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Performance Budget Submission for Congressional Justification

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Priority 4—The National Healthcare Quality Report ($7,145,000, including $4,850,000 in the MEPS activity)

The Agency's reauthorization calls for the development of a national report on the quality of healthcare in the United States. In developing this report, the Agency is called on by the legislation to expand the Medical Expenditure Panel Survey (MEPS) to collect information on quality (select for description). The Agency also is charged with assuring coordination with the private sector in developing the report.

In its report on AHRQ's reauthorization, the Senate Health Education Labor and Pension Committee provided guidance:

"Beginning in fiscal year 2003, the Secretary, acting through the Director, is to submit an annual report on national trends in health care quality, drawing upon the enhanced MEPS survey and other available data. The Committee expects the Agency to use a variety of measures to develop this annual picture of how health care quality is faring. The legislation directs the Agency to take into account any outcomes measurements generally collected by private sector accreditation organizations to assure that the reported information is not inconsistent with what is being collected through other programs. The committee hopes that this annual report will provide an opportunity for quality performance comparisons."

The legislative history of this provision makes clear that the Committees do not envision a normative report. That is, the report should not set benchmarks or a single standard of quality that health plans or health care practitioners are expected to meet. Nor do the Committees expect the report to provide health plan or health care practitioner-specific performance information. Instead, the report should reflect a national perspective on overall trends in the quality of care. It should be based upon enhancements mandated for MEPS in fiscal year 2001 and, where possible, draw upon existing data from AHRQ, other Federal agencies and, where available, the private sector.

Sec. 913 (a)(1)

Beginning in fiscal year 2001, the Director shall ensure that the survey conducted under subsection (a)(1) will:

(A) identify year determinants of health outcomes and functional status, the needs of special populations in such variables as well as an understanding of these changes over time, relationships to healthcare access and use, and to monitor the overall national impact of Federal and State policy changes on healthcare;
(B) provide information on the quality of care and patient outcomes for frequently occurring clinical conditions for a nationally representative sample of the population including rural residents; and
(C) provide reliable national estimates for children and persons with special healthcare needs through the use of supplements or periodic expansions of the survey.

The Agency's coordination of the development of a National Healthcare Quality Report is also responsive to the President's Quality Commission report, which concluded that "the lack of comprehensive information on the quality of American health care is unacceptable." Finally, the recent Institute of Medicine's Commission on medical errors called for a national report on progress on that issue. These mandates envision a report that goes beyond a compilation of available data and statistics to provide a framework for those public and private entities with an interest in improving the quality and safety of patient care.

The Content of the Report

When fully realized, the Report will include information on:

  • Consumer and patient assessments of health care quality—e.g., the degree to which health plans and providers treat them with respect and how well people judge the health care system to be meeting the needs of their chronically ill family members, including children.
  • Clinical quality measures for common health care services—e.g., amount and appropriateness of preventive services, and the appropriate use of drugs such as first-line antibiotics for ear infections or aspirin after heart attacks.
  • Performance measures related to the management and outcomes of acute and chronic conditions—e.g., complication rates after common medical procedures, blood glucose control of patients with diabetes, and outcomes of errors in the delivery of care across a variety of settings and populations, such as surgical complication rates and readmission following procedures.
  • The choice of measures will be guided by multiple inputs, including the recommendations from the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, the Agency's re-authorization, the National Forum on Health Care Quality Measurement and Reporting, the Institute of Medicine's Special Initiative on Health Care Quality, and the Agency's National Advisory Council. In fiscal year 2001, AHRQ will make substantial progress toward the development of this report.

Developing the Report

Examples of the required steps to develop the first Report to the Nation on the Quality of Health Care in America:

  • Assemble the available scientific evidence on the impact of key health care services and the way these services are organized and delivered on the quality and safety of patient care.
  • Narrow the list to those factors that have the greatest impact, positive or negative, on the quality and safety of patient care.
  • Determine whether there are valid and reliable quality measures and data currently being collected by the public or private sectors that enable us to assess and track these factors.
  • If these data are not nationally representative, determine their usefulness in contributing to the national picture being presented by the report.
  • Strengthen and integrate existing databases, both public and private.
  • Develop and test new measures of quality, as well as new strategies for data collection, where gaps are identified.

