Significant Items

Budget Estimates for Appropriations Committees, Fiscal Year 2010

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

FY 2009 House Report No. 110-XXX

Quality, Effectiveness, and Efficiency Research

1.      House (Rept. 110-XXX)

In addition, the Committee is deeply concerned about declines in the number of and funding for, training grants for the next generation of researchers. Failure to fund such grants stifles the workforce and knowledge base needed to respond to the Nation's growing health care challenges, including aging baby boomers, unsustainable rising costs, and declining health status. The Committee provides AHRQ with additional funding for training grants to ensure America stays competitive in the global research market. In addition, the Committee urges the Department of Health and Human Services to expand funding for AHRQ's investigator-initiated research and training grants in its FY 2010 budget request
Action Taken or to be Taken:
In FY 2010, AHRQ will continue its strong commitment to support the next generation of researchers and investigator-initiated research. In FY 2010, AHRQ will continue support for the National Research Services Award (NRSA) program, which supports approximately 90 new health services research trainees every year. The NRSA program supports a total of 160 trainees annually. AHRQ will also continue support for its career development programs, which will support 10 new research career development awards to clinicians and doctorally prepared trainees. In FY 2010, AHRQ will continue $1.5 million in support for its infrastructure development program, which provides institutional funding for the development of research capacity to conduct health services research.
In order to ensure support for investigator-initiated research AHRQ has released two new funding opportunity announcements to inform the health services research community of current agency research priorities and to stimulate new investigator-initiated research grant applications. Funding priority will be given to investigator-initiated grant applications responding to these funding announcements. Additionally, the FY 2009 appropriations bill provides for a significant increase in funding for this investigator-initiated research.

Diabetes

2.      House (Rept. 110-XXX)

In order to incentivize and improve long-term health outcomes for Medicare and VA beneficiaries, among others, the Committee encourages AHRQ, in collaboration with CDC and NIH, to prioritize the development of a case mix adjustment methodology that can be used with performance measurement of blood glucose control. The Committee encourages AHRQ to conduct a feasibility study on the state of the art in developing such a tool and a plan, with set timelines, for producing a validated methodology for use by CMS and the VA health care systems, at a minimum, in those program's quality reporting initiatives.
Action Taken or to be Taken:
Intensive management of hemoglobin A1c can reduce the risk of complications of diabetes. Many organizations including the American Association of Clinical Endocrinologists/American College of Endocrinology, the American Diabetes Association, and the American Geriatrics Society recommend target A1c levels of 7 percent or less as appropriate clinical goals. However, development of performance measures based on A1c for public reporting or pay-for-performance have been more controversial.
There is general agreement that poor control of A1c can be reliably measured and reported, and the National Quality Forum (NQF) has twice endorsed such a measure for public reporting. The current measure is percentage of patient with most recent A1c level greater than 9 percent. There is also general agreement that risk adjustment of this measure is not needed since almost all patients with diabetes would benefit from an A1c level under 9 percent.
In contrast, NQF has twice failed to endorse a measure of tight control of A1c (less than 7 percent) for public reporting while recognizing this as an appropriate clinical goal. The reason is that different providers may treat patient populations who differ in their severity of diabetes, presence of co-morbidities, and adherence to treatment recommendations. Tight control of A1c may not be appropriate for severely ill patients with limited life expectancy, while providers who care for large numbers of non-adherent patients may be unfairly disadvantaged in comparisons with providers who care for no non-adherent patients.
Risk adjustment was recognized as one way to level the playing field when comparing providers based on tight control of A1c. Studies have identified a number of patient characteristics associated with A1c level including age, gender, race, ethnicity, BMI, severity of diabetes, duration of diabetes, type of treatment for diabetes, co-morbidities, life expectancy, medication adherence, and self-monitoring adherence. However, to date, no one has developed a risk adjustment methodology for use with A1c measurement. Alternatives to risk adjustment for A1c have also been advanced. These include using a continuous weighted measure rather than a dichotomous measure, focusing on good control (A1c < 8%) rather than tight control, or stratifying by risk rather than seeking to adjust for it.
AHRQ could seek to advance A1c measurement in a number of ways. First, AHRQ could convene experts to propose consensus methods for measuring, adjusting, or stratifying A1c. However, when this was last done in 2006, experts did not come to agreement of a single methodology. Second, AHRQ could provide support to a research group to develop a new methodology. This could be in the form of support to groups that have large A1c databases such as the VA system or one of AHRQ's ACTION partners.

