AHRQ Annual Highlights, 2010

The Agency for Healthcare Research and Quality (AHRQ) is committed to helping the Nation improve our health care system. To fulfill its mission, AHRQ conducts and supports a wide range of health services research. This report presents key findings from AHRQ's research portfolio during Fiscal Year 2010.

Contents

Introduction
Portfolios of Research
Medical Expenditure Panel Survey
Patient-Centered Outcomes Research/Comparative Effectiveness Portfolio
Patient Safety Portfolio
Health Information Technology Portfolio
Prevention/Care Management Portfolio
Value Portfolio and Related Activities
Crosscutting Activities
Conclusion
Abbreviations 

Introduction

In fiscal year 2010 (FY10), the Agency for Healthcare Research and Quality (AHRQ) was able to increase key investments to help improve the safety and quality of health care, ensure access to care, increase the value of health care, reduce disparities, and increase the use of health information technology.

In addition, the Patient Protection and Affordable Care Act (Affordable Care Act), signed by the President into law on March 23, 2010, brought new and exciting opportunities to improve the quality, safety, efficiency, and effectiveness of health care services.

Patient Safety and Quality

In the largest Federal investment connecting medical liability to quality, AHRQ awarded $25 million in funding to support efforts by States and health systems to implement and evaluate patient safety approaches and medical liability reform models. In addition, AHRQ also invested $17 million to expand projects to help prevent healthcare-associated infections (HAIs). The most common complication of hospital care, HAIs cause approximately 2 million infections and 99,000 deaths annually with a cost between $28 billion to $33 billion. One FY10 project, the Comprehensive Unit-based Safety Program (CUSP), shows significant promise in reducing central line-associated blood stream infections. A direct outgrowth of earlier successful AHRQ-funded efforts, CUSP reduced the rate of central line-associated blood stream infections by two-thirds within 3 months and over 18 months saved more than 1,500 lives and nearly $200 million. AHRQ is now supporting the implementation of CUSP to all 50 States.

American Recovery and Reinvestment Act

Funding from the American Recovery and Reinvestment Act (Recovery Act), signed into law by President Obama in February 2009, allowed AHRQ to expand its work in support of comparative effectiveness research including enhancing the Effective Health Care Program. The overarching goal of comparative effectiveness research is to improve health outcomes by providing evidence to patients and their medical providers to help them make the best decisions. AHRQ's collaborative and transparent Effective Health Care Program provides patients, clinicians, and others with evidence-based information to make informed decisions about health care.

Of the $1.1 billion contained within the Recovery Act for comparative effectiveness research, $300 million was allocated to AHRQ, $400 million to the National Institutes of Health (NIH), and $400 million to the Office of the Secretary of Health and Human Services (HHS). Beginning in FY09, AHRQ began issuing funding opportunity announcements and working with NIH and the Office of the Secretary to coordinate comparative effectiveness research under the Recovery Act. AHRQ agreed to manage the Office of the Secretary's $400 million.

Recovery Act funds awarded from the Office of the Secretary focus on four main areas:

• Data infrastructure awards to enhance existing infrastructure and develop new databases, networks, and registries to make both public and private comparative effectiveness research endeavors robust and sustainable over time.
• Dissemination, translation, and implementation awards focused on ensuring the results of comparative effectiveness research are disseminated, implemented, and used by patients, families, and clinicians.
• Research awards to provide key information on the relative benefits and harms of various medical and health system interventions.
• Patient-Centered Outcomes Research (PCOR) inventory and evaluation awards to catalog PCOR comparative effectiveness research activities and infrastructure to track investments in comparative effectiveness research going forward.

To execute Recovery Act funding effectively, AHRQ awards focus on the following areas of PCOR/comparative effectiveness research:

