Meeting Summary

November 13, 2009

Minutes from the November 13, 2009, meeting of the Agency for Healthcare Research and Quality's National Advisory Council (NAC) are available on this page.

Contents

Call To Order
Director's Update
Subcommittee on Patient Safety and Medical Liability Report and Discussion
Quality Measures for Children's Healthcare in Medicaid and CHIP Subcommmittee
The 2009 National Healthcare Quality and Disparities Reports
Public Comment
Chairman's Wrapup, Member Comments
Adjournment

NAC Members Present

Neil Powe, M.D., M.P.H., M.B.A., San Francisco General Hospital (Chair)
Timothy J. Brei, M.D., Indiana University School of Medicine
Nancy E. Donaldson, D.N.Sc., R.N., FAAN, Center for Nursing Research & Innovation, University of California, San Francisco (by telephone)
Andrew J. Fishmann, M.D., F.C.C.P., F.A.C.P., Good Samaritan Hospital
Robert S. Galvin, M.D., General Electric (by telephone)
Arthur Garson, Jr., M.D., M.P.H., University of Virginia
Wishwa N. Kapoor, M.D., M.P.H., University of Pittsburgh
Lisa M. Latts, M.D., M.B.A., M.S.P.H., WellPoint Inc. (by telephone)
Kathleen Lohr, Ph.D., RTI International
Thomas P. Miller, J.D., American Enterprise Institute
Keith J. Mueller, Ph.D., Nebraska Center for Rural Health Research
Xavier Sevilla, M.D., FAAP, Manatee County Rural Health Services Inc. (by telephone)
David L. Shern, Ph.D., Mental Health America
Bruce Siegel, M.D., M.P.H., George Washington University
William Smith, Pharm.D., Ph.D., M.P.H., Virginia Commonwealth University
Myrl Weinberg, C.A.E., National Health Council
Anthony C. Wisniewski, J.D., U.S. Chamber of Commerce

Alternates Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Sarah Lutter, J.D., Office of Science Policy, National Institutes of Health

AHRQ Members and Staff Present

Carolyn M. Clancy, M.D., Director
Denise Dougherty, Ph.D., Child Health and Quality Improvement
Kathie Kendrick, M.S., C.S., R.N., Deputy Director
Katherine Crosson, Associate Director, CQuIPS
Ernest Moy, M.D., M.P.H.
Deborah Queenan, NAC Coordinator
Jean Slutsky, P.A., M.S.P.H., Director, Center for Outcomes and Evidence

Call To Order; Approval of July 24 Summary Report

NAC Chairman Neil Powe, M.D., M.P.H., M.B.A., called the meeting to order at 8:30 a.m., welcoming the NAC members, other participants, and visitors. He welcomed six new NAC members who were attending their first meeting—Nancy E. Donaldson, D.N.Sc., R.N., Arthur Garson, Jr., M.D., M.P.H., Lisa M. Latts, M.D., M.B.A., M.S.P.H., Keith J. Mueller, Ph.D., Xavier Sevilla, M.D., FAAP, and Bruce Siegel, M.D., M.P.H. New member Junius J. Gonzales, M.D., M.B.A., was unable to attend. The NAC members introduced themselves. Dr. Powe referred to the draft minutes of the previous NAC meeting (July 2009) and asked for changes and approval. The NAC members approved the July meeting minutes with no changes.

Dr. Powe announced that Carolyn Clancy, M.D., had been reappointed Director of AHRQ by the new administration.

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Director's Update

The Big Picture

Carolyn Clancy, M.D., AHRQ Director, welcomed the NAC members and noted that orientation for the new members will occur at the April 2010 meeting, when additional new members will be present.  She stated that six members were retiring from the NAC—Jane Barlow, M.D., Timothy Brei, M.D., Andrew Fishmann, M.D., Thomas Miller, J.D., Neil Powe, M.D., and Anthony Wisniewski, J.D.

Dr. Clancy reported on AHRQ activities during the previous months.

