AHCPR Fiscal Year 2000 Performance Plan

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Goal 3: Foster translation and dissemination of new knowledge into practice by developing and providing information, products, and tools on outcomes; quality; and access, cost, and use of care. (HCQO)

Strategy

This phase of the cycle of research bridges the gap between the development of new knowledge and its implementation in the health care system. It is a phase on which AHCPR is placing increased emphasis, as illustrated by the fiscal year 2000 budget priority (3), Translating Research into Practice. Building on the previous 10 years of research findings, AHCPR will identify ongoing gaps between what we know now and what we do in health care and will begin to close those gaps through research and demonstrations that develop and test implementation strategies in different settings in the health care system. A major focus within this goal is identifying existing implementation strategies in use in health care settings and demonstrating their applicability to wide spread dissemination in other areas of the system.

AHCPR places considerable focus on developing tools and products that facilitate the transfer of research findings into practice. The Agency has a well developed dissemination system that includes publications development, the Publications Clearinghouse, and an award winning Web site. This emphasis is critical to the Agency's success. Ongoing plans include incorporating regular customer feedback into Agency operations to continue to improve our efforts.

AHCPR recognizes that it is unable to bridge this gap with its resources alone. A major aspect of the Agency's approach is to leverage its own resources through the development of partnerships. These partnerships, within HHS, with other Federal agencies, and with private sector professional and consumer advocate organizations, enable the Agency to create distribution mechanisms for its information, products, and tools. The fiscal year 2000 initiative Translating Research Into Practice provides an increased commitment to translating research into practice. The Agency also will continue to focus on its own distribution mechanisms, such as the Agency's publications clearinghouse, to ensure that they are effective in disseminating Agency products.

Previous Successes in Implementing Research

AHCPR research has identified numerous opportunities for improvement in the quality of care. Some recent findings from AHCPR research include:

Patient and consumer participation: An area of focused attention is developing information for patients when they act as consumers and make choices of the health plans and providers they will use. AHCPR's Consumer Assessment of Health Plans Study (CAHPS®) is the tool that provides consumers with accurate, easily understood information. CAHPS® is a set of questionnaires and reporting templates that provide consumers and purchasers with objective information to help them assess and choose among health plans. CAHPS® is currently being used by over 25 plans, employers, purchasing coalitions, and State-level health care offices. The Health Care Financing Administration will begin reporting results for the CAHPS® managed care survey in the Fall of 1998. And in 1999, the Office of Personnel Management will use the CAHPS® Survey and Reporting Kit to obtain data from and report results to the 9 million employees covered by the Federal Employees Health Benefits Program. (FEHBP).
CAHPS®: Darendia McCauley, Director of Quality Assurance for the Oklahoma Health Care Authority, reports that "...CAHPS®...has provided us with a credible product, which has been thoroughly researched and has the support of HCFA. This is very important in gaining support for the assessment internally, with the provider community, and with the State legislature." Further survey plans for Oklahoma include a 1998 CAHPS® project for the Medicaid managed care enrollees and state employee populations.
Decisionmaking: AHCPR-funded research has shown that by involving patients in decisions about their treatment choices, quality, satisfaction, and even patient outcomes can be improved. However, physicians, rather than patients, still make the decisions about treatment for terminal illness. A majority of hospitalized patients (58 percent) with a terminal disease want to receive life-sustaining treatments if it will prolong their life, even for 1 week. However, researchers at the University of North Carolina found that patients desiring such treatment were not significantly more likely to get it than those who did not want it (55 percent vs 51 percent). Patient preferences did not determine the use of these treatments, nor did higher costs as a result of these preferences. One explanation is that physicians were the predominant decision makers, and are often reluctant to order procedures that will not prolong life but will increase suffering. Also, factors such as availability of resources (e.g., intensive care unit [ICU] beds) and provider attitudes influence the use of these treatments.
Implementation approaches: A recent randomized trial studied the effects of local medical opinion leaders and system change on quality of care for acute myocardial infarction. The study found that, in hospitals using local medical opinion leaders, the proportion of elderly heart attack patients given aspirin or beta blockers increased by 21 percent for aspirin use and 33 percent for beta blocker use, compared with other hospitals in the study which only received written information on the use of aspirin and beta blockers for doctors practicing there.
Underuse: An AHCPR-sponsored study found that only 21 percent of eligible Medicare patients who suffered acute myocardial infarction received beta blockers. Yet the mortality rate among those patients treated with beta blockers was 43 percent less that those not offered treatment, and patients who received beta blockers are rehospitalized for heart ailments 22 percent less often than those who don't receive them.
Disparities in quality of care: The Agency's research has greatly contributed to our understanding of the pervasive and often severe disparities in the quality of care for racial and ethnic minorities. For instance, the odds for blacks with colorectal cancer of dying in the hospital were 59 to 98 percent higher than for white patients. Blacks were 27 to 41 percent less likely than whites to have a major colorectal therapeutic procedure and blacks were almost twice as likely to die in the hospital with a primary tumor, as well as 1.7 times as likely to die in hospital with complications.
Overuse: Each year, 4 million adults develop community acquired pneumonia (CAP), resulting in nearly one million hospitalizations. Costs for treatment of CAP exceed $1 billion per year, of which roughly $100 million is spent on antibiotic therapy. Using the antibiotic erythromycin for treating most outpatients aged 60 and younger significantly reduces treatment costs compared with use of other antibiotics ($5.43 vs. $18.51) and has no adverse effects on medical outcomes.
Variations: AHCPR research has shown that rates of hospitalization and the use of procedures (such as hysterectomy) commonly vary three to five fold or more, depending on the state or region.

