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Performance Budget Submission for Congressional Justification

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Clinical Preventive Services

The vast majority of premature death and disability in the United States results from preventable causes. Research has concluded that there is strong evidence that a variety of clinical preventive services can prevent some of the leading causes of death or disability. At the same time, research also shows that clinicians do not provide all the services their patients need, and that patients request services that have been found to be ineffective or to have unproven benefits.

AHCPR provides a variety of material to educate a variety of audiences about clinical preventive services. For clinicians and other individuals in the health care system, AHCPR provides copies of the Clinician's Handbook of Preventive Services, 2nd Edition. This user-friendly manual is divided into two sections: children/adolescents and adults/older adults. Chapters in each section provide information on screening tests, immunizations, and counseling. Each chapter includes a description of the target condition, risk factors for the condition, the effectiveness of the prevention service, a list of relevant recommendations by major authorities, instructions for performing the service, and listings of patient and provider resources. The Clinician's Handbook is designed for use by both clinicians and students, and includes a chapter with practical tips for incorporating preventive material into office systems.

For health care consumers, AHCPR provides a Personal Health Guide (for adults) and a Child Health Guide. These pocket-sized booklets briefly explain prevention topics such as weight, blood pressure, immunizations, physical activity, and tobacco use. Designed to encourage consumers to actively participate in their preventive care, each booklet contains easy-to-use record forms that serve as prompts for consumers to receive timely preventive care.

For the medical office or clinic staff members, AHCPR developed:

  • Preventive care flow sheets for tracking and prompting preventive services and childhood immunizations.
  • Patient reminder postcards (child/adult) for reminding patients to come in for preventive services.
  • Waiting room posters to prompt patients to ask about prevention and preventive care timeline posters to remind clinicians, office staff, and patients when preventive care is recommended.

Select to access PPIP online materials.

The following organizations are AHCPR's partners in promoting clinical preventive services. The promotions have included: presenting materials at conferences, printing materials and making them available to their constituents, providing technical assistance/training to clinicians interested in using PPIP, and evaluating outcomes. They include:

  • American Academy of Family Physicians.
  • American Academy of Nurse Practitioners.
  • American Academy of Pediatrics.
  • American Cancer Society.
  • American College of Preventive Medicine.
  • Association of Teachers of Preventive Medicine.
  • National Association of Pediatric Nurse Associates and Practitioners.

U.S. Preventive Services Task Force (USPSTF). The U.S. Preventive Services Task Force (USPSTF) was first convened by the U.S. Public Health Service in 1984 to systematically review the evidence of effectiveness of a wide range of clinical preventive services, including screening tests, counseling, immunizations, and chemoprophylaxis. The pioneering efforts of the Task Force—to rigorously evaluate clinical research in order to assess the merits of preventive measures—culminated in the 1989 Guide to Clinical Preventive Services.

Updated recommendations were released in late 1995 and published the following year in an expanded second edition of the Guide. Following the release of the second edition of the Guide, responsibility for the USPSTF was moved to AHCPR (select to access the Second Edition online). This report is intended for primary care clinicians: physicians, nurses, nurse practitioners, physician assistants, other allied health professionals, and students. It provides recommendations for clinical practice on preventive interventions—screening tests, counseling interventions, immunizations, and chemoprophylactic regimens—for the prevention of more than 80 target conditions.

In June 1998, AHCPR selected two Clinical Prevention Centers to support the work of the USPSTF. The Centers, already under contract to AHCPR as two of 12 Evidence-based Practice Centers, are Research Triangle Institute (RTI) in collaboration with the University of North Carolina at Chapel Hill (UNC), and Oregon Health Sciences University (OHSU). The new topics being reviewed by the Clinical Prevention Centers include:

  • Chemoprophylaxis to prevent breast cancer.
  • Vitamin supplementation to prevent cancer or chronic heart disease.
  • Screening for bacterial vaginosis in pregnancy.
  • Developmental screening in children.

