Online Performance Appendix: Performance Detail, Crosscutting Activities Related to Quality, Effectiveness, and Efficiency Research (continued)

Budget Estimates for Appropriations Committees, Fiscal Year 2011

This appendix provides more detailed performance information for all HHS measures related to the Agency for Healthcare Research and Quality's budget.

Research Contracts and IAAs

Examples of types of research contracts and IAAs AHRQ has supported related to Crosscutting Activities includes the following:

Data Contracts: Data activities coordinate AHRQ data collection and analysis activities across the Agency. Projects include HCUP, the HIV Research Network, and a variety of small data collection and processing contracts.

  • HCUP. Efforts to improve the quality, safety, effectiveness, and efficiency of health care and reduce disparities in the United States require detailed knowledge about how the health care delivery system works now and how different organizational and financial arrangements affect this performance. Improving health care requires easy access to detailed information and data on costs, access to health care, quality, and outcomes that can be used for research and policymaking at the national, State, and local levels. It also requires tools to measure and track progress in these areas. The Healthcare Cost and Utilization Project (HCUP) provides the necessary data through a long-standing partnership with State data organizations, hospital associations, and private data organizations. HCUP is a family of health care databases and related software tools and products that support the mission of AHRQ. HCUP includes the largest collection of all-payer, encounter-level data in the United States, beginning in 1988. It includes detailed information on 90 percent of all inpatient stays in the country—including information about the diagnosis, the procedures, the cost, and who paid for the care, as well as encrypted non-identifiable demographic information. For over 27 States, it also includes ambulatory surgery and emergency department data. Support for the HCUP contract totals $4.1 million in FY 2010 and $5.8 million in FY 2011.

Expand and Improve Data and Tools

The HCUP databases have been a powerful resource for the development of tools that can be applied to other similar databases by health services researchers and decisionmakers. The expanded data and tools can then be translated to inform decisionmaking and improve health care delivery. A major achievement in 2009 was the creation and release of the largest all-payer emergency department database in the United States. The first Nationwide Emergency Department Sample (NEDS) database was created to enable national analyses of emergency department (ED) utilization patterns and support public health professionals, administrators, policymakers, and clinicians in their decisionmaking regarding this critical source of care. The NEDS contains clinical and non-clinical information on patients, regardless of payer—including those covered by Medicare, Medicaid, private insurance, and the uninsured. The ED serves a dual role in the U.S. health care system infrastructure as a point of entry for approximately 50 percent of inpatient hospital admissions and as a setting for treat-and-release outpatient visits. The second NEDS will be available to the public by March 2010, and annually thereafter. Additionally, HCUP will produce two other nationwide databases, the Nationwide Inpatient Sample (NIS) and the Kids' Inpatient Database (KID) along with over 100 state-level databases in 2011. HCUP tools and software will also be created and updated in 2011 to help health services researchers and decision makers to use HCUP and other similar databases. For example, HCUPnet, a free, on-line query system is based on data from HCUP and provides quick and easy access to health statistics and information on hospital inpatient and emergency department utilization.

In FY 2009, AHRQ also met our performance target (see performance table #1.3.15) to increase the number of partners contributing outpatient data to the HCUP databases. AHRQ added data from Wyoming for a total of 40 statewide data organizations participating in HCUP. The number of State Ambulatory Surgery Databases increased by one partner (Hawaii) and the number of State Emergency Department Databases increased by one partner (North Carolina). They were selected based on the diversity—in terms of geographic representation and population ethnicity—they bring to the project, along with data quality performance and their ability to facilitate timely processing of data. This outcome met the goal by adding three new Partner databases. HCUP has matured to the point of having incorporated most of the available and viable data collections that met the long established goal criteria for the project. Because HCUP teams with organizations that already collect data for various purposes, the project is, of course, limited by the number of U.S. States with established inpatient and outpatient data collections. We set the FY 2011 goal to increase the number of partners providing data by 2.

