July 23, 2010
Minutes from the July 23, 2010, meeting of the Agency for Healthcare Research and Quality's National Advisory Council (NAC) are available on this page.
Call to Order; Approval of April 9 Summary Report
Quality Improvement Priorities and Implications for AHRQ
Targeting Health Disparities
The CMS Innovations Center
Update from Communities
Chairman's Wrap-Up, Final Comments
NAC Members Present
Bruce Siegel, M.D., M.P.H., George Washington University (Chair)
Helen Darling, M.A., National Business Group on Health
Louise-Marie Dembry, M.D., M.S., M.B.A., Yale New Haven Hospital
Nancy E. Donaldson, D.N.Sc., R.N., FAAN, Center for Nursing Research & Innovation, University of California, San Francisco
Silvia M. Ferretti, D.O., Lake Erie College of Osteopathic Medicine
Arthur Garson, Jr., M.D., M.P.H., University of Virginia
Junius J. Gonzales, M.D., M.B.A., University of South Florida
Helen W. Haskell, Mothers Against Medical Error
Wishwa N. Kapoor, M.D., M.P.H., University of Pittsburgh
Lisa M. Latts, M.D., M.B.A., M.S.P.H., WellPoint Inc.
Keith J. Mueller, Ph.D., Nebraska Center for Rural Health Research
Welton O'Neal, Jr., Pharm.D., Takeda Pharmaceuticals North America, Inc.
Michael K. Raymond, M.D., Skokie Hospital
Katherine A. Schneider, M.D., M.Phil., AtlantiCare Health System
Xavier Sevilla, M.D., FAAP, Manatee County Rural Health Services, Inc.
David L. Shern, Ph.D., Mental Health America
Myrl Weinberg, C.A.E., National Health Council
David Atkins, M.D., M.P.H., Veterans Health Administration
Sarah Lutter, J.D., Office of Science Policy, National Institutes of Health (NIH)
Jane Sisk, Ph.D., Centers for Disease Control and Prevention (CDC)
AHRQ Members and Staff Present
Carolyn M. Clancy, M.D., Director
Irene Fraser, Ph.D., Director, Center for Delivery, Organization, and Markets
Kathleen Kendrick, M.S., C.S., R.N., Deputy Director
Ernest Moy, M.D., M.P.H.
Jean Slutsky, P.A., M.S.P.H., Director, Center for Outcomes and Evidence
Jaime Zimmerman, M.P.H., NAC Coordinator
Call to Order; Approval of April 9 Summary Report
Meeting Chair Bruce Siegel, M.D., M.P.H., called the group to order at 8:30 a.m., welcoming the NAC members, other participants, and visitors. The new NAC members in attendance were Helen Darling, M.A., Louise-Marie Dembry, M.D., M.S., M.B.A., Silvia M. Ferretti, D.O., Helen W. Haskell, Welton O'Neal, Jr., Pharm.D., and Katherine A. Schneider, M.D., M.Phil. New member Ardis Dee Hoven, M.D., was unable to attend.
The NAC members introduced themselves. Dr. Siegel referred to the draft minutes of the previous NAC meeting (April 2010) and asked for changes and approval. The NAC members approved the April meeting minutes with no changes.
Carolyn M. Clancy, M.D., Director of AHRQ, announced that Dr. Siegel recently became the Chief Executive Officer of the National Association of Public Hospitals and Health Systems and Keith J. Mueller, Ph.D., recently became the Gerhard Hartman Professor and Department Head, Health Management and Policy, College of Public Health, University of Iowa.
The Big Picture
Dr. Clancy reported that The Patient Protections and Affordable Care Act was passed and became Public Law 111-148. The law presents many opportunities for AHRQ, and some of its provisions have yet to be funded. The Obama administration proposed a fiscal year (FY) 2011 budget that included $611 million for AHRQ, a substantial increase from AHRQ's $397 million budget in FY 2010. The House proposed a $411 million budget for FY 2011; the budgeting process is still in early stages.