The Centers have begun work on these topics this year and reports should begin being available within a year of work commencing. In the future, the following areas will receive top priority as update topics:

  • Screening for diabetes mellitus.
  • Newborn hearing screening.
  • Screening for skin cancer.
  • Screening for breast cancer (including genetic screening).
  • Counseling unintended pregnancy.
  • Screening for high cholesterol.
  • Postmenopausal hormone replacement therapy.
  • Screening for chlamydial infection.
  • Screening for depression.

To speed implementation of new and updated recommendation, the Task Force will release individual reports and recommendations as they are completed. The third full edition of the Guide is anticipated for release in late 2002.

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Improving the Capacity to Deliver Quality Health Care

As an agency that has distinguished itself by conducting and sponsoring research on the structure, process, and outcomes of care, AHCPR has contributed to the Nation's quality of health care agenda since its inception. AHCPR's research in quality falls into two categories: quality information for choice; and quality information for improvement.

The Quality Initiative

The Quality Initiative, announced in fiscal year 1999, is being carried out through a two-pronged approach: targeted grants (in response to Request for Applications [RFAs]) and investigator-initiated grants.

Results of this research will provide consumers with understandable and reliable information to help them make critical decisions about their health care. In addition, the research supported through the Initiative will provide private and public purchasers with have more information about the quality of the care they purchase for their employees, their dependents and beneficiaries, as well as new strategies to improve their purchasing power.

Targeted Research. The first step in the Quality Initiative involves the development and release of a series of RFAs and one RFP to support research on quality of health care. These projects respond to the report, Quality First, developed by the President's Commission on Consumer Protection and Quality in the Health Care Industry, which called for a significant investment in the further development of research, tools, and information for patients, practitioners, purchasers, and payers.

  • The "Quality Measurement for Vulnerable Populations" RFA ($3.0 million) calls for research to develop and test new quality measures that can be used in the purchase or improvement of health care services for populations identified as vulnerable in the Commission report.
  • The "Translating Evidence into Practice" RFA ($2.0 million) calls for research to generate new knowledge about approaches, both innovative and established, which are effective and cost-effective in promoting the use of rigorously derived evidence in clinical settings and lead to improved health care practice and sustained practitioner behavior change. AHCPR is particularly interested in studies that implement AHCPR-supported evidence-based tools and information.
  • The "Assessment of Quality Improvement Strategies in Health Care" RFA ($2.0 million) calls for research to rigorously evaluate strategies for improving health care quality that are currently in widespread use by organized quality improvement systems including HCFA's PROs and those of large purchasers.
  • The Centers for Education and Research on Therapeutics (CERTs) Program ($2.0 million), which was authorized by Section 409 of the Food and Drug Administration Modernization Act, is a 3-year program that will support demonstration centers. This program seeks new and more effective ways to develop, translate and disseminate objective information on therapeutics to health care providers and other decision makers to improve practice and the quality of health care. The long-term goal of the program will be to improve the quality of care while reducing costs. The Centers will conduct research aimed at improving the quality of health care, while reducing costs, by increasing the appropriate use of drugs, biological products and devices, mitigating errors, and by preventing potential adverse effects. Studies will, in addition, examine the comparative effectiveness and safety of drugs, biological products and devices. This program will help develop the evidence base for the appropriate and safe use of drugs, biological products and medical devices that clinicians, health system leaders and patients need for making the best possible decisions.
  • Development of a National Quality Improvement System ($2.0 million) RFP is driven in part by the recommendations of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Currently, health care policymakers cannot obtain an accurate understanding of the state of health care quality at the national level or understand how changes, such as the movement toward managed care or legislative efforts such as the Children's Health Initiative, influence the quality of care received. The reports from this initiative will provide one tool in addressing broad public concerns about the quality of health care. The reports will be developed to provide:
    1. Evidence that demonstrate areas of concern in quality of care, and ultimately, areas that should be targeted for improvement.
    2. The ability to document whether health care quality is stable, improving, or declining.
    3. A template to guide future development of quality measures including the identification of critical gaps in our measurement capabilities.
    4. National benchmarks against which specific states, health plans, and providers could compare themselves.
    The aim of this effort is to test the feasibility of creating a reporting system for health care quality whereby the "whole" is generated from a review of nationally representative consumer assessments of health care quality, hospital care quality indicators, survey information, large administrative and clinical datasets, and emerging data on health care quality. As a foundation, this effort will build on the Agency's investment in Consumer Assessment of Health Plans (CAHPS®), Healthcare Cost and Utilization Project (HCUP) (specifically HCUP Quality Indicators), and the Medical Expenditure Panel Survey (MEPS).

