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AHRQ Annual Report on Research and Management, FY 2001

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Strategic Goals and Performance Planning

Strategic Planning at AHRQ

The AHRQ strategic plan guides the overall management of the Agency, and it serves as a road map for AHRQ activities during the year. Each year, during planning and budget development activities, we assess the progress the Agency has made toward achieving each of the goals and plan for work in years to come. The program performance information that follows here is arrayed according to our strategic plan goals and is consistent with the requirements of the Government Performance and Results Act of 1993 (GPRA).

Goal 1: Support Improvements in Health Outcomes. This goal focuses on research to understand and improve decisionmaking at all levels of the health care system, the outcomes of health care, and in particular, what works, for whom, when, and at what cost.

Selected highlights from AHRQ funded evidence reports or technology assessments that are relevant for State or Federal health policy decisions follow.

  • Evidence from a review of the impact of behavioral interventions on dietary outcomes considered to be relevant to cancer risk—such as dietary fat intake and consumption of fruits and vegetables—was incorporated into a review for the National Cancer Policy Board (a joint National Cancer Institute (NCI/Institute of Medicine (IOM) collaboration). In addition, the NCI has broadly disseminated the evidence report, posted a link to the report on its Web site, and highlighted the evidence at a variety of investigator meetings, including the American Institute for Cancer Research conference.
  • A recent review of studies that compared conventional and newer Pap tests with the current standard found that, although the conventional Pap test is only moderately accurate, serial testing (Pap testing every 3 to 5 years) will probably detect abnormalities missed in one screening because cervical cancer usually is a slow-growing disease, and many low-grade lesions regress spontaneously. Findings from this report have been considered by two large HMOs—Excellus Healthcare (Blue Cross/Blue Shield of upstate New York) and Henry Ford (Detroit)—to develop coverage policies with respect to cervical cancer screening using new liquid-based technologies. In addition, the cost-effectiveness model from this report is being used by a major pharmaceutical company to assist in the planning and evaluation of a human papillomavirus virus (HPV) vaccine, and the U.S. Preventive Services Task Forces used the evidence in the formulation of its recommendations on cervical cancer screening.
  • Research showed that routine medical testing prior to cataract surgery does not improve outcomes and in most cases is unnecessary.

Goal 2: Strengthen Quality Measurement and Improvement. This goal involves support for research to develop valid and reproducible measures of the processes and outcomes of care, studies to identify the causes of medical errors and ways to prevent them, research to develop strategies for incorporating quality improvement measures into programs, and studies on dissemination and implementation of validated quality improvement measures and tools.

These examples illustrate how findings from AHRQ research have been used by our public and private partners.

  • The American Academy of Pediatrics developed a clinical practice guideline on treatment of attention deficit and hyperactivity disorder based on our evidence report on the same topic.
  • The Centers for Medicare & Medicaid Services used U.S. Preventive Services Task Force recommendations to develop messages for consumers and clinicians regarding Medicare-covered services for osteoporosis, cervical cancer, prostate cancer, and breast cancer.
  • The American Society of Adolescent Medicine used the AHRQ evidence report on pharmacotherapy for alcohol dependence as the basis for their guideline on the same topic.
  • Research sponsored by AHRQ found that the antifungal medication fluconazole may help prevent the development of thrush (a disorder caused by infection of the mouth with yeast) in the mouths of HIV-infected patients.

Goal 3: Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures. In working toward this goal, we support research to identify ways to enhance access to care, particularly for vulnerable populations; determine what works and doesn't work in health care to ensure the appropriate use of services; and develop new ways to promote cost-effectiveness in the use of scarce health care resources.

