Objective 3.3: Develop and facilitate the use of new tools, talent, products, and implementation methodologies stemming from research portfolio. Fiscal Year 2000 Priority (3), "Translating Research Into Practice," focuses on the translation and dissemination of research findings, products, and tools to foster adoption and use in health care settings.

Indicator 1: Demonstration of use of at least 3 AHRQ research findings in systematic efforts to Translate Research Into Practice (TRIP). Baseline: Under development.

Results

In Fiscal Year 2000 AHRQ funded thirteen TRIP projects to take research findings sponsored by AHRQ, and systematically implement them and measure the impact of their use. The examples of the types of projects are listed below.

• Nancy Watson (University of Rochester) - evaluation of a model of care for translating the AHRQ Urinary Incontinence (UI) Guideline into practice in nursing homes.
• Steve Ornstein (Medical University of South Carolina) - applies approach tested in prior AHRQ research of academic detailing to primary and secondary prevention of coronary heart disease & stroke in outpatient setting.
• David Bates (Brigham & Women's Hospital) - a study to improve safety by computerizing outpatient prescribing. Built on previous AHRQ-funded studies on inpatient errors. Includes studies cited in the IOM report on medical errors.
• Jeroan Allison (University of Alabama) - an Internet intervention to increase Chlamydia screening.

Indicator 2

Funding of a minimum of 5 major projects that will develop products, tools, or methodologies for implementing research findings into practice in significant segments of the health care system (i.e., potential to be generalizable across health care systems, provider-types, or clinical areas.)

Result

The Agency was extremely successful in launching its new focus on translating research into practice in Fiscal Year 2000. This initiative consisted of a three part strategy of first, expanding the capacity to conduct and translate research in actual practice settings by developing networks; second, funding new research to determine the most effective behavioral and other interventions to promote practice improvement; and third, sponsoring efforts to take existing AHRQ findings, applying them in practice, and evaluating the impact on patient quality and outcomes. The latter is described above. The first two parts are detailed below.

In Fiscal Year 2000, AHRQ awarded planning grants to 19 primary care practice-based research networks (PBRNs). A PBRN is a group of ambulatory practices devoted principally to the care of patients, affiliated with each other in order to investigate questions related to community-based practice. The networks receiving awards are required to design systems that will facilitate the translation of research into practice and to assess the impact of these systems on care delivered. The following are brief descriptions of five of the projects funded through this initiative:

• William Tierney, M.D., Regenstrief Institute for Health Care, Indianapolis, Indiana, is the director of ResNet, a network of 18 practices of general internal medicine, pediatrics, family medicine and obstetrics and gynecology. The network intends to use its highly developed medical informatics system to increase the implementation and evaluation of practice guidelines and survey instruments for assessing patient-centered outcomes.
• George Rust, M.D., M.P.H., Morehouse School of Medicine, Atlanta, Georgia, is the director of the Southeast Regional Clinicians' Network which is composed of 142 federally-funded community health centers in 8 southern states which serve about 1.5 million persons who are medically underserved. The network will concentrate on implementation strategies to improve health outcomes related to high-impact, high-disparity conditions such as asthma and hypertension.
• Richard Wasserman, M.D., M.P.H., the American Academy of Pediatrics and the University of Vermont, Burlington, Vermont, is the director of a network named PROS (Pediatric Research in Office Settings), a national network that includes 1,582 practitioners from 540 pediatric practices in 49 states. PROS will focus on an enhanced process for disseminating practice-specific feedback of study results to participating practitioners as well as dissemination of published data to groups external to the network.
• Ken Kallail, Ph.D., University of Kansas School of Medicine, Wichita, Kansas, is the director of the Kansas Rural Practice Research Network, a new network that includes 26 physicians in primary care practices that serve communities of less than 3000 population in rural Kansas. A priority of the network is the development of systems that will increase the capability of participating practices to obtain data that will improve the quality of care provided. It also proposes to serve as a testing site for implementation tools or methods yet to be tested in primary care practices in small rural communities.
• John Wasson, M.D., Dartmouth Medical School, Hanover, New Hampshire, is the director of COOP, the Dartmouth/Northern New England Primary Care Cooperative Research Network, the oldest primary care practice-based research network in the country. COOP will focus its implementation efforts on collaborative information development, using its interaction technology for information transfer among providers and between providers and patients, including minorities and those who are socio-economically disadvantaged.

