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2.1.2 Performance Goal 2: To develop the evidence base for policymakers and health systems to use in making decisions about what services to pay for, how to structure those services, and how those services
to health care services continues to be a challenge for many Americans. This
is particularly true for the poor, the uninsured, and members of minority
groups, and rural residents. In addition, the changing organization and financing
of care has raised new questions about access to a range of health services
including emergency and specialty care. At the same time examples of inappropriate
care, including over utilization and misuse of services, continue to be documented.
Through ongoing development of nationally representative and more specialized
databases, the production of public-use data products, and research and analyses
conducted by AHRQ staff, the Agency addresses critical policy issues pertaining
to the access, cost and use of health care.
to the effects of payment and organizational structures and processes on the
cost, quality and equity of health care services are essential components
of this research initiative. Research results are intended to:
- Improve clinical practice.
- Improve the health care system's ability to provide access to and deliver high quality, high-value health care.
- Provide policymakers with the ability to assess the impact of payment and organizational changes on outcomes, quality, access, cost, and use of health care services.
the IOM report, Crossing the Quality Chasm, AHRQ will fund applications
that provide rigorous, objective, and essential evidence required by public
and private decisionmakers seeking to understand and improve the health care
system, to make changes in health care delivery, insurance, and financing,
and to manage the system in a manner that would induce efficient, effective,
equitable, accessible and timely health care.
to be addressed by such research include:
- How do different payment methodologies and financial incentives within the health care system affect health care quality, costs, and access?
How do payment methodologies affect the behavior of health care organizations and individual providers?
Which payment arrangements among patients, providers, and health plans enhance patient-centered knowledge of and involvement with treatment regimens?
How do payment policies affect decisions about the purchase and selection of health services and health insurance?
What is the role of quality in such decisions?
What are the effects of such decisions on health care costs?
- What has been the impact of purchaser and public sector initiatives on quality, costs, and access to health care and health insurance? Of particular interest is the impact of employer and
coalition efforts on the quality and cost-effectiveness of care in the marketplace,
the impact of State efforts to monitor and improve access and quality and
the impact of public and private payment changes on access to health care
and to health insurance for vulnerable populations.
- What organizational structures and processes are most likely to sustain high-quality, efficient, effective, timely, and accessible health care?
- How do different patterns and levels of market competition affect the quality and cost of care?
In addition, AHRQ will fund projects in basic methodological
work to support such research, including: development of payment methodologies;
improvements in analytical and empirical methods required to simultaneously
address issues of efficiency, quality, and equity; and, improvement in data
collection methods and qualitative methods needed to understand the structure
of new health care organizations and an evolving health care system.
Strategies to Improve Access, Foster Appropriate Use and Reduce Unnecessary Expenditures
Centers to Eliminate Ethnic/Racial Disparities. The health of
Americans has improved over the past few decades, but not all Americans have
benefited equally. Many ethnic and racial groups have not shared in the advances
in health outcomes and health care. To understand the causes and factors
of these inequalities, AHRQ in September 2000 awarded grants to nine centers
to conduct a series of related studies. Now known as Excellence Centers
to Eliminate Ethnic/Racial Disparities (EXCEED), the grants bring together
teams of both new and experienced investigators in a five-year effort to analyze
underlying causes and contributing factors for racial and ethnic disparities
in health care and to identify and implement strategies for reducing and eliminating
them. The centers of excellence approach enables an assembly of a critical
mass of investigators to address a group of projects linked by a central theme,
such as communication or cultural competency. In addition, the centers are
able to train new investigators with an interest in minority health services
The EXCEED program joins a series of AHRQ initiatives
aimed at improving the health and health care of priority populations and
eliminating racial and ethnic disparities in health outcomes and in health
care access and service delivery. AHRQ expects that lessons learned from
understanding and eliminating racial and ethnic disparities in health and
health care as well as the practical tools and strategies to eliminate these
disparities would be generalizable beyond the communities studied. By focusing
on the attributes of the ethnic and racial groups, the underlying etiologies
for the disparities, and components and conditions of interventions to eliminate
the disparities, these projects should produce findings that are widely applicable
for minority as well as majority populations across the county.
