Eisenberg Conference Center, 540 Gaither Road
July 13, 2012
Minutes from the July 13, 2012, meeting of the Agency for Healthcare Research and Quality's National Advisory Council are available on this page.
Call to Order and Approval of April 13, 2012, Summary Report
Health Care Costs
Ambulatory Care Safety
Chairman's Wrap-Up and NAC Input
National Advisory Council (NAC) Members Present
Bruce Siegel, MD, MPH, National Association of Public Hospitals and Health Systems (Chair)
Mitra Behroozi, JD, 1199SEIU Benefit and Pension Funds
Helen Darling, MA, National Business Group on Health (by telephone)
Louise-Marie Dembry, MD, MS, MBA, Yale-New Haven Hospital
Silvia M. Ferretti, DO, Lake Erie College of Osteopathic Medicine
Helen W. Haskell, Mothers Against Medical Error
Ardis Dee Hoven, MD, University of Kentucky College of Medicine
Michael P. Johnson, PT, PhD, OCS, Bayada Home Health Care
Newell E. McElwee, PharmD, MSPH, Merck Global Affairs
Andrea H. McGuire, MD, MBA, Meridian Health Plan
Henry H. Ng, MD, MPH, FAAP, FACP, MetroHealth Medical Center
Welton O'Neal, Jr., PharmD, CryerHealth LLC
David F. Penson, MD, MPH, Vanderbilt University Medical Center
Christopher Queram, MA, Wisconsin Collaborative for Healthcare Quality
Katherine A. Schneider, MD, M.Phil., AtlantiCare Health System
Harry P. Selker, MD, MSPH, Tufts University
Alan R. Spitzer, MD, Pediatrix Medical Group (by telephone)
Jeffery Thompson, MD, MPH, Washington State Medicaid Purchasing Administration
Janet S. Wyatt, PhD, RN, Institute of Pediatric Nursing
Alternate Members Present
Atkins, MD, MPH, Veterans Health Administration
Goodrich, MD, MHS, Centers for Medicare & Medicaid Services
S. Holmes, National Center for Health Statistics, Centers for Disease Control
AHRQ Staff Members Present
Carolyn M. Clancy, MD, Director
Boyce Ginieczki, PhD, Acting Deputy Director
Jamie Zimmerman, MPH, NAC Coordinator
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of April 13, 2012, Summary Report
Siegel, MD, MPH, Chair of the National Advisory Council (NAC), Agency for
Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m.
and welcomed the NAC members, other participants, and visitors. He noted that
new NAC member Henry H. Ng, MD, MPH, of MetroHealth Medical Center, was attending his first meeting.
Siegel referred to the draft minutes of the previous NAC meeting (April 13,
2012) and asked for changes and approval. The NAC members approved the April
13, 2012, meeting minutes with no changes.
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M. Clancy, MD, AHRQ Director, welcomed the NAC members, speakers, and other
guests. She noted that Katherine A. Schneider, MD, MPhil, recently became
Executive Vice President and Chief Medical Officer of Medecision, Inc. Ardis Dee Hoven, MD, recently became President-Elect of the American Medical Association.
Welton O'Neal, Jr., PharmD, became Executive Director, Foundation for Managed
Care Pharmacy, and Vice President of Pharmacy Affairs, Academy of Managed Care Pharmacy.
Clancy reviewed the AHRQ FY 2012 budget, which features a core of $369 million,
with an additional $12 million from Prevention and Public Health Funds and an additional
$24 million from the Patient-Centered Outcomes Research Trust Fund. The core
allocation includes $16.6 million for Patient-Centered Outcomes Research
(PCOR), $108.4 million for crosscutting grants (research innovations), $65.6
million for patient safety, $25.6 million for health information technology
(IT), $15.9 million for prevention/care management, and $3.7 million for value
FY 2013 budget request features a core of $334.5 million, to which are added
$12 million from Prevention and Public Health Funds and $62.4 million from the
Patient-Centered Outcomes Research Trust Fund. The FY 2013 request for the core
budget reflects decreases in most of the research areas. The contribution from
the Patient-Centered Outcomes Research Trust Fund increases significantly to
Clancy reviewed the following recent accomplishments:
- The 2011 National Healthcare Disparities Report and the 2011 National
Healthcare Quality Report were released in April. The quality report
indicates that quality is improving slowly overall, with heart care improving
dramatically. The number of disparities that were improving, although few,
exceeded the number that were worsening.