Investigator-Initiated Research. The second approach of the Quality Initiative is to fund investigator-initiated research. Approximately $4.0 million will be spent in quality research through this mechanism. Three grants related to quality have already been approved:

  • Managed Care Features Affecting Quality for CAD Patients (Duke University, Durham, NC). This project will strengthen quality measurement for processes and outcomes of care for coronary patients. These measures will aid the understanding of outcomes of health care and, in particular, what works for whom, while addressing issues pertaining to the types of health care services American's use.
  • Disease Management for Asthmatics in Medicaid HMOs (University of Pennsylvania, Philadelphia, PA). This project will conduct a randomized controlled clinical trial to evaluate an asthma disease management plan which is designed to improve the quality of primary care for adults being treated in Medicaid health maintenance organizations (HMOs). The effectiveness of the program will be judged by its effect on health care utilization, medication compliance, quality of life, and cost effectiveness.
  • School Mental Health: Quality Care and Positive Outcome (University of Maryland at Baltimore). This project examines the relationship between the treatment process in school-based mental health programs and youth outcomes, including functional status, quality of life and satisfaction, for youth between the ages of 11 and 18. The project will evaluate the effects of mental health treatments delivered in school-based mental health clinics and develop quality of care measures relevant to adolescents.

Ongoing Research to Measure and Improve the Quality of Health Care

In fiscal year 1998, AHCPR funded quality-related research through a variety of mechanisms including two RFAs, investigator-initiated research, small grants, dissertations research, conferences, and Small Business Innovation Research Contracts (SBIRs).

Eight grants from the RFA, "Health Care Quality Improvement and Quality Assurance Research," were awarded for a total of $7.6 million over 5 years. These research projects will help build a better science base for measuring and improving quality of care. They will provide new ways to measure quality and will offer comparative information that will help physicians and providers improve health care outcomes. Selected grant topics include:

  • Predicting Risk for Hysterectomy Complications. This project will create predictive models that can be used by physicians and patients when making decisions about surgery. Hysterectomy is a procedure with a high level of unexplained variation in use and complications, especially among minorities. Methods for estimating and adjusting risk and severity are necessary to make comparisons of performance among providers who may be treating patients with conditions of greater severity and higher risk.
  • Validation of Quality Measures for Hip Replacement. This project will create quality indicators for elective total hip replacement, using information from medical record reviews and hospital and patient surveys. Currently, there are no validated measures of quality for total hip replacement. This research also will develop a cumulative index of quality, which could have implications for other surgical and medical interventions.
  • Pressure Ulcer Rates in Describing Nursing Home Quality. This study will examine the development of pressure ulcers and create a model to predict their occurrence. The model then will be used to adjust for patient risk while evaluating different methods of describing nursing home performance. Ultimately, these results will help provide information on the quality of nursing homes and how it can be improved.

Grants submitted through the RFA, "Quality of Care Under Varying Features of Managed Care Organization," were jointly funded with the AAHP Foundation and involve collaborations with 32 health plans. These six grants will examine how particular managed care policies and practices (such as protocols governing the referral of patients to medical specialists and arrangements for paying physicians) affect the quality of care for patients living with chronic illnesses.

Examples of Products and Tools Resulting from Ongoing Quality-Related AHCPR Activities:

  • Your Guide to Choosing Quality Health Care. A quality navigational tool that encourages patients and consumers to use evidence-based information on quality to make all health care decisions.
  • CONQUEST. Quality improvement software tool that provides critical information on 1,200 clinical quality measures.
  • Case Studies from the Quality Improvement Support System. Reflects the experiences in continuous quality improvement of 15 organizations. Highlights successful and unsuccessful efforts and lists key features and lessons learned.
  • Theory and Reality of Value-based Purchasing. Lessons from the Pioneers. Describes some of the most promising examples of private business initiatives that build quality considerations into health care purchasing decisions. Profiles nine companies and coalitions, and summarizes their activities.