Dr. Clancy reviewed the following recent accomplishments:
- AHRQ released the annual State Snapsots, providing State-by-State data on health care quality. The greatest improvements were seen in Maine, Maryland, Wyoming, South Carolina, and the District of Columbia. The smallest improvements were seen in North Dakota, Texas, West Virginia, Nebraska, and Washington.
- The State Snapshots feature a new section on health insurance, gauging the quality of care of payers.
- AHRQ released the new National Healthcare Quality Report and National Healthcare Disparities Report. Among the new features is a focus on obesity and the finding that obese adults who are black, Hispanic, or poor, or have less than a high school education are less likely to receive diet advice from a doctor. Most overweight children and one-third of obese adults are not told by their doctors that they are overweight.
- A study published in the Journal of the American Medical Association revealed that 10 percent of all sickle cell patients are rehospitalized within 30 days. For patients aged 18 to 30, about 41 percent are rehospitalized within 30 days.
- An AHRQ-funded study found that bar code technology combined with electronic records reduces medication errors—for example, a 51-percent reduction in potential drug-related adverse events.
- An AHRQ-supported study found that intensity-modulated radiation therapy for treatment of head and neck cancer is better than traditional radiation in avoiding the severe side effect known as "dry mouth."
- AHRQ introduced "My Own Network Powered by AHRQ" (MONAHRQ), a sofware program which allows users to input administrative data and generate a data-driven Web site. The program is already being used by organizations throughout the United States.
- AHRQ is playing a role in supporting 20 demonstration and planning grants to evaluate potential medical liability reforms and effects on patient safety. Overall funding for the program is $25 million.
- AHRQ worked with the Ad Council to produce print and video spots that encourage men to seek preventive health care. (Dr. Clancy played one of the video spots for the meeting participants.)
- AHRQ published guides on emergency, evacuation, and recovery. They are available at https://www.ahrq.gov/prep.
- An AHRQ-supported comparative effectiveness report found that most rotator cuff tears are treatable, yet evidence for the ideal timing of surgery is lacking.
- In an impact case study, the Johns Hopkins Bloomberg School of Public Health has integrated the Medical Expenditure Panel Survey (MEPS) in graduate and doctoral classes.
- A knowledge transfer case study conducted in hospitals in Iowa, Illinois, and New York employed the AHRQ guide Preventing Hospital-Acquired Venous Thromboembolism, leading to new or revised prevention protocols in 13 hospitals.
- A knowledge transfer case study by the Texas Health and Human Services Commission utilized the Medicaid Care Management Learning Network to improve patient involvement and to encourage health management and use of evidence-based care.
- A knowledge transfer case study by the Iowa Healthcare Collaborative featured guidance on using AHRQ quality indicators for hospital-level comparative reporting.
AHRQ Program Updates
Dr. Clancy provided the following program updates:
- AHRQ launched its new Patient Centered Medical Home (PCMH) Web site in July. The site serves policymakers and researchers and features a searchable database of articles and a series of white papers on medical home topics.
- AHRQ is supporting efforts to acquire knowledge about medical homes. These include retrospective evaluations in Minnesota and Texas and 2-year grants to study the transforming of primary care practice.
- The U.S. Preventive Services Task Force will take on additional roles under the new health care act. It appointed four new members—Kirsten Bibbins-Domingo, M.D., Ph.D., Adelita Gonzales Cantu, R.N., Ph.D., Glenn Flores, M.D., and Carolina Reyes, M.D. The Task Force recently launched a public comment period for its draft recommendations. This new policy will serve the purpose of determining whether the Task Force has overlooked any important evidence.
- AHRQ's Effective Health Care initiative has taken advantage of various Web-based social media tools, such as Twitter.
- AHRQ recently supported continuing medical education, or CME/CE, activities, focusing on, as examples, diabetes, heart and blood vessel conditions, and muscle, bone, and joint conditions.
