Long-term Care

Long-term Care

Long-term Goal: Improve quality and safety in all long-term care settings and during transitions across settings.

Data Source:  National Health Care Quality Report based on CMS's Minimum Data Set and Outcome and Assessment Information Set (OASIS) data.
Data Validation:  AHRQ products under go extensive peer review for merit and relevance.
Cross Reference:  SG-1/5/6; HP2010-1; 500-Day Plan—Transform the Healthcare System.

a. New measure—FY 2004.
b. Limited AHRQ funding produced a draft manual. No current funding/ongoing activities are associated with this initiative.
c. New measure—FY 2006.
 

An Institute of Medicine (IOM) report entitled Improving the Quality of Long-term Care (2001) states that concerns about problems in the quality of long-term care persist despite some improvements in recent years, and are reflected in, and spurred by, recent government reports, congressional hearings, newspaper stories, and criminal and civil court cases. "Examples of high priority quality and safety concerns are the high prevalence of pressure ulcers, the large number of residents having serious falls, medical and drug errors, preventable hospitalizations caused by inadequate care management at transitions from hospital to long term care, and the difficulty consumers of assisted living and residential care have evaluating the quality and services provided in those settings."

The purpose of AHRQ's Long-term Care Portfolio is to develop processes and tools supported by evidence-based research and to foster the integration of those processes and tools into the practice of long term care so that providers can improve quality and safety while reducing costs and consumers of long term care have tools available to make informed decisions.

To meet these goals the Long-term Care Portfolio funds research to develop evidence to support tool development and test the impact on quality of integrating evidence-based tools into every day practice. It partners with stakeholders to disseminate evidence-based tools, and evaluates approaches to implementing these practices into the day-to-day practice of care received by longterm care users. The portfolio is currently focusing on preventing pressure ulcers and injurious falls in nursing homes, improving care management of person discharged from hospital to home health, and improving tools to help consumers of assisted living make informed choices.

In 2006, the Portfolio expanded its pressure ulcer prevention projects to help train Medicare Quality Improvement Organizations (QIOs) in decision support approaches to pressure ulcer prevention care. It also began efforts to disseminate the falls prevention program. In 2006 projects that assess the state of the art of assisted living consumer tools were completed. The 2007 projects build on early small studies of pressure ulcer and falls prevention in nursing homes that have been shown to improve quality and it is part of the Portfolio's strategy to bring these interventions to scale.

In 2008, as in 2007, AHRQ continues to develop tools to help consumers make informed choices about their use of home and community-based and institutional-based long-term care services. In 2008 the Portfolio continues to expand its development, implementation, and dissemination activities for these four priority areas.

Return to Contents

Pharmaceutical Outcomes

Long-term Goal: By 2014 antibiotic inappropriate use in children between the ages of one and fourteen should be such that use is reduced from 0.56 prescriptions per year to 0.42 per child (25%).

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

Data Source:  The data source for trends in children's use of antibiotics is the Medical Expenditure Panel Survey (MEPS). MEPS is one of the core national sentinel data resources for tracking trends in health care use and expenditures. MEPS is widely used by researchers in academia, government, and other research institutions and is recognized as a premier source of nationally representative data on medical use and expenditures. The data source for trends in congestive heart failure readmission rates and reduced hospitalization for upper gastrointestinal bleeding is the Healthcare Cost and Utilization Project (HCUP) database. HCUP is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of 37 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.
Data Validation:  The 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 has been cleared and meets standards for adequate response rates, and timely release of public use data files. The validity of the HCUP data is verified several times a year by 37 state data organizations and then at the federal level by AHRQ.
Cross Reference:  SG-1/5; HP2010-14/17; 500-Day Plan—Transform the Healthcare System.

d. New measure beginning FY 2004 for PARTed program.

Reduction in antibiotic use should be associated reduction of adverse reactions to medication and the cost of medical care. It may also be associated with improvement in the rates of resistant organisms. A two-fold approach to this reduction is needed, through both the clinician and the caretaker. This goal includes children, a priority population for AHRQ. Antibiotic resistance is an important public health problem. During this past year, this target was not achieved. Concerns have been raised as to our inability to separate inappropriate use from appropriate use. During the upcoming year, we will discuss narrowing the target to diagnoses that more appropriately identify inappropriate usage (e.g., antibiotic usage for viral illness).

In FY 2006, efforts have continued to reduce congestive heart failure hospital readmission rates in those between 65 and 85 years of age. A recent study of patients undergoing home health care highlighted some issues related to hospitalization. A recent AHRQ-funded grantee publication from the Centers for Education and Research on Therapeutics (CERTs) showed improvement in patient-based education on discharge when improvements were made through usage of an IT intervention. Lack of education during this transition of care may well be one of the major causes of re-hospitalizations.

The third major long-term goal of the portfolio is to reduce hospitalizations for upper gastrointestinal bleeding in those between 65 and 85 year of age. During FY2006, a number of studies and projects have been underway within the portfolio that relate to appropriate use of products that can cause bleeding.

A recent CERTs-funded study showed that. Doctors ordered 15 percent fewer prescriptions for drugs that can interact with the blood thinner warfarin by using a computerized system that produced a safety alert whenever the interacting drug's name was keyed in. Whenever a doctor in one of the 15 primary care clinics, involved in the study, prescribed any drug that would interact with warfarin to cause abnormal bleeding, an alert on the computer screen would tell the doctor the potential adverse outcome and suggest an alternative medication. AHRQ's Office of Communications and Knowledge Transfer developed a dissemination plan for this study finding. Although the incidence of hospitalizations did not drop this past year, the cost for these hospitalizations did drop.