Expansion of Quality Care Measures (Q-Span). The Expansion of Quality of Care Measures (Q-Span) project is designed to strengthen the science base of quality measurement while expanding the scope and availability of validated, ready-to-use measures. Q-Span builds on past work in quality measurement by public and private organizations through eight cooperative agreements to develop and test additional clinical performance measures for specific conditions, patient populations, and health care settings.

Once the new measures are ready for use, they will be added to the more than 1,200 performance measures included in AHCPR's Computerized Needs-Oriented Quality Measurement Evaluation System (CONQUEST), a unique software tool for helping health plans, providers, and others identify, understand, evaluate, and select clinical measures to assess and improve the quality of the health care they provide. A summary of Q-Span projects is provided below:

  • Clinical Performance Measures for Dental Care Plans. Performance measures are being developed and tested for two major dental diseases: dental caries and periodontal disease.
  • Developing and Testing Asthma Quality of Care Measures. Measures of quality of care are being developed and tested on patients requiring emergency or hospital care for acute asthma exacerbations, and modeling techniques will be used to identify the key predictors of the asthma outcomes measured.
  • Development of a Global Quality Assessment Tool for Managed Care. Process measures are being developed for care delivered to adult men and women over age 50. A complimentary project with the HCFA will address children and adult women. These measures will be combined into a global measure of the performance of health plans.
  • Expansion of Quality Measures for Cardiovascular Diseases. This project focuses on a group of interrelated cardiovascular conditions (acute myocardial infarction, congestive heart failure, and hypertension).
  • Functional Outcomes in Patients with Hip Fractures. Hip fracture in the elderly is frequent, serious, and expensive. The functional status of 500 patients is being followed for 6 months from occurrence through hospital and rehabilitative care. Interventions to improve specific care processes are being evaluated against outcomes.
  • Measuring Quality by Achievable Benchmarks of Care. A cross-section of Alabama providers and plans is being compared on various measures of quality of care for diabetes mellitus and breast cancer screening using a specially designed approach to benchmarking. This work will be implemented by HCFA PROs in Connecticut in fiscal year 1999.
  • Ongoing Development and Evaluation of HEDIS Measures. The National Committee on Quality Assurance's Health Plan Employer Data and Information Set (HEDIS) is widely used to measure performance of health care plans. This project is developing operational specifications for certain HEDIS measures and validating them against appropriate outcomes.
  • Quality Outcomes in Subacute and Home Care Programs. Subacute care in nursing homes and home care programs have grown in importance as hospital lengths of stay have decreased. This project is measuring quality of post-acute care in these two transitional settings.

Healthcare Cost and Utilization Project's Quality Indicators

The value of information on health care quality has never been so widely recognized, yet many organizations lack the resources and/or expertise to build a quality information program from the ground up. Recognizing this, the Healthcare Cost and Utilization Project's Quality Indicators (HCUP QIs) were developed specifically to meet the short-term needs for information on health care quality, using standardized, user-friendly methods and existing sources of data.

HCUP QIs is a new computer software tool for routine self-assessments of inpatient care and/or evaluation of community access to primary care, which will be conducted by hospitals, hospital associations, and states. The HCUP Quality Indicators were designed to capitalize on the availability of administrative data on inpatient stays to produce information about:

  • Avoidable adverse outcomes (for example, in hospital mortality following common surgical procedures, complications such as postsurgical pneumonia).
  • Utilization of specific inpatient procedures thought to be over-, under-, or misused (such as hysterectomy).
  • Access to care in the community, as reflected in hospitalizations for ambulatory care-sensitive conditions (conditions amenable to management in an ambulatory setting, for example, pediatric asthma).

