1. AHRQ Update Francis D. Chesley, Jr., M.D. Director, Office of Extramural Research, Education, and Priority Populations June 6, 2004

2. Overview “News You Can Use” “News You Can Use” What’s New at AHRQ What’s New at AHRQ TRIPP Now! TRIPP Now! Qs and As Qs and As

3. FY 2004 Budget FY 2004 Budget = $304,000,000 FY 2004 Budget = $304,000,000 – Translating Research into Practice and Policy – Prevention Research – Health Information Technology – Quality and Patient Safety – Bioterrorism Preparedness

4. FY 1995 - FY 2005 Appropriation History Dollar in Millions February 26, 2003 J:/fms/FY2000-2004apphist.ppt

5. FY 2004 Patient Safety FY 2004 Patient Safety = $79.5 Million FY 2004 Patient Safety = $79.5 Million – $50 M Patient Safety Health Care Information Technology (IT) Initiative (Grants and Contracts) $26 M for small and rural hospitals $26 M for small and rural hospitals Facilitate uptake of IT technologies Facilitate uptake of IT technologies – $10 M promoting and accelerating the development, adoption, and diffusion of IT in health care (All Contracts) – $2 M Patient Safety Improvement Corps (IAA) – $17.5 M Patient Safety Commitments Contracts)

6. FY04 HIT Investment $62 million initiative: $62 million initiative: – $26 million: earmarked for implementing proven technologies in small and rural communities (where HIT penetration has been low) – $24 million: targeted for developing, implementing, and evaluating the use of new and innovative technologies to improve patient safety and quality of care in diverse health care settings. – $12M: targeted for clinical data standards and interoperability

7. FY 2004 Non-Patient Safety Grants: Grants: – $5 million in new funds to renew existing grant programs including small, conference, dissertation, career, M-RISP, and BRIC awards Contracts: Contracts: – Overall decrease of $4 million. A total of $5 million is provided to support data collection and dissemination efforts – based on the reviews by OMB HCUP - $2 million HCUP - $2 million CAHPS - $1 million CAHPS - $1 million MEPS - $2 million MEPS - $2 million

8. FY 2005 Request FY 2005 Request = $303,695,000 FY 2005 Request = $303,695,000 – Maintains the FY 2004 Enacted Level – Although there is no increase in funds, a number of grants and contracts end in FY 2004 allowing us to reinvest these funds in new grants and contracts in FY 2005

9. FY 2005 Patient Safety FY 2005 Patient Safety = $84 Million FY 2005 Patient Safety = $84 Million – An increase of $4.5 M over FY 2004 – Continues funding of the $50 M Patient Safety Health Care Information Technology (IT) Program $7 M in planning grants end in FY 2004. Re- invest these funds in new implementation grants in FY 2005 $7 M in planning grants end in FY 2004. Re- invest these funds in new implementation grants in FY 2005

10. FY 2005 Non-Patient Safety GRANTS: Renewal of Existing AHRQ Programs (+$14.039 Million) GRANTS: Renewal of Existing AHRQ Programs (+$14.039 Million) – Small, Conference and Dissertation Grants – Career Development Awards – BRIC and M-RISP – HIT Implementation – CERTs – PBRNs

11. FY 2005 Non-Patient Safety New Program (+$6.3 Million) New Program (+$6.3 Million) – Research Empowering America’s Changing Healthcare System (REACHES) will focus on adoption and assessment, and will fund demonstration projects for translating existing research into clinical practice and managing a changing environment in health care organizations (includes contract component)

12. FY 2005 MEPS FY 2005 MEPS - $55.3 million FY 2005 MEPS - $55.3 million – Maintains the FY 2004 enacted level

13. Ongoing Opportunities Renewed Program Announcements Renewed Program Announcements – Translating Research Into Practice and Policy – Impact of Payment and Organization on Cost, Quality, and Equity – Patient-Centered Care BT Program Announcement BT Program Announcement

