Research on Health Care Costs, Quality and Outcomes (HCQO)

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Performance Budget Submission for Congressional Justification

Priority III—Translating Research into Practice ($13.500 Million)

Introduction

The past decade has seen formidable breakthroughs in science, but too few of those breakthroughs have been put into practice. Wide variation in practice patterns and outcomes continue, and a gap persists between what we know and the care that we deliver. This gap is found consistently across settings, professions, and populations. This priority will narrow the gap between (1) what we know and what we do and (2) what works for the majority and what works for ethnic minorities, people with chronic conditions, and children.

Research consistently shows that it takes at least 6 to 10 years to make a new health care discovery common practice. We need to dramatically shorten this time by assisting doctors, patients, health systems and purchasers to use new knowledge in their daily health care activities.

AHCPR-sponsored research has identified numerous opportunities for improvement in the quality of care. These fall within three general categories: the underuse of effective services, the overuse of services, and the wide variation in care received across the country, especially among members of racial/ethnic minorities.

Within each of these categories, recent findings from AHCPR-supported research include:

Underuse: Millions of Americans do not receive appropriate health care, leading to unnecessary illness, complications, poor outcomes, and additional costs. An AHCPR-supported study found that only 21 percent of eligible Medicare patients who suffered acute myocardial infarction (AMI) received beta-blockers. Yet the mortality rate among those treated with beta-blockers was 43 percent less than those not offered this treatment, and patients who receive beta-blockers are rehospitalized for heart ailments 22 percent less often than those who do not receive them. At HCFA's request, the National Committee for Quality Assurance used the findings of this study as the basis for changing the HEDIS 3.0 performance measurement for beta-blocker use after AMI to include patients over 75 years of age. HEDIS is being used by HCFA to assess the quality provided by Medicare HMOs.
Overuse: Far too much health care is either unnecessary or leads to increased costs when less expensive alternatives exist. For instance, a recent study found that less expensive antibiotics are also effective for adults with pneumonia. Each year, 4 million adults develop community-acquired pneumonia (CAP), resulting in nearly one million hospitalizations. Costs for treatment of CAP exceed $1 billion per year, of which roughly $100 million is spent on antibiotic therapy. Using the antibiotic erythromycin for treating most outpatients aged 60 and younger significantly reduces treatment costs compared with use of other antibiotics ($5.43 vs. $18.51) and has no adverse effects on medical outcomes.
Variations: A pioneer in this field of research, Dr. Jack Wennberg, has stated that in health care "geography is destiny." AHCPR research has shown that rates of hospitalization and the use of procedures (such as hysterectomy) commonly vary three- to five-fold or more, depending on the State or region. In addition, the Agency's research has greatly contributed to our understanding of the pervasive and often severe disparities in the quality of care for racial and ethnic minorities.

Action Plan

Priority III. Summary, Translating Research Into Practice

Item	Cost, millions
Identifying aims for improvement	In base
Establish public-private partnerships and practice networks	$2.500
Experiments that test the effectiveness of improvement approaches	9.500
Measure the success of these strategies and promote broader implementation	1.200
Research management (3 full-time equivalents)	0.300
Total	$13.500

Specific activities have been identified under each of the above steps which are the result of an internal planning process that involved all Agency staff. These activities were chosen based on the following criteria:

Alignment with the AHCPR Strategic Plan.
Responsiveness to the President's Commission recommendations.
Potential users of the research.
Relevance to policies and priorities of the Department and Nation.
Gaps in knowledge and the AHCPR portfolio.
Extent to which it built on prior AHCPR work.
Existence of an explicit evaluation to determine process, outputs and products needed for the Government Performance and Results Act (GPRA).
Continuation of the fiscal year 1999 investment in the Secretary's Quality Initiative.

Step 1: Identify aims for improvement (No Additional Cost—Included in the base).

The President's Commission report called on the Nation to establish clear aims for improvement and suggested the initial set below. We will rapidly identify both medical conditions and issues which will serve as the basis for this priority. AHCPR will use criteria, based in part on those proposed by the Commission, to identify the areas of study. These include: conditions/settings where most improvement can occur, conditions/settings where wide variability in practice exists, conditions that are common and/or costly, conditions/settings for which wide disparities in care exist for racial/ethnic minorities, and conditions which account for a large burden of disease and poor quality of life. In particular, we will work closely with HCFA to support and complement its GPRA goals that identify specific targets for improvement.