The nursing journal Image recently published a study that used HCUP QIs and 1993 discharge data from AHCPR's Nationwide Inpatient Sample—a component of the agency's Healthcare Cost and Utilization Project (HCUP). This study found that patients who have surgery done in hospitals that have fewer registered nurses per patient than other hospitals run a higher risk of developing avoidable complications following their operations (select for press release).

The study found hospitals that provided 1 more hour of nursing care per patient day (than the average nursing care hours per patient day) had almost 10 percent fewer patients with urinary tract infections and 8 percent fewer patients with pneumonia. One hour more per day of nursing care is about a 17 percent increase in nurse staffing levels.

After analyzing data from 506 hospitals in 10 states, the study found that the fewer full-time equivalent registered nurses per inpatient day a hospital has, the greater is its incidence of urinary tract infection, pneumonia, formation of blood clots, pulmonary congestion and other lung-related problems following major surgery. These are complications that nurses can often prevent by getting patients out of bed and walking after surgery, by monitoring them closely and through other hands-on nursing skills.

Research Finding. A total of 1.2 million registered nurses work in hospitals, where they make up nearly a quarter of hospital staff and constitute their single largest labor cost. AHCPR research found that patients who have surgery in hospitals that have fewer registered nurses per patients run a higher risk of developing avoidable complications following surgery.

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Help for Patients and Consumers of Health Care

The demand for information on quality has grown dramatically over the last decade as consumers and purchasers increasingly seek to make choices based on value. Patients' understanding of their health care needs and choices is critical to promoting high quality care.

AHCPR-funded research has shown that by involving patients in decisions about their treatment choices, quality, satisfaction, and even patient outcomes can be improved. Research has shown, however, that physicians, rather than patients, still make the decisions about treatment for terminal illness. Critical to efforts to move toward shared decisionmaking is a better understanding of which strategies work for which patients. This is particularly important for patients from diverse backgrounds, where cultural and linguistic factors are not well understood. Active patient involvement in care has been shown to be one of the most powerful strategies to result in changes in practitioner behavior leading to better quality.

Consumer Assessment of Health Plans (CAHPS®). AHCPR will continue to support a major initiative to assist consumers in selecting high quality health plans and services. The project, the Consumer Assessment of Health Plans (CAHPS®) study, provides a consumers-eye view of the care and service they receive from health providers. The survey kit can be used by managed care plans, employers and others to obtain consumers' views of the care they are receiving.

The CAHPS® kit contains a set of questionnaires that ask about consumers' experiences with their health plans; sample formats for reporting results to consumers; and detailed instructions to help implement the surveys and produce the reports. The questionnaires have been standardized so that assessments can be compared across health plans, across patient populations and over time. Health care purchasers implement the survey, produce the reports and provide results to consumers. CAHPS® also contains survey questions that address health care of children, people with chronic conditions, or other special populations. Select for an example (3 KB) of the reports that can be generated from the CAHPS® survey.

Currently, CAHPS® is expected to help more than 90 million Americans with their 1999 health care benefits decisions. In February 1998, approximately 130,000 Medicare enrollees in managed care plans were among the first to benefit from this survey. Medicare used CAHPS® to conduct the first-ever survey of beneficiaries in every Medicare managed care plan to assess their experiences with managed care. In addition, the Office of Personnel Management (OPM) adopted CAHPS® for use by the Federal Employees Health Benefits Program. OPM will use CAHPS® to survey Federal employees and report back the findings of the survey to them to help in the selection of health plans during Federal open season. These two new users make 19 States and other demonstrations sites that have used and evaluated CAHPS® in a variety of settings, including Medicaid programs, large employers, and health plan purchasing coalitions. The figure on the following page displays populations surveyed, by state, using CAHPS®.

Select for U.S. map (7 KB) showing population surveyed by State.

Jeanne Kelly, President of the Vermont Employers Health Alliance agrees that "nationwide participation of other organizations allows us to benchmark our own managed care plans. Before [CAHPS®], we could only look at our own plan with no comparisons." Ms. Kelly also points out that "CAHPS® allows survey and comparison of different kinds of plans—HMO, preferred provider organization (PPO), and indemnity. We were using the old (10-year-old!) Group Health Association model, which only applies to HMOs."

