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Priority 2—Informatics ($5,000,000)
AHRQ has a rich history of funding research and development in the field of medical informatics, dating back to the early 1970s, when AHRQ's predecessor, the National Center for Health Services Research, sponsored early research in medical informatics. Many of the computerized interventions that are commonplace today in clinical settings, such as drug-interaction alerts, had their genesis in these early grant initiatives. Between 1969 and 1990, AHRQ funded 89 grants that developed applications in various clinical settings and studied their impact on the costs, quality and outcomes of care. Despite this history, informatics research investments have not kept pace with the explosion of opportunities brought by the information revolution and the consolidation of the health care system. Indeed, from 1990 to 1996, only 12 informatics research applications have been supported. In addition, this research has dealt more with the immediate impacts, as shown in the box, and less on the impact of these applications on the quality and cost-effectiveness of care.
Research finding: A 6-year observational study, led by John H. Siegel, evaluated the implementation of a system to continuously monitor the physiologic and metabolic functions of critically ill patients. The investigators found that use of this system reduced surgical mortality by 8 percent and trauma mortality from 25 percent to 7.5 percent.
The Agency's fiscal year 2001 request is designed to build on past Agency successes in identifying fruitful areas for applying information technology to health care and to renew Agency and Federal leadership in health informatics. Information technology applications are a critical element to the improvement of the health care system, its outcomes, and efficiency.
Most of the emphasis to date has been on the use of informatics in the improvement of the delivery of evidence-based information to decisionmakers—and this must continue. However, the information superhighway is a two-way street; equally important is the use of information technology applications to enhance the collection of patient and practitioner data, including quality and outcomes data, as an integral part of patient care.
The AHRQ fiscal year 2001 Request begins to rectify this deficiency by proposing investments in both types of traffic on the information superhighway, as well as using computer systems to analyze data and to guide decisionmaking. Data and applications, especially Web-based applications and decision-support tools, to assist providers and patients in providing and choosing high quality care and promoting patient safety will be tested to determine their impact on health care quality, outcomes and cost. Innovations to improve the quality, privacy and confidentiality of data collected from providers and health care systems will be fostered and evaluated to maximize the use of patient data for research and analysis that advances the Nation's understanding of care today.
AHRQ-funded studies of the use of computerized patient records and other medical information system applications showed that overall costs could be reduced, administrative efficiencies achieved, and patient management improved. These benefits could be further enhanced by linking automated patient information to computer-based decision-support aids and reminder systems, a concerted focus of AHRQ studies during the 1980s. While the type of benefit varied with the setting of the study, almost all demonstrated some improvement: more preventive care was delivered, follow-up was more systematic, care was more coordinated, and patient needs were better met when these systems were implemented. In addition, costs were often reduced.
The Agency recently funded an evaluation of the use of computerized decision-support systems which reported that, despite advances in the technology of informatics, applications have lagged behind and that use by providers and the public has been disappointing. The gap is comparable to the gaps that exist for other areas of health care (e.g., clinical prevention or chronic disease care) between what we know and what we do. To enhance the development of user-friendly informatics tools and to translate these developments into practice, AHRQ proposes a new initiative in informatics comparable to its tool development and TRIP initiatives in other areas of health care.
In fiscal year 2001, AHRQ proposes a three-part investment in informatics research to improve health care:
- Further developing Web-based applications for health systems and providers to improve quality.
- Developing and testing of informatics applications, clinical decision-support systems and computerized patient records to reduce medical errors, improve patient safety, and promote quality improvement in diverse health care settings.
- Improving the efficiency, quality, privacy and security of health care data.
Each of the activities noted below will have collaboration as a central feature. The Agency will work closely with such Federal partners as the National Library of Medicine, other NIH agencies, HCFA, DoD, and VA, plus private sector and State partners. To assure that AHRQ's investments are targeted to the user community's most pressing challenges, the Agency will begin a planning process in fiscal year 2000 to engage Federal and private-sector partners in determining the details of each of the components outlined below. In developing the agenda on informatics and medical errors, the Agency will work closely with the partners identified earlier in Priority 1: Enhancing Patient Safety. This open priority-setting process will also help ensure that the results of the AHRQ informatics initiative guide public and private investment decisions about medical informatics tools that improve quality of and access to care and that address rising health care costs.
