Skip Navigation Archive: U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archive print banner
Performance Budget Submission for Congressional Justification

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Activities in Support of All Goals

Health Services Research Training

At this time of rapid change and restructuring in the nation's health care delivery system, the need for persons trained to conduct research and perform analyses to assist decision makers in both health policy and health care delivery settings is critical. The Institute of Medicine's (IOM) Committee on Health Outcomes for Older People recently noted that advances in research methodology, data analysis, and interpretation hold the promise for "significant breakthroughs" in addressing a variety of research questions within the next decade.

However, the committee expressed reservations about the adequacy of the current research infrastructure and, in particular, the research workforce, to meet this challenge. Though some private training support is available, it is highly targeted and has decreased compared to past years. The ability of academic health centers and other educational institutions to use internal resources to support the career development of junior researchers is dwindling because of more generalized cost pressures. Another IOM group, specifically addressing health services research workforce and educational issues, concluded: "Like research and education in the biomedical and clinical sciences, generally, health services research and research training are public goods worthy of support by society as a whole."

In response to the needs outlined by the IOM, AHCPR developed incentive awards for innovative approaches to health services research training that are responsive to the research and analytic needs of the evolving health care delivery system. The intent of the awards is to support the design and implementation of new models for training health services researchers to address emerging issues in health care policy and delivery and to respond to the changing analytic needs of health care providers, payers, and policy makers. The awards represent seed money to support developmental efforts not readily supported by existing training mechanisms. They are aimed at developing and sustaining novel and unique educational approaches geared to enhancing established health services research training programs.

Priority Populations

Health services research has documented the marked variations in health status and access to appropriate health care services for certain groups, notably racial and ethnic minorities. Within the context of increasing reliance on States and markets to address enduring health care problems, the unique needs of minorities are especially relevant to Medicaid policymakers. Health services research must do a better job of bringing science-based information to bear on these variations so that the health of minorities, women, and children is enhanced.

AHCPR will build upon the findings of the Minority MEDTEP Centers and lay the groundwork for Centers of Excellence that will develop and test targeted intervention strategies designed to improve the health outcomes of minority populations. These interventions will target a number of the high-priority areas of disparity identified in past research, such as:

1. Women's and children's health
  • A larger proportion of white women with breast cancer undergo biopsy compared to non-white women; non-white women have a significant delay in diagnostic testing for breast cancer and receive less intensive evaluations than white women.
  • Black women undergoing hysterectomy had higher mortality rates, higher complication rates, and longer hospital stays than white women.
  • Black children with asthma were much less likely to be prescribed a nebulizer for home use than white children.
  • Rates of low birth weight in Cambodian, Filipino, Indian, Japanese, Laotian, and Thai women were higher than the U.S. national goal.
  • Latino and black women are much less likely to undergo amniocentesis and chorionic villus sampling than white and Asian women. Latinos over 35 years of age are three times more likely to give birth to a Down Syndrome affected infant than white women, and black women are nearly twice as likely to do so.

2. Heart disease and diabetes

  • Black patients are less likely to undergo coronary artery bypass grafting than white patients and are less likely to receive cardiac revascularization.
  • Most minority groups in the US have higher rates of adult-onset diabetes as well as more complications and death from the disease than do whites.
  • Minority individual suffer from six times more cases of diabetic kidney disease than whites.

3. Health insurance and health care access

  • More than one-third of Mexican Americans lack health insurance. Uninsured Mexican Americans are most in need of health care and are least likely to receive it.
  • One study revealed that black patients received fewer hospital services than white patients.
  • A study revealed that fewer black AIDS patients received preventive drugs from AIDS-related pneumonia (PCP) than white AIDS patients.

AHCPR supports a number of important women's health research projects as part of its ongoing research agenda. Additional research is needed, targeted to three broad issues of special significance to women: reduction of disparities and improving health outcomes among minority women; addressing issues related to women and quality of care; and clinical studies of improving the quality of life for women with multiple chronic illnesses.

By almost any standard, the health of African-American women is worse than for white women: they are 50 percent more likely to die of heart disease, four times more likely to die of stroke, and one-third more like to die of breast cancer. There are gaps in health status for most other racial and ethnic groups as well. Some of these differences can be attribute to poverty and lack of access to care and technologies, but, even when adjusted for socioeconomic status, important differences remain. Increased work is needed to synthesize scientific studies related to the effectiveness of programs and services designed to raise the health status of women of color, and to initiate a series of clinical and cost-effectiveness studies to provide information about which interventions make a difference in health outcomes for minority women. In FY 1998, AHCPR will develop a targeted solicitation to address these needs.