• Horizon scanning awards will identify new and emerging issues for comparative effectiveness review investments. Some of the richest topics for comparative effectiveness research will likely be found at the frontier of new health care and systems interventions, where there may be great promise but uncertain population benefits and risks. Horizon scanning is vital to understanding the relevant health care context and landscape, as a basis for identifying and beginning to prioritize among research needs.
• Evidence synthesis awards will increase the number of comparative effectiveness reviews conducted through AHRQ's Evidence-based Practice Center (EPC). The ultimate goal of comparative effectiveness research reviews is to present the "state of the science" on a given topic in a manner that can be directly applied to decisions made by users of health care information. These users include clinicians, patients and caregivers, policymakers, and payers, and may be individuals or their related organizations. This program allows for input from all perspectives into the development of the research and implementation of the findings.
• Evidence gap identification awards will develop a formal process that will involve stakeholders, including clinicians, funding agencies, and researchers, to consider the gaps identified in systematic comparative effectiveness reviews. This will help shape future research agendas and set priorities for a national investment in new comparative effectiveness research based on the findings. Some projects have already been completed and identify future research topics in the important areas of hip fracture, prostate cancer, breast cancer, and diabetes.
• Translation and dissemination awards will expand AHRQ's translation and dissemination activities and strengthen the infrastructure supporting these activities by supporting grantees in developing and implementing innovative approaches to integrating comparative effectiveness research findings into clinical practice and health care decisionmaking. For example, one research team is adapting a summary of evidence about antidepressants produced by AHRQ for use as a decision aid—a tool that helps patients, including those with low health literacy, understand the pros and cons of these medicines. Other researchers will adapt, evaluate, and disseminate AHRQ summary guides on hypertension and type 2 diabetes for hard-to-reach and underserved black men, including men who are homeless or living in public housing, men in the correctional system, and men who participate in faith-based organizations.
• Evidence generation awards will establish a coordinated national investment in practical/pragmatic comparative effectiveness research. These studies will measure effectiveness—the benefit the treatment produces in routine clinical practice—and will include novel study designs focusing on real-world populations. One of the many projects will compare the effectiveness of surgery and radiation for localized prostate cancer, the most common male cancer. It will focus on modern technologies and control for differences in patients and treatments that may affect outcomes. Another study will compare treatments of bipolar disorder in real-world settings. Figuring out which treatments work best for which patients helps individuals assess options when making decisions regarding health care.
• Training and career development awards support the career development of clinicians and doctoral researchers focusing their research on the synthesis, generation, and translation of new scientific evidence and analytic tools for comparative effectiveness research. These awards will train leaders in comparative effectiveness research who will contribute substantially to transforming our health system to one centered on improved health outcomes for all patients.
• The Community Forum initiative will expand AHRQ's existing efforts to obtain professional and consumer input to inform its Effective Health Care Program activities, build methods and capacity for obtaining public input, and allow the program to obtain guidance and insights from a broader public involvement.

Mission

As 1 of 12 agencies within HHS, the mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. The Agency fulfills this mission by working with information that:

• Reduces the risk of harm from health care services by using evidence-based research and technology to promote the delivery of the best possible care.
• Transforms the practice of health care to achieve wider access to effective services and reduce unnecessary health care costs.
• Improves health care outcomes by encouraging providers, consumers, and patients to use evidence-based information to make informed treatment decisions.

Ultimately, the Agency achieves its goals by translating research into improved health care practice and policy. Health care providers, patients, policymakers, payers, administrators, and others use AHRQ research findings to improve health care quality, accessibility, and outcomes of care. Disseminating AHRQ's research findings helps support a Nation of healthier, more productive people and results in an enhanced return on the Nation's substantial investment in health care. This report presents key accomplishments, initiatives, and research findings from AHRQ's research Portfolios during FY10.

The Agency's mission helps HHS achieve its strategic goals to transform health care, implement the Recovery Act, promote early childhood health and development, help Americans achieve and maintain healthy weight, prevent and reduce tobacco use, protect the health and safety of Americans in public health emergencies, accelerate the process of scientific discovery to improve patient care, and ensure program integrity and responsible stewardship. The Agency has a broad research portfolio that touches on nearly every aspect of health care including:

• Clinical practice.
• Outcomes and effectiveness of care.
• Evidence-based practice.
• Primary care and care for priority populations.
• Health care quality.
• Patient safety/medical errors.
• Organization and delivery of care and use of health care resources.
• Health care costs and financing.
• Health information technology.
• Knowledge transfer.

AHRQ's Customers

Clinicians use AHRQ's evidence-based tools and research to deliver high-quality health care and to work with their patients as partners. AHRQ also provides clinicians with clinical decision-support tools as well as access to evidence-based guidelines, preventive care recommendations, and quality measures.

