AHRQ Annual Highlights, 2009 (continued)
Knowledge Transfer and Implementation Program
Translating research into practice as quickly as possible is a high priority for AHRQ. As part of its mission to develop programs for disseminating and implementing the results of Agency activities, the Office of Communications and Knowledge Transfer (OCKT) directs a Knowledge Transfer and Implementation Program to promote the use of AHRQ tools, products, and initiatives by various stakeholders. Working with contractors, Knowledge Transfer activities consist of a series of projects that disseminate and implement AHRQ products, tools, and research to a specific target audience. The goals are to:
- Enhance awareness about AHRQ's tools, research, and products.
- Increase knowledge about the suite of AHRQ tools available.
- Assist target audiences in the actual implementation of AHRQ tools, research, and products.
- Gain feedback regarding the successes and barriers that organizations are experiencing in implementing AHRQ initiatives.
- Develop case studies showing how target audiences have actually disseminated and implemented specific AHRQ products.
Pharmacy Suite of Tools
By developing partnerships with key organizations and associations, this project disseminated and promoted products and tools developed from AHRQ's Effective Health Care Program, which supports the Comparative Effectiveness Portfolio. In FY09, this project established collaborative relationships with six pharmacy-related specialty societies to help disseminate Comparative Effectiveness reports and articles to the pharmacy community including the American Pharmacists Association, American Society of Health-System Pharmacists, American College of Clinical Pharmacy, Academy of Managed Care Pharmacy, American Association of Colleges of Pharmacy, and American Society of Consultant Pharmacists. In addition, in partnership with the American Pharmacy Association, the project produced three Web conferences based on Comparative Effectiveness reports and articles. Over 600 people attended the Web conferences, which included certified continuing pharmacy credits for participants:
- Comparative Effectiveness, Safety, and Indications of Insulin Analogues in Premixed Formulations for Adults with Type 2 Diabetes—discussed the effectiveness and safety of premixed insulin analogues as well as practical and effective therapy options for patients with diabetes.
- Atypical Antipsychotic Drugs and the Risk of Sudden Cardiac Death—described AHRQ's Comparative Effectiveness program and the scientific resources it provides to inform health care decisions and evidence-based practice, compared the risk of sudden cardiac death associated with the use of the two classes of antipsychotic drugs.
- Comparative Effectiveness Research: Relevance and Applications to Pharmacy—explains comparative effectiveness research, differentiates pharmaceutical comparative effectiveness studies from traditional efficacy studies, and describes how to apply comparative effectiveness research to pharmacy practice.
Purchasers Suite of Tools
This project promoted selected AHRQ products to purchasers of health care in the private sector in support of the Value Research, Comparative Effectiveness, Patient Safety, and Prevention Care Management Portfolios. Three Web conferences were developed and conducted as part of a series of events targeted to the purchaser and employer audience. Over 200 people participated in the Web conferences.
- Setting the Quality Agenda—focused on AHRQ tools designed to help users assess the quality of care in their communities and identify gaps or variations in the quality of care provided. Tools that were featured included HCUPnet, EQUIPS (now known as MONAHRQ), Prevention Quality Indicators Mapping Tools, and CAHPS®.
- Promoting a Healthy Workforce—employers, employer coalitions, other purchasers, and consumers were invited to join experts from AHRQ to discuss how patient-focused guides, videos, and other tools such as recommendations from the U.S. Preventive Services Task Force and the Comparative Effectiveness Research Guides for Consumers can support employees who want to be more active and involved in their health care.
- Principles of Effective Public Reporting—experts discussed the principles of effective public reporting and talked about tools and resources developed by AHRQ to promote effective public reporting and an increased understanding around quality data in health care. Two of the featured AHRQ tools were the Health Topics Model Report and the Composite Model Report.
