Significant Items

Budget Estimates for Appropriations Committees, Fiscal Year 2011

This statement summarizes budget information submitted to Congress for fiscal year 2011 by the Agency for Healthcare Research and Quality (AHRQ).

 

FY 2010 House Report No. 111-222

Ambulatory Patient Safety

1. House (Rept. 111-222) p. 153/ 154

The Committee recognizes AHRQ's efforts to examine the risks associated with the migration of healthcare into ambulatory settings. In light of the growing number of incidents involving syringe reuse and hepatitis C transmission across the country, the Committee urges AHRQ to expand the ambulatory safety and quality program to identify the inherent risks in ambulatory settings and to develop potential solutions for protecting patients. AHRQ is encouraged to partner with CDC for assessment, content expertise, and evaluation activities to enable these efforts.
Action Taken or to be Taken:
Since 2007, AHRQ has funded several patient safety initiatives that directly addressed the patient safety and quality needs of patients in the ambulatory care settings .Specifically, the three-year Risk Informed Intervention Development and Implementation of Safe Practices in Ambulatory Care Settings projects have focused on the identification, development, testing and implementation of safe practice interventions in the ambulatory care settings. Building on a set of successful planning grants, AHRQ issued another funding opportunity announcement in 2008 and several proposals were awarded funds, e.g. implementation interventions were proposed for home care settings, transfer of pediatric patients from the NICU to an ambulatory care and for conditions such as ambulatory procedural sedation.
In preparation for FY 2010 funding, the Agency worked in close collaboration with the CDC, CMS, and the Office of the Secretary to identify healthcare-associated infections (HAI)-related projects focused on the ambulatory setting including assisted living facilities, outpatient clinics, and primary care practices at the community level. Expanding on the highly successful Keystone Project, the Agency will fund efforts to implement and test the CUSP modeling ambulatory care settings nationwide. The Agency is working closely with HHS to ensure that all of the FY 2010 initiatives are in close alignment with HAI National Action Plan second tier level implementation focus: ambulatory surgical care centers and dialysis units. We look forward to collaborating with CDC and others, as we have successfully done with our HAI work, on finding the most effective ways of protecting patients from hepatitis C.

Methicillin-Resistant Staphylococcus Aureus (MRSA) Collaborative Research Initiative

2. House (Rept. 111-222) p.153

The Committee urges AHRQ to support investigator-initiated research aimed at identifying new interventions to reduce infections. Just as the basic science of the agents that cause HAIs is evolving, so is the knowledge about how to prevent and treat them. Although in some cases adequate knowledge about how to reduce HAIs is available and the primary barrier is how to implement and apply that knowledge, in other cases, optimal solutions are not apparent. Support for novel approaches is one way to expand the arsenal of interventions aimed at reducing HAIs, including MRSA.
Action Taken or to be Taken:
AHRQ developed a funding opportunity announcement (FOA) that was posted in January 2010, and will be awarded in early spring 2010 to prevent and more effectively manage healthcare-associated infections in the both hospital and ambulatory care settings. Specifically,the FOA research priorities are the 1) development, implementation, and demonstration of the prevention and management of HAIs, along with the determination of the costs of such interventions; 2) determination of the efficacy, effectiveness, and costs of the preventive interventions; 3) population-level studies on the patient risk factors, sources, and disease genotypes of antibiotic-resistant organisms that can result in perceived HAIs.The scientific and practical knowledge to be achieved through these funded research efforts will identify the practical and cost-effective approaches to preventing and managing HAIs.

Maternity Care Models

3. House (Rept. 111-222) p. 152

Therefore, the Committee encourages AHRQ to study the comparative effectiveness of different maternity care models and practices, including both physician and non-physician providers; all three birth settings of hospital, birth centers, and planned home birth; and the practices of elective induction, primary elective cesarean section, and repeat cesarean section.
Action Taken or to be Taken:
AHRQ agrees that safe and effective maternity care models and practices are important research areas. AHRQ will explore the appropriate mechanisms and study designs under which these types of studies can be conducted. AHRQ welcomes the opportunity to work with maternity care providers to help determine effective strategies to examine the various maternity care models and practices.

