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In 2005, the research agenda of the Agency for Healthcare Research and Quality (AHRQ) reflected a shift to emphasize the translation of research into practice. This report presents key findings from AHRQ's 2005 research portfolio. It highlights advances and progress in moving from research to practice.
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Improving the Safety and Quality of Health Care
Using Health Information Technology to Improve Patient Safety and Quality
Promoting the Use of Evidence
Eliminating Disparities in Health Care
Developing Tools and Data for Research and Policymaking
Ensuring the Value in Health Care
Preparing for Public Health Emergencies
Looking to the Future
The U.S. health care system is considered by many to be the finest in the world. Americans are living longer, healthier lives, thanks to significant advances in biomedical and health services research.
The translation of research findings into clinical practice has raised awareness of the importance of appropriate preventive services—such as timely screenings for cancer, heart disease, and other serious conditions—and the crucial role that sustaining a healthy lifestyle plays in maintaining health and enhancing quality of life.
However, our health care system faces many challenges, including:
- Improving the quality and safety of health care.
- Ensuring access to care.
- Increasing value for health care.
- Reducing disparities.
- Increasing the use of health information technology.
- Finding new avenues to translate research into practice.
We have made progress in meeting these challenges, but we can and must do better.
The Agency for Healthcare Research and Quality (AHRQ)—one of the 12 agencies in the Department of Health and Human Services—plays an important role in responding to the challenges faced by our health care system. The Agency's mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans and support efforts to translate research into practice. One of the ways we fulfill this mission is to conduct and support health services research that:
- Reduces the risk of harm from health care services by using evidence-based research and technology to promote the delivery of the best possible care.
- Transforms research into practice to achieve wider access of effective health care services and reduce unnecessary health care costs.
- Improves health care outcomes by encouraging providers, consumers, and patients to use evidence-based information to make informed treatment choices/decisions.
The Agency's research agenda is user-driven—that is, AHRQ actively responds to the needs of its customers and we work with the users of our research to help them make measurable differences in the health care system.
In 2005, AHRQ's research agenda reflected a shift in the scope and nature of health services research to emphasize the translation of research into practice. Our goal is to make an impact on health care and the health care system.
Providers, purchasers, policymakers, researchers, and the public all need evidence-based information that not only identifies problems with patient safety, quality, and disparities in health care, but also offers solutions.
This report presents key findings from AHRQ's 2005 research portfolio. It highlights the advances made and our progress in moving from research to practice.
AHRQ's QualityTools™ Web Site Promotes Access to Health Care Quality Information
QualityTools™ is a Web-based clearinghouse for practical, ready-to-use tools for measuring and improving the quality of health care. These tools include Web sites, databases, reports, fact sheets, guides, or other mechanisms that assist health care professionals, policymakers, health plans, employers, patients, and consumers in the development, promotion, or enhancement of health care quality within a practice, organization, or in an individual's daily life. For access to these tools and information, go to http://www.innovations.ahrq.gov.
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Improving the Safety and Quality of Health Care
- Supports research on the scope and impact of medical errors.
- Identifies the root causes of threats to patient safety.
- Examines effective ways to make system-level changes to help prevent errors.
- Evaluates the effectiveness of information technology as a way to reduce errors and increase efficiency.
Dissemination and translation of these research findings and methods to reduce errors is also critical to improving the safety and quality of health care. To make changes at the system level, there must be an environment, or culture, within health care settings that encourages health professionals to share information about medical errors and ways to prevent them.
Partnerships in Implementing Patient Safety
In 2005, AHRQ awarded over $9 million for Partnerships in Implementing Patient Safety grants to fund 17 projects over 2 years. These projects will assist health care institutions in implementing safe practice interventions that show evidence of eliminating or reducing risks, hazards, and harms associated with the process of care. The goals of these projects are to:
- Identify the medical errors, risks, hazards, or harms.
- Develop an intervention implementation plan.
- Demonstrate the impact of the intervention on the process of care.
- Determine the efficacy of the intervention for adoption.