14. Training Opportunities Pre and Postdoctoral Training Pre and Postdoctoral Training – National Research Service Awards (NRSA) Institutional Training Programs (T32) Institutional Training Programs (T32) Individual Predoctoral Fellowships (F31) and Individual Predoctoral Fellowships (F31) and Individual Postdoctoral Fellowships (F32) Individual Postdoctoral Fellowships (F32) – Dissertation Grants (R36) Career Development Awards Career Development Awards – Mentored Clinical Scientist Awards (K08) – Independent Scientist Awards (K02) Research Infrastructure Support Programs Research Infrastructure Support Programs – Minority Research Infrastructure Support Program – Building Research Infrastructure and Capacity

15. Training: What Success Looks Like Graduation Publication Visibility & Dissemination Change Practices Save Lives and Dollars

16. Overview “News you can use” “News you can use” What’s New at AHRQ What’s New at AHRQ TRIPP Now! TRIPP Now! Qs and As Qs and As

17. Healthcare Research and Quality Act (PL. 106-129) “Beginning in fiscal year 2003, the Secretary, acting through the Director, AHRQ shall submit to Congress “Beginning in fiscal year 2003, the Secretary, acting through the Director, AHRQ shall submit to Congress – an annual report on national trends in the quality of health care provided to the American people – An annual report on “prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations.”

18. HHS Reports: Quality and Disparities in Health Care First national comprehensive efforts to measure the quality of health care in America and disparities in access to health care services for priority populations First national comprehensive efforts to measure the quality of health care in America and disparities in access to health care services for priority populations Presents data for clinical conditions, (cancer, diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory disease) Presents data for clinical conditions, (cancer, diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory disease) Includes data on maternal and child health, nursing home and home health care, and patient safety Includes data on maternal and child health, nursing home and home health care, and patient safety

19. How Reports Are Related Disparities in health care presented as quality provided to different populations Disparities in health care presented as quality provided to different populations Improving quality can result in concurrent decreases in disparities associated with race and gender (e.g., ESRD) Improving quality can result in concurrent decreases in disparities associated with race and gender (e.g., ESRD) NHDR focuses on NHDR focuses on – Equity dimension of quality – Access-related barriers to quality care

20. NHQR: Missed Opportunities Only 30% of patients with diabetes receive all recommended tests Only 30% of patients with diabetes receive all recommended tests 90% of adults are screened for high blood pressure – but only 25% are controlled 90% of adults are screened for high blood pressure – but only 25% are controlled Nearly 1/3 of adults and children with asthma do NOT receive effective treatment Nearly 1/3 of adults and children with asthma do NOT receive effective treatment Almost 20% of persons with a usual source of care report that they are not asked about medications to prevent interactions Almost 20% of persons with a usual source of care report that they are not asked about medications to prevent interactions

21. NHQR-DR Summary (1) 37 of 57 areas with trend data presented in the NHQR show no improvement or have deteriorated 37 of 57 areas with trend data presented in the NHQR show no improvement or have deteriorated Fewer than one in five people with hypertension have it under control Fewer than one in five people with hypertension have it under control About one in five elderly Americans prescribed inappropriate/potentially harmful medications About one in five elderly Americans prescribed inappropriate/potentially harmful medications High quality health care is not a given in the U.S. health care system. Patient Safety: Inappropriate drug prescription for community-dwelling elderly Americans 0 2 4 6 8 10 12 14 16 19961998 11 drugs that should always be avoided 8 drugs that are rarely appropriate 14 drugs that have some indications but are often misused Percent of the elderly

22. NHQR-DR Summary (2) Blacks and Hispanics — score lower than whites on about half of quality measures Blacks and Hispanics — score lower than whites on about half of quality measures Hispanics and Asians — score lower than whites on about two-thirds of access measures Hispanics and Asians — score lower than whites on about two-thirds of access measures Poor people — score lower on about two-thirds of quality and access measures Poor people — score lower on about two-thirds of quality and access measures Gaps in health care quality are particularly acute for certain racial, ethnic, and socioeconomic groups.

