Meeting Minutes, April 2016
National Advisory Council
NAC Members Present
Elizabeth A. McGlynn, Ph.D., Kaiser Permanente (Chair)
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health
Alice S. Bast, Beyond Celiac
Christina J. Calamaro, Ph.D., CRNP, Nemours/Alfred I. duPont Hospital for Children
Shari Davidson, National Business Group on Health
Jennifer E. DeVoe, M.D., D.Phil., M.Phil., M.C.R., Oregon Health & Science University (via telephone)
Mary Fermazin, M.D., M.P.A., Health Services Advisory Group, Inc.
Donald A. Goldmann, M.D., Institute for Healthcare Improvement; Harvard Medical School
Kevin L. Grumbach, M.D., School of Medicine, University of California, San Francisco
Ann L. Hendrich, Ph.D., R.N., FAAN, Ascension Health (via telephone)
Mary D. Naylor, Ph.D., R.N., FAAN, University of Pennsylvania School of Nursing
Monica E. Peek, M.D., M.P.H., M.Sc., The University of Chicago
Lucy A. Savitz, Ph.D., M.B.A., Intermountain Healthcare (via telephone)
J. Sanford Schwartz, M.D., University of Pennsylvania
Paul E. Sherman, M.D., M.H.A., CPE, FAAP, Group Health Physicians
Jed Weissberg, M.D., FACP, Institute for Clinical and Economic Review
Bob O’Brien, U.S. Department of Veterans Affairs (for David Atkins, M.D.)
Chisara Asomugha, M.D., Centers for Medicare & Medicaid Services (for Patrick Conway, M.D., via telephone)
Charles J. Rothwell, M.B.A., M.S., National Center for Health Statistics, Centers for Disease Control and Prevention
AHRQ Staff Members Present
Sharon B. Arnold, Ph.D., Acting Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Elizabeth A. McGlynn, Ph.D., 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. She referred to the draft minutes of the previous NAC meeting (November 3, 2015) and asked for changes and approval. The NAC members voted unanimously to approve the November meeting minutes with no changes.
Dr. McGlynn welcomed the following new NAC members:
- Alice S. Bast, Chief Executive Officer, Beyond Celiac.
- Christina J. Calamaro, Ph.D., CRNP, Director of Research for Nursing, Nemours/Alfred I. duPont Hospital for Children.
- Donald A. Goldmann, M.D., Chief Medical and Scientific Officer, Institute for Healthcare Improvement, and Clinical Professor of Pediatrics, Harvard Medical School.
- Monica E. Peek, M.D., M.P.H., M.Sc., Associate Professor of Medicine, Associate Director, Chicago Center for Diabetes Translation Research, The University of Chicago.
- Lucy A. Savitz, Ph.D., M.B.A., Assistant Vice President for Delivery System Science, Institute for Healthcare Leadership, Intermountain Healthcare.
New member José Julio Escarce, M.D., Ph.D., Professor of Medicine, David Geffen School of Medicine, University of California, Los Angeles, could not attend the meeting.
Sharon B. Arnold, Ph.D., AHRQ Acting Director, welcomed the NAC members, speakers, and other guests. She noted that NAC member Paul B. Ginsburg, Ph.D., recently was chosen to lead the new Leonard D. Schaeffer Initiative for Innovation in Health Policy, a partnership between the Center for Health Policy at Brookings and the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.
Dr. Arnold reminded the group that seven NAC members will rotate off the council in November 2016. AHRQ will seek nominations for new members. It will seek experts within a range of backgrounds, including research and evaluation; medical practice; representation of health care plans, providers, and purchasers; administration of delivery systems; and experience in other areas such as health care economics, information systems, law, ethics, business, public policy, and consumer/patient issues.
Dr. Arnold announced that David Knutson, M.S., has joined AHRQ as Director, Center for Delivery, Organization, and Markets. He was formerly a senior research fellow at the University of Minnesota.
Jeffrey Brady, M.D., M.P.H., Director of AHRQ’s Center for Quality Improvement and Patient Safety, recently was promoted to Rear Admiral and continues to serve in the U.S. Public Health Service.
The U.S. Department of Health and Human Services (HHS) has recognized and awarded two AHRQ teams for innovation. The AHRQ project to use social media and crowdsourcing to improve patient engagement in Evidence-based Practice Center reports to help improve those reports was selected as one of 24 finalists for the HHS Ignite Accelerator awards. A planned AHRQ health information technology (IT) project for patient-reported outcome measures was selected to participate in the HHS Competes Boot Camp. Both AHRQ projects will receive coaching/mentorship.
