Many organizations and individuals are interested in care coordination, particularly as it relates to concerns about inefficiencies and suboptimal quality in the U.S. health care system. The Institute of Medicine identified care coordination as one of 20 national priorities for action to improve quality along its six dimensions of making care safe, effective, patient centered, timely, efficient, and equitable. The burgeoning number of aging Americans with chronic illnesses and the increasing complexity of care create challenges to coordination experienced at every level—the patient, the clinical practice, and the system. Care coordination interventions are particularly attractive in that they have the potential to improve both efficiency and quality. This final Evidence Report in the series “Closing the Quality Gap” by the Stanford-UCSF Evidence-based Practice Center addresses the topic of care coordination. This report describes our working definition of care coordination, summarizes some of the evidence about the effectiveness of care coordination interventions from systematic reviews, and presents relevant frameworks for the development and evaluation of future interventions. This approach may be useful to system-level policymakers, service-level decisionmakers, and patients. System-level policymakers have responsibility for paying for health care services for large numbers of individuals and making decisions about how to coordinate care at a system level in ways that minimize their financial risks and maximize the health care received by their population of patients. Service-level decisionmakers are involved in providing health care services to individual patients or a panel of patients, and therefore tackle care coordination at the service delivery level. Depending upon the particular local environment, they make decisions related to care coordination to maximize health care outcomes and use resources efficiently. Patients and their families are assuming increasingly active roles in health care decisionmaking and are navigating an increasingly complex health care system with consumer-driven health plans and other efforts to involve them more. The patient often experiences first-hand problems of coordination, and therefore may be just as interested as health care professionals in understanding care coordination. The key questions addressed in this Report relate to four areas: Ongoing Efforts in Care Coordination and Gaps in the Evidence: What aspects of care coordination are of greatest interest to healthcare decisionmakers? What are the key gaps in the care coordination evidence base? Definitions of Care Coordination and Related Terms: What definitions exist for care coordination? What definition could be formulated to apply to systematic reviews? Review of Systematic Reviews of Care Coordination Interventions: Which care coordination interventions have been evaluated by systematic reviews and how were they defined? What is the evidence regarding the health benefits of these care coordination interventions as summarized in the systematic review(s)? In particular, is the effectiveness of care coordination interventions related to the setting in which care is being coordinated, the component of care being coordinated, or the type of disease or patients for whom care is being coordinated? Have the costs of care coordination interventions been evaluated in any of these systematic reviews, and if so what is known? Conceptual Frameworks and Their Application to Evaluating Care Coordination Interventions: What concepts are important to understand and relate to each other for future evaluations of care coordination? What conceptual frameworks could be applied to support development and evaluation of strategies to improve care coordination? What measures have been used to assess care coordination? How do these frameworks relate to quality improvement strategies evaluated in the previous Closing the Quality Gap series reports?
This review seeks to synthesize evidence regarding the efficacy and effectiveness of interventions to improve medication adherence among adults across a broad array of chronic conditions. This report is part of a larger initiative, the Closing the Quality Gap: Revisiting the State of the Science series. This series builds on the Agency for Healthcare Research and Quality (AHRQ) 2004-07 collection of publications, Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, which summarized the evidence on quality improvement strategies for chronic conditions. This new series continues to summarize evidence on means to improve quality of care, but it focuses on selected settings, interventions, and clinical conditions. Our report addresses the comparative effectiveness of adherence intervention strategies, one keystone to improving the gap between potential and realized quality health care.
