Meeting Minutes, July 2018
National Advisory Council
Call to Order and Approval of March 16, 2018, Meeting Summary
Director's Welcome and Update
Update on AHRQ Data, Analytics, and Insights
Addressing the Opioid Crisis: An Update
Health Services Research and the C-Suite
Chair's Wrap-Up and Adjournment
NAC Members Present
Donald A. Goldmann, M.D., Institute for Healthcare Improvement, Boston Children’s Hospital, Harvard Medical School (Chair)
Karen S. Amstutz, M.D., M.B.A., Magellan Health
Alice S. Bast, Beyond Celiac
Cathy J. Bradley, Ph.D., M.P.A., University of Colorado Cancer Center
Sheila P. Burke, M.P.A., R.N., FAAN, Baker Donelson
Christina J. Calamaro, Ph.D., CRNP, Children’s Healthcare of Atlanta (via telephone)
Beth Ann Daugherty, M.P.H., R.N., Sparrow Clinton Hospital
Robert S. Dittus, M.D., M.P.H., Vanderbilt University Medical Center
José Julio Escarce, M.D., Ph.D., University of California, Los Angeles
Barbara A. Fain, J.D., M.P.P., Betsy Lehman Center for Patient Safety
Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Stanford University School of Medicine
Andrew L. Masica, M.D., M.S.C.I., S.F.H.M., Baylor Scott & White Health
Monica E. Peek, M.D., M.P.H., M.Sc., The University of Chicago
Jerry L. Penso, M.D., M.B.A., American Medical Group Association
Lucy A. Savitz, Ph.D., M.B.A., Intermountain Healthcare (via telephone)
William H. Shrank, M.D., M.S.H.S., University of Pittsburgh Medical Center
David Atkins, M.D., M.P.H., Veterans Health Administration
Shari M. Ling, M.D., Centers for Medicare & Medicaid Services (for Kate Goodrich)
Chesley Richards, M.D., M.P.H., FACP, Centers for Disease Control and Prevention
AHRQ Staff Members Present
Gopal Khanna, M.B.A., Director
Francis D. Chesley, Jr., M.D., Acting Deputy Director
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
David Meyers, M.D., Chief Medical Officer
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of March 16, 2018, Meeting Summary
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 8:30 a.m. and welcomed the NAC members, other participants, and visitors. He noted the presence of the following new members: Karen S. Amstutz, M.D., M.B.A.; Cathy J. Bradley, Ph.D., M.P.A.; Sheila P. Burke, M.P.A., R.N., FAAN; Beth Ann Daugherty, M.P.H., R.N.; Barbara A. Fain, J.D., M.P.P.; Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S.; Andrew L. Masica, M.D., M.S.C.I., S.F.H.M.; Jerry L. Penso, M.D., M.B.A.; and William H. Shrank, M.D., M.S.H.S.
Dr. Goldmann referred to the draft minutes of the previous NAC meeting (March 16, 2018) and asked for changes and approval. The NAC members voted unanimously to approve the March meeting minutes with no changes.
Dr. Goldmann stated that he supported AHRQ Director Gopal Khanna’s desire that this meeting feature new thinking about health services research and the future of the AAgency. The Federal agencies, with their distinct disciplines, are nevertheless knitted together in those disciplines and have a capacity to move forward with shared creativity. AHRQ’s NAC members are an eclectic group, offering wide-ranging perspectives on health care services in the United States. Dr. Goldmann pointed to the critical analysis of guidelines from the Surviving Sepsis campaign, which demonstrated the ability of a range of experts to develop helpful conclusions.
Director's Welcome and Update
Gopal Khanna, M.B.A., Director, AHRQ, and Francis D. Chesley, Jr., M.D., Acting Deputy Director, AHRQ
Mr. Khanna welcomed the meeting participants. He extolled the professionalism and talents of his colleagues at the Agencyand stated that he relishes the opportunity to hear from experts in the field. He proposed that all are united in a vision, a cause, and a purpose to extend safe, evidence-based care for the American people. One key in pursuing such a purpose is the study of trends in the health care landscape. Mr. Khanna listed some current trends:
- New players in the health care marketplace, from small startups to large companies.