Cost-effectiveness Analysis

AHCPR plays a critical role in nurturing the development of the scientific tools of health services research. Most of these tools are developed through investigator-initiated work. One method, however, warrants a targeted effort across the Agency because of its increasing policy relevance: cost-effectiveness analysis (CEA). Purchasers and consumers of health care services are increasingly concerned with not just the effectiveness but the value of the care being provided. By forcing an explicit approach to the decision making process and providing a framework for identifying and considering as many of the relevant costs and benefits as is feasible, CEA can improve decision making in both the private and public sectors. Yet, many questions remain about the quality of CEAs; their comparability, impact, and potential for bias; how they are used in managed care decision making; and the effects of their use on health systems management and patient care.

AHCPR is building on past Agency work in this field, as well as the 1996 landmark report, "Cost Effectiveness in Health and Medicine," to begin to address these questions. The Agency is focusing on two areas: developing better basic tools for CEA; and the applications of CEA, including the use of CEA in patient decision making.

Dissemination Activities

AHCPR promotes widespread distribution and assimilation of its information and research products through a variety of dissemination methods including: publication in professional journals; provider and consumer materials; press conferences; interviews and story placement with the medical/trade press; and articles in the popular press.

AHCPR's Home Page on the World Wide Web has allowed ready access to our research findings, consumer publications, and information for applicants. AHCPR has had well over 2 million hits on the site in 1997, up from 1 million in 1996. The web site was redesigned in 1997 to respond to customer suggestions and make it more user friendly. AHCPR will continue to upgrade and revise various sections of the site including, a "virtual newsroom" for the press to help disseminate AHCPR's studies and products. The site will be evaluated later this year to decide what other upgrades/redesigns would be helpful.

The User Liaison Program (ULP) synthesizes and disseminates research findings to state, Federal, and local policy makers in easily understood and usable formats. The ULP plays a key role in AHCPR's efforts to support capacity-building for public health at the state and local level through policy-thematic workshops, skill-building workshops, and technical assistance.

Specifically, two workshops that were conducted in 1997 and are planned again in 1998 that focus on providing technical assistance to local policy makers include:

  • "Local Health Departments in a Managed Care Environment"—This workshop was designed to compliment the AHCPR publication "Assessing Roles, Responsibilities, and Activities in a Managed Care Environment: A Workbook for Local Health Officials" by providing a forum for further examination and discussion of the issues raised in it. This workshop was held twice in FY 1997 and will be repeated in FY 1998.
  • "What Do We Do About the Uninsured?"—The purpose of this workshop was to examine the latest research findings on the uninsured and what state governments have been doing to ameliorate this persistent problem—focusing on programs and policies that have been developed and implemented.

In addition, the ULP is planning a series of technical assistance workshops in FY 1998 designed to help State legislators and executive branch officials plan for and implement the State Children's Health Insurance Program (SCHIP) recently enacted by Congress. The workshops are being developed in cooperation with ASPE, HCFA, HRSA, the National Governors Association, and the National Conference of State Legislators.

Return to HCQO Table of Contents

Prior Year Funding

Funding and full-time equivalent (FTE) staffing levels for the Research on Health Costs, Quality and Outcomes program over the five-year period prior to FY 1998 has been as follows:

Year AmountFTEs
1994 $141,968,000 227
1995 $141,962,000 226
1996 $107,939,000 222
1997 $102,863,000 216
1998 Appropriation $107,905,000 226

Return to HCQO Table of Contents

FY 1999 Request

The FY 1999 Request includes funding for commitments and provides for new extramural research in areas such as outcomes and effectiveness; measuring quality; health care markets, organization and delivery; and evidence-based practice. The Request also includes continued funding for the Medical Expenditures Panel Survey (MEPS) at $27,800,000, a reduction of $8,500,000 from the FY 1998 level.