Examples of AHRQ research findings at work include:

  • The Healthcare Association of New York and the Texas Health Care Information Council disseminated data from AHRQ's Healthcare Cost and Utilization Project (HCUP) that led regional hospitals to reform internal practices, form collaborations to improve quality of care, and inform the public about variations in certain treatment patterns or medical procedures, such as heart bypass surgery and cesarean deliveries.
  • AHRQ's research portfolio on low-income populations has informed the work of the Health Resources and Services Administration (HRSA) on evaluating and improving the health care safety net. In addition, our research has played an important role in the Centers for Disease Control's Free Vaccine Program, which supports the delivery of immunizations in primary care settings.

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Goal 1—Outcomes

Outcomes Research Portfolio

For more than a decade, AHRQ has been supporting research on the outcomes and effectiveness of health care. Outcomes research provides evidence about the benefits, risks, and results of treatments so clinicians and patients can make more informed health care choices.

Outcomes research answers a number of very basic questions about the health care system: What works and doesn't work? Is it having the desired effect? Does it provide value for the money spent? The answers to these questions form a solid foundation for efforts to improve health care quality and patient safety, enhance access to care, and improve the cost-effectiveness of care.

In addition, outcomes research also examines variations in care from one part of the country to another and from one population group to another. Time and again, studies have documented that therapies as commonplace as hysterectomy and hernia repair are performed much more frequently in some regions than in others, even when there is no difference in the underlying rates of disease. By linking the care people get to the outcomes they experience, outcomes research has become the key to developing better ways to monitor and improve the quality of care provided in hospitals, physicians' offices, and other health care settings.

The results of AHRQ-funded outcomes research (e.g., quality measures and other tools) are becoming part of the "report cards" that purchasers and consumers can use to assess the quality of care provided in health plans. For public programs such as Medicaid and Medicare, outcomes research provides policymakers with the tools to monitor and improve quality, both in traditional health plans and in managed care.

In FY 2001, AHRQ's outcomes research portfolio included more than 70 ongoing projects that focused on a wide range of topics, as well as a number of flagship programs such as the Centers for Education and Research on Therapeutics (CERTs), Evidence-based Practice Centers (EPCs), and the U.S. Preventive Services Task Force (USPSTF).

Examples of findings from recent AHRQ-supported outcomes research include:

  • Otitis media. Each year, about 280,000 children under age 3 with persistent fluid and inflammation of the middle ear have tubes inserted in their ears—a procedure called tympanostomy. Now, an AHRQ-supported study has found that in most cases, tympanostomy does not measurably improve children's speech, language, cognitive abilities, or psychosocial development up to age 3. The study enrolled 588 infants and followed them to age 3.
  • Community-acquired pneumonia. More than 2 million cases of community- acquired pneumonia (CAP) are diagnosed each year in the United States, resulting in about 10 million physician visits, 500,000 hospitalizations, and 45,000 deaths, making it one of the leading causes of mortality and health care expenditures for Medicare beneficiaries. AHRQ-supported researchers developed a Pneumonia Severity Index (PSI) to identify which patients were most at risk of dying from CAP and demonstrated its validity to guide decisions made by clinicians, patients, and families about which patients need hospitalization and which patients can be safely treated at home. In related work, the investigators found that adding one blood test further enhances this decision. For patients who are hospitalized, the investigators evaluated when patients can be safely switched to oral antibiotics to decrease the length of stay. The investigators are now working with quality improvement organizations in Pennsylvania and Connecticut to improve clinical decisions about hospitalization and improve quality of care for Medicare beneficiaries.
  • Lower respiratory tract infection in nursing home residents. Lower respiratory tract infection is a leading cause of hospitalization and mortality in nursing home residents. Moreover, it is difficult to accurately diagnose in individuals who have multiple chronic illnesses and atypical findings. An AHRQ-supported study evaluated over 1,400 episodes of lower respiratory infections in 36 Missouri nursing homes and developed a tool that can help clinicians determine which patients have severe infections and need to be hospitalized and which can be safely treated in the nursing home, thus avoiding discomfort and complications.
  • Cost-effective approaches to improve detection and management of depression. Depression is a leading cause of decreased function and time lost from work. Multiple studies have found that the majority of clinically depressed patients are not identified; for those who are detected, treatment often is inadequate. An AHRQ-supported study to improve quality of care for depressed patients substantially increased both detection and adequate treatment rates. The intervention was designed to fit the circumstances and coverage of individual practices and patients (rather than a "one size fits all" approach). At the end of 2 years, patients receiving care in diverse health care settings who participated in the quality improvement program were more likely to have their symptoms recognized, received more appropriate treatment, returned to normal function more rapidly, and missed less time from work than those who received usual care. This intervention was found to be both cost effective and straightforward to implement in other settings. The research team developed tools for broad use in health care organizations, and they have received thousands of inquiries for these materials.

