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Developing Tools and Data for Research and Policymaking
Efforts to improve the quality and efficiency of health care and reduce disparities in the United States must be based on a thorough understanding of how the Nation's health systems work and how different organizational and financial arrangements affect health care. AHRQ has a broad portfolio of data on costs, access to health care, quality, and outcomes that can be used for research and policymaking.
Medical Expenditure Panel Survey
MEPS is the only national source of annual data on the specific health services that Americans use, how frequently the services are used, the cost of the services, and the methods of paying for those services. MEPS is designed to help us understand how the growth of managed care, changes in private health insurance, and other dynamics of today's market-driven health care delivery system have affected, and are likely to affect, the kinds, amounts, and costs of health care that Americans use. MEPS provides the foundation for estimating the impact of changes on different economic groups or special populations such as the poor, elderly, veterans, the uninsured, or racial/ethnic groups. For example:
- Data from 2004 show that white non-Hispanics under the age of 65 make up about 65 percent of the U.S. population and almost 50 percent of the population who are uninsured.
- In 2003, wage earners who earned low hourly wages were at greater risk for being uninsured. Only 53 percent of workers earning less than $10 per hour obtained job-related coverage, in contrast to 93 percent of workers earning $15 or more per hour.
- In 2002, about 95 percent of families had some health care expenses, and the total expenses for these families averaged $6,928.
- Since 1996, expenditures for prescribed medicines purchased by the elderly in the U.S. community population increased 116 percent, from $23.1 billion total reported in 1996 to $49.9 billion reported in 2002.
- In 2002, 30.8 percent of families with an elderly member had out-of-pocket expenses that accounted for greater than 5 percent of family income, compared with 6.8 percent of families without an elderly member.
More information on MEPS can be found online at http://www.meps.ahrq.gov.
How MEPS Data Are Used In the Private Sector
RTI International, an independent research organization, has developed a software-based tool using data from AHRQ's MEPS program. The tool, called the Obesity Cost Calculator, was developed for the National Business Group on Health (NBGH). It enables NBGH member organizations to determine their obesity-related costs by accurately quantifying the increase in obesity-related costs for people who are obese, but not eligible for bariatric surgery and those who are obese and eligible for bariatric surgery. Based on the cost information produced by the calculator, a variety of interventions can be evaluated for costs and benefits.
Healthcare Cost and Utilization Project
The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by AHRQ. HCUP databases bring together the data collection efforts of 39 State data organizations, hospital associations, private data organizations, and the Federal government to create a national information resource of patient-level health care data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.
The largest growth in HCUP has been in outpatient data initiatives—the acquisition of additional State Ambulatory Surgery Databases and State Emergency Department Databases, partnership discussions about improving outpatient data collection and measurement of the quality of outpatient care, and dissemination of outpatient data and its capacity. In 2005, 22 States contributed ambulatory surgery data for a combined total of 13.7 million visits in 2,410 facilities (mostly hospital-based but including some free-standing sites). In addition, 17 States contributed outpatient emergency department data, for a combined total of 17.8 million visits in 1,035 hospitals.
Recent findings from HCUP data are as follows:
- The number of hospital admissions for HIV infection in the United States declined from a high of 149,000 in 1995—just before approval of life-prolonging protease inhibitor drugs—to 70,000 admissions in 2003. During the same period, the percentage of AIDS patients who died in the hospital dropped by 32 percent—from a death rate of 12.5 percent in 1995 to 8.5 percent in 2003.
- In 2002, 5 of the top 10 conditions for hospitalization were due to cardiovascular disease: coronary atherosclerosis, congestive heart failure, chest pain, heart attack, and irregular heart beat.
- In 2002, about 30 percent of patients had hypertension in addition to another diagnosis.
- The aggregate total billed for hospital care has increased significantly from 1997 to 2002 for each of the four major payer categories, with the largest increases in charges seen for Medicaid and the uninsured:
- 29 percent increase for Medicare.