In fiscal years 1997 and 1998, the level of MEPS funding was over twenty million dollars more than the base level in FY 1996, without a concurrent increase in total funding. AHCPR's ability to fund new research was severely curtailed and the area of research on minority health care was particularly hard hit. Funding for the Research Centers on Minority Populations ended in FY 1997 and new research funds were not available to build on the findings of those Centers or to initiate research in new areas. In FY 1999, some leveling off of MEPS requirements should occur and those funds will be redirected to support new and enhanced research on outcomes and effectiveness, and cost, use and accessibility of health care services for minority populations. A particular emphasis will be placed on research and demonstrations to identify effective approaches to reduce or eliminate the existing disparities in the quality, outcomes, and access to care for minority populations for conditions including cancer, diabetes, HIV/AIDS, infant mortality and cardiovascular disease. AHCPR will also use these funds to build on past work in the area of women's health, targeting three broad issues of special significance to women: reduction of disparities and improving health outcomes among minority women; addressing issues related to women and quality of care; and clinical studies of improving the quality of life for women with multiple chronic illnesses. A modest effort to improve cost effectiveness analysis (CEA), an important scientific tool of growing in significance in health services research, will also be supported.

An increase of $25,000,000 over the FY 1998 Appropriation will support the Secretarial Initiative to Improve Health Care Quality ($15,000,000) and new extramural research in key emphasis areas, i.e., the elderly and chronically ill ($5,000,000), clinical preventive services ($2,000,000), Centers for Education and Research Therapeutics [CERTs] ($1,000,000), and children's health ($2,000,000).

Return to HCQO Table of Contents

Improve Health Care Quality ($15,000,000)

The Government plays a number of key roles in improving health care quality. As the major purchaser of health care services, the Government has a responsibility to make effective use of its purchasing power to assure that the individuals it serves receive quality health care services at a reasonable price. As a leading provider of health care services, the Government has the responsibility to assure that its programs continuously assess and improve the quality of care that they provide. As the leading funder of health research, the Government has the responsibility to provide the objective scientific information that Americans need to make more informed health care choices.

The Department's Quality Initiative will:

  • Facilitate Consumers' Use of Information on Quality. Consumers seldom have the information they need to make informed decisions about health plans, providers, and treatments. In a market-driven health care system, informed decisions will lead to better quality care. This initiative will enable consumers to understand and use quality information effectively.
  • Strengthen Value-Based Purchasing by the Department. This initiative will use the Department's power as a major health care purchaser to ensure High quality care through prudent, value-based purchasing decisions. The Department will use key elements in purchasing, such as reimbursement criteria, contract specifications, performance measures to assess health care quality, and standards for access to culturally competent providers and adequate provider networks. This initiative will develop purchasing models, strategies and implementation plans for strengthening purchasing power across the Department.
  • Improve the Quality of Health Care Services Delivered Directly by HHS Programs. The Department provides direct care through many programs, each of which has its own quality improvement activities. This initiative will identify quality improvement strategies that work and promote their adoption across these programs.
  • Expand Research that Improves Quality. The Department has a substantial portfolio of research on quality of care, but translating that knowledge base into concrete improvements in health care is still a challenge. This initiative will support research to develop and determine which quality improvement methods work, and in which settings. It will also support research to understand how to redesign the tasks of delivering care, to eliminate unnecessary steps and minimize the chances for error.
  • Measure National Health Care Quality. Little objective information currently exists to determine what is happening to the overall quality of health care in America. Under this initiative the Department will build upon existing data reporting systems to provide an ongoing picture of the state of health care quality, an early warning system for quality problems, and opportunities for improvement.

Return to HCQO Table of Contents

Improve Outcomes for the Elderly and Chronically Ill ($5,000,000)

In FY 1999, AHCPR will launch an initiative to improve health outcomes for the elderly and chronically ill by providing clinicians and health care systems with the knowledge they need to identify and provide effective care in the most cost-effective settings.

This initiative responds to the 1997 report by the Institute of Medicine that called for increased research on health outcomes for the elderly. Specifically, this initiative will:

  • Develop a "toolbox" of well-defined and validated measurement instruments, including a core set of outcomes measures to address the top conditions paid for by Medicare, that have been specifically tested for use in older individuals in different health care settings, including managed care and fee for services.
  • Examine how various system characteristics, including how physicians are compensated, which services are "carved-out" and provided separately, and the degree of clinical integration, affect the health outcomes for the elderly and chronically ill including studies to identify the most cost-effective solutions for both the Medicare and Medicaid populations.
  • Include a specific focus on the health outcomes and needs of racial and ethnic minorities and women, who represent a large and growing proportion of this population.

Rationale for the Initiative. Along with longer life expectancy and a boom in the elderly population has come an increase in people whose elder years are complicated by substantial functional disability from chronic diseases. In fact, a substantial portion of the increase in the elderly will come from a tripling in the number of those over 85 and nearly half of these will suffer from Alzheimer's or other dementias. These startling facts raise unique challenges for the health care system of today and the future.

