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

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

Authorizing Legislation: Federal funds pursuant to Title IX and Section 927(c) of the Public Health Service Act (PHSA).

A. Statement of Budget

The Agency for Healthcare Research and Quality's (AHRQ) requests $271,564,000 for Research on Health Costs, Quality and Outcomes (HCQO) at the FY 2008 Request—an increase of $10,872,000 from the FY 2007 Continuing Resolution level. These funds are being financed using PHS Evaluation Funds.

B. Program Description

The purpose of the activities funded under the Research on Health Costs, Quality and Outcomes (HCQO) budget line is to support, conduct and disseminate research to improve the outcomes, quality, cost, use and accessibility of health care. Accordingly, the Agency has developed four main strategic goal areas:

• Goal 1: Safety/Quality.
• Goal 2: Efficiency.
• Goal 3: Effectiveness.
• Goal 4: Organizational Excellence.

Select for the performance analysis and rationale for the HCQO budget request. For a more detailed performance analysis (tabular format), select Detail of Performance Analysis.

Mechanisms of Support

Through the HCQO budget activity, AHRQ provides financial support to public and private nonprofit entities and individuals through the award of grants, cooperative agreements, and contracts.

Program Announcements (PAs) are used to invite research grant applications for new or ongoing activities of a general nature, and Requests for Applications (RFAs) are used to invite applications for a targeted area of research. Grant applications are reviewed for scientific and technical merit by a peer review group with appropriate expertise. Funding decisions are based on the quality of the proposed project, availability of funds, and portfolio needs and performance goals.

In addition to large research project grants that have an average duration of 3 to 4 years, AHRQ also supports one-year small research and conference grants that facilitate the initiation of studies for preliminary short-term projects, as well as training grants, such as dissertations, career development awards, and National Research Service Awards (NRSAs).

AHRQ also awards contracts to carry out a wide variety of directed health services research and administrative activities. The availability of Requests for Proposals (RFPs) for AHRQ contracts is announced in the Commerce Business Daily (CBD), published by the U.S. Department of Commerce. Like research project grants, proposals received in response to these RFPs are peer reviewed for scientific and technical merit by a panel of experts in accordance with the evaluation criteria specified in the RFP.

5-Year Table Reflecting Dollars and FTEs

Funding for the HCQO program during the last 5 years has been as follows:

C. Performance Analysis by Strategic Goal Plan

HCQO: Safety/Quality

Increasing the safety and quality of health care for all Americans is a primary emphasis at AHRQ. Patient safety was quickly elevated to national importance in November 1999, when the Institute of Medicine's report, To Err is Human: Building a Safer Health System, estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. Almost immediately, the Senate Committee on Appropriations began hearings on patient safety issues that resulted in the Committee directing AHRQ to lead the national effort to combat medical errors and improve the quality and safety of patient care. One of AHRQ's leading long-term goals is to prevent, mitigate and decrease the number of errors, risks, hazards and quality gaps associated with health care and their harmful impact on patients.

Consequently, safety and quality are of the highest priorities within AHRQ. Leaders of our health care system have demonstrated a commitment to improve the quality and safety of care for all Americans, and with their help, AHRQ has successfully built the foundation for a national Patient Safety Initiative. The mission of this agency-wide strategic goal is to reduce the risk of harm from health care services by promoting the delivery of appropriate care that achieves the best quality outcome.

Safety/Quality Strategic Plan Goal

The results and investments in patient safety and quality are now being incorporated into practice. Below are examples of how this work is being used.

• In November 2006, AHRQ released 10 Patient Safety Tips for Hospitals. This new tipsheet provides evidence-based research findings that cover a range of activities including how to reduce the likelihood of fatigue-related mistakes, ensuring safety in intensive care units (ICUs), using technology to improve clinical care, and more. Each tip provides a brief synopsis of key data or findings from AHRQ-supported research to help organizations recognize the benefit of changing their current practices. AHRQ is also working with hospitals, nurses, medical residency program directors, and others to disseminate these findings.

