Meeting Minutes, July 13, 2012
Eisenberg Conference Center, 540 Gaither Road Rockville, Maryland
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.
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
David Atkins, MD, MPH, Veterans Health Administration
Kate Goodrich, MD, MHS, Centers for Medicare & Medicaid Services
Julia S. Holmes, National Center for Health Statistics, Centers for Disease Control and Prevention
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
Bruce 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.
Dr. 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.
Carolyn 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.
The Big Picture
Dr. 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 research.
The 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 $62.4 million.
Dr. 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.
- The 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.
- New State Snapshots were released and feature State-specific health care quality information and trends.
- A new videonovela helps patients to compare diabetes treatments. Aprende a vivir (Learn To Live) features a family drama focusing on challenges of managing diabetes.
- As 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.
- Highmark 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.
- Hospitals in Nebraska, New Mexico, and New York have employed AHRQ's brochure "Preventing Hospital-Acquired Venous Thromboembolism (VTE): A Guide for Effective Quality Improvement."
- Hospitals in Maine, Georgia, Indiana, Maryland, Missouri, and Michigan have employed AHRQ's toolkit, "Medications at Transition and Clinical Handoffs (MATCH)."
- The 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 MONAHRQ.
- An 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.
- The 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 satisfaction.
AHRQ Program Updates
Dr. Clancy reviewed the following AHRQ program activities:
- AHRQ 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.
- An 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.
- Latest (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.
- Currently 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 Award).
- The 6th Annual TeamSTEPPS National Conference took place in June 2012 in Nashville. The large number of new attendees shared best practices to promote executive leadership engagement.
- Multiple 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.
- AHRQ 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."
- The 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.
- Two 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.
- AHRQ 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 support.
- The 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 months.
- AHRQ released a new version of the MONAHRQ software program, with additional health topics and indicators, new customization options, and new technical design features.
- AHRQ released a new toolkit for implementing E-prescribing in independent pharmacies. The Agency also released a toolkit for implementing E-prescribing in physician offices.
- A 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).
- AHRQ 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.
- Project 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 population.
- AcademyHealth 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 ).
- AHRQ 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.
- The 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."
Alan 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.
Dr. 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.
Jeffery 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.
Ms. 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.
Harry 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.
Dr. Johnson noted that the physical therapy community has been addressing the issue of nonsurgical treatment for urinary incontinence for some time.
Health Care Costs
Steven B. Cohen, Ph.D., AHRQ, and David Meyers, MD, AHRQ
Steven 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.
Data 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.
For 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 measures.
A 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.
David 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.
Dr. 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.
Dr. 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.
Dr. 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.
Helen 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.
Dr. 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?
Newell 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 made.
Dr. 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.
David 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.
Dr. 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.
Helen 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 modeling methods.
Dr. 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.
Dr. 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).
Ambulatory Care Safety
Jeffrey Brady, MD, MPH, AHRQ
Jeffrey 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.
AHRQ's 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 settings.
AHRQ 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 launch.
A 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 Answer campaign for better clinician-patient communication and in an AHRQ guide about using blood-thinning medications (print and DVD).
Dr. 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.
Dr. 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.
Dr. 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.
Dr. 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.
Dr. 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 settings.
Ms. 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.
Bonnie 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.
Chairman's Wrap-Up and NAC Input
Dr. Siegel asked the NAC members for final comments and suggestions for the next agenda.
- Dr. 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 presentations.
- Ms. Darling noted that the upcoming changes in the health care system and payment will affect behaviors. We should recognize the possibilities early.
- Dr. Selker suggested that the NAC consider manpower issues for assessment activities. It also might discuss more potential partnering opportunities.
- Dr. O'Neal proposed standardizing, in health IT systems, the identification of medication therapy management. That might lead to reduced costs.
- Dr. Thompson suggested that NAC consider case management issues.
- Dr. Schneider suggested having further discussion about the National Quality Strategy.
- Dr. Wyatt proposed two topics for future discussion: Defining inadequate response/treatment failure and operational strategies for engaging patients.
- Dr. 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.
Dr. 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.