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AHCPR invites suggestions for outcomes/effectiveness research topics

The Agency for Health Care Policy and Research has begun the process of identifying topics and setting priorities for its outcomes and effectiveness research program. This program focuses on the prevention, diagnosis, treatment, and/or management of common diseases and clinical conditions.

Outcomes and effectiveness research encompasses three main areas of emphasis: 1) determination of the clinical interventions that are most effective, cost effective, and appropriate; 2) development of methods and data to advance effectiveness research; and 3) dissemination of research findings and evaluation of their impact on clinical practice and outcomes. The program focuses on conditions that meet the following criteria:

  • Have a high incidence or prevalence in the general population or major population subgroups.
  • Involve controversy or uncertainty about the effectiveness of available clinical strategies.
  • Result in high health care costs.
  • Have an impact on the Medicare and Medicaid programs.
  • Lend themselves to study because data are available or can be readily developed.

All outcomes and effectiveness research is expected to be: 1) generalizable—concerned with the outcomes that can be expected in typical patients; 2) practical—address questions that have high clinical and policy significance with a design that takes into consideration the eventual implementation of findings; 3) patient-centered—evaluate health care in terms of outcomes that emphasize the patient's experience and perspective; and 4) multidisciplinary—involve teams of researchers who bring together the knowledge and expertise of both the clinical and social sciences.

Since 1989, AHCPR has supported significant advances in medical effectiveness research, especially through its Patient Outcomes Research Teams (PORTs). PORTs are large-scale, 5-year studies designed to determine "what works best" in clinical treatment for common diseases and conditions. Examples of clinical conditions previously addressed include: ischemic heart disease, low back pain, cataracts, and stroke prevention.

In 1993, AHCPR introduced a new generation of PORT research, known as PORT II. Like the original PORTs, PORT II projects are pragmatic, methodologically sophisticated, multidisciplinary and focus on patient outcomes for common clinical problems. However, they differ from the original PORTs by their individualized research strategies and their expected impact on clinical practice, patient outcomes, and health care policy. PORT IIs focus on the establishment of direct linkages between practice and outcomes and on research methods that facilitate direct comparisons of two or more distinct clinical strategies. Examples of clinical conditions previously addressed include: localized breast cancer, cardiac arrhythmia, and prostate disease.

AHCPR has initiated a three-stage process to identify and prioritize topics for future outcomes and effectiveness research: 1) develop a preliminary list of priority topics and reasons for importance; 2) convene an expert panel to review and assess the preliminary research priorities and suggested criteria; and 3) identify which topic areas can be addressed most appropriately using outcomes and effectiveness research methods.

AHCPR invites suggestions of topics and priorities from health care providers, insurers, health-related societies, consumers, and others. Nominees should provide a clear rationale and supporting evidence for the importance and clinical relevance of their suggested topic. Suggestions must be received by July 29, 1996. Responses and programmatic inquiries should be directed to: Carolyn Clancy, M.D., Acting Director, Center for Outcomes and Effectiveness Research, (301) 427-1600.

AHCPR will not reply to individual responses but will consider all submissions in developing the research priorities. This request for suggestions on future research topics was published in the Federal Register on May 28, 1996.

Emphasis areas identified for AHCPR's small grant program

The Agency for Health Care Policy and Research has announced a special emphasis area under its ongoing Small Project Grant Program. AHCPR and the Robert Wood Johnson Foundation (RWJ) are entering a partnership to cosponsor this special initiative for funding projects that involve collaboration between medical and public health organizations. (Select PA PAR-96-028 published in the NIH Guide for Grants and Contracts, February 23, 1996.) To facilitate this partnership initiative, a single one-time receipt date of July 31, 1996, has been established.