  As an example, AHRQ-funded research has found that the rate of serious medical errors at two Boston hospital ICUs dropped 36 percent when 30-hour-in-a-row work shifts for first-year residents were eliminated. Based on these findings, hospitals should eliminate the tradition of shifts of more than 30 consecutive hours by interns working in ICUs, the tipsheet advises. In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to no more than 80 hours per week.

  Also, hospitals could use computer-based order entry systems to reduce catheter-related urinary tract infections. This evidence is based on AHRQ research that found that systems that prompted catheter removal after 72 hours decreased the duration of urinary catheterization and incidence of urinary tract infections.

• In October 2006, AHRQ issued a report that concluded that performing a common heart surgery without bypassing the cardiopulmonary system may cut down on the number of surgery-related strokes and other short-term complications.

  Traditionally, coronary artery bypass graft (CABG) surgery has depended heavily on cardiopulmonary bypass (CPB), particularly as its harmful effects have been reduced. However, many cardiac surgeons have in the past few years become interested in avoiding CPB altogether, a procedure known as "off-pump" CABG surgery. The findings of this study, released in the November issue of the journal Stroke, indicate that off-pump CABG is associated with lower incidence of stroke, atrial fibrillation, and health care-associated infection. Specifically, they found that the off-pump procedure could prevent approximately 10 strokes per 1,000 CABGs, a 50-percent reduction in the risk faced by patients undergoing the surgery. Approximately 280,000 CABGs are performed in the United States each year.

• AHRQ continues to support of a monthly peer-reviewed, Web-based online journal and forum on patient safety and health care quality called the AHRQ WebM&M (Morbidity and Mortality Rounds on the Web). This site features expert analysis of medical errors reported anonymously by our readers, interactive learning modules on patient safety ("Spotlight Cases"), Perspectives on Safety, and forums for online discussion. Select for an example of one of the cases discussed in the December online issue. Following the case description, a commentary regarding the "near miss" is provided by a physician. To view the commentary in its entirety as well as the take home points, please visit http://Webmm.ahrq.gov.

  

• In FY 2006 AHRQ's patient safety program funded 19 grants for approximately $5 million under its "Improving Patient Safety Through Simulaton Research" request for applications. The projects focus on assessing and evaluating the roles that simulation can play to improve the safe delivery of quality health care. The simulation projects focus on a range of interventions that can contribute to a safer health care environment, including effective communication among members of the health care team, disclosure of medical errors to patients and their families, the effects of implementing health information technology, and patient handoffs and transitions within hospitals. Several projects focus on teamwork in high-risk settings such as emergency departments, labor and delivery units, and intensive care units. These projects will have an immediate and long-term impact by accelerating the implementation of new simulation tools to improve patient safety. The projects span a wide spectrum of settings and populations, in 16 states throughout the United States, including Children's Hospital of Philadelphia, Louisiana State University Health Sciences Center in New Orleans, and Scott and White Hospital in Temple, Texas. For a complete listing of the 19 projects, go to https://www.ahrq.gov/qual/simulproj.htm.

  What is Medical Simulation? Medical simulation involves scenarios in which real-life medical situations are re-created so that health care providers can practice new procedures and techniques before performing them on patients and potentially placing them at risk. These projects will inform providers, health educators, payers, policy makers, patients, and the public about the effective use of simulation in preventing medical errors and improving patient safety.

• On January 11, 2007 AHRQ released the 2006 National Healthcare Quality Report (NHQR) and its companion document, the 2006 National Healthcare Disparities Report (NHDR). These reports measure quality and disparities in four key areas of health care: effectiveness, patient safety, timeliness, and patient centeredness.

