Online Performance Appendix: Performance Detail, Prevention and Care Management

The purpose of AHRQ's Prevention/Care Management portfolio is to improve the quality, safety, efficiency, and effectiveness of the delivery of evidence-based preventive services and chronic care management in ambulatory care settings. We seek to accomplish our mission by:

• Supporting clinical decisionmaking for preventive services through the generation of new knowledge, the synthesis of evidence, and the dissemination and implementation of evidence-based recommendations.
• Supporting the evidence base for and implementation of activities to improve primary care and clinical outcomes through
  • Health care redesign.
  • Clinical-community linkages.
  • Self-management support.
  • Integration of health information technology.
  • Care coordination.

Generation of New Knowledge

In FY 2009, several activities have been undertaken to accelerate the pace of research on complex patients (patients with multiple chronic conditions). First, Portfolio staff convened a meeting of the 18 investigators who were awarded grants in this area in FY 2008. The purpose of the meeting was to encourage the investigators to explore opportunities for collaboration as an efficient way to move the field ahead more rapidly. Portfolio staff also issued a funding opportunity limited to these 18 institutions to support collaborations that will advance the creation of large, clinically focused data sets and the refinement of methods to study complex patients.

AHRQ deliberately limited the competition to these 18 institutions. In FY 2008, in reviewing applications for the original grant award, we learned that little work is being done in the field of understanding prevention and care management for people with multiple chronic conditions. We awarded 18 grants to the most advanced investigators in this field. In FY 2009, we brought the investigators together for an in-person meeting to encourage them to form collaborations to accelerate the pace of knowledge generation in this area. In spite of the challenges faced by the grantees, most were making significant progress toward the goal of better understanding the prioritized health care needs of patients with multiple chronic conditions.

In order to leverage limited funding resources to achieve maximum progress in the field and to encourage collaboration among these research leaders, we then issued an announcement for a limited competition R21 grant opportunity among the original 18 institutions. This will allow a few of the original 18 grantees to build bridges between their projects, for example, by merging data into shared databases or refining methodologies to better study this population. Our goal for this work is to expand the research infrastructure for future investigations on the population of patients with multiple chronic diseases.

Knowledge Synthesis and Dissemination

The Portfolio fulfills AHRQ's congressionally mandated role to convene the U.S. Preventive Services Task Force (USPSTF). The USPSTF is mandated to conduct scientific evidence reviews of a broad array of clinical preventive services (screening, counseling, and preventive medication) and to develop recommendations for the health care provider community. The Portfolio provides ongoing administrative, research, technical, and dissemination support to the USPSTF, which is an independent panel of nationally renowned, non-Federal experts in prevention and evidence-based medicine comprising primary care clinicians (e.g., internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists) with strong science backgrounds.

The USPSTF develops and releases evidence-based recommendations for the health care provider community to improve the delivery of appropriate preventive services in the clinical setting. The multi-year process of generating a recommendation begins with a solicitation of topic nominations through a Federal Register notice and consultation with stakeholders. The USPSTF prioritizes nominated topics for review and for updating. From the pool of USPSTF prioritized topics, portfolio staff selects specific clinical preventive service(s) based on Agency and Departmental strategic goals to focus the portfolio's work.

In FY 2009 (as of April 13, 2009) the USPSTF has released six recommendations on clinical preventive services: three for screening services, two for counseling services, and one for preventive medication. Five other recommendations are pending publication, and work was either been initiated or continued on approximately 30 topics.

As reflected in key outcome measures for FY 2008 and FY 2009, and to continue through 2014, portfolio staff have prioritized knowledge generation, dissemination, and implementation work in the area of screening for colorectal cancer (CRC). This preventive service has been prioritized because current rates of uptake of screening for CRC are low, CRC is the third most common cancer in the United States, and there are health disparities in receipt of the service.

In 2009, two reports were published in the Annals of Internal Medicine in conjunction with the publication of the updated USPSTF recommendation on Screening for Colorectal Cancer. These included a systematic evidence review conducted by the Oregon Evidence-based Practice Center¹ and a decision analysis of CRC screening tests that focused on age to begin and end screening, and on screening intervals. This work was conducted by the Cancer Intervention and Surveillance Modeling Network (CISNET).²

Based on this evidence, the USPSTF recommended screening for CRC using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75 years. For the first time, the USPSTF recommended that screening for CRC should stop after age 85, and it recommended against routine screening for adults age 76-85. Finally, the USPSTF found insufficient evidence to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for CRC.

USPSTF recommendations provide one essential foundation for dissemination, implementation, and integration activities within the portfolio. In FY 2009, Portfolio staff worked with The Centers for Medicare and Medicaid Services (CMS) and the National Committee on Quality Assurance (NCQA) to inform national coverage decisions and performance measures on screening for CRC. For example, Portfolio staff, the Chair of the USPSTF, and the principal investigators of the evidence reports referenced above gave several presentations on the evidence regarding screening for CRC using CT colonography and the rationale for the USPSTF recommendations. These presentations were made to staff at CMS and the Medicare Evidence Development and Coverage Advisory Committee (MEDCAC).