National Quality Strategy (NQS) First Annual Progress Report was released in
April (http://www.ahrq.gov/workingforquality/). The NQS is continuing
stakeholder engagement, efforts to align and streamline measurement across HHS
programs, and efforts to align HHS goals with NQS priorities. Plans for
stakeholder engagement involve a national strategy for data collection,
measurement, and reporting; organizational infrastructure at the community
level; and the reform of payment and delivery systems.
State Snapshots were released and feature State-specific health care quality
information and trends.
new videonovela helps patients to compare diabetes treatments. Aprende a
vivir (Learn To Live) features a family drama focusing on challenges of
part of the Effective Health Care Program, AHRQ distributed a new brochure
about non-surgical treatments for urinary incontinence in women.
- Arizona has used the
AHRQ-supported report "Vaginal Birth After Cesarean Section (VBAC): New
Insights," which indicates that VBAC might be safe in large hospitals; however,
outcomes are mixed in other settings.
in Pennsylvania, West Virginia, and Delaware has used AHRQ's Health Literacy
Universal Precautions Toolkit and the "Questions Are the Answer" public
education campaign to educate physicians about the relationships between health
literacy and outcomes.
in Nebraska, New Mexico, and New York have employed AHRQ's brochure "Preventing
Hospital-Acquired Venous Thromboembolism (VTE): A Guide for Effective Quality
in Maine, Georgia, Indiana, Maryland, Missouri, and Michigan have employed
AHRQ's toolkit, "Medications at Transition and Clinical Handoffs (MATCH)."
Arkansas Department of Health adopted AHRQ's MONAHRQ Web software system to
develop hospital data and reports and launched a public MONAHRQ Web site. The
Maine Health Data Organization is using the MONAHRQ Learning Network to report
data and facilitate online discussions. The Utah Department of Health now uses
AHRQ report, "Maternal and Neonatal Outcomes of Elective Induction of Labor,"
helped the Ohio Medicaid program to reduce labor inductions without clear
medical indications in near-term infants during an 18-month period.
Woodhull Medical and Mental Health Center in New York used AHRQ's Emergency
Severity Index triage system to help address an increase in emergency
department visits, thereby shortening waiting times and improving patient
Clancy reviewed the following AHRQ program activities:
has continued to redesign its Web site to manage content and enhance the users'
experience. A new primary navigation structure recently was tested and resulted
in improvements in loading content.
AHRQ-supported article in a recent issue of Health Affairs discussed
possible savings that might have accrued to individuals if health care reform
had begun in 2001.
(2011) data for the MEPS Insurance Component (of the Medical Expenditure Panel
Survey) will be released in July. AHRQ is collaborating with the National
Cancer Institute, Centers for Disease Control and Prevention, and others to enhance
the MEPS to support cancer survivorship research.
there are 75 Patient Safety Organizations (PSOs) in the United States, working
with more than 2,000 providers. A beta version of the new readmissions common
format will be published in September. The Office of the National Coordinator
is sponsoring an award program to produce applications that enhance patient
safety event reporting using common formats (the Purple Button Challenge
6th Annual TeamSTEPPS National Conference took place in June 2012 in Nashville.
The large number of new attendees shared best practices to promote executive
departments, led by the Centers for Medicare & Medicaid Services and
including AHRQ, are engaging in an effort to reduce healthcare-associated
infections. Results are due in September.
is partnering with the Uniformed Services University of the Health Sciences
(USUHS) to pilot a graduate-level course titled "Patient Safety and Quality in
an IT-Driven World."