Electronic Preventive Services Selector (ePSS)
The AHRQ Electronic Preventive Services Selector (ePSS) project supported the Prevention/Care Management Portfolio. The ePSS is an interactive tool, initially designed for use on PDAs or desktop computers, to help primary care clinicians incorporate the screening, counseling, and preventive services recommendations of the USPSTF that are appropriate for their patients. In FY09, AHRQ sponsored a project to examine the feasibility of and potential approaches to integrating the ePSS tool in electronic formats, such as reminder systems and electronic medical records (EMR). AHRQ worked with organizations and tested specific approaches, as follows:
- Prosocial Applications, Inc. provides a personal health record system services called SmartPHR™, which provides health care planning and communication tools for patients with chronic conditions. ePSS access was presented to SmartPHR™ customers as an informational and education resource to assist patients to make more informed decisions with their care providers. The intent was to also provide the ePSS via Web services application programming interface in a later version of the SmartPHR™.
- The Indian Health Service (IHS) is the Federal agency responsible for providing medical and public health services to members of federally recognized tribes and Alaska Natives. The electronic medical record used by the IHS is the Resource and Patient Management System (RPMS). A gap analysis was conducted to determine the logic and data elements utilized by AHRQ's ePSS for identifying preventive services and those used by the IHS system. It was determined that the RPMS contains sufficient data elements so that the USPSTF recommendations can easily be built into the Best Practice and Health Maintenance sections of the existing RPMS Health Summary.
- Michigan State University/Clinical Content Consultants conducted a proof of concept for the ePSS using a commercial EMR that focused on demonstrating the viability of utilizing the ePSS tool. The proof of concept successfully demonstrated a Web service call and the use of a PDF file digital library to access recommendations of the Task Force.
- The State of Oregon's Division of Medical Assistance Programs (DMAP) oversees the Oregon Health Plan (OHP), which is a public and private partnership that ensures universal access to a basic level of health care for Oregonians. DMAP's approach was to utilize the ePSS from a population perspective using the OHP. Clients are covered from DMAP's Prioritized List of Health Services, which uses Task Force recommendations as the baseline for this list and the ePSS as a means of monitoring and administrating services in the OHP. DMAP plans to fully integrate the ePSS with its information system.
Hospital Product Line
This project supported the Patient Safety Portfolio. Its purpose was to increase awareness of AHRQ among hospitals and health systems and help hospitals enhance their quality and safety by implementing AHRQ products and tools. Technical assistance was provided to individual hospitals as well as groups of hospitals in the form of in-person meetings, Web conferences, and conference calls. As a result of this project:
- Critical access hospitals in Nebraska and North Dakota hospitals were trained to use TeamSTEPPS to improve the safety culture in their respective hospitals. A subset of the Nebraska hospitals conducted the AHRQ Hospital Culture Survey pre- and post-training to document the impact of the training.
- Hospitals in New York, Illinois, and Iowa were trained on the Preventing Hospital-Acquired Venous Thromboembolism (VTE): A Guide for Effective Quality Improvement toolkit. Many of these hospitals have implemented new VTE prophylaxis protocols, and have changed how they measure prophylaxis rates as a result.
- Several hospitals implemented the Improving Patient Flow in the Emergency Department (ED) Toolkit and as a result decreased the amount of time it took a patient to see a clinician as well as the number of patients leaving the ED without being seen.
Public Health Emergency Preparedness: Tools for States
This project supported the Prevention/Care Management Portfolio. It assisted communities in identifying and using AHRQ products in the development of their emergency response plans and to facilitate the broad dissemination and uptake of AHRQ emergency preparedness products by local emergency preparedness planners, community partners, national associations, and other Federal agencies. Mono/Inyo Counties in California, and Howard County, Maryland, were selected for implementation of AHRQ products. As a result:
- Both Mono/Inyo and Howard counties implemented AHRQ resources in their emergency preparedness plans. AHRQ staff and project consultants helped to assess sites' organizational structures, population needs, gaps in preparedness plans, and opportunities for engagement.
- AHRQ products that were used and/or disseminated include:
- Alternate Care Site Selection Tool/Disaster Alternate Care Facilities: Selection and Operation (DACF)
- Emergency Preparedness Resource Inventory (EPRI)
- Adapting Community Call Centers for Crisis Support (Call Centers)
- Community-Based Mass Prophylaxis: A Planning Guide
- BERM 2.0 (Computer Staffing Model for Bioterrorism Response)
- Hospital Surge Model
- Mass Evacuation Transportation Model
- Home Health Care During an Influenza Pandemic: Issues and Resources Report.