AHRQ Small Business Innovation Research Programs are developing and testing:
- A prototype print, video and interactive voice-response (IVR) telephone systems to assist low-literate, minimally English proficient, minority and low-income consumers in communicating with plans and providers
- 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
- A prototype interactive Web-based tool that small and medium-sized employers could use to become better purchasers of health care coverage
- A prototype multi-media self-care tools for the Internet. The interactive self-care tool will use videos and other materials from the National AIDS Treatment Advocacy Project (NATP) to help patients with AIDS understand and adhere to their medication regimens.
- A prototype self-care management system will be developed for patients with chronic pain, incorporating tailored print guides and a supplementary integrated voice-response (IVR) system, "Tell-A-Doc," designed to enhance patient-physician communication and for tracking of systems.
AHRQ has already shown its ability to create and sustain award-winning and user-friendly Web-based applications. The Agency's Web site has been recognized numerous times in the last four years as a leader in providing relevant and evidence-based information. Two of AHRQ's most successful tools have been CONQUEST and the National Guideline Clearinghouse™. These databases of performance measures and clinical guidelines, respectively, provide evidence-based comparative information to health professionals. In the first year of operation, the National Guideline Clearinghouse™ had over 8 million requests and over 14 million hits—and the use of CONQUEST is also growing rapidly.
"[O]nly recently have I discovered the awesome power in the guideline.gov site. Within the TennCare program ... the guidelines have been immensely helpful. Thanks for a great site!!"
—TennCare Associate Pharmacy Director
HCUPnet is another successful tool recently made available. HCUPnet is an interactive, online service designed for health policymakers, policy analysts, researchers and others to quickly answer questions about hospital care use, outcomes, and charges. Queries can be national, regional or specific to 1 of 10 participating States. Menu-driven HCUPnet guides users in tailoring specific queries about hospital care online, and with a click of a button, users receive answers within seconds.
HCUPnet serves all users with a need to identify , analyze and compare hospital statistics at the national, regional and State levels. It is used to describe patterns of care for uncommon as well as common diseases, to analyze hospital procedures, including those that are performed infrequently, and to study the care of population sub-groups such as children, women, senior citizens and the uninsured.
Evidence-based information has too often been difficult to find on the Internet because of numerous sites differentiated by audience and purpose. In fiscal year 2001, we will develop and pilot a system that will make it possible for all audiences to navigate one site to find the tools for their specific needs. For example, information about guidelines for treating asthma could be linked with tools for assessing whether best practices are implemented (performance measures) and information on interventions that improve quality and safety for asthma patients (technology assessments). Organizing these tools around conditions will enable, for the first time, multiple decisionmakers to do "one-stop shopping."
In addition, the use of Web-based electronic health records has strong potential for permitting providers and patients to retrieve clinical information about previous tests and treatments. For example, in the course of a year, many times mothers of school-age children must search across multiple providers to find the immunization records required for school admission; many people do not remember the last time they received a tetanus vaccine or booster shot and so receive another one when unnecessary; and many patients suffer allergic responses—to drugs, food and other sources—that could be prevented. The key to reducing or avoiding this unnecessary burden of time, pain and resource use is the availability of the right information at the right time. At the same time, it is imperative that such systems have safeguards in place to ensure the confidentiality of those records. This component will investigate the value of Web-based electronic health records for improving the operation of the health care system for health providers and patients.
Endorsements of AHRQ's Web site
Use of AHRQ's Web site continues to increase with more than 15.5 million hits in fiscal year 1999, compared to 2.9 million in fiscal year 1997. Examples of Web accolades include:
- "Silver Platter Site" by Ask Jeeves, the Internet's premier question answering service, handling millions of questions each day
- "Valuable Resource" by CiteLine for quality of content, overall usability, and value to health care professionals.
- "Top Health Association" site on Worldwide Nurse, the Internet's nursing resource.
Patient Safety and Quality Improvement Informatics
The potential of informatics in efforts to improve patient safety and quality, particularly for vulnerable populations, has yet to be properly harnessed. This research component will support the development of informatics tools that assist in the access and use of guidelines and other quality improvement tools and strategies that have been shown to be effective at reducing medical errors and improving patient safety. Prior AHRQ-funded research in this area has identified improvements in quality and resource use from informatics applications (e.g., reduced adverse drug events, reduced resource use by offering suggestions of lower-cost drugs having the same effectiveness, and improved prevention service delivery with prompts and reminders).