Organisation for Economic Co-operation and Development (OECD) is using AHRQ
quality indicators for its Health at a Glance program. The program tracks and
compares health and health care across member countries.
AHRQ-supported research articles made the list of Health Affairs' Top 10
Most Read Articles for January–June 2012. One article focused on health
literacy. The other focused on the use by consumers of cost and quality
information to help make choices in health care.
is offering a new Web portal focused on integrating behavioral health and
primary care. The AHRQ Web site also is offering information on self-management
U.S. Preventive Services Task Force released five final recommendations in
recent months, addressing counseling to prevent skin cancer, screening for
prostate cancer, interventions to prevent falls, screening for and management
of obesity, and behavioral counseling to promote healthful diets and physical
activity. The task force also posted five draft recommendations in recent
released a new version of the MONAHRQ software program, with additional health
topics and indicators, new customization options, and new technical design
released a new toolkit for implementing E-prescribing in independent
pharmacies. The Agency also released a toolkit for implementing E-prescribing
in physician offices.
new evidence-based practice center report indicated that application of health IT
has improved various process, clinical, and intermediate outcomes in the
environment of patient-centered care (http://www.ahrq.gov/clinic/tp/pcchittp.htm).
awarded two ACTION II task orders to study the use of health IT to support the
redesign of practices in ambulatory care and to understand causal relationships
between health IT and workflow. The projects are being conducted by the
Billings Clinic and Research Triangle Institute.
ECHO (involving health IT and telemedicine) published, in the New England
Journal of Medicine, results showing reduced disparities and improved
provider satisfaction. The Veterans Health Administration recently adopted the
ECHO program for certain conditions, which is helpful for the VA's dispersed
has overseen a program to collect, synthesize, and share lessons learned in
building electronic data infrastructure for comparative effectiveness research
(CER). The program seeks to advance methods in CER analytics, informatics, and
governance. It supports dissemination of knowledge through electronic
documents, webinars, and articles (for example, a recent supplement in Medical
Care) (http://www.edm-forum.org ).
recently released a number of translation products in areas including ADHD in
children, tests for musculoskeletal complaints in children, chronic pelvic
pain, mechanical thrombectomy, and pain management in hip fracture.
2012 AHRQ Annual Conference will take place September 9–11, 2012, at the
Bethesda North Marriott Hotel & Conference Center. The title is "Moving
Ahead: Leveraging Knowledge and Action to Improve Health Care Quality."
R. Spitzer, MD, referred to the efforts regarding health IT, noting that many
people continue to write notes rather than take advantage of the electronic
processes. Where is the transition to the use of health IT working well, and
how might we disseminate that information? Dr. Clancy suggested that the
regional extension centers could help. Dr. Spitzer suggested beginning in the
university medical settings, where the next generation of physicians is working/learning.
Hoven noted that larger physician practices tend to do a better job in that
area (IT). Workflow issues are considerable. We need interoperability of the
systems and standards for collecting data. Financial incentives might help.
Jane Durney Crowley suggested a focus on institutional support and productivity
in individual cases. The behaviors of individual practices need to be
understood. This must be an ongoing process, and we must identify the processes
that are most effective. Dr. Ng emphasized a need for training in health IT and
data collection, especially for lesbian, gay, bisexual, and transgender people.
Thompson, MD, MPH, stated that electronic medical record systems do not
afford interoperability. The systems should be designed to speak to each other.
The behaviors of the users also must be addressed. We should identify the
factors that improve effectiveness. Michael P. Johnson, PT, PhD, stressed
the fact that many non-physicians are involved in the processes for electronic
medical records. Communication is important. E-prescribing is a challenge.
Crowley cited a need for research on the boundary between primary care and
specialties. For many patients, that area is complex. Dr. Hoven agreed, noting
that physicians often are fearful of handing-off patients. She suggested that
local communities address the issues. Dr. Schneider raised the issue of IT in
collaborative care management, which could be an opportunity to examine
possibilities. One key is to build tools into the workflow.
