Meeting Minutes, April 12, 2013

Contents

Call to Order and Approval of November 9, 2012, Meeting Summary
Director's Update
Pediatric Measures and Use
Levers for Change: Closing the Quality Gap
Public Comments
Chairman's Wrap-Up and NAC Input
Adjournment

NAC Members Present

Bruce Siegel, M.D., M.P.H., National Association of Public Hospitals and Health Systems (Chair)
Gregory Baker, R.Ph., Take Care Employer Solutions Group
Mitra Behroozi, J.D., 1199SEIU Benefit and Pension Funds
Paul N. Casale, M.D., FACC, Lancaster General Hospital
Francis J. Crosson, M.D., American Medical Association
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Mercy Family of Companies
Leon L. Haley, Jr., M.D., M.H.S.A., FACEP, Grady Health System
Michael P. Johnson, P.T., Ph.D., OCS, Bayada Home Health Care
Carol Matyka, M.A., National Breast Cancer Coalition
Newell E. McElwee III, Pharm.D., M.S.P.H., Merck Global Medical Affairs
Andrea H. McGuire, M.D., M.B.A., Meridian Health Plan
Victor M. Montori, M.D., M.Sc., Mayo Clinic College of Medicine
Henry H. Ng, M.D., M.P.H., FAAP, FACP, MetroHealth Medical Center
Christopher Queram, M.A., Wisconsin Collaborative for Healthcare Quality
Jean Rexford, Connecticut Center for Patient Safety
Harry P. Selker, M.D., M.S.P.H., Tufts University
Alan R. Spitzer, M.D., MEDNAX Services/Pediatrix Medical Group
Jeffery Thompson, M.D., M.P.H., Mercer
Janet S. Wyatt, Ph.D., R.N., FAANP, Institute of Pediatric Nursing

Alternates Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Patrick Conway, M.D., Centers for Medicare & Medicaid Services
Sandra L. Decker, Ph.D., National Center for Health Statistics

AHRQ Staff Members Present

Carolyn M. Clancy, M.D., Director
Boyce Ginieczki, Ph.D., Acting Deputy Director
Jaime Zimmerman, M.P.H., NAC Coordinator
Karen Brooks, CMP, NAC Coordinator

Call to Order and Approval of November 9, 2012, Meeting Summary

Bruce Siegel, M.D., M.P.H., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:40 a.m. and welcomed the NAC members, other participants, and visitors. He introduced seven new NAC members, Gergory Baker, R.Ph., Take Care Employer Solutions Group, Francis J. Crosson, M.D., the American Medical Association, Andrea Gelzer, M.D., M.S., The AmeriHealth Mercy Family of Companies, Leon L. Haley, Jr., M.D., M.H.S.A., Grady Health System, Carol Matyka, M.A., National Breast Cancer Coalition, Victor M. Montori, M.D., M.Sc., Mayo Clinic College of Medicine, and Jean Rexford, Connecticut Center for Patient Safety.

Dr. Siegel referred to the draft minutes of the previous NAC meeting (November 9, 2012) and asked for changes and approval. The NAC members approved the November 9, 2012, meeting minutes with no changes.

Return to Contents

Director's Update

Carolyn M. Clancy, M.D., AHRQ Director, welcomed the NAC members, speakers, and other guests. She began her update on AHRQ activities by discussing the Federal funding picture.

The Big Picture

Dr. Clancy stated that the FY 2013 full-year continuing resolution funding for AHRQ is a base of $429.693 million (with adjustment for the sequester). The monies come from the PHS Evaluation Fund ($350.488 million), the Prevention and Public Health Fund ($6.465 million), and the Patient-Centered Outcomes Research Trust Fund (PCORTF) ($57.547 million).

The President's FY 2014 budget request for AHRQ is a total of $433.7 million. This features $20.7 million for prevention/care management, $3.3 million for value research, $25.6 million for health information technology (HIT), $62.6 million for patient safety (including $34 million for health care-associated infections), $88.9 million for cross-cutting research (including $8.9 million in new grants), $63.8 million for the Medical Expenditure Panel Survey (MEPS), and $68.8 million for program support. The base features no funding for Patient-Centered Outcomes Research, but $100 million will come from the PCORTF.