- 47 percent increase for Medicaid.
- 31 percent increase for private insurers.
- 39 percent increase for the uninsured.
For more information on HCUP databases and software, go to http://www.ahrq.gov/research/data/hcup/index.html.
AHRQ Quality Indicators
AHRQ has developed an array of health care decisionmaking and research tools that can be used by audiences such as program managers, purchasers, consumers, researchers, government agencies, and others. One tool, the AHRQ Quality Indicators (QIs), is widely used to:
- Highlight potential quality concerns.
- Identify areas that need further study and investigation.
- Track changes over time.
The AHRQ QIs are a set of indicators organized into three modules, each of which measures quality associated with the delivery of care occurring in either an outpatient or an inpatient setting:
- Prevention Quality Indictors (PQIs) are ambulatory care-sensitive conditions that identify adult hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.
- Inpatient Quality Indicators (IQIs) reflect quality of care for adults inside hospitals and include: inpatient mortality for medical conditions; inpatient mortality for surgical procedures; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures may be associated with lower mortality.
- Patient Safety Indicators (PSIs) also reflect quality of care for adults inside hospitals, but focus on potentially avoidable complications and iatrogenic events.
The AHRQ QIs are being used for national, State-level, and hospital-level public reporting and tracking:
- AHRQ's National Healthcare Quality and Disparities Reports and their derivative products incorporate many PQIs and PSIs for tracking and reporting at the national level. Selected IQIs and composite measures are planned for inclusion in future reports.
- The demand for information to better inform consumers has increased, specifically demand for standardized hospital-level comparative data as a result of concern over quality and patient safety in the hospital setting. Currently, there are eight States that report some or all of the AHRQ QIs: Texas, New York, Wisconsin, Massachusetts, Oregon, California, Utah, and Florida. Kentucky and Iowa are both planning to publicly report the AHRQ QIs in the next year or so.
More information on the AHRQ QIs can be found on the Web site at http://www.qualityindicators.ahrq.gov.
AHRQ's Quality Indicators Document Quality of Care for Medicare Beneficiaries
The Medicare Payment Advisory Commission (MedPAC) used the Quality Indicators to evaluate the quality of care for Medicare's 40 million beneficiaries. MedPAC applied mortality measures from the Inpatient Quality Indicators to calculate mortality for such conditions as pneumonia, acute myocardial infarction, stroke, and congestive heart failure. To evaluate patient safety in the hospital, MedPAC used AHRQ's Patient Safety Indicators to identify adverse events. Applying the Prevention Quality Indicators, they studied the trends in the rates of potentially preventable hospital admissions.
The Chairman of MedPAC, Glenn Hackbarth, testified before the Subcommittee on Health of the House Committee on Ways and Means on March 18, 2004. His testimony, titled "Improving Quality through Medicare Payment Policy," identified AHRQ as the source of the tools needed to document and follow critical markers of the quality of care delivered to Medicare beneficiaries.
Consumer Assessment of Healthcare Providers and Systems
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program is a multi-year AHRQ initiative. Originally, CAHPS referred to AHRQ's Consumer Assessment of Health Plans Study; that name was changed in 2005 to reflect the evolution of the program from its initial focus on enrollees' experiences with health plans to a broader focus on experiences with various aspects of the health care system. AHRQ first launched the program in October 1995 in response to concerns about the lack of good information about the quality of health plans from the enrollees' perspective.
Over time, the program has expanded beyond its original focus on health plans to address a range of health care services and meet the various needs of health care consumers, purchasers, health plans, providers, and policymakers. The first stage of this program is referred to as CAHPS I. The second, current stage, is referred to as CAHPS II.
In 2005, development and evaluation of the CAHPS Hospital Survey (known as H-CAHPS or Hospital CAHPS) was completed. The CAHPS Hospital Survey is a standardized survey of the experiences of adult inpatients with hospital care and services.