President's Commission Report: Aims for Improvement

Reducing the underlying causes of illness, injury, and disability.
Expanding research on new treatments and evidence of effectiveness.
Ensuring the appropriate use of health care services.
Reducing health care errors.
Addressing oversupply and undersupply of health care resources.
Increasing patients' participation in their care.

Step 2: Establish public private-partnerships and practice networks—$2.500 million.

AHCPR has been extremely successful in establishing public-private partnerships both in translating our research so that it is useable to the public and translating our research into practice. We will continue to work with partners in the public and private sectors, including purchasers, health plans, providers, primary care practice networks, patient advocacy groups and quality improvement organizations to identify opportunities for broad collaborations and the implementation of research findings.

We will use as models successful collaborations with consumer-oriented organizations, health plans, and practice-based networks such as those of family practitioners, internists, pediatricians, and subspecialists. We will select sites based on their current efforts and capacity to improve care.

Specific activities will include:

Managed care organizations (MCOs). MCOs are "natural laboratories" that have potential not otherwise available to capture evidence about how specific managed care delivery and organizational practices impact the delivery of care, and how best to translate these and other research findings into practice. Previously, AHCPR lacked a mechanism to take advantage of these "test-beds" and data analysis opportunities to learn about what managed care practices work. Under this initiative, the Agency is in a position to assemble a select group of MCOs with encounter-level data and actively engage them in timely research projects of importance to the Nation. For example, the MCO network could help answer questions about safety net providers (including community health centers), the role of informatics, and clinical information systems.
Grants to clinical practice networks, in particular primary networks, to conduct research on the effects, including outcomes and costs, of quality improvement interventions.

The following are examples of successful partnerships and collaborations that have been effective in translating AHCPR's research for use by consumers and for use in practice. We will use these partnerships as models to establish new partnerships as well as build on our existing partnerships:

Partnerships: Translating AHCPR's Research for Public Use

AHCPR partnered with the YWCA to print and disseminate AHCPR's mammography consumer guide in English, Spanish, and four Asian languages to approximately 20,000 underserved women as part of its national program to promote breast cancer education, screening, and support for women.
A large insurance company in the State of Washington distributed between 100,000 and 300,000 copies of AHCPR's prostate consumer brochure to all male Medicare recipients in the State.
AHCPR collaborated with American Association of Retired Persons (AARP) to publish in AARP's Pharmacy Newsletter the recommendations contained in AHCPR's cardiac rehabilitation consumer guide. They also promoted the Prescriptions Medicines and You brochure as part of "Talk About Prescriptions Month" and the Smoking Cessation consumer brochure, You Can Quit Smoking, as part of the "Great American Smokeout Month."

Partnerships: Translating Research Into Practice

A hallmark of AHCPR's Evidence-based Practice initiative is that public- and private-sector organizations plan to implement the findings of the Evidence-based Practice Centers in their programs. For example, the Health Care Financing Administration has asked AHCPR to evaluate swallowing problems in the elderly. Swallowing problems, highly prevalent among the elderly, are a high cost to Medicare—about $17,000,000 for the year ending March 1996. In addition, there is a high variation among diagnosis and treatment of swallowing problems. The evidence report on attention deficit/hyperactivity disorder was nominated by the American Academy of Pediatrics and the American Psychiatric Association. Both Associations plan to collaborate on the development of a practice improvement program using the analysis produced by the Evidence-based Practice Center.
AHCPR's efforts to build the evidence base for better health care include finding innovative formats for promoting the use of evidence in practice. This innovation includes using new technology and working with partners to translate and disseminate research into practice. For example, AHCPR, and its partners, the American Association of Health Plans and the American Medical Association, have developed an Internet-based National Guideline Clearinghouse™ (NGC) which will be a one-stop-shop for clinical practice guidelines when it is released later this year.
Currently, AHCPR, RAND, Merck and Co., and Glaxo Wellcome, Inc. are collaborating in the support of a landmark study using HIV Cost and Services Utilization Study (HCSUS) that examines the use of and costs associated with multi-drug combination therapies, including protease inhibitors, for treatment of human immunodeficiency virus.

Step 3: Fund experiments that test the effectiveness of improvement approaches ($9.500 million).