Policymakers, purchasers, health plans, and health systems use AHRQ research to make more informed decisions on health care services, insurance, costs, access, and quality. Public policymakers use the information produced by AHRQ to expand their capability to monitor and evaluate changes in the health care system and to devise policies designed to improve its performance. AHRQ works with State policymakers to strengthen their Medicaid programs through a learning network of all Medicaid Medical Directors. In addition, AHRQ has worked closely with States on new efforts to assess and improve quality of care for children enrolled in CHIP and Medicaid.

Purchasers use the products of AHRQ-sponsored research to obtain high-quality health care services. Health plan and delivery system administrators use the findings and tools developed through AHRQ sponsored research to make choices on how to improve the health care system's ability to provide access to and deliver high-quality, high-value care.

AHRQ research helps consumers get and use objective, evidence-based information on how to choose health plans, doctors, or hospitals. In addition, AHRQ helps consumers play an active role in their health care and reduce the likelihood that they will be subject to a medical error. Personal health guides developed by AHRQ help people keep track of their preventive care and other health services they receive.

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Portfolios of Research

Research at AHRQ is performed under Portfolios that encompass nearly every aspect of health care. These research Portfolios include: Patient-Centered Outcomes Research, often referred to as Comparative Effectiveness, Patient Safety, Health Information Technology, Prevention/Care Management, and Value. AHRQ also has a number of Crosscutting Activities related to quality, effectiveness, and efficiency. AHRQ's Knowledge Transfer and Implementation Program supports these Portfolios by disseminating products, tools, and research to specific audiences taking full advantage of all new media and electronic networking vehicles.

Patient-Centered Outcomes Research/Comparative Effectiveness

The mission of the Comparative Effectiveness Portfolio is to provide health care decisionmakers—including patients, clinicians, purchasers, and policymakers—with up-to-date, evidence-based information about their treatment options to make informed health care decisions. The evidence is generated from research studies that compare drugs, medical devices, test, surgeries, or ways to deliver health care.

Patient Safety

This Portfolio aims to identify risks and hazards that lead to medical errors and find ways to prevent patient injury associated with delivery of health care. Important goals include: providing information on the scope and impact of medical errors, identifying the root causes of threats to patient safety, and examining effective ways to make system-level changes to help prevent errors. Disseminating and translating research findings and methods to reduce errors are also important. Additionally, the portfolio aims to develop an environment or culture within health care settings that encourages health professionals to share and report information about medical errors and ways to prevent them.

Health Information Technology

This Portfolio aims to identify challenges to health information technology (IT) adoption and use, solutions and best practices for making health IT work, and tools that will help hospitals and clinicians successfully incorporate new health IT. Research supported by the Portfolio aims to develop evidence and inform policy and practice on how health IT can improve the quality of American health care. Further portfolio goals include making the best evidence and consumer health information available electronically when and where it is needed, and developing secure and private electronic health records.

Prevention/Care Management

The mission of the Prevention/Care Management Portfolio is to improve the quality, safety, efficiency, and effectiveness of the delivery of evidence-based preventive services and chronic care management in ambulatory care settings. Portfolio goals include:

1. Supporting clinical decisionmaking for preventive services through the generation of new knowledge, synthesis of evidence, and dissemination and implementation of evidence-based recommendations.
2. Developing the evidence base for and implementation of activities to improve primary care and clinical outcomes through health care redesign, clinical-community linkages, self management support, integration of health IT, and care coordination.

Value

The goal of the Value Portfolio is to help assure that consumers and patients are served by health care organizations that reduce unnecessary costs (waste) while maintaining or improving quality. This is done by developing measures, data, evidence, tools, and strategies that health care organizations, systems, insurers, purchasers, and policymakers use to reduce unnecessary costs while maintaining or improving quality. Strategies include process redesign, leadership and management strategies, organizational and community-wide quality improvement initiatives, legal and regulatory changes, consumer choice, public reporting, incentives, and payment changes. Also, the portfolio conducts and supports methodological work and modeling to improve data and research, and to facilitate its use for policy and management.

Crosscutting Activities

The activities in this area provide the core infrastructure used by the AHRQ portfolios to do their work. Activities in this Portfolio include data collection and measurement, dissemination and translation, and program evaluation. In addition, support is provided for investigator-initiated and targeted research grants and contracts that focus on health services research in the areas of quality, effectiveness, and efficiency.

Knowledge Transfer and Implementation Program

Translating research into practice as quickly as possible is a high priority for AHRQ. As part of its mission to develop programs for disseminating and implementing the results of Agency activities, the Office of Communications and Knowledge Transfer directs a Knowledge Transfer and Implementation Program to promote the use of AHRQ tools, products, and initiatives by various stakeholders. Knowledge Transfer activities consist of a series of projects that disseminate and implement AHRQ products, tools, and research to a specific target audience. The goals are to:

• Enhance awareness about AHRQ's tools, research, and products.
• Assist target audiences in the actual implementation of AHRQ tools, research, and products.
• Gain feedback regarding the successes and barriers that organizations are experiencing in implementing AHRQ initiatives.
• Develop case studies showing how target audiences have actually disseminated and implemented specific AHRQ products.

Examples of dissemination projects and case studies are provided throughout this report. For more information about AHRQ's Knowledge Transfer program, go to https://www.ahrq.gov/news/ktint.htm.

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Medical Expenditure Panel Survey

In addition to research portfolios, AHRQ supports the Medical Expenditure Panel Survey (MEPS). In FY10, MEPS was instrumental in informing HHS as well as the White House on health care spending and the costs and availability of health insurance, especially in the context of health reform legislation. Data from MEPS were incorporated into responses to a series of Congressional requests for assistance on information regarding employer costs for health insurance, health expenditures, and Medicaid participation rates. MEPS data were also used to update the Chronic Disease Cost Calculator, a tool for estimating the burden and cost of chronic disease among Medicaid beneficiaries. During FY10, the MEPS program produced 17 public use files and more than 35 statistical publications. This year, publications focused on trends in employer-sponsored insurance and trends in expenditures for specific services.

MEPS is the only national source of annual data on the specific health services that Americans use, how frequently they are used, their cost, and the sources of paying for them. MEPS is designed to help the managers and users of the nation's health care system understand how changes in private health insurance, and other dynamics of today's market-driven health care delivery system, affect health care in America. MEPS provides the foundation for estimating the impact of health policy changes on different economic groups and special populations, such as the poor, elderly, the uninsured, and racial/ethnic groups.

MEPS consists of a family of surveys that gather information about families and individuals, their medical providers, and employers across the United States. The MEPS Household Component (MEPS-HC) collects information from families on demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment. MEPS-HC public use data files released in FY10 cover the calendar year 2008, as well as early look data for 2009. These data files include full-year population characteristics; job information, home health care use and expenses; expenses for other medical equipment and services; and dental, medical, emergency room, office-based provider, and outpatient hospital visits. MEPS also surveys medical providers of persons in the MEPS-HC to supplement information on health care expenses and payments.

The MEPS Insurance Component (MEPS-IC) collects data from a sample of private- and public-sector employers on the health insurance plans they offer their employees. The collected data include the number and types of private insurance plans offered (if any), premiums, contributions by employers and employees, eligibility requirements, benefits associated with these plans, and employer characteristics. MEPS-IC data released in FY10 included 2009 MEPS-IC Health Insurance Tables—National Estimates, as well as State and Metro Area Estimates.

MEPS and the Chronic Disease Cost Calculator

To help the States estimate the burden and financial impact of chronic diseases among their Medicaid beneficiaries, the Centers for Disease Control and Prevention and RTI International, in partnership with AHRQ, the National Association of Chronic Disease Directors, and the National Pharmaceutical Council, developed the Chronic Disease Cost Calculator.

The Chronic Disease Cost Calculator is a downloadable tool that makes use of MEPS data to support States in:

1. Estimating State Medicaid expenditures for six chronic diseases—congestive heart failure, heart disease, stroke, hypertension, cancer, and diabetes.
2. Generating estimates of the costs to Medicaid of selected chronic diseases using customized inputs (e.g., prevalence rates and treatment costs).

In FY10, these updates have been incorporated into Version 2 of the Chronic Disease Cost Calculator, which includes:

• Estimates of the prevalence and costs of asthma, arthritis, and depression.
• Expanded estimates, including costs to Medicare, private payers, and the total population.
• Estimates of absenteeism costs; and
• Projections of future medical costs over the next 10 years.

Requests for Assistance on Health Initiatives

MEPS is an important data source to inform health care policy decisionmaking at the State and national levels. This was especially true as health reform initiatives were considered at the Federal level. In FY10, Congressional and Executive Branch analysts requested MEPS data on health care expenditures, including the costs of health insurance to employers and employees, costs of private health insurance, out-of-pocket spending, the financial burden of health care, consumers' use of assisted living, and the costs of emergency room care compared with care provided in physicians' offices. All analyses are posted at http://www.ahrq.gov. Table 1 briefly summarizes some of the responses AHRQ provided to specific requests in FY10.

