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Developing and Promoting the Use of Evidence
AHRQ supports efforts to improve health care by building the foundation of evidence for interventions and approaches in clinical practice. Patients, providers, and payers all need information on which treatments work most effectively, whom these treatments work for, under what circumstances, and the risks involved. This information needs to be objective, reliable, understandable, and easily accessible. AHRQ supports several initiatives to help synthesize and translate evidence-based information on health care effectiveness.
Evidence-based Practice Centers
Under AHRQ's Evidence-based Practice Centers (EPCs), institutions in the United States and Canada receive 5-year contracts to review all relevant scientific literature on clinical, behavioral, organizational and financing topics, methodology of systematic reviews, and other health care delivery issues, and produce evidence reports and technology assessments. The information in these reports is used by Federal and State agencies, private-sector professional societies, health delivery systems, providers, payers, and others committed to evidence-based health care for informing and developing coverage decisions, quality measures, educational materials and tools, guidelines, and research agendas.
Since the program was created in 1997, the EPCs have produced and published nearly 200 evidence reports on a variety of health care topics. Beginning in 2005, the EPCs began researching and preparing new evidence and technology reports as well as Comparative Effectiveness Reviews on medications, devices, and other relevant interventions for AHRQ's Effective Health Care Program.
In 2007, AHRQ announced the 14 institutions who will receive 5-year contracts which comprise the third iteration of its EPC program:
- Blue Cross and Blue Shield Association Technology Evaluation Center.
- Duke University.
- ECRI Institute.
- Johns Hopkins University.
- McMaster University.
- New England Medical Center Hospitals.
- Oregon Evidence-based Practice Center.
- RAND Corporation.
- RTI International/University of North Carolina at Chapel Hill.
- University of Alberta.
- University of Connecticut.
- Minnesota Evidence-based Practice Center.
- University of Ottawa.
- Vanderbilt University Medical Center.
The EPCs will develop reports of the scientific literature in the following focus areas:
- U.S. Preventive Services Task Force, where they will conduct systematic reviews of the evidence on specific topics in clinical prevention and provide technical support that will serve as the scientific basis for Task Force recommendations.
- AHRQ's Technology Assessment Program, where they will assess the clinical utility of medical interventions to assist the Centers for Medicare & Medicaid Services make informed decisions regarding its Medicare program.
- The Generalist Program, for which they will continue producing reports each year with private and Federal partners on a range of clinical, behavioral, economic, and health care delivery topics.
- The Effective Health Care Program, for which they will provide high-quality, reliable data in the form of comparative effectiveness reviews to help patients, clinicians, and policymakers make the best health care decisions.
- The Scientific Resource Center, through which they will provide scientific and methodologic technical support to the Generalist and Effective Health Care programs.
Recent research findings from the EPC program
In 2007, the EPCs released 20 new evidence and technology reports. Examples include:
- Treatment of Primary and Secondary Osteoarthritis of the Knee. This report found that glucosamine and chondroitin, over-the-counter dietary supplement ingredients that are used widely because of their purported benefits to relieve knee pain and improve physical functioning, appear to be no more effective than placebos. The review also failed to find convincing evidence of benefit from arthroscopic surgery to clean the knee joint with or without removal of debris and loose cartilage.
- Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 5—Asthma Care. This report concludes that a wide variety of types of quality improvement interventions have been found to improve the outcomes and processes of care for children and adults with asthma. Young children with asthma benefit most from quality improvement strategies that also include their caregivers or parents. General populations with asthma can have clinically significant improvements after participating in self-monitoring, self-management, or patient education interventions.
- A Critical Analysis of Care Coordination Strategies for Children With Special Health Care Needs. This technical review found that despite progress in defining care coordination and children with special health care needs (CSHCN), there remains considerable variation in current analytic approaches and definitions. However, some progress has been made in developing care coordination strategies for CSHCN and there is a major need to evaluate the impact of these strategies on health outcomes and costs.
For more about the Evidence-based Practice Center program, go to http://www.ahrq.gov/research/findings/evidence-based-reports/centers/index.html.
Evidence report used to develop clinical practice guidelines on occupational asthma
The American College of Chest Physicians (ACCP) used findings from AHRQ's Evidence Report No. 129, Diagnosis and Management of Work-Related Asthma, to develop a clinical practice guideline as well as a user-friendly clinical resource guide on occupational asthma for physicians and patients. The guides were
developed by a panel of 15 methodological and clinical experts, including the lead methodologists from the Alberta Evidence-based Practice Center who authored the evidence report, and other experts from ACCP's airways and occupational and environmental subspecialty network groups. ACCP intends to
develop a user-friendly version of the guideline in the form of an educational/informational resource on CD-ROM for both patients and physicians and is in the process of implementing a broad dissemination strategy for its new guideline on occupational asthma.