Evidence is needed that these benefits can be achieved other than in specialized academic centers that already use computers extensively. The findings of this program will show where computerized decision-support systems result in net gains in quality and cost measures, and will identify the roadblocks to effective use and how they can be overcome. These findings will guide technology investment decisions for clinicians, health administrators, heath plan managers, and health policymakers in the public and private sectors.
A critical aspect of this research is on the future contributions of the applications of computer-based patient record systems and computerized decision-support systems. The Agency's primary research focus will be on the role these systems play in enhancing providers' and systems' ability to identify and act on opportunities to improve patient care, reduce medical errors, and improve patient safety. This research will help us understand where information technology reduces the level of effort required to achieve quality improvements or avert a potential error that could lead to patient harm.
Research will be solicited to advance knowledge about:
- How clinical practice guidelines and patient care data can be linked using computerized decision-support systems to improve the information available for medical decisionmaking at the point of care.
- How this information can be accessed while maintaining the confidentiality of personal health information.
- What is the impact of the factors (productivity, privacy, physician-patient relationship, costs, and others) that influence provider and patient acceptance of decision-support applications in health service delivery.
Research finding: An AHRQ-funded randomized trial in Indiana found that computer-generated reminders increased discussions about advance directives and completion of advance directive forms by patients and clinicians.
The final component of this investment will be to promote the diffusion of successful informatics applications to other settings of care, to promote patient safety and quality. To date, many information technology research projects have had a focus on specific computer programs for supporting medical decisions, specific hospital departments, and specific services. Notably, primary care settings have been under-investigated. There has been little development of methods to understand the context or systems within which individual informatics applications exist and the role that these systems play in enabling, or impeding, the diffusion and uptake of innovation. Part of evaluating these systems issues will also address the identification of best practices in the implementation and widespread diffusion of effective computer-based patient record systems. Implementation studies will develop information about the barriers to translation and diffusion that materially affect levels of net benefits and the means by which those barriers have been overcome.
Improving the Efficiency, Quality, Privacy and Security of Health Care Data
The third component of the Informatics investment will support Departmental and private-sector efforts to improve the nature of data available for quality and outcomes improvement, research and surveillance. Encouraging the development of the health informatics infrastructure is not solely the role of the Federal government. Significant collaboration with appropriate private and other public-sector organizations is essential, both for developing and carrying out a shared vision and for avoiding unnecessary duplication of effort. While AHRQ will play a leadership role, the success of the health informatics infrastructure component will depend on reaching partners whose programs and businesses depend on common features of the infrastructure.
Networks and Applications to Improve Data Collection and Linkages
AHRQ will invest in developing and testing innovative strategies for the collection of data in clinical settings, including primary care and specialty settings. This could include, for example, the collection of quality information from patients, the measurement of functional outcomes for elderly patients in primary care, or the integration of clinical research into community-based settings. In fiscal year 2000, AHRQ is beginning to lay the foundation for this type of activity by establishing partnerships with networks of practices and integrated delivery systems. The fiscal year 2001 investment will allow these networks and others to pilot innovative approaches to integrate quality and outcomes data collection into the care process through the use of computer systems and networks.
AHRQ also will test potential systems to link data from diverse sources in order to better track episodes of illness and the use of health care across settings and over time. The goal of the project is to allow population-based analyses and to create analytic linkages between health care system inputs, patient characteristics, and outcomes of care. The goal of these systems will be to enable studies of rehospitalization, selective referral, comprehensive utilization of outpatient and inpatient services, and outcomes for events that occur outside the health care system (e.g., post-hospital mortality), as well as other topics.
Privacy and Confidentiality
How Congress, the Administration, and indeed the Nation address these critical issues could dramatically affect our future ability to conduct health services research, improve quality, and maintain patient privacy and confidentiality of personal health information. In fiscal year 1999, AHRQ is beginning an initiative with the Institute of Medicine to investigate how Institutional Review Boards handle the protection of human subjects in health services research, particularly with respect to information for large data sets.