Public Health Emergency Preparedness: Web Conferences
The four national Web conferences on public health emergency preparedness supported the Prevention/Care Management Portfolio and allowed wide dissemination of AHRQ's public health emergency preparedness products to a broad field of stakeholders. Audiences ranged in size from 700-1,300 participants that included Federal, State, and local public health agencies, health care facilities, and policymakers.
- Lessons Learned from the Field of Emergency Preparedness—focused on supporting community emergency preparedness planning in the event of a natural or man-made disaster that could overwhelm health care facilities with a surge of patients with diverse medical needs.
- Planning and Practicing for a Disaster—engaged developers of selected AHRQ preparedness tools, as well as planners who have used the tools, to demonstrate and give insights on managing mass medical care, resource allocation, and patient evacuation.
- Planning and Preparedness for Children's Needs in Public Health Emergencies—highlighted the crucial differences between adults and children and responding to these with research to help address the needs of children in emergencies. In addition to the resources for protecting and caring for children who are in a hospital or a school during a public health emergency, speakers shared perspectives on both clinical preparedness and school-based preparedness from the National Commission on Children and Disasters, the Assistant Secretary for Preparedness and Response's Hospital Preparedness Program, and the U.S. Department of Education.
- Planning for an Influenza Pandemic in the Home Health Care Sector—speakers addressed concerns that a pandemic influenza outbreak could exceed the industry's current capacity to respond if hospital patients who are well enough to be discharged but who still need care are added to the half-million patients currently receiving home health care services.
- AHRQ products that were used and/or disseminated through national Web conferences:
- Mass Medical Care with Scarce Resources.
- Rocky Mountain Regional Care Model for Bioterrorist Events.
- Emergency Preparedness Resource Inventory (EPRI).
- Mass Evacuation Transportation Model.
- Hospital Surge Model.
- National Mass Patient and Evacuee Movement, Regulating, and Tracking System: Recommendations.
- Tool for Evaluating Core Elements of Hospital Disaster Drills.
- School-Based Emergency Preparedness: A National Analysis and Recommended Protocol.
- Pediatric Hospital Surge Capacity in Public Health Emergencies.
- Home Health Care During an Influenza Pandemic: Issues and Resources.
- Mass Casualty Events Models and Tools To Support Planning and Response for Pandemic and All Hazards Preparedness.
Using AHRQ technology assessments to inform coverage decisions
As a result of AHRQ's Knowledge Transfer Program, several State Medicaid policymakers have used the AHRQ Technology Assessment, Non-Invasive Imaging for Coronary Artery Disease, to help inform coverage decisions in their States. The technology assessment, which examined the scientific evidence on direct non-invasive imaging tests for evaluating coronary artery disease, has proven useful to the Medicaid Medical Directors' Learning Network.
One of the imaging tests examined in the technology assessment is computed tomographic angiography (CTA), a specialized x-ray that examines blood flow in arteries when they are filled with a contrast material. The report concluded that the evidence base for CTA's ability to identify, quantify, or characterize coronary artery disease was limited.
James J. Figge, MD, MBA, Medical Director, Office of Health Insurance Programs, New York State Department of Health, notes that the AHRQ technology assessment was "the single most important item we considered" in making an initial coverage decision for CTA. Robert Moon, Medical Director, Office of Health Policy, Alabama Medicaid Agency, used the report findings to analyze whether the State agency should conduct in-house prior authorizations for CTA or use a prior authorization contractor. Alabama officials used the technology assessment findings to support Medicaid's decision not to cover this procedure unless a unique medical justification was supplied.