  The NHQR employs a wide range of measures, including health care outcomes such as hospital-acquired infections and reductions in deaths from certain diseases. It also measures how well the health care system is using specific treatments that are known to work most effectively. The NHDR compares these measures by race and ethnicity and by income. It also measures access to care, using indicators such as health insurance status and frequency of visits to a physician. Examples of findings in the NHQR and NHDR include:

  • Only about 52 percent of adults reported receiving recommended colorectal cancer screenings. About 56,000 Americans die from colorectal cancer, and 150,000 new cases are diagnosed each year. In 2002, the AHRQ-supported U.S Preventive Services Task Force urged initial screenings at age 50 and earlier for people at high risk.
  • Fewer than half of obese adults reported being counseled about diet by a health care professional. About one-third of American adults are obese, increasing the risks of high blood pressure, type 2 diabetes, stroke, heart disease and osteoarthritis. The Task Force recommends "intensive counseling and behavioral interventions" for obese adults.
  • Only 49 percent of people with asthma said they were told how to change their environment, and 28 percent reported receiving an asthma management plan. Asthma causes about 500,000 hospitalizations annually.
  • Only 48 percent of adults with diabetes received all three recommended screenings—blood sugar tests, foot exams and eye exams—to prevent disease complications. AHRQ estimates about $2.5 billion could be saved each year by eliminating hospitalizations related to diabetes complications.
  • Overall, the review of 40 core quality measures found a 3.1 percent increase in the quality of care—the same rate of improvement as the previous 2 years. Except for vaccinations for children, adolescents, and the elderly, which improved by almost 6 percent, the improvement rate for other preventive measures—screenings, advice, and prenatal care—was less than 2 percent. The greatest quality gains occurred in U.S. hospitals, where quality improved 7.8 percent. Ambulatory care—health services provided at doctors' offices, clinics or other settings without an overnight stay—improved by 3.2 percent. Nursing home and home health care improved by 1 percent.
  • As in previous years, the federal disparities report found access to care varied widely between racial, ethnic and economic groups. Blacks received poorer quality care than whites for 73 percent of the core measures included in the disparities report. Hispanics received poorer quality of care than non-Hispanic whites for 77 percent of the measures. Poor people received lower quality of care than high-income people for 71 percent of the measures. Those variations were particularly apparent in the area of prevention. Obese blacks were less likely to be told they were overweight by their doctor or other health care provider. Colorectal cancer screening rates were significantly lower for blacks and Asians when compared with whites. Among people 65 and older, blacks, Hispanics and those in lower income groups were less likely to have ever received a vaccine to prevent pneumonia.

• AHRQ, in partnership with The Council of State Governments, released Asthma Care Quality Improvement: A Resource Guide for State Action and its companion Workbook, both of which are designed to help state leaders identify measures of asthma care quality, assemble data on asthma care, assess areas of care most in need of improvement, learn what other states have done to improve asthma care, and develop a plan for improving the quality of care for their states. This new Resource Guide uses data from AHRQ's National Healthcare Quality Report and National Healthcare Disparities Report and Web-based State Snapshots to help inform the Nation and States, respectively, about the quality of asthma care.

• In FY 2006, AHRQ partnered with United Health Foundation to distribute more than 400,000 copies of the 2006 Guide to Clinical Preventive Services, a new guide to evidence-based clinical preventive services recommendations, to clinicians nationwide. The guide contains 53 new or revised recommendations from the AHRQ-sponsored U.S. Preventive Services Task Force, which is the leading independent panel of private-sector experts in prevention and primary care and conducts rigorous, impartial assessments of the scientific evidence for abroad range of preventive services. Its recommendations are considered the gold standard for clinical preventive services.

  Recommendations focus on screenings for obesity, breast cancer, abdominal aortic aneurysm, and HIV; hormone therapy for the prevention of chronic conditions in postmenopausal women; and diet and behavioral counseling. The recommendations are grouped by cancer; cardiovascular problems; infectious diseases; mental and substance abuse disorders; metabolic, nutritional, and endocrine disorders; musculoskeletal conditions; and obstetric and gynecological conditions.

  United Health Foundation is working with medical and nursing societies, including the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Academy of Nurse Practitioners, and the American Osteopathic Association to provide free copies of the guide to their members. AHRQ will also distribute the guide on request.

• A new Electronic Preventive Services Selector (ePSS) tool for primary care clinicians to use when recommending preventive services for their patients was released in FY 2006. The interactive tool is designed for use on a personal digital assistant (PDA) or desktop computer to allow clinicians to access the latest recommendations from the AHRQ-sponsored U.S. Preventive Services Task Force. It is designed to serve as an aid to clinical decision-making at the point of care and contains 110 recommendations for specific populations covering 59 separate preventive services topics. The "real time" search function allows a clinician to input a patient's age, gender, and selected behavioral risk factors, such as whether or not they smoke, in the appropriate fields. The software cross-references the patient characteristics entered with the applicable Task Force recommendations and generates a report specifically tailored for that patient.