U.S. Preventive Services Task Force

The U.S. Preventive Services Task Force (USPSTF) is another critical source of information on what does and does not work in the health care system specific to clinical prevention. First convened in 1984, the USPSTF is an independent panel of health care experts. The Task Force is charged with evaluating the scientific evidence for the effectiveness of a range of clinical preventive services—including common screening tests, counseling for health behavior change, and chemoprevention—and producing age- and risk-factor-specific recommendations for these services. The Task Force published its first set of recommendations in the 1989 Guide to Clinical Preventive Services, which was revised in 1995.

The third USPSTF was convened in early FY 1999 and began work on 12 initial topics selected by Task Force members based on preliminary work by two of AHRQ's Evidence-based Practice Centers: the Research Triangle Institute/University of North Carolina at Chapel Hill and the Oregon Health & Science University. The selection process included:

  • A preliminary literature search of new information on prevention and screening published since 1995.
  • Consultation with professional societies, health care organizations, and outside prevention experts.
  • A review of current levels of controversy and variations in practice.
  • Consideration of the potential for a change from the 1995 USPSTF recommendations.

Select for Topics in Progress.

The 12 topics are:

  • Chemoprevention (for example, tamoxifen and related drugs) to prevent breast cancer (new topic).
  • Vitamin supplementation to prevent cancer or coronary heart disease (vitamin E, folate, beta carotene, and vitamin C) (new topic).
  • Screening for bacterial vaginosis in pregnancy (new topic).
  • Developmental screening in children (new topic).
  • Screening for diabetes mellitus (updated topic).
  • Newborn hearing screening (updated topic).
  • Screening for skin cancer (updated topic).
  • Counseling to prevent unintended pregnancy (updated topic).
  • Screening for high cholesterol (updated topic).
  • Postmenopausal hormone therapy (updated topic).
  • Screening for chlamydial infection (updated topic).
  • Screening for depression (updated topic).

In FY 2001, the third USPSTF issued its first four recommendations covering chlamydia screening, lipid screening, skin cancer, and bacterial vaginosis.

Chlamydia screening. The Task Force recommended that primary care clinicians screen all sexually active women ages 25 and younger for chlamydia, as well as older women who are at risk for chlamydia, as part of regular health care visits.

Chlamydia is the most common bacterial sexually transmitted disease in the United States, with an estimated 3 million new cases each year. Most women have no symptoms when initially infected, but if they go untreated, they can develop pelvic inflammatory disease, infertility, and other serious health problems, including increased risk of HIV infection. Treatment with antibiotics is easy and effective.

Lipid screening. In a broadening of its 1996 recommendations, the USPSTF recommended that regular screening for high blood cholesterol and other lipid abnormalities, which can lead to coronary heart disease, should not have an upper age limit (previously set by the panel at age 65).

The USPSTF also issued a new recommendation calling for the screening of younger adults for lipid abnormalities beginning at age 20 if they have risk factors for coronary heart disease such as diabetes, family history of heart disease, tobacco use, or high blood pressure. In addition, the panel revised its 1996 statement to recommend that for initial screening purposes, clinicians measure high density lipoprotein (HDL) cholesterol along with total cholesterol.

Skin cancer. The Task Force concluded, based on its most recent review of the literature, that there is still insufficient scientific evidence to determine whether regular total body skin examination for skin cancer is effective in reducing illness and death. This is the same conclusion the Task Force reached in 1996.

