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Performance Budget Submission for Congressional Justification

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Research on Health Care Costs, Quality and
Outcomes (HCQO)


Purpose and Method of Operation
Improving Clinical Practice
Patient Outcomes Research Teams (PORTS)
Pharmaceutical Outcomes Research
Evidence-based Practice
Improving the Health Care System's Delivery of Care
Consumer Decision Making
Consumer Decision Making—Smoking Cessation Initiative in FY 1998
Consumer Decision Making—Small Business Innovation Research (SBIR)
Impact of Market Forces
Managed Care
Primary Care
Quality Measurement and Improvement
Tracking the Nation's Progress
Activities in Support of All Goals
Prior Year Funding
FY 1999 Request

Purpose and Method of Operation

The purpose of the Research on Health Care Costs, Quality and Outcomes (HCQO) program is to support and conduct research that improves the outcomes, quality, and cost, use, and accessibility of health care services. To achieve this purpose, the HCQO budget activity has three main areas of focus: (1) Improving clinical practice, (2) Improving the health care system's capacity to deliver quality care, and (3) Tracking the Nation's progress by providing policy makers with the capability to monitor and evaluate the impact of system changes on cost, use, and accessibility of health care.

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Improving Clinical Practice

HCQO focuses on improving health outcomes—a diverse area that reflects a convergence of multiple themes in research on health care delivery:

  • The existence of variations in practice.
  • The increasing occurrence of chronic diseases, a result of the successes of acute care medicine and demographic shifts in the population.
  • Growing interest in the impact of different modalities and financing arrangements on outcomes.
  • Continued interest in the evaluation and appropriate use of medical technologies and clinical services, including pharmaceuticals, primary and preventive care, and specialized services.

Outcomes and effectiveness research continues to be a central component of AHCPR's portfolio of extramural research. Outcomes research as a field is also maturing, and in the Fall 1997, the Agency sponsored a national conference to bring together key leaders in research and practice to determine the "state of the science" and chart the course for the next 10 years of investment in outcomes research. This report will be published by early Spring 1998, and available on the AHCPR Web site. Some recent findings of AHCPR-supported outcomes research include:

  • While cardiac disease remains the number one cause of mortality in the United States and the most expensive category of illness for the Medicare program, mortality from cardiac disease has been decreasing for the past 15 years. Investigators from Harvard developed a model to study which interventions—prevention or acute treatment—have led to the decline in mortality. Their results suggest that more than 50 percent of the observed decline can be attributed to improvements in treatment (e.g., diagnostic and therapeutic advances).
  • Many patients with heart attacks do not receive thrombolytic therapy ("clot-busters"). Investigators from the New England Medical Center have developed a tool that provides for each individual the expected mortality at 30 days and one year if treated with thrombolytics—and if NOT treated. The results are printed on the patient's EKG when they are first seen in the Emergency Room. A trial to assess whether this will increase the proportion of eligible patients receiving recommended treatment is in progress; the investigators are also working with the major manufacturer of EKG machines to make this tool widely available.
  • Patients admitted to the hospital with a heart attack may be cared for by a cardiologist, primary care physician or both. Investigators at Harvard examined care provided to Medicare beneficiaries in New York and Texas and found that: cardiologists tended to provide care to younger and less ill individuals, and were more likely to recommend invasive testing and surgery than primary care physicians. Cardiologists were also more likely to comply with some but not all recommended medical treatments than primary care physicians. There were no differences in mortality at one year associated with physician specialty. The results indicate areas for needed quality improvement by all physicians, and emphasize the importance of hospital as well as physician factors in mortality from heart attacks.
  • Investigators from Dartmouth worked with cardiovascular surgeons in Northern New England to improve quality of care for patients having bypass surgery (CABG). The intervention resulted in a significant 24 percent reduction in mortality.

