Health Issues and Opportunities at AHRQ
Carolyn Clancy, M.D., Director Agency for Healthcare Research and Quality
March 5, 2008
Mr. Chairman and Members of the Committee, I am pleased to be here today to discuss with you health issues and opportunities at AHRQ. As you may know, AHRQ's mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. We do this by supporting research to improve the quality of health care, reduce its cost, improve patient safety, and address medical errors.
Our mission is driven by the needs of the people who use our research—patients, clinicians, health system leaders, and policymakers. A major focus for us is to translate the findings of our research into practice and policy. We work closely with our partner agencies in the Department of Health and Human Services to achieve this objective.
The agency's research agenda is broad and spans from promoting health care information technology to reducing medical errors; from supporting comparative effectiveness research to enhancing Americans' health care quality.
Today, I would to like to first highlight for the Committee our work in the area of comparative effectiveness research, which has recently received a lot of interest
Comparative Effectiveness Research
Mr. Chairman, AHRQ was authorized to perform comparative effectiveness research under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. MMA authorizes AHRQ to conduct and support research with a focus on outcomes, comparative clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. The focus of this research is based on the top 10 conditions (go to the table) that are common and costly among those whose health care is funded by Medicare, Medicaid, and the State Children's Health Insurance Program. The list of priority conditions was developed with substantial input from the public and stakeholders.
10 Priority Conditions for Comparative Effectiveness Research
The comparative effectiveness research program was established using an existing infrastructure of our Evidence-based Practice Centers and created capacity for rapid-cycle comparative effectiveness research, and translation of comparative effectiveness findings for patients, clinicians, and policymakers.
Since 2005, the Effective Health Care Program has released 14 comparative effectiveness reviews. These reviews ranged from diagnostic evaluation of technologies for abnormal breast cancer screening to comparative effectiveness of drugs for depression to treatments for prostate cancer. As an example, one review found that drugs can be as effective as surgery in the management of gastroesophageal reflux disease (GERD), better known as heartburn. GERD is one of the most common health conditions in older Americans and results in $10 billion annually in direct health care costs.
We are beginning to see an impact from AHRQ's comparative effectiveness research. It is used by a variety of groups who make decisions about health care. For example, Consumer Reports Best Buy Drugs, a public education project of Consumers Union, uses these findings to help health care professionals and patients determine which drugs and other medical treatments work best for certain health conditions. The National Business Group on Health uses this research to provide employers and their employees' best available evidence for designing benefits and making treatment choices. Medscape, an online medical information and education tool for specialists, primary care physicians, and other health professionals, uses the reports for clinicians to get continuing education. In addition, most of the reports are published concurrently in one of the Annals of Internal Medicine, one of the premier medical journals.
A recent Congressional Budget Office [CBO] report indicates that only a limited amount of evidence is available about which treatments work best for which patients and whether the added benefits of more effective and more expensive services are sufficient to warrant their added costs. The CBO report suggests that comparative effectiveness research could help reduce health care spending without affecting health overall. The bottom line is that "doing the right thing"—using comparative effectiveness to improve the quality of health care—will enhance the value of our investments in health care.
Mr. Chairman, I would like to thank the Committee for its continued support for comparative effectiveness research and, in particular, for doubling the Agency's funding in this critical area from $15 million to $30 million in FY 2008. With this increase, the number of comparative effectiveness reviews and technical briefs and other products will double. New research studies will include surgical interventions, prescription drugs, heart disease, infectious diseases, and obesity. Continued investments in comparative effectiveness research at AHRQ will help us fill the evidence gap identified by CBO and provide better health care value for Medicare beneficiaries and all Americans.
Health Information Technology
However, simply producing comparative effectiveness research isn't sufficient to improve the quality and value of health care services. Creating the means and capacity will put the findings of research quickly at the fingertips of health care professionals and patients. For that, we need "smart" health IT, health information technology.
AHRQ's unique contribution to health information technology (health IT) is a key element in achieving this goal and bringing health care into the 21st century. Since 2004, AHRQ has invested $199 million in grants and contracts in 48 States to support and stimulate investment in health IT, especially in rural and underserved areas.
Increased investments in this area would foster a collaborative effort between AHRQ's health IT research and comparative effectiveness programs to develop a way of quickly and efficiently delivering the findings of research to health care professionals and patients. For example, comparative effectiveness research shows that a certain drug is best to treat high blood pressure. As soon as the health care professional enters a diagnosis of high blood pressure into a patient's electronic medical record, a prescription for that drug is generated automatically. The electronic medical record would generate a warning against using that drug if the patient is allergic or shouldn't take it for some other reason. In this case, it would offer alternatives. Similarly, the same system can collect information on unexpected patient harms to patients from treatments.
We also would work to create a system that would, with the right Federal, State, and private sector partnerships, help implement electronic prescribing throughout the health care system in a way that improved quality, rather than the haphazard way that it is currently occurring.