Reviewing transition issues, Dr. Clancy noted that former NAC member Regina Benjamin, M.D., became the U.S. Surgeon General, former NAC member J. James Rohack, M.D., became President of the American Medical Association, and former NAC member Mary Wakefield became an administrator at the Health Resources and Services Administration.  Former NAC member Brent James, M.D., of Intermountain Health Care, was featured recently in a large article in The New York Times Magazine. 

Dr. Clancy reported that AHRQ has been contributing to the drafting of legislation for health care reform and has been working with Medicaid on quality measures.  AHRQ's new Patient Safety Medical Liability Reform Demonstration Subcommittee has been meeting and will report today (two solicitations have been released).  The agency is operating under a continuing resolution pending passage of the FY 2010 Budget.  New AHRQ funding opportunities include:

• Medical Liability Reform & Patient Safety Planning Grants (R21).
• Medical Liability Reform & Patient Safety Demonstration Projects (R18).
• Limited Competition: Innovative Adaptation and Dissemination of AHRQ CER Products (iADAPT) (R18).
• Limited Competition: AHRQ Clinical and Health Outcomes Initiative in CE (CHOICE) (R01).
• Partnerships in Implementing Patient Safety (PIPS-II) (R18).

The American Recovery and Reinvestment Act (ARRA) featured $1.1 billion for comparative effectiveness research (CER), including $300 million for AHRQ.  It directed that CER be "consistent with departmental policies relating to the inclusion of women and minorities."  Congress does not intend for the money to be used to mandate coverage reimbursement or other policies for any public or private payer.  AHRQ and the National Institutes of Health (NIH) co-lead a CER workgroup.  ARRA also funds activities in health information technology (health IT) and prevention.  Dr. Clancy reviewed the timeline for ARRA, including the release of AHRQ operations plans. 

Dr. Clancy reviewed the definition of CER as provided in the recovery act.  The Institute of Medicine (IOM) developed a list of national priority topics for CER, calling for an evolving set of priorities and emphasizing care delivery.  The framework for CER created by the Department of Health and Human Services (HHS) features horizon scanning, evidence identification and scanning, interventions, and dissemination/translation.  The final steps can include, for example, phone applications (apps).

The HHS has a spending plan to complement AHRQ and NIH activities in data infrastructure, dissemination, translation, implementation, and priority populations.  The AHRQ spending plan for CER funds includes stakeholder input, horizon scanning, evidence synthesis and generation, and research training and support.  The recovery act calls for establishment of incentives for providers who become "meaningful users" of electronic health records.  Meaningful use is a challenging issue.  A federal health IT policy committee workgroup is developing criteria for a definition of it.  A payment rule is forthcoming.  AHRQ will provide evidence for how criteria for meaningful use might help to achieve the goal of high quality high value health care.

Discussion

Wishwa Kapoor, M.D., wondered about the future of CER after the ARRA program concludes.  Dr. Clancy noted a proposed bill to create a center at AHRQ supported by Medicare funds.  A senate proposal features creation of a not-for-profit entity.  Kathleen Lohr, Ph.D., wondered about relationships between CER, meaningful use, and pay-for-performance measures.  Dr. Clancy responded that a future committee on meaningful use will take up issues such as quality, resources, measures, and priorities.  Dr. Powe asked about the amount of ARRA funds distributed so far.  Dr. Clancy responded that about one-third of the CER funds has been distributed, with a focus on job creation.  David Shern, Ph.D., recommended conducting an analysis of implementation.  Perhaps AHRQ could serve as a monitoring body.

Recent Accomplishments

Dr. Clancy reported the following impact case studies.