Recent Accomplishments

Dr. Clancy reviewed the following recent accomplishments:

• An AHRQ-funded study published in the New England Journal of Medicine found that the use of standard written checklists improved surgical safety, reducing errors during surgical crises by 75 percent. The investigators had simulated crises and assessed reactions of 17 surgical teams at 3 Boston hospitals.
• New results of efforts to reduce central line-associated bloodstream infections (CLABSIs) using AHRQ's Comprehensive Unit-Based Safety Program (CUSP) were a reduction of 58 percent in infections in newborns in studied neonatal intensive care units (NICUs). It was estimated that the efforts prevented 131 infections and 41 deaths. The CUSP toolkit is available online at http://www.ahrq.gov/professionals/quality-patient-safety/cusp/index.html.
• AHRQ worked with the Centers for Medicare & Medicaid Services to develop a blueprint for electronic health records that capture child-relevant health information. The format features recommendations for child-specific data elements, such as applications of vaccines.
• A new evidence report published by AHRQ identifies the top 10 patient safety strategies that can be used immediately by health care providers. The report cites evidence regarding implementation, adoption, and context.
• The Virginia Department of Health Office of Family Services/Department for Aging and Rehabilitation used funding from the Federal Recovery Act to expand its program in chronic disease self-management to 49 cities and counties. Analysis revealed an increased ability to manage chronic disease and quicker increases in physical activities.
• The Partners in Health (PIH) program and Regenstrief Institute used AHRQ research funding to develop OpenMRS, a flexible, open-source electronic medical records system. The system is being used in the United States, Canada, Europe, and developing countries.
• The Colorado Regional Health Information Organization used an AHRQ contract to develop a point-of-care inquiry system for four Denver-area emergency departments. Demonstration projects for health IT have resulted in secure data-sharing of more than 1.8 million patients, improving quality and care coordination.
• The Rhode Island Department of Health developed a State health information exchange with the help of the Rhode Island Quality Institute. The program features patient consent for data inclusion and data user agreements for providers. 
• AHRQ launched its new Web site on March 1, 2013. The site features faster content loading and presents information based on types of audiences and users. It provides access for mobile technologies.

AHRQ Program Updates

Dr. Clancy reviewed the following AHRQ program activities:

