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AHRQ Annual Report on Research and Management, FY 2002

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Strategic Goals and Performance Planning at AHRQ

The Agency for Healthcare Research and Quality's 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.

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.

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.

Goal 1 – Outcomes Research

Measuring the Benefits, Risks, and Results of Research

Rapidly rising healthcare costs, questions about effective medical treatments, and the need for efficient delivery of health care services are the reasons why outcomes research has been one of AHRQ's core activities for over a decade. Patient outcomes research provides evidence about the benefits, risks, and results of treatments that take place in "real world" settings so clinicians and patients can make more informed health care choices.

Outcomes research answers a number of very fundamental questions about health care services: What works and doesn't work? Is it having the desired effect? Does it provide value for the resources used? 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.

Outcomes research also looks at differences in care from one part of the country to another and from one population group to another. Repeatedly, 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 rates of disease.

The results of AHRQ-funded outcomes research—such as the effectiveness of given treatments or clinical intervention strategies—and patient health outcomes measures often serve as the foundation for the development of various quality indicators and other tools, which increasingly are being integrated into 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 evaluate, monitor, and improve the delivery of effective health care services in the most efficient manner. By linking the care people get to the outcomes they experience, outcomes research has become the key to developing cost-effective ways to improve the quality of care.

In 2002, AHRQ's outcomes research portfolio included more than 100 projects that addressed a wide range of topics; focused on disparities based on sex, ethnicity, age, socioeconomic status, and geographic location; and encompassed a number of AHRQ's 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.

Examples of findings from recent AHRQ supported outcomes studies and projects currently underway include:

  • Prescription drugs: An AHRQ study published in the New England Journal of Medicine found that a carefully designed and implemented prescription drug reference-pricing policy reduced overall drug expenditures without any obvious adverse clinical outcomes for the beneficiaries. Reference drug pricing programs work on the principle that if several drugs work equally well for a certain condition, the program will fully fund the drug that costs the least. Patients may choose the more expensive drug, but the program will only reimburse them for the cost of the lowest cost reference drug(s). This study, which examined data 2 years before and 1 year after implementation of a reference-based pricing policy in the province of British Columbia, focused specifically on a large group of elderly Canadian Pharmacare beneficiaries who took drugs to treat hypertension.
  • Heart disease: AHRQ-supported research found that patients who take beta-blockers (drugs to slow the heart rate and reduce contractions of the heart muscle) prior to bypass surgery appear to have improved survival and fewer complications during and after the procedure. Researchers indicate that up to 1,000 lives potentially could be saved each year by giving patients beta-blockers before bypass surgery.
  • Children's health: An AHRQ study found that all of the cases of rickets among pediatric patients in North Carolina occurred in black children who were breast-fed and who had not had vitamin D supplementation. As a result, the State is now providing free vitamin D supplementation to breast-fed infants and children aged 6 weeks and older. Over a 16-month period, more than 1,500 children received this supplement at a cost of about $1.50 per child.
  • Women's health: An AHRQ-sponsored study found that among women with mild to moderate pelvic inflammatory disease (PID), rates of pregnancy, recurrent PID, and chronic pelvic pain were no different for inpatient versus outpatient treatment of PID. Inpatient treatment is more than 10 times as expensive as outpatient treatment. The effectiveness of outpatient as compared with inpatient antibiotic treatment had not been demonstrated before this study.
  • Diabetes. An AHRQ study found that patients with both adult-onset (type 2) diabetes and other chronic conditions can still achieve good blood sugar control if they receive intensive therapy at a specialty diabetes clinic. Therapy included adding or changing oral medications or adding insulin to the treatment regimen.
  • Hip fracture: An AHRQ-supported study found that medical staff in hospitals, rehabilitation facilities, and nursing homes could improve patient outcomes for the approximately 350,000 hip fractures that occur annually in the United States by focusing on reducing the risk of complications that often leave patients unable to work or lead to death. Currently, four of every ten patients are unable to walk without total assistance by 6 months after the fracture, and one-fourth of patients die within a year of their injury. In addition to pain and suffering, hip fracture and its consequences have a large economic impact, with hospital charges alone totaling roughly $6 billion a year.
  • Lower respiratory infection. Lower respiratory infection (LRI) is one of the most common causes of death and hospitalization among nursing home residents. Although hospitalization can be lifesaving for the sickest patients, for those who are less ill there is considerable risk of incurring avoidable harm and additional expense from needless hospitalization. AHRQ-sponsored research studied nursing home residents with LRI and developed a strategy to predict which patients were at highest risk of hospitalization and which could be more effectively treated in the nursing home. Their findings demonstrated that up to 52 percent of nursing home residents with LRI are at low risk of death and may not require hospital admission.
  • Stroke: Based on AHRQ's research, Medicare's Peer Review Organizations have implemented 73 projects in 42 States to increase anti-clotting therapy for Medicare beneficiaries who have suffered a stroke. The percentage of Medicare patients discharged on this therapy has increased from 58.4 to 71.1 percent.
  • Heart attack: The goal of this ongoing AHRQ study is to develop a tool to help emergency medical teams responding to a heart attack patient determine whether the time delay required to transport the patient to a high-volume cardiac hospital versus a community hospital is justified. Researchers will also evaluate the incorporation of this tool into electrocardiograph equipment that records how electrical impulses move through the heart muscle as it contracts and relaxes.
  • Organ donation: Prior to the 1980s, kidney transplants from living donors offered the only hope of recovery for patients with end-stage renal disease. However, improved surgical techniques, organ matching, rejection treatment, and organ preservation made kidney transplants from cadaver donors possible beginning in the late 1970s. Although organ donation rates have increased over the last 10 years, the supply of cadaver donors remains far short of the demand, and transplant centers are returning to living donations. The goal of this AHRQ-sponsored study is to design a model living-donor transplant program based on an evaluation of transplant center and individual barriers as well as facilitators of living donations.
  • Domestic violence: Although domestic violence affects about 25 percent of U.S. women and 8 percent of U.S. men during their lifetimes, there is little information about the long-term health care effects for the victims. An AHRQ-sponsored study is attempting to close this gap by evaluating the medical care use, patterns, and costs associated with domestic violence, as well as the impact over time on the victims and their children.
  • Working conditions: Some anecdotal indications suggest that low nurse staffing, increased use of overtime, and other changes in hospital working conditions are putting patients at a greater risk for adverse outcomes. An AHRQ-supported study is examining the relationship between adverse outcomes and use of overtime among nurses and measuring other conditions in the nurses' work environment affecting staffing and workload such as nursing skill mix, job strain, and risk of injury.