• The National Network of Libraries of Medicine incorporated AHRQ's Questions Are the Answers video into its patient safety resource seminar.
• Suburban hospital in Maryland used AHRQ's emergency preparedness tools in a knowledge transfer case study as part of its disaster-readiness planning.
• Massachusetts used the AHRQ-sponsored Elders Learning Network and AHRQ-funded Chronic Disease Self-Management Program in a knowledge transfer case study to implement evidence based programs—with an emphasis on Hispanic elders.
• Maine used the AHRQ-sponsored Elders Learning Network  and AHRQ-funded Chronic Disease Self-Management Program, implementing and expanding  the latter. The program found that behavioral change was not correlated with self-knowledge.  It was correlated with self-efficacy.
• AHRQ worked with organizations to disseminate its DVD (a 10-minute video) about blood thinning medications.
• AHRQ expanded its reach through Web-based social media (podcasts, twitter, YouTube) and featured a page about social media capabilities at www.ahrq.gov.
• AHRQ created new Spanish-language guides for prostate cancer, diabetes, and high blood pressure.
• AHRQ added information about particle beam radiation therapy to its Web site (effective care).
• AHRQ added information about unproven breast cancer medications to its Web site (effective care).
• The U.S. Preventive Services Task Force released recommendations on screening newborns for jaundice.  It found the evidence for screening billirubin to be inadequate.
• Two new interactive tools from AHRQ will help emergency planners and responders run care facilities during disasters.
• A comparative effectiveness review found that two medications commonly used to treat high blood pressure appear to be effective in treating stable ischemic heart disease.
• HHS awarded $17 million to fight health-care-associated infections. of that, $8 million will fund a national expansion of the Keystone Project.

AHRQ Program Updates

Dr. Clancy provided the following program updates:

• The U.S. Preventive Services Task Force soon will publish recommendations for screening for breast cancer, screening for depression in adults, and screening for obesity in children.
• AHRQ is supporting the Patient-Centered Medical Home model of primary care as it is considered in the House and Senate health care reform proposals.  It held a national conference in July to discuss a policy-relevant research agenda and is establishing resources to support the model.  AHRQ will develop, synthesize, and disseminate evidence.  It will convene stakeholders.
• AHRQ published a health IT summary report and offered it on the Web.
• In October, AHRQ supported a meeting focused on reducing health disparities through health IT, featuring discussions of case studies in pediatric asthma, lower extremity amputation, prenatal care, and patient-provider communication. AHRQ aided efforts to provide the Medicaid/Children's Health Insurance Program (CHIP) with technical assistance for health IT, supporting webinars and workshops.
• The 2009 National Healthcare Quality and Disparities Reports moved to departmental clearance and likely will be released in December or January.  The 2010 reports are being developed.
• There now are 72 Patient Safety Organizations (PSOs) in 26 states and the District of Columbia.  The first PSO annual meeting was held in September 2009.  Common formats for regulations will be released soon.  A PSO self-assessment guide will be published soon.  (A list of PSOs was distributed to the NAC members.)
• The Consumer Assessment of Health Plans and Providers (CAHPS®) program is developing a survey for cancer care.  A draft will be available next summer.  The 2009 CAHPS Health Plan Survey Chartbook is available on the AHRQ Web site.
• AHRQ anticipates $17 million in funding in FY 2010 for hospital care-associated infections (HAIs).  It produced a new fact sheet about HAIs and is collaborating with OS, NIH, the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare & Medicaid Services (CMS).  Responsibility for the Medicare Patient Safety Monitoring System was transferred from CMS to AHRQ.
• A large expansion of TeamSTEPPS® is being conducted.  The Department of Defense has worked with AHRQ to support new efforts in the reporting of patient safety events, patient engagement, diagnostic errors, health literacy, and more.
• AHRQ supported the development and release of new Effective Health Care summary guides in November 2009.  The agency redesigned the Effective Health Care Web site.
• The Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program released results of a study of the use of tiotropium in patients with chronic obstructive pulmonary disease, finding heterogeneous effects related to combination treatments.  Two new DEcIDE solicitations were released.  One targets evidence development, the other targets scientific methods.
• AHRQ-supported evidence-based practice centers are conducting a variety of research reviews.
• The Centers for Education on Research and Therapeutics (CERTs) activities were recognized and expanded by NIH and the Food and Drug Administration (FDA), with the Cincinnati CERT awarded an NIH R01 and CERTs centers playing a role in the FDA's Sentinel Initiative (adverse events).
• The National Guidelines Clearinghouse™ now features more than 2,400 guidelines. The National Quality Measures Clearinghouse now features more than 1,800 measures.  The Editorial Board is helping to explore changes to inclusion criteria for both clearinghouses.
• The AHRQ-supported Healthcare Innovations Exchange introduced an online "Chats on Change" in October.  in November, it offered a webinar on innovation failure.
• The AHRQ Effective Health Care (EHC) report "Comparative Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibrillation" helped to inform the Medicare Coverage Group's discussions.
• AHRQ continued to develop the Web-based MONAHRQ program for inputting data and creating a Web site.
• A new CAHPS® tool focuses on health literacy and maps items to AMA-recommended health literacy practices.
• A new HCUP statistical brief addresses emergency department visits for injurious falls among the elderly.
• HCUP data were used in a study of in-hospital mortality rates for uninsured children.
• AHRQ offered assistance to HHS, the Office of Management and Budget (OMB), the Council of Economic Advisors, the White House, and Congress regarding data resources and modeling efforts to inform policy and health reform initiatives.
• A fourth annual AHRQ conference will take place in September 2010.