Hydrocephalus Research.

3.      House (Rept. 110-XXX)

Congress has expressed its support for increased public awareness, professional education, and research on hydrocephalus. The Committee encourages AHRQ to support research projects to increase awareness of the medical issues, prevalence, and societal cost associated with hydrocephalus
Action Taken or to be Taken:
To date, AHRQ has not funded research directly related to hydrocephalus. However, two of the priority conditions under our Effective Health Care program include functional limitation and disability and pregnancy, including preterm birth. As we continue to expand our research portfolio, we will consider the merits of supporting research projects associated with hydrocephalus.

Viral Hepatitis

4.      House (Rept. 110-XXX)

Much remains to he learned on the costs, quality, and outcomes of treatments for hepatitis B and C. The Committee urges AHRQ to develop and disseminate evidencebased information to health care providers and patients as a significant step in reducing the incidence and improving the access to and outcomes from treatments for these epidemic diseases.
Action Taken or to be Taken:
The AHRQ Evidence-Based Practice Centers (EPC) program has several recent products on the topic of hepatitis B. The EPC Report Management of Chronic Hepatitis B was published in October 2008 ( http://www.ahrq.gov/clinic/tp/hepbtp.htm) and presented in three sessions at an NIH Consensus Development Conference on October 20-22, 2008 ( http://consensus.nih.gov/2008/2008HepatitisBCDC120main.htm). In addition, a manuscript was published electronically on January 6, 2009 in Annals of Internal Medicine and the print publication date is January 20, 2009. Additional manuscripts are in preparation and submission to professional journals focusing on liver disease.
Previously, AHRQ published an evidence report on Management of Chronic Hepatitis C in June 2002. Additionally, several research grants have produced the following findings that show that self-reported hepatitis B and C virus infections had low sensitivity among HIV-infected patients and there is limited effectiveness of antiviral treatment for hepatitis C in an urban HIV clinic.
AHRQ will continue to support research to help develop and disseminate evidence-based information to health care providers and patients on treatments for conditions such as hepatitis B and C, so that providers and patients can make informed decisions on what treatments work best.

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FY 2009 Senate Report No. 110-410

Spina Bifida

1.      Senate (Rept. 110-410), p. 141

The Committee encourages AHRQ to continue and expand the development of a National Spina Bifida Patient Registry in collaboration with the Centers for Disease Control and Prevention (CDC).
Action Taken or to be Taken:
A Professional Advisory Committee on Spina Bifida has agreed upon registry items. In late FY 2008, academic centers with expertise in spina bifida (research and practice) were awarded cooperative agreements to work with CDC to determine the registry items and begin to submit data. There is a paucity of evidence on efficacious and effective clinical treatment and management strategies for people with spina bifida, and there is a potential that the registry data can provide a basis for posing clinical research questions that could be addressed.
In FY 2009, AHRQ funded a conference grant to the Spina Bifida Association in support of the First World Congress on Spina Bifida Research and Care, which provided a forum for developing and examining basic and clinical research on spina bifida. Building on this activity, in FY 2010, AHRQ will continue to collaborate with the CDC in the development of a National Spina Bifida Patient Registry.

Training Grants

2.      Senate (Rept. 110-410), p. 141

The Committee is deeply concerned about declines in the number of, and funding for, training grants for the next generation of researchers. Failure to fund such grants stifles the workforce and knowledge base needed to respond to the Nation's growing health care challenges, including aging baby boomers, unsustainable rising costs, and declining health status. The Committee urges the administration to expand funding for AHRQ's training grants in its FY 2010 budget request.
Action Taken or to be Taken:
In FY 2010 AHRQ will continue its strong commitment to support the next generation of researchers. In FY 2010 AHRQ will continue support for the National Research Services Award (NRSA) program, which supports approximately 90 new health services research trainees every year. The NRSA program supports a total of 160 trainees annually. AHRQ will also continue support for its career development programs, which will support 10 new research career development awards to clinicians and doctorally prepared trainees. In FY 2010 AHRQ will continue $1.5 million in support for its infrastructure development program, which provides institutional funding for the development of research capacity to conduct health services research.
Additionally, AHRQ plans to expand training opportunities to build intellectual and organizational capacity in the field as the Agency increases its investment in comparative effectiveness research.