HCUP provides critical information on the U.S. health care system such as:

  • Inflation-adjusted aggregate costs for hospital stays rose from $222.4 billion in 1997 to $343.9 billion in 2007—an increase of 55 percent.
  • The most important driver of cost increases was greater intensity of services provided during the hospital stay. Costs per discharge increased by 3.1 percent annually.
  • The fastest increase in costs was for infectious and parasitic diseases, more than doubling between 1997 ($6.6 billion) and 2007 ($15.3 billion). Septicemia (blood infection) was responsible for almost all (94 percent) of the increase in costs of infectious and parasitic conditions as it tripled in costs from $4.1 billion in 1997 to $12.3 billion in 2007.
  • Between 1997 and 2007, the number of uninsured discharges grew by 38 percent and the number Medicaid discharges grew by 36 percent—more than double the rate of growth of all discharges (14 percent). The number of Medicare discharges grew by 14 percent while stays billed to private insurance grew by just 2 percent.
  • In 2007, costs for Medicare stays amounted to $156.0 billion and Medicaid stays accounted for $50.4 billion—accounting for about 60 percent of total hospital costs. Discharges billed to private insurance accounted for 31 percent ($107.8 billion), while the uninsured accounted for a much smaller share (5 percent, or $16.5 billion).
  • C-section was the most frequent major operating room procedure—performed on 1.5 million women in 2007. Growth in C-sections, up 85 percent between 1997 and 2007, outpaced increases in most other frequently performed maternal procedures and was among the fastest growing procedures for women 18-44 years old.
  • Diagnostic cardiac catheterization was performed on 890,000 males and 581,000 females in 2007 and ranked as the 2nd most frequent procedure in men and the 4th most frequent procedure in women.
  • Blood transfusions occurred in one out of every 10 hospital stays that included a procedure. There were 1.1 million stays with this procedure in 1997 and 2.6 million in 2007, for a cumulative growth of 140 percent.
  • From 1997 to 2007:
    • Respiratory intubation rose steadily, increasing 48 percent.
    • Knee replacement increased by 86 percent.
    • Hemodialysis procedures for renal failure grew by 66 percent.
    • The use of tube feeding during infant hospitalizations increased 219 percent, compared with a 16-percent growth in all infant discharges.

HCUP also produces Statistical Briefs which are a series of Web-based publications containing information from HCUP. These publications provide concise, easy-to-read information on hospital care, costs, quality, utilization, access, and trends for all payers (including Medicare, Medicaid, private insurance, and the uninsured). Each Statistical Brief covers an important health care issue. For example, in nine of eleven categories of potentially preventable hospitalizations, hospitalization rates declined more rapidly or rose less rapidly for older adults than for younger adults between 2005 and 2007, following the implementation of Medicare Part D to cover drug costs.

Figure 2. Rates of potentially preventable hospitalizations declined faster among older adults than among working age adults between 2003 and 2007

Citation: Stranges, E., Friedman, B. Trends in Potentially Preventable Hospitalization Rates Declined for Older Adults, 2003-2007. HCUP Statistical Brief #83. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. (Plugin Software Help)

  • The HIV Research Network (HIVRN). The HIVRN is a network of HIV providers who pool data and collaborate on research to provide policymakers and investigators with timely information about the access to and cost, quality, and safety of, HIV care; and to share information and best practices in the Network. The Network is sponsored by: AHRQ, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), the Office of AIDS Research at the National Institutes of Health (NIH), and the Office of the Assistant Secretary for Planning and Evaluation. AHRQ's funding for this activity is $1,413,000 in FY 2010. No funding is provided for FY 2011.

Measurement Contracts: Crosscutting activities support measurement activities. These activities include support for the National Healthcare Quality Report, the National Healthcare Disparities Report, Quality Indicators (QIs) and the contract component of the CAHPS® grants activities.