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Subcommittee On Patient Safety and Medical Liability Report and Discussion

Robert Galvin, M.D., General Electric

Dr. Robert Galvin reported on progress of the NAC Patient Safety and Medical Liability Subcommittee, which he chairs.  He distributed to the NAC members the minutes of a subcommittee meeting that took place on October 26, 2009.  The meeting produced a long list of concerns and recommendations from the large number of experts, stakeholders, and advocacy groups that are members of the subcommittee. The meeting attendees considered the following evaluation criteria:

• Significance
• Approach
• Investigators
• Environment
• Collaborative research experience
• Patient resources
• Stakeholder involvement
• Innovation.

Dr. Galvin reported a general agreement among the attendees that the liability system is failing today.  It requires major reforms.  To advance safety, we need to collect evidence and study feedback loops in the liability system and health system.  Research should lead to actionable ideas.  The meeting was remarkable for its production of fresh ideas.  Many of the attendees agreed that the current medical liability system does not serve patients and providers well.  We need greater transparency, the use of demonstration projects, a proper consideration of evidence-based clinical practice guidelines, and evidence for what works.  A current lack of consensus slows legislative change and progress.   

Discussion

Ms. Weinberg emphasized the need to document parts of the system that work well.  Medical applications should address both safety and liability.

Dr. Siegel wondered about the potential role of health system governing bodies (e.g., hospital boards) in assessing what does and does not work.  Dr. Galvin noted that the October meeting included examples of systems that have attempted to address the problems.

Dr. Lohr wondered about the extent to which state laws complicate medical liability issues.  What is generalizable?  We need to tease out what works and what does not work.  Dr. Clancy noted that AHRQ soon will support an evaluation of alternatives for medical liablity.  A consideration of liability (evaluation plan) will be required in grant applications.

Dr. Sevilla asked about the concept of a safe harbor.  Dr. Galvin stated that the meeting attendees did not promote that idea to a great extent, preferring other strategies. Dr. Clancy added that AHRQ evaluated the safe harbor idea some years ago, finding that such guidelines are difficult to adapt.

Dr. Donaldson expressed support for the idea of studying feedback loops in the system.  We need to understand factors relating to delays in knowledge transfer and system breakdowns.

Anthony Wisniewski cautioned about efforts to address tort reform, and he encouraged  the subcommittee to consider the issue of using experts in specialty courts for medical suits.  AHRQ could play a role and offer credibility. 

Dr. Clancy added the fact (brought out in the October meeting) that legal reform is different from insurance reform.  Measures have shown that patient safety has been declining.  AHRQ is developing reports that will support discussions of these issues.

Quality Measures For Children's Healthcare in Medicaid and CHIP Subcommmittee

Kathleen Lohr, Ph.D., and Timothy Brei, M.D.

