Meeting Minutes, March 2018
NAC Members Present
Donald A. Goldmann, M.D., Boston Children’s Hospital, Institute for Healthcare Improvement, Harvard Medical School (Chair)
Alice S. Bast, Beyond Celiac
Christina J. Calamaro, Ph.D., CRNP, Children’s Healthcare of Atlanta
Robert S. Dittus, M.D., M.P.H., Vanderbilt University Medical Center
José Julio Escarce, M.D., Ph.D., University of California, Los Angeles
Monica E. Peek, M.D., M.P.H., M.Sc., The University of Chicago
Lucy A. Savitz, Ph.D., M.B.A., Intermountain Healthcare
Liza M. Catucci, U.S. Department of Veterans Affairs (for David Atkins)
Kate Goodrich, M.D., Centers for Medicare & Medicaid Services
Michael Lauer, M.D., National Institutes of Health
AHRQ Staff Members Present
Francis D. Chesley, Jr., M.D., Acting Deputy Director
Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
Lucie M. Levine, Chief Financial Officer
David Meyers, M.D., Chief Medical Officer
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Donald A. Goldmann, M.D., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 11 a.m. and welcomed the NAC members, other participants, and visitors. He referred to the draft minutes of the previous NAC meeting (November 3, 2017) and asked for changes and approval. The NAC members voted unanimously to approve the November meeting minutes with no changes.
Dr. Goldmann introduced Francis D. Chesley, Jr., M.D., who was recently appointed Acting Deputy Director of AHRQ. Dr. Chesley introduced the session for the Director’s Update.
Dr. Chesley conveyed warm regards to the NAC members from AHRQ Director Gopal Khanna, M.B.A., who was unable to join the meeting, and noted the appointment of Ginger Mackay-Smith, M.P.H., as Acting Director of AHRQ’s Center for Delivery, Organization, and Markets. Leaders within four AHRQ departments then provided updates on recent AHRQ activities.
Lucie M. Levine stated that the Agency currently is operating under a continuing resolution for fiscal year (FY) 2018. An omnibus bill may be presented within a week. Ms. Levine then provided details on the President’s proposed FY 2019 budget for AHRQ that addresses the possible transition of AHRQ’s highest priority activities to a new entity, the National Institute for Research on Safety and Quality, which would be within the National Institutes of Health. The President’s FY 2019 budget request for the new entity is $380.3 million, a decrease of $41.3 million from FY 2018. The proposal includes $256 million in discretionary funds and $124.3 million in mandatory funds from the Patient-Centered Outcomes Research (PCOR) Trust Fund. AHRQ representatives will be attending House and Senate budget committee meetings to provide information in the upcoming months. House markup for the FY 2019 budget will be released in June. The Senate markup will follow.
The President’s proposed budget includes $69.8 million for patient safety research, $72.2 million for the Medical Expenditure Panel Survey (MEPS), $7.4 million for the U.S. Preventive Services Task Force, $1 million for the Evidence-Based Practice Center (EPC) Program, $10 million for the Healthcare Cost and Utilization Project (HCUP), $35.2 million for ongoing investigator-initiated research and training grants (no new grants are proposed), and $4.5 million for developing evidence in preventing and treating opioid misuse in primary care. The figure for MEPS includes support for new plans to expand the MEPS sample to improve national estimates, subgroup analysis, and the capacity for State estimates. The MEPS program also will develop and field new self-administered mental health questionnaires.
The proposed budget indicates reductions in portfolios for Health Information Technology Research and Health Services Research, Data, and Dissemination, including the elimination of programs in Quality Indicators, data analytics support, dissemination and implementation contracts, and the Consumer Assessment of Healthcare Providers and Systems.
David Meyers, M.D., FAAFP, reported on AHRQ’s efforts to address the opioid crisis, providing the following examples:
- An AHRQ grantee in Washington worked with 20 rural primary care practices and identified successful strategies for using team-based care to improve chronic pain management.
- An ARHQ grantee in New Mexico developed and tested a novel, reproducible model for translating and communicating evidence from EPC reports to rural, low-income, underserved, multiethnic communities.
- AHRQ has now posted 250 tools for delivering medication-assisted treatment.
- AHRQ has developed a platform and architecture for electronic clinical decision support (CDS Connect).
Dr. Meyers noted that AHRQ’s EvidenceNOW program has reached more than 1,500 small primary care practices. The program features partnerships to improve heart health care using PCOR evidence. Future plans by the Agency include scaling efforts in the opioid crisis, advancing the dissemination of PCOR findings, and supporting progress in learning health systems.