The projects focus on safe practice interventions that can be generalized to other settings of care and for use by those who wish to adapt and/or adopt the safe practices interventions to improve patient safety. About half focus on reducing medication errors. Others are focused on applying interventions to improve health care team communications. AHRQ will widely disseminate the tools developed from the projects, including the implementation toolkits, for adaptation and/or adoption by other institutions. These implementation projects will inform AHRQ, providers, patients, payers, policymakers, and the public how safe practice interventions can be successfully implemented in diverse health care settings and lead to safer and better health care for all Americans.
For a complete list of projects, go to http://www.ahrq.gov/qual/pips.htm.
Patient Safety Network
AHRQ launched the Patient Safety Network (PSNet), a "one-stop" online portal that provides resources for improving patient safety and preventing medical errors. It is the first comprehensive effort to help health care providers, administrators, and consumers learn about all aspects of patient safety.
The Web site provides a broad range of information on patient safety resources, tools, and conferences. PSNet users can customize the site around their unique interests and needs by creating a "My PSNet" page. Weekly updates are available to subscribers on patient safety findings, literature, tools, and conferences. PSNet can be found at http://psnet.ahrq.gov.
Advances in Patient Safety: From Research to Implementation
AHRQ released Advances in Patient Safety: From Research to Implementation, a 4-volume set of 140 peer-reviewed articles representing an overview of patient safety studies funded by AHRQ and other government agencies. The articles contain information on nearly every dimension of patient safety, including new research findings on medication safety, technology, investigative approaches to better treatment, process analyses, human factors, and practical tools for preventing medical errors and harm. The four-volume set is available at http://www.ahrq.gov/qual/advances.
Hospital Survey on Patient Safety Culture
AHRQ partnered with Premier, Inc., the Department of Defense, and the American Hospital Association to release the Hospital Survey on Patient Safety Culture, a new tool to help hospitals and health systems evaluate employee attitudes about patient safety within their facilities. The survey can also be used to track changes in patient safety over time and evaluate the impact of patient safety interventions. It can be found at http://www.ahrq.gov/qual/hospculture/.
Hospital Survey on Patient Safety Culture Helps Providers Set Priorities
The Palo Alto Medical Foundation in San Francisco administered the Hospital Survey on Patient Safety Culture in September 2005 to 1,180 staff members and received responses from 73 percent of the employees. Palo Alto is using the survey to establish a baseline measurement of employee perceptions to see how their combined efforts for improvement are working. Results of the survey helped establish priorities. For example, 76 percent of those responding had never completed an incident report, an area that Palo Alto will make an immediate priority.
Recent Research Findings on Patient Safety and Quality of Health Care
- Interns who worked the traditional 30 consecutive hours every other shift in intensive care units made 36 more serious medical errors than they did on an intervention schedule that limited work shifts to 16 hours and reduced weekly work from about 80 hours to 63. The rate of serious medication errors was 21 percent greater on the traditional schedule than on the new schedule.
- Over 20 percent of the patients admitted to two intensive care units experienced an adverse event. Of the adverse events, 45 percent were preventable and many involved medications—such as giving patients the wrong dose. Over 90 percent of all incidents occurred during routine care, not on admission or during an emergency intervention.
- Real-time safety audits performed during routine hospital neonatal intensive care unit work can quickly detect a broad range of medical errors. The audit system detected 338 errors during a 5-week study period.
AHRQ Announces Audio Newscast Series: Healthcare 411
In 2005, AHRQ created a new service to help Americans become informed about the Agency's latest health care research findings, news, and information. It's Healthcare 411—a weekly audio newscast that features synopses of AHRQ's latest findings and information on current health care topics.
The weekly newscasts will be distributed through Apple® iTunes®, Yahoo® PodCasts, and other Web sites that provide health information to their customers, patients, students, employees, or health care personnel. Parts of the audio newscasts are also used by the Department of Health and Human Services' new radio service, Healthbeat, and they are distributed to radio stations across the country as well as audio networks within stores such as Giant Food and Wal-Mart.
The newscasts can be heard through a computer or downloaded to a portable digital player such as an iPod® at www.healthcare411.org.