Integrated Delivery System Research Networks. The Integrated
Delivery System Research Networks (IDSRN) is a new model of field-based research
that links the Nation's top researchers with some of the largest health care
systems to conduct research on cutting edge issues in health care on an accelerated
The IDSRN was developed
explicitly by AHRQ to capitalize on the research capacity of, and research
opportunities occurring within, integrated delivery systems. The network
creates, supports, and disseminates scientific evidence about what works and
what does not regarding measurement systems and organizational "best practices"
related to care delivery and research diffusion. It also provides a cadre
of delivery-affiliated researchers and sites to test ways to adapt and apply
As a group, the
IDSRN provides health services in a wide variety of organizational care settings
to over 34 million Americans, including the privately insured, Medicare and
Medicaid patients, the uninsured, ethnic and racial minorities, and rural
and inner-city residents. Moreover, each of the nine IDSRN partners have
the following three unique attributes that make it particularly well suited
for conducting time-sensitive research:
Available Data: each of the IDSRN
partners collect and maintain administrative, claims, encounter and other
data on large populations that are clinically, demographically and geographically
Research Experience: IDSRN partners
include some of the country's leading health services researchers with expertise
in quantitative and qualitative methodologies as well as first hand knowledge
of emerging issue areas which have critical policy or managerial implications.
Management authority to implement
health care interventions: IDSRN partners have responsibility for managing
delivery systems and are in a position to implement financial and organizations
strategies, e.g., selective contracting with physicians and hospitals for
specific approaches to diffuse clinical guidelines within the system.
Primary Care Based Research Networks. Over the past decade, Primary
Care Based Research Networks (PBRNs) have emerged as a promising approach
to the scientific study of primary care. A PBRN is a group of ambulatory
practices devoted principally to the primary care of patients, affiliated
with each other, and often with an academic or professional organization,
in order to investigate questions related to community-based practice. Typically,
PBRNs draw on the experience and insight of practicing clinicians to identify
and frame research questions whose answers can improve the practice of primary
care. By linking these questions with rigorous research methods, the PBRN
can produce research findings that are immediately relevant to the clinician
and, in theory, more easily assimilated into everyday practice. In addition,
data is readily available which will provide useful information on who receives
care, where and how often.
In September 2001, 18 PBRN networks were awarded
continuation grants (cooperative agreements) to conduct network-defining surveys,
using standardized instruments. The surveys will provide baseline data on
the clinicians enrolled in each network, the services provided, and the characteristics
of patients receiving those services. Potential uses of the data include
practice benchmarking and guiding the selection and design of specific PBRN
research projects. Four of the networks were awarded additional funds to
pilot test and evaluate electronic methods of collecting and aggregating practice-derived
research data. Two networks were awarded additional funds to assess clinician
and patient knowledge and attitudes about protecting the privacy and confidentiality
of research data.
goal is to improve the capacity of PBRNs to expand the primary care knowledge
base and to establish mechanisms that will assure that new knowledge is incorporated
into actual practice and its impact is assessed.
HIV Research Network. As new HIV/AIDS therapies become available, policymakers require reliable information about the type and costs of the health care services persons with
HIV disease are receiving—such that informed resource-allocation decisions
can be made. The HIV Cost and Services Utilization Study (HCSUS) is the first
major research effort to collect information on a nationally representative
sample of people receiving HIV care. HCSUS is examining costs of care, utilization
of services, access to care, quality of care, quality of life, unmet needs
for medical and non-medical services, social support, satisfaction with medical care, and knowledge
of HIV therapies.
HCSUS is composed of a core study and several supplemental studies. The core study has enrolled a national sample
of 2,864 HIV-infected adults who were receiving ongoing or regular medical
care in the first 2 months of 1996. Respondents were sampled from 28 urban
areas and 24 clusters of rural counties in the United States. Patients receiving services in hospitals,
clinics, and private practice settings were enrolled. HCSUS over-sampled
women and members of staff model health maintenance organizations to obtain
more precise information on these specific populations. Supplemental studies
are examining HIV care delivery in rural areas, prevalence of mental and substance
abuse disorders, oral health of HIV-positive individuals, and issues related
to HIV-infected persons over 50 years of age. A consortium of private and
government institutions are conducting HCSUS. Local and national advisory
groups have been established to facilitate communication between the HIV community
and the research consortium.