P. Selker, MD, MSPH, stated a need for workforce training. The number of
training awards being offered has been decreasing. Dr. Clancy noted that other
mechanisms to support training are available. We need to determine where
training and grants are needed. Christopher Queram, MA, expressed concern
about the disconnect between local and national priorities. The Affordable Care
Act contains many data requirements. Dr. Clancy noted the intention to make the
national data strategy as local as possible, with uniformity.
Johnson noted that the physical therapy community has been addressing the issue
of nonsurgical treatment for urinary incontinence for some time.
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Health Care Costs
B. Cohen, Ph.D., AHRQ, and David Meyers, MD, AHRQ
B. Cohen, Ph.D., Director of AHRQ's Center for Financing, Access, and Cost
Trends, presented background and data relating to trends in medical
expenditures—especially concentrations in expenditures. Health care
expenditures compose one-sixth of the U.S. economy and are projected to become
one-fifth of the gross domestic product (GDP) during the next decade. The distribution of expenditures
features significant concentrations.
from the MEPS allow for the study of the distribution of expenditures and
sources of payment. For example, the data can illustrate concentrations related
to patients with multiple chronic conditions. Dr. Cohen described components of
the MEPS and listed government agencies that make use of the MEPS data. Data
are derived from patients, physicians, pharmacies, and elsewhere.
some time now, the top 5 percent of patients have accounted for about one-half
of all U.S. health care expenditures. Characteristics that influence high
levels of expenditures include chronic conditions, end-of-life care, in-patient
care (unnecessary readmissions), medical errors, overuse of health services,
and obesity. The five conditions accounting for greatest expenditures are heart
disease, cancer, mental disorders, trauma-related disorders, and COPD/asthma.
Regarding chronic conditions, Dr. Cohen stressed the fact that complexity of
the conditions, rather than age, drives the increased expenditures. In general,
factors for cost projection models are the following: Demographic/economic
characteristics, health status measures, health insurance coverage, health
conditions, accidental events (trauma), utilization measures, and expenditure
program by the Camden Coalition focused on 36 super-utilizers of health care
living in a housing project. By doing so, the program was able to reduce
monthly hospital bills from about $1.2 million to $0.5 million. Progress can be
made by focusing on prevention, care management, obesity control, patient
safety, accountable care, and medical errors.
Meyers, MD, Director of AHRQ's Center for Primary Care, Prevention, and
Clinical Partnerships, described the HHS vision and strategic framework
addressing multiple chronic conditions (MCC). Goals include the following:
- Foster changes in health care and the public health system that improve the health of those with MCC.
- Maximize the use of proven self-care management by people with MCC.
- Provide better tools and information to care deliverers serving people with MCC.
- Facilitate research focused on MCC and patients with MCC.
Meyers stressed that MCC is an organizing focus of AHRQ's prevention and
chronic care portfolio. AHRQ supports prevention with the work of the Centers
for Excellence in Clinical Preventive Services and the U.S. Preventive Services
Task Force, and the development of composite measures for clinical preventive
services among older adults. Addressing prevention requires a focus on primary
care and the patient-centered medical home model. AHRQ created the MCC Research
Network, which has funded 18 exploratory grants focused on the use of
preventive services, 14 exploratory grants focused on comparative
effectiveness, and 13 infrastructure development grants to create publicly
available datasets. One of the funded projects produced early results showing
that a substantial number of Medicare beneficiaries received colonoscopy
screening even when potential harms outweighed potential benefits.
Johnson noted that the MEPS has a great deal of data on particular diseases.
How might that be used to produce a stronger impact? Dr. Johnson suggested that
indexes might be used to capture even more data.
Thompson asked how the impacts of costs might be teased from the data. Dr.
Cohen replied that a regression to the mean can make such attempts difficult. A
future all-claims database will expand the potential for analyses. Randomized
trials are required to study interventions.
Darling, MA, raised the issue of the patient's role and accountability. Also,
might the physician's behavior be part of the problem? Is one key a need for
better engagement—especially for certain clinical procedures? How might we
determine what the patient needs to know, and how might we address that need?