• A report published in the Journal of the American Medical Informatics Association estimated the effect of the use of computerized provider order entry (CPOE) systems on medication errors. Processing prescriptions through a CPOE system decreases the likelihood of error by 48 percent.
• A new AHRQ published report describes tests of approaches for delivering patient-centered care, finding positive results for health IT applications that support patient-centered care.
• AHRQ developed "Designing Consumer Health IT: A Guide for Developers and Systems Designers," featuring recommendations for designers, developers, and vendors of consumer health IT applications.
• The Health IT Hazard Manager Final Report was released in the summer of 2012. The Hazard Manager software provides simulations for identifying problems.
• Two 5-year clinical decision support demonstration projects are being completed in 2013—one at Brigham and Women's Hospital and one at Yale University School of Medicine. The projects feature models for developing, implementing, and evaluating clinical decision support.
• AHRQ and the National Science Foundation supported projects to use industrial and systems engineering to seek goals for a new patient-centered health care system and to foster collaborations between health services researchers and industrial and systems engineers.
• AHRQ is supporting an active aging research center to improve the health and functioning of older adults using health IT. The University of Wisconsin-Madison is developing and testing Elder Tree, a community-based system.
• Pending approval by the Office of Management and Budget, AHRQ will investigate how small to medium-sized care organizations utilize health IT in efforts to redesign practices. It will focus on administrative workflow and patient communication.
• AHRQ posted 14 new evidence-based practice reports, or systematic reviews, from the Effective Health Care Program. They include the topics of chronic cough, acute migraine treatment in emergency settings, chronic plaque psoriasis, childhood trauma, cryptorchidism, hepatitis C screening, hepatitis C treatment adherence, gestational diabetes mellitus, and restless legs syndrome.
• AHRQ published evidence-based practice center (EPC) updates for publications on the topics of making health care safer and closing the quality gap.
• Recent translated print products include consumer brochures on medicines for rheumatoid arthritis, medicines for psoriatic arthritis, and treatment for open-angle glaucoma.
• AHRQ published a new user's guide titled "Developing a Protocol for Observational Comparative Effectiveness Research." The guide identifies best practices and is a resource for researchers who are developing studies in observational comparative effectiveness research. It is available as an ebook.
• AHRQ is sponsoring a journal supplement to advance research methods for evaluating patient health outcomes in rare diseases. It will appear in the Journal of General Internal Medicine in 2014. The call for papers and general information are available at https://effectivehealthcare.ahrq.gov.
• AHRQ partnered with Health Services Research in its April 2013 issue devoted to simulation methods for health services research.
• A revised Re-Engineered Discharge (RED) toolkit was released and features comprehensive guidance to avoid re-hospitalizations and components for serving patients with limited English proficiency.
• A new toolkit for preventing falls in hospitals features a Web-based design and guidance for a multidisciplinary change team.
• In partnership with the Minnesota Hospital Association, AHRQ funded a pilot HCUP study testing the feasibility of linking hospital administrative data and laboratory data in a statewide collection. "Harnessing the Power of Enhanced Data for Healthcare Quality Improvement" was published in the Journal of Healthcare Management (Nov-Dec 2012).
• The HCUP program released findings about preventable hospital admissions, revealing that, between 2005 and 2010, the number of potentially preventable hospital admissions decreased by 6.2 percent for adults. For children, the reduction was nearly 40 percent, led by a strong reduction in admissions for pediatric gastroenteritis. The estimated cost reduction for children was about 32 percent.
• AHRQ's Patient-Centered Medical Home Program will be supporting a webinar program on delivery system research methods beginning in April. Topics include fuzzy set analysis, statistical process control, logic models, formative evaluation, and mixed methods.
• The process that developed a set of core measures for voluntary reporting in State Medicaid and CHIP programs (a NAC subcommittee known as SNAC) is moving into a phase for reassessment of measures with an eye to retiring less useful or less appropriate measures. Various CHIPRA Centers of Excellence are in a process of identifying new measures.
• Ongoing collaborations with the MEPS program include efforts by government agencies (OMB, ASPE, CDC) to ensure that Federal surveys are responsive to changes introduced by the Affordable Care Act and efforts by the National Cancer Institute, the CDC, the American Cancer Society, and the Livestrong Foundation to enhance MEPS content to support cancer survivorship research.
• AHRQ is enhancing the MEPS Insurance Component with data on variation in premiums by smoking status. New targeted studies revealing the analytic capacity of MEPS include the topics of Medicaid and CHIP eligibility, tax simulations, monthly expenditures, concentration and persistence of medical expenditures, immigration/citizenship, premiums/assets, burden analyses, and adherence to preventive care guidelines.
• Since the previous NAC meeting, the U.S. Preventive Services Task Force (USPSTF) posted six draft recommendations and five draft research plans. It published final recommendations for (1) Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults and (2) Vitamin D and Calcium Supplementation To Prevent Fractures. The USPSTF is conducting a pilot process for posting draft evidence reports and draft recommendations simultaneously for public comment.
• An AHRQ-supported video series on Vermont's statewide public-private initiative seeking to provide incentives and infrastructure for delivery of coordinated health services received a Telly Award.
• Within the Patient-Centered Medical Home Program, AHRQ published "Case Studies of Leading Primary Care Practice Facilitation Programs," describing case studies of four national innovators in primary care practice facilitation.
• AHRQ released the new TeamSTEPPS® for Primary Care Environment module early because of high demand.
• The Patient Safety Organization (PSO) Web site features a new brochure, "Choosing a Patient Safety Organization—Tips for Hospitals and Health Care Providers." Copies can be ordered from the AHRQ Clearinghouse at AHRQpubs@ahrq.hhs.gov.
• The Centers for Medicare & Medicaid Services (CMS) issued a memorandum for hospitals and State survey agencies regarding comprehensive safety reporting using AHRQ common formats.
• The REDUCE-MRSA trial of targeted versus universal decolonization to prevent MRSA and all-cause bloodstream infections in intensive care units was concluded and soon will be published in a major journal. The trial featured a large group of hospitals and produced significant results.
• A new project is targeting infections in end-stage renal disease patients. The National Opportunity To Improve Infection Control in ESRD (NOTICE) seeks to reduce bloodstream infections in dialysis patients with the use of a comprehensive change package. The package is being tested in 60 dialysis facilities across the United States.
• In February, AHRQ awarded the 5-year Consumer Assessment of Healthcare Providers and Systems (CAHPS®)/Surveys on Patient Safety Culture (SOPS) IV User Network contract to Westat. The contract supports quality improvement resources, providing technical assistance to users of CAHPS surveys and users of the Surveys of Patient Safety Culture and supporting production and analysis of CAHPS and SOPS databases.

Discussion

Dr. Gelzer raised the issue of behavioral health comorbidity with chronic diseases, encouraging AHRQ to consider the development of research plans. Dr. Clancy noted that some work in this area is under way. Mitra Behroozi, J.D., added the issue of mental disorders associated with childbirth. In general, we need to address the integration of behavioral health and primary care. Dr. Montori suggested that issues of multiple chronic conditions be brought together with ideas of patient-centered care. David Atkins, M.D., M.P.H., noted work at the Veterans Administration on the patient-centered medical home, including the overlay of medical comorbidities and mental health.