This activity is intended to advance and continue the work of the national Medicine/Public Health Initiative. The purpose is to create an ongoing working partnership between the two professions to improve the health and health care of the American people. A conference held in March 1996, "National Congress: Medicine and Public Health Initiative," yielded recommendations for potential new collaborative activities, such as this special emphasis area. A copy of the conference summary can be obtained by contacting Stanley J. Reiser, M.D., M.P.A., Ph.D., at (713) 792-5140.

AHCPR's special program emphasis under this initiative is for research and demonstration grants facilitating medicine and public health collaboration in health services research or demonstrations. Of particular interest are projects focused on addressing the health needs of populations through enhanced cooperation between medical practitioners, public health entities, and health care delivery organizations. Meritorious applications will be funded under the AHCPR Small Project Grant Program.

RWJ plans to fund separately small project and conference grants under this initiative that facilitate convening key stakeholders within a community to promote collaboration between medical and public health organizations.

It should be noted that because of limited funding for these special emphasis small grants, AHCPR expects to limit individual awards to up to $25,000 for direct costs, with approximately four to five awards. RWJ expects to limit awards to less than $20,000 in total costs, with approximately five to six awards. RWJ's policies for funding of indirect costs differ from AHCPR/HHS policies. For information on RWJ's indirect cost policies, contact Stanley J. Reiser, M.D., M.P.A., Ph.D. (see inquiries information, below).

Applications for Research and Demonstration Grants under this initiative involving medicine and public health collaboration in health services research should be submitted to AHCPR no later than July 31 to: Office of Scientific Affairs, Attention: Medicine/Public Health Initiative, Small Project Grants, Suite 400, 2101 East Jefferson Street, Rockville, MD 20852.

Applications submitted to AHCPR will be reviewed in accordance with ongoing AHCPR Small Project Grant review criteria and procedures, and grants will be administered in accordance with AHCPR and HHS grants policies.

Applications for RWJ funding for project and conference grants addressing RWJ interests should be submitted no later than July 31, to: Stanley J. Reiser, M.D., M.P.A., Ph.D., Program on Humanities and Technology in Health Care, University of Texas, 6431 Fannin, P.O. Box 20708, Houston, TX 77225.

Applications submitted for RWJ funding will be reviewed in accordance with RWJ procedures for grants review and will be administered in accordance with RWJ grants policies and procedures. Although investigators may apply to both AHCPR and RWJ, they are encouraged to focus on only one topic and select one or the other potential funding source, depending on the topic selected. Applications submitted for this initiative will not be funded jointly by AHCPR and RWJ. AHCPR and RWJ intend to operate separate, parallel review processes and to share funding decisions prior to awards to avoid duplicative funding. Investigators will be asked to provide a signed statement specifically authorizing the sharing of applications and, as applicable, summary statements of initial reviews, between AHCPR and RWJ.

For AHCPR application materials, contact the AHCPR Publications Clearinghouse

Programmatic inquiries should be directed to Carolyn M. Clancy, M.D., Director, Center for Primary Care Research, AHCPR, (301) 427-1600.

For information about RWJ application procedures and specific questions about this initiative, contact the RWJ designated representative, Stanley J. Reiser, M.D., M.P.A., Ph.D., (713) 792-5140.

AHCPR to support new quality measurement network

The Agency for Health Care Policy and Research is accepting proposals to create a new national resource for quality measurement. The project, to be called the Quality Measurement Network (QMNet), ultimately may aid in the creation of a free-standing quality network. The purpose of QMNet is to further the state of the art in clinical performance measurement and to assist clinicians, quality improvement managers, health care administrators, health plans, and purchasers in identifying and using clinical performance measures.

According to AHCPR's Administrator Clifton R. Gaus, Sc.D., the goal is for QMNet to become a comprehensive, publicly accessible, quality measurement resource to help both public and private sector efforts to improve the quality of health care.

QMNet will focus on maximizing the capabilities of CONQUEST 1.0 (the Computerized Needs-Oriented Quality Measurement Evaluation System), a landmark computer tool designed to make it easier for health plans, providers, and purchasers to identify, choose, and use clinical performance measures.

