Research Activities, January 2014
New Director Revamps AHRQ's Mission
Richard Kronick, Ph.D., who took the helm of AHRQ in September, has led an effort to revamp the Agency's mission in collaboration with AHRQ's senior leadership team, Department of Health and Human Services (HHS) partners, and key stakeholders. The new mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with HHS and other partners to make sure that the evidence is understood and used. Research Activities (RA) spoke with Dr. Kronick about his new vision for the Agency.
RA: Using evidence to transform health care seems to be the hallmark of your vision for AHRQ and at the center of the Agency's revamped mission. Is that a shift in what AHRQ had previously been doing?
RK: First, I am well aware that hardly anyone pays attention to mission statements. When I shared the new mission statement at an all-hands meeting of approximately 300 AHRQ staff, I asked how many people knew what the Agency's previous mission statement was. Only a smattering of hands went up. Similarly, hardly any members of AHRQ's National Advisory Council knew the Agency's previous mission statement. Acknowledging that not much attention gets paid to mission statements, I'll point out some nuanced changes from the previous statement to the new one. Even though the Agency has always done so, the mission statement now clearly identifies our focus as producing evidence and making sure that the evidence is understood and used.
The previous mission statement said that our job was to make health care safer, higher quality, more effective. As a relatively small agency, it is unrealistic to think that we can do much to make health care safer, higher quality, and more effective on our own, but we are very well positioned to produce evidence about how to accomplish these goals, and to work with others to make sure the evidence is understood and used. The new mission statement explicitly states that producing evidence on how to improve accessibility, equitability, and affordability is central to our job. But we can't do all of this alone.
RA: Is that the reason you have emphasized the importance of collaborating with HHS and other partners?
RK: There are two reasons collaborations are important. First and foremost, as mentioned, we can't do it all by ourselves. We have 300 people and a little more than $400 million in our budget, which for a health services research agency, makes us a pretty good sized organization. It's not nearly big enough of course, and in the context of a $2.7 trillion health care system with 800,000 physicians, 5,000 hospitals and more than 3 million nurses, we are very small. If what we are trying to do is make the health care system safer, higher quality, more equitable, affordable, and accessible, we can't do that much by ourselves and we need partners to help understand, use, and implement the evidence we produce.
Further, we are part of a Department that is purchasing more than a $1 trillion worth of health care annually, and we have an opportunity to inform and guide potential levers such as the Medicare and Medicaid Programs, HRSA's (Health Resources and Services Administration) community health centers, and other initiatives to accomplish our mission. Providing evidence to guide the work of key HHS initiatives is a role we are uniquely able to play. While CMS, NIH, and CDC produce evidence on various aspects of health care, we are the only agency with the sole mission of producing evidence to improve the delivery of health care services and health outcomes. The second reason for collaboration is to generate support for the Agency among stakeholders who are invested in our success. Especially in these times, one can never have too many friends!
RA: The Agency's first priority is to work on the national initiative created by the Affordable Care Act to harness the potential of patient-centered outcomes research (PCOR). What projects will AHRQ undertake to accomplish this?
RK: The first project we are working on in this area is a very exciting initiative to provide support to small- and medium-sized primary care practices to help them and their patients improve outcomes on cardiovascular risk factors, the so-called ABCS (aspirin, blood pressure, cholesterol, and smoking), and more broadly to help them adopt practices based on PCOR findings as they emerge. We've seen some of the larger and more organized medical groups in the country make progress in this area over the last few years by creating the kinds of teamwork and clinical decision support systems to accomplish it.
For example, some of these large systems will not wait for people with high blood pressure to come in for a visit, but will create a registry of patients with high blood pressure and reach out to them and work proactively on making progress in reducing their blood pressure. Small- and medium-sized physician practices don't have the resources to establish these types of systems.
RA: Making health care safer, a longtime AHRQ priority, is priority number 2. AHRQ has made many dramatic improvements in hospital safety. What safety areas do you plan to focus on?
RK: AHRQ's patient safety research supports improvements in all settings of health care, and we intend to maintain that ongoing support while we also take advantage of key opportunities to make care safer in the near term. First, we plan to accelerate patient safety improvements in hospitals, where we expect even better results and greater improvements can be achieved. Using AHRQ patient safety tools, we will continue to support the momentum generated by the Partnership for Patients and the nation's progress in reducing hospital-acquired conditions (HACs). These activities will aim to reduce rates of venous thromboembolism, falls, pressure ulcers, and adverse drug events.