The HIV Network goal is to provide
timely and relevant information to policymakers about the resources utilized
to treat persons with HIV. It is important to obtain timely data because
quickly occurring therapeutic advances, the shifting epidemiology of HIV infection,
and the rapid diffusion of managed care are having a major effect on patterns
of health care resource utilization for HIV. Nearly $9 billion was spent
in 2002 by Medicaid, Medicare, the Department of Veterans Affairs, and the
Ryan White CARE Act to treat those with HIV.
Healthcare Cost and Utilization Project. The unprecedented volume and
pace of change in the U.S. health
care system and the non-uniform changes that are occurring across the country
require a new information paradigm that is scientifically sound for use at
the national, regional, and State levels.
The Healthcare Cost and Utilization Project
(HCUP) is a Federal-State-industry partnership to build a standardized, multi-State
health data system that is made available to the public. Maintained by AHRQ,
HCUP comprises a family of administrative longitudinal databases—including
State-specific hospital-discharge databases and a national sample of discharges
from community hospitals—and powerful, user-friendly software that can be
used with both HCUP data and with other administrative databases.
HCUP databases fill a unique niche and are
increasingly being tapped by analysts and researchers interested in hospital
utilization, access, charges, quality, and outcomes. The data are used to:
- Describe patterns of care for uncommon as well as common diseases.
- Analyze hospital procedures.
- Study the care of population subgroups such as minorities, children, women, and the uninsured.
Researchers and policymakers use HCUP
data to identify, track, analyze, and compare trends at the national, regional,
and State levels.
FY 2004 performance goals and targets
Increase the number of partners
contributing data to the HCUP databases by 5% above FY2000 baseline.
5% increase over FY00
2.1.3 Performance Goal 3: To build the capacity
for improving the Quality of Health Care Delivery through Research and Training
Program Description and Context
Today's health environment continues to change rapidly. Consolidation of health plans, movement
of patients and providers into managed care settings, efforts to contain rising
health care costs, fears that cost containment measures will lower the quality
of care, and persistent problems in access to care and health insurance coverage
for many Americans are issues of great concern.
Public and private purchasers are experimenting with new, untested financing strategies, organizational
arrangements and delivery approaches. Health plans and providers are seeking
to measure and improve the effectiveness and cost-effectiveness of the care
they purchase or provide.
Decisionmakers at all levels in the health care system rely on this critical knowledge to
inform effective choices. For example:
- Purchasers are looking for value, for high-quality care at a reasonable cost.
- Patients and caregivers want to make informed decisions about preventive and other primary
care services, treatments, providers, and health care plans.
- Clinicians need information to make the best possible decisions for and with their
- Health plans
need information to determine which services to cover.
providers (hospitals, groups, systems of care, et al.) need information
to make decisions.
need to understand the ramifications of available policy options.
Health services research addresses these issues
by providing information to help people make decisions at the clinical, system
and policy levels. Ensuring this requires an adequate number of highly qualified
research scholars. AHRQ therefore continues its commitment to support the
education of future research leaders through a variety of research and institutional
Strategies to Improve the Quality of Health Care
Delivery through Research and Training
Service Awards. AHRQ supports 24 U.S. academic institutions that offer advanced health
services research training. These programs provide tuition support and stipends
to qualified pre-doctoral and postdoctoral students.
Dissertation Research Grants. Dissertation research
funding is available for students conducting doctoral-level research on some
aspect of the health care system. These grant awards are often the first
step toward establishing a career in health services research.
Career Development Awards. AHRQ began to support career development activities
in FY 2000. These awards, provided to individuals embarking on a research
career, allow individuals time and resources to gain experience in carrying
out actual research. The intent is to provide transitional support for newly-trained
investigators in order to launch them on research careers. This program supports
two career development programs:
- Mentored Clinical Scientist Development Award (K08) in Health Services Research. This research
award provides support for the development of outstanding clinician research
scientists with a focus on development as an independent scientist.