For more information on the CAHPS, go to http://www.ahrq.gov/cahps/.
Most Medicare Patients Get Access to Needed Care
The CAHPS Health Plan Survey 3.0 results for 2004 and 2005 in the commercial, Medicaid, State Children's Health Insurance Program, and Medicare Managed Care sections show that 83 percent of Medicare enrollees in 2005 responded to questions about access to needed care as "not a problem." In contrast, questions related to getting care quickly received the least positive responses—only 58 percent of Medicare enrollees responded "not a problem" to these questions.
HIV Cost and Services Utilization Survey
The HIV Cost and Services Utilization Survey (HCSUS) was the first study to examine the health status and health care use of a nationally representative sample of adults infected with HIV. Data from HCSUS have been used to address a number of policy-relevant issues, such as variation in access to antiretroviral therapy. Recent findings from the HCSUS show:
- More than one-third (36 percent) of HIV-infected parents fear transmitting HIV to their children, and 42 percent fear catching an infection from their children. Avoidance of behaviors such as kissing, sharing utensils, or hugging was especially prevalent among Spanish-speaking parents (78 percent) vs. those who spoke English (23 percent).
- The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act provides funds for comprehensive care for vulnerable individuals with HIV infection in all 50 States. Researchers analyzed data from the HCSUS to examine whether the CARE Act clinics differed from other HIV clinics in the characteristics of their patients and their organization, staffing, and services. Overall, patients seen at the CARE Act centers received more comprehensive care than did patients at other HIV clinics.
HIV Research Network
The purpose of the HIV Research Network (HIVRN) is to collect and analyze timely data on HIV health services and to implement strategies to improve the quality of care delivered to all people with HIV disease.
Policymakers, service providers, and patients need to know how often people with HIV infection receive specific services and what factors are related to receiving more or fewer services. They also need to know about effective methods, procedures, and processes for improving the quality and safety of care provided to HIV patients. Indeed, one of the major goals of the HIVRN is to examine patient safety and other quality-related issues.
The HIV community is an important place in which to study safety issues, and the network provides an excellent opportunity to improve the safety and quality of HIV care within the network and then across the country. Patients with HIV disease have compromised immune systems that leave them with a diminished capacity to combat infections, untoward consequences of drug reactions, and harm resulting from medical errors.
The HIVRN includes an active intranet on which members exchange information on best practices instituted to minimize the risk of errors. All participating sites are regularly surveyed to obtain information on quality-improvement mechanisms that have been instituted for patients with HIV and methods found to be successful at one site are shared with other members of the HIVRN.
HIVnet is a tool that provides information on inpatient and outpatient utilization by people with HIV disease based on data collected by the HIVRN. These statistics are derived from 12 medical practices that provided comprehensive resource utilization data for 2000.
In September 2005, AHRQ sponsored the publication of a supplement to the journal Medical Care that features seven new empirical studies on health care for people with HIV disease. Five of the seven studies were based on data from AHRQ's HIVRN. The studies examined data for both adults and children on hospitalizations, inpatient and outpatient visits, prophylaxis for opportunistic illnesses, and the impact of highly active antiretroviral therapy.
For more information on the HIVRN and HIVnet, go to http://www.ahrq.gov/data/hivnet.htm.
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Ensuring the Value in Health Care
Health care costs in America continue to rise. According to the most recent data from MEPS, total health care expenses in 2003 were $895 billion compared with $810 billion in 2002—an increase of 10.5 percent. Health insurance premiums increased 9.2 percent in 2003. The average annual total premium for single coverage was $3,481 compared with $3,189 in 2002. Family coverage averaged $9,249 compared with $8,469 in 2002.
Given the increasing costs of health care, it is vitally important to help Americans achieve wider access to high-quality health care and become more efficient in providing that care. The goal is to provide safe and effective health care, with the best possible outcomes, at the lowest possible cost. AHRQ directs many of its activities toward improving efficiency through the design of systems that assure safe and effective treatment and reduce waste and cost. For example:
- Data from HCUP show that with appropriate primary care for diabetes complications, the Nation could save nearly $2.5 billion in hospital costs, with significant potential savings obtained in Medicare ($1.3 billion of total costs) and Medicaid ($386 million of total costs).
- Women who live in areas with a high number of managed care organizations (HMOs) were nearly twice as likely to have recently received a mammogram or Pap smear and were 58 percent more likely to have had a recent clinical breast exam than women in areas with low managed care penetration.
- Among adult ICU patients who died during their hospital stay, those who had ethics consultations had fewer hospital days and lower hospital costs compared with patients who did not have a consultation (an average of 8 days vs. 11 days, and $24,938 vs. $30,184, respectively). Researchers estimate that an ethics consultation practice would reduce treatment costs in a hospital with 40 ICU beds by $157,380 per year.
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Preparing for Public Health Emergencies
AHRQ supports research assessing and improving the ability of the U.S. health care system to respond to public health emergencies that result from natural, biological, chemical, nuclear, and other disasters. These research projects examine an array of issues related to clinicians, hospitals, and health care systems, including the need to establish linkages among these providers with local and State public health departments, emergency personnel, and others preparing to respond to events that have the potential to cause mass casualties.
In the Wake of Hurricane Katrina . . .
Tools from the report, Use of Former (Shuttered) Hospitals to Expand Surge Capacity, were released on the AHRQ Web site immediately after Hurricane Katrina struck. The tools gave emergency responders and public health officials useful, practical resources for opening shuttered hospitals during the emergency. The report and its tools can also be used to assess existing facilities to meet future needs.
Material posted included separate, fill-in-the-blank checklists for chief administrators, facilities experts, medical personnel, security experts, equipment and supply experts, and medical gas system verifiers to use in evaluating a facility. It also contains checklists that help emergency planners assess and fulfill management and staffing needs and determine any additional expertise required, as well as a list of supplies and equipment needed for operation of a reopened facility.
The report can be found online at https://archive.ahrq.gov/research/shuttered.
Here are examples of tools now available as a result of AHRQ research:
Emergency Preparedness Resource Inventory
This Web-based tool can help local, regional, and State planners compile customized inventories of health care and emergency resources to prepare for incidents, estimate gaps, and support future resource investment decisions. The resource inventory helps first responders figure out where emergency equipment and medicines are located, how much is available, and whom to contact to obtain those resources.
The Emergency Preparedness Resource Inventory software tool and accompanying supporting documents can be found online at https://archive.ahrq.gov/research/epri.
Real-time Population Health Monitoring Technology Can Detect Abnormal Trends in Diseases
The Massachusetts Department of Public Health (MDPH) is using technology from the Automated Epidemiologic Geotemporal Integrated Surveillance (AEGIS) system, a project supported through AHRQ's Bioterrorism and Emergency Preparedness Research Program. AEGIS, which acquires and processes clinical data to detect abnormal patterns of disease in the population, is a leading-edge population monitoring system. Front-line clinicians are generally better at recognizing individual cases than patterns of cases over time and across a geographic region.
AEGIS augments the capabilities of the alert clinician by monitoring these larger trends. While traditional surveillance systems rely on voluntary reports from providers to acquire data, AEGIS acquires data continuously through fully automated routines. Real-time population health monitoring technology is useful not only for the detection of bioterrorism, but also for general public health monitoring, clinical medicine, quality improvement, patient safety, and research.
The Decontamination of Children: Preparedness and Response for Hospital Emergency Departments
This 27-minute video trains emergency responders and hospital emergency department staff to decontaminate children after being exposed to hazardous chemicals during an attack or other disaster. It provides a step-by-step demonstration of the decontamination process in real time and trains clinicians about the nuances of treating infants and children, who require special attention during decontamination procedures.