Crosscutting Activities Related to Quality, Effectiveness, and Efficiency Research

4. House (Rept. 111-222) p. 154

The Committee values AHRQ for its critical role in supporting health services research to improve health care quality, reduce costs, advance patient safety, decrease medical errors, eliminate health care disparities, and broaden access to essential services. However, the Committee is troubled that AHRQ's investigator-initiated research portfolio has languished even though many of the sentinel studies that have changed the face of health and health care in the U.S. are the result of researchers' ingenuity and creativity. The Committee provides AHRQ additional funding for investigator-initiated research to advance discovery and the free marketplace of ideas.
Action Taken or to be Taken:
AHRQ is continuing to make strides toward increasing opportunities in the area of investigator-initiated research. The Agency greatly appreciates the additional resources that the Committee has provided AHRQ. Investigator-initiated research has provided the foundation for many of AHRQ's current program and activities. In response, AHRQ is expanding its funding for large and small investigator-initiated research grants, as well as research demonstration grants. AHRQ will fund projects with a balanced approach across the array of Agency research priorities. AHRQ will commence funding for these grants immediately, and continue through the fiscal year.

Building the Next Generation of Researchers

5. House (Rept. 111-222) p. 154

The Committee is concerned about declines in the number of, and funding for, training grants for the next generation of researchers. The Committee urges AHRQ to provide greater support to pre- and post-doctoral training grants and fellowships to ensure America stays competitive in the global research market.
Action Taken or to be Taken:
The Agency for Healthcare Research and Quality is deeply committed to addressing the needs for pre- and postdoctoral training to support the growing needs of the global research market. In FY 2010 AHRQ will allocate funds provided through the American Recovery and Reinvestment Act of 2009 (ARRA) to support pre- and post-doctoral training through the National Research Service Award (NRSA) institutional training programs. Approximately $5 million in grant funds will be awarded for postdoctoral training of health services and clinical researchers who have made a commitment to focus their research in the area of comparing the effectiveness of different medical options. The Agency anticipates making approximately 5-7 institutional awards which would support approximately 30 to 40 postdoctoral fellows over a 3 year award period in this research area. Additionally AHRQ will continue its long-standing support for pre- and post-doctoral training through the NRSA program, providing support for approximately 200 pre and postdoctoral trainees.

Broadening the Evidence Base in Response to Health Care

6. House (Rept. 111-222) p. 155

The Committee recognizes that AHRQ's research portfolio focuses predominantly on patient safety, health care quality, and patient-centered health research. Unfortunately, these efforts have included less research on ways to improve the quality and efficiency of the health care system as a whole, and have resulted in relatively little funding to study what drives health care costs or to determine how to achieve needed improvements in efficiency. The Committee urges AHRQ to develop a more balanced research agenda, supporting all aspects of health care research outlined in its statutory mission, including, the costs, utilization of, and access to, health care and the ways in which health care services are organized, delivered, and financed.
Action Taken or to be Taken:
AHRQ continues to work toward achieving a more balanced research portfolio. While targeted research investments have comprised a large portion of our budget, the additional resources that the Committee has provided in area of investigator-initiated research will enable the Agency to expand its research agenda to include broader aspects of health care, including organization and delivery of health services. In response, AHRQ is expanding its funding for large and small investigator-initiated research grants, as well as research demonstration grants. AHRQ will fund projects with a balanced approach across the array of Agency research portfolios. AHRQ will commence funding for these grants immediately, and continue through the fiscal year.