At the same time, others remain active and in the workforce with the expectation that their chronic illness will be adequately managed by the health care system. The growing demands being placed on long-term and home-care facilities have also raised questions about the adequacy, cost, and quality of these services. Chronic disease is the main cause of disability in this country, the number one reason that people use health services, and accounts for 70 percent of health care resources. Yet the health care system is arranged largely for acute care. There is growing evidence that this structure is neither efficient nor particularly effective at meeting the needs of persons with chronic and disabling conditions and is not cost-effective. The challenge here is to determine what works best in providing high-quality, cost-effective care, whether in the acute, ambulatory setting, long term care, or home based settings.

The elderly are more likely to have multiple clinical conditions, use multiple medications, and suffer from a variety of impairments (e.g., poor vision or hearing). In addition, this older population is projected to be much more racially and ethnically diverse than ever before: the number of elderly blacks will more than triple and the Hispanic population will increase 11-fold by the middle of the next century. Finally, women are likely to make up a substantial percentage of the elderly, including over 70 percent of those over 85.

These changes in the burden of disease and the racial/ethnic and gender make up of the elderly create new challenges for the health care system. Health services research has amply demonstrated that significant differences exist in the type and quality of care received by racial/ethnic minorities and women. Research must now identify effective strategies for overcoming these differences where they reflect poor quality or lead to worse outcomes.

At the same time, managed care is transforming how care is provided to the chronically ill and disabled. It is not clear to what extent coverage and payment policies provide for the range of clinical and support services needed by the chronically ill. For the most frail, systems of care developed over decades within communities are being disrupted as the financing is shifted from public or nonprofit entities to managed care organizations and cross-subsidies are eliminated. Other aspects of care needs of the chronically ill could benefit from the new incentives in managed care. For example, self-management, long known to be a key factor in maintaining function and reducing disability for those with chronic illness, is being actively promoted by managed care organizations.

Return to HCQO Table of Contents

Clinical Preventive Services ($2,000,000)

There is great interest among providers and patients in the delivery of the full range of appropriate preventive care—screening tests for the early detection of disease, advice to help people change their risky health-related behaviors, and immunizations to prevent infections. These interventions have enormous potential to improve the health of the American people, but without careful assessment of what works and what doesn't, costs could be astronomical. This initiative will support 2-4 major new assessments of preventive services and updates of priority topics, providing targeted, timely information to help providers and patients make appropriate decisions on preventive services.

AHCPR also will sponsor the Put Prevention into Practice (PPIP) initiative, which will develop and disseminate materials for providers, health plans, consumers and purchasers. This will help them choose and deliver appropriate preventive care--ranging from screening tests to immunizations to health-related behavior changes. It will also make consumers aware of how they can improve their health through prevention activities. Many of these recommendations derive from US Preventive Services Task Force reports, and PPIP serves to increase awareness of USPSTF conclusions, to facilitate implementation of USPSTF recommendations, and to improve quality of clinical preventive care. Products of PPIP will be directly disseminated in a wide variety of ways, including public-private partnerships to develop and disseminate new materials and to evaluate impact of USPSTF recommendations and PPIP materials. PPIP will maintain Website to provide access to USPSTF and PPIP materials.

Return to HCQO Table of Contents

Centers for Education and Research Therapeutics (CERTs) ($1,000,000)

The recently-passed Food and Drug Administration Modernization and Accountability Act of 1997 includes new responsibilities for AHCPR. A level of $1,000,000 will allow AHCPR to make grants to support the establishment and operation of two Centers for Education and Research Therapeutics (CERTs). The CERTs will increase the awareness of new uses and risks of medical products; provide information to health care participants to help them use new products most effectively; improve the appropriate use of medical products by health professionals; and prevent adverse effects of medical products and the consequences of these effects.

Return to HCQO Table of Contents

Children's Health ($2,000,000)

In FY 1999, AHCPR will enhance its existing portfolio of activities related to key issues in child health. This initiative responds to the focus on child health reflected in the Secretarial Initiative on Child Health and the State State Child Health Insurance Program (SCHIP). With the passage of SCHIP as part of the Balanced Budget Act of 1997, the nation is once again focused on health care for children and adolescents, especially those in low-income families. SCHIP provides a landmark opportunity to develop and apply tools to measure and improve the quality of care for children in this country. This initiative will support:

  1. Applied research and demonstrations to develop a toolbox of measures, instruments, and proven strategies to improve quality and outcomes of care.
  2. Outcomes research on the most important challenges in children's health.
  3. Research and evaluations on the impact of various state and local approaches to implementing the SCHIP legislation to identify evidence-based practices.
  4. Dissemination of findings and technical assistance to states, providers, and communities about what works in improving child health.