- Independent Scientist Award (K02) in Health Services Research. The K02 provides support
for newly-independent investigators with a clinical or research doctoral
Minority Research Infrastructure Support Program. AHRQ 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 FY 2001,
AHRQ launched the Minority Research Infrastructure Support Program (M-RISP).
The goals of the M-RISP program are to increase the number of minority health
services researchers and to build capacity for institutions to conduct health
services research intended to improve health for racial and ethnic minorities.
Building Research Infrastructure & Capacity
Program (BRIC). In order to build research capacity in States
that have not traditionally been involved in health service research, the
Building Research Infrastructure & Capacity Program (BRIC), funds four
two-year planning grants to pilot test the feasibility of developing a new
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. These grants
will stimulate sustainable improvements in capacity and/or multi-disciplinary
centers supporting investigators and multiple research projects with a thematic
Developing the Evidence Base for Policymakers
and Health Systems To Use in Making Decisions about
What Services To Pay for, How to Structure Those Services, and How those Services
Women with Pelvic Inflammatory Disease
Treated as Outpatients Have Long-term Outcomes Comparable to Those Treated
as Inpatients. Women with mild to moderate pelvic
inflammatory disease (PID)—a leading cause of infertility—who are treated
as outpatients have recovery and reproductive outcomes similar to those for
women treated in hospitals. Each year, about 1.2 million women are treated
for PID, a sexually transmitted disease that causes infection and inflammation
of all or some of the pelvic organs. Untreated, it can cause chronic pelvic
pain, ectopic pregnancy, and infertility. Over 100,000 women with PID are
hospitalized each year, and about 15 percent of them have acute and serious
versions of the disease that require intensive inpatient treatment. But for
approximately 85,000 women with mild or moderate PID, who currently are being
hospitalized, treating them as outpatients may save approximately $500 million
New Case Study Indicates that Mental Health
Parity Did Not Raise Costs for a Large Employer Who Used a Managed Care Arrangement. Using a managed care "carve-out"
arrangement to provide equal coverage for mental health services did not raise
costs for one large employer. Researchers examined the impact of a State's
mental health parity mandate on a large employer group that simultaneously
implemented a managed care "carve-out" for its mental health and substance
abuse benefits. Carve-outs are services provided within a standard health
benefit package but delivered and managed by a separate organization. The
researchers, compared plan costs, use patterns and access in the one year
prior to the changes with the three years following the changes.
Although the number of people
treated for mental health problems increased nearly 50 percent, the costs
to the plan for mental health services declined by almost 40 percent over
the four-year study period. Costs for employees and spouses together remained
flat over the study period while costs for children and adolescents declined
by 64 percent. Most of this decline was due to reducing the lengths of stay
for inpatient mental health treatment. Managed care did not limit access
to outpatient treatment; there was nearly a 50 percent increase in the number
of people using outpatient treatment with no change in the average number
Black and Hispanic HIV Patients Are Less
Likely to Get Experimental Medications. A Nationwide study sponsored
by AHRQ showed that black and Hispanic HIV patients are only about half as
likely as non-Hispanic whites to participate in clinical trials of new medications
designed to slow the progression of the disease. Together, blacks and Hispanics
comprise roughly 48 percent of the HIV patient population: 33 percent and
15 percent respectively.
Black and Hispanic patients'
limited attempts to obtain experimental HIV medications may reflect lack of
awareness of clinical trials in minority communities, as well as suspicion
and distrust of trials and researchers. Black patients were less than half
as likely as white non-Hispanic patients to try to obtain an experimental
HIV medication. Findings suggest that to boost minority participation in
trials, structural barriers such as research-entry criteria, enrollment and
tracking procedures, and study center operations, as well as clinical researchers'
attitudes and practices need to be examined. Other factors contributing to
a reduced likelihood of participation in a clinical trial were having less
than a high school education, being in a commercial HMO, and receiving primary
care eight miles or more from where the clinical trial was held.
FY 2004 performance goals and targets
Increase the number of minority
researchers trained as health services researchers by 5% annually.
5% increase over FY 2003 baseline.
Support training programs for
junior-level researchers and mid-career scientists.
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