Dr. Clancy cited the role of organizational partners in addressing such issues
and spreading information. Dr. Meyers suggested that the clinical community
take the lead in advancing engagement to reduce overuse. Perhaps a site for
information about engagement could be established.
Spitzer noted that some patients are forced to overutilize services, being
forwarded to multiple specialists. He suggested that physicians be taught to
think of "my patient" rather than "the patient." Mitra Behroozi, JD,
encouraged AHRQ to consider the medical institution, such as the medical home,
as a whole, including all patients. What are the effects of prices on costs?
E. McElwee, PharmD, MSPH, raised the issue of modeling. Dr. Cohen stated
that the MEPS program could examine the data on individuals and simulate the
effects of changes in practice patterns. However, assumptions would have to be
Schneider noted that, in addition to reducing the use/expenditure for those in
the top percentile of use, we must work to ensure that those who use less
health care do not move into the high-use stratum. She noted, as an aside, that
credit scores predict readmissions—a fact that could be used in modeling.
Atkins, MD, MPH, urged AHRQ to consider two questions: Do high users
represent preventable costs? Is high use a flag for appropriateness? There is
little research on the issues involved in de-implementing practices. The value
agenda should include research on policy as it drives value.
Selker cautioned that discussions about concentrations of expenses could be
misinterpreted as discussions about rationing. He encouraged AHRQ to use the
MEPS data to support intervention research. Some research based on the health
IT dataset is being conducted now.
W. Haskell urged AHRQ to study the proportion of high health care use that is
the result of hospital-acquired conditions. David F. Penson, MD, MPH,
suggested looking at the Cancer Intervention and Surveillance Modeling Network
(CISNET). Perhaps AHRQ could advertise datasets within a network and solicit
Hoven stated a need to teach new patients how to use the health system wisely.
There will be changes in care delivery models, and payment will follow
delivery. Janet S. Wyatt, PhD, RN, added the importance of team-driven
primary care, in which nursing plays an important role.
Wyatt encouraged AHRQ to consider the need for early detection of
osteoarthritis and the rising incidence and cost of knee replacement. Nurse
practitioners are important to the health care team. Dr. Thompson stressed the
importance of studying differences in the prescribing behaviors of
practitioners (for example, relating to narcotics).
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Ambulatory Care Safety
Brady, MD, MPH, AHRQ
Brady, MD, MPH, Medical Officer and Patient Safety Portfolio Lead at AHRQ,
reviewed issues of safety in ambulatory (non-hospital and non-long term) care
settings. Most patient safety research projects have addressed the hospital
setting. Challenges in ambulatory care include the following:
- A lack of human and financial resources to support robust efforts in safety and quality improvement.
- The logistical complexity of ambulatory care, featuring problems in information exchange.
- Longer waits to identify and document errors.
- Greater reliance on patients as sources of information and for their understanding of care protocols—creating opportunities for safety events to occur.
patient safety portfolio has a goal of improving the quality of care delivered
to patients by decreasing or eliminating health care risks and harms. Dr. Brady
presented examples of recent AHRQ-funded research efforts in the area of
ambulatory care. On its Web site, AHRQ cites more than 7,500 patient safety
resources, including 650 resources for ambulatory care, 123 resources for
residential facilities, 66 resources for outpatient surgery, and 52 resources
for patient transport. AHRQ's Morbidity & Mortality site (M&M) features
260 cases and commentaries (patient safety lessons), including many for ambulatory
has supported patient safety culture surveys in various settings, examining
factors including teamwork, staffing, training, hand-offs, communication,
organizational learning, responses to mistakes, and management support for
patient safety. The Medical Office Survey on Patient Safety Culture is being
pilot-tested in 200 offices. AHRQ developed and has provided instructions for
planning and implementing strategies that improve patient flow in emergency
departments. AHRQ's HIV Research Network, with 19 HIV treatment providers, has
identified methods and approaches for reducing medication errors. A new
Medication Error and Adverse Drug Event Reporting System (MEADERS) has
undergone extensive testing, especially to establish usability, prior to full
new series of common formats for patient safety event reporting in ambulatory
settings has been developed and will be tested and revised as needed. Dr. Brady
listed AHRQ research grants that address patient safety in ambulatory settings,
in particular, a diverse range of grants for simulated clinical applications.