HCQO: Efficiency

American health care should provide services of the highest quality, with the best possible outcomes, at the lowest possible cost. Striving to reach this ideal is a primary emphasis of AHRQ's mission with many of its activities directed at improving efficiency through the design of systems that assure safe and effective treatment and reduce waste and cost. The driving force of this agency-wide strategic goal is to promote the best possible medical outcomes for every patient at the lowest possible cost.

Health care costs in America continue to rise. According to the most recent data from the Medical Expenditure Panel Survey (MEPS), total health care expenses in 2003 were $895 billion compared with $810 billion in 2002—an increase of 10.5 percent. Health insurance premiums increased 9.2 percent in 2003. The average annual total premium for single coverage was $3,481 compared with $3,189 in 2002. Family coverage averaged $9,249 compared with $8,469 in 2002.

Given the increasing costs of health care, it is vitally important for us to find ways to help Americans achieve wider access to high-quality health care and become more efficient in providing that care. The goal is to provide safe and effective health care, with the best possible outcomes, at the lowest possible cost. AHRQ directs many of its activities toward improving efficiency through the design of systems that assure safe and effective treatment and reduce waste and cost. For example:

• Data from the Healthcare Costs & Utilization Project (HCUP) show that with appropriate primary care for diabetes complications, the nation could save nearly $2.5 billion in hospital costs, with significant potential savings obtained in Medicare ($1.3 billion of total costs) and Medicaid ($386 million of total costs).
• Women who live in areas with a high number of managed care organizations (MCOs) were nearly twice as likely to have recently received a mammogram or Pap smear and were 58 percent more likely to have had a recent clinical breast exam than women in areas with low managed care penetration.

Efficiency

Prevention

Our Prevention Portfolio is seeking to support the goal of efficiency by creating the ability to provide timely knowledge of clinical prevention that can promote wider access to effective health care services and thus could reduce health care costs. The U.S. Preventive Services Task Force (USPSTF) generates evidence-based recommendations on clinical preventive services based on the benefits and harms to the patient. These recommendations can guide others in prioritizing resources for clinical prevention that could lead to increased access and decreased costs. By "increasing the timeliness and responsiveness of the USPSTF to emerging needs in clinical prevention", the Prevention Portfolio can support the Agency's overall goal of efficiency.

Pharmaceutical Outcomes

Within the pharmaceutical outcomes portfolio, trend analysis and baseline measures have been developed through the use of MEPS and HCUP and in consultation with the AHRQ research community. As a result of this planning and evaluation activity, all relevant AHRQ-funded activities have been compiled and summarized and ten-year goals for improvement have been established. Work with partners is planned to support the achievement of these targets. Work is ongoing for the development of an efficiency goal related to improved prevention of re-hospitalization for congestive heart failure.

HCQO: Effectiveness

To assure the effectiveness of health care research and information is to assure that it leads to the intended and expected desirable outcomes. Supporting activities that improve the effectiveness of American health care is one of AHRQ's strategic goals. Assuring that providers and consumers get appropriate and timely health care information and treatment choices are key activities supporting that goal.

One significant AHRQ investment focuses on how best to define and measure the effectiveness of health care services. Other areas of work focus on disease prevention and assuring that health care providers and consumers have the information they need to adopt healthy life styles. Additional AHRQ efforts include providing reliable information when health care providers and patients must consider the relative effectiveness of various treatment protocols and the appropriateness of alternative pharmaceutical choices.

Effectiveness

Data Development

The effectiveness strategic plan goal includes two large data development portfolio programs: CAHPS® and the Healthcare Cost and Utilization Project (HCUP).