Over the past decade, a growing body of research and online resources has emerged to provide guidance on effective practices for publicly reporting information on provider performance for consumers. These recommendations are for the most part evidence based and assume that an effective report is one that contains performance information that consumers understand and find both credible and relevant. In addition, information is conveyed in a way that makes it as easy as possible for consumers to use it to make good choices among providers. Another key audience for performance reporting is physicians themselves. Health plans and medical groups have sponsored private physician “performance feedback” reports for many years, with the intention of supporting internal quality improvement efforts as well as patient care management. More recently, multistakeholder community quality collaboratives, including roughly half of the Chartered Value Exchanges (CVEs) supported by the Agency for Healthcare Research and Quality (AHRQ), have begun to produce some type of private report for physicians in parallel to their public report for consumers. These groups recognize that a single report designed for one audience cannot meet the needs of both. In addition, the Centers for Medicare & Medicaid Services (CMS) has sponsored pilot studies of the effects of providing individual physicians and medical groups with performance feedback based on claims data and CMS's Physician Quality Reporting System. In contrast with public reports, private reports are often confidential and limited in distribution to those with a “need to know.” Thus, little research even of a descriptive nature has been conducted on the various forms that private reporting has taken. Limited discussion of how to define and measure the effectiveness of such reports and little published evaluation research are available. Therefore, the science of private “feedback reporting” for physicians is nascent at best. As CVEs and other community quality collaboratives consider strategies for private feedback reporting to physicians and other health care providers, they will need to address basic issues such as report design and distribution. They also will need to examine their role in relation to existing and planned internal performance reporting activities of the health systems and medical practices in their markets. In contrast to public reporting for consumers, where the role of a neutral, multistakeholder collaborative is relatively well accepted as a source of objective, communitywide performance data, the role of community collaboratives in private feedback reporting is not always so clearly defined. Many health plans and health systems, which may themselves be collaborative members, have developed very sophisticated internal reporting systems of their own based on electronic health records. In the context of these and other private performance reporting initiatives, community collaboratives will need to determine the unique value-added features that their private feedback reports can provide. The goal is to complement rather than compete with reports from their provider members or other report sponsors. This resource document is intended to provide practical information and guidance primarily to CVEs and other community quality collaboratives interested in the design, dissemination, and use of private feedback reports on physician performance.
A substantial amount of research exists demonstrating that health care frequently fails to meet the current standards of quality care. Errors, suboptimal management or control of disease, and overutilization or underutilization of services are more likely to occur when high quality evidence-based health care is not provided. In a quality improvement framework that includes measuring, influencing, and improving quality, public reporting (making quality, safety, or performance data publicly available) is categorized as a means of influencing quality by providing incentives for change. This report focuses on how the public reporting of health care quality information may provide incentives for quality improvement that ultimately produce higher quality care. It is part of the Closing the Quality Gap: Revisiting the State of the Science series, which examines the role of several interventions in promoting quality health care. Quality might be influenced by the different incentives public reports create for different people and organizations. The incentives may be for the consumers of health care, including patients, families, or advocates who act on the behalf of patients, or for other purchasers of health care services, such as employers, who select the options available to their employees. Public reporting can also provide incentives for the individuals and organizations that provide or arrange care, including individual clinicians, hospitals, long-term facilities or services, and health plans. Patients are motivated by the desire to maximize the benefits they derive from health care by obtaining the highest quality of care available. Individual clinicians, hospitals, and other organizations that provide or arrange health care want to attract new patients or members and avoid losing existing ones. They may also be motivated by concern about their reputation among their peers or by professional and organizational commitments to providing high-quality care. This report was designed to update the last published systematic review, given the significant changes that have occurred in the scope and nature of public reporting. Medicare has substantially expanded its public reporting program, health data from many more sources are now available with minimal restrictions, new technologies allow aggregating data from consumer feedback sites, and applications have been built to help customize and simplify the combination of data from multiple sources. These trends and continuing commitments to transparency and patient-centered health care are likely to contribute to substantial increases in the amount of publicly available data on health care quality. The scope of this review was determined by a definition designed to situate public reporting in the context of quality improvement, the theme of the Closing the Quality Gap: Revisiting the State of the Science series. Given the resources devoted to public reporting and the desire to synthesize existing research knowledge to inform future public reporting efforts, the objectives of this systematic review were: To determine the effectiveness of public reporting as a quality improvement strategy by evaluating the evidence available about whether public reporting results in improvements in health care delivery and patient outcomes (Key Question 1) and evidence of harms resulting from public reporting (Key Question 2); To determine whether public reporting leads to changes in health care delivery or changes in patients' or purchasers' behaviors (intermediate outcomes) that may contribute to improved quality of care (Key Questions 3 and 4); To identify characteristics of public reports and contextual factors that can increase or decrease the impact of public reporting (Key Questions 5 and 6).