Previous Successes in Partnerships—Smoking Cessation Public-Private Partnership Summary

Robert Wood Johnson-funded dissemination

The American Medical Association (AMA):

Reprinted 200,000 Helping Smokers Quit pocket guides. The pocket guides were mailed to 200,000 primary care physicians—family/general practice, internal medicine, pediatricians and obstetricians/gynecologists—along with a letter from the AMA's Executive Vice President.

The National Medical Association (NMA):

Reprinting all guideline products for NMA physician members and other nonmember minority physicians and health care providers
Continues to conduct training symposiums for clinicians; in addition to cessation including training with college freshman, sophomores and juniors
Expanding dissemination beyond health care providers so that the message comes from both ends of the treatment continuum

The American College of Obstetricians and Gynecologists (ACOG):

Reprinted 40,000 Helping Smokers Quit pocket guides and mailed to all 37,000 ACOG members.

The American Academy of Pediatrics (AAP):

Reprinted 50,000 Smoking Cessation Quick Reference and Helping Smokers Quit pocket guides. The brochures were distributed as part of a mailing to AAP's physician members along with a letter from Richard Heyman, Chairman of the committee on Substance Abuse.

The American Medical Women's Association:

Reprinted 13,000 Helping Smokers Quit pocket guides. The brochures were mailed to all 13,000 members of the association.
Organized and trained a Master Faculty program, in collaboration with ACOG. The objective of the program is to train a core group of physician-teachers, who will, in turn, train hundreds of their peers around the country.

The Nursing Center for Tobacco Intervention, Ohio State University College of Nursing:

Distributed copies of the Helping Smokers Quit pocket guide to advanced practice nurses nationwide.

The RWJ-funded Managed Care Initiative ($6.76 million over a 4-year period):

The focus is on helping managed health care plans define and implement the changes needed to institutionalize tobacco intervention as part of basic health care. Taking advantage of new guidelines and standards, the Initiative should stimulate efforts by managed care organizations to experiment with how to help individuals stop or not start smoking. Assistance will be provided to make sure these new service approaches are designed using best available knowledge and are evaluated in order to produce useful evidence about "best practices." Other partners in this effort are AHCPR, CDC, National Cancer Institute (NCI), AAHP, and the HMO Group.

Goal 3 Fiscal Year 1999 Objectives and Indicators

Fiscal Year 1999 Objective 3.1: Promote distribution of AHCPR publications, products, and tools through intermediary organizations.

Indicators
Formation of a minimum of five partnerships to support dissemination of AHCPR products through intermediary organizations, such as health plans and professional organizations.

Baseline in fiscal year 1998: 13 partnerships used to disseminate materials. Eight of the partnerships involved products that are being phased out.

Indicators Summary
Numerator—Number of additional partnerships formed to disseminate AHCPR products in fiscal year 1999

Type and Significance
Process and output: As illustrated under "Success in Partnerships," partnerships are a significant method of leveraging resources to print and distribute materials, hold conferences, and fund other important dissemination mechanisms.

Data Collection
The Office of Health Care Information maintains statistics on who the partners are, the size of the target audience, and the number of products provided for dissemination.

Fiscal Year 1999 Objective 3.2: Maximize dissemination of information, tools, and products developed from research results for use in practice settings.

Indicators

Number of hits on the Web site (Baseline: 2.9 million per year in 1997, nearly triple the hits in 1996.)
Number of inquiries handled on Web site. (Baseline in fiscal year 1997, 1300; in fiscal year 1998, 2500)
Number of Uploaded documents. (Baseline in fiscal year 1997, 950; in fiscal year 1998, 1450)

Indicators Summary

Number of hits on Web site
Number of accesses and downloads of information.

Type and Significance
Output: The award winning AHCPR Web site is one of the Agency's primary mechanisms for reaching a wide variety of users. Maintaining and increasing the use of the Web site is a clear indication of the value of Agency information.

Data Collection
Automatically collected by Web site. OMB clearance for online evaluation by users. Feedback is used to redesign site.