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program is a multi-year initiative of AHRQ. Originally, CAHPS® referred to the AHRQ's Consumer Assessment of Health Plans Study; however, that name was changed in 2005 to reflect the evolution of the program from its initial focus on enrollees' experiences with health plans, including federal employees and Medicare beneficiaries enrolled in Massachusetts plans, to a broader focus on experiences with various aspects of the health care system. AHRQ first launched the program in October 1995 in response to concerns about the lack of good information about the quality of health plans from the enrollees' perspective.

Over time, the program has expanded beyond its original focus on health plans to address a range of health care services and meet the various needs of health care consumers, purchasers, health plans, providers, and policymakers. The first stage of this program is referred to as CAHPS® I. The second, current stage, is referred to as CAHPS® II.

The CAHPS® Hospital Survey is a standardized survey of the experiences of adult inpatients with hospital care and services. In January 2006, the CAHPS® Hospital Survey was approved, and national implementation plans are proceeding. A short "dry run" of the survey implementation will be conducted with participating hospitals to give hospitals and vendors first-hand experience in collecting and transmitting the survey data (without public reporting of results). National implementation of the CAHPS® Hospital Survey is scheduled for Fall 2006. Hospitals across the country will begin using this survey and voluntarily reporting data to the Centers for Medicare & Medicaid Services (CMS). CMS plans to initiate public reporting of those results in late 2007.

The CAHPS® Consortium is refining and expanding the family of ambulatory care surveys to be more attuned to the needs of sponsors and variations in health care markets. The content and structure of the Health Plan Survey is being streamlined to focus the core questionnaire more on essential health plan functions, such as customer service, denial of service, and complaints and appeals. A new survey, CAHPS® Clinician and Group Survey will be finalized by the Spring of 2006 and asks patients about their recent experiences with physicians and other staff. The CAHPS® People with Mobility Impairments Survey asks adults with mobility impairments about their experiences with health care and services. The CAHPS® American Indian Survey is being developed in collaboration with the Choctaw Nation Health Service and asks adult American Indians about their experiences with Choctaw Nation health care facilities.

HCUP is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership. HCUP databases bring together the data collection efforts of State data organizations, hospital associations, private data organizations, and the Federal government to create a national information resource of patient-level health care data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.

Information from HCUP provides insight into a wide array of conditions and issues. Here are just a few of the news reports in 2006 based on HCUP data:

• The National Hospital Bill. In 2004, the national hospital bill totaled almost $800 billion for nearly 39 million hospital stays. Sixty percent of the national bill for hospital care was billed to two government payers, Medicare ($363 billion) and Medicaid ($112 billion), while $252 billion was billed to private insurance.
• Elderly Hospital Stays. From 1997 to 2004, elderly individuals represented approximately 12 percent of the U.S. population each year; however, this age group accounted for a substantially larger portion of hospital stays annually—about 35 percent.
• Uninsured Hospitalizations. One out of five uninsured hospital stays was for the treatment of conditions related to pregnancy, childbirth, and newborn infants. Injury accounted for 11 percent of all uninsured hospital stays, which was higher than for privately insured stays (6.8 percent). Nearly 11 percent of uninsured hospital stays were for mental health and substance abuse disorders—almost three times the rate for privately insured stays.
• Obesity Surgery. From 1998 to 2004, the total number of bariatric surgeries increased nine-fold, from 13,386 to 121,055. Women accounted for 82.0 percent of all bariatric surgeries in 2004.
• Influenza. The elderly were more likely than any other age group to be hospitalized for influenza—27.9 hospital stays per 100,000 population for ages 65 and above—compared with 8.1 stays per 100,000 for those younger than 18, 1.7 stays for 18-44 year olds, and 4.4 stays per 100,000 for 45-64 year olds. The in-hospital death rate for patients 85 years and older with influenza was more than twice the in-hospital death rate for influenza patients between 65 and 84 years of age (7.9 percent versus 3.3 percent).
• C-Section Deliveries and Vaginal Birth after C-Section. Over a quarter of childbirths are delivered via C-section—a 38 percent increase from 1997, when about a fifth of deliveries were performed via C-section. Since 1997, the rate of vaginal births after C-section (VBAC) has decreased from 35.3 VBACs per 100 women who had a previous C-section to 13.7 in 2003—a decline of more than 60 percent.
• Preventable Hospitalizations among Minorities. Many preventable hospitalizations are higher among minorities. Hospitalization rates for hypertension and for diabetes without complications were 5 times higher for blacks than for non-Hispanic whites. Hospitalization rates for pediatric asthma, adult asthma, perforated appendix, dehydration, and low birth weight were also highest among blacks. Hispanics had the highest rates of admission for elderly asthma, pediatric gastroenteritis, and urinary tract infection.
• Alcohol Abuse. There were nearly 210,000 hospitalizations for alcohol abuse disorders, amounting to about $2 billion in aggregate charges annually. Alcohol abuse was a concomitant condition for an additional 1.1 million hospital stays; thus, over 3 percent of all hospital stays included some mention of alcohol abuse.
• Pressure Sores. In 2003, there were 455,000 hospital stays during which pressure sores were noted—a 63 percent increase from 11 years earlier.