Dr. Arnold stated that the FY 2016 AHRQ budget is $334 million, which is $29.7 million less than the previous year’s budget (an 8% drop). Because of the decrease, AHRQ will eliminate support for the Quality Measures Clearinghouse, MONAHRQ, and the Health Care Innovations Exchange. The agency will seek to produce the National Healthcare Quality and Disparities Report more efficiently (at less cost). It will reduce or eliminate new evidence reviews, implementation and rapid cycle research projects, program evaluations, and activities in dissemination and implementation. Research support to study multiple chronic conditions will be put on hold.
For FY 2017, the President has requested $363.7 million in discretionary funds for AHRQ, an increase of $29.7 million. The total requested program level includes an added $106 million from the Patient-Centered Outcomes Research (PCOR) Trust Fund.
How AHRQ Makes a Difference
Dr. Arnold described the three main activities by which the agency makes a difference:
- It invests in research and evidence to understand how to make health care safer and improve quality.
- It creates materials for teaching and training health care systems and professionals to catalyze improvements in care.
- It generates measures and data used to track and improve performance and evaluate progress of the U.S. health system.
Dr. Arnold presented the following agency updates.
Research and Evidence
- A recent accounting found that, from 2010 to 2014, there was a 17 percent reduction in hospital-acquired conditions. About 87,000 lives were saved.
- AHRQ is receiving the 2016 Award of Excellence in Health Research from the Physician Insurers Association of America. The award commends "AHRQ’s dedication to develop evidence to maximize the quality, accessibility, and affordability of health care and to work within HHS and with other stakeholders to ensure that AHRQ findings are understood and used."
- AHRQ has called for applications for research to expand access to treatment for opioid abuse disorders. The program will feature up to $12 million for up to four research demonstration projects. It will support development of medication-assisted treatment (MAT) in rural primary care practices. MAT combines Food and Drug Administration (FDA)-approved medications with psychosocial treatments.
- The U.S. Preventive Services Task Force (USPSTF) has made many final recommendations and draft recommendations in recent months. Topics with a final recommendation include breast cancer screening, depression screening, screening for autism spectrum disorder, impaired visual acuity screening, and screening for chronic obstructive pulmonary disease.
- The USPSTF has called for nominations for new members. Nominations must be received by May 15, 2016.
- The Evidence-based Practice Centers have produced a long list of systematic reviews. Their topics include calcineurin inhibitors for kidney transplant, contrast-induced nephropathy, diagnosis and management of infantile hemangioma, diagnosis of celiac disease, and early diagnosis, prevention, and treatment of Clostridium difficile.
- AHRQ contributed to a special issue of Health Services Research in December, supporting five papers that focused on incentives for physicians.
- AHRQ produced new special emphasis notices for future research in the areas of health IT safety, shared decisionmaking, and delivery of primary care.
Tools and Training
- AHRQ produced a new toolkit to help hospitals prevent catheter-associated urinary tract infections. It was part of the 4-year project to promote use of the Comprehensive Unit-based Safety Program (CUSP).
- AHRQ released new patient resources to help treat alcohol use disorder. One publication focuses on medication. Others are research summaries to facilitate discussions between clinicians and patients.
- AHRQ released tools to help long-time smokers make informed decisions about lung cancer screening with low-dose computed tomography. The tools support discussions between patients and providers.
- A new AHRQ brochure helps organizations choose Patient Safety Organizations (PSOs). A new Centers for Medicare & Medicaid Services (CMS) regulation allows qualified health plans to meet Affordable Care Act requirements by contracting with hospitals that work with PSOs.
Data and Methods
- A new AHRQ Stat Brief on mastectomies indicates that breast cancer rates have remained constant while the rate of women undergoing mastectomies has risen significantly. Single and double mastectomies are performed increasingly as outpatient procedures. There is an increase in double mastectomies among women who do not have cancer (although a low rate).
- A new AHRQ Stat Brief indicates that mental or substance abuse disorders were involved in more than one-fourth of hospital stays by teenagers in 2012. Mood disorders and cannabis use were most common.
- An AHRQ-supported study found that a gap between public hospital payments and private-insurance hospital payments is growing, with the latter increasing over the former. Another study found that the use of capitation continues to decline.
- A study of the effect of the Affordable Care Act on labor hours found little to no change when considering a possible trend toward greater amounts of part-time work.