Jeffrey Brady, M.D., M.P.H., reported on AHRQ efforts to address safety threats, providing the following examples.
- AHRQ’s Patient Safety Learning Laboratories, through 13 grant projects, are designing and testing solutions to address health care risks and hazards.
- A new funding opportunity seeks the alignment of aims and research findings with information needed by C-suite officers and other stakeholders in health care systems. Part of that is to learn from grant holders the impact of their grant work.
- Two examples of current grants are a project employing human-centered designs (e.g., the built environment) to improve perioperative outcomes and a project examining qualitative and quantitative approaches to problems in radiology and imaging procedures.
- The Agency produced an updated guide/toolkit, “Improving Your Laboratory Testing Process,” to improve standardization and systemization of laboratory testing processes.
- AHRQ is developing the Quality and Safety Review System for efficient measurement of hospital-acquired conditions (HACs) at the national level and in hospitals. Pilot testng is underway. The system will serve as a robust platform for patient safety and quality improvement, offering data to guide decisions.
Dr. Brady provided a graphic that noted changes in rates of various causes of HACs in recent years. For example, rates of HACs related to adverse drug events have been falling for the past 5 years.
Data and Insights
Joel W. Cohen, Ph.D., focused on AHRQ’s MEPS program. He asked a series of questions regarding various health data then showed how the MEPS can answer the questions readily. For example, the answer to the question “What is the average cost of employer-sponsored health insurance in Michigan?” can be found easily in the MEPS database ($5,906 for a single plan and $17,113 for a family plan in 2016). Recent advancements in MEPS include the posting of flexible, user-friendly summary data tables on the website and an expanded sampling of veterans’ health care data for the database. In the near future, AHRQ intends to expand the sampling for the MEPS household survey and intends to add a supplemental questionnaire on mental health care.
Dr. Cohen provided screen shots of the new summary data tables, which address the areas of health insurance, medical conditions, prescribed drugs, accessibility/quality of care, and use/expenditures/populations. He noted some recent uses of MEPS data, such as in an article in the Journal of the American Medical Association, for which AHRQ provided a graphical presentation of medical expenditures relating to adult obesity.
Ms. Levine explained that the term “discretionary” refers to funding that lies within a certain budget authority—in this case, Congress—as opposed to mandatory funding, which is funding mandated by law each year, such as Medicare funding. Dr. Goldmann wondered whether the elimination of AHRQ’s work in Quality Indicators might mean a shifting of that effort to other agencies. Ms. Levine noted that Congress has asked for a study of health services research and likely will wait for that study to finish before making large changes to AHRQ.
Dr. Goldmann asked about integrating the streams of effort in an area such as the opioid crisis response. Dr. Meyers responded that AHRQ is spending much time in coordinating across the various streams and attending to the five priorities of the HHS Secretary. AHRQ is participating in activities with many stakeholder partners. Lucy A. Savitz, Ph.D., M.B.A., asked about a recent problem with claims data for people with substance abuse diagnosis. Jenny A. Schnaier, M.A., responded that the HCUP program did not lose the data. Considering the current efforts responding to the opioid crisis, Dr. Savitz urged AHRQ to ensure that quality improvement work is included in evidence syntheses. Dr. Meyers responded that AHRQ is seeking ways to ensure that the EPC program promotes such evidence. Christina J. Calamaro, Ph.D., CRNP, raised the idea of crosswalking primary care data and surgical data to help illuminate issues of communication in opioid prescribing.
Dr. Brady noted that the measures in the Quality and Safety Review System are aligned with those in the National Health Safety Network. The methods of the former are new and feature a population approach. Monica E. Peek, M.D., M.P.H., M.Sc., wondered whether AHRQ has considered broadening the definition of the term “patient safety” beyond hospital settings. Dr. Brady stated that AHRQ has expanded its focus to all settings of care and to transitions of care. Dr. Chesley added that AHRQ has a funding announcement focused on research that spans the continuum of settings of care.
Dr. Savitz applauded the MEPS feature allowing one to download codes and adapt them to apply to a particular dataset.
Jenny A. Schnaier, M.A., Program Analyst, AHRQ Center for Delivery, Organization, and Markets, and Kevin C. Heslin, Ph.D., AHRQ Center for Delivery, Organization, and Markets
Ms. Schnaier described AHRQ’s HCUP, which is a comprehensive set of publicly available, all-payer, health care data covering 97 percent of the U.S population. HCUP collects data on hospital inpatients and from emergency departments and ambulatory surgery sites. HCUP data allow for analyses of common and uncommon conditions and procedures. The data are national and derive from the States. The data are record level, simple to use, and available on the HCUP website. Forty-seven States and the District of Columbia provide the data, derived from administrative billing records. HCUP features seven types of databases: State inpatient, State emergency department, a national inpatient sample, a kids inpatient sample, a nationwide emergency department sample, national readmissions, and State ambulatory surgery and services (the last is coming soon).