Helping Consumers Understand and Get Quality Health Care
In 2005, AHRQ released several publications to help consumers identify high-quality health care and make decisions about the care they receive. These are a part of AHRQ's consumer education campaign to help people take a more active role in their own health care:
- Guide to Health Care Quality: How To Know It When You See It (http://www.ahrq.gov/consumer/guidetoq). This publication includes steps that consumers can take to improve their quality of care and explains the difference between clinical measures and consumer ratings. It also includes Web sites and telephone numbers for selected organizations and other resources.
- Next Steps After Your Diagnosis: Finding Information and Support (http://www.ahrq.gov/consumer/diaginfo.htm). This booklet is designed to help patients who have been diagnosed with an illness learn more about their condition and treatment options. It includes a list of 10 important questions for patients to ask their doctors, designed to help people understand their disease or condition, how it might be treated, and what they need to know before making treatment decisions.
- Having Surgery? What You Need to Know. This publication is intended to help patients make informed decisions when planning for surgery. It includes questions to help patients obtain needed information on such issues as anesthesia, alternatives to surgery, recovery times, costs, doctor qualifications, second opinions, and more. The publication can be viewed and downloaded at http://www.ahrq.gov/consumer/surgery/surgery.htm.
- Tips for Taking Medicines Safely. This video Web program features information from AHRQ to help consumers take medicines safely.
For additional consumer publications and resources, go to http://www.ahrq.gov/consumer.
AHRQ Reaches Out to Help Consumers Understand Health Care Quality
In 2005, AHRQ held three consumer town hall meetings in Chapel Hill, Oklahoma City, and Philadelphia. More than 300 participants heard about national and local efforts to improve health care quality. Attendees also received AHRQ's Guide to Health Care Quality, which gave them more information on what they can do to become active and informed members of their health care team.
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Using Health Information Technology to Improve Patient Safety and Quality
For over 30 years, AHRQ has funded and supported the use of health information technology (HIT) to improve health care. Since 2004, over $166 million has been awarded in grants and contracts to help communities, hospitals, providers, and health care systems develop, implement, and evaluate health information technologies.
The overall goal is to improve patient safety by reducing medical errors; increasing information sharing between providers, laboratories, pharmacies, and patients; ensuring safer patient transitions between health care settings; and reducing duplicative and unnecessary testing.
AHRQ also created the National Resource Center for Health Information Technology. The resource center will aid grantees and other Federal partners by providing technical assistance and a focus for collaboration. It will serve as a repository for best practices and lessons learned, and offer needed tools to help providers explore the adoption and use of HIT to improve patient safety and quality of care.
For more information on AHRQ-funded projects, findings, and resources for planning, implementing, and evaluating HIT, go to http://healthit.ahrq.gov/.
Recent Research Findings on HIT
- Adding psychotropic medication dosing and selection guidelines to a computerized order entry system improved prescribing and reduced falls among elderly inpatients at one hospital. Use of computerized guidelines increased adherence to recommended daily doses from 19 to 29 percent and reduced prescribing of nonrecommended drugs from 10.8 percent to 7.6 percent of total orders. Patients whose doctors used the guidelines also had a lower in-hospital fall rate.
- Smaller medical groups report lower adoption rates of an electronic health record (EHR) system, noting that cost is the top barrier to implementation. The average purchase and implementation cost of an EHR system is approximately $32,000 and maintenance costs are about $1,500 a month per full-time physician. Medical groups with 20 or more full-time physicians have a 19.5 percent adoption rate compared with 18.9 percent for groups with 11 to 20 full-time physicians, 15.2 percent for groups with 6 to 10 full-time physicians, and 12.5 percent for groups with 5 or fewer full-time physicians.
- While computerized physician order entry (CPOE) is expected to reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors. One hospital study found 22 situations in which the CPOE system increased the probability of medication errors. Flaws identified by the study included selection of the wrong patient because of difficulties in reading computer screens, inability to view all of some patients' medications on one screen, delayed entry about the administration of drugs, and computer downtime for maintenance or repair.
AHRQ Funds New IT System In a Hospital Designed Around Patient Safety Principles
A new IT system was implemented at St. Joseph's Community Hospital in West Bend, WI, a brand-new 80-bed facility designed with an emphasis on patient safety. St. Joseph's is a nonprofit, acute care hospital with more than 6,100 admissions a year. The new hospital is designed around a specific set of safety-focused principles, including better visibility of patients to staff, increased patient involvement with care, reduced staff fatigue, automation where possible, and standardization. Specific adverse events were targeted for prevention through better design, including operative and post-operative complications and infections, medication errors, patient falls, wrong-site surgeries, and MRI hazards. Scheduling, pharmacy, and medication administration are all being automated and centralized in the
new IT system and patients will be able to access portions of their medical records from home or from their bedsides as inpatients.