Additional details on these requests can be found at https://www.ahrq.gov/data/mreqahi.htm. 

Table 1. MEPS responses to request for assistance on health initiatives for FY10

MEPS Publications

MEPS data are displayed in a full range of analytic publications, including statistical briefs, research findings, methodology reports, and chartbooks. Examples follow of the findings in these publications:

• The annual premium for an employer-sponsored family health plan cost about 54 percent more in 2009 than it did in 2000: $13,027 versus $8,437 respectively, adjusted for inflation. During the same period, the average cost of an annual premium for a single individual rose by 41 percent, from an inflation-adjusted $3,308 to $4,669. In addition:
  • Just under a third (30.5 percent) of the 59 million U.S. workers who were enrolled in employer-sponsored health plans had family coverage, while about half were enrolled in single coverage plans, and nearly one-fifth had employee-plus-one coverage; that is, a plan that covered only the employee plus one family member at a lower premium than full family coverage.
  • Among the 10 largest States, New York had the highest average premiums, ranging from $13,757 for family plans to $5,121 for single coverage, while Ohio had the lowest, ranging from $11,870 for family coverage to $4,261 for single coverage plans.
  • The average annual employee contributions to health insurance premiums were $3,474 for family coverage (26.7 percent of the average family premium), $2,363 for employee-plus-one coverage (26.1 percent of the average premium) and $957 for single coverage (20.5 percent of the average single premium).
  • About 21 percent of workers with single coverage, 10 percent with employee-plus-one coverage, and 11 percent with family coverage made no contribution toward their health insurance premium. However, these proportions varied among the 10 largest States.
• In 2007, only a third of the 16.5 million Americans who reported that they had diabetes had all three examinations that are considered critical for managing their disease and preventing complications: checking the patient's blood sugar levels, examining their eyes for damage, and evaluating their feet for indications of poor circulation.
  • Just 58 percent reported having had one or two of the exams, while 3 percent didn't have any done, and 6 percent said they didn't know if they had had any of these tests.
  • Privately insured adults ages 18 to 64 were twice as likely as adults who were uninsured to have had all three tests (36 percent vs.18 percent).
  • About 40 percent of adults ages 65 and older with diabetes who had Medicare plus a secondary private insurance plan had had all three tests, compared with 31.5 percent of those with Medicare only.
• For Americans ages 45 to 64 in 2006, total health care expenses ($370 billion) were about double the inflation-adjusted total for 1996 ($187 billion). The proportion of people ages 45 to 64 who incurred medical expenses did not change (about 89 percent), but average annual health care expenses for those with expenses increased from $3,849 (after adjusting for inflation) to $5,455. Prescribed medicines were a substantially higher proportion of total expenses in 2006 than in 1996 (25 percent and 15 percent, respectively). The proportion of total expenses for hospital inpatient care decreased (from 36 percent to 26 percent). The average expense per service rendered increased significantly (in 2006 dollars):
  • Physician office visit: $128 in 1996 to $207 in 2006
  • Inpatient hospital day: $3,005 to $3,491
  • Emergency room visit: $563 to $947
  • Dental visit: $195 to $265
  • Prescription medicines: $103 to $199
• Purchases of cholesterol and diabetes prescription drugs by elderly Medicare beneficiaries reached nearly $19 billion in 2007—about one-fourth of the approximately $82 billion spent for medications for the elderly. Metabolic drugs, which are used to reduce cholesterol levels, keep diabetes under control, and combat weight and thyroid problems, topped the list of the five leading categories of drugs purchased by the elderly. The other four drug classes in the top five categories in 2007 were:
  • Cardiovascular drugs, including blood pressure medicines, diuretics, and drugs to control abnormal heart rhythms such as atrial fibrillation ($15 billion)
  • Central nervous system drugs, such as arthritis and other pain medications ($8 billion)
  • Gastrointestinal drugs, which include anti-acid medications ($7 billion)
  • Hormones, to treat osteoporosis, cancer, and other conditions ($5 billion)

Reports, data files, and additional information on MEPS are available online at http://meps.ahrq.gov.