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Prevention Research: Keeping People Healthy

General acceptance of preventive screening as a part of routine medical care didn't occur until the 1960s. Despite this acceptance, there was little evidence that screening tests and other preventive interventions actually improved patient outcomes. To address these issues, the U.S. Preventive Services Task Force (USPSTF) was established.

The Task Force is a critical source of information on what does and does not work in the health care system specific to clinical prevention. The Agency for Healthcare Research and Quality oversees the Task Force. First convened in 1984, the Task Force is an independent panel of health care experts who evaluate scientific evidence for the effectiveness of a range of clinical preventive services—including common screening tests, counseling for health behavior change, and chemoprevention (the use of drugs to reduce the risk of a disease)— and produce 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 Task Force 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). The Task Force is updating the 70 chapters in its 1996 report, and AHRQ is releasing the revised recommendations incrementally, as they are completed, on the agency's Web site, through the National Clearinghouse, and in medical journals.

The third Task Force, convened in 1999, began work on 12 initial topics selected by Task Force members based on preliminary work by two of the 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; and consideration of the potential for a change from the 1995 Task Force recommendations.

In 2002, AHRQ solicited nominations of qualified individuals to serve as Task Force members. Members are eligible to serve for 3-year terms with an option for reappointment. A list of the topics selected by the third Task Force follows.

  • Chemoprevention (heart disease and cancer).
  • 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).

Also in 2002, the third Task Force issued the following recommendations covering colorectal cancer, osteoporosis, hormone replacement therapy, depression, chemoprevention, and breast cancer.