  • Support of the Development and release of the annual National Healthcare Quality Report and its companion document, the National Healthcare Disparities Report. These reports measure quality and disparities in four key areas of health care: effectiveness, patient safety, timeliness, and patient centeredness. In addition, AHRQ provides a State Snapshots Web tool that was launched in 2005 (available at It is an application that helps State health leaders, researchers, consumers, and others understand the status of health care quality in individual States, including each State's strengths and weaknesses. The 51 State Snapshots—every State plus Washington, DC—are based on 129 quality measures, each of which evaluates a different segment of health care performance. While the measures are the products of complex statistical formulas, they are expressed on the Web site as simple, five-color "performance meter" illustrations. Support for these contracts and IAAs totals $2.9 million in both FY 2010.
  • Quality Indicators (QIs). One widely used HCUP tool is the AHRQ Quality Indicators (QIs) — a set of quality measures developed from HCUP data. Support for QIs total $0.4 million in both FY 2010 and 2011. This measure set is organized into four modules—Prevention, Inpatient, Patient Safety, and Pediatrics. The Prevention Quality Indicators (PQIs) focus on ambulatory care sensitive conditions that identify adult hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care. Inpatient Quality Indicators (IQIs) reflect quality of care for adults inside hospitals and include: Inpatient mortality for medical conditions; inpatient mortality for surgical procedures; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures may be associated with lower mortality. Patient Safety Indicators (PSIs) also reflect quality of care for adults inside hospitals, but focus on potentially avoidable complications and iatrogenic events. Pediatric Quality Indicators (PDIs) reflect quality of care for children below the age of 18 and neonates inside hospitals and identify potentially avoidable hospitalizations among children. These measures are free and made publicly available as part of an AHRQ supported software package. Please see

The AHRQ QIs are based upon a few guiding principles which make them unique. They:

  • Were developed using readily available administrative data (HCUP).
  • Use a transparent methodology.
  • Are risk adjusted and use a readily available, familiar methodology.
  • Are constantly refined based on user input.
  • Are updated and maintained by a trusted source; and
  • Have documentation and program software in the public domain.

The HCUP/QI family of data and products supports the achievements of a number of AHRQ objectives including two major goals:

  • Expand and improve data and tools.
  • Expand use of HCUP and the AHRQ Quality Indicators (QIs) by policymakers and others.

Expand Use of HCUP and the AHRQ Quality Indicators by Policymakers and Others

The AHRQ QIs are widely used for quality improvement and public reporting initiatives. We saw several major successes in FY 2009 most notably the addition of 4 states now doing hospital level public reporting of the AHRQ Quality Indicators and the CMS adoption of the AHRQ QIs in its 2009 IPPS Rule.

AHRQ has fully met its 2009 performance target (see performance table 1.3.22): "3 new organizations use HCUP/QIs to assess potential areas of quality improvement, and at least 2 of them will develop and implement an intervention based on the QIs. Impact will be observed in 1 new organization after the development and implementation of an intervention based on the QIs."

As the result of NQF endorsement in FY 2008, a growing number of States are using the Quality Indicators for public reporting of hospital quality. In FY 2009, New Jersey, California, Nevada and Oklahoma became the 13th, 14th, 15th and 16th states to use the AHRQ Quality Indicators in a hospital level public report card. With these new states reporting using the AHRQ QIs, AHRQ exceeded its 2009 performance target (see performance table 1.3.22). The state of Maryland used the Prevention Quality Indicators to measure potential cost savings in Maryland and identified interventions tied to reducing admissions for CHF, Diabetes, UTI, Dehydration and Bacterial Pneumonia. In addition, NYU Medical Center noted a high rate of Postop DVT/PE in 2006. They implemented a training program for coders, with targeted feedback about coding errors, which increased coding accuracy from 71% in 2006 to 100% in the 2nd and 3rd quarters of 2009. They also implemented departmental standards for VTE prophylaxis (including risk assessment, documentation of contraindications to prophylaxis, and condition/procedure-specific recommendations) and required CPOE order sets. A new Quality Indicators Learning Institute assisted states interested in using the AHRQ QIs to use the indicators effectively, and provided technical assistance to new States or communities as they plan their public reporting efforts. Through this initiative, AHRQ has become aware of additional states that are in the planning stages of hospital level public reporting in FY 2010. Also in FY09, AHRQ began a new initiative focused on developing a toolkit for hospitals that would identify best practices and interventions for addressing quality problems highlighted by the AHRQ QIs. In FY 2010, development, testing and implementation of a draft hospital level toolkit will occur. The final toolkit will be publicly available in FY 2011.