23. NHQR-DR Summary (3) Only 40% of people get smoking cessation counseling in the hospital. Only 60% get counseling during office visits Only 40% of people get smoking cessation counseling in the hospital. Only 60% get counseling during office visits Black, Hispanic, poor adults— less likely to receive colorectal and breast cancer screening, influenza immunization Black, Hispanic, poor adults— less likely to receive colorectal and breast cancer screening, influenza immunization Black, Hispanic,American Indian women—less likely to receive prenatal care Black, Hispanic,American Indian women—less likely to receive prenatal care Black, Hispanic, poor children— less likely to receive dental care Black, Hispanic, poor children— less likely to receive dental care Black, Hispanic, poor elderly— less likely to receive pneumococcal vaccination Black, Hispanic, poor elderly— less likely to receive pneumococcal vaccination Quality and disparity gaps are worse in preventive services.

24. NHQR-DR Summary (4) Use of beta-blockers for heart attack patients rose from 21% of eligible patients in the early 1990s to 79%. 45 States are at or above 70% on this measure. Use of beta-blockers for heart attack patients rose from 21% of eligible patients in the early 1990s to 79%. 45 States are at or above 70% on this measure. 70% of women over 40 get mammograms for breast cancer. This exceeds Healthy People 2010 objective. 70% of women over 40 get mammograms for breast cancer. This exceeds Healthy People 2010 objective. Black women have higher screening rates for cervical cancer. Death rates among black women are falling at twice the rate as white women. Black women have higher screening rates for cervical cancer. Death rates among black women are falling at twice the rate as white women. Quality improvement efforts have resulted in reductions in black-white differences in hemodialysis. Quality improvement efforts have resulted in reductions in black-white differences in hemodialysis. Percent of AMI patients prescribed a beta blocker at discharge by State Significantly below national avg. No different from national avg. Significantly above national avg. Improvement in quality and disparities is possible.

25. Take Home Points The reports provide the most comprehensive picture of healthcare quality and disparities to date The reports provide the most comprehensive picture of healthcare quality and disparities to date Their value lies in the actions and improvements that they will stimulate Their value lies in the actions and improvements that they will stimulate They identify a core set of measures on which assessments of quality and access can be based They identify a core set of measures on which assessments of quality and access can be based They will monitor progress towards improvements in quality and access They will monitor progress towards improvements in quality and access

26. Priority Areas for Implementation Diabetes: IOM priority area; measures in both reports Diabetes: IOM priority area; measures in both reports Respiratory Disease: IOM priority area (Asthma; smoking); measures in both reports – priority population (children) Respiratory Disease: IOM priority area (Asthma; smoking); measures in both reports – priority population (children) Both areas are national priorities and also particularly important for priority populations Both areas are national priorities and also particularly important for priority populations

27. DHHS Disparities Council The Secretary has convened a DHHS Disparities Council to coordinate disparities research across the Department The Secretary has convened a DHHS Disparities Council to coordinate disparities research across the Department AHRQ is leading a Council workgroup: AHRQ is leading a Council workgroup: – To develop strategies to address disparities – To make recommendations for using the NHDR and NHQR to address disparities

29. Recent Conference on MEPS Informing Health Policy MEPS: Informing Policy on Health Insurance Coverage and Health Care Costs: May 13, 2004 – Capitol Hill, D.C. Highlighted recent research efforts from the survey focused on healthcare costs and coverage that help inform consumer and purchaser decisions. Highlighted recent research efforts from the survey focused on healthcare costs and coverage that help inform consumer and purchaser decisions. Facilitated discussion of utility of MEPS to inform policy and decisions by consumers and purchasers Facilitated discussion of utility of MEPS to inform policy and decisions by consumers and purchasers

30. Types of Analyses Supported by MEPS Prescribed Medicine Data Trends in out of pocket burdens across all major population subgroups Trends in out of pocket burdens across all major population subgroups Examine burden on individuals and families Examine burden on individuals and families Prevalence of potentially inappropriate prescribing patterns Prevalence of potentially inappropriate prescribing patterns Trends in use and expenditures by therapeutic category: e.g. statins, anti- depressants, analgesics, proton pump inhibitors Trends in use and expenditures by therapeutic category: e.g. statins, anti- depressants, analgesics, proton pump inhibitors

31. New Workshops September 20-21 - Hands-on Workshop in Rockville- Using the MEPS Prescribed Drug and Condition Files September 20-21 - Hands-on Workshop in Rockville- Using the MEPS Prescribed Drug and Condition Files November 30-Dec 1 - Hands-on Workshop in Rockville – MEPS Linking Issues November 30-Dec 1 - Hands-on Workshop in Rockville – MEPS Linking Issues Cyber Seminars- 2005 Cyber Seminars- 2005 http://www.meps.ahrq.gov http://www.meps.ahrq.gov http://www.meps.ahrq.gov

32. HCUP to the Rescue! HCU P

33. 3 New States Join HCUP Partnership Recent Additions 1. Ohio – greatly improves Midwest representation 2. Nevada 3. South Dakota HCUP Now Includes: – 36 State Partners – 90% of all U.S. hospital stays – over 31 million discharges

34. New HCUPnet Helps Both Researchers and Policy Analysts Includes cost data beginning 2000 Includes cost data beginning 2000 Has separate paths for researchers and policymakers/non-researchers Has separate paths for researchers and policymakers/non-researchers Is easier to print Is easier to print To access the new HCUPnet or information about the HCUP databases, go to: http://www.hcup-us.ahrq.gov/home.jsp

36. MMA Section 1013

37. What is Section 1013? To improve the quality, effectiveness and efficiency of health care delivered through Medicare, Medicaid and the S-CHIP programs To improve the quality, effectiveness and efficiency of health care delivered through Medicare, Medicaid and the S-CHIP programs $50 million is authorized in Fiscal Year 2004 for AHRQ to conduct and support research with a focus on outcomes, comparative clinical effectiveness and appropriateness of health care items and services (including pharmaceutical drugs), including strategies for how these items and services are organized, managed and delivered $50 million is authorized in Fiscal Year 2004 for AHRQ to conduct and support research with a focus on outcomes, comparative clinical effectiveness and appropriateness of health care items and services (including pharmaceutical drugs), including strategies for how these items and services are organized, managed and delivered

38. What is Section 1013? By June 2004, the Secretary shall establish an initial list of research priorities (including those related to prescription drugs) By June 2004, the Secretary shall establish an initial list of research priorities (including those related to prescription drugs) Priorities may include health care items and services which impose a high cost on Medicare, Medicaid or S-CHIP, including those that may be underutilized or over utilized Priorities may include health care items and services which impose a high cost on Medicare, Medicaid or S-CHIP, including those that may be underutilized or over utilized

39. What is Section 1013? By June 2005, the Secretary shall identify options to disseminate in a timely fashion outcomes, quality of patient care, clinical data and patient-reported outcomes, which could include voluntary collaboration with private and public entities By June 2005, the Secretary shall identify options to disseminate in a timely fashion outcomes, quality of patient care, clinical data and patient-reported outcomes, which could include voluntary collaboration with private and public entities No later than December 2005, AHRQ shall complete its evaluation and synthesis of available scientific evidence related to the initial list developed by the Secretary, which shall be made available to the Medicare program, other health plans, and the public No later than December 2005, AHRQ shall complete its evaluation and synthesis of available scientific evidence related to the initial list developed by the Secretary, which shall be made available to the Medicare program, other health plans, and the public

40. What is Not in Section 1013? AHRQ shall not mandate national standards of clinical practice or quality health care standards AHRQ shall not mandate national standards of clinical practice or quality health care standards CMS may not use data obtained through this provision to withhold coverage of a prescription drug CMS may not use data obtained through this provision to withhold coverage of a prescription drug No mandate to perform cost- effectiveness studies No mandate to perform cost- effectiveness studies No appropriation in FY 04 No appropriation in FY 04

41. Implementation of Section 1013

42. Overview “News you can use” “News you can use” What’s New at AHRQ What’s New at AHRQ TRIPP Now! TRIPP Now! Qs and As Qs and As

