration of new research findings into community-based primary care practices.
To build capacity in primary care research, AHRQ supports training for primary care investigators, as well as intramural visiting researchers through our Kerr White Scholars Program. We encourage investigators to submit concept papers describing planned research projects for our review.
Directed Versus Investigator-Initiated Research
To ensure achievement of the funding objectives established for it by Congress, AHRQ devotes much of its available research dollars to directed research. Agency staff, in consultation with external stakeholders, devises explicit research questions and strategies that are communicated through requests for applications (RFAs) to the research community. AHRQ also funds research questions that are generated by the research community. However, the shift of dollars toward directed research has led to slower growth in the pool of funds available for investigator-initiated research. We will be able to fund some investigator-initiated grants this year and remain very committed to finding greater appropriations for them in the future. AHRQ has also increased the budget limit for investigator-initiated small grants to $100, 000 in total costs. We recognize research that relies on the creativity of individual researchers often produces significant advances in primary care research. AHRQ will continue to work with decision-makers to clarify the important contribution of investigator-initiated research.
CPCR and AHRQ 2001 Priorities
Through targeted appropriations, Congress may direct federal research agencies to support or conduct studies focused on specific clinical or policy-related issues. The Agency has assumed a leadership role in the Federal government's effort to address the problem of patient safety and medical errors. AHRQ's patient safety demonstration program includes a portfolio of projects that will assess the effectiveness of diverse reporting strategies and IT innovation on the identification, management, and reduction of medical errors. AHRQ has recently received more than $50 million in targeted funds for research on such topics as patient safety, clinical informatics, and health care working conditions. These new appropriations have paved the way for CPCR to add other areas of interest to our research agenda, including patient safety in office-based primary care settings and the effect of IT on primary care practice.
CPCR is the lead center for clinical informatics as AHRQ and will be responsible for an upcoming RFA on clinical informatics and patient safety. Projects funded under the RFA will support the evaluation of innovative IT applications, such as decision support systems and hand-held electronic prescription systems that can be used to improve safety and quality of care. We will also support research that examines the barriers to acceptance and adoption of IT by providers and patients, as well as effective strategies to maintain data confidentiality. AHRQ is particularly interested in informatics applications that emphasize ambulatory settings and priority populations. AHRQ's growing investment in clinical informatics will provide an important foundation for a larger domain of research critically related to CPCR's mission: how can IT be used to improve access, quality, and outcomes of primary care?
As research on the health care workforce represents a core interest for the Center, CPCR has been designated a lead center for an upcoming RFA on health care working conditions and quality of care. Projects funded under this RFA will assess the relationship between health care working conditions and the safety and quality of healthcare. We are also interested in interventions aimed at improving working conditions and quality of care, targeted to partnerships between researchers and health care organizations.
Primary Care Practice-Based Research Networks
The popularity of practice-based research networks (PBRNs) as laboratories for primary care research has grown rapidly over the past decade. The major objective of PBRNs is to move from studies based in a limited number of providers' offices to research based in networks of offices that pool their patient data to produce large, more generalizable samples in an efficient and timely manner. In September 2000, we awarded planning grants to 19 primary care PBRNs. As a group, the network involves almost 2, 000 practices or community health centers in 49 states. The practices include approximately 5, 000 primary care clinicians that care for almost 7 million patients. The practices are located in a wide variety of settings, including rural and inner-city, with racially diverse and underserved populations. The funded networks will develop PBRN-specific plans to:
- Increase electronic collection and aggregation of practice derived data.
- Increase capacity to evaluate the health care of racial/ethnic minority and underserved populations.
- Create systems to facilitate the implementation of research findings by network clinicians.
In FY01, support for these networks will be directed to specific data-related issues. We will hopefully be able to provide support for additional PBRNs in the future.
Recognizing the need for greater emphasis on the patient safety in ambulatory settings there will be funds set-aside for projects conducted by PBRNs as part of AHRQ's FY01 Patient Safety Demonstration Program. These will include $2 million set-aside for PBRN-based demonstration projects focusing on medical errors and patient safety reporting and $500, 000 set-aside to support PBRN studies on the impact of working conditions on the quality of care delivered by primary care providers.
CPCR's Intramural Research
Our strategic plan requires that we both support and conduct primary care research. With the recruitment of new leadership and a growing staff of highly skilled primary care researchers, CPCR has begun to develop a more significant portfolio of intramural primary care research conducted in-house by our own researchers. Our work is largely based on secondary data sources, such as AHRQ's Medical Expenditure Panel Survey and the Healthcare Cost and Utilization project. The goal is that exploratory intramural research, largely based on secondary data, will be able to inform primary care-related research questions and issues that we will pose to the extramural researcher community to address, using a wider range of studies.
AHRQ's slogan is "quality research for quality healthcare." To improve access, quality, and utilization of primary care services, it is critical that we conduct and support research that allows us to develop new and innovative approaches to health care delivery. Please visit the AHRQ website (http://www.ahrq.gov) for CPCR's concept paper format, as well as information on upcoming funding and training opportunities. We would welcome your input and suggestions into our user-driven research agenda.
1. Title IX – (Healthcare Research an Quality Act of 1999), Title IX of the Public Health Services Act (42 USC 299 et seq).