Dr. Lohr reported on efforts of this subcommittee, which has been developing a set of core measures for children's healthcare quality, drawing from the large number of measures that exist.  Public Law 111-3, Title IV, called on the HHS Secretary to identify and publish for general comment a core set of child health quality measures by January 1, 2010.  The subcommittee, chaired by Jeffrey Schiff, M.D., M.B.A.,and Rita Mangione-Smith, M.D., and including Drs. Lohr and Brei, of the NAC, worked throughout the summer and fall against a tight deadline.

Dr. Lohr reviewed the timeline and processes of the committee, which seeks a posting of final draft measures by December 18, 2009 (an initial core set of measures). Candidate measures were assessed for validity, feasibility, and importance. They were ranked and posted for public comment during the summer months (the public also could nominate measures). The developers recognized that a scope of measures could include grounded measures (currently feasible), intermediate measures (in use in some states), and aspirational measures (needed in the future). They sought to create a set of up to 25 grounded measures. Dr. Lohr presented the final draft set of 25 measures in order of rank (immunizations for 2-year-olds was ranked #1). The measures represent a broad range of conditions and an emphasis on prevention and health promotion. Most are to be applied in the ambulatory setting.

Dr. Brei reviewed issues that were revealed during the process to develop the set of measures:

• A lack of standardization of duration of enrollment measures.
• A lack of standardization of denominators across measures.
• A need to expand the use of measures across the entire Medicaid/CHIP population.
• Inconsistent disparities reporting.
• Missing/needed measures (e.g., specialty care, inpatient care, mental health treatment, substance abuse care, medical home healthcare).

Discussion

Dr. Brei expressed a hope for strategies to develop additional measures in the future.  Dr. Fishmann suggested identifying measures for pediatric asthma for both inpatient and emergency cases.

Dr. Sevilla praised the work of the subcommittee and described his experience of learning that many measures are found to be insufficient to the task.  We need research to establish validity, and we need to develop more outcomes measures.  Dr. Brei noted that the process will be aided by the identification of needed measures by the Joint Commission.  Dr. Schiff added that the Medicaid Medical Directors will continue to push the measures process.  The average level of evidence for the measures chosen by the subcommittee is about a B.  It is expected that the measurement set will evolve over time.   

Dr. Powe suggested that the subcommittee identify areas in the measures that can target minority groups.  Dr. Smith proposed the future addition of measures related to medications.  Dr. Lohr stated that the subcommittee process represented a new model for undertaking such activities.  She encouraged the NAC members to continue to forward comments to AHRQ (E-mail).

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The 2009 National Healthcare Quality and Disparities Reports

Ernest Moy, M.D., M.P.H., AHRQ

Dr. Ernest Moy provided an update on the National Healthcare Quality Report and the National Healthcare Disparities Report, highlighting new attributes in the 2009 versions.  The reports have appeared annually since 2003.  They were mandated by the 1999 Healthcare Research Quality Act.  The 2009 reports are in clearance and will be released soon.

The 2009 reports feature new sections on healthcare-associated infections and care coordination.  They indicate measures that have been retired and feature improvements in the sections on lifestyle modifications, functional status preservation (and rehabilitation), and supportive and palliative care.  The 2009 Dispartities Report has a new section for underinsurance (or "unaffordability").  The 2009 Quality Report has new sections for health insurance and quality and patient safety culture in hospitals.  It features added efficiency measures.

Dr. Moy encouraged the NAC members to provide guidance on the State Snapshots provided in the reports.  The Snapshots in the 2009 reports feature additional links to state report cards, settings, and clinical quality.  They contain more rankings within states (for comparing states), more disparities measures, a new focus on payer differences, and graphics showing variations across all states.  Dr. Moy stated that the 2010 reports might feature measures for rural populations, adverse-events, health IT, and efficiency.

Discussion

Dr. Miller suggested that the report developers consider adding data on employer contributions to health insurance.  He also suggested adding, within the state shapshots, data on payers for areas of disparities.  Dr. Powe cited a need to include more measures for disparities in general (which don't seem to be improving).