Diabetes

7. House (Rept. 111-222) p. 155

The Committee encourages AHRQ to seek to advance the development of an appropriate A1c management quality measure by providing support to develop a new measure or measures and/or ways to adapt current measures to support this goal. This could be in the form of support to groups that have large A1c databases, such as the Veterans Administration system or one of AHRQ's Accelerating Change and Transformation in Organizations and Networks partners.
Action Taken or to be Taken:
Intensive management of blood glucose levels as reflected in the A1c, is believed to reduce the risk of long term complications associated with type 2 diabetes. Groups have worked to develop quality measures based on the A1c level for many years. However, one of the key reasons that the Physician Quality Reporting Initiative and other initiatives do not use A1c is because they depend on claims data which can only tell you if the test was ordered, but not the result. AHRQ is actively supporting efforts with ARRA funding and through our core programs to enhance the utility of supplementing administrative billing (claims) data with clinical electronic data, including laboratory test results such as A1c.
Currently, AHRQ is seeking to advance A1c quality measurement in a number of ways. Several AHRQ-sponsored studies are underway in the Effective Health Care Program's Diabetes Multi-Center Research Consortium (DMCRC). These studies will help to identify optimal therapies and glycemic control for different patient populations. A study in progress is specifically examining the relative effectiveness of intensive glycemic control vs. conventional control in type 2 diabetes, addressing the question in a real-world setting utilizing electronic health care records from a large cohort of approximately 30,000 patients drawn from five health systems between 2002 and 2009. Other relevant relative effectiveness studies examine the impact of various oral antidiabetic drugs, insulin and combination therapies, and bariatric surgery on the A1c level and long term complications. These studies all utilize electronic healthcare records including local and national data from the Veterans Affairs (VA) Healthcare system, data from the Baylor Health Care System (BHCS) in Dallas, Texas and the Christiana Care Health System (CCHS) in Delaware, and data from three HMO Research Network health systems: Kaiser Permanente Northern California, Kaiser Permanente Southern California, and HealthPartners in Minneapolis.
As a member of the Diabetes Mellitus Interagency Coordinating Committee (DMICC), AHRQ communicates and collaborates with other members of the Department of Health and Human Services and other federal agencies to identify effective practices and barriers to improved care for individuals with diabetes. Future meetings will discuss the impact of different therapies on outcomes for diabetes from the federal perspective.
AHRQ is also interested in expanding research related to patient adherence with treatments for diabetes. High proportions of patients with diabetes do not adhere to provider recommendations about diet, weight loss, exercise, and pharmacologic treatment. A better understanding of causes of non-adherence with treatments for diabetes could ultimately yield corresponding quality measures.

Mindfulness-based Stress Reduction

8. House (Rept. 111-222) p.155

Mindfulness-based stress reduction (MBSR) is the most commonly used meditation-based intervention in medical settings in the U.S. There is a growing body of scientific literature that has examined the impact of MBSR on pain, brain function, immune function, and on the symptoms and underlying biological mediators of some diseases, such as cardiovascular disease, psoriasis, and cancer. However, the extent to which MBSR might affect health care utilization has never been systemically studied. Even modest reductions in health care utilization could translate into significant dollar savings cumulatively throughout the nation and may have implications for health care policy. The Committee urges AHRQ to support research to determine whether MBSR impacts health care utilization.

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FY 2010 Senate Report No. 111-66

Lyme Disease

1. Senate (Rept. 111- 66) p. 133

The Committee encourages AHRQ to create a comprehensive clearinghouse of peer-reviewed tick-borne diseases literature that will include literature on persistent infection, appropriately organized for use by the scientific community, treating physicians, and the public.
Action Taken or to be Taken:
AHRQ agrees that there is significant uncertainty regarding the existing evidence and definition of persistent infection with tick-borne diseases. AHRQ recognizes the seriousness of tick-borne illness. In 2008, nearly 29,000 confirmed cases of Lyme disease, alone, were reported to the CDC. AHRQ will explore different options for providing current scientific information in a usable format for scientists, clinicians, and patients on tick-borne diseases.

Building the Next Generation of Researchers

2. Senate (Rept. 111- 66) p.133

The Committee is deeply concerned about declines in the number of, and funding for, training grants for the next generation of researchers. The Committee urges AHRQ to provide greater support to pre- and post-doctoral training grants and fellowships to ensure America stays competitive in the global research market.
Action Taken or to be Taken:
The Agency for Healthcare Research and Quality is deeply committed to addressing the needs for pre- and postdoctoral training to support the growing needs of the global research market. In FY 2010 AHRQ will allocate funds provided through the American Recovery and Reinvestment Act of 2009 (ARRA) to support pre- and post-doctoral training through the National Research Service Award (NRSA) institutional training programs. Approximately $5 million in grant funds will be awarded for postdoctoral training of health services and clinical researchers who have made a commitment to focus their research in the area of comparing the effectiveness of different medical options. The Agency anticipates making approximately 5-7 institutional awards which would support approximately 30 to 40 postdoctoral fellows over a 3 year award period in this research area. Additionally AHRQ will continue its long-standing support for pre- and post-doctoral training through the NRSA program, providing support for approximately 200 pre and postdoctoral trainees.

Comparative Effectiveness Research

3. Senate (Rept. 111-66) p.133

The Committee encourages AHRQ to expand the Evidence-based Practice Centers to focus on a broad range of interventions affecting health, including non-clinical programs and interventions, organizational and system characteristics, as well as policies and regulations.
Action Taken or to be Taken:
AHRQ has funded and will continue to support Evidence-based Practice Center (EPC) studies on all aspects of relevant health care. In the past, the EPC's have conducted studies that look at care coordination, bioterrorism, patient safety, health information technology, and financing and economic incentives. AHRQ expects the EPCs to continue to perform studies on non-clinical topics, such as the use, barrier, and drivers of health information technology, preventive care, and support strategies for children with special health care needs.