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Patient Outcomes Research Teams (PORTS)

Much has been learned from the investments in the 14 original Patient Outcomes Research Team (PORT) and 11 PORT II projects, both in terms of effective care (for costly and common conditions such as diabetes, coronary heart disease, and complications of childbirth) as well as new ways to evaluate outcomes appropriately. Select for a complete listing of PORT and PORT II projects. Findings and publications continue to be generated from the original 14 PORTS, as well as translation of research findings into practice. To cite the most recent example, in November 1997, four managed care organizations in the Washington, D.C. area released a major education and quality improvement program for community acquired pneumonia, and explicitly stated that their program is based on outcomes research funded by AHCPR. Specifically, investigators working on the community-acquired pneumonia PORT, an illness that is one of the most common reasons for hospital admission for Medicare beneficiaries and one of the top 10 most costly diagnoses for the Medicare program, have examined factors associated with hospital admission from the perspective of physicians and patients, factors that influence length of stay, and factors associated with quality of care for hospitalized patients. Findings published in medical journals include:

  • Development of a risk-stratification index to predict those individuals with very low risk of mortality who can safely be treated at home (New England Journal of Medicine).
  • Identification of specific factors (intravenous antibiotics and nursing support at home) that would permit more than 50 percent of low-risk patients to be treated at home (Archives of Internal Medicine).
  • In conjunction with the American Thoracic Society, demonstrated that less costly antibiotics are also more effective for treating community-acquired pneumonia (Journal of the American Medical Association).

In addition, the Diabetes PORT has examined treatment patterns for patients with Type 2 diabetes, the more common type of diabetes in the United States. Their recently published work has demonstrated that insulin treatment is significantly more costly and not always more effective than oral agents. They have worked closely with leading professional organizations to assure that these results are disseminated widely.

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Pharmaceutical Outcomes Research

The purpose of AHCPR's pharmaceutical outcomes research is to determine what practices, with regard to such issues as prescribing, patient education, reimbursement, and drug utilization review, are associated with the best outcomes for patients (including cost) with common conditions, in uncontrolled, real world situations. This research is clearly distinct from the kind of pharmaceutical research done by the Food and Drug Administration and other Federal agencies, because this research goes beyond questions of drug safety and efficacy.

One recent AHCPR-funded study at the University of Colorado Health Science Center looked at more than 12,000 children, 13 years of age and younger, enrolled in Colorado's fee-for-service Medicaid program, and treated for a new episode of acute otitis media (ear infection). This study discovered that treatment of common ear infections in children with antibiotics, such as amoxicillin instead of more costly choices, could save millions of dollars a year without changing recovery rates. Middle ear infection is the most frequent reason for giving antibiotics to children in the United States. No single antibiotic has been found to be superior in treating this condition. However, costs vary widely, from less than $3 to more than $62 for a course of treatment. If, in one year, only half the prescriptions written used a lower cost antibiotic, Colorado's Medicaid program would have saved approximately $400,000.

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Evidence-based Practice

In 1997, the Agency successfully launched its initiative to promote the use of evidence in everyday care through the funding of National Evidence-based Practice Centers (EPCs) and establishing a National Guideline Clearinghouse™. The latter is a joint effort by AHCPR, the American Association of Health Plans, and the American Medical Association, developed over an 18 month-period in 1996 and 1997.

In October 1997 AHCPR announced the first set of topics assigned to the 12 EPCs. Select for EPC topics and centers.

The EPCs will make important contributions to promoting evidence-based practice in two ways. First, they will conduct rigorous and systematic reviews of all of the relevant scientific literature about these topics. Unlike mere syntheses of the literature, they will assess the appropriateness of the research design of each study, the extent to which the study adequately controlled for threats to the validity of the study's findings, and the appropriateness of the statistical tests and how they were applied. Where appropriate, they will conduct additional analyses. This will provide clinicians and other health care professionals with a clear understanding of the strengths and weaknesses of the available scientific literature. Second, to assure that the work of the EPCs is translated into practice quickly, AHCPR will only assign a topic to an EPC when one or more organizations (such as managed care organizations, medical specialty societies, federal purchasers, and others) have made a commitment to use the EPC report to develop their own quality improvement strategies. In addition, the EPC findings (evidence reports or technology assessments) will be broadly disseminated.

AHCPR will also conduct evaluation studies on EPCs, to be reported in the fiscal year (FY) 1999 Performance Report. These evaluation studies will review the quality and usefulness of the evidence reports and technology assessments produced by the Evidence-based Practice Centers and the impact of the use of these products on the health care system.