- Available modules for the AHRQ Quality Indicators now include Prevention Quality Indicators, Inpatient Quality Indicators, Patient Safety Indicators, and Pediatric Quality Indicators. The ICD-9-CM Version 6.0 Patient Safety Indicators and Prevention Quality Indicators will be released in June 2016. The ICD-9-CM Version 6.0 Inpatient Quality Indicators and Pediatric Quality Indicators will be released in August 2016. The ICD-10-CM/PCS Version 6.0 will be released in May 2016. (ICD-9 is the International Classification of Diseases, Ninth Revision; ICD-10 is the Tenth Revision.)
Regarding the AHRQ budget and cutbacks, Dr. Arnold noted that the Quality Measures ClearinghouseTM remains on the Web site, although reduced, because AHRQ has obtained funds from other sources. The reduction in the AHRQ budget targeted the area of health services research, data, and dissemination (a line item). Current grants are not being cut during their operation/cycle. Funds coming to AHRQ from the PCOR Trust Fund must be directed narrowly to PCOR goals. AHRQ’s Centers for Education and Research on Therapeutics program has been dropped. The agency is seeking other Federal funding sources to address the MONAHRQ program, the Healthcare Quality and Disparities Report, and more. Shari Davidson encouraged the agency to consider private partners.
In response to a question, Dr. Arnold noted that the USPSTF is an independent group, which receives support from AHRQ, as in AHRQ’s funding of evidence reviews and its cataloging of comments. the Evidence-based Practice Centers, which produce the reviews, have sustained no cuts.
Dr. Arnold asked the NAC members to consider two questions:
- How do we let the research community know that we have funds available for investigators?
- How do we get investigators to submit strong proposals?
The NAC members inquired about the payline for grant proposal acceptances. Dr. Arnold stated that it is near 30 percent. The proposal reviewers consider well the skill sets of the applicants. J. Sanford Schwartz, M.D., suggested that AHRQ send notices for new funding to past applicants and their institutions. The agency might indicate that its payline is comparable to the paylines of others (National Institutes of Health, Patient-Centered Outcomes Research Institute). Dr. Savitz suggested that AHRQ use large meetings and health care-related organizations to advertise its grant possibilities. Dr. Goldmann suggested that the agency announce needs for particular areas of research. Program announcements should feature clear statements of intent. Dr. Schwartz noted that, in the past, AHRQ offered a link to a statement of reasons why grants fail to be funded, which can be helpful.
Regarding the research on trends in capitation, Dr. Arnold noted that the AHRQ study looked at actual payments to providers. However, there are complications and alternative payment methods that may or may not indicate fee for service. Also, some services were not captured. Dr. Goldmann encouraged AHRQ to be clear about these issues in messages to the public. Ms. Davidson suggested that Accountable Care Organizations (ACOs) are becoming more mature and may lead to more capitation in the years to come. Joel Cohen, Ph.D., of AHRQ, added that ACOs can end up using fee for service as well.
Dr. Arnold asked the members to consider two additional questions:
- Given the policy and research questions that increasingly are being asked, are there new data resources that AHRQ should consider developing?
- What is the continued value of our existing data sources?
Dr. Peek suggested that AHRQ consider data sources that are not focused on health care delivery. Perhaps AHRQ could collaborate with other government agencies with regard to that. Dr. Goldmann pointed to potential changes in data sources and suggested that AHRQ try to make sense of the source trends. Dr. Schwartz suggested that AHRQ convene a group to consolidate information about the data efforts by the various stakeholders and to link efforts. Perhaps datasets could be integrated. Dr. Arnold stated that the team responsible for updating ICD-9 to ICD-10 is uncovering some of that information. Ms. Bast and Mary Fermazin, M.D., M.P.A., stressed the importance of standardizing, or harmonizing, registries. Dr. Fermazin stated that a multipayer data source with alignment would be helpful. An aggregated database for medication data also would be helpful.
Dr. Arnold stated that understanding the organization of care is important. We often lump together disparate activities, such as payments. There is a difference between an electronic health record and how data flow into that tool. We should seek to understand better clinical workflow, or the variability in workflow. It is complex.
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement, AHRQ
Dr. Bierman presented issues in primary care, noting AHRQ’s mission statement:
Revitalizing the Nation’s primary care system is foundational to achieving AHRQ’s mission of improving the quality, safety, accessibility, equity, and affordability of health care for all Americans.
Dr. Bierman described the agency’s investments in primary care–related research and evidence, teaching and training, and generation of measures and data.
AHRQ’s Center for Evidence and Practice Improvement features the Evidence-based Practice Center program, the USPSTF program, the Division of Decision Science and Patient Engagement, the Division of Health Information Technology, and the Division of Practice Improvement.
The Center also features the National Center for Excellence in Primary Care Research (NCEPCR), which is a home, or a linking, for primary care efforts at the agency. NCEPCR is AHRQ’s main point of contact with the primary care community. It communicates evidence from AHRQ’s research to researchers, primary care professionals, health care decisionmakers, patients, and families.
AHRQ’s research portfolio has emphases on the patient-centered medical home, the transformation of primary care, practice facilitation, care for people with multiple chronic conditions, the primary care workforce, and the primary care practice-based research networks. The EvidenceNOW program seeks to advance heart health in primary care. It features seven regional projects across the Nation.
AHRQ tools that address primary care include the TeamSTEPPS training program for primary care teams; a USPSTF app for screening, counseling, and preventive medication services; and a health literacy precautions toolkit. AHRQ also offers tools for measurement in primary care/ambulatory care (e.g., the CAHPS® program), with a goal of care improvement.
Looking to the future, Dr. Bierman reviewed the timeline for the ongoing EvidenceNOW project. Having completed the recruitment phase, the program will continue to implement its quality improvement interventions and data collection. Postintervention evaluation will take place from November 2017 to May 2018.
AHRQ will fund three research demonstration projects to support the implementation of MAT in rural primary care. MAT is an evidence-based approach that uses FDA-approved medications for opioid abuse. Addressing barriers, the implementation may involve training of physicians and counseling for patients.
AHRQ released a Special Emphasis Notice calling for research proposals to advance primary care. The notice describes a variety of aspects of primary care that researchers might target. The agency also will continue other primary care research programs, for example, in clinical decision support, patient-reported outcome measures, patient engagement, and patient safety.
Dr. Bierman stressed AHRQ’s commitment to integrating primary care with other health and community services. She asked the NAC members to propose and consider other priority areas within primary care that the agency might address in upcoming years.
The NAC members cautioned the agency about asking too much of the primary care community. Dr. Bierman noted that the agency performs some tracking of the use of its products. It is working to disseminate the products more widely and is open to suggestions.
Ms. Davidson stated that, for employers, the area of behavioral health is especially active right now. She encouraged ARHQ to support primary care in that area. There is a need for health plans to agree on quality measures for behavioral health care. Tools for consumers to use in the area of prescription drugs would be welcome. Dr. Bierman asked the NAC members to visit the Center’s Web site and make suggestions for enhancing the tools and measures. Kevin L. Grumbach, M.D., suggested that the Web site provide more links to the many good activities in primary care. He called for the development of holistic integrated measures in primary care. We need more nondisease-related research.
Dr. Fermazin called for research on diagnostic errors in ambulatory care. She encouraged the measurement of core functions of primary care (access, engagement). AHRQ might speak with organizations to develop ideas. The role of primary care in postacute transformation is in need of study. Jennifer E. DeVoe, M.D., D.Phil., M.Phil., M.C.R., proposed holding an international meeting of primary care experts, with an eye toward research and initiatives.
Jed Weissberg, M.D., FACP, again cautioned against asking too much of primary care. Specialty care should perhaps take on some of the primary tasks. Dr. Goldmann added the problem of burnout in primary care. There is an onslaught of measurement. We should look at the primary care team and shared decisionmaking. The TeamSTEPPS program provides good tools yet does not complete a holistic picture. Community needs assessment might help.
Dr. Schwartz wondered whether the work of the USPSTF might be tied to the research agenda. AHRQ might consider coordinating more with the National Institutes of Health in research on issues such as chronic diseases and health IT, combining funding. Dr. Calamaro called for new models of care and attention to care transitions and chronic illness. Dr. Bierman stated a need to focus on small and medium practices. She asked the NAC members to forward names of people who might sit on study sections and might help to shift their priorities.
Dr. McGlynn cited the need to better integrate information into clinical care. For primary care, we need to learn what patients want, which then can be addressed. Dr. Grumbach noted that there is no evaluation of the practice transformation space. He called for evaluation or studies of outcomes. Chisara Asomugha, M.D., noted the development of CMS affinity groups, which are addressing many areas, such as behavioral health and population health, and could work with AHRQ.
There were no public comments.
Elizabeth A. McGlynn, Ph.D., NAC Chair
Dr. McGlynn began a final session on future AHRQ initiatives by asking the NAC members to consider the agency’s particular role as it relates to how the health care system can function most effectively. She asked the members to respond in light of the possibility that AHRQ might receive a boost in its FY 2017 funding. Should some areas receive more attention?