Dr. Lohr proposed adding measures for patient-reported outcomes.  Dr. Brei proposed adding quality measures for children's healthcare.  David Atkins, M.D., M.P.H., suggested a consideration of events reporting at the payer level, noting differences in resources.  Dr. Fishmann noted that hospitalist programs might drive utilization.  Perhaps they should be identified.

Wishwa Kapoor, M.D., M.P.H., wondered whether the reports are being used.  Dr. Moy responded that demand for the reports is substantial.  However, the extent of their use has not been determined.  The Institute of Medicine is studying usability.    

Dr. Lohr encouraged the report developers to consider measures for community health centers.  David Shern, Ph.D., suggested highlighting states that demonstrate exemplary progress.

Institute of Medicine

Cheryl Ulmer, a senior program officer at the IOM, reported on work of an IOM subcommittee on data and measurement.  It has focused on issues of data standardization and race and language as they relate to quality in healthcare.  A report will be released in December.  Ms. Ulmer encouraged the NAC members to contact IOM with suggestions.  Dr. Lohr encouraged the IOM to define language use and to consider literacy, as opposed to health literacy.

Sheila P. Burke, R.N., M.P.A., of the IOM, stated that the IOM subcommittee's views are being written up and the process is near closure.  She noted that the IOM underscores the role of AHRQ, which becomes increasingly important.  The IOM seeks ways to increase its impact and to effect changes.  Dr. Burke offered IOM resources to the NAC.

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Public Comment

A representative of the American College of Sports Medicine encouraged AHRQ to forward its National Healthcare Quality and Disparities Reports to the offices of all governors and to showcase research that is being conducted by AHRQ.

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Chairman's Wrapup, Member Comments

Dr. Powe invited the NAC members to make final comments and farewells.

• Dr. Fishmann, who was retiring from the NAC, expressed great appreciation for the people involved.  He encouraged the NAC members to take up the issue of end-of-life care, and he emphasized a need for registries.
• Dr. Miller, who was retiring from the NAC, thanked Dr. Clancy for the informative updates through the years.  He stressed the importance of AHRQ's MEPS data, on which many initiatives rely.  He encouraged AHRQ to continue to ask—What do patients need?  What do patients think about the qualilty of care?  He encouraged AHRQ to address the issue of high-cost medical conditions.   
• Ms. Weinberg wondered whether the increase in funding for CER might reduce the funding of other areas.  She cited a need to establish where CER fits in the larger picture of healthcare quality.
• Dr. Kapoor called for the development of methods for CER.  AHRQ might take the lead in workforce issues (which are daunting).  It also might consider the issue of deterioration in primary care.
• Dr. Atkins suggested that AHRQ examine the issue of when to use randomized trials and when to use observational studies.  An emphasis on population health is good but presents a challenge regarding non-integrated systems.
• Dr. Shern stated that he sensed a new era of cooperation for activities in healthcare quality.  One area to be addressed is multiple chronic illnesses.  For CER, we must determine how to study interventions.  
• Dr. Smith called on AHRQ to address the issue of medications and to increase the research effort in that area.
• Mr. Wisniewski, who was retiring from the NAC, stated that it had been honor to play a role.  He applauded AHRQ for its leadership in CER and stressed the importance of public-private partnerships for CER.  He encouraged AHRQ to address workplace wellness and to contribute to the issue of tort reform, in particular, by supporting the use of expert witnesses in claims cases.
• Dr. Siegel expressed hope that AHRQ will play a role in the upcoming national health care inititatives.
• Dr. Brei, who was retiring from the NAC, cited an increase in AHRQ's visibility during the past 3 years.  He encouraged the agency to address children's healthcare and the healthcare of people with disabilities.  Important areas for the future include registries, people with multiple conditions, and health IT.
• Dr. Lohr recommended that AHRQ return to the issue of cost-effectiveness. She noted that important areas for the future include studies of methods and multiple chronic conditions.
• Dr. Clancy thanked the NAC members for their contributions.

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Adjournment

Dr. Powe emphasized that AHRQ is in a position to lead in the efforts to improve healthcare quality.  He thanked the participants and adjourned the meeting.

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