Bacterial vaginosis. Bacterial vaginosis is a common condition among women of childbearing age that results in a vaginal discharge caused by an imbalance in vaginal bacteria. Despite research showing that pregnant women with bacterial vaginosis have a higher risk of preterm delivery, the Task Force has concluded that the evidence does not merit regular screening for bacterial vaginosis in all pregnant women as an effective way to reduce the incidence of preterm delivery.

For women at high risk due to a previous preterm delivery, however, the USPSTF found conflicting results regarding the benefit of screening and treatment and concluded that these options be left to the discretion of clinicians.

The USPSTF conducts impartial assessments of scientific evidence for a broad range of clinical conditions to produce recommendations for the regular provision of clinical preventive services. The Task Force grades the strength of evidence, as follows: A (strongly recommends), B (recommends), C (makes no recommendation for or against), D (recommends against), and I (insufficient evidence to recommend for or against).

As the panel updates the 70 chapters in its 1996 report, it is issuing revised recommendations as they are completed on the AHRQ Web site, the National Guideline Clearinghouse™, and in medical journals. Releasing the recommendations as they are finished rather than all at once, as in the past, will get them into the hands of clinicians more quickly.

Put Prevention Into Practice

AHRQ's Put Prevention Into Practice (PPIP) program helps translate the evidence-based recommendations of the U.S. Preventive Services Task Force into practice through the development and dissemination of resources for providers, patients, and office systems. PPIP emphasizes the importance of a comprehensive, system-wide, team approach to delivering effective preventive interventions. AHRQ works closely with public and private partners to disseminate PPIP resources. PPIP materials include information on preventive services recommendations; an implementation guide, including flowsheets and other forms; and personal health guides for children, adults, and people over 50.

During FY 2001—in conjunction with the release by the third USPSTF of its recommendations on screening for chlamydia, lipid disorders, bacterial vaginosis in pregnancy, and skin cancer—work was completed on a new information kit, What's New in Clinical Prevention? The kit includes factsheets on the newly released topics and other information to promote the Task Force and PPIP.

During FY 2001, work was completed on A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach. The guide describes easy to follow, logical steps to develop a formal system for delivering clinical preventive services. It is based on scientific and empirical evidence and has been found effective in many settings. The new guide breaks the process into small, manageable tasks; provides tools for tracking the delivery of preventive care, such as flowsheets and health risk profiles; includes worksheets and templates; and identifies resources for more information.

Texas uses PPIP in clinical practice

The Texas Department of Health has implemented PPIP in various clinical settings throughout the State. They organized a PPIP central office to provide oversight and trained regional public health nurses to provide technical assistance. The nurses work with individual sites to assess readiness, ensure that PPIP tools are used effectively, monitor chart documentation, and help the sites link with local resources for referrals. The central office focuses on promoting quality assurance, developing prevention systems and materials, and providing guidance to clinicians, not only in Texas but in other parts of the country as well.

Examples of specialized PPIP tools developed by Texas include:

  • Health risk profile that identifies genetic, behavioral, and environmental risk factors.
  • Readiness tool that can be used to assess readiness of a clinical practice to implement PPIP.
  • Patient education materials on primary prevention for various health risks.
  • Policies and procedures manual that helps individual practices design tailored PPIP systems.

Centers for Education and Research on Therapeutics

Neither patients nor their caregivers should have to guess which therapies are the best or live in fear that a mistake will be made in treatment. This is the basis of AHRQ's Centers for Education and Research on Therapeutics (CERTs) program. AHRQ was given authority to support the CERTs initiative under the Food and Drug Modernization Act of 1997. Between 1999 and 2000, AHRQ established seven centers under the CERTs program, each of which focuses on therapies used in a particular population or therapeutic area. The CERTs conduct research and provide education that will advance the optimal use of drugs, medical devices, and biological products.