In fiscal year 2000, the Agency plans to work with the National Institutes of Health, the National Library of Medicine, and others to address the ethical dimensions of privacy and the nature of training that clinicians and researchers receive in these areas. In fiscal year 2001, AHRQ proposes to build on these exploratory investments to study best practices and identify strategies that maximize our ability to safeguard patient data while enhancing its availability for research and quality improvement.
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Priority 3—Improving Worker Health ($10,000,000)
The health of American workers has traditionally been addressed through initiatives designed to prevent acute injury in the workplace. Drawing upon the fields of occupational health and safety, environmental health, and human factors analysis, workplace initiatives during the past decade have reduced the rate of worker injury through a focus on the individual worker and specific interventions that can improve safety on the job.
This research initiative will complement those efforts by addressing very different dimensions of employee health. It begins with the recognition that the health and quality of workers' lives, workplace productivity, and the incidence of long-term disability are influenced by health conditions or injuries that occur outside as well as inside the workplace and by the availability of appropriate, timely and quality medical treatment for these conditions. Thus, this initiative targets those conditions that result in significant economic impact due to employee days lost from work or poor productivity. In addition, recent efforts to restructure the health care workplace, often in response to pressures to reduce costs, suggest that the resulting work environment and processes can affect, both positively and negatively, the health and quality of workers' lives as well as the patients for whom they care.
Employers and labor unions can play important roles in addressing these aspects of worker health by choosing and promoting high quality health care for workers and managers, by ensuring that the most effective evidence-based treatments are available to those in need of medical care, and by carefully assessing the implications of alternative approaches to restructuring the health care workplace and the processes by which care is delivered. This initiative will develop and extend the evidence base for decisionmaking by employees and their employers, and by the clinicians and health care systems to which they turn for medical treatment.
This research initiative is made up of three parts:
- Research on improving the quality of the health care delivery systems through which workers receive health care services.
- Research on the quality of the health care workplace and its impact on patient quality and outcomes.
- Research on the clinical interventions that workers receive to reduce the burden of illness borne by workers and the economic impact of illness on the workplace.
Despite the importance of these issues, surprisingly little health services research has addressed them. For example, few studies have examined the quality of the systems through which care is provided to chronically ill workers, developed performance measures for comparing and evaluating such systems, or assessed which health system interventions are most effective at reducing the number of days lost from work from various conditions for employees and their families.
The need for further research on the quality of the workplace was demonstrated at a conference, Effect of Working Conditions on the Quality of Care, convened last year by AHRQ and other agencies and Departments participating in the Quality Interagency Coordination (QuIC) Task Force. The conference, recognizing that nursing homes, personal care facilities, and hospitals have the highest nonfatal occupational injury and illness rates in the service industries, reviewed existing evidence regarding the role of working conditions in health care institutions. The research presented at the conference highlighted the importance of the quality of the workplace environment—not only for worker satisfaction, worker health, and the avoidance of disability but also for its secondary impact on the quality and productivity of the work performed. In health care institutions, this is especially critical, because the way work is organized and staffed not only poses threats to the health and well-being of workers but may have an impact on the quality of care they provide to patients and the safety of their patients.
The three components of this initiative build upon the research agenda that emerged from that conference—research issues identified by large purchasers, employers, the labor community, and States in discussions with the Agency—and the Agency's past research investments in outcomes and effectiveness research.
In combination, these three components will address underlying issues that are of critical importance to employers, employees and the Nation at large, such as:
- How to measure and purchase high quality care for workers.
- Effective interventions or strategies to maximize outcomes, reduce the burden of worker illness and prevent disability.
- Initiatives to enhance the ability of workers to return to the same job on a long-term basis (not simply return to any job and not return only in the short term).
- Workforce retention (given the high costs of recruitment and training).
- The inter-relationships between health care outcomes, quality of care, and productivity.
In reauthorizing the Agency last year, Congress stressed the importance of AHRQ serving as a "science partner" with the public and private sectors and working collaboratively with interested parties to improve the outcomes, quality and cost of care. The Agency will extend its current partnerships with health care systems and purchasers in the private and public sectors and involve business and labor from different segments of the economy, State and Federal worker's compensation entities, and other Federal agencies involved in occupational health and safety research in the planning and implementation of the research, demonstrations, and evaluations undertaken as part of this initiative.