In FY 2009, Portfolio staff continued to serve as full and active members of the National Colorectal Cancer Roundtable, and a joint project is underway with Federal and non-Federal partners to translate implementation guidance into more accessible electronic formats to improve the delivery of screening. This electronic tool should be finalized in FY 2009.

In FY 2008, portfolio staff selected a counseling service, Counseling to Promote a Healthy Lifestyle (which includes diet and physical activity), as a second priority area for work in upcoming years. In FY 2009, AHRQ commissioned a work plan from the Oregon Evidence-based Practice Center to update the USPSTF recommendations on counseling to promote a healthy diet and physical activity. The final work plan approved by the USPSTF is primarily designed to address the effectiveness of primary care-relevant counseling interventions to improve diet and physical activity, with a focus on the reduction of cardiovascular disease and related chronic diseases in adults. In addition to examining behavioral outcomes, the final evidence review will also report on relevant intermediate outcomes (e.g., measures related to diabetes, hypertension, dyslipidemia, and weight), and distal health outcomes (death and morbidity related to cardiovascular disease). The final evidence report will be completed in FY2010.

Implementation and Use of Knowledge

In FY 2008, with the American Medical Association and the Association of State and Territorial Health Officials, AHRQ co-sponsored Linking Clinical Practice and the Community for Health Promotion, a summit aimed at encouraging collaboration, coordination, and integration among health care providers, institutions, and community resources. Participants examined successful partnerships at health system, community, and State levels, and identified strategies to overcome partnership barriers.

In FY 2009, in order to facilitate ongoing collaboration among summit participants and to disseminate their work to a larger audience, a special resource page was added to AHRQ's Web-based Innovations Exchange (http://www.innovations.ahrq.gov). Innovation profiles and tools from the Innovations Exchange collection address promoting healthy behaviors and linkages among health care delivery, public health, and community-based interventions.

The FY 2010 President's Budget for Prevention and Care Management is $7,100,000, a level equal to the FY 2009 Omnibus level. These funds will allow AHRQ to continue funding important research on prevention and care management, including the following activities:

• Provide support to large and small grants related to prevention and care management research, with a focus on grants that implement findings from the exploratory work completed in FY 2009 on optimizing prevention and care management in complex patients.
• Provide support to rapid-cycle grants to study ambulatory practices across the U.S. that have attempted to transform their practices into patient-centered medical homes.
• Support Evidence-based Practice Centers to conduct systematic evidence reviews for use by the USPSTF in making recommendations on clinical preventive services.
• Generate and synthesize knowledge regarding the ways in which new recommendations and evidence-based services are incorporated into clinical practice and/or health care systems.
• Promote the implementation and use of appropriate evidence-based clinical services.
• Convene the USPSTF three times during the fiscal year.
• Support the training of preventive medicine residents in evidence-based medicine.

By 2010, integration of Prevention and Care Management into one Portfolio will be complete and work will continue to support the new strategic goals. In FY 2009, work began with Agency-sponsored evaluators to establish performance measures and data sources to reflect the work of the new integrated Prevention and Care Management Portfolio.

In addition, as shown in the Outputs and Outcomes Tables below, in FY 2010 AHRQ will establish the baseline screening rate for men and women age 50+ who report having been screened for CRC. AHRQ faces many challenges in being able to measure the impact of the Portfolio on screening rates, including the availability of trend data. Specifically, the Prevention/Care Management Portfolio does not direct or control how preventive services usage data are gathered via the National Health Information Survey (NHIS), or how and when the data are presented in the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) (which also must rely on how questions are worded in the NHIS and other national surveys).

In 2010, work will be completed on two systematic evidence reviews, one on counseling to promote a healthy diet and one on counseling to promote physical activity. These reports will assist the Task Force in making a bundle recommendation on counseling to promote a healthy lifestyle to be implemented in clinical practice. Portfolio staff will finalize the strategic plan for dissemination and implementation work in this topic area. These interim outputs ultimately support the appropriate delivery of this service to Americans.

Findings from the grant program, Optimizing Prevention and Healthcare Management in Complex Patients, will be available in 2010. The results may be used to guide the development of a funding opportunity announcement for grants that implement the results of the exploratory studies.

Long-Term Objective 1: To translate evidence-based knowledge into current recommendations for the provision of clinical preventive services that are implemented as part of routine clinical practice, thereby contributing to improvements in the quality of preventive care and improved health outcomes in the general population and in priority populations.

¹Whitlock EP, Lin JS, Liles E, Beil TL, and Fu R. (2008) Screening for colorectal cancer: A targeted, updated systematic review for the U.S. Preventive Services Task Force. AIM 149(9):638-58.
²Zauber AG, Lansdorp-Vogelaar I, Knudsen AB, Wilschut J, van Ballegooijen M, and Kuntz KM. (2008). Evaluating test strategies for colorectal cancer screening: A decision analysis for the U.S. Preventive Services Task Force. AIM 149(9):659-69.

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