In addition, AHRQ has partnered with nine Integrated Delivery System Networks (IDSRN) to link the nation's top researchers with the some of the country's largest health care systems. This new model of field-based research will enable AHRQ to accelerate the pace of its research on key concerns such as medical care quality and safety, access to services and costs. As a group, the networks provide health services to over 34 million Americans, including the privately insured, Medicare and Medicaid patients, and the uninsured. A complete list of these is available on the Agency's website at: http://www.ahrq.gov/news/press/pr2000/rapresppr.htm.

In Fiscal Year 2000, 10 projects were initiated with these systems, including the following:

• Researching the Implementation of Practice Guidelines. Developed on the basis of AHRQ-Supported Evidence Reports with Priority Populations: More research is needed to understand factors that lead to effective implementation of practice guidelines. In particular, additional research is needed on whether different populations of providers and patients require different factors for effective implementation of change. The purpose of this project is to evaluate evidence-based implementation of a clinical practice guideline based on an AHRQ-supported evidence report. The evaluation will address AHRQ's priority populations within an integrated delivery system.
• Assessing Impact of Organizational Interventions. System design can affect patient access, patient satisfaction, and efficiency of care. Yet little systematic research exists to guide clinic and practice managers. The purpose of this project is to give an integrated delivery system the opportunity to implement an organizational intervention and include an evaluation component from the outset, so that the integrated delivery system itself and other system and policy leaders can learn from the experiment in real time. Examples of the interventions to be implemented include centralizing medication management for patients requiring anticoagulant (Coumadin) therapy to improve adherence to clinical guidelines, and establishing case management programs to reduce emergency care and promote preventive care for low-income patients.

Under the Translating Research into Practice II (TRIP II) and Systems-related Best Practices to Improve Patient Safety RFAs, the Agency has funded 10 projects which will develop products, tools, or methodologies for implementing research findings. Below are a sampling of these projects which test computer based tools to decrease medical errors and increase the delivery of appropriate care in outpatient settings (Bates), study the determinants of errors in primary care and neonatal intensive care units, improve asthma care to low income children, and increase chlamydiae screening with an internet-based intervention:

• Improving Quality with Outpatient Decision Support. The project will develop paper-based and electronic guideline reminders and alerts for an outpatient setting. Participants will be physicians of the Beth Israel and Massachusetts General Hospitals and their outpatient clinics. The reminders and alerts will target health maintenance (e.g. cholesterol, mammograms, Pap tests and influenza vaccines), disease management (e.g., diabetes), medication management (e.g., statin drugs, H2 blockers, NSAIDS, MI and beta blockers, MI and aspirin),and ancillary test ordering. The investigators will evaluate the impact of these alerts, reminders, and guidelines on physician compliance with evidence based recommendations. The impact of electronic result tracking and follow-up systems on physician compliance with guidelines also will be evaluated. Patient, physician, and system barriers to compliance will be assessed in an array of clinical settings.
• Improving Pain Management in Nursing Homes. Jones, Katherine R., Ph.D., University of Colorado Health Sciences Center. This 3 year study proposes to develop and implement a culturally-competent intervention to improve the quality of pain management in 12 nursing homes. Specific aims are to 1) develop and implement a multi-modal, culturally-competent, evidence-based educational and behavioral intervention to improve pain assessment and pain management in nursing homes; 2) improve pain assessment procedures and pain management strategies being used in nursing homes; 3) improve resident, family, and staff knowledge and attitudes toward pain assessment and pain management; 4) evaluate the influence of organizational variables on achieving desired clinical and educational outcomes; and 5) assess the cost-effectiveness of the multi-modal intervention for disseminating pain assessment and pain management knowledge to nursing homes.
• Developing an Asthma Management Model for Head Start. Perla A. Vargas, Ph.D., Arkansas Children's Hospital. This randomized design project purposes to develop an evidence-based asthma case management model for low-income minority children enrolled in 29 Head Start Programs in cooperation with Pulaski County Head Start and the Arkansas Foundation for Medical Care. The outcomes of interest include asthma-related school absences, asthma symptoms, asthma management (drug use, office visits, self-management), quality of life, emergency department visits, hospital use, and program costs.