A short clip of the video is online at https://archive.gov/research/decontam.htm.
National Hospital Available Beds for Emergencies and Disasters (HAvBED) system
This report explores the feasibility of a national real-time hospital-bed tracking system to address a surge of patients during a mass casualty event. The report includes a discussion of the components of the HAvBED system, including the communications protocol, database, and Geographic Information System; a virtual tour of the system; standardized hospital bed definitions to provide uniform terminology for organizations tracking bed availability; reviews of existing bed-tracking systems; and conceptual and technical recommendations.
The report is available online at https://archive.ahrq.gov/prep/havbed.
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Looking to the Future
In the coming months and years, AHRQ will continue to focus on ways to improve the quality, safety, and cost-effectiveness of health care in America. In 2006, we will pursue an ambitious research agenda. Examples of key programs follow.
Patient Safety and Quality Improvement Act of 2005 and Patient Safety Organizations
The Patient Safety and Quality Improvement Act of 2005 amended the Public Health Service Act to encourage a culture of safety in health care organizations. It provides legal protection of information voluntarily reported to patient safety organizations (PSOs). To encourage health care providers to work with the PSOs, the Act provides Federal confidentiality and privilege protections. The Act prohibits the use of these analyses in civil, administrative, or disciplinary proceedings and limits their use in criminal proceedings.
AHRQ is developing plans to help implement the Act as a science partner to the PSOs and health care providers. The Agency's goals are to advance the methodologies that identify the most important causes of threats to patient safety, identify best practices for addressing those threats, and share the lessons learned as widely as possible.
Expansion of the Effective Health Care Program
In 2005, the Effective Health Care Program focused initially on issues of special importance to Medicare. Section 1013 of the MMA authorizes the Secretary of Health and Human Services to regularly consider priority areas for research under this Section. In 2006, the priority list will be updated to include Medicaid and the State Children's Health Insurance Program (SCHIP).
A listening session was held in early 2006 to solicit input on research priorities for the Effective Health Care Program, including an open forum in which participants gave oral comments on suggested topics for study and the structure of the priority lists (e.g., disease/condition, type of intervention, affected population, etc.). An online link was available until March 15, 2006, allowing people to suggest additional priority conditions, which will be considered for inclusion in the priority conditions list in 2006-2007. Although only those conditions nominated by March 15, 2006 will receive consideration, people can continue to make nominations for priority conditions at any time at http://effectivehealthcare.ahrq.gov/.
In 2006, three projects within the DEcIDE network will develop methodological tools for analyzing pharmaceutical data that result from implementation of Part D (the prescription drug benefit program) of the MMA. The major goals of these projects are to develop:
- An evidence-based approach to standardizing drug prescription statistics and outcome measures of the safety of drugs.
- Algorithms for identifying usage patterns.
- A data system and empirical framework for identifying and capturing adverse drug events.
Registries for Evaluating Patient Outcomes
Registries for Evaluating Patient Outcomes is a DEcIDE Network project that will produce a reference guide to help health care organizations design and operate successful patient registries to track the outcomes of medical treatments, including drugs. The guide will be online and reside on both the AHRQ and Centers for Medicare & Medicaid Services (CMS) Web sites. It will define standards and best practices, criteria for evaluating registries and the quality of their data, and guidance on how registry data can be used to conduct valid scientific research.
AHRQ is creating the Innovations Clearinghouse, an online searchable database and repository of innovations in health service delivery. Its purpose will be to capture effective methods of disseminating and sustaining improvements in the delivery of health care.
The clearinghouse will serve as a forum for learning about innovation and change by providing a national-level, publicly accessible mechanism for obtaining objective, detailed information on health care innovations and tools and promote their dissemination, replication, adaptation, and use.