Editor's Note: See CONQUEST 1.0 for more information.

Through the advice of an expert panel, the QMNet contractor will examine and evaluate the framework of CONQUEST 1.0, modifying and expanding it where necessary and appropriate to improve its clinical relevance and value. The contractor also will develop a feasibility study for transforming QMNet into a self-supporting entity at the end of the contract period.

This solicitation was published in the May 14 Commerce Business Daily and was released May 29, 1996. The closing date for proposals is July 15, 1996.

AHCPR funds new projects

The Agency for Health Care Policy and Research has awarded new research and conference grants, as described below. Please note that investigators generally do not publish findings until a study has ended or is nearing completion.

AHCPR UI guideline: Application in nursing homes
Prin. investigator: Nancy M. Watson, Ph.D.
Organization: University of Rochester, Rochester, NY
Project no: AHCPR grant HS08491
Period: 6/1/96 to 5/31/99
First year funding: $201,635

Facilitating home care of neonatal chronic lung disease
Prin. investigator: Thomas M. O'Shea, M.D.
Organization: Bowman Gray School of Medicine, Winston-Salem, NC
Project no: AHCPR grant HS07928
Period: 7/1/96 to 6/30/01
First year funding: $266,967

Right heart catheterization: Appropriate/effective use
Prin. investigator: Alfred F. Connors, M.D.
Organization: Case Western Reserve University, Cleveland, OH
Project no: AHCPR grant HS08354
Period: 7/1/96 to 6/30/98
First year funding: $372,595

Selective cervical spine radiography in blunt trauma
Prin. investigator: William R. Mower, M.D.
Organization: University of California, Los Angeles, Los Angeles, CA
Project no: AHCPR grant HS08239
Period: 8/1/96 to 7/31/98
First year funding: $621,570

Superspecialization of medical and surgical subspecialties
Prin. investigator: Jose Escarce, M.D.
Organization: University of Pennsylvania, Philadelphia, PA
Project no: AHCPR grant HS08573
Period: 6/1/96 to 5/31/98
First year funding: $271,721

Understanding health values of HIV-infected patients
Prin. investigator: Joel Tsevat, M.D.
Organization: University of Cincinnati, Cincinnati, OH
Project no: AHCPR grant HS09103
Period: 9/1/96 to 8/31/97
Funding: $160,160

Small Grant

Assessing pediatric quality of life in a clinical trial
Prin. investigator: Robert D. Annett, Ph.D.
Organization: University of New Mexico, Albuquerque, NM
Project no: AHCPR grant HS09123
Period: 6/1/96 to 5/31/98
First year funding: $36,329

Conference Grants

Child health services research
Prin. investigator: Christopher B. Forrest, M.D.,Ph.D.
Organization: Johns Hopkins School of Hygiene and Public Health, Baltimore, MD
Project no: AHCPR grant HS09320
Period: 5/1/96 to 4/30/97
Funding: $22,454

HMO research network national conference
Prin. investigator: Andrew F. Nelson, M.P.H.
Organization: Group Health Foundation, Minneapolis, MN
Project no: AHCPR grant HS09319
Period: 5/1/96 to 4/30/97
Funding: $19,894

Medicine/public health initiative
Prin. investigator: Stanley J. Reiser, M.D., Ph.D.
Organization: University of Texas, Houston, TX
Project no: AHCPR grant HS09252
Period: 3/1/96 to 2/28/97
Funding: $50,000

Public-private health care purchasing partnerships
Prin. investigator: James D. Mortimer, B.A.
Organization: Midwest Business Group on Health, Chicago, IL
Project no: AHCPR grant HS09292
Period: 5/1/96 to 4/30/97
Funding: $50,000

Second annual NRSA training meeting, 1996
Prin. investigator: Kevin A. Schulman, M.D.
Organization: Georgetown University, Washington, DC
Project no: AHCPR grant HS09289
Period: 5/1/96 to 4/30/97
Funding: $75,000

New publications available from NTIS

The following final reports of research projects funded by AHCPR are now available from the National Technical Information Service (NTIS).