Current Evidence-based Practice Centers (EPCs)

Contract Topic
Research Triangle Institute and University of North Carolina Pharmacotherapy for alcohol dependence
University of California and Stanford University Management of stable angina
MetaWorks, Inc., Boston, MA Diagnosis of sleep apnea
McMaster University Treatment of attention deficit/ hyperactivity disorder
Oregon Health Sciences University Rehabilitation of persons with traumatic brain injury
Blue Cross and Blue Shield Association Technical Evaluation Center (TEC) Testosterone suppression treatment for prostatic cancer
Duke University Evaluation of cervical cytology
University of Texas Depression treatment with new drugs
Johns Hopkins University Evaluation and treatment of new onset of a trial fibrillation in the elderly
RAND Corporation, Santa Monica, CA Prevention and management of urinary complications in paralyzed persons
New England Medical Center Diagnosis and treatment of acute sinusitis
ECRI, Plymouth Meeting, PA Diagnosis and treatment of dysphagia/swallowing problems in the elderly

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Improving the Health Care System's Delivery of Care

Clinical services are not delivered in isolation. Their accessibility and quality are also affected by the settings in which care is delivered, the processes and structures that organizations put into place to manage those clinical services and the clinical and support personnel that provide them, the scope of (or lack of) insurance coverage patients have for reimbursing those services, and the processes that organizations put into place for measuring and improving the quality of the care provided. In fact, the national policy debate on quality has focused almost exclusively on non-clinical determinants of quality, such as:

  • Financing (limits on benefits/services/reimbursement).
  • Management of services (limitations on length of stay or referrals, the shift to outpatient care, the use of financial incentives and cost-sharing).
  • Limitations on the clinician's relationship with the patient.

Despite the importance of these factors to the American public and Federal and State policy makers, we have little scientific evidence regarding their impact on quality. AHCPR supports research in this area to improve the health care system's capacity to deliver quality care.

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Consumer Decision Making

AHCPR has a strong commitment to improving the ability of consumers to make informed choices in health care. The Agency has identified three key choices that consumers face: choosing a health plan, choosing a doctor or provider, and when confronted by illness, choosing appropriate treatment. In each of these areas, the Agency supports a diverse set of grant and contract research.

AHCPR will continue to support a major initiative to assist consumers in selecting high quality health plans and services. The project, entitled the Consumer Assessments of Health Plans (CAHPS®) study, consists of cooperative agreements totaling more than $10 million over five years with three consortia headed by the Research Triangle Institute, the RAND Corporation, and Harvard Medical School. CAHPS® is a ground-breaking effort to determine the factors that contribute most to consumer assessments of health plans; find ways to measure those factors; and determine if providing this information to consumers assists them in choosing high quality health plans.

In phase 2 of the project, begun in Spring 1997, CAHPS® was demonstrated and evaluated in a variety of settings that include Medicaid programs, large employers, and health plan purchasing coalitions. Select for a list of CAHPS® demonstration sites.

In these sites, CAHPS® survey instruments and reporting formats will be used to collect and report information to the public. Members of the CAHPS® teams provided technical assistance and performed a systematic process and outcome evaluation of the CAHPS® products. Using qualitative and quantitative methods, this evaluation was aimed at improving the CAHPS® surveys and reports and determining the usefulness of CAHPS® products to consumers and purchasers in selecting health care plans and services.

CAHPS® Demonstration Sites

Harvard University Population SurveyedComments
Washington State Health Care Authority Implemented CAHPS® with 21,500 State employees in 17 plans in Fall 1997 Print guide was disseminated Fall 1997; some participants also have computer guide; Harvard producing plan-level and purchaser- level reports.
Massachusetts Medicaid Will implement CAHPS® with Medicaid recipients in 1998.  
State of Colorado With NCQA, performed comparison study of NCQA's Member Satisfaction Survey with CAHPS® instrument with members of 6 managed care plans in Colorado.  

RAND Site Population SurveyedComments
New Jersey Medicaid Surveyed approximately 5,500 Medicaid recipients in 11 HMOs Reports to be disseminated to new Medicaid recipients in January 1998
Florida Medicaid Used an early version of CAHPS® in 1996 Both print and computer guide are being tested in Florida
Iowa Medicaid Surveyed Medicaid recipients in 2 HMOs, 1 FFS and 1 PCCM plan Will not send report or conduct evaluation in 1997, but will do both in 1998
Maryland Medicaid Will implement CAHPS® with Medicaid recipients in 1998 

RTI Site Population SurveyedComments
Kansas Foundation for Medical Care Surveyed state employees; employees of 2 private companies; Medicaid recipients in Kansas City; Medicare beneficiaries in Kansas City Print guide distributed to State employees in October 1997; private companies are not reporting the results
Oregon Will implement CAHPS® with State employees and Medicaid recipients in Spring 1998. Developing report card w/CAHPS® and other quality info
State of Iowa Employees Health Benefits To Be Determined Negotiations still underway; possible site for 1998

In addition to the AHCPR-supported demonstration projects, states and other local governments are using CAHPS® to conduct their own surveys. In November 1997, the State of New Jersey released a report, New Jersey HMOs: Performance Results, which rates the state's HMOs based upon interviews with 5,500 HMO members using the CAHPS® instrument. This is just one of at least nine states and various counties, in addition to Medicare, that has a commitment to using CAHPS®.

In January 1998, the Quality Measurement Advisory Service (QMAS), the Picker Institute, and Harvard University joined forces to build the first national database of patient-derived assessments of health plans using the results from CAHPS®. Fifteen groups, including Medicaid agencies, business coalitions, and States, have expressed interest in participating, according to QMAS.

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Consumer Decision Making—Smoking Cessation Initiative in FY 1998

Consumer decisions about treatments are directly informed by the results of outcomes research and the development of tools to bring scientific findings to the lay public. The Agency's activities in this area include the new Smoking Cessation Two-Three Initiative that seeks to enlist the help of all clinicians to get their patients who smoke to quit. The Initiative highlights the AHCPR-sponsored smoking cessation Clinical Practice Guideline released in 1996 recommending that two questions: "Do You Smoke?" and "Do You Want To Quit?" be part of every medical assessment by clinicians. This should be followed by an intervention as brief as three minutes recommending smoking cessation treatments proven to work. Research shows that smokers have the best chance of quitting when their health care providers get involved.

To aid clinicians in the intervention, AHCPR has developed a Smoking Cessation Consumer Tools Kit, complete with four, easy-to-read, write-ups that address particular concerns of smokers, especially those in challenging situations such as First Time Quitters, Multiple Quit Attempts, Pregnancy and Smoking, and Smokers Facing Surgery.

The Initiative follows an AHCPR-funded report released in December 1997 that found smoking cessation efforts to be cost-effective. According to The Cost Effectiveness of AHCPR's Smoking Cessation Guideline Report, while all types of cessation treatment were found to be cost-effective, those involving more intensive counseling and the nicotine patch proved to be especially worthwhile. Smoking cessation interventions are less costly than other preventive medical interventions such as the treatment of high cholesterol. In fact, at an average cost of about $2,600 per year of life saved, smoking cessation treatment is especially cost-effective when compared with cholesterol treatment, a routine intervention which costs nearly forty times as much to treat a year.

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Consumer Decision Making—Small Business Innovation Research (SBIR)

AHCPR supports a number of SBIR projects designed to tests innovative strategies for assisting consumer decision making. Several projects include:

  • Elder Care—This contract will develop an interactive CD-ROM program to assist families in deciding on the best living/care arrangement for elderly relatives—home, personal care homes, nursing homes. The decision model will allow families to evaluate their elderly relatives' ability to function in each setting, as well as the families' ability to provide care. Decision factors address physical and cognitive ability, psychosocial and financial issues. This tool could be adapted for any number of public programs, such as Medicare and Medicaid.
  • How to Evaluate Information from Providers: Tools for Non-mainstream Populations—Under this project "low-barrier" decision tools will be developed. That is, consumer information will be developed to help low literate, minimally English proficient, minority and low income individuals better use health care services. The goal of the project is to develop prototype print, video, and interactive voice response (IVR) telephone systems to assist consumers in communicating with plans and providers. The IVR should help individuals to understand and evaluate the information and advice they are given by providers with respect to illnesses and treatments, so that there is more shared decision making. These tools should be adaptable for public programs.

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