Return to Contents

Prevention

Long-term Goal: To translate evidence-based knowledge into current recommendations for clinical preventive services that are implemented as part of routine clinical practice to improve the health of all Americans.

Data Source:  National Health Quality Report; National Healthcare Disparities Report; AHRQ—USPSTF/Preventive Services website; AHRQ product distribution process; AHRQ Preventive services databases (internal); Web trends; AHRQ Publications Clearinghouse; National Guideline Clearinghouse™; Preventive Services Selector Tool; Evidence Based Practice Center task order documents
Data Validation:  Because the Prevention Portfolio cannot collect primary quantitative data regarding healthcare service delivery or quality, it relies on federal partners and federal public release data sources for these measures, which include the National Health Quality Report and National Healthcare Disparities Report. As legislated by Congress, AHRQ produces these reports annually. Data comprising the reports are drawn from multiple databases (e.g., MEPS, HCUP, CAHPS® [Consumer Assessment of Healthcare Providers and Systems]) supported by AHRQ, in addition to other databases (such as the National Health Interview Survey [NHIS], supported by CDC). These reports and the databases from which they are drawn are considered definitive sources of healthcare quality measures. Other data sources (qualitative): Stakeholder meetings, expert panel meetings, and focus groups. Qualitative data were gathered primarily by outside contractors. The information obtained was analyzed, synthesized and reported using established methodology. Because of the limitations of qualitative data with respect to validity, the results obtained from these sources were used to identify successful case studies, themes, and areas for future opportunity. Other data sources (internal): Database established to monitor the timeliness of current recommendations. Database established in 2006 to track partnership development and collaborative activities with public and private organizations.
Cross Reference:  SG-1/5; HP2010-13/14/15/16/18/19/21/22/24/25/27; 500-Day Plan: Transform the Healthcare System; prevention; improving the clinical research network.

e. Data are for 7/1/05-6/30/06.
f. New measure developed FY 2004.
g. New measure developed FY 2005.

The prevention portfolio focuses on increasing the quality and quantity of preventive services with the goal of improving health and health care quality. Each of the measures supports the improved delivery of clinical preventive services in the primary care setting. In FY 2005, the portfolio successfully completed the targets for each of the performance goals. In FY 2006, the portfolio continues it work by:

• Developing targeted products for clinicians, consumers and employers by improving and increasing the distribution of Prevention Portfolio products and tools is a critical means of expanding the 'reach' of evidence-based clinical preventive services. To reach as many clinicians, consumers, and employers as possible, a mix of products and tools has been developed and is currently being tracked. These products and tools include electronic media (AHRQ Preventive Services Web site, PDA clinical services selector tool, AHRQ Prevention Listserv), print publications for clinicians (2005/2006 Guide to Clinical Preventive Services), print publications/products for consumers (e.g., Adult Preventive Services timeline/wall chart), a guide to preventive services developed for health care purchasers, and web and print publications oriented toward academic audiences (e.g., peer-review journal articles for clinicians and researchers). Insurance coverage for clinical preventive services removes an economic barrier to access. AHRQ provided technical assistance to National Business Group on Health and CDC in development of a Purchaser's Guide for clinical preventive services to provide employers and benefit managers and consultants with evidence-based guidelines for Summary Benefit Plans that are based on the US Preventive Services Task Force recommendations.
• Enacting processes for topic submission/nomination developed in FY 2005 and track number of topics nominated by producing recommendations that are responsive to the needs of practicing clinicians which is critical to getting the recommendations implemented into routine clinical practice and improving health. The process for submitting (nominating) topics that was developed by the new USPSTF topic prioritization workgroup in FY 2005 has been implemented, with the result that 32 topics were nominated by federal agencies and professional organizations to be considered for review by the USPSTF in response to the Federal Register notice. Consideration of these topics by the USPSTF topic prioritization work group has been completed and recommendations have been made to the full Task Force regarding their review. As a result two new topics have been added to the queue for review by Evidence-Based Practice Centers (EPCs).
• Track improvements in timeliness by producing evidence-based recommendations in a timely way is essential to the translation of research on clinical preventive services into high quality, effective, and safe health care that improves the health and well-being of Americans. In FY 2005, the USPSTF and AHRQ staff established and implemented processes to identify, select, and prioritize topics for review and updating. Keeping recommendations updated within the National Guideline Clearinghouse™ standards involves constant consideration of new evidence and careful allocation of Task Force resources because a variable number of topics need to be considered for updating each year. The Prevention Portfolio is on track to maintain the high level of performance achieved in FY 2005 in keeping topics up to date. FY 2006 data by December 2006.
• Develop targeted partnerships related to the elderly, colorectal cancer screening and healthy behaviors as indicated by data from FY 2005. Strong partnerships have been established with many federal and non-federal partners to strategically leverage and expand the work of the Prevention Portfolio. This strong foundation of effective partnerships provides a springboard for multiple activities of differing intensity, duration, scope, and reach that targets different audiences. For FY 2006, these activities include a focus on employers and purchasers of benefit plans (development of the National Business Group on Health [NBGH] Purchasers Guide to evidence-based clinical preventive services including colorectal screening and healthy behavior counseling); facilitating linkages between clinical providers of preventive services and public health programs and community based social service organizations (CDC partnership with Steps to a Healthier US—prevention of chronic disease through healthy behaviors; Administration on Aging/CDC partnership supporting evidence based prevention programs for older adults); support to clinical providers through their health professional societies (partnership with Partnership for Prevention Health Professional Roundtable).

Return to Contents
Proceed to Next Section