Focus of Centers for Education and Research on Therapeutics (CERTs)

  • Duke University: Approved drugs and therapeutic devices in cardiovascular medicine.
  • Georgetown University: Reduction of drug interactions, particularly in women.
  • University of North Carolina: Rational use of therapeutics in pediatric populations.
  • Vanderbilt University: Prescription medication use in the Medicaid managed care population.
  • HMO Research Network: Use of large managed care databases to study prescribing patterns, dosing outcomes, and policy input.
  • University of Pennsylvania: Antibiotic drug resistance, drug use, and intervention studies.
  • University of Alabama: Therapeutics for musculoskeletal disorders.

The U.S. system of developing and marketing medical products, which requires that adequate and well-controlled studies show that products are safe and effective for their intended use, has produced great benefits. The system does have some drawbacks, however. Although drugs, medical devices, and biological products improve health for thousands of people, side effects, misuse, and overuse of products seriously impair the health of many others. The fact is that many patients potentially could benefit from a therapy but do not receive it; this may be through lack of information, oversight, or in the mistaken belief that the therapy will do them harm. In addition, studies may not test medical products in combination with other therapies often used by the same patients. Further, once approved, drugs and devices often are used for purposes other than those for which they were approved—sometimes these uses are supported by studies, but not always. Finally, some side effects of medical products emerge only after they have been approved for sale, when large numbers of people begin to use them.

The CERTs program aims to fill these information gaps by:

  • Answering important questions that have not been addressed.
  • Providing results, positive or negative, for all to see.
  • Striving to develop a learning curriculum for current and future caregivers.

Finally, the CERTs program represents a major step toward giving people the information they need to make the best choices possible. The participants in the CERTs program—Federal government agencies, academic organizations, managed care organizations, drug and device companies, practitioners, commercial research groups, and consumer groups, among others—have voluntarily committed to seeking answers together, putting society's interests first.

Following are a few examples of how the CERTs serve as a trusted national resource for people seeking to improve health through the best use of medical therapies.

  • The University of North Carolina (UNC) CERT developed and implemented an adverse drug event (ADE) reporting system for hospitalized infants, children, and adolescents. Over a 14-month period, pediatric ADE reporting jumped 500 percent to an average of nearly six reports per day. More than 70 percent of the reports involved only potential ADEs, such as prescribing an incorrect dose, that never reached the patient because a nurse or pharmacist intervened. The program has been so successful that it is being expanded to all patient-care areas at UNC.
  • The costs of antibiotic resistance are very high, both in financial and human terms. Estimates range from $75 million to $7.5 billion for costs related to resistant infections, which carry at least twice the risk of serious illness and hospitalization as infections that respond to drugs. For example, patients with acne often take oral antibiotics for many years, but the effects of these drugs on the patients and their families are not well understood. The University of Pennsylvania CERT is carrying out case-control and observational cohort studies to examine the possible link between long-term tetracycline use for acne and the development of both antibiotic resistance and infections.
  • Some commonly prescribed drugs can affect the electrical properties of the heart and may trigger life-threatening arrhythmias. The Vanderbilt University CERT considered the class of drugs called antipsychotics, which are used to treat schizophrenia and other serious mental illnesses. Compared with people who had never used these medicines, those who were taking high doses were more than twice as likely to die suddenly from cardiac causes. For patients who had severe cardiovascular disease, rates of sudden cardiac death were more than three times higher among those who took antipsychotics. Even among those with moderate or mild heart disease, rates of sudden cardiac death were proportionally higher among patients who took antipsychotics compared with those who didn't.

Evidence-based Practice Centers

AHRQ's 12 Evidence-based Practice Centers (EPCs) develop evidence reports and technology assessments on therapies and technologies that are common, expensive, and/or significant for the Medicare and Medicaid populations. The EPCs systematically review and analyze the published scientific literature to develop the reports. During their reviews, the EPCs flag areas where the evidence base is sparse and suggest future research directions.