Safety in ambulatory settings also is addressed in AHRQ's “Questions Are the
Answers” campaign for better clinician-patient communication and in an AHRQ
guide about using blood-thinning medications (print and DVD).
Brady concluded that, despite some patient safety improvements, progress in
ambulatory care settings lags behind that of hospital efforts. AHRQ is
committed to making significant improvements in the ambulatory area.
Siegel wondered whether the alignment of physician practices with hospital
systems can help patient safety processes. Dr. Penson urged AHRQ to make the
issue of outpatient/ambulatory surgery a priority. It has serious safety issues.
Transitioning between inpatient and outpatient practices can be difficult. It
was suggested that AHRQ partner with organizations that feature sophisticated
reporting systems. Dr. Wyatt noted that the U.S. Food and Drug Administration
employs the Sentinel System. Perhaps it could eventually be used to engage
consumers. AHRQ could partner and harmonize. Efforts to standardize health IT
(devices), employing common formats, are under way.
Ng encouraged AHRQ to consider multifaceted processes that can offer benefits
to lesbian, gay, bisexual, and transgender people. Ms. Haskell stressed the
importance of care coordination within the ambulatory setting. Patients can
have difficulty negotiating a variety of specialists. TeamSTEPPS® is conducting
some foundational work in that area.
Selker called for research on hand-off systems. We need models for
provider-to-patient communication. Printed guides are helpful. Ms. Darling
noted the consumer trend toward the use of electronic apps, which could be helpful.
Dr. McElwee noted that the Health Resources and Services Administration has an
audio program about communicating with low-literacy patients.
Thompson raised issues about dispensing by pharmacies (overriding edits) and
dosages prescribed by physicians (especially high dosages). Louise-Marie
Dembry, MD, MS, MBA, noted medical safety risks that result from the
physical structures of settings (ambulatory surgery centers, home care). Dr.
O'Neal emphasized the need for cultural competencies in ambulatory care
Crowley called for studies to develop evidence for safe procedures in various
environments. Dr. Johnson stressed the high risks in home health care,
including the lack of backup aid. Dr. Brady cited an AHRQ report on home health
care that includes issues of technology. Dr. Hoven stated that addressing the
issues described in this discussion will require funding.
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Helm, a student in dietetics, urged AHRQ to consider the underlying factors of
nutrition in chronic diseases. She proposed that dieticians too be part of the
health care team. Dr. Clancy agreed that the current medical force
underemphasizes nutrition. We need teaching. There are challenges.
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Chairman's Wrap-Up and NAC Input
Siegel asked the NAC members for final comments and suggestions for the next
Siegel wondered whether AHRQ should examine how its programs are making a
contribution in building infrastructure in individual States. He applauded the
inclusion of guide-questions at the end of each of this meeting's
Darling noted that the upcoming changes in the health care system and payment
will affect behaviors. We should recognize the possibilities early.
Selker suggested that the NAC consider manpower issues for assessment
activities. It also might discuss more potential partnering opportunities.
O'Neal proposed standardizing, in health IT systems, the identification of
medication therapy management. That might lead to reduced costs.
Thompson suggested that NAC consider case management issues.
Schneider suggested having further discussion about the National Quality
Wyatt proposed two topics for future discussion: Defining inadequate
response/treatment failure and operational strategies for engaging patients.
Atkins proposed a discussion about how to make AHRQ research more timely and
partnered and a discussion of engaging partners up-front to speed
implementation of results.
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Clancy thanked the group and stated that the next NAC meeting will take place
on November 9, 2012. Dr. Siegel thanked the NAC members, invited speakers, and
guests and adjourned the meeting at 3:30 p.m.
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Current as of November 2012
National Advisory Council: Meeting Summary, July 13, 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/nacminutes/nacmin071312.htm