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Promoting the Use of Evidence
AHRQ has a long history of research on enhancing clinical practice and the potential for evidence-based approaches to improve health care. This evidence needs to be understandable, easily accessible, objective, and place the ever-increasing number of scientific studies into context. AHRQ is committed to accelerating the adoption of research findings into practice so that all Americans benefit from advances in biomedical science and health services research.
Evidence-based Practice Centers
Created in 1997, AHRQ's Evidence-based Practice Centers (EPCs) have released over 130 new evidence and technology reports. The reports are intended to inform health plans, providers, purchasers, and the health care system as a whole by providing essential science-based information that can improve the quality of health care. The EPCs systematically review relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate. In 2005, the EPCs released 29 new reports. Some of these reports are highlighted below:
- Pharmacological and Surgical Treatment of Obesity. This report concluded that surgery for extremely obese patients who have tried and failed to lose weight with exercise and diet may be more effective for weight reduction. Surgery may help these patients control their blood pressure, diabetes, and other health problems that can result from obesity such as heart disease, musculoskeletal disorders, and sleep apnea.
- Melatonin for Treatment of Sleep Disorders. Melatonin supplements taken to treat sleep problems appear to be safe when used over a period of days or weeks, but when used over months or years, their safety is unclear. Researchers also found there is some benefit in using melatonin in the short term to treat delayed sleep-phase syndrome in people with primary sleep disorders. However, melatonin seems to have no effect on sleep efficiency, sleep quality, wakefulness after sleep onset, total sleep time, or time spent in rapid eye movement (REM) sleep.
- Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. This report found evidence indicating that depression is as common in women during pregnancy as it is after giving birth. The report also found that health care providers and patients may not recognize depression during pregnancy because its symptoms, such as tiredness, trouble sleeping, emotional changes, and weight gain, can also occur with pregnancy. Researchers found that psychotherapy and/or antidepressants can be effective in treating women with perinatal depression.
- Post-Myocardial Infarction Depression. This report indicates that one in five patients hospitalized for heart attack suffers from major depression. These patients may be more likely than other heart attack patients to need hospital care again within a year for a cardiac problem and are three times as likely to die from a future attack or other heart problems.
For more information on the EPCs and the reports available, go to http://www.ahrq.gov/clinic/epc.
AHRQ Evidence Report Leads to Use of Quality Improvement Strategies
Bon Secours Health System, a member of the Premier alliance, is using six of the nine quality improvement (QI) strategies outlined in AHRQ's Evidence Report, Closing the Quality Gap, as the template for its "Quality First" initiative. AHRQ's QI strategies serve as the platform for quality improvement activities among Bon Secours hospitals. This initiative, a best-practices diffusion program, is being implemented across each of Bon Secours' 13 member acute-care hospitals. The six AHRQ QI strategies included in the program are:
- Provider reminder systems.
- Facilitated relay of clinical data to providers.
- Audit and feedback.
- Provider education.
- Organizational change.
- Financial incentives, regulation, and policy.
U.S. Preventive Services Task Force
The U.S. Preventive Services Task Force (USPSTF) is an independent panel of private-sector experts in prevention and primary care sponsored by AHRQ. It conducts rigorous, impartial scientific assessments of the effectiveness of a broad range of clinical preventive services, including screening tests, chemoprevention, immunizations, and counseling. The USPSTF also develops recommendations that are considered the gold standard for clinical preventive services.
In 2005, the USPSTF released The Guide to Clinical Preventive Services 2005: Recommendations of the U.S. Preventive Services Task Force. This easy-to-use, 6 x 9-inch pocket guide includes the USPSTF recommendations on prevention and early detection for cancer; heart and vascular diseases; infectious diseases; injury and violence; mental health conditions and substance abuse; metabolic, nutritional, and endocrine conditions; musculoskeletal conditions; and obstetric and gynecological conditions. The pocket guide contains a summary table in the front for quick reference.
Another option for accessing USPSTF recommendations is AHRQ's online personal digital assistant (PDA) program, the Electronic Preventive Services Selector (ePSS). The program lets users search USPSTF recommendations by patient age, sex, and pregnancy status. The tool, updated frequently with the newest recommendations, can be downloaded to a PDA or used on the Web at http://pda.ahrq.gov.
Some of the new recommendations issued in 2005 by the USPSTF include:
To obtain more information about the USPSTF and access its clinical decision support tools and reports, go to http://www.ahrq.gov/clinic/prevenix.htm.
Effective Health Care Program
In 2005, AHRQ launched its new Effective Health Care Program. Authorized under Section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the Effective Health Care Program is designed to help clinicians and patients determine which drugs and other medical treatments work best for certain health conditions. The new program includes three components:
- Comparative Effectiveness Reviews will be developed by AHRQ's existing network of 13 EPCs. The EPCs will focus on comparing the effectiveness of different treatments, including drugs, and will identify gaps in knowledge, indicating where new research is needed.
- Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) research centers will carry out accelerated studies, including research focused on filling the gaps about treatment effectiveness. The 13 DEcIDE centers will analyze data from insurers, health plans, and other partner organizations, including Medicare, to answer questions about the use, benefits, and risks of medications and other therapies.
- The John M. Eisenberg Clinical Decisions and Communications Science Center, named in honor of the late AHRQ Director, John M. Eisenberg, M.D., will work to improve the communication of research findings to a variety of audiences, including consumers, clinicians, payers, and health care policymakers. The Eisenberg Center will also conduct its own research on the effective, rapid, and efficient communication of research findings into medical practices.
In 2005, AHRQ released its first comparative effectiveness review, Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease. This report found that a class of drugs called proton pump inhibitors can be as effective as surgery in relieving the symptoms of gastroeseophageal reflux disease for the majority of patients whose disease is uncomplicated.
For more information on the Effective Health Care Program, go to http://effectivehealthcare.ahrq.gov.
Centers for Education and Research on Therapeutics
The Centers for Education and Research on Therapeutics (CERTs) demonstration program is a national initiative to conduct research and provide education that advances the optimal use of therapeutics (i.e., drugs, medical devices, and biological products). The program consists of seven research centers and a Coordinating Center and is administered as a cooperative agreement by AHRQ in consultation with the Food and Drug Administration. As part of the Effective Health Care Program, in 2005, the CERTs centers began completing seven methodologic projects related to comparative effectiveness under Section 1013 of the MMA.
Research findings from the CERTs for 2005 include:
- Patients with acne who use topical or oral antibiotics for more than 6 weeks are about twice as likely to develop and seek care for an upper respiratory tract infection than patients not using antibiotics.
- The antimalarial drug hydroxychloroquine (HCQ) appears to reduce the risk of new damage to joints, connective tissues, and organs in patients who have systemic lupus erythematosus, especially if they have not yet developed damage when they begin HCQ treatment. Patients receiving HCQ who had no damage had a 45-percent decrease in the risk of damage accrual.
- Using group or individual academic detailing helped increase the use of diuretics or beta-blockers to treat hypertension by 13.2 percent and 12.5 percent (respectively) compared with 6.2 percent for usual care practices that received only a mailed practice guideline.
Additional information on the CERTs program and its findings can be found at http://www.ahrq.govhttp://certs.hhs.gov/about/certsovr.htm.
National Guideline Clearinghouse™
The National Guideline Clearinghouse™ (NGC) is a Web-based resource for information on over 1,800 evidence-based clinical practice guidelines. Since becoming fully operational in early 1999, the NGC has logged over 21 million visits and now receives over 600,000 visits each month. The NGC helps physicians, nurses, and other health professionals obtain objective, detailed information on clinical practice guidelines. Users can access abstracts, link to full-text guidelines where they are available, and generate side-by-side comparisons for any combination of two or more guidelines.
Recent enhancements to the NGC include:
- Palm®-based PDA downloads of the complete NGC summary for all guidelines represented in the data base.
- An electronic forum, NGC-L, for exchanging information on clinical practice guidelines, their development, implementation, and use.
For more information about the NGC, go to http://www.guideline.gov.
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Eliminating Disparities in Health Care
AHRQ is leading Federal research efforts to develop knowledge and tools to help eliminate health care disparities in the United States. AHRQ supports and conducts research and evaluations of health care with emphasis on disparities related to race, ethnicity, and socioeconomic status. The Agency focuses on priority populations including minorities, women, children, the elderly, low-income individuals, and people with special health care needs such as people with disabilities, or those who need chronic care or end-of-life care.
AHRQ recently released the 2005 National Healthcare Quality Report (NHQR) and its companion document, the 2005 National Healthcare Disparities Report (NHDR). These reports, issued annually, measure quality and disparities in four key areas of health care: effectiveness, patient safety, timeliness, and patient centeredness.
The NHQR employs a wide range of measures, including health care outcomes such as hospital-acquired infections and reductions in deaths from certain diseases. It also measures how well the health care system is using specific treatments known to work most effectively. The NHDR compares these measures by race and ethnicity and by income. It also measures access to care, using indicators such as health insurance status and frequency of visits to a physician. This year, for the first time, the report also shows trends in health care disparities from year to year.
Examples of findings in the NHQR and NHDR include:
- Rates of late-stage breast cancer decreased more rapidly from 1992 to 2002 among black women (169 to 161 per 100,000 women) than among white women (152 to 151 per 100,000), resulting in a narrowing disparity.
- Treatment of heart failure improved more rapidly from 2002 to 2003 among American Indian Medicare beneficiaries (69 percent to 74 percent) than among white Medicare beneficiaries (73 percent to 74 percent), resulting in elimination of this disparity.
- The diseases and populations that showed the most improvement in quality measures are diabetes, heart disease, respiratory conditions, nursing home care, and maternal and child health care. The overall rate of change for these measures was 5.4 percent.
- The five core measures of patient safety improved by 10.2 percent. These core measures included four complications of care (central line-associated bloodstream infection in intensive care unit (ICU) patients; ICU patients who develop ventilator-associated pneumonia; Medicare beneficiaries with postoperative pulmonary embolus or deep vein thrombosis; and Medicare beneficiaries with central venous catheter-associated mechanical complication) and one measure for prescribing medications (the elderly with inappropriate medications).
The reports are available online at http://www.innovations.ahrq.gov.
Diabetes Care Quality Improvement: A Resource Guide for State Action
In partnership with the Council of State Governments, AHRQ released Diabetes Care Quality Improvement: A Resource Guide for State Action and its companion publication A Workbook for State Action. Both the Resource Guide and Workbook are designed to help States assess the quality of diabetes care and develop quality improvement strategies. The Resource Guide and Workbook provide an overview of the factors that:
- Affect quality of care for diabetes.
- Present the core elements of health care quality improvement.
- Assist State policymakers in using the data from AHRQ's 2003 NHQR for planning State-level
quality improvement activities.
- Provide a variety of best practices and policy approaches that national organizations, the Federal
government, and States have implemented related to diabetes quality improvement.
The Resource Guide and Workbook are available online at http://www.ahrq.gov/qual/diabqualoc.htm.
National Health Plan Learning Collaborative To Reduce Disparities and Improve Quality
AHRQ launched a new partnership designed to help reduce disparities in health care for people with diabetes and other conditions. "The National Health Plan Learning Collaborative To Reduce Disparities and Improve Quality" is the first national effort to go beyond research and actively tackle racial and ethnic inequities in health care service delivery. Over 3 years, the collaborative is testing ways to improve the collection and analysis of data on race and ethnicity, matching those data to the existing Health Plan Employer Data and Information Set Quality Measures, developing quality improvement interventions that close the gaps in care, and producing results that can be replicated by other health insurers and providers serving Medicare, Medicaid, and commercial populations.
This collaborative brings together nine of the Nation's largest health insurance plans:
- Harvard Pilgrim Health Care.
- Highmark Inc.
- Kaiser Permanente.
- Molina Healthcare.
- UnitedHealth Group (UnitedHealthcare, Ovations, and AmeriChoice).
- WellPoint, Inc.
Several other organizations are participating.
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