- The Centers for Education and Research in Therapeutics (CERTs) announced the chairs of future National Steering Committees—Craig Brater, M.D., Indiana University School of Medicine (for December 2012) and David Ballard, M.D., Ph.D., Baylor Health Care System (for December 2014).
- A new resource on comparative effectiveness research (CER) methods was published in the June 2010 issue of Medical Care. The supplement featured 22 original articles on CER. It can be downloaded at http://www.effectivehealthcare.ahrq.gov.
- AHRQ technology assessment findings were cited in a Medicare public meeting in April. The issue was radiation therapy for localized prostate cancer.
- AHRQ released research reviews on (1) comparative effectiveness of in-hospital use of recombinant factor VIIa for off-label indications versus usual care, (2) comparative effectiveness and safety of radiotherapy treatments for head and neck cancers, and (3) comparative effectiveness of nonoperative and operative treatments for rotator cuff tears.
- AHRQ released Selecting Quality and Resource Use Measures: A Decision Guide for Community Quality Collaboratives, which addresses questions that community leaders and stakeholders often ask about those topics. (https://www.ahrq.gov/qual/perfmeasguide)
- The Healthcare Cost and Utilization Project (HCUP) released a statistical brief, Readmissions and Multiple Emergency Department Visits in Selected States, 2006-2007, which revealed that about a quarter of hospital patients in 12 States were readmitted for the condition that prompted an initial hospitalization.
- AHRQ awarded $5.8 million to the Health Research and Educational Trust to help States support staffing needs at hospitals engaging in a program to reduce central line-associated bloodstream infections. The program builds on the success of the Michigan Keystone Project.
- There are now 83 Patient Safety Organizations (PSOs) in 30 States and the District of Columbia. Common formats for patient safety events, with technical specifications, were released in March 2010.
- The Consumer Assessment of Health Providers and Systems (CAHPS®) received the endorsement of the National Quality Forum (NQF) for its Nursing Home CAHPS. The CAHPS® program is developing a cancer care survey and initiatives for a patient-centered medical home and home- and community-based services.
- The 2009 MEPS Insurance Component (MEPS-IC) Family Premium Estimates were released for use in setting State tax credits for small firms under the new health care reform act. (MEPS is AHRQ's Medical Expenditure Panel Survey). The MEPS served to inform various Federal deliberations for the new health care act.
- AHRQ's new Web site features a section on the technical assistance about health initiatives that are requested and offered.
- The fourth annual AHRQ conference will take place September 26-29, 2010, in Bethesda, Maryland. The theme is "Better Care, Better Health: Delivering on Quality for All Americans." Atul Gawande will be keynote speaker.
Myrl Weinberg wondered about analytic programs for interpreting data and about CER methods. Dr. Clancy stated that AHRQ's work has grown from an initial emphasis on outcomes research, and the agency has learned about the limitations of billing data and the need for methods for interpreting clinical data (especially electronic data). Xavier Sevilla, M.D., asked whether the MONAHRQ program can be of use to small entities. Irene Fraser, Ph.D., noted that it can be used by entities with access to hospital data, including hospitals, public health agencies, and chartered value exchanges, and it can handle multiple providers.
Dr. Clancy noted that the new health care act features significant funds for CER—a total of $1.1 billion. The Institute of Medicine determined that CER should be broadened beyond specific clinical conditions to address care delivery strategies. in fact, the funds for CER are allocated broadly across the Department of Health & Human Services (HHS). Dr. Clancy cited expenditures to improve care delivery, to provide specific clinical interventions, and to support infrastructure and data development. Michael K. Raymond, M.D., wondered whether the stimulus program coincided with the end of Medical Payment Advisory Commission (MedPAC). Dr. Clancy stated that MedPAC still exists.