43. New AHRQ Mission Statement To improve the quality, safety, efficiency, and effectiveness of health care for all Americans

44. Implications of ‘New’ Mission Implications of ‘New’ Mission Emphasis on production and use of evidence Emphasis on production and use of evidence Increased emphasis on ‘value-added’ approach to grant making Increased emphasis on ‘value-added’ approach to grant making Increased synergy between intramural and extramural research: within portfolios Increased synergy between intramural and extramural research: within portfolios Enhanced emphasis on problem-solving  user input into the relevance question Enhanced emphasis on problem-solving  user input into the relevance question

45. Safety/QualityEfficiencyEffectiveness System Capacity and Emergency Preparedness Data Development Care Management Cost, Organization and Scoio- Economics Health Information Technology Long-Term Care Pharmaceutical Outcomes Prevention Training Quality/Safety of Patient Care Portfolios of Work

46. AHRQ – As a Science Partner Fund and conduct research on issues important to decisionmakers Fund and conduct research on issues important to decisionmakers – Clinical – Health System – Policy Close the gap between evidence and practice Close the gap between evidence and practice Nurture the next generation of health services researchers Nurture the next generation of health services researchers

47. AHRQ Core Activities Research: Discovering New Knowledge Implementation: Turning Evidence into Action Improvements in Quality & Outcomes

48. Supply-Side Research Paradigm Research world: Questions Hypothesis Study Publication User world: Many needs Beliefs & interests Decision processes The winding road to a receptor site

49. Research world: Questions Hypothesis Study User world: Many needs Beliefs & interests Decision processes Demand/Supply Side Model

50. What We Have Learned Knowing the right thing to do is NOT = doing it! Knowing the right thing to do is NOT = doing it! Improvement must be based on science Improvement must be based on science Patients as participants are far more effective than patients as ‘recipients’ Patients as participants are far more effective than patients as ‘recipients’ Researchers may not be the best implementers Researchers may not be the best implementers Folks at all levels are engaged Folks at all levels are engaged

51. Translational Challenges Are researchers change agents? Are researchers change agents? What is the appropriate skill set? What is the appropriate skill set? In the research world are there incentives for TRIPP (tenure, promotion, career track)? In the research world are there incentives for TRIPP (tenure, promotion, career track)? How do we train translational researchers? How do we train translational researchers? What are the incentives for TRIPP? What are the incentives for TRIPP?

53. Ten Roles of Government in Health Care Quality Purchase health care Purchase health care Provide health care Provide health care Assure access for vulnerable populations Assure access for vulnerable populations Monitor health care quality Monitor health care quality Regulate health care markets Regulate health care markets Inform health care decision- makers Inform health care decision- makers Support acquisition of new knowledge Support acquisition of new knowledge Support development of health technologies and practices Support development of health technologies and practices Train the health care researchers Train the health care researchers Convene stakeholders Convene stakeholders

54. Getting a Grant: Before Develop and refine question and develops testable hypotheses. Develop and refine question and develops testable hypotheses. Submit grant. Submit grant. Receive grant! -  do immense amounts of work; publish; get promoted. Receive grant! -  do immense amounts of work; publish; get promoted. Start all over again. Start all over again. Receptor sites for findings assumed Receptor sites for findings assumed Contact with program staff optional Contact with program staff optional

55. Getting a Grant: Future Develop idea – consult with users Develop idea – consult with users Before submission, identify who will use findings and how Before submission, identify who will use findings and how Include in application clear plan for ongoing consultation with users Include in application clear plan for ongoing consultation with users Include users in peer review Include users in peer review Share key findings* with users before publication Share key findings* with users before publication Consultation with program staff essential Consultation with program staff essential

56. Research Implementation: Debunked Assumption Question Hypothesis Study Publications Changes in practice

57. “Opportunity is missed by most because it is dressed in overalls and looks like work.” “Opportunity is missed by most because it is dressed in overalls and looks like work.” Thomas Edison

58. QUESTIONS??