- The consolidation and integration of health care delivery systems.
- The aging U.S. population.
- The digital revolution.
The health care delivery system is evolving rapidly, and there are many opportunities for AHRQ to play a role. The Agency needs to reinvent itself, while recognizing its competencies in research, data, and analytics. AHRQ can provide data and insights for clinicians and policymakers, with a goal of moving toward high-quality care. Mr. Khanna asked the NAC members to consider how AHRQ can leverage its core competencies. The chief executive officers of health care delivery systems have stated that they need research results that can be operationalized.
AHRQ must address unmet needs, such as those occurring in today’s opioid epidemic. In responding to a mandate of the Secretary of the U.S. Department of Health and Human Services (HHS), AHRQ seeks to support health care that is value-based, available, and affordable. We need to achieve lower drug pricing while not discouraging innovation. The Agency must be nimble and efficient. It must contribute, as a current high priority, to solutions for the opioid crisis. Mr. Khanna asked the NAC members to consider the unmet needs, to suggest what AHRQ can do in response, and to envision how AHRQ can position itself for the future.
Dr. Chesley reported that AHRQ’s budget for FY 2018 is $334 million, which is a $10 million increase over the FY 2017 budget. It includes an additional $6 million to support investigator-initiated research and a $4 million increase in the Medical Expenditure Panel Survey (MEPS) program. The Agency’s Office of Management Services has developed a new contract invoice system, which is an electronic platform that modernizes contract processing activities, making them more efficient. That is a response to a requirement from the HHS Secretary. The Office of Management Services also has executed a new process to provide leadership for executive development, that is, to cultivate future leaders among AHRQ staff.
Dr. Chesley reported that the National Guidelines Clearinghouse has ended as a result of a contract expiration. AHRQ is undertaking a project to study the possible sustainability of the clearinghouse/database in the future. That goal might require the use of private/public partnerships. Meanwhile, the clearinghouse’s data are being preserved.
Dr. Goldmann urged the NAC members to consider core competencies of AHRQ. He asked, “What do we not want to lose?” “Where must the Agency adapt?” “What should be funded?” Perhaps the Agency can be more receptive and can broaden the scope of health services research. It can identify needed partnerships and inform those partnerships with AHRQ values. Perhaps the opioid crisis can be used as a lens for examining the capacities of AHRQ and health services research. Other concerns, too, could be used as a lens, triggering discussion.
Robert S. Dittus, M.D., M.P.H., agreed that AHRQ’s work in mitigating the opioid crisis could be used as a lens, demonstrating the capacity for approaches to care, assimilating the drivers and processes, and promoting implementation science. He suggested identifying a conceptual framework for AHRQ, including ideas such as effectiveness, process measures, and implementation strategies.
Dr. Goldmann added the idea that such a framework could describe AHRQ’s role among the Federal agencies and elsewhere. Monica E. Peek, M.D., M.P.H., M.Sc., emphasized AHRQ’s capacity for managing data and analytics. She cited the importance of learning by creating bridges inside and outside the health care delivery system and by tracking health outcomes.
Lucy A. Savitz, Ph.D., M.B.A., cited the importance of promoting the unique efforts of AHRQ. She expressed concern about losing support for the National Guidelines Clearinghouse and cautioned about possibly losing support from the Patient-Centered Outcomes Research Trust Fund. We need to communicate the value of such initiatives.
Dr. Amstutz stated that AHRQ has a role and strength as a convener. It can offer guidance for those who manage care plans, for studies of evidence-based approaches, and in other areas needing more rigor. Dr. Amstutz emphasized the importance of data integration and the ability to use data. Dr. Goldmann added the need to identify who in the Government is responsible for determining which agencies should be made aware of AHRQ’s guidance.
David Atkins, M.D., M.P.H., stated that AHRQ can be involved in a larger aspect of research in health services, offering help to the smaller research projects around the Nation. It can address data quality and sharing. Dr. Atkins cited the challenge of addressing quality—of even defining the word. AHRQ can address issues of both data quality and data integration. It could seek to identify ways of putting the patient first to improve the quality of life.