Lisa M. Latts, M.D., asked about the issue of liability reform and patient safety. Dr. Clancy noted that studies linking the two issues (e.g., observing defensive medicine) are difficult to perform. Ms. Darling suggested that people desire health care information to be conveyed in traditional formats, not only as elements of the new Web-based social media. She also proposed that AHRQ consider a new name for the concept of "medical home."
Nancy E. Donaldson, D.N.Sc., R.N., raised the issue of educating young medical scholars/researchers in investigative methods and data. Dr. Clancy suggested that this topic be discussed at the November NAC meeting. David L. Shern, Ph.D., added the need to address issues of co-morbidities and modeling. David Atkins, M.D., stated the need to develop common metrics for evaluation.
Quality Improvement Priorities and Implications for AHRQ
Dr. Clancy asked the NAC members to consider future AHRQ initiatives in light of the new health care act. AHRQ has been conferring with other agencies to coordinate efforts. The law directs the HHS Secretary to support a national strategy to improve health care quality and to employ benchmarks. There will be an interagency working group on health care quality. The law calls for the use of payments and other levers to improve care. Activities will include the development of quality measures and efforts to improve the collection, analysis, and reporting of data. AHRQ will be offering technical assistance in the front lines of care.
Issues to consider include public-private collaborations, a focus on outcomes, a focus on shared accountability, and the role of AHRQ in spread and change management. Arthur Garson, Jr., M.D., M.P.H., proposed the development of a list of 10 or 15 quality goals for the Nation. Dr. Clancy suggested that the language in the act virtually demands that (as in calling for benchmarks). Two large goals in particular will be a reduction in readmissions and a reduction in health care-associated infections.
Dr. Donaldson added the issues of process (coordination, integration), the harmonization of measures, and the possible use of rapid cycle models. Dr. Schneider cited a need for greater measurement on the improvement side of the health care equation. We should link goals to tools. Unnecessary measures should be deleted. Ms. Weinberg suggested that AHRQ work to disseminate actionable information to stakeholders/consumers.
Keith J. Mueller, Ph.D., suggested that AHRQ support studies of adopting and embedding change in organizations. Dr. Sevilla encouraged AHRQ to study what good quality health care means to the consumer. Ms. Haskell too cited the importance of the patient perspective, including experience regarding quality and safety. Ms. Darling suggested that AHRQ continue to focus on technical assistance, with metrics for accomplishment. There should be metrics for action and accountability—perhaps built into contracting arrangements.
Dr. Shern noted that the voluntary health organizations can be valuable partners, especially in areas of implementation (e.g., the issue of health literacy). AHRQ might investigate the knowledge that has been gained from implementation science. Jane Sisk, Ph.D., cited the need to ensure that goals align with the goals of Healthy People 2020. Dr. Raymond encouraged the use of structured process outcomes. Dr. Atkins wondered whether AHRQ could have a focus on efforts to bend the cost curve for health care, addressing, for example, issues of overuse and efficiency. Dr. Clancy noted that the health care act includes a provision for an Extension Service Model. She recognized that there will be a political dimension to the agency's efforts, involving, for example, people's wants and expectations.
Targeting Health Disparities
Kalahn Taylor-Clark, Ph.D., M.P.H., The Brookings Institution
Dr. Taylor-Clark described the Quality Alliance Steering Committee, a stakeholder group which supports the implementation and use of standard health care performance information. It offers planning, oversight, and coordination in efforts to foster patient-centered measurement and reporting and encourages the use of best practices. The Committee features a racial and ethnic health care equity initiative, with a goal of developing best practices for collecting, monitoring, and disclosing race/ethnicity data to promote equity in care across all groups. Dr. Taylor-Clark described a pilot project in Massachusetts, which provided technical assistance for acquiring race data and learned of difficulties in doing so. The study led to the following recommendations:
- That health plans report only race/ethnicity data that are self-reported by members or guardians.
- That reported data from third-party sources be allowed if the data are obtained from members or guardians.
- That regulations support the collection of data on patient-preferred spoken and written language, and
- That thresholds for reporting race, ethnicity, and language be increased over time.