Specific Activities to be Pursued in Fiscal Year 2001 to Create the Report

First and foremost, this initiative is founded on collaboration and partnership. It builds on the current and planned efforts of the Department and external partners regarding quality measurement and reporting. Specifically, activities will be coordinated with those of the CDC and other agencies in the Department to promote regular interchange during program development, implementation and evaluation.

Equally important will be formal partnerships with private-sector quality measurement efforts. These currently include those of NCQA, JCAHO, American Accreditation HealthCare/Commission (formerly known as URAC), purchaser initiatives, and the Robert Wood Johnson Foundation's Community Tracking Study. Each of these will be examined for synergy and integration into this project as part of the budget proposal. Fiscal year 2001 funds will support three coordinated activities, detailed below.

Determining the Scope and Content of the Report

The Agency began an effort in fiscal year 1999 to design the overall content and scope of this initiative. In addition to input from the Agency's National Advisory Council, an Institute of Medicine (IOM) advisory panel on the development of the Report will provide input and guidance to this effort and identify the major elements integral to the report. The IOM is uniquely positioned to provide input because it has been conducting a Quality Initiative for the last 3 years. In addition, the Agency will work closely with the newly established National Forum on Health Care Quality Measurement and Reporting (National Quality Forum). This activity will be integrated with the data collection and report design efforts to ensure that the reporting format and design will help to convey an accurate and credible message.

Integrating and Analyzing Data from the Public and Private Sector

The reauthorization directs the Agency, beginning in fiscal year 2001, to enhance its MEPS survey to provide information on the treatment of common clinical conditions over time for a nationally representative portion of the population. These enhancements will build on work during fiscal year 2000 and will begin to yield data in late fiscal year 2002 and early fiscal year 2003, just in time for this report. Because of the limitations in sample size of the MEPS, only care for the most common conditions can be assessed through this platform. Consequently, the MEPS data can only serve as one starting point for this report.

Other Agency databases and projects also will contribute to the report. The Healthcare Cost and Utilization Project (HCUP), which currently brings together the hospital inpatient discharge data from 22 States and ambulatory surgery data from 9 States, will provide an important adjunct to the MEPS. To increase representativeness and expand capacity for State-level research, the fiscal year 2001 request provides for an expansion in the number of States providing inpatient data as well as an increase in the number of States providing ambulatory surgery and emergency department data.

Finally, a third AHRQ initiative will contribute to this data infrastructure. Results from the Consumer Assessment of Health Plans (CAHPS®) survey were available to 90 million Americans in 1999. The Agency funded the creation of a national CAHPS® Benchmarking Database (NCBD) to collect and make available the results of this survey. NCBD contains data from 24 State Medicaid programs; 10 other State initiatives, such as State employee health insurance programs; 34 private sponsors, including health plans, purchasing coalitions and private employers; and the U.S. Office of Personnel Management. Data are available on over 550 health plans. In fiscal year 2001, the Agency will expand the collection of data using CAHPS® to move toward nationally representative estimates of the experiences of care in America, as perceived by the users of care, on such dimensions as satisfaction, whether they were treated with respect, and whether the services provided were timely and appropriate.

Developing, Testing, Producing and Evaluating the Report

Fiscal year 2001 funding will be used to support a strategy for report development successfully used with CAHPS® that emphasizes the use of research and evidence at each step of report development, testing, dissemination and evaluation. A portion of the fiscal year 2001 investment will be applied to identifying the appropriate format for the policymaker target audience, developing prototypes, and beginning evaluations of the report structure.

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Priority 5—Improving Clinical Prevention ($2,000,000)

Improvements in the delivery of clinical preventive services have paved the way for an expanded focus, not just on the number of people who receive the service, but also on improvements in the quality of those services. Advances in early detection of selected conditions now mean that millions of Americans are treated earlier and more effectively than in the past. For example, the performance of mammograms and Pap smears for early detection of breast and cervical cancers has saved millions of lives.