Indicators
Number of State and local governments trained in the understanding and use of health services research findings through User Liaison Program (ULP) Workshops.

Baseline—Meetings held: 10 held in fiscal year 1997, 9 held in fiscal year 1998, 12 scheduled in fiscal year 1999.

Baseline—Number of attendees: 538 attendees in calendar year 1997.

Baseline—States represented: fiscal year 1997 and 1998—all 50 States and Puerto Rico.

Indicators Summary
Number of ULP workshops.
Number of attendees.
Number of States represented at training.

Type and Significance
Output: ULP is driven by an annual planning cycle where State and local policymakers help develop the programs/targets for the following year.

Data Collection
Automatically collected by ULP program. Reports format will be developed in fiscal year 1999.

Indicators
Number of hits on National Guideline Clearinghouse™ with analysis of use by page, type of guidelines accessed, whether the guideline was downloaded, and linkages to other sites.

Baseline: The NGC began operations on 12/15/98. The fiscal year 1999 data will be the baseline data.

Indicators Summary
Number of hits on NGC Web site.

Type and Significance
Output: The NGC is a new initiative undertaken with the American Association of Health Plans and the American Medical Association. It provides electronic access to the widest selection of clinical practice guidelines available from public and private organizations. By understanding how and when users access and apply the information we can improve the service. In addition, we will collect information on how users believe the information is helping improve the care they provide.

Data Collection
Automatically collected by Web site.

Indicators
At least five purchasers/businesses use AHCPR findings to make decisions.

Baseline: Data will be collected in fiscal year 1999.

Indicators Summary
Numerator—Number documented use of AHCPR findings by purchasers/businesses.
Denominator—Number of requests for findings reports from purchasers/businesses.

Type and Significance
Outcome: Much of the information currently available is pertinent to decisions that purchasers of health care coverage for employees must make about the health care benefit packages they offer employees.

Data Collection
Part of customer survey plan submitted for OMB clearance.

Fiscal Year 1999 Objective 3.3: Develop and facilitate the use of new tools, talent, products, and implementation methodologies stemming from research portfolio.

Indicators
1. Evidence-based Practice Centers (EPCs) produce a minimum of 12 evidence reports and technology assessments that can serve as the basis for interventions to enhance health outcomes and quality by improving practice (i.e., practice guidelines, quality measures, and other quality improvement tools). At least four reports are being used by customers to develop practice guidelines or other interventions.

Baseline in fiscal year 1998—12 reports produced. Fiscal year 1999 will be the first year any interventions will be in development based on the reports.

Indicators Summary
Numerator—Number of reports produced.

Type and Significance
Outcome

Data Collection
Collection of these data will be required as part of the design of demonstration products funded by AHCPR.

Indicators
2. The AHCPR software product CONQUEST 2.0 released in fiscal year 1999 containing new measures, including measures for new conditions, and updated measures. Contract awarded to create Web-based product for more timely updating of information contained within the product.

Indicators Summary
Not applicable.

Type and Significance
Output: Contract=process

Indicators
Funding of a minimum of five major projects that will develop products, tools, or methodologies for implementing research findings into practice in significant segments of the health care system (i.e., potential to be generalizable across health care systems, provider-types, or clinical areas).

Baseline will be collected in fiscal year 1999.

Indicators Summary
Numerator—Number of projects funded to develop products, tools, or methodologies.
Denominator—Number of extramural and intramural projects funded.

Type and Significance
Process

Data Collection
Projects will be identified by the program staff and through use of the grants management database.

Indicators
At least two new tools, products, or methodologies become available from projects funded between fiscal year 1993 and fiscal year 1996.

Baseline will be data collected in fiscal year 1999.

Indicators Summary
Numerator—Number of new tools, products, or methodologies that become available.

Type and Significance
Output: Projects must be developed and implemented to begin closing the gap between what we know and what we do. They will form the initial set of projects—including grants, demonstrations, and contracts—that will show actual outcomes in terms of quantifiable changes in health care quality to be reported in fiscal year 2003 and 2004 performance reports.

Data Collection
Tracked through the grants management database and through coordination with program staff and the Research Translation Team.

Indicators
Support a minimum of 150 pre- and post-doctoral trainees.

Baseline: 150 trainees funded per year. Commitment is to maintain the current level of support in fiscal year 1999.

Indicators Summary
Numerator—Number of trainees funded by AHCPR in fiscal year 1999.

Type and Significance
Output: AHCPR is an important source of funding for health services researchers. This support will help fill the gap that currently exists between number of qualified researchers needed and those available.

Data Collection
Tracked through the automated information management system.

Goal 3 Fiscal Year 2000 Objectives and Indicators

Fiscal Year 2000 Objective 3.1: Promote distribution of AHCPR publications, products, and tools through intermediary organizations.