Alice S. Bast, who serves as a patient representative for the NAC, brought up the idea of raising the visibility of AHRQ. She stressed the importance of respecting the patient’s voice.
Dr. Hernandez-Boussard added that AHRQ has funded some research work relating to the opioid crisis. How might that and ongoing work be advertised?
Update on AHRQ Data, Analytics, and Insights
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends, AHRQ
Dr. Cohen introduced a session on AHRQ’s efforts regarding health care delivery data. AHRQ has begun a new in-house project, the Data Enterprise Group, to better position the Agency to be more productive in the data area and to strategize. AHRQ’s competencies in this area include the development of data platforms and the use of analytic expertise. AHRQ-supported platforms include the administrative data of the Healthcare Cost and Utilization Project (HCUP) and the survey data of the MEPS program and the Consumer Assessment of Healthcare Providers and Systems program. AHRQ provides analytic expertise by employing economists, epidemiologists, clinicians, and sociologists. Users of AHRQ data programs include Federal agencies and offices and many private sector enterprises. AHRQ uses its data to create the annual National Healthcare Quality and Disparities Report.
AHRQ’s data enterprise strategy will seek to expand its data and analytic capacities, especially improving analytic tools. It will support responses to questions such as “When you change the system, what is the effect on providers and organizations?” It will consider whether there would be a strength in combining the MEPS and HCUP programs, that is, combining the supply and demand angles. How might data collected by the various Federal agencies be coordinated? AHRQ will be seeking to fill data gaps, improve data sharing and governance, enhance analytic tools, and engage customers to maximize value and obtain insights. Dr. Cohen asked the NAC members to offer actionable ideas as they consider the following questions:
- What future challenge or question do you see facing the health care system nationally or in your area over the next 10 years?
- What kinds of problems are you trying to solve with data?
- What information/data are you missing to be able to solve those problems?
- What kinds of challenges do you face in obtaining and working with data?
- How can we make data more actionable and address critical local, State, and national priorities in health?
Dr. Masica raised the issue of shifting to value-based health care delivery. This will require data that are actionable and must address the challenge of benchmarks. AHRQ could be a champion.
Dr. Shrank, in responding to the first question, cited the challenge of making research timely and nimble. With changing policies and questions, researchers need to be able to pivot in their work. A methodical approach will not always serve the needs. How can AHRQ approach funding and data to serve an environment full of rapid change? We need to focus energy and resources on the right topics. Setaside money and ready contractors might help to shift research when needed. Another strategy for nimble research could be separate funding of the evaluation of a pragmatic trial while a payer or provider pays for the study itself. Another idea is a rapid-turnaround study with a clear path toward scaling-up.
Dr. Hernandez-Boussard called for the ability to link patients across studies. We need data that help to address the patient trajectory within the continuum of care.
Dr. Dittus questioned the ability of AHRQ to be a Big Data source. Large private companies have much more money to support Big Data. AHRQ should perhaps support partnerships and offer unique resources. Today’s studies of learning health systems are in need of data. AHRQ could help there, perhaps even own the space. AHRQ could offer expertise regarding care delivery, processes, and measures.
Dr. Bradley suggested that AHRQ address the idea of using data to answer meaningful questions and support policy. Perhaps models and simulation could be used to make data acquisition timelier.
Dr. Savitz raised the issue of the grant review process, which is long and leads to issues of relevance and timeliness. There also is an issue of data that are censored. Perhaps AHRQ could act as steward, promoting transparency and identifying gaps. We need better understanding of the interplay of social determinants and risk factors, especially with respect to readmissions.
José Julio Escarce, M.D., Ph.D., stated that the breadth of health care services research needs to be maintained. We must not marginalize fruitful research, and we must respect a need for some long-term research. The field must embrace all types of research. Health services research must strive to understand agents and institutions, responses to incentives, and more. Dr. Escarce called on the MEPS program to respond to world trends and to follow trends over time. Could MEPS data be linked with Centers for Medicare & Medicaid Services administrative data? To Medicaid administrative data? To the National Health and Nutrition Examination Survey?
Dr. Goldmann suggested that the issue of integration of data sources be discussed in a future NAC meeting. The meaning of long-term research also could be discussed.
Dr. Fain cited the challenge of the availability of safety data. In many cases, people do not know how to think about patient safety. Metrics don’t support many of the questions about patient safety. Perhaps AHRQ could address these issues. Jeff Brady, M.D., of AHRQ, responded that safety is an on ramp to quality. Many competencies apply to both ideas. There is the problem that additional safety measures can mean more work for health care deliverers. Dr. Chesley noted that the AHRQ grant program fosters some quality activities.
Dr. Burke, referring to the question about making data actionable, stated the importance of knowing the audience. We must understand what data are collected and from whom. What is the value of data and how should the data be used? Relevance must be established. The patient must understand the information given by providers.
Dr. Goldmann agreed. The potential role for the Agency in considering such issues (the patients, the data, the scaling) could be discussed in a future NAC meeting as well as the relationships with foundation work.
Christina J. Calamaro, Ph.D., agreed that information should be made relevant to patients. Outcome information is helpful in the clinic. AHRQ could play a role in developing models of health care delivery. It could address issues surrounding the use of de-identified data and large datasets. Dr. Cohen noted that the Agency features a secure data center, from which data cannot be removed. Linking to private claims data is not possible. Dr. Chesley called for developing steps to solve such problems.
Dr. Amstutz added that there is a patchwork of State regulations regarding data, limiting their use. To make data more useful, we can incorporate analytic tools, standard metrics, and visualization standards.
Dr. Peek noted that health care systems today are attempting to incorporate social determinants of health into screening. However, rigor is missing. What measures should be used? Which measures are associated with significant change? We need tracking and analysis of the items, validation in measurement, and an evidence base to inform action. AHRQ could help by providing leadership and guidance. Dr. Shrank noted the lack of standards regarding social determinants of health despite the fact that some institutions are attempting to capture them.
Dr. Penso raised issues surrounding a move to value health care, including costs of care and quality of care. Some are seeking to identify the cost drivers that affect particular populations. There are operational costs, internal costs, and efficient ways to reduce them. Ultimately, we will have to reduce expenses, which are always rising. AHRQ might be able to offer guidance. Cost drivers are related to social determinants. Dr. Goldmann noted that the National Quality Forum has moved away from the use of process measures and has been focusing instead on the use of outcome measures. That change features a burden of measurement. AHRQ might consider that issue in moving forward.
Regading data sharing, Dr. Masica raised the issue of a gap between legal compliance and the regulatory community. Perhaps AHRQ could address that problem.
Ms. Daugherty stated that small offices in rural areas can benefit their data collection by working with payers. AHRQ should consider better publicizing the fact that it collects data.
Dr. Hernandez-Boussard asked about AHRQ’s position regarding the move to a use of e-measures (electronic health-record measures). AHRQ has indicated that the development of better standards for such data collection could support that move. Dr. Dittus called for the development of measures that can cause a health care delivery system to improve. A catalog of such measures would be helpful. Today we are missing many determining variables.
Dr. Escarce called for basic and applied research in process and outcome measures. Health systems are not presented with a scope in addressing social determinants. Regarding the search for value, we have to recognize that higher quality health care likely will be more expensive. Patient-centered care still needs to be defined and investigated. Ms. Bast agreed that we need a standard definition of patient centricity.
Dr. Goldmann ended the discussion by emphasizing the need for partnerships. AHRQ should consider purposes and strategies surrounding the MEPS and HCUP programs. It should address additional data needs and gaps, recognizing that it does not perhaps have the wherewithal to join the Big Data community at this point. Perhaps it can play a role. Big Data is not characterized by hypothesis-driven research. AHRQ should seek to preserve basic science and research.
Dr. Goldmann suggested the NAC members address the issue of partnerships in a future meeting.