Centers for Education and Research on Therapeutics
The Centers for Education & Research on Therapeutics (CERTs) is a national program that conducts research and provides education to advance the optimal use of drugs, biologicals, and medical devices. The CERTs program, which is administered by AHRQ in partnership with the Food and Drug Administration, was originally authorized by Congress in 1997 to examine the benefits, risks, and cost-effectiveness of therapeutic products; educate patients, consumers, doctors, pharmacists, and other clinical personnel; and improve quality of care while reducing unnecessary costs by increasing appropriate use of therapeutics and preventing adverse effects and their medical consequences.
In 2007, AHRQ awarded $41.2 million which will be distributed over the next 4 years for a new CERTs coordinating center and 10 research centers as part of the CERTs program. In addition to the existing centers, four new centers were previously funded in 2006 for a 5-year period. The new AHRQ-funded CERTs Coordinating Center is Kaiser Permanente's Center for Health Research in Portland, Oregon. The four new centers receiving first-time funding are:
- Brigham and Women's Hospital in Boston will focus on how health information technology can improve the safe use of medications.
- The University of Illinois at Chicago will focus on how reinvigorating formularies promote best medication uses.
- Cincinnati's Children's Hospital Medical Center will focus on improving pediatric patient care.
- The University of Chicago will focus on hospital use of medications and other therapeutics and their clinical and economic implications.
Six previously funded CERTs research centers won new funding awards:
- Duke University (therapies for disorders of the heart and blood vessels).
- Harvard Pilgrim Health Care on behalf of the HMO Research Network (drug use, safety, and effectiveness in defined populations cared for by health plans).
- University of Alabama at Birmingham (therapies for disorders of the joints and bones).
- The Arizona CERT at The Critical Path Institute (potentially harmful drug interactions, particularly in women).
- University of Pennsylvania (therapies for infectious diseases).
- Vanderbilt University (prescription drug use in Medicaid and Veterans populations).
The remaining four centers, which received funding in 2006, are:
- MD Anderson, Texas (risk and health communication; patient, consumer, and professional education).
- Rutgers, The State University of New Jersey (mental health therapies).
- University of Iowa (improving elderly care).
- Weill Medical College of Cornell University, New York (therapeutic medical devices).
Recent research findings from the CERTs program
- One study found that less than half of heart attack patients regularly took beta-blockers during the first year after their heart attack even though they had health insurance and prescription drug coverage. During the year after hospital discharge, only 45 percent of patients were adherent to beta-blockers, with the biggest drop in adherence between 30 and 90 days. After accounting for multiple factors, significant predictors of lower adherence were participation in a Medicare+Choice plan (compared with a commercial plan), residence in the Southeast, and ages 35 to 64 years.
- Widespread use of fluoroquinolines (FQs) has resulted in an increasing number of FQ-resistant bacterial infections in both hospitals and long-term care medical facilities, according to two studies. Researchers found that long-term care patients who had used FQ antibiotics in the past were at greater risk of developing FQ-resistant Escherichia coli urinary tract infections. A second study showed that the annual prevalence of FQ-resistant Pseudomonas aeruginosa at one hospital increased from 15 percent in 1991 to 41 percent in 2000.
More information about the CERTs program can be found at http://certs.hhs.gov/about/certsovr.htm.
National Guideline Clearinghouse™
In 2007, AHRQ's National Guideline Clearinghouse™ (NGC), in conjunction with the AHRQ's National Quality Measures Clearinghouse™ (NQMC), introduced a new Expert Commentary, a feature specifically designed to respond to the need for expert guidance on understanding, interpreting, and evaluating clinical practice guidelines and quality measures. To make the Expert Commentary a reality, NGC/NQMC assembled a 22-member Editorial Board comprised of members with a record of accomplishment and nationally or internationally recognized expertise in one or more topic areas relevant to the Clearinghouses.
The NGC is a Web-based resource for information on over 2,200 evidence-based clinical practice guidelines. Since becoming fully operational in early 1999, the NGC has had over 37 million visits and now receives over 1 million visits each month. The NGC helps health care providers, health plans, integrated delivery systems, purchasers, and others obtain objective, detailed information on clinical practice guidelines. For more information about the NGC, go to www.guideline.gov.