Prevention

Americans die prematurely every year as a result of diseases that often are preventable, such as heart disease, diabetes, some cancers, and HIV/AIDS. To address these issues, AHRQ convenes the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts in primary health care and prevention. The mission of the task force is to conduct comprehensive assessments of a wide range of preventive services to include screening tests, counseling activities, immunizations, and preventive therapies. A recent recommendation concerned use of estrogen:

• The USPSTF issued a new recommendation against the routine use of estrogen to prevent chronic conditions such as heart disease, stroke and osteoporosis in postmenopausal women who have undergone a hysterectomy. The Task Force noted that, although estrogen can have positive effects such as reducing the risk for fractures, hormone therapy should not be used routinely because it appears to increase women's risk for potentially life-threatening clots that block blood vessels (venous thromboembolism), stroke, dementia and mild cognitive impairment. The Task Force noted that while the use of estrogen reduces the risk for fracture, drugs such as bisphosphonates and calcitonin are available and effective in helping prevent fractures in women diagnosed with osteoporosis. The Task Force concluded that for most women, the harmful effects of estrogen therapy outweigh any benefits for fracture and other chronic conditions.

The recommendations of the U.S. Preventive Services Task Force are now available on a hand held personal digital assistant (PDA) or desktop computer. A new Electronic Preventive Services Selector (ePSS) tool for primary care clinicians to use when recommending preventive services for their patients was released in FY 2006. The interactive tool is designed for use on a personal digital assistant (PDA) or desktop computer to allow clinicians to access the latest recommendations from the AHRQ-sponsored U.S. Preventive Services Task Force. It is designed to serve as an aid to clinical decision-making at the point of care and contains 110 recommendations for specific populations covering 59 separate preventive services topics. The "real time" search function allows a clinician to input a patient's age, gender, and selected behavioral risk factors, such as whether or not they smoke, in the appropriate fields. The software cross-references the patient characteristics entered with the applicable Task Force recommendations and generates a report specifically tailored for that patient.

Pharmaceutical Outcomes

In 2005, the Effective Health Care Program focused initially on issues of special importance to Medicare. Section 1013 of the MMA authorizes the Secretary of Health and Human Services to regularly consider priority areas for research under this Section. In 2006, the priority list will be updated to include Medicaid and the State Children's Health Insurance Program (SCHIP). A Listening Session was held in early 2006 to solicit input on research priorities for the Effective Health Care Program that included an open forum in which participants gave oral comments on suggested topics for study and the structure of the priority lists (e.g., disease/condition, type of intervention, effected population, etc.). A link online was available until March 15, 2006, which allowed people to make suggestions for additional priority conditions, which will be considered for inclusion in the priority conditions list in 2006-2007. People can continue to make nominations for priority conditions at any time through the Web site at https://effectivehealthcare.ahrq.gov/get-involved/suggest-topic.

During 2006, three projects within the DEcIDE network will develop methodological tools for analyzing pharmaceutical data that result from implementation of Part D (the prescription drug benefit program) of the MMA. The major goals of these projects are to develop:

1. An evidence-based approach to standardizing drug prescription statistics and outcome measures of the safety of drugs.
2. Algorithms for identifying usage patterns.
3. A data system and empirical framework for identifying and capturing adverse drug events.

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