Diabetes

4. Senate (Rept. 111- 66) p.133

The Committee notes that appropriate management of hemoglobin A1c can reduce the risk of complications of diabetes. Yet several quality measurement programs such as CMS' Physician Quality Reporting Initiative do not reward appropriate management of hemoglobin A1c due to the lack of consensus on a methodology for developing outcomes-focused measures. The Committee urges AHRQ to advance the development of an appropriate A1c management quality measure, possibly through support of organizations that have large A1c databases, such as the Veterans Administration system, or one of AHRQ's Accelerating Change and Transformation in Organizations and Networks [ACTION] partners.
Action Taken or to be Taken:
Intensive management of blood glucose levels as reflected in the A1c, is believed to reduce the risk of long term complications associated with type 2 diabetes. Groups have worked to develop quality measures based on the A1c level for many years. However, one of the key reasons that the Physician Quality Reporting Initiative and other initiatives do not use A1c is because they depend on claims data which can only tell you if the test was ordered, but not the result. AHRQ is actively supporting efforts with ARRA funding and through our core programs to enhance the utility of supplementing administrative billing (claims) data with clinical electronic data, including laboratory test results such as A1c.
Currently, AHRQ is seeking to advance A1c quality measurement in a number of ways. Several AHRQ-sponsored studies are underway in the Effective Health Care Program's Diabetes Multi-Center Research Consortium (DMCRC). These studies will help to identify optimal therapies and glycemic control for different patient populations. A study in progress is specifically examining the relative effectiveness of intensive glycemic control vs. conventional control in type 2 diabetes, addressing the question in a real-world setting utilizing electronic health care records from a large cohort of approximately 30,000 patients drawn from five health systems between 2002 and 2009. Other relevant relative effectiveness studies examine the impact of various oral antidiabetic drugs, insulin and combination therapies, and bariatric surgery on the A1c level and long term complications. These studies all utilize electronic healthcare records including local and national data from the Veterans Affairs (VA) Healthcare system, data from the Baylor Health Care System (BHCS) in Dallas, Texas and the Christiana Care Health System (CCHS) in Delaware, and data from three HMO Research Network health systems: Kaiser Permanente Northern California, Kaiser Permanente Southern California, and HealthPartners in Minneapolis.
As a member of the Diabetes Mellitus Interagency Coordinating Committee (DMICC), AHRQ communicates and collaborates with other members of the Department of Health and Human Services and other federal agencies to identify effective practices and barriers to improved care for individuals with diabetes.
Future meetings will discuss the impact of different therapies on outcomes for diabetes from the federal perspective.
AHRQ is also interested in expanding research related to patient adherence with treatments for diabetes. High proportions of patients with diabetes do not adhere to provider recommendations about diet, weight loss, exercise, and pharmacologic treatment. A better understanding of causes of non-adherence with treatments for diabetes could ultimately yield corresponding quality measures.

Moving Research Into Practice

5. Senate (Rept. 111- 66) p.133

Health services research has great potential to improve health and health care when widely disseminated and used. The Committee supports AHRQ's research translation activities, including practice-based research centers and learning networks that are designed to better understand health care delivery and move the best available research and decisionmaking tools into health care practice. The Committee encourages AHRQ to expand these programs.
Action Taken or to be Taken:
AHRQ is building on its successful efforts to translate and disseminate research so it can be used to improve practice and policy. For example, the Agency supports research networks that rapidly develop and assess methods and tools to assure that new scientific evidence is incorporated into clinical care in real-world practice settings. These networks include a group of ten primary care practice-based research networks (PBRNs) comprised of over 2000 community-based practices that are located across the country and provide primary care services for 12 million Americans, and the Accelerating Change and Transformation in Organizations and Networks (ACTION), which consist of 15 large partnerships and collaborating organizations that provide health care to more than 100 million Americans.
AHRQ also is supporting a number of learning networks designed to bring together organizations to learn about and implement AHRQ-supported research and tools. For example, the AHRQ Learning Network for Chartered Value Exchanges is a national program which brings together 24 regional health improvement collaboratives from across the country. In aggregate, these collaboratives involve more than 575 health care leaders and represent over 124 million lives. In addition, AHRQ's Knowledge Transfer and Implementation Program works to promote and encourage the use of AHRQ tools, products, and initiatives by various stakeholders. The project includes projects targeted to clinicians, pharmacists, purchasers as well as a series of learning networks, such as the Elders Prevention Learning Network, Hispanic Elders Learning Network, Long-Term Care Quality Improvement Learning Network, Medicaid Care Management Learning, Medicaid Medical Directors' Learning Network, and the Quality Indicators Learning Institute.
AHRQ will continue to look for opportunities to expand programs that support research translation activities.