United States Preventive Services Task Force
In 2007, the U.S. Preventive Services Task Force (Task Force) continued to provide the "gold standard," recommendations that help build the evidence base for preventive services provided in this Nation. It was first convened by the U.S. Public Health Service in 1984. Sponsored by AHRQ since 1998, the Task Force is the leading independent panel of private-sector experts in prevention and primary care. The Task Force conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. AHRQ provides technical and administrative support, but the recommendations of the panel are its own. The mission of the Task Force is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.
Two new evidence-based consumer checklists released by AHRQ are based in part on Task Force recommendations: Men: Stay Healthy at Any Age: Your Checklist for Health and Women: Stay Healthy at Any Age: Your Checklist for Health. These checklists are designed to help men and women understand which medical checkup tests they need to stay healthy at any age and are available in English and Spanish. The checklist for men includes recommendations about cholesterol checks, tests for high blood pressure, colorectal cancer screening and recent Task Force recommendations on screening for abdominal aortic aneurysm, HIV and obesity. The checklist for women includes recommendations about screening for high cholesterol; breast, cervical and colorectal cancers; and osteoporosis. It also includes recent Task Force recommendations on obesity screening and screening for HIV for all pregnant women. The checklists are available on the AHRQ Web site at https://archive.ahrq.gov/patients-consumers/patient-involvement/healthy-men/index.html and https://archive.ahrq.gov/patients-consumers/prevention/lifestyle/healthy-women.html.
The Task Force released the following new or updated recommendations in 2007:
- Screening for Carotid Artery Stenosis—recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population.
- Screening for High Blood Pressure—recommends screening for high blood pressure in adults
aged 18 and older.
- Aspirin or Nonsteroidal Anti-inflammatory Drugs for the Primary Prevention of Colorectal Cancer—recommends against the routine use of aspirin and nonsteroidal anti-inflammatory drugs to prevent colorectal cancer in individuals at average risk for colorectal cancer.
- Screening for Chlamydial Infection—recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk, as well as all pregnant women aged 24 and younger and for older pregnant women who are at increased risk.
- Screening for Sickle Cell Disease in Newborns—recommends screening for sickle cell disease in newborns.
- Screening for Lipid Disorders in Children—concludes that the evidence is insufficient to recommend for or against routine screening for lipid disorders in infants, children, adolescents, or young adults (up to age 20).
- Counseling About Proper Use of Motor Vehicle Occupant Restraints and Avoidance of Alcohol Use While Driving—concludes that the current evidence is insufficient to assess the incremental benefit, beyond the efficacy of legislation and community-based interventions, of counseling in the primary care setting, in improving rates of proper use of motor vehicle occupant restraints (child safety seats, booster seats, and lap-and-shoulder belts).
More information on the Task Force as well as copies of reports and guides can be found at http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/uspstf/index.html.
Primary Care Practice-Based Research Networks
Primary care practice-based research networks (PBRNs) are organized groups of primary care clinicians and practices that work together with academic researchers to study issues related to health care, including improvement of the quality of care. The 120 primary care PBRNs known to be active in the U.S. include about 20,000 practices of pediatrics, family medicine, and general internal medicine located in all 50 States. These practices provide care for more than 20 million Americans. In 2007, AHRQ awarded over $4 million of grant funding to PBRNs for projects related to implementing health information technology and improving patient safety in primary care practices. In addition, AHRQ supports the growth and development of these networks through peer learning groups, a national PBRN registry, public and protected Internet sites, and an annual national PBRN conference.
Rapid Turn-Around Studies on Implementing Evidence Into Practice Conducted Within Primary Care PBRNs
In 2007 AHRQ awarded contracts to 10 primary care PBRNs to conduct studies on accelerating the implementation of evidence into practice and improving the quality of primary care. The following are examples of PBRN projects initiated in 2007:
- CaReNet, a Colorado-based network, and NCNC, a consortium of four networks located in North Carolina, are assessing the direct and indirect costs to primary care practices of collecting and reporting the quality performance measurement data required by certain insurers/payors.
- ACORN, a network headquartered in northern Virginia, is identifying barriers and potential solutions for collecting and reporting quality performance data in primary care offices.
- OKPRN, an Oklahoma-based PBRN, is studying the use of health information technology by primary care practices to support self care management among their patients during a pandemic influenza event.