Viral Hepatitis

3.      Senate (Rept. 110-410), p. 141

The Committee believes that much remains to be learned about the costs, quality and outcomes of treatments for hepatitis B and C. The Committee encourages AHRQ to develop and disseminate evidence-based information to health care providers and patients as a significant step in reducing the incidence of hepatitis, as well as improving access to, and outcomes from, treatments for these epidemic diseases
Action Taken or to be Taken:
The AHRQ Evidence-Based Practice Centers (EPC) program has several recent products on the topic of hepatitis B. The EPC Report Management of Chronic Hepatitis B was published in October 2008 ( http://www.ahrq.gov/clinic/tp/hepbtp.htm) and presented in three sessions at an NIH Consensus Development Conference on October 20-22, 2008 ( http://consensus.nih.gov/2008/2008HepatitisBCDC120main.htm). In addition, a manuscript was published electronically on January 6, 2009 in Annals of Internal Medicine and the print publication date is January 20, 2009. Additional manuscripts are in preparation and submission to professional journals focusing on liver disease
Previously, AHRQ published an evidence report on Management of Chronic Hepatitis C, in June 2002. Additionally, several research grants have produced the following findings that show that self-reported hepatitis B and C virus infections had low sensitivity among HIV-infected patients and there is limited effectiveness of antiviral treatment for hepatitis C in an urban HIV clinic.
AHRQ will continue to support research to help develop and disseminate evidence-based information to health care providers and patients on treatments for conditions such as hepatitis B and C, so that providers and patients can make informed decisions on what treatments work best.

HIV Early Diagnosis

4.      Senate (Rept. 110-410), p. 141

The Committee recognizes the high economic burden associated with a positive diagnosis of HIV/AIDS. The Committee encourages AHRQ to prepare a study comparing the economic burden of an early diagnosis to that of a later diagnosis.
Action Taken or to be Taken:
AHRQ has developed a study to compare the economic burden of an early HIV diagnosis to that of a late HIV diagnosis and submitted it to the Committee on March 10, 2009. The results of this study show that patients with HIV infection who present for care late incur higher direct HIV treatment costs per year than those who initially present earlier in the disease process.

MRSA

5.      Senate (Rept. 110-410), p. 141

Of the total amount provided for HCQO the Committee has included $5,000,000 for activities to identify and reduce the spread of methicillin-resistant Staphylococcus aureus (MRSA) and other health care-associated infections. The Committee is concerned about the prevalence of these preventable infections and has provided a second year of funding for this initiative at AHRQ due to its expertise with patient safety and quality of care issues. The Committee encourages AHRQ to continue its collaboration with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS).
Action Taken or to be Taken:
In 2007, AHRQ was asked to work in close collaboration with CMS and CDC to identify and reduce the spread of MRSA and other health care-associated infections. A working committee was established and the group met at least two times per month and identified a portfolio of specifically-targeted projects. Brief descriptions of the projects follow:

1.   Testing Spread and Implementation of Novel MRSA-Reducing Practices

$1,800,000—Using AHRQ's ACTION Network that helps translate research into practice:

  • Reduce rates of MRSA infection by at least 30 percent from baseline.
  • Develop measures of organizational barriers and facilitators that inhibit or facilitate spread of the MRSA interventions.

2.   Optimizing the Initial Evaluation and Treatment of Suspected Community-Acquired MRSA Infections in Primary Care Practice

$1,200,000—Using AHRQ's network of primary care practices:

  • Establish baseline and increase clinician adherence to recommended CDC management guidance to greater than 75 percent for treatment of skin/soft tissue infections in 75 primary care practices.
  • Reduce number of unscheduled return visits to a practice and/or ER for skin/soft tissue infections by 20 percent.
  • Reduce number of hospitalizations related to skin infections initially treated in the ambulatory setting by at least 30 percent.

3.   Identifying Potentially Modifiable Factors Associated with Hospitalization for Community-Acquired MRSA

$750,000—Augmenting AHRQ's State and Regional Demonstration Project in Health Information Technology:

  • Identify potentially modifiable risk factors in patients hospitalized with community-acquired MRSA.
  • Describe ambulatory care patterns for patients with community-acquired MRSA prior to hospitalization.
  • Develop statistical models to identify ambulatory care practices that could be modified to prevent hospitalizations related to community-acquired MRSA infections.