Another major focus will be our continued efforts in reducing healthcare-associated infections (HAIs). Our poster child is our work on central line-associated bloodstream infections (CLABSIs). Our efforts resulted in more than a 40 percent reduction in CLABSIs in more than 1,000 hospitals where the Comprehensive Unit-Based Safety Program (CUSP) was implemented. More recently we have been applying a similar, adapted CUSP approach to reduce catheter-associated urinary tract infections (CAUTIs) and, so far, that project is generating promising results. Hospital units that have implemented the program for 14 months have achieved close to a 20 percent reduction in CAUTIs. We've seen nearly a 40 percent reduction in hospital units that are not ICUs (intensive care units), but less progress in ICUs where it's more difficult to change the practice of putting catheters in and keeping them in.
We're also extending use of CUSP into other areas, particularly to reduce surgical site infections in both inpatient and ambulatory surgery and reduce ventilator-acquired pneumonia. A third safety focus targets harm from obstetrical care by reducing perinatal patient safety events such as uterine rupture during labor, birth trauma, maternal blood transfusion, and third or fourth degree perineal laceration. Patient safety improvements in nursing homes are another set of goals AHRQ will address. This initiative will make use of the Agency's collection of tools and resources that are designed to help nursing homes implement interventions to reduce pressure ulcers, falls, HAIs, and hospital admissions.
Finally, we are examining the impact of communication and resolution programs to improve patient safety and reduce medical liability in a diverse set of hospitals. Using this approach, the hospital and physicians approach patients who have been harmed by a medical error and communicate the error, apologize for it, and work in a cooperative way to reach a resolution. The program already shows promising results. For example, the University of Illinois Hospital and Health Sciences System reduced claims and lawsuits by 40 percent per quarter compared to before program implementation. In addition, malpractice insurance premiums were 22 percent lower in 2012 than in 2010, and in 2013, premiums were 31 percent lower.
Further, the program saved payers like Medicare and Medicaid $4.7 million. AHRQ will draw from the findings of recent research projects to develop and refine a toolkit for implementing a communication and resolution program in other organizations. The project team will then evaluate the toolkit and its implementation in various tests sites in preparation for broader implementation.
RA: Where do you expect AHRQ to make the biggest impact on patient safety in the next few years?
RK: The continued progress in reducing HAIs and adverse events in hospitals and nursing homes, extending from what we've learned from our success in the inpatient setting to other settings, and our work in improving patient safety and reducing medical liability with communication and dispute resolution. On the near horizon we look to make progress in measuring and reducing diagnostic errors. System-based factors such as information flow and communication between clinicians, along with cognitive mistakes, can all contribute to the challenge of getting the right diagnosis. Care delivered in the outpatient setting is particularly vulnerable to diagnostic errors, but we can build on some of the early research that has been done to understand and address that issue.
RA: Priority 3 is to evaluate Affordable Care Act coverage expansions to increase health care accessibility. What do you plan to evaluate and what difference will it make?
RK: We plan to produce evidence that the Secretary of HHS, members of Congress, and other policymakers will need to make informed decisions about coverage expansion and other aspects of the Affordable Care Act moving forward. We've already seen that the Affordable Care Act is not static. Like any major piece of social legislation, as its being implemented, further adjustments and changes will be made. Policymakers will need better information about the effects of the coverage expansions in order to make better decisions as they work on making these adjustments. We will be evaluating a variety of questions about the impact of the Affordable Care Act on health care use, health outcomes, financial stability, labor markets, and employer and employee decisions regarding employer-sponsored insurance.
We are quite confident that the fraction of people with a usual source of care will increase. Based on data from AHRQ's Medical Expenditure Panel Survey, about 40 percent of the uninsured have a usual source of care and at least 80 percent of Medicaid- and privately insured persons have a usual source of care. I'd be shocked if having a usual source of care doesn't rise to near 80 percent among the newly insured. We are pretty sure that utilization of health care will also increase and the cost barriers to care access will come down, since the uninsured are much more likely to report than the insured that they didn't get care that they needed because of cost, although the magnitude of the change is much less certain.
We'll also be analyzing the effects of the law on financial security. A major function of insurance is to protect people's finances when they get sick, and understanding how much protection is provided and what effect the greater protection has on labor force participation and general well-being will be important. In addition, we will be examining the effectiveness of various approaches to outreach and enrollment.