As mentioned above, the Center for Medicare & Medicaid Services (CMS) incorporated nine AHRQ Patient Safety Indicators in its 2009 IPPS Rule (acute hospital inpatient prospective payment system). CMS has held a national "dry run" of the measures with its hospitals and is planning on releasing the measures by hospital on its Hospital Compare Web site in FY 2010. It is anticipated that as CMS incorporates the AHRQ QIs into its reporting and payment programs, a large number of new hospitals, hospital systems and other organizations will be using the AHRQ QIs. In early FY 2010, the state of Illinois went live with its web-based publicly report using the AHRQ QIs. By the end of 2010, it is likely that AHRQ will exceed its original performance target. In FY 2011, AHRQ will continue to support the AHRQ Quality Indicators and facilitate its use by new organizations, including the full implementation of the AHRQ QIs in the CMS 2009 IPPS Rule. The CMS 2010 IPPS Rule identified additional AHRQ Quality Indicators that CMS may report on Hospital Compare. These additional measures would be tested and/or implemented on Hospital Compare in FY 2011.

  • Survey Users Network (SUN). The SUN assists in development and dissemination of CAHPS® products. The SUN contract coordinates the work of the CAHPS® consortium; prepares CAHPS® products for dissemination to potential users in electronic and hardcopy format; delivers a range of technical assistance to users; provides technical and logistical support for conferences and meetings; and operates the National CAHPS® Benchmarking Database (NCBD). Support for this contract is $1.6 million in FY 2010.

Dissemination and Translation Contracts: AHRQ supports a variety of contracts for projects that disseminate AHRQ products, tools, and research to target groups and provide assistance in implementing them. Examples of activities in this category include the following:

  • Contracts to support the National Quality Measures Clearinghouse (NQMC) and its companion the National Guideline Clearinghouse (NGC). The NQMC and the NGC provide open access to thousands of quality measures and clinical practice guidelines to clinicians and health care providers. The NQMC and NGC receive close to 2 million visits each month. They can be found at and Support for these two clearinghouses total $7.0 million in FY 2010.
  • Knowledge Transfer and Applications Support and Exhibit Logistics Support. These contracts develop and implement integrated knowledge transfer and application strategies using a wide range of innovative methods that will increase the rates of application and use of research findings in health care policy and practice by AHRQ stakeholders. These stakeholders include health and hospital system decision makers, State and local policymakers, health care purchasers, and providers. Support for these contracts total $4.25 million in FY 2010.
  • AHRQ Publications Clearinghouse. This contract operates a Publications Clearinghouse for the storage and distribution of AHRQ publications (available at; maintains and manages AHRQ's automated mailing/inventory control system; and manages the storage and shipping of AHRQ exhibits. Support for this contract totals $1.9 million in FY 2010.
  • Electronic Dissemination Program. The Web Management Team is staffed by onsite contractors, with the exception of the Web Manager and the Intranet Coordinator who are AHRQ staff. The Team provides support to numerous public Web sites sponsored by AHRQ, extranets with business partners, the Intranet, and several portal initiatives of the Department where AHRQ is a partner. Support for this contract totals $1.9 million in FY 2010.

Data Management. AHRQ supports a variety of contracts that assist AHRQ in managing data. Examples of activities in this category AHRQ Applications Development and Maintenance support. This work allows AHRQ to support agency system and application requirements and to quickly adopt and implement both department and agency technology standards. The contractor provides support in the following areas; process improvement, business analysis, systems analysis, system design, software development, application operations and maintenance, testing and deployment of complex technologies into the existing IT environment. Additional general IT support is provided to support agency system and application requirements and to quickly adopt and implement both department and agency technology standards. Assistance is also provided in the areas of: technology evaluation and feasibility studies, process re-engineering, business analysis, systems analysis, system design, enterprise architecture, IT Security and CIO support to include business risk assessments, electronic commerce and E-Government, and support of legislative and OMB and Departmental directives. Overall data management support is provided at $5.3 million in both FYs 2010 and 2011.

Grant Review Support. This contract provides technical, analytic, and logistical support services to the Office of Extramural Research, Education, and Priority Populations (OEREP) in furtherance of its mission to oversee AHRQ's initial review processes; to facilitate ethics review procedures and education for intramural research; and to facilitate general OEREP communication and analytic responsibilities. Support for this contract is provided at $1.9 million in FYs 2010 and 2011.

IAAs with Federal Government. An Inter-agency Agreement (IAA) is an agreement between AHRQ and other Federal Agencies.Crosscutting Activities provides support for IAAs and requisitions that provide overall direction and support to all portfolios. The level of IAA support varies by fiscal year, but ARHQ estimates $7.8 million for FY 2010.