The longstanding cornerstone of medicine “first, do no harm” exists because of the fragility of life and health during medical care encounters, and represents the medical profession's understanding that patient safety has always been an important part of quality health care. Recently, however, concerns and evidence have mounted about the complexities of the health care system potentially causing patient deaths and significant unintended adverse effects. With a major national interest in addressing patient safety issues, a wide spectrum of individuals and organizations are working toward developing methods and systems to detect, characterize, and report potentially preventable adverse events. These activities are crucial precursors to prioritizing areas for action and for studying the effects of approaches to reduce sources of medical error. As part of this activity, the Evidence-based Practice Center (EPC) at the University of California San Francisco and Stanford University (UCSF-Stanford), with collaboration from the University of California Davis, was commissioned by the Agency for Healthcare Research and Quality (AHRQ) to review and improve the evidence base related to potential patient safety indicators (PSIs) that can be developed from routinely collected administrative data. For the purposes of this report, PSIs refer to measures that screen for potential problems that patients experience resulting from exposure to the health care system, and that are likely amenable to prevention by changes at the level of the system. The primary goal of this report is to document the evidence from a variety of sources on potential measures of patient safety suitable for use based on hospital discharge abstract data. The approach to identification and evaluation of PSIs presented in this report serves as the basis for development of a third module for the AHRQ QI tool set. This third module will be the Patient Safety Indicators (PSIs), which focus on potentially preventable instances of harm to patients, such as surgical complications and other iatrogenic events. The two other modules are the Prevention Quality Indicators, based on hospital admissions that might have been avoided through high-quality outpatient care; and the Inpatient Quality Indicators, consisting of inpatient mortality, utilization of procedures for which there are questions of overuse, underuse, or misuse; as well as volume of procedures for which higher volume is consistently associated with lower mortality.
This review is part of the Closing the Quality Gap: Revisiting the State of the Science series, which aims to provide critical analysis of the existing literature on quality improvement strategies for a selection of diseases and practices. The review focuses on “bundled payment,” a strategy for health care quality improvement and cost containment. This strategy has been the subject of increasing interest, with the Centers for Medicare & Medicaid Services announcing a large national bundled payment initiative in August 2011. Other reviews in the series will address a range of quality improvement topics arising from portfolios (areas of research) of the Agency for Healthcare Research and Quality (AHRQ). We define “bundled payment” as a method in which payments to health care providers are related to the predetermined expected costs of a grouping, or “bundle,” of related health care services. In contrast, fee-for-service payment typically involves payments for individual services, while capitation involves a single per capita prospective payment for all services over a fixed period of time, regardless of the number of services or episodes of care provided within that period. Within the bundled payment model, a variety of specific payment methods are possible. Bundles may be defined in different ways, covering varying periods of time and including single or multiple health care providers of different types. In addition, given the diversity and complexity of the U.S. health care delivery system, bundled payment programs may be implemented in a variety of contexts that may influence their effects on spending and quality. Bundled payment should create a financial incentive for providers to reduce the number and cost of services contained in the bundle. Providers are typically given discretion over the allocation of the services used to treat the patient's episode most effectively. This flexibility may encourage providers to use resources to coordinate care; often, these services are not reimbursed under fee-for-service payment. If the bundle includes services delivered by multiple providers in multiple settings, providers have to create a mechanism for managing the shared payment for a given treatment or condition, which could also foster coordination. Several types of undesired effects of bundled payment have also been postulated. The most significant potential undesired effects include underuse of effective services within the bundle, avoidance of high-risk patients, and an increase in the number of bundles reimbursed (increasing health spending). Providers under bundled payment may “game” the system by changing coding practices to maximize reimbursement for the bundle (“upcoding”) or by moving services in time or location to qualify for separate reimbursement (“unbundling”). This review was designed to address the uncertainties about the effects of bundled payment on spending and quality measures. It should help readers (1) understand what the evidence shows about the effects of bundled payment on health care spending and quality of care, and (2) understand key design and contextual features of bundled payment programs and their association with bundled payment effects. The review addressed three Key Questions: 1. What does the evidence show on the effects of bundled payment versus usual (predominantly fee-for-service) payment on health care spending and quality measures? 2. Does the evidence show differences in the effects of bundled payment systems by key design features? 3. Does the evidence show differences in the effects of bundled payment systems by key contextual factors?
The prevalence and incidence of chronic conditions have implications for policy and healthcare utilization. Valid information about risk factors is important in reducing the burden of chronic diseases. Although systems to rank the strength of the recommendations about effective interventions consider all evidence from observational studies as low, prevalence and risk factors for chronic diseases can be evaluated only in observational studies. Public policy decisions should be based on applicable and unbiased results from high quality studies. Assessing the quality of observational studies is an important part of evidence-based reports made for the Agency for Healthcare Research and Quality (AHRQ). An extensive review of all available systems for rating the strength of scientific evidence and concluded that future efforts need to identify valid and reliable quality ratings for observational studies. Different methodological aspects, including selective treatment assignment, access to health care, or provider characteristics may have different importance for studies that examine treatment effects and prevalence of chronic conditions or the association of disease risk factors with patient mortality and morbidity. Therefore, quality evaluation that is part of grading of a body of evidence must be tailored to the methodological aspects and quality standards of nontherapeutic observational studies. The present collaborative project sought to develop valid and reliable quality criteria of observational studies that examine the incidence or prevalence of chronic conditions and risk factors for diseases. We propose criteria for the design, reporting standards, and assessment of nontherapeutic observational studies in systematic reviews and evidence-based reports. We developed two checklists, one for studies of incidence or prevalence and another for risk factors, based on our literature review and in collaboration with experts from other Evidence-based Practice Centers and the Centers for Disease Control and Prevention. The protocol to construct the checklists was based on a conceptual model of the development of indexes, rating scales, or other appraisals to describe and measure symptoms, physical signs, and other clinical phenomena in clinical medicine. We defined external validity as the extent to which the results of a study can be generalized to the target population. Applicability may differ from external validity by the definition of the target population; well designed studies from different countries with good external validity can have low applicability to the U.S. population. We defined internal validity as the extent to which the results of a study are correct for the subjects and the associations detected are truly caused by exposure. We defined biases the checklists should address, but avoided labeling biases in quality evaluation because of differences in definitions of biases and because of applicability of previously labeled selection, information, differential verification, context, treatment paradox, disease progression, and other biases to interventional studies.
The Centers for Disease Control and Prevention (CDC) define a healthcare-associated infection (HAI) as: “[A] localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting.” The CDC estimates that in 2002 there were 1.7 million HAI and 99,000 HAI-associated deaths in hospitals. The four largest categories of HAI, responsible for more than 80 percent of all reported HAI, are central line–associated bloodstream infections (CLABSI, 14%), ventilator associated pneumonia (VAP, 15%), surgical site infections (SSI, 22%), and catheter-associated urinary tract infections (CAUTI, 32%). In a CDC report, national costs of HAI were estimated, based on 2002 infection rates and adjusted to 2007 dollars using the Consumer Price Index for inpatient hospital services. Estimates of the total annual direct medical costs of HAI for U.S. hospitals ranged from $35.7 billion to $45 billion. The prevention and reduction of HAI is a top priority for the U.S. Department of Health and Human Services. A call to action for the elimination of HAI has been issued jointly by the Association for Professionals in Infection Control and Epidemiology, Inc., the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, the Association of State and Territorial Health Officials, the Council of State and Territorial Epidemiologists, the Pediatric Infectious Diseases Society, and the CDC. In a consensus statement issued by these groups, a plan for the elimination of HAI includes the promotion of adherence to evidence-based practices through partnering, educating, implementing, and investing. In 2003, the Institute of Medicine (IOM) published a report, Priority Areas for National Action: Transforming Health Care Quality. The report identified 20 clinical topics for which there are quality concerns because of the gap between knowledge of the topic and integration of that knowledge into the clinical setting. In response to the IOM report, the Agency for Healthcare Research and Quality (AHRQ) initiated a series of technical reviews on quality improvement strategies focused on improving the quality of care for the IOM's 20 priority areas. This systematic review updates the AHRQ Evidence Report Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies: Volume 6—Prevention of Healthcare Associated Infections. From here on, this report is referred to as the 2007 report. The objective of that evidence review was to identify QI strategies that successfully increase adherence to effective preventive interventions and reduce infection rates for CLABSI, VAP, SSI, and CAUTI. The current review expands the settings to be considered from primarily hospitals to include ambulatory surgery centers, freestanding dialysis centers, and long-term care facilities, where the prevention of HAI needs to be addressed as well. Where applicable, the current report also applies the recommendation of a report prepared for AHRQ by RAND Health in which the impact of context on the effectiveness of patient safety practices is assessed. The context of an intervention can have an important impact on whether preventive interventions are adopted. Key Questions for this report follow. Key Question 1. Which quality improvement strategies are effective in reducing the following healthcare-associated infections - Central line–associated bloodstream infections (CLABSI), Ventilator-associated pneumonia (VAP), Surgical site infections (SSI), Catheter-associated urinary tract infections (CAUTI)? Key Question 2. What is the impact of the health care context on the effectiveness of quality improvement strategies, including reducing infections and increasing adherence to preventive interventions?
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Efforts to improve the quality and value of health care increasingly emphasize a critical role for the meaningful use of clinical decision support systems (CDSSs) and electronic knowledge management systems (KMSs). For the purpose of this review, a clinical decision support system is defined as “any electronic system designed to aid directly in clinical decisionmaking, in which characteristics of individual patients are used to generate patient-specific assessments or recommendations that are then presented to clinicians for consideration.” Examples of electronic CDSSs include alerts, reminders, order sets, drug-dosage calculations, and care-summary dashboards that provide performance feedback on quality indicators or benchmarks. In contrast, a knowledge management system is defined as a tool that selectively provides information relevant to the characteristics or circumstances of a clinical situation but which requires human interpretation for direct application to a specific patient. Examples of electronic KMSs include information retrieval tools and knowledge resources that consist of distilled primary literature on evidence-based practices. An information retrieval tool is defined as an electronic tool designed to aid clinicians in the search and retrieval of context-specific knowledge from information sources based on patient-specific information from a clinical information system to facilitate decisionmaking at the point of care of for a specific care situation. A knowledge resource is defined as an electronic resource comprising distilled primary literature that allows selection of content that is germane to a specific patient to facilitate decisionmaking at the point of care or for a specific care situation. The objective of a CDSS is to apply clinical knowledge in the context of patient-specific information to aid clinicians in the process of making decisions. Electronic KMSs can further support decisionmaking in any care situation by providing a range of strategies and resources to create, represent, and distribute knowledge for application by a human in clinical practice. As a form of health information technology, CDSSs and KMSs can serve as information tools to align clinician decisionmaking with best practice guidelines and evidence-based medical knowledge at the point of care as well as assist with information management to support clinicians' decisionmaking abilities. This evidence report is part of a three-report series focusing on the strategic goals of the Agency for Healthcare Research and Quality's (AHRQ's) health information technology portfolio. This report specifically explores facilitating health care decisionmaking through health information technology. Supporting health care decisionmaking is a core element of the meaningful use criteria for EHRs. As the expected level of sophistication of EHRs increases in the evolving definitions of meaningful use, the need for more sophisticated CDSSs/KMSs is imperative, as is the need for better operational use of these systems. This increasing importance of CDSSs/KMSs acknowledges that EHRs alone are not an end but are instead a tool to augment the delivery of safe, evidence-based, high-quality health care through more consistent and sound decisionmaking. The goals of this report were to summarize the available evidence related to CDSSs and KMSs, highlight the limitations of the evidence, and identify areas for future research. The key questions considered in this review were: KQ 1: What evidence-based study designs have been used to determine the clinical effectiveness of electronic knowledge management and CDSSs? KQ 2: What contextual factors/features influence the effectiveness or success of electronic knowledge management and CDSSs? KQ 3: What is the impact of introducing electronic knowledge management and CDSSs? KQ 4: What generalizable knowledge can be integrated into electronic knowledge management and CDSSs to improve health care quality?
The United States spends a greater proportion of its gross domestic product on health care than any other country in the world (17.6 percent in 2009), yet often fails to provide high quality and efficient health care. U.S. health care has traditionally been based on a solid foundation of primary care to meet the majority of preventive, acute, and chronic health care needs of its population; however, the recent challenges facing health care in the United States have been particularly magnified within the primary care setting. Access to primary care is limited in many areas, particularly rural communities. Fewer U.S. physicians are choosing primary care as a profession, and satisfaction among primary care physicians has waned amid the growing demands of office-based practice. There has been growing concern that current models of primary care will not be sustainable for meeting the broad health care needs of the American population. The patient-centered medical home (PCMH) is a model of primary care transformation that seeks to meet the variety of health care needs of patients and to improve patient and staff experiences, outcomes, safety, and system efficiency. The term “medical home” was first used by the American Academy of Pediatrics in 1967 to describe the concept of a single centralized source of care and medical record for children with special health care needs. The current concept of PCMH has been greatly expanded and is based on 40 years of previous efforts to redesign primary care to provide the highest quality of care possible. The chronic care model, a conceptual model for organizing chronic illness care that is associated with improved health outcomes, is the cornerstone of PCMH. Interventions based on the chronic care model (CCM) and focused on single conditions such as diabetes mellitus, asthma, chronic obstructive pulmonary disease, or depression have been shown to improve patient outcomes and/or quality of care. PCMH builds on this model and is intended to address the full range of patient-focused health care needs. As defined by physician and consumer groups, the core principles of the PCMH are wide-ranging team-based care, patient-centered orientation toward the whole person, care that is coordinated across all elements of the health care system and the patient's community, enhanced access to care that uses alternative methods of communication, and a systems-based approach to quality and safety. As part of the Closing the Quality Gap: Revisiting the State of the Science series of reviews by Evidence-based Practice Centers (EPCs), this systematic review was commissioned to identify completed and ongoing efforts to evaluate the comprehensive PCMH model, summarize current evidence for this model, and identify gaps in the evidence. Because the PCMH model is being implemented widely but the number of completed studies was expected to be small, the identification of ongoing studies was an important goal of this review. The Key Questions include: KQ 1. In published, primary care–based evaluations of comprehensive PCMH interventions, what are the effects of the PCMH on patient and staff experiences, process of care, clinical outcomes, and economic outcomes? KQ 2. In published, primary care–based evaluations of comprehensive PCMH interventions, what individual PCMH components have been implemented? KQ 3. In published, primary care–based evaluations of comprehensive PCMH interventions, what financial models and implementation strategies have been used to support uptake? KQ 4. What primary care–based studies evaluating the effects of comprehensive PCMH interventions on patient and staff experiences, process of care, clinical outcomes, or economic outcomes are currently underway? In these ongoing studies, what are the study designs, PCMH components, comparators, settings, financial models, and outcomes to be evaluated?
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. 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.
Healthcare-associated infections (HAIs) are considered to be the greatest risk patients face in the hospital environment. HAIs can occur in any patient care setting, but infections in hospitalized patients account for the vast majority of HAIs. Hospitalized patients are additionally susceptible to experiencing serious consequences of HAIs due to comorbid illnesses. According to estimates from the Centers for Disease Control and Prevention (CDC), up to two million patients (nearly one in 20 hospitalized patients) experience a healthcare-associated infection every year in the U.S., leading to approximately 88,000 deaths and $4.5 billion in extra costs per year. Moreover, the incidence of HAIs appears to have increased over the last three decades, despite the fact that the majority of HAIs are thought to be preventable. Efforts to monitor and prevent HAIs have existed for decades. These efforts have followed the public health methodology of surveillance and prevention. The effectiveness of such methods was provided by the Study of the Effectiveness of Nosocomial Infection Control study, which demonstrated that hospitals with structured infection control programs achieved sustained reductions in HAI rates, whereas hospitals with less comprehensive programs saw increased infection rates. The growing focus on improving patient safety over the past few years has catalyzed even greater efforts to curb HAIs. Public reporting of infection rates has been proposed as a means of educating patients and encouraging preventive efforts; currently, six states require reporting of HAIs, and legislation requiring some type of reporting has been proposed in the majority of states. Within the hospital, surgical site infections (SSI) and three types of infections common in intensive care unit patients are particularly prevalent—central-line associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections. Together, these infections account for more than 80 percent of all HAIs. In this report, we systematically review the evidence supporting quality improvement strategies to reduce the incidence of these key healthcare-associated infections. We intend to identify strategies that successfully increase adherence to effective preventive practices for each of these infections and reduce infection rates. Our specific research questions are: 1. Do quality improvement strategies increase adherence to evidence-based preventive interventions for healthcare-associated infections? 2. What are the critical components of effective QI strategies? 3. What are the limitations of current research in this field, and what areas require further study? We defined a “preventive intervention” as a specific infection control practice that has been demonstrated to reduce the incidence of a HAI. To identify target preventive interventions, we reviewed the CDC guidelines for prevention of surgical site infection, prevention of intravascular catheter-related infections, prevention of healthcare-associated pneumonia, and prevention of catheter-associated urinary tract infection. Hand hygiene was identified as an important preventive intervention for all HAIs. The disease-specific target preventive interventions we identified are as follows: Surgical site infection: appropriate perioperative antibiotic prophylaxis (including appropriate antibiotic selection, timing, and duration), perioperative glucose control, and decreasing shaving of the operative site; Central line-associated bloodstream infection: adherence to maximal sterile barrier precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral catheterization; Ventilator-associated pneumonia: semirecumbent patient positioning and daily assessment of readiness for ventilator weaning; Catheter-associated urinary tract infection: reduction in unnecessary catheter use and adherence to aseptic catheter insertion and catheter care.
A shortage of registered nurses, in combination with increased workload, has the potential to threaten quality of care. Increasing the nurse to patient ratios has been recommended as a means to improve patient safety. However, the cost effectiveness of increasing registered nurse (RN) staffing is controversial. This systematic review analyzes associations between hospital nurse staffing and patient outcomes with consideration of variables that could influence the primary association. The basic research questions were: 1. How is a specific nurse to patient ratio associated with patient outcomes (i.e., mortality; adverse drug events, nurse quality outcomes, length of stay; patient satisfaction with nurse care)? How does this association vary by patient characteristics, nurse characteristics, organizational characteristics, and nursing outcomes? 2. How is a measure of nurse work hours (hours per patient or patient day) associated with the same patient outcomes? 3. What factors influence nurse staffing policies? 4. What nurse staffing strategies are effective for improving the patient outcomes listed in question 1? 5. What gaps in research on nurse staffing and patient outcomes can be identified to address in future studies? Questions 1, 2, and 4 are addressed in the systematic review using meta-analytic approaches. The literature associated with question 3 does not lend itself to meta-analysis. Questions 1 and 2 address the same basic association but employ two different measures of nurse staffing. The nurse to patient ratio relies on a general ratio, which may include all nurses assigned to a unit, including non-clinical time, whereas nurse work hours look specifically at nurses involved in patient care. Even beyond this distinction, the varied ways staffing rates are calculated complicates pooling data.
The Agency for Healthcare Research and Quality (AHRQ) sponsors research to improve the quality, effectiveness, and safety of health care in the United States. Evidence reports and technology assessments generated through AHRQ's Effective Health Care Program provide science-based information about common, relevant health conditions and technologies to serve the needs of patients, clinicians, insurance payers, and other end users. Evidence reports typically target scientific researchers in related fields, rather than the patients or clinicians who ultimately make health-related decisions. For this review, we view the evidence as moving along a continuum beginning with its collection and systematic review, followed by communicating and translating it for audiences as needed, diffusing and disseminating it, adopting and implementing it, and sustaining and evaluating its impact, with adjustments as needed. We define evidence as data that have been assembled, reviewed, and presented by evidence developers and that have been used to make recommendations. Our review included only the second and third phases in the evidence continuum: communication and dissemination. Clear communication and active dissemination of evidence to all relevant audiences in easy-to-understand formats are critical to increasing awareness, consideration, adoption, and use of evidence, and to accomplishing AHRQ's mission. By evaluating the comparative effectiveness of communication techniques and dissemination strategies, this review informs efforts to make evidence reports summarizing current research both more easily accessible for evidence translators, health educators, patients, and clinicians and more likely to be used to influence individual decisions, change practice, and inform future research. Due to the complexities of our topic, we present separate results for the three separate systematic reviews—one for communication, one for dissemination, and a third for uncertainty—each addressing a separate but related Key Question (KQ). Combined, these three separate reviews provide information on how to best translate and disseminate research-based evidence reports. This systematic review has three related components; all focus on promoting informed decisions about health-related behaviors and decisions among patients and clinicians. First, it addresses the comparative effectiveness of communicating evidence in various contents and formats that increase the likelihood that target audiences will both understand and use the information. Second, it examines the comparative effectiveness of a variety of approaches for disseminating evidence from those who develop it to those who are expected to use it. Third, it examines the comparative effectiveness of various ways of communicating uncertainty associated with health-related evidence to different target audiences, including evidence translators, health educators, patients, and clinicians. Key Question 1: Communication Strategies To Promote the Use of Health Care Evidence KQ: a. What is the comparative effectiveness of communication strategies to promote the use of health and health care evidence by patients and clinicians? b. How does the comparative effectiveness of communication strategies vary by patients and clinicians? Key Question 2: Dissemination Strategies To Promote the Use of Health Care Evidence KQ 2: a. What is the comparative effectiveness of dissemination strategies to promote the use of health and health care evidence for patients and clinicians? b. How does the comparative effectiveness of dissemination strategies vary by patients and clinicians? Key Question 3: Explaining Uncertain Evidence KQ3: What is the comparative effectiveness of different ways of explaining uncertain health and health care evidence to patients and clinicians?
The global community has collaboratively taken responsibility for advancing health for all and codified this commitment in the Millennium Development Goals. The global effort has enabled standardization of approaches, including the agreement that evidence-based decision making is a norm for health policy, practice, and programs. The U.S. Agency for International Development (USAID) is likewise committed to evidence-based, innovative, efficacious, effective and sustainable global health programs. Evidence based decision making is critical to informing and guiding programming in global health intervention, global health policies, and programs. However, many current evidence evaluation frameworks have evolved from the clinical model where physician decision making is determined by rigorous systematic review of data derived from randomized clinical trials (RCTs) which emphasize efficacy for the individual patient. Evidence requirements for global health programs are complex, and include three streams: efficacy at the individual level, effectiveness at the population level, and sustainability at the host country level. A standardized approach to evaluation of evidence will strengthen and support global health strategies, programs, and practice optimizing limited resources for maximal health impact. The Global Health Evidence Evaluation Framework project is aimed at developing an evidence framework for the purposes of informing efficacious, effective, sustainable global health programs at the community and scale level. This project represents collaboration between the project team and an interdisciplinary group of experts, called the Technical Expert Panel, or TEP. Each key step of the project requires both preparatory work on the part of the project team and then consideration and discussion by the TEP, with synthesis of the TEP discussion and decisions then made by the project team. Preliminary Key Questions were: What is the role of context in the effectiveness and scalability of global health interventions/programs at the community and population level? What descriptions of elements of study design and execution are necessary to reach conclusions about effectiveness? What descriptions of elements of implementation are necessary to reach conclusions about scalability and sustainability? The six steps of the project are to: 1. Assemble an interdisciplinary panel of experts. 2. Select a set of “exemplar interventions or programs.” Note “exemplar” means “characteristic of its kind.” These exemplars are needed because they provide the “real world” examples to use when developing and testing frameworks and criteria. 3. Perform a focused literature review on the exemplar interventions, to elucidate what is currently being reported regarding evaluations of the exemplar interventions and to identify gaps in the evidence. 4. Perform an assessment of strengths and limitations of existing frameworks for assessing global health interventions. 5. Identify and/or develop of criteria to meet identified needs or gaps in existing frameworks. 6. Pilot test the draft criteria.
Comparative effectiveness or patient-centered outcomes research (CER/PCOR) has been defined by the Federal Coordinating Council for CER as “the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in 'real world' settings.” The purpose of CER/PCOR is “to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decisionmakers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances.” The interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic tests, behavioral changes, and delivery system strategies. CER/PCOR designs may include clinical trials, observational studies, secondary analyses of databases, systematic reviews with or without meta-analyses, and cost-effectiveness analyses. The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports health services research to improve the quality of health care and promote evidence-based decisionmaking; AHRQ supports a variety of CER/PCOR activities through its Effective Health Care (EHC) Program. The EHC Program funds individual researchers, research centers, and academic organizations that work with AHRQ to produce effectiveness and comparative effectiveness research for clinicians, consumers, and policymakers. To contribute to its agenda for CER/PCOR activities related to mental health, AHRQ contracted the RTI International-University of North Carolina (RTI-UNC) Evidence-based Practice Center (EPC) and the Scientific Resource Center Stakeholder Engagement Team to engage a broad and representative group of stakeholders to discuss issues related to serious mental illness (SMI) in a series of three meetings (Issues Exploration Forum [IEF]), as detailed in the methods section. The results of three large comparative effectiveness trials have been sobering, and arguably have highlighted the limitations of our current ability to help many patients afflicted with schizophrenia, bipolar disorder, and depression. The overarching purpose of this Issues Exploration Forum was to contribute to the establishment of priorities to guide CER/PCOR activities in mental health by engaging a diverse group of stakeholders. We aimed to focus on an area of mental health with significant unmet need despite available interventions and an area in which conducting CER/PCOR is likely to have an impact on reducing variation and uncertainty in clinical practice and outcomes, reducing methodological and conceptual uncertainty, and reducing disease burden. Additional objectives were to identify knowledge gaps in the area of SMI and to generate and prioritize topics for future CER/PCOR, including topics for evidence synthesis (i.e., systematic reviews, comparative effectiveness reviews).
As protectors of the public's health, State governments play a vital role in preventing asthma and controlling its consequences. Most States have some public resources invested in asthma prevention, monitoring, and care programs, although the level of investment may vary from State to State. As health care purchasers, States are responsible for ensuring that the health care they pay for on behalf of State employees, Medicaid clients, and other recipients meet standards of quality. There are a number of reasons why States may want to take a closer look at improving quality of care for asthma, including: The increased prevalence of asthma, especially among children and adolescents; The disparities between various racial and ethnic groups in diagnosis and quality of asthma care; Interventions and treatment that can successfully control the disease and prevent attacks; The high health care cost of uncontrolled asthma and the potential for return on investment for purchasers, including State Medicaid agencies, through asthma quality improvement. The aim of this Workbook is to help State leaders develop information to support health care quality improvement. Its written exercises should help State leaders begin to think about an effective partnership for an initiative, assembly of available data for their State, questions to raise about interpretation of the data, and quality improvement techniques. It also should help readers apply information and concepts from the Resource Guide to their own States. Upon completion of the Workbook, State leaders will be able to: Understand the key factors that determine whether there is a need for an asthma care quality improvement in their State (i.e., “make the case”); Identify partners to plan, develop, and support a quality improvement strategy for asthma; Identify national, public-private, Federal, State, and local resources and activities related to asthma quality improvement; Identify appropriate asthma data sources and measures and develop estimates from data for assessing the State's performance in providing asthma care; Identify opportunities to contribute to improving asthma care quality. This Workbook is a start for State leaders interested in learning about quality improvement for asthma care. The actual planning, implementation, tracking, and evaluation of an asthma care quality improvement program will go well beyond this Workbook and its companion Resource Guide. Carrying out such a program will require a team of experts: State leaders and agency staff, program staff, topic experts, researchers, health specialists, statisticians, data collection experts, evaluation researchers, and representatives from stakeholder groups
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