In addition to passage of SCHIP, the first major expansion of health insurance coverage for children since 1963, there are other reasons why children merit an enhanced focus in health services research. The Nation already spends an estimated $95 billion annually on so-called personal health services (traditional health care) for children (AHCPR estimate). While this was a mere 15 percent of total spending on personal health services in 1995, there are other characteristics of children and children's health care that require that children get special attention in health services research. These include the characteristics of childhood as a unique developmental stage of life, the continuity between child and adult health, and the distinctive organization and financing of children's health services. Each aspect presents several unique conceptual and methodological implications for quality, outcomes, cost, use, and access.

Quality and children. Just as health care quality research will be the Agency's highest priority, its child health portfolio will also focus primarily on health care quality research as related to children. The greatest need today is to develop and validate better measures of the process and outcomes of care. Currently, the National Committee on Quality Assurance has been able to convince managed care organizations to report on only nine quality measures specifically on children's health care. Only one of these is directly on the effective treatment for childhood disorders, when the primary interest of parents and children is the ability of the health care system to get children better when they get sick. Recent reviews make clear the lack of measures for quality of care for children, relative to those for adults. For example, a recent survey of Medicaid managed care directors finds that State Medicaid directors are eager to get technical assistance with the identification and development of quality measures for children in the AFDC and disabled populations. As the Balanced Budget Act of 1997 permits more States to use 1115 waivers to expand enrollment of poor in managed care organizations, it also requires the Secretary to work with States and an external quality measurement organization to develop quality measures for Medicaid managed care (Public Law 105-33).

Measurement of quality for children is not an aim in itself. States have also expressed a need for technical assistance in using information on quality to guide consumer choice in Medicaid, and to strengthen health plans' approaches to measurement-based quality improvement. A landmark May 1997 conference on children and quality research--cosponsored by AHCPR, seven other Federal agencies and several private organizations--made clear the lack of attention that has been paid to disseminating information on differential quality in child health to parents, children, and others interested in value-purchasing of children's health care (Halfon and McGlynn, Health Services Research special supplement, in press). Quality improvement strategies in child health are being implemented by States and health plans (e.g., State of Vermont activity on otitis media), but few are based on research-based evidence of prior effectiveness, or are being subject to rigorous evaluations.

Cost, Use, and Access. Within an overall context of system change, the financing and delivery of health services to children have evolved rapidly. Over the last five years, there has been a steady erosion in employer-based insurance coverage for dependent children at the same time as a rise in Medicaid financing. Simultaneously, many States have embraced Medicaid managed care insurance coverage. The Nation is now embarking on a major State-specific expansion of health insurance for children as a result of SCHIP. Renewed attention to cost, use, and access research will help assess the impact of these unprecedented changes in health care delivery on children.

The introduction of SCHIP has made the federal and State governments newly aware that some basic questions about children's coverage, access, and use of services have yet to be resolved. The Medical Expenditures Panel Survey's continuous data collection and other sources of data available to AHCPR will provide a rich data source for examining some of these questions at the national level. Under the Secretarial Initiative on Child Health, AHCPR has the co-lead with the Office of the Assistant Secretary for Planning and Evaluation (ASPE) on developing a research and evaluation strategy to help answer SCHIP and SCHIP-related questions.

Coordination with other agencies. Critical to the Agency's work is close collaboration with other Federal components that have unique authorities and responsibilities to sponsor and conduct child health research, notably the National Institute for Child Health and Human Development (NICHD/NIH), the Centers for Disease Control and Prevention (CDC), and HRSA's Maternal and Child Health Bureau (MCHB) and Bureau for Primary Health Care (BPHC). As a co-lead on the Secretarial Child Health Initiative, AHCPR also works closely with HCFA, ASPE, SAMHSA, IHS, and other operating and staff divisions on issues related to children's health and health care. The agency has lead or co-lead in areas of research and evaluation and quality, as well as participation in overall leadership for the initiative.

Return to HCQO Table of Contents

Current as of February 1998


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care