Evaluation Activities. AHRQ's Planning, Evaluation, and Analysis Task Order Contract (PEATOC) and Other Agency Evaluation activities provide a mechanism to facilitate the production of focused, high-priority planning, evaluation, and other types of quantitative and qualitative analytical products for all portfolios and crosscutting issues within the Agency. Support for this contract totals $2.15 million in FYs 2010.

Performance Trends by Program

CERTs: With the exception of the antibiotic prescription measure (for which external evaluators have suggested important refinements to discern appropriate antibiotic prescribing), all CERTs performance measures were met or exceeded.

CAHPS®: In FY 2007, CAHPS® met the performance target (see performance measure 1.3.23) to increase 40 percent over the baseline of the user community. In FY 2007 AHRQ increased this usage to 41 percent over the baseline of 100 million users—141 million users of CAHPS® information—and maintained this performance level in 2008. In FY 2008, the program did not meet its target of increasing the number of using 42 percent over the baseline. This is due to the fact that no new major organization adopted the CAHPS® tool and therefore, no increase in usage was noted. In FY 2009, the program proposed a 44% increase over the baseline. We did not meet this goal because a) ABMS (American Board of Medical Specialties) has moved more slowly than we anticipated in use of the Clinician/Group CAHPS® Survey as part of their accreditation process and b) CMS did not begin using the Home Health Care Survey in the beginning of 2009 as they had projected. For FY 2010 and 2011, the program proposes increases of 46% and 48% respectively. Given the fact that CMS is now collecting Home Health Care data, we feel that the FY 2010 goal is likely to be met. Our ability to meet the 2011 goal (and goals beyond that year) will depend on how many organizations implement the Surveys for PCMH, Cancer CAHPS® and Surgical CAHPS. Given that there is a requirement for CMS to obtain CAHPS® Health Plan data for CHIPRA reporting, we expect to see increased use of this survey by state Medicaid programs in 2011 and 2012.

HCUP: Over the past 5 years, the cumulative number of partners contributing data to HCUP databases have been steadily increasing resulting in a more robust and representative data resource. Since 2005, we have added 22 unique inpatient, ambulatory surgery or emergency department databases to HCUP. Successfully efforts are already underway to bring the remaining state databases into HCUP by 2011.

QIs: Over the past 5 years, the number of new organizations using the AHRQ Quality Indicators has steadily increased. In 2005, there were 3 state organizations that publicly reported the AHRQ Quality Indicators at the hospital level. In 2009, that number rose to 16 state organizations.

Long-Term Objective 1: Reduce antibiotic inappropriate use in children between the ages of one and fourteen.

4.4.1: The number of prescriptions of antibiotics per child aged 1 to 14 in the U.S. (Outcome)20110.50 per child per yearOct 31, 2011
20100.51 per child per yearOct 31, 2010
20090.51 per child per year0.55 per child (Target Met – Result falls within measurement error)
20080.52 per child per year0.58 per child (Target Not Met)
20070.53 per child per year0.52 per child (Target Met)
20060.54 per child per year0.60 per child (Target Not Met)
MeasureData SourceData Validation
4.4.1MEPSThe MEPS family of surveys includes a Medical Provider Survey and a Pharmacy Verification Survey to allow data validation studies in addition to serving as the primary source of medical expenditure data for the survey. The MEPS survey meets OMB standards for adequate response rates, and timely release of public use data files.

Long-Term Objective 2: Reduce congestive heart failure hospital readmission rates in those between 65 and 85 years of age.

4.4.2: The percentage of hospital readmissions within 6 months for congestive heart failure in patients between 65 and 85 years of age (Outcome)201133.5%Oct 31, 2011
201034%Oct 31, 2010
200934.5%35.48% (Target Not Met)
200835%31.91% (Target Met)
200735.5%36.51% (Target Not Met)
200636%36.74% (Target Not Met)
MeasureData SourceData Validation
4.4.2HCUPHCUP and QI Project Officers use established methodology to check data.

Long-Term Objective 3: Reduce hospitalization for upper GI bleeding in those between 65 and 85 year of age.