Health IT has breathtaking potential to change dramatically how patients receive health care services. Currently, we need to go to a doctor's office or clinic for health care information and services that are tailored to our individual needs and preferences. Under the concept of a health IT-enabled "medical home," anywhere with a computer and Internet access—one's home, a library, a school—can be a place where people can connect with their health care providers for this type of service.
To ensure that we harness the power that health IT has to offer, we need to develop an evidence-based strategy to help clinicians and health care leaders decide which health IT innovations should be adopted and how they should be implemented to maximize value—both to clinicians and patients today and to the public health and research enterprises.
We know that health IT is not a magic bullet for improving the quality, safety, and value of health care. We also need a change in the culture of health care that takes a systematic approach to eliminating medical errors and improving overall quality.
Just last month, we published a proposed rule implementing the Patient Safety and Quality Improvement Act. This proposed rule improves the quality and safety of health care for all Americans by fostering the establishment of patient safety organizations—private entities recognized by the Secretary of Health and Human Services to collect and analyze patient safety events reported by health care providers. They are new and separate from all currently existing entities that are addressing health care quality.
The new rule provides us with an opportunity for an important future investment in efforts to reduce avoidable harms to patients. With additional funding, we could accelerate the development of patient safety event reporting systems as well as other provisions in the Patient Safety and Quality Improvement Act.
Another opportunity would be for AHRQ to expand the Patient Safety Improvement Corps—a group of health care professionals from State government and hospitals specially trained in strategies to reduce medical errors. We could expand the Corps to include other professionals in a greater number of communities.
Additional opportunities exist to accelerate the development and implementation of evidence-based tools to health care professionals nationwide. This would include the development of assessment tools that could be used to gauge the culture of safety in health care settings such as dialysis centers, nursing homes, physicians' offices, and freestanding clinics.
Our investments in patient safety have already shown improvements in care and have increased the commitment to patient safety in many health care settings. For example, AHRQ supported research at Johns Hopkins University that developed a program that instituted a simple five-step checklist designed to prevent certain hospital infections in intensive care units (ICUs) throughout Michigan. Among other things, the checklist reminds doctors to wash their hands and put on a sterile gown and gloves before putting intravenous (IV) lines into patients. As a result of taking this simple step, the rate of bloodstream infections from IV lines was reduced by two-thirds within 3 months. In addition, the average ICU decreased its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million. One leader in critical care medicine described these results as one of the most important developments in a generation.
This is just one example of how our investments in patient safety have made improvements in care. We recognize that our health care system is massive, with over $2 trillion spent annually on care, and that our investments are only the tip of the iceberg. There is a lot more that needs to be done.
Value in Health Care
Mr. Chairman, so far I have raised a number of opportunities that we see as critical steps toward improving the quality of health care. I would now like to highlight steps that we can take to help ensure that we are getting value in our investments.
As we are all aware, growth in health care costs is placing a tremendous burden on Federal and State budgets, threatening employer capacity to provide health insurance, and straining personal finances. Through research that we have supported, we know that a large part of this cost can be attributed to the inappropriate use of resources.
In an effort to create value for our health care investments, AHRQ is supporting efforts to measure, track, and report on healthcare quality and how health care services are used. These efforts give us a snapshot of the health care system and show us where we need to make improvements and adjustments.
For example, through a partnership with State hospital associations and State data agencies, AHRQ's Healthcare Cost and Utilization Project or HCUP, has data on 90 percent of all the hospital discharges in the country, as well as emergency department and ambulatory data from about half the States.
HCUP provides a rich data source for Federal, State, and local policymakers, as well as individual communities seeking to improve quality and reduce waste. For example, the National Institutes of Health has used the data from HCUP to determine that a questioned rotavirus vaccine was indeed safe, resulting in a go-ahead for immunizing children around the world. Also, Federal policymakers have used it to create benchmark data on influenza rates and MRSA. The future opportunity that many States see right now is linking administrative or billing data to smart HIT so that health care challenges can be rapidly identified and addressed, and State leaders can assess the impact of changes in policy on health care and people's health.
Finally, since we recognize that many value improvements require communitywide actions, we have recently launched Secretary Leavitt's Value-Driven Health Care Initiative. The ultimate goal of the Initiative is to increase value and quality of care that Americans' receive. AHRQ has recently launched 14 community- and statewide collaboratives in 12 States. These multistakeholder groups will be working to track, publicly report, and improve quality across their communities. These 14 and additional communities to be selected later this year will be front-row customers for the products of comparative effectiveness research, greatly expanding the number of Americans who benefit from taxpayer-supported research investments. Clinicians and patients confront challenges in making the best decisions every day; our job is to make sure that evidence-based information is available when and where it is needed
Mr. Chairman, I want to thank you for the opportunity to discuss with the Committee how continued investments in AHRQ's essential programs will improve quality and value in health care.