- ORPRN, a network of practices located in rural Oregon, is assessing the clinical and financial impact of introducing into primary care practices a nurse-based chronic care management program.
Practice-Based Research Network Resource Center
The Practice-Based Research Network Resource Center provides resources and assistance to PBRNs engaged in clinical and health services research. Registration with the Resource Center allows PBRN researchers access to:
- Technical expertise for collecting and managing data.
- Methodological expertise and experience necessary for designing research projects.
- Resources for operating a primary care PBRN such as communication strategies, project and network management, and member recruitment and retention.
- Health information technology support and resources.
- Notification of funding and research opportunities.
- Forums for discussing PBRN issues with colleagues and experts in areas including quality improvement research within PBRNs.
A National Medication Error and Adverse Drug Event Reporting System for Ambulatory Care (MEADERS)
Through its PBRN Resource Center, AHRQ has supported PBRN researchers and practitioners in the design and testing of a user friendly system for reporting medication errors and adverse drug events observed in primary care practices. Since the system is Internet-based, it can be made easily accessible to any primary care practice with Internet access, while maintaining tight data security. With a single click, practitioners can opt to forward their report to the FDA's MedWatch program. During 2007, MEADERS was tested in 60 primary care practices that participate in four AHRQ-supported PBRNs. The results of this study, expected by the summer of 2008, will help AHRQ understand and remediate medication errors and adverse events that potentially lead to patient harm and hospital admissions.
National PBRN Research Conference
Over 250 people attended the 2007 AHRQ National PBRN Research Conference. Dr. Paul Thomas, an eminent PBRN researcher from the U.K., held a presentation titled "Organizing Strategies and Network Outcomes: Lessons from the U.K." which explored how four primary care research networks across London evaluated their research capacity, multidisciplinary collaboration and research productivity as a result of participation in a research network. In addition to this presentation, attendees also attended topical plenary sessions related to primary care research and PBRNs; participated in workshops addressing best practices, operations, information technology, quality improvement, and research methodology; and received updates on the most recent PBRN research.
Recent research findings from PBRNs
- Researchers surveyed adult primary care patients in four North Carolina family practices and found:
- 62 percent ate two or fewer fruits or vegetables daily.
- 42 percent had hypertension.
- 42 percent reported consuming protein less than two times a week.
- 41 percent were obese.
- 40 percent scored as high-risk on a diabetes risk screen.
- 40 percent reported engaging in no regular physical activity.
- 36 percent ate three or more desserts weekly.
- 30 percent reported eating three or more fast food meals weekly.
- 29 percent drank three or more high-sugar beverages weekly.
- 24 percent were current smokers.
- Researchers at the North Carolina Family Practice-Based Research Network analyzed survey responses from 258 patients who were considered at high risk for developing diabetes. The patients were asked about what helped and prevented them from engaging in physical activity. High-risk patients scored 10 points or higher on the American Diabetes Association risk test. They typically were patients who were older, overweight or obese, had a family history of diabetes or history of gestational diabetes, and were sedentary. Only 56 percent of these high-risk patients engaged in the recommended 150 minutes or more of moderate to vigorous activity per week. More individuals who had graduated from high school or attended college education met the recommended activity levels than those who did not graduate from high school (Figure 1).
Accelerating Change and Transformation in Organizations and Networks
During 2007, AHRQ awarded over $10.9 million in contracts to partnerships in the Agency's Accelerating Change and Transformation in Organizations and Networks (ACTION) program. These contracts will focus on health care organization and payment, patient safety, health information technology, prevention, and emergency preparedness.
Begun in 2006, ACTION is the successor to AHRQ's Integrated Delivery System Research Network. ACTION is a model of field-based research that fosters public-private collaboration in rapid-cycle, applied research. It links many of the Nation's largest healthcare systems with its top health services researchers. Each of ACTION's 15 partnerships has a demonstrated capacity to "turn research into practice" for proven interventions targeting those who manage, deliver, or receive health care services. As a network, ACTION provides health services in a wide variety of organizational care settings to at least 100 million Americans. The ACTION partnerships span all States and provide access to large numbers of providers, major health plans, hospitals, long-term care facilities, ambulatory care settings, and other care sites. Each partnership includes health care systems with large, robust databases, clinical and research expertise, and the authority to implement health care interventions.
More information on ACTION as well as the partnerships can be found on the AHRQ Web site at http://www.ahrq.gov/research/findings/factsheets/translating/action2/index.html.
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