Refer to the NTIS accession number when ordering.

Impact of Program Eligibility Criteria on Recipient Access and Continuity of Care: Experience of the MaineCare and Washington Basic Health Plans. AHCPR grant HS08448, 8/1/94 to 12/31/95. Elizabeth Kilbreth, M.S., Brandeis University, Waltham, MA.

This study compared a subsidized small business health insurance initiative and an income-eligibility family coverage initiative with regard to their impact on the scope of medical indigence in the respective States. Participant survey information was used to develop enrollment profiles for each program. Multinomial logit models were used to identify enrollee characteristics predictive of return to uninsured status and link disenrollment dynamics to program eligibility criteria.

Findings were that program eligibility criteria strongly influenced both enrollment and involuntary disenrollment. The individual income-based plan reached a far more heterogeneous uninsured population and had higher rates of enrollment than the small employer-based plan. Rates of involuntary disenrollment were proportionately much higher in the small business initiative plan and resulted in a return to uninsured status among approximately half of disenrollees (compared with 19 percent in the individual plan). Job change and family labor force characteristics were the factors that determined enrollment disposition in both programs. The enrollment success of the income-based program helped build political momentum in the host State for passage of a comprehensive reform measure, but the small business initiative failed to generate support among business interest groups for broader government intervention in health policy. (Abstract, executive summary, and final report of dissertation; NTIS accession no. PB96-159884, 244 pp; $44.00 paper, $19.50 microfiche)

Nursing Home Policy via Hierarchical Duration. AHCPR grant HS07306, 7/1/92 to 6/30/95. Carl N. Morris, Ph.D., Harvard Medical School, Boston, MA.

The primary goal of this study was to develop and apply statistical methods for estimation of duration (survival) times in nursing home lengths of stay and in other relevant health policy applications. Improved statistical analyses of duration data have increased understanding of nursing home spend-down and of the long-term care demands on Medicaid resources. Additionally, the methods developed in this study expand the set of policy questions that can be answered in other settings where problems of length-of-stay bias, multiple outcomes, heterogeneity, and censoring occur. (Abstract, executive summary, and final report; NTIS accession no. PB96-166327, 25 pp; $19.50 paper,$10.00 microfiche)

Predictions and Outcomes in Congestive Heart Failure. AHCPR grant HS06274, 4/1/90 to 3/31/95. Wally R. Smith, M.D., Virginia Commonwealth University, Richmond, VA.

Little is known about how well physicians make triage decisions about which patients should be admitted to the intensive care unit (ICU). Current guidelines suggest physicians faced with triage decisions should estimate the probability that their patients will soon develop severe complications, as well as the patients' comparative survival probabilities. This unique cohort study followed patients with new and existing congestive heart failure (CHF) seen initially in the emergency room. All patients were followed, whether admitted to the ICU, a regular hospital unit, or discharged home. Physicians were asked to predict their patients' outcomes. Measurements included the quality of physicians' judgments of the probability of CHF complications in their patients at 4 days and survival at 90 days and 1 year, as well as the development and validation of predictive models of these outcomes. The prevalence of complications at 4 days was low (4.3 percent). Physicians were only moderately able to predict complications and/or survival. Models of 90-day and 1-year survival based on traditionally used variables, and those based on "off-the-shelf" models of ICU survival, performed no better or only marginally better than the physicians. The difficulty physicians and current predictive models have in distinguishing which patients may experience poor short-term CHF outcomes suggests that utilization of ICU resources may not be improved by applying current guidelines. (Abstract, executive summary, and final report; NTIS accession no. PB96-163951, 70 pp; $21.50 paper, $10.00 microfiche)

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