Michael P. Johnson, P.T., Ph.D., OCS, noted that Bayada Home Health Care is participating in the Colorado Regional Health Information Organization's point-of-care inquiry system for Denver-area emergency departments. The experience has been positive. Dr. Johnson cited a need for guidance to address the issue of falls in community settings.

Harry P. Selker, M.D., M.S.P.H., suggested that AHRQ perform data tracking (e.g., with MEPS) that could be used to assess trends that occur as a result of the Affordable Care Act. Steven Cohen, Ph.D., and Ernest Moy, M.D., both of AHRQ, noted potential plans to invest in longitudinal profiles related to disparities and target populations.

Newell E. McElwee III, Pharm.D., M.S.P.H., suggested that the new user's guide, "Developing a Protocol for Observational Comparative Effectiveness Research," might present a process that is too epidemiological (too slow) for some investigators.

Dr. Montori raised the issue of completeness of reporting. What is the percentage of studies that achieve publication?

Jeffery Thompson, M.D., M.P.H., proposed that health services research regarding chronic care be extended to research in social systems (homelessness and other factors). Dr. Clancy proposed that a representative from the Center for Primary Care, Prevention, and Clinical Partnerships (CP3) be invited to speak at the next NAC meeting.

Tribute to Director Clancy

Dr. Siegel asked that the meeting's agenda be interrupted so that the group could pay tribute to Director Clancy, who recently announced that she will be leaving the agency. He stated that Dr. Clancy has been with AHRQ for more than 20 years and has served as Director for the past 10 years. She has a long history of working ahead of the curve, for example, by promoting the development of health informatics. Many of her efforts during the past decades have become standard elements of the health services research vernacular.

The NAC members praised Dr. Clancy for being a strong role model and for touching many lives. They cited the welcoming atmosphere of AHRQ and its particular emphases, such as health care disparities. AHRQ is one of the smaller government agencies, yet Dr. Clancy has shown grit in ensuring that its efforts have been felt. She has attracted and retained excellent researchers. She has navigated political waves. She has applied a robust multi-stakeholder approach in addressing the issues of quality and safety in health care services. She has championed evidence-based practices and patient-centered research.

On behalf of the NAC members, Dr. Siegel presented to Dr. Clancy a large inscribed glass vase as a gift of appreciation. The inscription states, "We recognize Dr. Clancy's decade of superb leadership and commitment to improving the quality of health care in our nation for the health of its people." Dr. Clancy thanked the NAC members and emphasized that the work of health care services research is a team sport.

Return to Contents

Pediatric Measures and Use

Alan R. Spitzer, M.D., MEDNAX Services/Pediatrix Medical Group

Dr. Spitzer described the work of the Pediatrix Medical Group, which is engaged in a program to harness large amounts of patient data ("big data") for efforts to improve care. Big data have the capacity to generate new knowledge, rapidly disseminate knowledge, create personalized medicine initiatives, and allow delivery of better health information directly to patients. The Pediatrix Medical Group annually admits nearly 100,000 patients to NICUs across the United States.

Dr. Spitzer reviewed the development of the Pediatrix BabySteps program, beginning with the creation of an electronic health record (EHR) system in 1996 and development of a clinical data warehouse in 2004. The BabySteps program facilitates complex data extraction for use in coding, outcome information, research, and quality improvement. It features automated, validated extraction. The program's clinical data warehouse, with information on more than 919,000 neonates, is the most complete database of its type.

Dr. Spitzer outlined the program's features, including quality improvement summits for physicians, toolkits, access to the warehouse, and available data reports (activity, morbidity, mortality, management, and more). Specific reports and associated graphs clearly reveal trends for neonate issues (such as the use of breast milk) in different hospitals. Dr. Spitzer noted how the program can inform parents about issues and comparative outcomes in neonatal care. The BabySteps program is an example of re-engineering care to produce optimal outcomes. It has presented data that stimulated reductions in the use of unhelpful treatments. It has produced significant improvements in a range of neonate health issues.

Discussion

The NAC members suggested that the BabySteps program include a focus on the functional capacity of surviving babies. Dr. Spitzer stated that a report on hearing will be published soon. Followup on functional capacity is difficult because of the loss of contacts. Maternal and prenatal data also are difficult to collect.