Improving the Quality of Health Care Delivery Systems
Workers, employers and society share a common interest in seeing that workers are healthy, productive, and protected from disability. However, when an injury occurs, it is also critical that high quality systems of care are in place to promote good outcomes, avoid permanent disability, enhance the ability of workers to return to work on a long-term basis to the same job, and assure that their ongoing health problems are managed in ways that maximize their ability to function at work and be productive. The health care systems used by workers play a significant role in determining whether these goals are met. Yet there is little scientific evidence available that can enable employees or employers in the public or private sectors to identify systems that are effective in addressing these goals. This initiative will begin development of that knowledge base.
While AHRQ and others have supported the development and validation of quality measures for health plans serving employees, there have been few studies of the use of these strategies to improve the quality of care in plans and systems that care for injured or disabled workers. Unlike general health plans, there are no accepted quality standards for worker's compensation medical care, and no studies that have systematically examined quality or access.
The health care needs of injured or ill workers are generally addressed in one of two ways. For chronic care or work-aggravated conditions, workers generally rely upon the health insurance policies offered by their employer, union or association. Acute injuries in the workplace are generally covered through the medical component of State worker's compensation programs and, if permanent disability results, the long-term costs are addressed by the disability component of worker's compensation.
This initiative will focus on three general health care conditions: health care treatments for acute conditions that are potentially disabling or life threatening; management of the resulting disability, if it occurs; and management of chronic disease. Particular initiatives could include:
- Studies of the effectiveness of alternative approaches to managing chronic care conditions in ways that maximize the worker's ability to function at work and remain productive.
- Studies that identify the most effective approaches for preventing or minimizing permanent disability resulting from specific acute care injuries.
- Development of validated performance measures that are appropriate to worker's compensation programs. Performance measures are needed in a number of key domains, including access to care, primary prevention, diagnosis, clinical treatment, disability prevention, and outcomes.
- Assessment of the effectiveness of alternative approaches to the delivery of medical care under worker's compensation, such as the impact on outcomes, functionality and worker satisfaction with the transition to managed care, the mandatory use of treatment guidelines, and worker participation in vocational rehabilitation.
- Technical assistance to State officials through AHRQ's User Liaison Program on issues related to worker's compensation, disability and chronic care.
Improving the Quality of the Health Care Workplace
This initiative also focuses on the quality of the health care workplace for three reasons. First, nursing and personal care facilities and hospitals have the highest nonfatal occupational injury and illness rates in the service industries (14.2 cases and 9.2 cases, respectively, per 100 full-time workers in 1998). To put these numbers into perspective, it is useful to note that they exceed those for the construction industry (8.8 cases/100 FTEs) and are significantly larger than the rate for all of private industry (6.7 cases/100 FTEs). While these rates have declined over time as a result of traditional workplace initiatives, the rates remain unacceptable.
Second, a recent conference, Effect of Working Conditions on the Quality of Care, convened by AHRQ and other agencies participating in the Quality Interagency Coordination (QuIC) Task Force, identified a growing body of evidence that suggests that working conditions in health care institutions can influence the health of workers and may affect the quality and productivity of the work performed (in this case, affecting the quality and outcomes of patient care). Thus, this initiative builds upon the research agenda that is now emerging from that conference.
Finally, issues of staffing in hospitals and nursing homes have been issues of increasing attention to Congress and State legislatures. With increasing financial pressures on health care institutions, there has been a tendency to decrease staffing and, in some instances, to assign responsibilities to less-trained staff. Health care workers describe the increased pressures on them as having potentially deleterious effects on their own health and on their ability to deliver high quality care. This phenomenon has not been evaluated to determine whether it endangers workers' and patients' health, as well as to determine its magnitude.
Examples of research issues identified by conference participants that may be addressed by this initiative include:
- Systems research. How do changes in work processes affect worker and patient safety? Does an integrated systems approach, developed for aviation safety, apply in the health care workplace? To what extent does "re-engineering" the processes of delivering care and the structure of the overall work environment affect worker health and satisfaction as well as the quality of patient care? Are there characteristics that define healthy work organizations that impact both quality of care and working conditions?
- Staffing levels and skill mix. What effects do staffing and skill mix have on patient satisfaction and health outcome measures? How do these factors affect worker illness and injury rates? Are there optimal staffing ratios?
- Staff turnover. What are the factors that influence staff turnover? What effect does turnover have on cost and the quality of care? Do these factors differ among different health worker groups or professions? What strategies have been effective in increasing staff retention? Do different work organization strategies affect job longevity?