- David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, saw the goal for AHRQ as deploying evidence-based practices efficiently. That requires fitting different organizational/business models. It requires different types of funding to influence provider behaviors. Dr. Ballard suggested that we need accountability thresholds, changing behaviors, new tactics, and resources. Coordination among Federal agencies (as in co-funding) is difficult; yet it can lead to leveraging.
- Dr. Weissberg stressed the importance of aligning the missions of Federal agencies. He encouraged more support for health IT research. We need health IT modules that can work for each vendor (interoperability). We need more clinical decision support.
- Dr. McGlynn cited the need for conceptual models, classification systems, and data infrastructure to understand the role of organization in health care. AHRQ is well suited to address issues in diagnostic care. Dr. McGlynn suggested that ARHQ should be ready to fill a role in the research portfolio in case the Patient-Centered Outcomes Research Institute does not get reauthorized. AHRQ might help patients to be partners in research. Dr. Arnold noted that AHRQ will be communicating with a new administration about AHRQ’s strengths and ability to lead.
- Ms. Davidson proposed the goal of helping physicians to incorporate evidence-based medicine through the designs of health plans. Dr. McGlynn cited a need for a common language and better communication to support health services research.
- Dr. Peek encouraged AHRQ to engage advertisers to develop public messages and narratives. Ms. Bast suggested use of the phrase “living better longer.” She stressed the need for clear, concise messages.
- Dr. McGlynn cited a need for research on developing systems and training teams. Dr. Schwartz suggested that AHRQ use possible new money to strengthen current programs rather than develop new programs. One example would be the health IT area.
- Dr. Goldmann cautioned about the use of so-called "implementation science," because it lacks the idea of scale-up and ignores the difficulty of scale-up. The idea that legislation will lead to optimal care is a myth. The idea that value-based payment will lead to optimal care is a myth. The idea that basic scientists can perform implementation and scale-up is a myth. Patients should know that they are not being harmed and that they are simply being given the needed care. Dr. Goldmann called for AHRQ to define its role in supporting data functionality.
- Dr. Grumbach suggested that AHRQ develop a message of what it does uniquely, such as getting tools into people’s hands. Dr. Savitz suggested that the agency develop, for its Requests for Applications, requirements for dissemination and examine the value of its investments. It might seek to understand the value of patient-reported measures. What is the clinically relevant change in a measure? What measures can be used across a continuum?
- Dr. Schwartz agreed on the need for clear, key messaging, and he suggested that the agency promote the idea that it works to evaluate impact. Quality and safety measures have saved lives. Dr. Goldmann added that simply being visible is not enough.
- Charles J. Rothwell, M.B.A., M.S., encouraged AHRQ to provide data and reports that document issues of preventable morbidity and mortality. Ms. Davidson noted the benefit of using navigators and second opinions in health plans, to improve diagnoses and reduce the overuse of health care.
Dr. McGlynn asked the NAC members to continue thinking about these issues, especially relating to ARHQ programs that are already underway, and ways to collaborate with other Federal agencies.
Francis Chesley, M.D., Director of AHRQ’s Office of Extramural Research, Education, and Priority Populations, joined the discussion to provide more information on AHRQ’s funding capabilities. He stated that the agency in recent years has moved to a system of program announcements for 3-year research in three areas: general research, patient safety, and training.
Today AHRQ funds investigator-initiated research with a success rate of about 30 percent. The payline is closer to 20 percent. Funding is for 1) large applications (R01), 2) small applications, and 3) training grants. About 80 percent of the budget targets large grants. The remaining 20 percent targets small grants and training grants. AHRQ receives about a 1,000 grant applications each year.
There are five study sections, and one challenge is to get them up to speed (e.g., their composition) as the research priorities change. The agency constantly needs peer reviewers who can go beyond the scientific merit to consider the potential impact of research. The agency seeks equity in addressing priority populations; for example, it asks grant applicants to state the potential impact of research on certain populations.
Dr. Chesley stated that the topical interests of the five study sections are training, quality, effectiveness and outcomes, patient safety, and health economics. There is no stated emphasis on primary care, yet reviewers with backgrounds in primary care are included. A new study section can be formed, and the study sections can evolve. They serve as ambassadors for understanding the agency’s priorities.
Dr. McGlynn asked the group to forward any ideas for the agenda of the next meeting, which will take place on July 22. She thanked the NAC members, speakers, and other guests and adjourned the meeting.
Elizabeth A. McGlynn, Ph.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality