AHRQ Annual Highlights, 2008

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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 2008.

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Contents

Introduction
Promoting Patient Involvement in Health Care
Comparative Effectiveness
Developing and Promoting the Use of Evidence
Improving the Safety and Quality of Health Care
Using Health Information Technology to Improve Patient Safety and Quality
Eliminating Disparities in Health Care
Getting Value for Money Spent on Health Care
Developing Tools and Data for Research and Policymaking
Preparing for Public Health Emergencies
Health Care Innovations Exchange
AHRQ's Knowledge Transfer Initiative
Conclusion
Appendix

Introduction

The U.S. health care system continues to face challenges in improving the safety and quality of health care, ensuring access to care, increasing value for health care, reducing disparities, increasing the use of health information technology, and finding new avenues for translating research into practice. As reflected in the 2007 National Health Care Quality Report and National Healthcare Disparities Report, the rate of quality improvement appears to be slowing. Overall, the quality of health care improved by an average of 1.5 percent per year between the years 2000 and 2005. This represents a decline when compared with the 2.3 percent average annual rate between 1994 and 2005. Quality in some areas has improved such as counseling to quit smoking. There has been some progress in reducing disparities as reflected in the elimination of the disparity between the rates of black and white hemodialysis patients who had adequate dialysis and reduced disparities in childhood vaccinations. However, measures of patient safety showed an average annual improvement of only 1 percent.

As 1 of 12 agencies within the Department of Health and Human Services (HHS), the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. The Agency fulfills this mission by developing and working with the health care system to implement 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's goal is to improve the quality and safety of health care. It achieves this goal 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 individuals and 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 portfolio during fiscal year 2008.

The Agency's mission helps HHS achieve its strategic goals to improve the safety, quality, affordability, accessibility of health care; public health promotion and protection, disease prevention, and emergency preparedness; promote the economic and social well-being of individuals, families, and communities; and advance scientific and biomedical research and development related to health and human services. The Agency has a broad scope that touches on nearly every aspect of health care including:

• Clinical practice.
• Outcomes of care and effectiveness.
• Evidence-based medicine.
• 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 care system and public health preparedness.
• Health information technology.
• Knowledge transfer.

Toolkit Integrating Chronic Care Model and Business Strategies for Safety Net Hospitals Improving care for the chronically ill is one of the most pressing health needs of our time. To help more safety net organizations implement the Chronic Care Model effectively and sustainably, AHRQ contracted with Group Health's MacColl Institute, RAND Health, and the California Health Care Safety Net Institute to develop a toolkit. The toolkit, Integrating Chronic Care and Business Strategies in the Safety Net is designed to improve patient satisfaction and loyalty; increase staff satisfaction and retention; streamline workflow; enhance efficiency; position practices to capture pay-for performance and quality improvement bonuses; and improve financial return. The toolkit can be found at http://www.ahrq.gov/populations/businessstrategies.

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 guidelines and quality measures.

Policymakers, purchasers, health plans, and health systems use AHRQ research to make better 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. 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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Promoting Patient Involvement in Health Care

AHRQ joined with The Advertising Council (Ad Council) in 2008 to launch two new campaigns to encourage consumers to become more involved in their health care. The "Superheroes" and "Real Men Wear Gowns" campaigns complement AHRQ's existing efforts toward improving the safety and quality of health care, including the "Questions are the Answer" (http://www.ahrq.gov/questionsaretheanswer) campaign launched in March of 2007. The campaigns highlight the work of the U.S. Preventive Services Task Force, which is an independent panel of experts in primary care and prevention sponsored by AHRQ. "Superheroes" was created pro bono for the Ad Council by the advertising agency Casanova Pendrill, while "Real Men Wear Gowns" was created pro bono by McCann Erickson Detroit.

Superheroes

In March 2008, the Spanish-language national public service campaign, "Superheroes," was released. The theme features everyday mothers and fathers whose children see them as superheroes and encourages Hispanic adults to be more involved in their health care, especially preventive care. A comprehensive Web site, http://www.ahrq.gov/superheroes, provides tips on ways to stay healthy, talking with the doctor, recommendations on preventive testing, help in understanding prescriptions, a quiz, and glossary of medical terms as well as links to other resources that provide health information.

Real Men Wear Gowns

This campaign raises awareness among middle-aged men about the importance of preventive care. "Real Men Wear Gowns" helps men over 40 learn which preventive screening tests they need to get and when they need to get them. Its message is that being a real man means taking care of themselves (and their health) in order to be there for their families in the future. The campaign encourages men to visit a comprehensive Web site (http://www.ahrq.gov/healthymen/) that provides the recommended ages for preventive testing (as well as a list of tests), a quiz designed to assess their knowledge of preventive health care, tips for talking with the doctor, a glossary of consumer health terms, and links to online resources where men can find more medical information.

The public service advertising campaigns include television, radio, print, and Web advertising.

Navigating the Health Care System AHRQ director Carolyn Clancy, M.D., presents a series of brief, easy-to-understand advice columns designed to help consumers navigate the health care system, make decisions about their health care, recognize high-quality health care, be an informed health care consumer, and choose a hospital, doctor, and health plan. In 2008, subjects included: Helpful Steps To Take After You Get a Diagnosis. How To Use Hospital Emergency Rooms Wisely. Tips To Help You Find a Good Doctor. Simple Steps Can Reduce Health Care-Associated Infections. Do Your Homework Before You Choose A Hospital. Smart Choices: How to Choose a Health Plan That's Right for You. Your Experience in the Hospital and Why it Matters. Balancing Treatment Advice: Benefits, Risks, and Personal Choice. Busting Myths About Health Care Quality. Asking Questions About Medical Tests. What to Ask Before Surgery. Tips for Taking Medicines Safely The advice columns are on the AHRQ Web site at http://www.ahrq.gov/consumer/cc.htm.

New Tools Help Pharmacies Better Serve Patients with Limited Health Literacy

AHRQ released two new tools to help pharmacies provide better quality services to people with limited health literacy. The first, Is Our Pharmacy Meeting Patients' Needs? A Pharmacy Health Literacy Assessment Tool User's Guide (http://www.ahrq.gov/qual/pharmlit/) can help raise pharmacy staff awareness of health literacy issues, detect barriers that may prevent individuals with limited literacy skills from using and understanding health information provided by a pharmacy, and may help identify opportunities for improving services. The second tool, Strategies to Improve Communication between Pharmacy Staff and Patients: A Training Program for Pharmacy Staff (http://www.ahrq.gov/qual/pharmlit/pharmtrain.htm), includes the use of explanatory slides and small group breakout discussions. Participants role play using handouts before concluding with a question-and-answer session. The tools resulted from a study that was co-funded by AHRQ and the Robert Wood Johnson Foundation and were developed under contract by Emory University. More information about AHRQ's health literacy activities is available at http://www.ahrq.gov/browse/hlitix.htm.

Guide to help patients on Coumadin®/warfarin therapy ARHQ released a new consumer publication, Your Guide to Coumadin®/Warfarin Therapy. Warfarin is the second most common drug after insulin implicated in emergency room visits for adverse drug events, according to the Food and Drug Administration. This 20-page, easy-to-read patient brochure explains what patients should expect and watch out for while undergoing Coumadin®/warfarin therapy, including potentially dangerous side effects, and how to communicate effectively with their health care providers, as well as tips for lifestyle modifications. It also provides information on remembering when to take the medicine, learning how to stay safe while taking the medicine, maintaining a consistent diet, and alerting health care providers to concurrent drugs and/or supplements patients are taking to avoid any potential adverse interactions. The publication was developed through one of AHRQ's Partnership for Implementing Patient Safety (PIPS) grant projects at Kirkwood Community College. The new booklet can be found online at http://www.ahrq.gov/consumer/coumadin.htm. It is also featured on the SOS Rx Coalition's Web site, www.mybloodthinner.org.

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Comparative Effectiveness

AHRQ was authorized to perform comparative effectiveness research under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Conducted under the Agency's Effective Health Care Program (http://effectivehealthcare.ahrq.gov/), and launched in 2005, it focuses strategically on comparing the outcomes, clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. The Effective Health Care Program's primary principle is that all stakeholders should have the best available evidence on which to make decisions about health care items and services.