  • Colorectal cancer: The Task Force in its strongest ever recommendation for colorectal cancer screening urges that all adults age 50 and over get screened for the disease, the Nation's second leading cause of cancer deaths. Various screening tests are available, making it possible for patients and their doctors to decide which test is most appropriate for each individual. Although each of these tests is effective in diagnosing colorectal cancer at an early stage when it is treatable, the Task Force noted that there is no single best test for all patients. Options include at-home fecal occult blood test (FOBT); flexible sigmoidoscopy; a combination of home FOBT and flexible sigmoidoscopy; colonoscopy; and double-contrast barium enema. Screening also can lead to early detection of adenomatous polyps—precancerous growths that can be removed to prevent them from progressing to cancer.
  • Osteoporosis: The Task Force recommends that women aged 65 and older be screened routinely for osteoporosis, and that women at high risk for fractures begin screening at age 60. Women are at greater risk than men for osteoporosis because their bones are less dense. The Task Force found good evidence that the risk for osteoporosis and fracture increases with age and other factors, bone density measurements accurately predict the risk for fractures in the short-term, and treating women with no symptoms of osteoporosis reduces their risk for fracture. Other osteoporosis risk factors cited include lower body weight and no current use of estrogen. The Task Force concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors.
  • Hormone replacement therapy: The Task Force recommends against the use of combined estrogen and progestin therapy for preventing cardiovascular disease and other chronic conditions in postmenopausal women; they also recommend that women who are considering whether to start or continue hormone therapy to relieve menopausal symptoms discuss their individual risks for specific chronic conditions and personal preferences with their clinician. Although the Task Force found evidence for both benefits and harms of combined estrogen and progestin therapy—one of the most commonly prescribed hormone regimens—they conclude that harmful effects of the combined therapy are likely to exceed the chronic disease prevention benefits for most women. The Task Force concludes that combined hormone therapy could increase bone mineral density and reduce the risk of fractures, and that it may reduce the risk of colorectal cancer. They also found equally strong evidence, however, that this therapy increases the risk for breast cancer, blood clots, stroke, and gallbladder disease, and that this therapy does not reduce the risk of heart disease but actually increases the risk of heart attacks. An estimated 14 million American women take hormone therapy.
  • Depression: The Task Force indicates that clinicians can identify up to 90 percent of patients who suffer from major depression by asking all patients they see two simple questions. The questions are: "Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?" This recommendation is the latest sign of the growing recognition that depression is one of the most common—and most commonly undiagnosed and untreated—chronic illnesses. About 19 million American adults suffer from depression, and estimates suggest that as many as two-thirds do not get treatment. This recommendation could bring many of these people into treatment and add millions to the numbers who are taking antidepressants such as Prozac. The Task Force adds that screening is only the first step—patients must have access to the right therapy and medicines, and health care systems must encourage patient followup care by clinicians.
  • Chemoprevention of heart disease: The Task Force strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease. Discussion with patients should address both the potential benefits and harms of aspirin therapy.
  • Chemoprevention of breast cancer: The Task Force recommends that clinicians discuss the potential benefits and risks of taking prescription medicines such as tamoxifen to reduce the risk of breast cancer with their female patients who are at high risk for the disease. Women are considered at high risk if they are over 40 and have a family history of breast cancer in a mother, sister, or daughter or have a history of abnormal cells on a breast biopsy. The Task Force also recommends against the use of these drugs by women at low or average risk for breast cancer because the harmful side effects may outweigh the potential benefits. Those side effects can include hot flashes, increased risk for blood clots in the legs or lungs, and increased risk for endometrial cancer.
  • Breast cancer: The Task Force recommends that women aged 40 and older have a mammogram with or without clinical beast examination every 1-2 years. They found fair evidence that mammography screening every 1-2 years could reduce breast cancer mortality by approximately 20 to 25 percent over 10 years. The evidence is strongest for women between the ages of 50 and 69, but the Task Force concludes benefits were likely to extend to women 40-49 as well. The Task Force published two earlier breast cancer screening recommendations, in 1989 and 1996, both of which endorsed mammography for women over age 50. The Task Force is now extending that recommendation to all women over age 40, even though the strongest evidence of benefit and reduced mortality from breast cancer applies to women aged 50-69. This recommendation acknowledges that there are some risks associated with mammography (e.g., false-positive results that lead to unnecessary biopsies or surgery), but that these risks lessen as women get older.

Two of the Task Force's 2002 assessments yielded insufficient evidence to make a recommendation: does counseling in primary care settings to promote physical activity lead to sustained increases in physical activity among adult patients, and does routine screening of newborns for hearing loss and earlier treatment resulting from screening lead to long-term improvements in language skills.

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Putting Prevention Into Practice

AHRQ's Put Prevention Into Practice (PPIP) program helps keep people healthy by translating the recommendations of the U.S. Preventive Services Task Force into practice. PPIP provides clinicians, office staff, and patients with various tools and resources to increase the delivery and use of recommended clinical preventive services. PPIP facilitates the delivery of services that can prevent some of the leading causes of death and disability, and it helps to combat barriers to the effective delivery of preventive care such as time constraints, lack of training, and patient anxiety about procedures and results.

Using PPIP Tools

PPIP tools are part of the STEP-UP (Study to Enhance Prevention by Understanding Practice) clinical trial. STEP-UP involves 80 family practices and clinics across Northeast Ohio in urban, rural, and suburban areas, including large Amish populations. The STEP-UP study evaluates a preventive related delivery intervention that is tailored to the unique characteristics of each practice. A nurse facilitator is assigned to each practice to identify special prevention-related needs of the practice population, such as immunizations, screenings, and counseling.

The STEP-UP manual provides tools that clinicians can use as-is or modify. PPIP materials included in this manual are adult and child preventive care flow sheets, child immunization flow sheets, posters, and patient reminder postcards. The STEP-UP trial plans to continue using PPIP tools because they can be easily adapted to clinicians' needs as they work to enhance the delivery of preventive services to local patient populations.

The PPIP program emphasizes that clinical prevention works and is important, that different people need different services, and that an extensive system-wide team approach is necessary to ensure that prevention is a routine part of every patient experience. AHRQ works closely with public and private partners to disseminate PPIP tools and resources, which include information on preventive services recommendations, an implementation guide for clinicians and health care systems, and personal health guides for children, adults, and people over 50.

In December 2001, AHRQ released A Step-by-Step Guide to Delivering Clinical Preventive Services: A System Approach designed for use by physicians, nurses, health educators, and office staff. The guide, which has been found to be effective in many clinical settings, explains how to deliver routine preventive care to every patient, tells what services to provide, describes how to involve all staff, and explains how to evaluate and refine systems. The guide breaks the process into small, manageable tasks, and it provides tools for tracking the delivery of preventive care, such as flow sheets (a simple form that gathers all the important data regarding a patient's condition) and health risk profiles. Other materials provided include questionnaires, presentation materials for use in introducing the system to administrators and office staff, and worksheets to identify staff interests and concerns.

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