4.4.3: The decrease in the rate of hospitalization for upper GI bleeding due to the adverse effects of medication or inappropriate treatment of peptic ulcer disease in patients between 65 and 85 years of age. (Outcome)2011-4%Oct 31, 2011
2010-3.5%Oct 31, 2010
2009-3%48.25/10,000 (3.0)(Target Met)
2008-1.8%49.75/10,000 (-3.5%)(Target Exceeded)
2007-2%51.56/10,000 (-5.2%)(Target Exceeded)
2006-2%54.38/10,000 (-1.1%),(Target Not Met)
4.4.4: The cost per capita of hospital admissions for upper GI bleeding among patients aged 65 to 84. (Efficiency)2011$88.82 per capitaOct 31, 2011
2010$89.78 per capitaOct 31, 2010
2009$90.75 per capita$83.81 per capita (Target Exceeded)
2008$91.71 per capita$87.10 per capita (Target Met)
2007$92.68 per capita$91.81 per capita (Target Met)
2006$93.64 per capita$93.36 per capita (Target Met)
MeasureData SourceData Validation
4.4.3HCUPHCUP and QI Project Officers use established methodology to check data.
4.4.4HCUPHCUP and QI Project Officers use established methodology to check data.


Long-Term Objective 4: Achieve wider access to effective health care services and reduce health care costs.

1.3.15: Cumulative number of partners contributing data to HCUP databases will exceed by 5% the FY 2000 baseline of 39. (Output)2011Increase # of partners providing dataOct 31, 2011
2010Increase # of partners providing dataOct 31, 2010
2009Increase # of partners providing data by 328 AS 27 ED
2008Increase # of partners contributing to HCUP databases27 AS 25 ED (Target Met)
2007Increase # of partners contributing to HCUP databases24 AS 22 ED (Target Met)
2006N/A21 Ambulatory Surgery (AS) 17 Emergency Department (ED) (Target Met)
1.3.22: Number of additional organizations per year that use Healthcare Cost and Utilization Project (HCUP) databases, products, or tools in health care quality improvement efforts. (Outcome)20113 organizationsOct 31, 2011
20103 organizationsOct 31, 2010
20093 organizations3 new organizations — Nevada State Hospital Association; Oklahoma State Hospital Association; Wisconsin State Hospital Association (Target Met)
20083 organizations5 new organizations — Kentucky Hospital Association; SSM Health Care; IN CHCS; Robert Wood Johnson; University Hospital (Target Met)
20073 organizations3 new organizations — CO Health Institute; OH Department of Health; Harvard Vanguard Medical Association & Atrias Health (Target Met)
20063 organizations3 new organizations — Organization for Economic Cooperation & Development; CT Office of Health Care Access; Dallas-Fort Worth Hospital Council (Target Met)
20052 organizations2 organizations (Target Met)
MeasureData SourceData Validation
1.3.15HCUP databaseHCUP Project Officer monitors the number of partners and reports by identifying the new data added to the existing baseline.
1.3.22HCUP databaseHCUP and QI Project Officers work with Project Contractors to monitor the field and collect specific information to validate the organizations' use and outcomes.

Long-Term Objective 5: Assure that providers and consumers/patients use beneficial and timely health care information to make informed decisions/choices.

1.3.23: The number of consumers who have access to customer satisfaction data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) to make health care choices. (Outcome)2011Increase 46% over baseline (146 million)Oct 31, 2011
2010Increase 46% over baseline (146 million)Oct 31, 2010
2009Increase 44% over baseline (144 million)41% (141 Million)(Target Not Met)
2008Increase 42% over baseline (142 million)41% (141 Million)(Target Not Met)
2007Increase 40% over baseline (140 million)41% (141 Million)(Target Met)
2006Increase baseline138 Million (Target Met)
MeasureData SourceData Validation
1.3.23CAHPS® database National CAHPS® Benchmarking DatabasePrior to placing survey and related reporting products in the public domain, a rigorous development, testing, and vetting process with stakeholders is followed. Survey results are analyzed to assess internal consistency, construct validity, and power to discriminate among measured providers.

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Current as of February 2010
Internet Citation: Online Performance Appendix: Performance Detail, Crosscutting Activities Related to Quality, Effectiveness, and Efficiency Research (continued): Budget Estimates for Appropriations Committees, Fiscal Year 2011. February 2010. Agency for Healthcare Research and Quality, Rockville, MD.