Having established the aims for improvement in Step 1 modeled on those proposed by the President's Commission, we will award demonstrations and research grants to identify and promote innovative implementation of research findings and the practice of evidence-based medicine. The Agency will leverage the substantial investments being made by these organizations in care improvement and focus our funds on the evaluation component of each intervention. Each of these grants and demonstrations will begin with the chosen aim, use a multidisciplinary approach, and be required to measure and evaluate impact within 3 to 5 years.

For each of the aims selected, we will measure and report progress toward the program goals. We will develop "lessons learned" summaries that synthesize the research findings with the work of the laboratories and the private-sector diffusion efforts. We will work with public- and private-sector partners to make available research findings, evidence-based tools, quality measures, and other information sponsored through this priority. In collaboration with our partners, we will identify the most effective ways to disseminate these findings, tools, and other information not only to the sites serving as laboratories for change, but to providers, purchasers, policymakers, consumers, and patients.

Specific activities will include:

Grants for innovative applications and demonstrations that could include: (1) Studying the implementation of evidence-based information in diverse health care settings to determine effective strategies for enhancing practitioner behavior change and improving patient behavior, knowledge, and satisfaction; (2) Identifying the factors which determine the success of quality improvement strategies and to what extent these vary by the nature of the problem addressed and the target population; (3) Testing innovative approaches to teaching evidence-based practice to health professionals, including physicians, nurses and dentists; (4) Improving the quality of care during transitions between health care settings, including primary care, acute hospital care and long-term care settings, and between specialists to improve integration and to build on the Agency's 1997 initiative to study care at the interface of primary and specialty care; and (5) Promoting the use of shared decisionmaking in clinical practice and evaluate its impact on quality, costs, and satisfaction ($2.000 million).
Demonstrations to develop and test methods for transferring knowledge across organizations, because so many successful quality improvement efforts are mostly limited to single institutions, including innovations in dissemination, the use of informatics, electronic medical records, and other information technology applications ($1.000 million).
Grants and demonstrations to develop and test effective systems approaches to reducing errors in medicine, including adverse drug events. AHCPR will also work with CDC to educate health providers about the dangers of antibiotic resistance (e.g., the superbug) ($2.000 million).
Demonstrations to improve the use of quality information (both clinical and consumer generated, such as CAHPS®) by consumers in both public and private settings and evaluate impact in terms of the decisions made by consumers, the changes in consumer behaviors, and any changes in quality and costs of care as a result of this information ($1.000 million).
Demonstrations to improve the quality of care for minority populations and reduce/eliminate the disparities in care which exist, including a specific focus on diabetes mellitus. Asthma will also be emphasized through the development of a User Liaison Program on asthma disease management ($3.500 million).

Step 4: Measure the success of these strategies and promote broader implementation ($1.200 million).

While the grants and demonstrations funded under Step 2 and Step 3 will yield specific solutions and strategies to improve quality and translate research into practice, it is also important to work simultaneously with national organizations and HCFA to promote broader application. AHCPR has been successful in the past using such partnerships as a way of "wholesaling information" so that others can carry our the "retail" function. Formal partnerships will be established with health professional associations, industry groups, patient representatives, and purchasers of care to distribute findings and track changes in care patterns. Many of these groups sponsor surveys and other data collection efforts that can be modified to capture information on clinical practices.

As in Step 3, for each of the aims selected, we will measure and report progress toward the program goals and develop "lessons learned." We will work with public- and private-sector partners to make available research findings, evidence-based tools, quality measures, and other information sponsored through this priority. In collaboration with our partners, we will identify the most effective ways to get these findings, tools, and other information not only to the sites serving as laboratories for change, but we will also disseminate this material to providers, purchasers, policymakers, consumers, and patients.

Specific activities include:

Developing partnerships with appropriate health care organizations to assure that CAHPS® products are kept up-to-date and available to both public and private users, including purchasers, plans, and providers.
Undertaking cooperative agreements with national organizations to facilitate dissemination of findings to track changes in care patterns.

Return to Contents

Current as of February 1999

Internet Citation:

Research on Health Care Costs, Quality and Outcomes (HCQO). From: Justification for Budget Estimates for Appropriations Committees, Fiscal Year 2000. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/about/cj2000/hcqo00a.htm