The Effective Health Care Program has three approaches to developing and translating information on the comparative effectiveness of different treatments and clinical practices:

• Research reviews: comprehensive reviews and synthesis of evidence prepared by the Evidence-based Practice Centers (EPCs).
• New research: reports that cover new evidence and analytical tools produced by AHRQ's Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network and the Centers for Education & Research on Therapeutics (CERTs).
• Summary guides: short, comprehensive summaries of research findings translated into a variety of useful formats by the John M. Eisenberg Clinical Decisions and Communications Science Center.

Healthcare 411 Healthcare 411 is a news series produced by AHRQ. These weekly audio and video programs feature news and information on current health care topics with synopses of AHRQ's latest research findings. The stories keep consumers, employers, health care providers, researchers, educators, and others informed about the findings of selected AHRQ-sponsored research. Also on this site are links to AHRQ's public service announcements on issues such as quitting smoking, taking medication safely, eating healthy, and the importance of regular visits to a doctor as well as messages encouraging patients to be involved in their health care and ask questions of all their health care providers. In 2008, newscasts released included: Health Literacy—People with limited health literacy may not get good results from their health care. Give Dad the Gift of a Healthy Reminder—Men are encouraged to visit their doctor for preventive screenings. How to Create a Patient Advisory Council—AHRQ releases a guide on how to develop a community-based patient advisory council. Tools and Tips for Choosing a Hospital—Unless it's a medical emergency, people often have a choice of where they get their hospital care but how do people pick the right hospital for them? English Skills Affect Hispanic Access to Health Care—Less than half of Hispanics who are not comfortable speaking English have a family doctor or visit a community health clinic. How to Deal with a Difficult Diagnosis—Being told about a new diagnosis can be a frightening experience—how to make better decisions about health care options. Healthcare 411 is online at http://healthcare411.ahrq.gov/.

Comparative Effectiveness Reviews

Comparative effectiveness reviews (CERs) systematically review and critically appraise existing research to synthesize knowledge on a particular topic. They also identify research gaps and make recommendations for studies and approaches to fill those gaps. Examples of CERs published in 2008 are briefly summarized here:

• Comparative Effectiveness of Therapies for Clinically Localized Prostate Cancer. The report indicates that patients who undergo complete prostate removal are less likely to experience urinary incontinence or other complications if the operation is done by an experienced surgeon in a hospital that does many of the procedures. However, the report also concludes that not enough scientific evidence exists to identify any prostate cancer treatment as most effective for all men. Clinician and consumer summary guides were also developed based on this report.
• Comparative Effectiveness of Treatments To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis. This report compares the effectiveness and risks of six bisphosphonates: alendronate (sold as Fosamax), etidronate (Didronel), ibandronate (Boniva), pamidronate (Aredia), risedronate (Actonel), and zoledronic acid (Zometa). The report also looked at estrogen, calcitonin (a man-made hormone), calcium, vitamin D, testosterone, parathyroid hormone, and selective estrogen receptor modulators. Not enough scientific evidence exists to establish whether bisphosphonates are better at preventing fractures than estrogen, calcitonin, or raloxifene, according to the report. Clinician and consumer summary guides were also developed based on this report.
• Comparative Effectiveness of Drug Therapy for Rheumatoid Arthritis and Psoriatic Arthritis in Adults. For patients with rheumatoid arthritis, combining one well-known, lower cost synthetic drug with one of six biologic medications often works best to reduce joint swelling or tenderness, according to this report. Researchers reviewed published evidence to compare the benefits and harms of three classes of medications: synthetic disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs, and corticosteroids. The report concluded that combining methotrexate, a synthetic DMARD, with one of the biologic DMARDs works better than using methotrexate or a biologic DMARD alone. The report also found that methotrexate works as effectively as the biologic DMARDs adalimumab and etanercept for patients who have early rheumatoid arthritis. Clinician and consumer summary guides were also developed based on this report.

Glossary Defines Terms in Comparative Effectiveness Research A Web-based glossary developed through the John M. Eisenberg Clinical Decisions and Communications Science Center offers an important new reference tool for researchers, consumers, clinicians, insurers, and others seeking information about the burgeoning science of comparative effectiveness. The glossary defines 93 terms or phrases, ranging from "adverse effect" to "meta-analysis" to "comparative effectiveness." In each case, a plain-language definition is followed by an example that illustrates the definition. The glossary also provides links between related terms. The glossary is online at http://effectivehealthcare.ahrq.gov/tools.cfm?tooltype=glossary.