Medicaid Medical Directors Learning Network
The Medicaid Medical Directors Learning Network (MMDLN) provided a forum for clinical leaders of State Medicaid programs to discuss their most pressing needs as policymakers, use relevant AHRQ products and related evidence to address their concerns, and determine their needs for future research. Through this project, they connected with other organizations interested in using evidence-based medicine to make policy decisions that impact Medicaid programs. The MMDLN supported the Comparative Effectiveness and Value Research Portfolios in FY09 through the following activities:
- For the first time, the Medicaid Medical Directors were asked to develop several clinical tracks at the annual National Association for State Medicaid Directors Fall 2008 meeting. Two of these tracks featured AHRQ products. One focused on pediatric obesity and featured the EPC report, Effectiveness of Weight Management Programs in Children and Adolescents. The other session discussed the Atypical Antipsychotic Use in Children project, which is a collaboration between 14 Medicaid Medical Directors and the Rutgers CERT to develop a workbook for other States interested in conducting their own data analyses on trends in atypical antipsychotic prescribing.
- The MMDLN held its 9th meeting with 34 members representing 31 States and the District of Columbia attending. Session topics included quality improvement opportunities for hospital readmissions, efforts to create a comprehensive quality measurement system for children's health care, an update on CMS's quality framework and other Medicaid quality-related initiatives, an interactive topic refinement exercise to gain feedback on two topics under review to become AHRQ EHC Program reports, and an opportunity to review and discuss how AHRQ resources are being used to make decisions. Overall, the MMDLN has nominated 28 topics to the EHC Program, and 19 of those topics are moving forward for comparative effective research either as a review, an update, a technical brief, or as potential new research.
- Chronic Disease Cost Calculator—a Web conference on the tool developed by the CDC and based on AHRQ's MEPS database for 74 State policymakers representing 28 States and the District of Columbia. Experts provided an overview of the calculator and a live demonstration on how to use the tool using the State of Kansas as an example.
- Integration of Mental Health/Substance Abuse and Primary Care—a Web conference on the EPC report, an expert from the Minnesota EPC gave an overview of the report to 17 Medicaid officials. Wyoming Medicaid presented their State's program to integrate primary care and mental health. During the questions and answer session, participants were particularly interested in how to incorporate the research findings and promising State practices into their respective Medicaid programs.
- EQUIPS (now MONAHRQ)—this Web conference provided an overview of the design and functionality of the EQUIPS tool and outlined current data considerations in the alpha testing phase to 39 participants from 24 States. The discussion included performance measures, customization of the Web output, and public reporting. Following the call, several participants responded that they would share this application with colleagues and begin discussions on future implementation. Four organizations also expressed interest in becoming beta testers.
- 2008 State Snapshots—this Web conference provided a live demonstration on how to use the Snapshots for 35 participants. New York's Medicaid Medical Director and the Utah Department of Health shared how they have used the Snapshots to improve quality in their respective States.
Hispanic Elders Learning Network
The Hispanic Elders Learning Network (HELN) supported the Prevention/Care Management Portfolio through the development of local, evidence-based intervention plans for reducing health disparities and improving the delivery of health care and related aging and social services for Hispanic elders. It fostered the development of interdisciplinary teams/coalitions in eight communities with large populations of Hispanic elders (Chicago; Houston; Los Angeles; McAllen; Miami; New York; San Antonio; and San Diego). In addition, it linked them together in a learning network with a team of national experts in the areas of health disparities measurement, evidence-based programs, community health, and organization. Some of the significant activities included:
- A total of 109 members participated on the HELN listserv throughout the project period.
- The AHRQ-sponsored/supported products that were disseminated through the listserv included:
- AHRQ National Healthcare Disparities Report and National Healthcare Quality Report.
- AHRQ Registries for Evaluating Patient Outcomes: A User's Guide-Final Research Report and AHRQ Registries for Evaluating Patient Outcomes: A User's Guide-Summary.
- AHRQ Superheroes Advertising Campaign.
- AHRQ Spanish-Language Consumer Guide on Osteoarthritis Drugs.
- AHRQ Pastillas para la Diabetes Tipo 2: Guía para Adultos.
- The project promoted the Chronic Disease Self-Management Program (CDSMP) and its Spanish version Tomando Control de Su Salud (Tomando) in support of community teams' development of local, evidence-based intervention plans. Six of the eight community teams want to use Tomando, or a modified version of it, as part of their intervention. The CDSMP was developed at the Stanford University Patient Education Research Center, in part with AHRQ funding.
- The success of this project was influential in establishing the Diabetes Self-Management Training (DSMT) Initiative, which builds upon the work and community teams of the HELN, and other teams to develop and implement a DSMT program in their community and expand the target population to all minorities.