Dr. Taylor-Clark noted a second study, in Montgomery County, Maryland, which revealed the importance of going outside the health care system to identify conditions that lead to disparities. The study involved smoking cessation efforts and aggregating data across hospitals. Dr. Taylor-Clark emphasized actions such as engaging community stakeholders and developing models that feature longer timeframes for collecting data. The Steering Committee plans to develop interim strategies (e.g., the use of indirect data) for acquiring and using data on race, ethnicity, and language at the regional level. It will develop strategies for incorporating considerations of equity in payment and delivery reform.
Dr. Taylor-Clark noted that the Massachusetts pilot was considered by public health officials to be a quality initiative. in contrast, hospital officials did not consider it to be a quality initiative. Dr. Latts encouraged the researchers to increase the use of indirect data, such as from name analyses. Dr. Raymond proposed support for a universal health insurance form featuring race/ethnicity elements (a current national claim form for inpatient care does not require race/ethnicity data). Dr. Clancy noted that the health care act separates the issues of disparities and quality. Dr. Donaldson cited the importance of harmonizing metrics across agencies and offering States incentives to adopt standards. Dr. Gonzales stressed that social determinants, or influences, will always be important to any sustained engagement.
The CMS Innovations Center
Anthony D. Rodgers, M.S., Center for Strategic Planning, Centers for Medicare & Medicaid Services (CMS)
Mr. Rodgers stated a need, in the wake of the new health care act, for CMS to consider a broader role in the health care delivery system. For example, there must be increased connectivity to the private sector. CMS's new Center for Medicare and Medicaid Innovation (CMI) has a purpose of testing innovative payment and service delivery models that reduce program expenditures. It will seek to preserve and enhance the quality of care and stress models that improve coordination, quality, and efficiency of health care services for CMS beneficiaries. One goal is to reduce the cycle times for demonstrations. Another is to work with States to bring Medicaid into a platform with Medicare.
Mr. Rodgers described staging and process components for innovation. These include the use of collaborative innovation laboratories, a health care delivery consortium, and health care innovation zones around academic centers. Quality Improvement Organizations (QIOs) might be involved through contract mechanisms. The CMS Innovation Center seeks to move from innovation to translation and to move away from transactional fee-for-service environments toward managed, accountable environments that organize care to achieve results and are patient-centered and integrated. It has an information technology framework and employs a value-driven decision support system based on a variety of data sources. Future work will include scaling up of new processes, developing tools, and creating and validating service delivery models. The CMI seeks to build an integrated, Web-based CMS.
Mr. Rodgers presented lists of claims data fields and data sets that will help to drive the next generation of innovations. There will be opportunities for data exchange and for building support utilities.
Mr. Rodgers stated that CMS is considering creating a board of stakeholders to advise the CMI. He expressed CMS's intention to develop metrics for performance transparency. For public transparency, CMS hopes to place data in the public domain. It intends to work with commercial health plans and organizations such as WellPoint to ensure that ACOs are goal driven. Dr. Dembry encouraged CMS to commit to spread and dissemination as it proceeds with demonstrations.
Ernest Moy, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ
Dr. Moy reviewed the latest State Snapshots, which are linked at the AHRQ Web site. He presented the site live on a screen, revealing examples of dashboards for the individual States and their various quality ratings. The results demonstrate large variability from State to State, and the site offers easy comparisons within categories such as payers, types of care, and settings of care.
One new feature is an "Innovations Exchange," to which users can link to view success stories for particular health conditions. The site features data in focus areas, such as diabetes and asthma, and offers comparisons in contextual areas, variations over time, and disparities between groups. A new section on variations allows comparison of each State to the Nation.
Dr. Garson suggested forwarding the State Snapshots link to legislators, so that they can observe its data capabilities. Even better would be visits by State Snapshots experts to legislators. Dr. Donaldson proposed conducting a Webinar about the site. Dr. Schneider cautioned that the dates of the data in the State Snapshots might put off some users (in other words, there is a lag—the current snapshots contain data from 2006).