Developing Evidence To Inform Decisions about Effectiveness

The Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) Network is a network of research centers that AHRQ created as part of its Effective Health Care Program in 2005 to generate new knowledge. The DEcIDE Network conducts accelerated practical studies about the outcomes, comparative clinical effectiveness, safety, and appropriateness of health care items and services. The Network provides research-based health organizations with access to electronic health information databases and the capacity to conduct rapid turnaround research.

New Spanish-language Consumer Guide Compares Oral Diabetes Medications Pastillas para la diabetes tipo 2 is a new consumer guide for Hispanic adults who have type 2 diabetes and need information to help them compare various oral medications for their illness. Based on the report, Comparative Effectiveness and Safety of Oral Diabetes Medications for Adults with Type 2 Diabetes, the guide organizes comparative research results according to patients' concerns and questions and assists them in using research results when talking with health care professionals about their diabetes medicines. It compares 10 generic and 13 brand-name diabetes medications and explains how each works to lower blood sugar, which of them may increase body weight, which may cause side effects such as stomach problems or swelling, and each pill's potential effect on "bad" and "good" cholesterol. The guide also warns patients to be alert for problems such as hypoglycemia—too-low blood sugar—which can be caused by certain diabetes pills, as well as other potential side effects. In addition, the guide provides an easy-to-understand comparison of the dose and average cost of each generic and brand-name diabetes medication and the appropriate dose when taken in combination.

DEcIDE Research Findings

In 2008, AHRQ released the following new research reports:

• Improving Patient Safety and Pharmacovigilance: Methods for Studying Dementia Treatment and Outcomes in Observational Databases. The study, conducted by the University of Maryland DEcIDE Center, used data from the 2002 Medicare Current Beneficiary Survey to estimate and describe the use of medications to treat Alzheimer's disease and related dementias (ADRD) and related behavioral symptoms among Medicare beneficiaries. The report indicates that about 3.4 million Medicare beneficiaries were diagnosed with ADRD of whom 58.9 percent resided in the community and 41.1 percent resided in long-term care facilities, with the use of anti-dementia drugs similar across settings. However, the researchers found that the use of atypical antipsychotics was much higher in long-term care settings than in the community (Figure 1).
• Infrastructure to Monitor Utilization and Outcomes of Gene-based Applications: An Assessment. This report indicates that current public health monitoring systems lack the capability to monitor the use or outcomes of gene-based tests and treatments. The new report is based on research conducted by the RTI International DEcIDE Center and calls for the creation of improved public health surveillance databases and health information technologies to monitor the use of gene-based tests and their impact on patient outcomes.
• Medicare Prescription Drug Data Development: Methods for Improving Patient Safety and Pharmacovigilance Using Observational Data. Researchers at the RTI International DEcIDE Center developed a data analytic framework and methods for pharmacoepidemiologic research on adverse drug events (ADEs) to improve methods for using claims data to examine patient safety and pharmacovigilance issues. The framework they developed can be applied to observational data and the methods readily adopted or adapted for use with Medicaid, employer, insurer, and Medicare claims data to examine specific drug classes and individual drugs for ADEs.
• Comparative Effects of Classes of Antidepressants on the Risk of Aspiration Pneumonia in the Aged. Researchers at the University of Pennsylvania School of Medicine DEcIDE Center examined whether antidepressant medications might increase the risk of hospitalization for pneumonia in the elderly. They found that, after adjusting for comorbidity, age, sex, and calendar year, antidepressants do not increase the risk of hospitalization for pneumonia or aspiration pneumonia in the elderly.

Figure 1. Use of atypical antipsychotics among Medicare beneficiaries residing in long-term care facilities and community-dwelling settings, 2002

DEcIDE Projects in Progress

At the close of 2008, DEcIDE had over 25 research projects in progress. The priority conditions and topics being studied include:

• Breathing conditions.
• Cancer.
• Diabetes.
• Digestive system conditions.
• Heart and blood vessel conditions.
• Mental health.
• Muscle, bone, and joint conditions.
• Research methodology.

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