Addressing the Opioid Crisis: An Update
David Meyers, M.D., FAAFP, Chief Medical Officer, AHRQ
Dr. Meyers introduced a session on AHRQ efforts to address the opioid epidemic. HHS has a five-point strategy for combating the epidemic, with attention to gaps and what might make a difference now. The strategy includes (1) better addiction prevention, treatment, and recovery services; (2) better data; (3) better pain management; (4) better targeting of overdose-reversing drugs; and (5) better research. Dr. Meyers described briefly each of those points, citing efforts by AHRQ in each case. He emphasized the second point, to which AHRQ can direct its capacity for data collection and analysis. For example, ARHQ data show changes in the population rates of opioid-related hospitalizations by State and by age group. Data indicate that the crisis now is affecting more women than men. The Agency is working to make its data more actionable. AHRQ has initiated, so far, only a modest amount of research addressing the crisis directly (#5). Dr. Meyers asked the NAC members to consider the question “What other opportunities are there for AHRQ to put its capabilities to work to combat the opioid crisis?”
Dr. Burke encouraged AHRQ to consider, in light of new partnerships and opportunities, the area of training. Perhaps new ideas about pain management could be directed, through training, at a new generation of health care workers. AHRQ might offer guidance based on research. Dr. Meyers agreed, noting that AHRQ could package and make information available. AHRQ usually favors a role in advising those already in practice. The Health Resources and Services Administration could play another role in this area.
Dr. Savitz proposed looking at the dentistry field as well as the medical field. A rethinking of the culture of pain management should apply to both. Dr. Goldmann suggested that AHRQ learn from the efforts in other countries. Dr. Amstutz stressed the importance of psychosocial support and care coordination in addressing pain-management issues.
Dr. Shrank cautioned that we must seek not to throw good money after bad. We should observe and synthesize what is being done now regarding care and pain management and employ comparative effectiveness research. Perhaps AHRQ could study the effects of policy changes (e.g., local changes in Medicaid). Dr. Meyers noted that AHRQ partners with the National Quality Forum, which created an opioid “playbook,” from which we might learn.
Dr. Fain asked about the possibilities for developing and testing new models for dissemination and implementation. She added the importance of understanding target audiences, what to communicate, and what channels to employ.
Dr. Hernandez-Boussard urged AHRQ to study how the crisis came to be, such as from a prior ethos of undertreating pain. AHRQ could play a role in considering the perspective of the patient and how to treat the average patient and the not-average patient for pain. Dr. Daugherty proposed studying, in general, the operations in States that are obtaining better results with patients.
Dr. Calamaro urged AHRQ to look at pediatric patients differently. It is important to consider the length of time for prescribing as well as the volume of medication. What systems are respecting and communicating that well, especially in pediatrics?
Drs. Bradley and Goldmann stated the importance of preparing for subsequent crises. We can use data to predict problems. We should examine underlying problems.
Dr. Dittus encouraged the Agency to take the opportunity to note and advertise its contributions. Dr. Meyers added that all Federal agencies are involved and coordinated. Dr. Goldmann added that it will be helpful to know who is doing what.
Dr. Masica proposed that AHRQ study the organizational levels. This is a complex problem, and high-level teams are trying to solve it. Dr. Goldmann asked the NAC members to suggest gaps that AHRQ could fill. Dr. Meyers responded that AHRQ could contribute by supporting health services research, practice improvement, and data. In particular, it could study the natural experiments demonstrating what is and is not working.
Health Services Research and the C-Suite
Francis D. Chesley, Jr., M.D., Acting Deputy Director, AHRQ
Dr. Chesley introduced a session on two AHRQ initiatives aimed at improving health system performance, especially by providing support to health care system leaders.
The Comparative Health System Performance Initiative is a large study to demonstrate how health care systems use evidence-based practices to improve outcomes and reduce costs in delivering care. It features the creation of a robust research database with which one can identify, classify, track, and compare health care systems. The initiative has been undertaken by Dartmouth University, the National Bureau of Economic Research, and RAND. In 2016, it produced a Compendium of U.S. Health Systems.
The Learning Health Systems Mentored Career Development Program is a K12 grant program supported by AHRQ and the Patient-Centered Outcomes Research Institute. Its purpose is to train clinicians and research scientists to conduct patient-centered outcomes research within learning health systems. It focuses on the generation, adoption, and application of evidence to improve the quality and safety of care. This training program embeds scholars at the interface of research, informatics, and clinical operations in learning health systems. It is creating a learning collaboration across funded centers of excellence for learning health system research training.