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Indicator 3

At least 2 new tools, products, or methodologies become available from projects funded between Fiscal Year 1993 and Fiscal Year 1996. (Baseline: 16 projects identified in Fiscal Year 1999.)

Results

The following are twenty-three examples of the many tools, products and methodologies that have resulted from projects funded by AHRQ between Fiscal Year 1993 and Fiscal Year 1996.

• Medicare Survey Instrument. Working with HCFA, AHRQ's Consumer Assessment of Health Plans team and their associated grantees developed a new survey instrument for evaluating the care for Medicare beneficiaries enrolled in fee for service plans. This survey was fielded for the first time in Fiscal Year 2000 and, for the first time, provides the ability to compare the quality of care between Medicare + choice programs and traditional Medicare fee-for-service plans from the consumer perspective.
• Nursing Home Data Book. The Nursing Home Compare Web site (http://www.medicare.gov/nhcompare/home.asp) permits comparison of quality indicators among nursing homes nationally. This data system was developed by Charlene Harrington at the University of California, San Francisco, with support from AHRQ. Quality indicators were developed using data from HCFA surveys and input from groups of stakeholders.
• EDECS Web Site. The Emergency Department Expert Charting System (EDECS), is a set of clinical guidelines embedded in an electronic charting system. It was designed to improve care of pediatric fever, low back pain, recurrent seizure, discharge/dysuria in males, and occupational exposure to blood and body fluids. Using a quasi-experimental design, the system was tested and found to improve appropriateness of diagnostic testing and treatment decisions, although effects varied by treatment module. The most striking success was with the module on occupational exposure. The CDC has supported establishment of a Web site (to be added) so that the system is available for use by any provider. Initially funded earlier, the project was still receiving funds in Fiscal Year 1993.
• Stroke Policy Model on CD-ROM. The Stroke Prevention PORT and AHRQ distributed a CD-ROM in Fiscal Year 2000 that provided complete documentation specifications for the Stroke Policy Model. The Stroke Policy Model is a clinical policy decision simulation tool for studying the costs and outcomes of the natural history of stroke, as well as the costs and outcomes associated with various preventive or therapeutic intervention strategies. The documentation, including programming codes, algorithms, and all input data used in the model is designed to help facilitate and encourage the use of this model in other related studies of stroke interventions by other researchers and clinical policy makers. In addition, this new tool can be used to help determine the return on investment from quality improvement programs focused on stroke prevention and treatment.
• Health Outcomes Research Methodology. The Center for Outcomes and Effectiveness Research organized a health outcomes methodology symposium in Fiscal Year 1999 and published all the symposium manuscripts and proceedings in the September 2000 supplement to the journal Medical Care. Health outcomes research in the past two decades has brought into focus the essential role of patients' perspectives in assessing effectiveness of health services. While the research field has benefited from the proliferation of patient-centered outcomes measures, most of which have not been evaluated extensively. Many methodological issues pertaining to measurement validity and interpretation also have yet to be adequately addressed. The symposium proceedings and manuscripts in the special issue of the Medical Care supplement reflect the collective and collaborative effort by the leading health outcomes researchers and the Agency in addressing those methodological challenges. It represents an important contribution to the outcomes research methodology field in guiding and motivating further deliberating, progress, and fulfillment in health outcomes assessment.
• Child Health Toolbox: Measuring Performance in Child Health Programs. AHRQ created an online learning program to help State and local policymakers and program directors and staff to answer questions about measuring health care performance in child health programs. The program provides a guide to using performance measurement in child health programs, and provides detailed information on a number of measures in general use.
• Artificial Neural Networks Statistical Modeling. Web-based tool that allows prediction of the five year survival rate for breast and colorectal cancer using artificial network modeling (a class of statistical methods).
• Six (6) State Ambulatory Surgery Databases (SASD) from HCUP. Six of the nine State Ambulatory Surgery Databases (SASD) from HCUP were made publicly available for the first time in Fiscal Year 2000. All six are available from a single point of access, the Central Distributor, under the auspices of AHRQ.
• Three (3) Statewide Inpatient Databases (SID) from HCUP. Three additional states of the 22 Statewide Inpatient Databases (SID) from HCUP are now available from a single point of access, the CentralDistributorr, under the auspices of AHRQ. These additional states increase the total number of states available through the CentralDistributorr to 14.
• Two (2) Clinical Classification Software (CCS). Two classification systems (single-level and multi-level) of the Clinical Classification Software (CCS) were updated in Fiscal Year 2000. The single-level CCS classifies all diagnoses and procedures into unique groups, and aggregates illnesses and conditions into 259 mutually exclusive categories. The multi-level CCS expands the single-level CCS into a hierarchical system, and groups single-level CCS categories into broader body systems or condition categories (e.g., "Diseases of the Circulatory System").
• Child Health Status Measure, Riley, Anne, Johns Hopkins University. The overall purpose of this project was to develop a health status instrument that can be used to measure comprehensively the health and illness profile of children aged 6-11. This instrument will have the potential of detecting aspects of child health that are responsive to health services or social interventions. It will be useful for describing the health of children in communities, for monitoring the impact of health plans serving defined populations of children, for evaluating the effect of interventions on children's health, and for relating differences in access and services to the health status of children from various sociodemographic groups.
• Adolescent Health Services Measure, Klein, Jonathan, University of Rochester. This project tested the validity and reliability of survey instruments to evaluate preventive services and the accessibility, comprehensiveness, and coordination of care delivered to adolescents by primary care providers.
• Clinical Performance Measures for Dental Care Plans. Development of standardized measures to assess clinical aspects of the performance of managed dental care plans:
  • Seven effectiveness of care measures assessing disease activity classification, preventive treatment, and outcomes for caries, periodontal disease, and tooth loss were developed.
  • Six use of services measures focusing on prophylaxes, third molar surgery, preventive, restorative, prosthetic, surgical and endodontic care were specified.
  • Five access to services measures addressing visit and examination rates, appointment waiting time, and provider availability and turnover were also specified.
• Database for Pediatric Studies (DPS) from HCUP. To address the need to provide a larger sample of pediatric conditions to facilitate study of specific conditions and procedures, a new data set was drawn from the SD, comprised of only children's hospitalizations. The DPS includes all pediatric discharges form all community hospitals from the 22 frame states, comprising 2581 hospitals and 3.7 million discharge records.
• The Children with Special Health Care Need (CSN). A component of the CAHPS® family of instruments, CSN includes:
  • The Core CAHPS® 2.0 Child Survey.
  • The CSN screening tool to identify children with chronic or special health care needs.
  • The CSN question supplement.
  • A CSN screener to identify children whose caretakers should complete the survey.
  • Guidelines for scoring and presenting the CSN measures.

  In the development of these tools, the CAHPS® team (funded by AHRQ) has collaborated with the National Committee for Quality Assurance (NCQA), and the Foundation for Accountability (funded by the Packard foundation). Like all CAHPS® tools, the purpose of the CSN instrument is to obtain valid and reliable information from consumers to assist them in selecting a high quality health plan that meets their needs. The Committee for Performance Measurement of the NCQA is considering accepting the CAHPS® CSN survey as part of HEDIS.