Improving the Quality of Preventive Services

The next frontier in clinical prevention health care research is to improve the quality of preventive services, to focus on populations who get not only fewer but also lower quality services, to study the cost-effectiveness and delivery of these clinical services, and to identify and address patient-related barriers to the use of clinical preventive services. This will build on previous AHRQ-sponsored research that, for example, documented the effectiveness and cost-effectiveness of counseling smokers to quit—research that has motivated health plans to increase coverage for and measurement of smoking cessation counseling. At the same time, the Nation needs research to inform clinicians and health care systems about better ways to measure and improve the quality of behavioral counseling delivered by clinicians, to ensure that it accomplishes its aim of changing patient behavior on the scale needed to have a measurable impact on mortality or health status.

Improving the Utilization of Preventive Services Among Vulnerable Populations

The clinical prevention initiative will focus, in particular, on populations who are receiving too few or low quality services or, in some instances, too many preventive services. Special emphasis will be placed on clinical prevention for vulnerable populations, including women, who generally live longer than men but report higher levels of disability and lower levels of function, much of which is preventable. The fiscal year 2001 investment will support approximately six new grants to develop new knowledge about critical opportunities for improving the quality and cost-effectiveness of clinical preventive care and new tools for measuring the quality of individual services, follow-up and organization of preventive care.

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Priority 6—Building Capacity for Health Services Research ($2,000,000)

The Training and Capacity Building Initiative proposed in fiscal year 2001 builds on progress in fiscal years 1999 and 2000. First, a systematic evaluation of the career paths and productivity of graduates of our training programs is underway and will guide targeted emphases in research training, such as coordinated curriculum development and recruitment, early career awards, and continuation education. Second, AHRQ will foster the next generation of health service researchers through infrastructure and capacity building.

Over the last 2 years, the Agency has engaged in a dialogue with the research and user communities to understand and project future capacity needs, and these investments directly address the priorities stated. Research career development awards, initiated in fiscal year 2000 and designed to provide transitional support for newly trained investigators in order to launch them on research careers, will be extended and expanded. In addition, the investments below will enable the Agency to respond to the need to diversify the workforce in health services—in terms of geography, institutions, and racial and ethnic composition.

Strengthening Minority Health Services Research Capacity

The Agency is committed to the Department's Initiative to Eliminate Racial and Ethnic Disparities in Health and the complementary Healthy People 2010 Goal to Eliminate Disparities in Health. A critical component in achieving these goals is to expand the Nation's health workforce to be more diverse and representative of the racial and ethnic populations in America. This includes bringing needed diversity to the health services research workforce.

By participating in the Department and White House Historically Black Colleges and University Initiatives, the Department's Hispanic Agenda for Action, and the White House Initiative in Educational Excellence for Hispanic-Americans, AHRQ intends to enhance the knowledge base regarding health care for these populations by increasing the number of trained minority health service researchers, as well as by building the capacity for institutions to conduct health services research intended to improve health for Hispanics and African-Americans.

While the Agency will also begin to expand its individual awards to minority investigators through its fiscal year 2000 investments, this alone will not address the capacity-building goals of the Agency, nor the White House and HHS Initiatives. To enhance research capacity at minority and minority-serving institutions, AHRQ will fund grants to develop and expand research infrastructure of institutions and their faculty to train health services researchers and to conduct rigorous health services research. This support will begin to enable one or two institutions with relatively small research programs to develop into significantly stronger health services research centers.

Addressing the Geographic and Disciplinary Gaps in Research Capacity

To build research capacity in States that have not traditionally been involved in health service research, the Institutional Training Innovative Incentive Award Program will be funded to pilot-test the feasibility of developing a program to broaden the geographic distribution of AHRQ funding and enhance the competitiveness for research funding of institutions located in States that have a low success rate for grant applications from AHRQ. Geographic regions that have received lesser amounts of AHRQ funding and have demonstrated a commitment to develop their research infrastructure will be eligible for these grants.

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Current as of February 2000

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