Quality in Endoscopy

6. Senate (Rept. 111-66) p. 133

Gastrointestinal [GI] endoscopic procedures, such as colonoscopy, and other outpatient procedural services represent a significant portion of healthcare spending, yet little attention has been focused on quality improvement. The Committee encourages AHRQ to validate already published quality measures for procedural services and to identify best practices that can improve patient outcomes. Collection of procedure and outcomes data from healthcare providers will be an important part of the effort to improve the quality of procedural services such as GI endoscopy.
Action Taken or to be Taken:
AHRQ agrees that quality gastrointestinal endoscopic procedures are an important component of health care for screening and diagnostic purposes. AHRQ will explore ways to identify valid quality measures for these procedures and the mechanisms for collecting both procedural and outcomes data from providers. AHRQ will meet with experts in the area of endoscopy, including representatives of the American Society of Gastrointestinal Endoscopy, to explore potential opportunities for improving the quality of endoscopy.

Restoring Innovation and Competitiveness

7. Senate (Rept. 111- 66) p.133/134

The Committee is pleased that AHRQ is working to address the decline in investigator- initiated research opportunities through its Innovations Research Portfolio. The Committee provides funding for AHRQ to expand this grant making program to advance discovery and the free marketplace of ideas, and urges AHRQ to provide more opportunities for investigator-initiated research through its other core programs, including the Effective Health Care Program.
Action Taken or to be Taken:
AHRQ is continuing to make strides toward increasing opportunities in the area of investigator-initiated research. The Agency greatly appreciates the additional resources that the Committee has provided AHRQ. Investigator-initiated research has provided the foundation for many of AHRQ's current program and activities. To this end, AHRQ is developing plans to include more investigator-initiated grant opportunities that impact a broader spectrum of the Agency's programs, such as the Effective Health Care Program. We look forward to working with the Committee and the Agency's stakeholders to develop a more comprehensive investigator-initiated research portfolio.

Temporomandibular Joint and Muscle Disorders

8. Senate (Rept. 111-66) p.134

The Committee is aware that temporomandibular joint and muscle disorders [TMJDs] affect over 35 million people in the United States. Symptoms of this disorder range from mild discomfort to severe pain that causes limitations in speaking, chewing and swallowing. Health care practitioners have amassed over 50 treatments for TMJDs with virtually no evidence of safety or efficacy based on randomized controlled clinical trials. The Committee urges AHRQ to conduct a study of the per-patient cost and efficacy/effectiveness of treatments for TMJDs, focusing on developments after a similar study was prepared in 2001.
Action Taken or to be Taken:
AHRQ understands the importance and burden of illness TMJD places on the American public. AHRQ will explore how to assess the existing literature and proposed treatments for TMJD and what specific new research would need to be conducted to address the underlying uncertainty about the effectiveness of different treatments.

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Consolidated Appropriations Conference Report, 2010

Patient-Centered Health Research

Conference Report (Rept. 111-117) p.1034

As proposed by the House, the conferees do not intend for the patient-centered health research funding to be used to mandate coverage, reimbursement, or other policies for any public or private payer. The funding shall be used to conduct or support research to evaluate and compare the clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition. Further, the conferees recognize that a ''one-size-fits-all'' approach to patient treatment is not the most medically appropriate solution to treating various conditions. Research conducted should be consistent with Departmental policies relating to the inclusion of women and minorities. The Senate did not propose similar language.
Action Taken or to be Taken:
AHRQ does not conduct research that mandates coverage or reimbursement for public and private payers. The funding is used to conduct or support research to evaluate and to compare the clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition. Additionally, AHRQ actively pursues research on under-represented populations and the effect of services on individual patients. In fact, the Agency plans to invest in a series of studies that measure the relative benefits that different treatments produce in routine clinical practice and will include novel study designs focusing on real-world under represented populations (children, elderly, racial and ethnic minorities, and other underserved populations).

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Current as of February 2010
Internet Citation: Significant Items: Budget Estimates for Appropriations Committees, Fiscal Year 2011. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/mission/budget/2011/sig11.html