Indicators
Formation of a minimum of five partnerships to support dissemination of AHCPR products through intermediary organizations, such as health plans and professional organizations.

Baseline in fiscal year 1998: 13 partnerships used to disseminate materials. Eight of the partnerships involved products that are being phased out.

Indicators Summary
Numerator—Number of partnerships formed to disseminate AHCPR products in fiscal year 2000

Data Collection
The Office of Health Care Information maintain statistics on who the partners are, the size of the target audience, and the number of products provided for dissemination.

Fiscal Year 2000 Objective 3.2: Maximize dissemination of information, tools, and products developed from research results for use in practice settings.

Indicators, Web Site

Number of hits on the Web site
Number of inquiries handled on Web site. Baseline in fiscal year 1997, 1300; in fiscal year 1998, 2500
Number of Uploaded documents. Baseline in fiscal year 1997, 950; in fiscal year 1998, 1450
Reports from user surveys on how the information requested was used.

Indicators Summary

Number of hits on Web site
Number of accesses and downloads of information
Reports from user feedback forms in fiscal year 2000.

Type and Significance
Output: The award-winning AHCPR Web site is one of the Agency's primary mechanisms for reaching a wide variety of users. Maintaining and increasing the use of the Web site is a clear indication of the value of Agency information.

Data Collection
Automatically collected by Web site. OMB clearance for online evaluation by users. Feedback is used to redesign site.

Indicators, User Liaison Program (ULP)

Number of State and local governments trained in the understanding and use of health services research findings through ULP Workshops
Reports from annual participants on how the information was used in decisionmaking.

Baseline—Meetings held: 10 held in fiscal year 1997, 9 held in fiscal year 1998, 12 scheduled in fiscal year 1999.

Baseline—Number of attendees: 538 attendees in calendar year 1997.

Baseline—States represented: fiscal year 1997 and 1998: all 50 States and Puerto Rico.

Indicators Summary
Number of ULP workshops.
Number of attendees.
Number of States represented at training.

Contrast numbers to fiscal year 1999.

Report

Type and Significance
Output: ULP is driven by an annual planning cycle where State and local policymakers help develop the programs/targets for the following year.

Data Collection
Automatically collected by ULP program. Reports format will be developed in fiscal year 1999.

Indicators, National Guideline Clearinghouse™
Number of hits on National Guideline Clearinghouse™ (NGC) with analysis of use by page, type of guidelines accessed, whether the guideline was downloaded, and linkages to other sites. Survey of a sample of users to understand the impact of use on decisions and patient care.

Baseline: The NGC began operations on 12/15/98. The fiscal year 1999 data will be the baseline data.

Indicators Summary
Number of hits on NGC Web site.

Numerator—Numbers on types of use of information requested (representative sample)
Denominator—Numbers of users surveyed

Data Collection
Automatically collected by Web site. OMB clearance for customer survey received in December 1998.

Indicators
At least 10 purchasers/businesses use AHCPR findings to make decisions.

Baseline: Under development.

Indicators Summary
Numerator—Number documented use of AHCPR findings by purchasers/businesses.
Denominator—Number of requests for findings reports from purchasers/businesses.

Data Collection
OMB clearance for customer survey received in December 1998.

Fiscal Year 2000 Objective 3.3: Develop and facilitate the use of new tools, talent, products, and implementation methodologies stemming from research portfolio. fiscal year 2000 Priority (3), "Translating Research Into Practice," focuses on the translation and dissemination of research findings, products, and tools to foster adoption and use in health care settings.

Indicators
Demonstration of a 10-percent improvement in the quality and/or outcomes in measurable indicators of care, including process, in at least five funded projects.

Baseline: Under development.

Indicators Summary
Numerator—Number of projects demonstrating 10% improvement in measurable indicators of care.
Denominator—Number of projects funded to develop and implement products, tools, or implementation methodologies.

Type and Significance
Outcome

Data Collection
Collection of this data will be required as part of the design of demonstration products funded by AHCPR.

Baseline: Under development.

Indicators Summary
Numerator—Number of projects funded to develop products, tools, or methodologies.
Denominator—Number of extramural and intramural projects funded.

Type and Significance
Process

Data Collection
Projects will be identified by the program staff and through use of the grants management database.

Indicators
At least two new tools, products, or methodologies become available from projects funded between fiscal year 1993 and fiscal year 1996.

Baseline under development.

Indicators Summary
Numerator—Number of new tools, products, or methodologies that become available.

Data Collection
Tracked through the grants management database and through coordination with program staff and the Research Translation Team.

Indicators
Support a 5 percent increase, at a minimum, in number of pre- and post-doctoral trainees.

Baseline: 150 trainees funded per year.

Indicators Summary
Numerator—Number of trainees funded by AHCPR in fiscal year 2000.

Data Collection
Tracked through the automated information management system.

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