HCUP produces user-friendly information packaged as methods, topical reports, and statistical briefs. For example, a recent brief is titled “Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014.” The project also offers Fast Stats that presents displays of trends in hospital use and HCUPnet, an online query system accessing HCUP statistics. The latter allows users to generate tables of outcomes by diagnoses and procedures. A new HCUP tool allows for county-level comparisons of hospitalization rates for opioids, alcohol, stimulants, and other drugs.
Dr. Heslin spoke of HCUP’s value in addressing the opioid epidemic. He stated two challenges:
- The opioid epidemic is a national problem, but health care is delivered at the local level.
- State data are valuable, but there is variation within each State. Dr. Heslin presented screen shots from the HCUPnet Community-Level Statistics, which feature maps and tables.
In particular, he presented graphic pages that show rates of hospital stays relating to alcohol and other drugs by county within each State. The results for each State revealed wide variations in rates between counties.
Dr. Heslin suggested that the county-level statistics be downloaded from HCUPnet and linked to other county-level data sources to support research. He reported that AHRQ is developing an opioid “hot spot” study that will feature the merging of county statistics and external data sources to inform local responses to the opioid epidemic. The HCUP group is considering ways to bring the information to researchers and would like to speak with State and local officials to discuss ways in which the information could be more actionable.
Dr. Savitz noted that her group has employed HCUP statistical codes while using up-to-date data. She thanked the HCUP group for its hard work. Dr. Goldmann wondered whether AHRQ has received feedback on the statistics from State legislators. Dr. Heslin noted that the Agency will be reaching out to organizations such as the National Governors Association and the National Conference of State Legislatures. The latter has a strong database of information on State legislation relating to opioid abuse. Dr. Goldmann asked about local media coverage when the data become available and suggested that AHRQ examine such possible media coverage. Howard Holland, Director of AHRQ’s Office of Communications, reported that AHRQ’s outreach efforts will include the targeting of media in regions where press can reach localities. AHRQ has a media distribution service in place. A hope is that such outreach will result in local stories in the press.
Dr. Chesley asked the NAC members to consider and discuss two questions:
- What future challenge or question do you see facing the health care system over the next 10 years?
- What do you see or want AHRQ’s role to be in answering the question of challenge?
Dr. Savitz cited the issue of access to care. How should that be defined? We need to advance our understanding of population health and learning health systems. How are we interacting? We need to build a science around social determinants. We need to address the issue of the high costs of drugs.
Dr. Calamaro stated the need to create crosswalks between or through databases. In light of the opioid crisis, we need to create an infrastructure of data that allows the data to be used readily.
Dr. Peek stated that AHRQ has been a leader in data issues, pushing the science of health care delivery. It now might consider and help coordinate how health systems can integrate all data that reflect population health, social determinants, and disparities.
Dr. Goldmann recalled a recent meeting that addressed the idea of democratizing the advancement in data technologies to the benefit of populations. Perhaps AHRQ could market data, leading to better engagement. People are not using data optimally.
Robert S. Dittus, M.D., M.P.H., stated that more data about systems and processes of care will lead to opportunities in care improvement, and AHRQ should consider focusing on that issue. He agreed with the call to engage population health and its related systems. He called for more implementation science and more research on the impacts of care systems.
Dr. Chesley stated that Director Gopal Khanna is stressing issues of data and data use and has noted that health care access has many determinants. The Director has called for a focus on the “person-360,” with more inclusive and transdisciplinary approaches. The integration of systems is important to realizing the potential of data. How can we use data sources to produce data solutions and make the solutions attractive to people?
Peggy Binzer, Executive Director of the Alliance for Quality Improvement and Patient Safety (AQIPS), spoke briefly about the Alliance’s work. AQIPS is a nonprofit professional association that represents patient safety organizations and their providers. It hopes to bring projects to AHRQ. One focus being addressed is the challenge of interoperability. Another is the issue of providers working with new technologies. The Alliance especially would like to work with AHRQ in the area of safety and health information technology, attacking issues such as standards and usability. It envisions creating a national collaborative of vendors and others to address health information technology issues.
Drs. Goldmann and Chesley thanked the NAC members and speakers for their input. Dr. Goldmann applauded AHRQ’s wisdom and experience. He noted that the next NAC meeting will take place July 18, 2018. He adjourned the meeting at 1p.m.
Donald A. Goldmann, M.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality