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Rapid Cycle Research
Following the attacks of September 11, 2001, public attention has increasingly focused on the realization that the Nation's health care system is ill prepared to respond to mass casualty incidents. This concern was heightened by the anthrax cases that followed in October 2001, which drew attention to bioterrorism and the various aspects of preparedness planning as they relate to mass casualty care due to infectious disease outbreaks.
AHRQ's bioterrorism initiative, which started in 2000 before the attacks, is a critical component of the larger U.S. Department of Health and Human Services initiative to develop public health programs to combat bioterrorism. The agency recognizes the need for a strong health infrastructure to coordinate, prepare for, and respond to acts of terrorism. To inform and assist primary care doctors and practices, community health centers, managed care organizations, emergency departments, and hospitals in meeting the health care needs of the U.S. population in the face of bioterrorist threats, AHRQ-supported research focuses on the following:
- Emergency preparedness of hospitals and health care systems for bioterrorism and other rare public health events.
- Technologies and methods to improve the links between the personal health care system, emergency response networks, and public health agencies.
- Training and information to prepare community clinicians to recognize the manifestations of bioterrorist agents and manage patients appropriately.
AHRQ's bioterrorism research is a natural outgrowth of the agency's ongoing efforts to develop evidence-based information to improve the quality of health care in the United States. Examples of products and tools that are currently or soon will be available include the following:
- Web-based training modules to teach health professionals how to address various biological agents. Separate modules exist for emergency room doctors, radiologists, pathologists, nurses, and infection control specialists. Clinicians can obtain continuing medical education (CME) credit.
- A Real-time Outbreak and Disease Surveillance (RODS) System for bioterrorist events. The purpose of RODS is to provide early warning of infectious disease outbreaks, possibly caused by an act of bioterrorism, so that treatment and control measures can be initiated to protect and save large numbers of people.
- Use of a city-wide electronic medical records system as a model for surveillance and detection of potential bioterrorism events across a wide range of health care facilities, including primary care practices, public health clinics, emergency rooms, and hospitals.
- A new online survey that hospitals can use to assess their capacity to handle potential victims of bioterrorism attacks or for evaluating existing emergency plans. The survey covers subjects such as biological weapons training for personnel, procedures to permit rapid recognition of credentialed staff from other facilities, on-call nursing policies, and designated areas of emergency overflow for patients.
Physician preparedness. A survey taken shortly after September 11, 2001, showed that on the eve of last years' anthrax attack, three-quarters of the 614 primary care physicians surveyed said they felt unprepared to recognize bioterrorism-related illnesses in their own patients. This survey, sponsored by AHRQ and the American Academy of Family Physicians, found that 38 percent of these physicians rate their knowledge of the diagnosis and management of bioterrorism-related illnesses as poor, and only about 18 percent said that they had prior bioterrorism training.
The survey also found that being familiar with the public health system did not prepare them for knowing what to do in case of a bioterrorist attack—only 57 percent reported knowing who to call to report a suspected bioterrorism case.
These findings underscore the importance of preparedness for family physicians. Because the symptoms caused by many bioterrorism agents mimic those of common illnesses, patients may seek care first from their family physicians.
In 2002, AHRQ received over $10 million to continue its efforts to support national preparedness for a bioterrorist event. AHRQ's current bioterrorism activities continue to support departmental initiatives in the three broad areas stated previously. Through various contract mechanisms, AHRQ-funded researchers are preparing tools and models that can be exported to States and interested entities for use in their bioterrorism preparedness planning initiatives. Examples of projects currently underway include:
- Development of national guidelines for dispensing medications and/or vaccinating large populations in the event of a bioterrorist event.
- A Web-based data tool and manual that facilitates health care systems' ability to monitor and track resources that would be needed to respond to a bioterrorist event. This work will be developed with rural hospitals as a model.
- A Regional Health Emergency Assistance Line and Triage Hub (HEALTH) Model addressing the integration and communication with public health agencies and other facilities for efficient management of patient care during and after a public health emergency such as a bioterrorist event.
- Development of a report that provides an overview of current knowledge on how disaster drills and training are being conducted and evaluated for bioterrorism preparedness and a tool for evaluating disaster drills and training that can be disseminated to States and other interested groups.
- Development of information technologies available in practice-based settings for surveillance of signs and symptoms of diseases that suggest bioterrorism in pediatric and adult primary care practices.
- Convening of an AHRQ-sponsored conference focused on preparedness and disaster responses for pediatric patients.
Future research initiatives will address considerations relevant to rural preparedness, vulnerable populations, pediatric care issues, and public-private partnerships related to the use of information technology for surveillance, detection, notification alerts, and education of clinicians.
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Making Timely HIV/AIDS Information Available
The HIV Research Network (HIVRN) is a network of HIV providers who pool data and collaborate on research to provide policymakers and investigators with timely information about access to and the cost, quality, and safety of HIV care; and to share information and best practices among those participating in the Network. The Network is sponsored by: AHRQ, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration, and the Office of AIDS Research at the National Institutes of Health (NIH).
Scientific advances in recommended treatment regimens for HIV disease have the potential to profoundly improve care provided to people with HIV. Medicaid, Medicare, the Department of Veterans Affairs, and the Ryan White CARE Act spend more than $12 billion each year to treat people with HIV disease. New drugs are being developed so rapidly that data collected as recently as 3 years ago do not reflect the current situation and cannot be used reliably for tracking the resources expended or the quality of care provided to people with HIV; reliable information on these topics is critical in informing policy and clinical practice. Policymakers, service providers, and patients need to know how often people with HIV infection receive specific services and what factors are related to receiving more or fewer services. The goal of the HIVRN is to disseminate this information widely, using the most recent data that are available.
To address the need for data on the treatment of people with HIV disease, AHRQ joined with the Department's Assistant Secretary for Policy and Evaluation (ASPE), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Health Resources and Services Administration (HRSA) in 1999 to establish a pilot HIV data center at the Johns Hopkins School of Medicine. Researchers at the data center tested on a small scale the feasibility of transmitting data from HIV caregivers. These included data on patient characteristics, payer data, clinical data, and data on the number of visits and admissions. In the initial phase of this project, the researchers succeeded in enrolling a set of HIV care providers in different regions of the United States and in establishing procedures for transferring data on HIV-related resource use and relevant clinical parameters to the HIV Research Network. Data on over 10,000 HIV-infected patients for calendar year 1999 were transferred to the HIVRN.
In 2000, the pilot was deemed successful, NIH's Office of AIDS Research joined the collaboration, and efforts were expanded to collect data from 18 providers who treat at least 14,000 people with HIV disease. This unique dataset permits analyses looking at patient characteristics, payer variation, drug therapy regimens, number of visits, and admissions. Preliminary data analyses indicated that there are serious disparities among people with HIV disease in their ability to receive expensive new drug therapies. Specifically, analyses show:
- Monthly inpatient care averaged $423 per patient, and monthly outpatient care averaged $168 per patient.
- The cost of highly active antiretroviral therapy (HAART) was partially offset by cost reductions associated with lower use of hospital inpatient care; HAART was associated with monthly inpatient costs of $389 compared with $470 among non-HAART users.
- White HIV-infected patients (55 percent) are more likely than blacks (48 percent) or Hispanics (44 percent) to receive new and expensive drug therapies.
- Men (70 percent) are more likely than women (56 percent) to receive new and expensive drug therapies.
- Privately insured patients (61 percent) are more likely to receive new and expensive drug therapies.
Based on the promising results from the pilot project, AHRQ initiated a contract to continue this project through FY 2005.
Starting in 2002, health officials and others can access HIV health care use data online through AHRQ's HIVnet, which draws from HIVRN data. This interactive service, found at https://archive.ahrq.gov/data/HIVnet.htm, provides statistical answers in real time to questions about HIV patients' use of outpatient and inpatient care by age, sex, race/ethnicity, HIV risk group, insurance status and type, protease inhibitor use, and other variables. HIVnet now has data for 1999 and 2000, and half of the data for 2001 have been added.
The HIVRN provides an ongoing means to collect information on resource use associated with HIV disease. It is a cost-effective way to obtain reasonably complete medical and financial information on a large number of HIV-infected patients, thus facilitating research on HIV care among different types of patients.
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Promoting Evidence-Based State and Local Health Policymaking
Outreach to State and Local Health Officials
AHRQ's User Liaison Program (ULP) synthesizes and distributes research findings to local and State policymakers so they can use it to make evidence-based decisions about health care policy. ULP holds small workshops, sponsors telephone and Web-supported audio conferences, and distributes other information to provide recent research findings to policymakers on the critical issues confronting them in today's changing health care marketplace. Topics are chosen with input from legislators, executive agency staff, and local officials.
In addition to providing information and tools to make informed health policy decisions, the ULP serves as a bridge between State and local health policymakers and the health services research community by bringing back to the Agency the research questions being asked by key policymakers. ULP workshops are user-driven, user-designed, and highly interactive, with an emphasis on information sharing between participants and presenters.
In FY 2002, ULP held 20 different activities: 10 national workshops, six State-based workshops, and four Web-assisted audio conferences. The activities were attended by 2,534 health care policymakers from all 50 States, the District of Columbia, Puerto Rico, Palau, and Guam. These activities covered a wide variety of issues such as bioterrorism, patient safety, racial/ethnic health disparities, long-term care, and rising health care costs.
AHRQ often receives feedback from workshop and audioconference participants on how they used the information shared at these events. Some examples of feedback include:
- The chairman of the Massachusetts State Senate's Committee on Health Care introduced legislation related to patient safety as a result of attending an AHRQ ULP workshop on patient safety and medical errors.
- The director of the Office of Community Health Services, Mississippi State Department of Health, shared materials and information from a ULP workshop on managed care with the State's Office of Regulation. The materials were used, along with materials from other sources, to initiate a meeting with the State Insurance Commissioner to explore how the State can carry out similar activities with its fledgling HMO industry.
- Based on lessons learned at an AHRQ ULP workshop, a former member of the California State Assembly convinced the Assembly to adopt a rule whereby every pilot health program had to identify with specificity the goals of the program, quantify the goals in measurable ways, and declare what constituted success or failure.
- The Assistant City Manager and Acting Director of Public Health for the City of Fort Worth, TX, used the workbook and other materials from ULP's workshop on managed care to help local health officials conceptualize, develop, and finalize the city's plan for streamlining public health.
- One city's Department of Health and Senior Services faced a legislative mandate to make major changes in its hospital charity care program. AHRQ's ULP program provided immediate assistance by helping them understand their choices and design a workable program that could be rapidly implemented in a crisis environment.
- A ULP workshop participant from Wisconsin shared materials from Ohio and Kentucky and several of the other presentations with the State's early childhood management team, who considered the pros and cons of rolling together actual programs. Subsequently, they developed a plan to create a "children's cabinet." Their plan is now under consideration in key State agencies.
- Participants from Ohio used materials received at the AHRQ ULP workshop to help them formulate plans for creating an advisory committee of advocacy groups for adults and children with special needs. The advisory group will work with State health officials on surveying needs, disseminating information and findings from the surveys, and providing context for survey results.
The October 2000 ULP State-specific conference, Strengthening the Safety Net: A Financial Analysis of New Hampshire Community Health Centers (CHCs), sponsored by AHRQ, resulted in the State of New Hampshire undertaking a number of followup activities designed to strengthen and stabilize its CHCs. The conference was cosponsored by the New Hampshire Department of Health and Human Services, AHRQ's User Liaison Program, and the Robert Wood Johnson Foundation State Initiatives in Health Care Reform and Access Projects.
Since the October 2000 conference, a number of activities have taken place:
- A second conference was held in December 2000, "The Health of New Hampshire's Community Hospital System: A Financial and Economic Analysis." The successful event emphasized the theme of community support and collaboration in strengthening CHCs and New Hampshire's health care safety net. The State is working with its Rural Health/Primary Care Program to broadly disseminate the CHC information shared at the conference to other States.
- Joint efforts with private-sector foundations and financial officers to identify long-term capital needs, secure access to long-term sources of funding, and identify and guarantee short-term lines of credit.
- Enrollment of all eligible patients in Medicaid and the State Children's Health Insurance Program; ongoing efforts to expand private health insurance coverage to people who cannot afford insurance coverage.
- Development of new/expansion of existing partnerships between New Hampshire's community hospitals, businesses, charities, and foundations to provide direct and in-kind support to CHCs.
Evaluating the User Liaison Program
In January 2001, AHRQ contracted with ABT Associates to evaluate the agency's User Liaison Program. ABT randomly selected high-ranking ULP program participants to determine how they used information obtained at the workshops and other programs.
- 80 percent of legislators and 89 percent of executive staff said they have used information gathered from the workshops either to improve their knowledge base on health matters or have applied it more directly and concretely in their work.
- 73 percent of legislators and 91 percent of executive staff have used the workshop notebooks after they returned home.
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Research Translation for Health Care Policymaking
In 2001 and 2002, AHRQ's ULP research translation team produced research syntheses targeted to AHRQ stakeholders—the Research in Action series. The purpose of these syntheses is to share research findings and the impact the findings have had so that other stakeholders can learn from our experiences and related research from the field. AHRQ produced three research in action syntheses in 2001 and eight in 2002.
Research syntheses published in FY 2002 were titled:
- Improving Care for Diabetes Patients Through Intensive Therapy and a Team Approach
- Preventing Disability in the Elderly with Chronic Disease
- Managing Osteoarthritis: Helping the Elderly Maintain Function and Mobility
- Expanding Patient-Centered Care to Empower Patients and Assist Providers
- Medical Informatics for Better and Safer Health Care
- Improving Treatment Decisions for Patients with Community-Acquired Pneumonia
- Prescription Drug Therapies: Reducing Costs and Improving Outcomes
- Reducing Costs in the Health Care System: learning from What Has Been Done
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