One of the decisions that will need to be made in the future is how to get people who aren't insured either to enroll in Medicaid or to purchase insurance in the marketplace, and there is a lot of uncertainty about how best to do this. We'll be analyzing the magnitude and nature of efforts. Finally, we will be analyzing the impact of coverage expansions on the labor market. Understanding what actually happens will be important information to provide to policymakers as they move forward to figure out how best to increase accessibility to health care services.
RA: Isn't this a new area of focus for AHRQ?
RK: Yes. As we've talked about, our revamped mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with others to make sure that the evidence is understood and used. The Affordable Care Act is the largest change in health care financing and the accessibility of health care since 1965, and it would be irresponsible of us to ignore this change. We couldn't do our job of producing evidence—in fact, we wouldn't be doing our job of producing evidence to improve accessibility—if we ignored evaluation of the largest change since 1965 in health care financing.
We have important contributions to make in collaboration with our colleagues at ASPE (HHS Office of the Assistant Secretary for Planning and Evaluation) and CMS. I'm also aware that engaging in this activity could potentially produce results many may not like. We may produce evidence that doesn't provide answers that the Secretary and key officials might want to see, but that it is still part of our job. The Secretary is aware of that possibility and is in full support of AHRQ's agenda.
RA: Your fourth priority is to improve health care affordability, efficiency, and cost transparency. Could you give me an example of a project you are planning?
RK: I'll give you two examples. The first is to provide technical assistance and support to States that are working to make price information more transparent. The Center for Consumer Information & Insurance Oversight recently awarded grants to about 20 states to strengthen their rate review processes. Those grants provide resources to States to work with data centers and in some cases State all-payer claims databases to produce information on prices that are paid to various hospitals, physicians, and other health care providers.
Over the years, AHRQ has worked with many of these State agencies through AHRQ's Healthcare Cost and Utilization Project, the largest database of nationwide and State-specific hospital care data in the U.S., as well as some work we've done with all-payer claims databases. It's clear many of these agencies are poised to do exciting work on price transparency, but many of them need assistance to efficiently get from where they are now to information that will be useful to consumers and purchasers. We will be providing some of that help to catalyze those efforts.
The second project is much broader, with more difficult outcomes to achieve, and still under development. The goal is to produce a compendium of knowledge about health care delivery systems and their performance in the United States. Our objective is to learn more about what choices have been made in structuring and organizing the systems, and to be able to assess the efficiency and quality of care that is produced and measured in this variety of delivery systems. I'm sure there will be a strong regional footprint in performance.
Building on decades of work from researchers at Dartmouth and elsewhere, we know that there are large differences across areas of the country in how health care is delivered. But even within regions, there is a lot of variation in performance, and we'll be working at trying to understand the factors related to variation in performance. We expect that this work will be a catalyst for encouraging and informing improvements in performance and more appropriate use of resources.
RA: Given the climate of budget constraints, will AHRQ have the resources to accomplish its revamped mission and how will you gauge its success?
RK: A big part of my job is to focus the work of the Agency. While we don't have enough resources to accomplish our mission as quickly and on as broad a scale that we might want, we certainly have the resources to make progress in each of the four priority areas. The key is to decide how best to invest the resources we have. In terms of gauging success, the proximate measure for success for the first priority on PCOR is our ability to demonstrate whether one or more techniques is successful in helping physicians and patients improve outcomes such as blood pressure and cholesterol levels and in improving the ability of practices to adopt new PCOR findings.
The longer term measure of success is whether the evidence we generate is used by CMS, private insurers, and health systems and put into practice more broadly. The priority directed at producing evidence to make health care safer is the easiest one for which to measure success. We will focus on measuring changes in adverse events, and on the rate of implementation of communication and resolution programs and the success of those programs.
The proximal measure of success for the efforts at describing health systems performance is whether we produce information that is perceived as credible and valid, and the longer term measure is whether the information is used by health systems, purchasers, and patients to spur efforts at performance improvement. Finally, for the accessibility priority, we will consider ourselves successful if we produce evidence about the impact of the Affordable Care Act on people and labor markets that is seen as useful by the Secretary and members of Congress.
Overall, we are focused on doing a better job of making sure that the evidence we produce is being used by policymakers, providers, and patients to improve care quality, safety, accessibility, equitability, and affordability.