Since 1997, the EPCs have conducted more than 80 systematic reviews and analyses of the literature on a wide spectrum of topics, and they have incorporated the results and conclusions into evidence reports and technology assessments. Some of these reviews are ongoing, and others have been published.

Potential users of these reports and assessments include doctors, medical and professional associations, health system managers, researchers, consumer organizations, and policymakers. These public- and private-sector organizations use the reports as the basis for developing their own clinical guidelines, performance measures, and other quality improvement tools and strategies. The reports and assessments often are used in formulating reimbursement and coverage policies. All EPCs collaborate with other medical and research organizations so that a broad range of experts can be included in the development process.

Nominations of topics are solicited routinely through notices in the Federal Register and are accepted on an ongoing basis. Professional organizations, health plans, providers, and others who nominate topics are considered partners and agree to use the evidence reports when they are completed. AHRQ invites comments from interested parties about the EPC program with respect to what has worked well, what has not worked well, and what changes and improvements could be made. We also are interested in suggestions about new opportunities, such as what steps the Agency can take to encourage more health care organizations and other relevant groups to translate EPC reports into clinical practice guidelines and related products.

AHRQ funded 28 new evidence topics in FY 2001. Seven of the topics were nominated by private-sector professional societies and providers, and two are part of AHRQ's patient safety initiative. Nineteen EPC reports were funded by other Federal agencies. One EPC found that bone density measured at the hip by dual energy x-ray absorptiometry (DXA) is the best predictor of hip fracture, and that repeating the bone density tests within the first year of treatment is not recommended. This finding is particularly important to the estimated 14 million American women over age 50 who are affected by low bone density at the hip. Another EPC found that a synthetic hormone developed to replace a natural hormone was effective in reducing the need for transfusions in cancer patients with anemia resulting from chemotherapy.

Examples of FY 2001 AHRQ-Funded EPC Reports and Technology Assessments

  • Effect of seasonal allergies on working populations.
  • Management of venous thrombosis.
  • Use of glycohemoglobin and microalbuminuria in diagnosis and monitoring of diabetes mellitus.
  • Neonatal hyperbilirubinemia.
  • Hyperbaric oxygen therapy for brain injury and stroke.
  • Vaginal birth following c-section.
  • Effect of patient safety on health care working conditions.
  • Management of bronchiolitis.
  • Management of coronary heart disease in women.
  • Making health care safer: Critical analysis of patient safety practices.

National Guideline Clearinghouse™

The National Guideline Clearinghouse™ (NGC) is an Internet resource for evidence-based clinical practice guidelines. It has been operational for 3 years and now contains more than 1,000 clinical practice guidelines. The NGC was developed by AHRQ in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP) to be a resource for physicians, nurses, educators, and other health care professionals.

Guidelines for the NGC site are submitted by over 165 health care organizations and other entities. New guidelines are added weekly. Over the past 3 years, NGC has had more than 4 million visitors, processed over 40 million requests, and received more than 81 million hits. More than 46,000 users visit the NGC each week.

AHRQ does not require users of the National Guideline Clearinghouse™ to register in order to use the site. However, AHRQ recently completed the second customer satisfaction survey of NGC, which does provide some insight into who uses the site. Physicians represented the largest portion of survey respondents (40.6 percent), followed by nurses and/or nurse practitioners (18.9 percent). More than 93 percent of respondents rated their overall satisfaction with NGC as either "fairly satisfied" or "very satisfied" compared with 89 percent for the first annual survey. Respondents also provided many useful comments on how they were using the site in their clinical work.

NGC Helps Disseminate Guidelines

The University of Michigan Health System (UMHS) in Ann Arbor has developed a program known as Guidelines Utilization, Implementation, Development, and Evaluation Studies (GUIDES). Now in its sixth year, UMHS has 10 of its guidelines in the National Guideline Clearinghouse™.

In responding to a recent survey of NGC, UMHS called the NGC especially valuable in disseminating their work and a wonderful enhancement to their existing processes.

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