Update from Communities
Nancy Clarke, Oregon Health Care Quality Corporation, and J. Marc Overhage, M.D., Ph.D., Quality Health First Program (Indiana)
Dr. Clancy introduced a segment featuring two reports from AHRQ's Chartered Value Exchange Program, which focuses on technical assistance, group learning, and resources for quality collaboratives in regions and communities.
Dr. Clarke described the Partner for Quality Care program in Oregon, which has a mission of measuring and improving the quality of health care through collaboration. The program recruits community partners, establishes and aligns messages, and develops materials. Ms. Clarke described onsite meetings featuring engagement with community members and the use of a "tele-town hall"—a strategy of cold-calling thousands of AARP members and inviting them to join a 1-hour discussion-and-question session over the telephone. The latter initiative had great success, with more than 800 people joining the call at one time. The Oregon program also maintains a Web site which features resources such as print materials and ratings of clinics across the State. Ms. Clarke outlined the program's view of success in quality enhancement and she welcomed AHRQ's ongoing provision of tools, its support for new ways to finance community roles in research and development, and its support for an infrastructure that weaves together community quality collaboratives.
Marc Overhage, M.D., Ph.D., described the Indiana Health Information Exchange and its quality improvement infrastructure. The program features a focus on health information technology and data. Dr. Overhage listed elements of an infrastructure for quality improvement, such as data, transparency, attribution, and the aligning of incentives. He focused on the idea of data reuse (the Indiana program features a "DOCS4DOCS" data delivery service). The Indiana Network for Patient Care is the Nation's largest standardized and integrated health information infrastructure, providing data to physicians at point of care. Dr. Overhage stressed that AHRQ can help the programs by identifying measures, indicating risk adjustments, supporting provider reporting and education as per guidelines, aligning incentives, and supporting public reporting and education.
Dr. Overhage stated that local leadership is a key to success and to developing transparency within communities. Ms. Clarke suggested that transparency efforts can begin in various ways. She stated that consumers are most concerned about losing access to care.
Dr. Kapoor wondered about the fear that some entities have about looking bad as a result of data and transparency. Ms. Clarke responded that her program uses a matrix that is non-public and a process to approve going public. Dr. Overhage stated that his program provides data monthly and allows clients to address issues prior to releasing a full report.
Dr. Donaldson suggested that the work of the value exchanges be linked to the efforts of the CMI. Dr. Schneider cited a need to consider relative versus absolute performance in reporting. Dr. Overhage noted that his group considers relative performance. Dr. Clancy encouraged the programs to include a smart use of benchmarking. Regarding the issue of "meaningful use," Dr. Overhage stated that it can help to drive improvement and Ms. Clarke stated that it can be a motivator.
Elaine Nichols, a patient-family-centered care advisor, asked Ms. Clarke about strategies for getting patients and physicians to the table. Ms. Clarke suggested contacting consumers and consumer advocates who have succeeded in doing that. A State patient safety commission might offer names of people who have been engaged. It also can help to find one or two physicians who are skilled in engaging consumers.
Eric Sullivan, Social & Scientific Systems, cited the difficulty of explaining outcomes measures to nurse practitioners and others. He encouraged AHRQ to help with that process.
Chairman's Wrap-Up, Final Comments
Dr. Siegel invited the NAC members to make final comments.
Sylvia Ferretti, D.O., encouraged AHRQ to bring quality-related processes to classrooms for young medical practitioners. Dr. Clancy stated that such efforts might be possible.
Dr. Clancy stated again the great opportunities that lie ahead. Quality improvement issues will remain a major theme. She thanked the participants for their input.
Dr. Siegel thanked the AHRQ staff and NAC members. He noted that the next NAC meeting will take place November 5, 2010. He adjourned the meeting at 3:00 p.m.
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