4.   Determining the Contribution of MRSA Originating in the Community and Longterm Care Facilities to the Rapidly Rising Occurrence of MRSA in Hospitalized Patients

$75,000—Using AHRQ's State-level database on hospital discharges (HCUP):

  • Identify the factors that are contributing to the rapid rise of MRSA in hospitalized patients.

5.   Producing Rapid Cycle State and National Estimates to Support and Evaluate the MRSA Initiative

$375,000—Healthcare Cost and Utilization Project:

  • Establish a baseline infection rate for MRSA and use rapid cycle estimates to measure and evaluate MRSA-initiative interventions at the hospital, community, regional, State, and national levels.

6.   Understanding MRSA Reservoirs in Assessing MRSA Solutions

$1,100,000—Using AHRQ's network on evidence-based care:

  • Describe the role of nursing homes in the propagation and maintenance of MRSA
  • Develop a tool for identifying critical points of MRSA transmission within a community to improve prevention resource allocation.
Funding awards were made in September 2008 and AHRQ expects to start receiving progress reports from the project officers in early spring 2009.

AHRQ will continue to work closely with CDC and CMS in this MRSA effort.

Health Cost, Quality, and Outcomes

6.      Senate (Rept. 110-410), p. 141

To advance discovery and the free marketplace of ideas, the Committee believes AHRQ must dedicate more funding to investigator-initiated research. For this reason, the Committee does not provide the $6,000,000 requested by the administration for a Health Insurance Decision Tool. Instead, the Committee strongly urges AHRQ to redirect these funds toward expanding its investment in investigator-initiated research.
Action Taken or to be Taken:
The FY 2009 appropriations bill provides AHRQ with resources to significantly increase its investment in investigator-initiated research. AHRQ greatly appreciates the Committee's efforts to enable us to invest in this critical area of research. Investigator-initiated research provides the foundation for which many of our current programs are built upon.

Ambulatory Patient Safety

7.      Senate (Rept. 110-410), p. 141

The Committee notes that while the scope, volume and complexity of ambulatory care has increased over the past decade, little is known about patient safety in ambulatory care settings. Few safety practices have been identified, and limited data exist on the nature of risk and hazards to patients and the threat to quality in ambulatory care 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 [ASQ] to identify the inherent risks in ambulatory settings and to develop potential solutions for protecting patients.
Action Taken or to be Taken:
AHRQ has recognized the need to expand its research and development in the area of ambulatory patient safety. AHRQ has invested in this area from the outset of our work in patient safety. Several projects such as, clarifying the impact of chaotic practice environments on the likelihood of patient safety events, can inform our future investments in this critical area.
AHRQ has pursued a two pronged effort by focusing of risk assessment and risk informed design of safe practices in ambulatory care. Because so little is known about where and in what manner there are risks and hazards in ambulatory care, AHRQ funded 20 risk assessment planning grants in FY 2008. The purpose of these one year R18 planning grants was to support proactive risk assessments and to model risks and known hazards that threaten patient safety in ambulatory care settings and in transitions of care. The use of proactive risk assessment has been widely used in high hazard institutions such as aviation, aerospace and nuclear power. The risk assessments and modeling lead to the identification of preventable patient injuries/harm and inform the development and deployment of intervention strategies that eliminate, mitigate, or minimize those harms and threats in ambulatory care settings.
A second part of AHRQ's approach to ambulatory patient safety has been to apply the results of risk models to projects to develop risk informed interventions in ambulatory care. AHRQ awarded 13 Risk Informed Design Projects in FY 2008 to design and implement new safe practices in ambulatory care. These projects are about one third of the way to completion. However the Agency believes that the combination of risk assessment and risk informed design of new safe practices will yield important results to improve the care of patients in ambulatory settings of care.
Additionally, AHRQ has invested about $21 million in health information technology (health IT) grants as part of its Ambulatory Safety and Quality program. The program's goal is to improve the safety and quality of ambulatory health care through health IT improvements, such as computerized surveillance of adverse drug events in the outpatient setting. A variety of ambulatory settings and organizations are addressed, from large integrated delivery systems to small provider practices and from urban settings to small rural communities.

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Current as of May 2009
Internet Citation: Significant Items: Budget Estimates for Appropriations Committees, Fiscal Year 2010. May 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cpi/about/mission/budget/2010/sig10.html