AHRQ State Snapshots support changes in legislation to improve primary and preventive care
The New York State Department of Health used the AHRQ State Snapshots to support legislation to improve primary and preventive care that provides patient self-management programs to Medicaid recipients.
Foster Gesten, MD, Medical Director of the Office of Health Insurance Programs in the New York State Department of Health, learned about the Snapshots through his participation in the AHRQ-sponsored Medicaid Medical Directors Learning Network. Compared with other States, New York is in the "weak" range for overall health care quality, as reported in the 2007 State Snapshots. New York's weakest measures include relatively high rates of hospital admissions for children with asthma, relatively high rates of hospital admissions for adults with diabetes having long-term complications, and relatively high rates of hospital admissions for adults with uncontrolled diabetes without complications.
New York's strongest measures include a relatively high rate for the percentage of short-stay nursing home residents who were assessed and given pneumococcal vaccination and a relatively low rate for the percentage of deaths among infants without low birth weight. The 2007 State Snapshots' composite measures of clinical care further indicate that New York State has room to improve in diabetes and asthma care, both having scored within the weak range. Gesten says that he used New York's State Snapshot as "a general clarion call that all is not well in the State."
In particular, the State Snapshot information, as well as AHRQ's Prevention Quality Indicator scores using Healthcare Cost and Utilization Project data, were used to make a case, "that the data supports our need to make an investment to improve primary care and preventive care in the ambulatory setting." According to Gesten, such educational efforts resulted in legislative reforms that will provide self-management education for Medicaid patients with diabetes and asthma.
Evidence-Based Disability and Disease Prevention for Elders Learning Network
The purpose of this project was to establish effective links between local aging services and clinical providers to provide more integrated approaches to serving elders. Many States and local communities have traditionally lacked an organized system of programs and services, which is a barrier to promoting health among older adults. To address the issues of fragmented services, the Area Agency on Aging, AHRQ, and CDC began Phase II of the Elders Learning Network (ELN), an action-based, shared learning network. This project sought to enhance collaboration and shared learning among ELN teams in Maine, Maryland, Massachusetts, Illinois, New Jersey, and Ohio through consistent communication and to promote relevant AHRQ and other related materials and products to help ELN teams work and activities. Its goals were to ensure access to community-and evidence-based programs; advance health care quality and contain health care costs; promote healthy communities and individual wellness addressing chronic conditions; connect health systems and community service network providers; build credibility and trust with elders and caregivers as a model for self-management; and build disability and disease prevention action plans by State teams. The major accomplishments of this project included:
- Integration of CDSMP training and the Tomando Control (Spanish translated version) programs into Area Agencies on Aging sponsoring evidence-based disease prevention and health programs.
- Senior care organizations working with primary care practice to disseminate program information.
- Increased credibility with health care and medical community (including recruiting physician champions), which enhanced partnerships.
- Convened a final meeting of Federal partners and ELN State teams where each reported on the benefits of collaboration, challenges, and lessons learned.
- The Illinois Team will be piloting four training workshops connecting CDSMP with care coordination/care management in a clinical setting.
- Massachusetts currently has three evidence-based CDSMPs and is now focused on building programs in the North Shore area. The State team ensures provider capacity meets the needs of the growing Latino population in the area.
- New Jersey is now actively coordinating provider connection to the State's previously existing CDSMP.
- Maine is developing partners in Central and Southern Maine to implement CDSMP.
Effective Health Care Outreach to Clinicians
The purpose of this project was to develop relationships with key clinician organizations and work with those organizations to keep their members informed of comparative effectiveness research findings from the Effective Health Care (EHC) Program. As a result, 30 clinician groups committed to promoting this research through membership distribution channels. Over time, each group has been updated about new product releases and encouraged to become increasingly engaged in the EHC Program by submitting topic nominations, serving as product reviewers, or other means.
These medical specialty and academic societies have used numerous mechanisms to both disseminate and increase the uptake of EHC products, including: using EHC evidence reviews and clinician summary guides to create online continuing educational opportunities; providing free advertising space to promote EHC research in professional publications; and co-sponsoring a direct mail campaign to encourage large orders of clinician summary guides for use in CME courses.