Dr. Chesley asked the NAC members to respond to a series of questions about how these programs (and others) might offer value to leaders’ efforts to operate and improve health systems. How can system leaders instill a culture of learning and improvement among staff and teams? System leaders need research findings sooner rather than later. They cannot afford to wait through the traditional research-publish paradigm. They need cross-system learning and sharing despite a competitive environment.
Dr. Shrank referred to the conflict between the researchers’ need for a healthy p-value (strong research result) and the leader/business community’s need for quick answers. One basic challenge is the complexity of real-world events and the difficulty of studying them. Perhaps AHRQ could develop guidance about such issues. How much rigor in the research can be sacrificed to obtain rapidly usable answers?
Dr. Dittus suggested that the use of Bayesian statistical methods can be helpful. Understanding user client needs is important. Study designs (and there are many types) are important, including understanding that rigor will result from factors such as using correct measures. We must build good infrastructure and culture in the research process. Dr. Chesley added that each of the K12 grants will feature a core curriculum. The curricula will evolve in time.
Dr. Peek suggested that the early dissemination and implementation of research findings could be abetted by journals that are open to receiving works in progress. Could AHRQ support that idea in any way?
Dr. Escarce raised the issue of the capacity of the researcher. The K12 training project offers hope of creating researchers who can address the need to speed up results. Tradeoffs are implicit for any research that will be used in practical applied ways. Yet the average researcher is trained in a particular way and is not familiar with the tradeoffs. Evaluation of the training project will be important.
Dr. Savitz wondered about the possibility of systems developing and using timely evidence that has not been published. Could usable data be derived and synthesized from evidence reports? There are ways in which separate delivery systems can come together and share experiences. Dr. Goldmann stressed the need to have a good structure and evaluation plan when systems or networks work together.
Dr. Penso stated the need for an emphasis on culture and learning. We should support curricula that can be transferred to lower levels of systems.
Shari M. Ling, M.D., noted that the Centers for Medicare & Medicaid Services is interested in improving health outcomes and is mindful of the administrative burden of some efforts. When seeking early dissemination of new ideas, we should consider the impediments or burdens associated with implementation.
Dr. Amstutz called for studies to estimate the impact on a system. That would require tools, and perhaps AHRQ could help develop them. AHRQ also could serve as a steward for research partnerships between academia and health systems, perhaps facilitating data-use agreements.
Dr. Masica also cited the issue of burdening the workload, as in the use of electronic health records. This is a problem for the rollout of new programs. A mark of success for a training program can be a high number of people embedded in operational programs. Dr. Masica called for simple studies with results that can be applied readily in a system. We should develop lists of best practices that a system could use in a flexible way.
Dr. Atkins proposed that AHRQ build on rapid natural research examples, support more reliable rigorous quality-improvement methods, and develop ideas for incentives in cases where advancement is not tied to publication. System improvement could be an incentive.
Dr. Penso cited the need for champions who can cause programs to gain priority. He agreed that we must find ways to reduce burdens associated with information technology in areas such as measurement and evaluation.
Dr. Goldmann praised the K12 program, expressing hope that the projects will grow. He cautioned that many organizations will not know how to use the program’s fellows optimally. Some fellows will be asked to build their own projects. They will use large datasets. Aligning their projects with organizational goals will be difficult. A capacity for spreading the innovations will require a common curriculum and respect for scaling-up. How can the projects be rolled up into metrics that define success of the program? How can we express the value of the collaborations? Dr. Shrank stated that there will be a persistent risk that fellowships will be less than perfect. The program can respond with good mentoring and good curricula.
There were no public comments.
Chair's Wrap-Up and Adjournment
Dr. Goldmann and Mr. Khanna thanked the NAC members and speakers for their input. Dr. Goldmann noted that the next NAC meeting will take place November 15, 2018. He adjourned the meeting at 2:45 p.m.
Donald A. Goldmann, M.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality