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Promoting the Use of Evidence
AHRQ supports research in areas that enhance clinical practice by building on the potential for evidence-based approaches to improve health care. Patients, providers, and payers all need information on which treatments work most effectively, whom these treatments work for, under what circumstances, and the risks involved. This information needs to be objective, reliable, understandable, and easily accessible. AHRQ has implemented several initiates to help synthesize and translate evidence-based information on health care effectiveness.
The American Heart Association Uses an AHRQ Evidence Report To Create Preventive Care Recommendations
The American Heart Association (AHA) used AHRQ's Evidence Report/Technology Assessment No. 80, Results of Systematic Review of Research on Diagnosis and Treatment of Coronary Heart Disease in Women, to help inform the recent update of AHA's Scientific Statement, Evidence-based Guidelines for the Prevention of Cardiovascular Disease in Women. The evidence report had a direct and substantial impact in formulating recommendations for improving the prevention of women's heart disease in primary care settings and increasing research on cardiovascular disease in women.
Evidence-based Practice Centers
Under the Evidence-based Practice Centers (EPC) program, AHRQ awards 5-year contracts to institutions in the United States and Canada to serve as EPCs. The EPCs review all relevant scientific literature on clinical, behavioral, and organization and financing topics to produce evidence reports and technology assessments. These reports are used for informing and developing coverage decisions, quality measures, educational materials and tools, guidelines, and research agendas. The EPCs also conduct research on methodology of systematic reviews. With this program, AHRQ became a "science partner" with private and public organizations such as the Center for Medicare & Medicaid Services and the U.S. Preventive Services Task Force.
Beginning in 2005, the EPCs began researching and preparing new evidence and technology reports as well as Comparative Effectiveness Reviews (CERs) on medications, devices, and other relevant intervention for AHRQ's Effective Health Care Program.
In 2006, the EPCs released 22 new evidence and technology reports. Examples include:
- Genomic Tests for Ovarian Cancer Detection and Management. This report found that many genomic tests that are currently used to diagnose and guide treatment of ovarian cancer are not shown to decrease the number of women who die from the disease or improve their quality of life.
- Management of Adnexal Mass. Adnexal masses are enlargements in the area of the ovaries and fallopian tubes that are sometimes a sign of ovarian cancer. The report concludes that it is not possible to estimate how well different diagnostic strategies will work. In particular, the common bimanual pelvic exam is not accurate in detecting adnexal masses or distinguishing benign from malignant masses.
- Telemedicine for the Medicare Population. This update of the 2001 report finds increased
evidence in favor of telemedicine, though
significant gaps still remain in the research.
Larger and more comprehensive clinical trials
are needed to further determine the benefits
of telemedicine in the Medicare population,
especially in the promising areas of
dermatology, psychiatry, neurology, and home health care.
- Management of Eating Disorders. The report
concludes that no medications are available
that effectively treat patients suffering from
anorexia nervosa, but a few behavioral
therapies may help prevent a relapse and
offer other limited benefits. The review also
found evidence that several medications and
behavioral therapies can help patients
suffering from bulimia nervosa and binge eating disorder.
- Cesarean Delivery on Maternal Request. This
report examined the use of cesarean delivery
in situations where there are no factors,
either for mother or child that would make
such a procedure medically advisable. The
report finds no major differences in the
results of a first-time cesarean delivery at the
mother's request and a planned vaginal
delivery but cautions that the evidence is too
weak to warrant a firm conclusion that there
are, in fact, no differences.
For more information on the EPCs and the reports available, go to http://www.ahrq.gov/clinic/epcix.htm.
The Social Security Administration Uses AHRQ Evidence Reports To Revise its Policies
The Social Security Administration (SSA) used AHRQ's Evidence Report Series, Criteria for Determining Disability in Infants and Children (Nos. 70, 72, and 73), to inform their policies on the evaluation of low birth weight in premature infants and linear and weight-related growth impairments in children. These
policies have a direct impact on the process for determining both initial and continuing eligibility for
Supplemental Security Income (SSI) benefits and, therefore, eligibility for Medicaid in many States. The SSA used the criteria from the report Criteria for Determining Disability in Infants and Children: Low Birth Weight in considering revisions to the policy for determining the most appropriate time at which to evaluate a low birth weight infant's continuing eligibility for SSI benefits.
Effective Health Care Program
The Agency's Effective Health Care Program,
launched in 2005, focuses strategically on
comparing the outcomes, clinical effectiveness,
and appropriateness of pharmaceuticals, devices,
and health care services. The Effective Health
Care Program's primary principle is that all
stakeholders should have the best available
evidence on which to make decisions about health care items and services.
The Effective Health Care Program has three approaches to research on the comparative effectiveness of different treatments and clinical practices:
- Review and synthesize knowledge through reports prepared by the EPCs.
- Promote and generate knowledge through AHRQ's Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network.
- Compile the findings and translate knowledge through the John M. Eisenberg Clinical Decisions and Communications Science Center.
Four new CERs were published in 2006. The reviews use a research methodology that
systematically and critically appraises existing
research to synthesize knowledge on a particular
topic. They also identify research gaps and make
recommendations for studies and approaches to
fill those gaps. The four CERs are briefly summarized here:
- Comparative Effectiveness Review, Effectiveness
of Noninvasive Diagnostic Tests for Breast
Abnormalities. Four common tests would miss
about 4 to 9 percent of cancer cases among
women testing negative who have average
risk for the disease, with potentially more
missed cancers among women at higher risk.
The four tests—magnetic resonance imaging,
ultrasonography, positron emission tomography scanning, and
scintimammography—would miss a
significant number of cases of cancer,
compared with immediate biopsy for women
at high-enough risk to warrant evaluation for breast cancer.
- Comparative Effectiveness of Epoetin and
Darbepoetin for Managing Anemia in Patients
Undergoing Cancer Treatment. This report
found that these drugs show no clinically
significant differences between improving
hemoglobin concentration or reducing the
need for transfusion. Studies directly
comparing epoetin and darbepoetin showed
no statistically significant difference in the
rates of thromboembolic events (blood clotting).
- Comparative Effectiveness and Safety of
Analgesics for Osteoarthritis. Two classes of
drugs commonly used to treat osteoarthritis—NSAIDs and COX-2 inhibitors—present similar, increased risks of heart attack while offering
about the same level of pain relief. The
exception is the drug naproxen, commonly
sold as Aleve® or Naprosyn®, a medication
that scientific evidence suggests presents a
lower risk of heart attack for some patients
than other NSAIDs or COX-2 inhibitors.
- Comparative Effectiveness of Management
Strategies for Renal Artery Stenosis. The
available evidence on renal artery stenosis
(RAS) treatments is inadequate to clearly
support angioplasty, with or without a stent,
over drug therapy. The published literature
did confirm that drug therapy and
angioplasty both improve blood pressure,
and they have similar impacts on slowing
down the worsening of kidney function, but
actual improvements in kidney function have
only been reported in angioplasty studies
that lacked direct comparisons with other therapies.
For more information on the Effective Health Care Program, go to http://effectivehealthcare.ahrq.gov.
Developing Evidence to Inform Decisions about Effectiveness
The Developing Evidence to Inform Decisions
about Effectiveness (DEcIDE) Network is a
network of research centers that AHRQ created
as part of its Effective Health Care Program in
2005 to generate new knowledge. The DEcIDE
Network conducts accelerated practical studies
about the outcomes, comparative clinical
effectiveness, safety, and appropriateness of
health care items and services.
The Network comprises research-based health organizations
with access to electronic health information
databases and the capacity to conduct rapid
turnaround research. Initial research focuses on
the outcomes of prescription drug use and other
interventions for which randomized controlled
trials would not be feasible or timely or would
raise ethical concerns that are difficult to
address. Other DEcIDE network projects may
focus on electronic registries, methods for
analyzing health databases, and prospective
observational or interventional studies.
DEcIDE: Registries for Evaluating Patient Outcomes
The purpose of the Registries for Evaluating
Patient Outcomes project is to produce a
reference for the design and use of successful
registries. The project will produce a Web-based
reference document defining standards and best
practices. The draft outline, based on the
stakeholder comments received in 2006, has
been prepared and is scheduled for release in
2007. A draft report is in preparation and will
include case studies to illustrate issues and
challenges in implementing registries.
DEcIDE Projects in Progress
At the close of 2006, DEcIDE had over 20
research projects in progress. The priority
conditions and topics being studied include:
- Arthritis and non-traumatic joint disorders.
- Cancer: quality measures for end-of-life care.
- Chronic obstructive pulmonary disease.
- Dementia including Alzheimer's disease.
- Depression and other mood disorders.
- Diabetes mellitus.
- Ischemic heart disease.
- Stroke and hypertension.
- Methodology for using administrative data, methods to improve safety of medication therapy, and establishing patient registries for evaluating patient outcomes.
Centers for Education and Research on
The Centers for Education and Research on
Therapeutics (CERTs) program is a national
initiative to increase awareness of the benefits
and risks of new, existing, or combined uses of
therapeutics through education and research.
The program consists of 11 research centers and
a Coordinating Center and is administered as a
cooperative agreement by AHRQ, in
consultation with the U.S. Food and Drug
In 2006, AHRQ awarded $16 million over the
next 5 years to establish four new CERTs:
- Rutgers, the State University of New Jersey in
New Brunswick, will work on improving the
safe and effective use of treatments for
mental health problems.
- University of Iowa in Iowa City will focus on
improving the safety and effectiveness of
medication use among the elderly.
- University of Texas M.D. Anderson Cancer
Center and Baylor College of Medicine in
Houston will focus on consumers and
strategies to help English- and Spanish-speaking
patients take prescription
- Weill Medical College of Cornell University
in New York City will focus on medical
devices to help clinicians, regulators, and
payers make decisions about how best to use
prosthetic orthopedic devices, including total
hip, total knee, and shoulder replacement.
Examples of recent research findings from the
CERTs program include:
- The chances of a major congenital
malformation among infants born to
mothers who took angiotensin converting
enzyme (ACE) inhibitors during the first
trimester of pregnancy were nearly three
times as high as in infants whose mothers
did not use any hypertension medications.
Researchers at the Vanderbilt University
CERT in Nashville found that major
congenital malformations were diagnosed in
856 (2.9 percent) of infants, and that 203
infants had more than one malformation.
Among infants exposed to ACE inhibitors in
the first trimester, the proportion born with
major congenital malformations was 7.1
percent, compared with 1.7 percent among
infants exposed to other antihypertensive
medications. AHRQ is sponsoring followup
studies on the effects of drug exposures
during pregnancy. The research on ACE
inhibitors and other related classes of
medications, such as the angiotensin receptor
blockers, will be conducted through its
DEcIDE research network, in consultation
with scientists from the Food and Drug
- The HMO Research Network CERT found
that nearly a third of outpatients taking the
anticoagulant warfarin were also prescribed
another drug that dangerously increased its
blood-thinning effect. Yet, when primary care doctors received computer alerts to such
drug-drug interactions at the time of
prescribing, the warfarin-interacting
medication prescription rate was reduced by
15 percent. Coinciding with the alerts, there
was an immediate and continued reduction
in the warfarin-interacting medication
prescription rate from 3,294 to 2,804 per
10,000 warfarin users per month.
- Pharmacists surveyed by researchers at the
Arizona CERT reported an average volume of
1,340 prescriptions per week processed at a
rate of nearly 17 prescriptions per hour. Over
85 percent of pharmacies possessed at least
one type of technology, with the most
predominant type being the countertop
tablet/capsule-counting device (62 percent of
pharmacies). About 55 percent of community
pharmacists surveyed in this study believed
that more than 70 percent of the
computerized drug-drug interaction (DDI)
alerts encountered in the previous week were
clinically insignificant. Community
pharmacy managers who could customize
DDI alerts on their computer system and
whose system provided detailed DDI
information were more likely to express
confidence in the pharmacy's computer
system to provide meaningful alerts. Yet half
of pharmacists surveyed stated that their
computer software did not allow
customization of DDI alerts.
More information on the CERTs and their
research is available at: http://certs.hhs.gov/about/certsovr.htm.
National Guideline Clearinghouse™
The National Guideline Clearinghouse™ (NGC)
is a Web-based resource for information on over
2,000 evidence-based clinical practice guidelines.
Since becoming fully operational in early 1999,
the NGC has had over 30 million visits and now
receives over 900,000 visits each month. The
NGC helps physicians, nurses, and other health
professionals, health care providers, health
plans, integrated delivery systems, purchasers,
and others obtain objective, detailed
information on clinical practice guidelines.
For more information about the NGC, go to: http://www.guideline.gov.
United States Preventive Services Task Force
The U.S. Preventive Services Task Force (Task
Force) was first convened by the U.S. Public
Health Service in 1984. Sponsored by AHRQ
since 1998, the Task Force is the leading
independent panel of private-sector experts in
prevention and primary care. The Task Force
conducts rigorous, impartial assessments of the
scientific evidence for the effectiveness of a
broad range of clinical preventive services,
including screening, counseling, and preventive
medications. Its recommendations are
considered the "gold standard" for clinical
preventive services. AHRQ provides technical
and administrative support, but the
recommendations of the panel are its own.
The mission of the Task Force is to:
- Evaluate the benefits of individual services based on age, gender, and risk factors for disease.
- Make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations.
- Identify a research agenda for clinical preventive care.
Examples of recent projects from the Task Force include:
- In 2006, AHRQ partnered with United Health
Foundation to distribute more than 400,000
copies of the Guide to Clinical Preventive
Services, 2006, a guide to clinical preventive
services recommendations of the Task Force,
to clinicians nationwide. The guide contains
53 new or revised recommendations on
screenings, preventive medications, and
behavioral counseling. The Guide to Clinical
Preventive Services, 2006 is available online at http://www.ahrq.gov/clinic/pocketgd.htm.
- AHRQ launched the Electronic Preventive
Services Selector (ePSS) tool for primary care
clinicians to use when recommending
preventive services for their patients. The
interactive tool can be used on a PDA or
desktop computer to allow clinicians to
access the latest recommendations from the
Task Force. The ePSS is designed to serve as
an aid to clinical decisionmaking at the point
of care and contains 110 recommendations
for specific populations covering 59 separate
preventive services topics. A clinician can
enter patient characteristics and generate a
report with the applicable Task Force
recommendations specifically tailored for
that patient. The tool is available for
download from the AHRQ Web site at http://www.ePSS.ahrq.gov.
- AHRQ also released the Adult Preventive
Services Timeline, a wall chart based on Task
Force recommendations that illustrates who
needs preventive services and when.
- Collaborating with the Centers for Disease
Control and Prevention and the National
Business Group on Health, AHRQ provided
scientific consultation and expertise to
support the development of A Purchaser's
Guide to Clinical Preventive Services: Moving
Science into Coverage. A Purchaser's Guide
provides large employers with information to
select, define, and implement preventive
medical benefits such as colorectal cancer
screening and tobacco use treatment.
- The Task Force released the following new or updated recommendations in 2006:
- Screening for Speech and Language Delay in Preschool Children—current evidence is
insufficient to recommend for or against
routine use of brief, formal screening
instruments (those that can be used in less
than 10 minutes) as a means to detect
speech and language delay in children up
to 5 years of age.
- Screening for Developmental Dysplasia of the Hip—evidence is insufficient to
recommend routine screening for
developmental dysplasia of the hip in
infants as a means to prevent adverse
- Screening and Supplementation for Iron Deficiency Anemia—in children aged 6 to
12 months who have no symptoms, the
Task Force found that there is insufficient
evidence to recommend for or against
routine screening for iron deficiency
anemia; however, children in this age
group who are at increased risk should
receive routine iron supplements. The
Task Force also recommended that
pregnant women should undergo routine
screening; however, there was insufficient
evidence to recommend for or against
routine iron supplementation in nonanemic
- Screening for Hemochromatosis—the Task
Force recommends against routine genetic
screening for hereditary hemachromatosis
in people who are asymptomatic.
- Screening for Lead Levels in Childhood and
Pregnancy—the evidence is insufficient to
recommend for or against routine
screening in children aged 1 to 5 who are
at increased risk but have no symptoms.
The Task Force recommends against
routine screening for children aged 1 to 5
who are at average risk and have no
symptoms and in pregnant women who
have no symptoms.
More information on the Task Force is on the AHRQ Web site at: http://www.ahrq.gov/clinic/prevenix.htm.
Accelerating Change and Transformation in Organizations and Networks
In March 2006, AHRQ awarded contracts to 15
partnerships for the Agency's new Accelerating
Change and Transformation in Organizations
and Networks (ACTION) program, the successor
to AHRQ's Integrated Delivery System Research
Network. ACTION is a model of field-based
research that fosters public-private collaboration
in rapid-cycle, applied research. It links many of
the Nation's largest healthcare systems with its
top health services researchers. Each ACTION
partnership has a demonstrated capacity to
"turn research into practice" for proven
interventions targeting those who manage,
deliver or receive health care services. As a
network, ACTION provides health services in a
wide variety of organizational care settings to at
least 100 million Americans.
The ACTION partnerships span all States and
provide access to large numbers of providers,
major health plans, hospitals, long-term care
facilities, ambulatory care settings, and other
care sites. Each partnership includes health care
systems with large, robust databases, clinical and
research expertise, and the authority to
implement health care interventions. ACTION
focuses on a wide variety of demand-driven,
practical, applied topics that are broadly
responsive to user needs and operational
interests and which are expected to be
generalizable across a number of settings.
More information on ACTION as well as the
partnerships can be found on the AHRQ Web site at: http://www.ahrq.gov/research/action.htm.
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