Indicator 4

Support a five percent increase, at a minimum, in number of pre- and post-doctoral trainees. (Baseline: 167 trainees funded in Fiscal Year 1999.)

Results

In Fiscal Year 2000, AHRQ increased by 40% the number of pre- and postdoctoral trainees and fellows it supported. Support was provided for 218 scholars through a variety of programs, including institutional and individual National Research Service Awards (NRSA) and dissertation grants. In addition, AHRQ launched two new career development programs: the Independent Scientist Award (K02) and the Mentored Clinical Scientist Development (K08) programs. These latter two programs supported an additional 16 scholars.

GPRA Goal 3 - Fiscal Year 2001 and 2002 Indicators

Objective	Fiscal Year 2001 Indicator	Fiscal Year 2002 Indicator
Objective 3.1: Maximize dissemination of information, tools, and products developed from research results for use in practice.	Partnerships At least 5 public-private partnerships are formed to implement research findings for decisionmakers. Budget: Commitment Base Formation of a minimum of 10 partnerships to support dissemination of AHRQ products through intermediary organizations, such as health plans and professional organizations. Budget: Commitment Base Web site: Number of hits on the Web site Number of inquiries handled on web site Number of Uploaded documents. Budget: Commitment Base User Liaison Program Number of State and local governments trained in the understanding and use of health services research findings through ULP Workshops. Budget: Commitment Base	Number of state and local governments trained and/or receiving technical assistance through ULP. Budget: Commitment Base At least 20 partnerships to disseminate and implement research findings are formed with public and private-sector organizations. Budget: Commitment Base Synthesis of at least 5 grant portfolio areas on quality of care across Agency's goals for persons with chronic care needs produced and disseminated with particular focus on outreach to managed care executives. Budget: Commitment Base Initiate development of a web-based toolbox to disseminate instruments used in translating research into practice; partner with at least five professional organizations, PROs, payers or advocacy groups to implement findings. Budget: Commitment Base
Objective 3.2: In Fiscal Year 2001 Develop and facilitate the use of new tools, talent, products, and implementation methodologies stemming from research portfolio.	Produce evidence summaries for use in Federal direct care providers' efforts to create guidelines. Budget: Commitment Base Evidence-based practice centers (EPCs) will produce a minimum of 12 evidence reports and technology assessments that can serve as the basis for interventions to enhance health outcomes and quality by improving practice. Budget: Commitment Base Support a minimum of 165 pre- and post-doctoral trainees. Budget: Commitment Base Support up to 3 Minority Research Infrastructure Support Program IM-RISP) grants in order to develop the health services research capabilities of traditionally minority-serving institutions. Support up to 6 Building Research Infrastructure and Capacity (BRIC) two-year planning grants in EPSCOR states and states which historically have received little or no research support from AHRQ. Fund at least 10 projects in tool development. For details, select Budget: Research and Training Grants, Quality Report, and Commitment Base.	Produce evidence summaries for use in Federal direct care providers' efforts to create guidelines. Budget: Commitment Base Evidence-based practice centers (EPCs) will produce a minimum of 12 evidence reports and technology assessments that can serve as the basis for interventions to enhance health outcomes and quality by improving practice. Budget: Commitment Base Build on and expand current efforts geared toward fostering and encouraging interest in health services research careers and outreach through the following. Enhanced infrastructure development and capacity building: Support a minimum of 165 pre- and post-doctoral trainees. Support up to 3 Minority Research Infrastructure Support Program IM-RISP) grants in order to develop the health services research capabilities of traditionally minority-serving institutions. Support up to 6 Building Research Infrastructure and Capacity (BRIC) two-year planning grants in EPSCOR states and states which historically have received little or no research support from AHRQ. Fund at least 10 projects in tool development. Supporting up to 10 new individual predoctoral awards to underrepresented minority students. Fund at least 15 projects in tool and data development. Budget page: Commitment Base

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