Small Business Innovation Research (SBIRs) and Consumer Choice.

In addition to CAHPS®, projects funded under the Small Business Innovation Research (SBIR) Program are developing innovative computer software and other materials to help consumers—including those who are members of minority groups, disabled, or have low reading skills—make informed choices about health care plans and providers. Highlights of several SBIR projects follow:

  • Elder Care. This project is developing 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.
  • Choice Card. This project has developed a multimedia kiosk (Choice Card) to assist individuals in Oregon and Connecticut making health plan choices. It allows each individual to indicate what factors, values, and preferences are important; to review and compare the relevant information across plans; and to act on the information by making an informed health plan enrollment choice. The Choice Card is targeted to the Medicaid population, but can be easily adapted to meet the needs of other populations (e.g., Medicare, uninsured, employee).
  • Plan Smart Choice. Plan Smart Choice is a software decision tool to assist Federal employees in selecting a health care plan. This project was built on previous work wherein investigators developed an interactive decision assistance software program to train consumers about the meaning of important health plan features and help them clarify personal preferences about health care coverage. The program mathematically links the users preferences to externally available valuative data about available health plans. Eventually the software program will be of use to both public- and private-sector employees.

In addition, in 1998 AHCPR issued an SBIR request for proposals that included three topics:

  • Assisting Purchasers to Use Information on Health Plan Performance.
  • Assisting Chronic Care Management.
  • Computer Decision Support Tools for Evidence-based Medicine.

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Managed Care

The face of America's medical systems has changed dramatically in the last decade as private market forces have transformed how health care is provided and purchased. Largely in reaction to spiraling costs, managed care is becoming the dominant health care delivery system. The number of Americans in HMOs is rising fast, from 15 million in 1984 to more than 50 million today. Managed care, interdependent systems that integrate the financing and delivery of health care services, differ in how they deliver care, ease of access to care, flexibility in physician choice, and services covered. Much remains to be learned about the long-term effects of managed care on access, cost, and quality of care.

AHCPR actively supports studies of these rapid changes and is working with the private sector to reach a consensus on how to increase quality and accountability in health care. By providing information on the effectiveness of alternative systems and management practices and by spotlighting both successes and problems, AHCPR will help improve the health care marketplace.

AHCPR is studying issues critical to the managed care debate including:

  • Switching Medicaid beneficiaries to managed care and the effect on access to health services is being studied in Washington State. The number of Medicaid recipients in managed care plans doubled in 1994.
  • Impact of continuous quality improvement on delivery of preventive services at primary care clinics is being investigated at two managed care organizations in Minnesota.
  • Effect of specialty training on primary care practice is being studied at Kaiser Permanente of Northern California. Factors being studied include the number of tests ordered and other services used, patient outcomes, and costs.
  • Adequacy of followup of patients with abnormal screening mammograms is being studied at the Henry Ford Health System in Detroit.
  • Compliance with guidelines for pediatric preventive care and cancer screening and the impact of incentives are being investigated in two studies at a Medicaid HMO in Philadelphia.
  • Methods of pain management of primary care doctors are being studied to determine if they are associated with different risks of dysfunctional chronic pain among patients with back pain and headache at Group Health Cooperative of Puget Sound.

Research Finding. Managed care patients spent 2 fewer days in an intensive care unit (ICU) than patients with fee-for-service health insurance, with the average stay for managed care patients costing $8,000 less. There was no difference in mortality or ICU readmission between the two groups. Patients were treated in the same teaching hospital by the same ICU specialists.

Research Finding. Fewer low birthweight infants and cost savings resulted from a self-help smoking cessation program for prenatal care patients of Maxicare Health Plans, a large HMO. Women in the program were 45 percent less likely to give birth to low birthweight infants. More than $3 in medical costs were saved for every $1 spent.

Research Finding. Chronically ill patients in managed care plans had better access to care than patients in fee-for-service plans, but their care was not as comprehensive, they waited longer for care, and physician-patient continuity was less in a study of 1,200 patients in three cities.

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