The following summaries provide specific examples of organizations that actively promoted the EHC Program research findings to members:
- American Academy of Nurse Practitioners (AANP): Announced the release of the oral diabetes medications and osteoarthritis clinician guides in the AANP SmartBriefs daily e-mail in April 2009 and placed an announcement about the gestational diabetes clinician guide in the AANP SmartBriefs in August 2009. SmartBriefs reach over 125,000 nurse practitioners. AANP also offered two online continuing education programs designed around EHC clinician guides and full comparative effectiveness reports. A continuing education program on the Comparative Effectiveness, Safety and Indications of Premixed Insulin Analogues for Adults with Type 2 Diabetes report was launched with 122 nurse practitioners completing the post-test and 108 receiving credit through the end of July 2009. In August 2009, they launched a new program on the Comparative Effectiveness of ACEIs and ARBs for Treating Essential Hypertension.
- American Osteopathic Association (AOA): Announced the release of the type 2 diabetes and osteoarthritis clinician guides in the Touchpoints monthly newsletter in June 2009. The item offered clinicians up to 200 free copies of clinician or consumer guides. A half-page public service ad also appeared in the Journal of the American Osteopathic Association in April and May 2009. The AOA has a membership base of 65,000 practicing doctors of osteopathic medicine.
- Johns Hopkins University School of Medicine: Announced the release of the osteoarthritis of the knee clinician guide in the "Resources" section of its Web site. In March 2009, the University also sent an e-mail blast announcement to its listserv of 150,000 clinicians promoting AHRQ type 2 diabetes and osteoarthritis clinician and consumer guides.
- Society for Academic Continuing Medical Education (SACME): In February 2009, SACME placed an article on the EHC Program in its quarterly online journal, INTERCOM.
Following its annual meeting, SACME distributed to members via e-mail an offer of up to 500 free copies of the insulin analogues and treatments for osteoarthritis clinician summary guides; 25 members ordered 11,036 copies of EHC guides in April 2009. In November, SACME sent out mailings to 265 members encouraging orders of up to 500 free copies each of clinician guides. The mailings, in envelopes co-branded with both AHRQ and SACME logos, included cover letters, sample guides, and publication order forms specially designed for SACME members. SACME members are individuals from medical schools, academic medical centers, medical specialty societies, teaching hospitals, schools of public health, and other organizations that promote development of continuing medical education.
In FY 2010, AHRQ is continuing to further its mission to improve the quality, safety, efficiency and effectiveness of health care for all Americans. In addition to its work to eliminate health care-associated infections, promote health IT, and provide data and information for decisionmaking, as of December 2009, the Agency had announced six new funding opportunities for comparative effectiveness research under the Recovery Act as well as two new funding opportunities to reform the medical liability system and improve patient safety. The evidence developed through AHRQ-sponsored research and analyses helps everyone involved in patient care make more informed decisions about what treatments work for whom, when and, at what point in their care. AHRQ will continue to invest in successful programs that develop and translate into evidence, knowledge and tools that can be used to make measurable improvements in health care in America through improved quality of care and patient outcomes and value gained for what we spend.
AHRQ - Agency for Healthcare Research and Quality
CDC - Centers for Disease Control and Prevention
CER - Comparative Effectiveness Review
CERT - Center for Education and Research on Therapeutics CMS - Centers for Medicare & Medicaid Services
DEcIDE - Developing Evidence to Inform Decisions about Effectiveness
EHC - Effective Health Care
EHR - electronic health record
EMR - electronic medical record
EPC - Evidence-based Practice Center
ePSS - Electronic Preventive Services Selector
FY09 - fiscal year 2009
health IT - health information technology
HCUP - Healthcare Cost and Utilization Project
HHS - Health and Human Services
HRSA - Health Resources and Services Administration
IHS - Indian Health Service
MEPS - Medical Expenditure Panel Survey
NHDR - National Healthcare Disparities Report
NHQR - National Healthcare Quality Report
NRC - National Resource Center for Health Information Technology
USPSTF - U.S. Preventive Services Task Force