- Measures. What are appropriate measures of worker satisfaction, worker turnover, cost, quality, and patient satisfaction. Are these related? What are the disincentives to workers' reporting adverse patient events? What mechanisms can be used to enhance near-miss reporting? What are the disincentives to reporting occupational illness and injury? How is information used?
- Medical management of injured workers. How do health services provided to workers (including return-to-work policies, implementation of work restrictions, etc.) impact worker health, worker's compensation costs, and long-term disability. Do these factors impact quality of patient care?
Nonfatal Occupational Injuries and Illness,
1998 Labor Department Data
||Illness and Injuries
|Service Sector, overall rate
|- Nursing/personal care facilities
|- Amusement/ recreation services
|Construction, overall rate
|Agriculture, overall rate
|Private Industry, overall rate
Reducing the Burden of Worker Illness:
Improving the Quality and Outcomes of Clinical Interventions
The health and quality of workers' lives is greatly affected by the effectiveness of the treatments they receive for disease or injury. In 1995 among currently employed adults, there was an average of 5.3 days lost from work due to acute and chronic conditions. Among youth ages 5-17 years, there was an average of 4.5 days lost from school due to acute and chronic conditions. We know very little, however, about the impact of effective treatment for chronic medical conditions on the ability of workers to be productive on the job, and almost nothing about the impact of parental loss of time from work or limited ability to function attributable to their children's clinical conditions. Recent studies have demonstrated that for selected chronic conditions (e.g., hypertension, diabetes, depression) effective treatment can enhance productivity at work.
Very little current research links the effectiveness of treatment for medical conditions with both time lost from work and productivity on the job, though we have begun to develop the tools to make that link. The aging of the workforce and a robust economy bring our lack of knowledge into sharp focus. This initiative will support research on the leading chronic conditions and explicitly link effectiveness of clinical care with the ability of patients to maintain productive work practices and to avoid permanent disability. These two aspects of worker health have rarely been effectively integrated; research on the outcomes of clinical care seldom incorporates a workplace perspective.
To close this gap, this initiative will use AHRQ's extensive expertise in the outcomes, effectiveness and quality of clinical care after the onset of disease or injury to target health conditions which result in a significant impact on the workplace, whether measured by time lost from work, productivity, or other measures. This will include conditions experienced by workers themselves as well as their dependents, to the extent that the latter affects their ability to function in the workplace. To ensure that this initiative appropriately complements the extensive research contributions of the National Institute for Occupational Safety and Health (NIOSH) on the causes and prevention of workplace injury, AHRQ will collaborate with NIOSH in the development and targeting of its research strategy.
AHRQ's prior investments in outcomes and effectiveness research have included important studies on musculoskeletal conditions and depression, both issues with significant impact on employee functioning. For example, the Agency supported research on low back pain, indications for total knee replacement, and hip fracture. The results of these studies have highlighted the need for better information—both by clinicians who treat workers and their patients—regarding the relationship between the processes and outcomes, or "end results," of care, including the effectiveness of physical therapy and other modalities.
Two important studies of chronic conditions, diabetes and depression, have persuasively demonstrated that improvements in clinical outcomes are closely related to ability to work. These studies are particularly noteworthy precisely because most studies of clinical interventions have not included both health and work-related outcomes. This initiative will specifically study the impact of health conditions on work and the relationship between clinical management strategies and work-related outcomes. A particular emphasis of this initiative will be to better understand the economic impact of chronic illness on the workplace. This is increasingly important as our population ages and remains productive and employed into later years. In addition, this initiative will include a focus on the impact of increasing dependent care demands for employees on their workplace productivity. To the extent that health care offered and paid for by employers is more effective at reducing the number of sick days for dependents, whether elderly relatives or chronically ill children, the impact of caregiving responsibilities is lessened, enabling the employee's earlier return to work and improved productivity while at work.
Research Finding: Employers now recognize the importance of depression to workers' ability to be productive. A recent study demonstrating the impact of a quality-improvement intervention for patients with depression is the product of an AHRQ-supported grant. In this study, workers with depression who were randomized to the quality-improvement intervention were significantly more likely than those in the control (usual care) group to be employed 12 months after the study was initiated.
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