CAHPS Hospital Survey
In January 2006, the U.S. Office of Management and Budget (OMB) approved the use of the CAHPS Hospital Survey, and national implementation plans are proceeding. A short "dry run" of the survey implementation will be conducted with participating hospitals to give hospitals and vendors first-hand experience in collecting and transmitting the survey data (without public reporting of results). National implementation of the CAHPS Hospital Survey is scheduled for fall 2006. Hospitals across the country will begin using this survey and voluntarily reporting data to the CMS, which plans to initiate public reporting of those results in late 2007.
The CAHPS Consortium is refining and expanding the family of ambulatory care surveys to be more attuned to the needs of sponsors and variations in health care markets. The content and structure of the Health Plan Survey is being streamlined to focus the core questionnaire more on essential health plan functions, such as customer service, denial of service, and complaints and appeals.
A new survey, CAHPS Clinician and Group Survey will be finalized by the spring of 2006 and asks patients about their recent experiences with physicians and other staff. The CAHPS People with Mobility Impairments Survey asks adults with mobility impairments about their experiences with health care and services. The CAHPS American Indian Survey is being developed in collaboration with the Choctaw Nation Health Service and asks adult American Indians about their experiences with Choctaw Nation health care facilities.
Accelerating Change and Transformation in Organizations and Networks (ACTION)
The ACTION program is the successor to AHRQ's Integrated Delivery System Research Network (IDSRN). ACTION's purpose is to promote innovation in health care delivery by accelerating the development, implementation, dissemination, and uptake of demand-driven and evidence-based products, tools, strategies, and findings. ACTION is composed of 15 partners and their collaborators who will build on the success of the IDSRN. ACTION is a 5-year program.
Pay for Performance
Early in 2006 AHRQ will produce two new products on pay for performance. Each employs a creative approach to meeting the needs of practitioners in the field. The first expedites the cycle of research so purchasers have quicker access to findings on pay for performance, and the second is being developed in collaboration with purchasers, who have identified pressing questions for researchers to address.
- In collaboration with the editor of Medical Care Research and Review, AHRQ engaged a multidisciplinary team of guest editors in an experiment to expedite the transfer of research on quality-based payment to public and private purchasers. The effort involves aggressive, systematic outreach to research teams across the country in an attempt to identify earliest findings, some based on partial data, appropriate for peer review and translation. From conceptualization to publication the project will take only 15 months.
- AHRQ will develop Pay-for-Performance: A Decision Guide for Purchasers. The Decision Guide is designed for use by public and private purchasers of health care services, including health plans, who are considering sponsorship of a pay-for-performance initiative. Twenty decisions, identified by 10 public and private purchasers, form the outline of the Decision Guide. For each of these key design decisions, the Decision Guide offers options as well as any available theoretical and empirical evidence.
Pilot Learning Network on Quality-Based Purchasing
AHRQ is sponsoring a pilot Learning Network on the topic of quality-based purchasing for 11 public and private purchasers who are poised to implement a quality-based payment scheme or a public report card. The pilot Network, which will roughly span a 1-½ year period, will feature opportunities to learn from research evidence as well as from peers' promising practices via a coordinated series of in-person workshops, Web-casts, audio conferences, and LISTSERVS®. Members of the Learning Network (two from each participating employer coalition and Medicaid agency) will learn about the:
- State of health care quality in their respective States.
- Science of quality measurement and quality measurement options.
- Evidence to guide pay-for-performance scheme design.
- Evidence to guide the development of public report cards.
- Evaluation strategies to capture the impact of a payment or report card initiative.
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The evidence developed through AHRQ-sponsored research and analyses helps everyone involved in patient care make more informed choices about what treatments work, for whom, when, and at what cost. Health care quality is improving, but much more remains to be done to achieve optimal quality. AHRQ will continue to invest in successful programs that develop and translate useful knowledge and tools so that the end result of the Agency's research will be measurable improvements in health care in America, gauged in terms of improved quality of life and patient outcomes, lives saved, and value gained for what we spend.
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AHRQ Publication No. 06-M028
Current as of May 2006