Dr. Spitzer noted that participating physicians, after observing the outcome data, tend to moderate their complaints about data collection. Dr. Johnson suggested that the program advertise the gross numbers for improvements in health and lives saved (not only percentage decreases).

Dr. Atkins encouraged the program to consider sources of variation, patient population effects, and clinic culture. Dr. Spitzer stressed that clinician decisionmaking represents the greatest source of variation. There are plans to study clinician behaviors. Dr. Thompson encouraged the program to integrate circumscribed data, such as time periods and c-sections. Henry H. Ng, M.D., M.P.H., FAAP, FACP, suggested that the program consider data on handoffs. Dr. Spitzer stated that about 60 percent of participating clinicians consult the database at least once every few weeks.

Return to Contents

Levers for Change: Closing the Quality Gap

Closing the Quality Gap Series:  A Summary

Christine Chang, M.D., M.P.H., Center for Outcomes and Evidence, AHRQ

Dr. Chang reviewed the results of a series of eight systematic reviews of the research literature developed by AHRQ-supported Evidence-Based Practice Centers. The reviews build on the Closing the Quality Gap initiative. The eight topics are as follows:

• QI measurement of outcomes for people with disabilities.
• Effects of bundled payment systems on health care spending and quality of care.
• Public reporting as a quality improvement strategy.
• Quality improvement interventions to address health disparities.
• Interventions to improve health care and palliative care for advanced and serious illness.
• Patient-centered medical home.
• Prevention of health care-associated infections.
• Comparative effectiveness of medication adherence interventions.

The series examines diverse approaches, study types, populations, interventions, comparators, outcomes, and settings. Many facts are revealed. For example, disabled populations rarely are included in studies with nondisabled patients. Organizational change is a common element of many effective quality improvement interventions. The reviews found that qualitative research suggests that patient use of public reporting varies by relevance, readability, and clarity. The reviews found that few studies have examined the impact of context on intervention effectiveness. Harms are rarely investigated in the literature.

Dr. Chang listed additional findings of the reviews and remarked that traditional systematic reviews can be poor fits for evaluating the literature involving complex, system-based interventions. Reviews suffer from a lack of common terminology and framework for quality improvement interventions and from inconsistent use of outcomes measures across studies.

ROI Analysis: Michigan Bariatric Surgical Collaborative

David C. Miller, M.D., M.P.H., University of Michigan

Dr. Miller reviewed the work of the Michigan Bariatric Surgical Collaborative, a group of 31 hospitals in Michigan engaged in quality improvement. He described a study that compared bariatric procedures performed in the collaborative's hospitals with bariatric procedures performed in other Michigan hospitals (all involving Blue Cross Blue Shield as payer). The study sought to assess relationships between quality improvements and cost savings. The investigators found that, during the period from 2008 to 2011, costs for bariatric surgery in both collaborative hospitals and noncollaborative hospitals declined, yet the decline in the collaborative hospitals was significantly greater. Final average costs (by 2011) in the collaborative hospitals were about $1,000 lower per patient per episode. Dr. Miller provided a breakdown of where the cost savings were achieved, for example, in the declines in complication rates. In general, savings could be attributed to improvements in care quality—with some savings attributable to practice style.

Blue Cross Blue Shield of Michigan Value Partnerships

Thomas Leyden, M.B.A., Blue Cross Blue Shield of Michigan

Mr. Leyden described systematic aspects of continuous quality improvement (CQI) programs in Michigan hospitals, supported by Blue Cross Blue Shield's (BCBS's) Value Partnerships Program. The program features all-payer registries, data collection and analysis, coordinating centers, and administrative leadership provided by BCBS of Michigan. Mr. Leyden noted assumptions of CQI programs, including the belief that cross-group/institution collaboration yields more than a competition on quality and allows for robust analyses of the links between processes and outcomes of care. He gave examples of improved care through Michigan programs, including the bariatric surgical collaborative described by Dr. Miller. CQI programs empower the provider community to self-optimize care in real-world situations. The locus of control remains with the providers. The programs use measurement to improve, not to judge. They can cause rapid change in evidence-based medicine and can disseminate best practices.

Discussion

The NAC members applauded the work. Dr. Miller noted aspects of the Michigan collaborative's educational component, including the use of comparative performance feedback. Dr. Montori wondered which changes first—costs or care quality. The NAC members suggested that the collaborative publicize the names of member hospitals. Perhaps some could become centers of excellence. The NAC members expressed concern for the lack of transparency in the program, which restricts information for patients. They suggested pathways toward greater transparency.

Return to Contents

Public Comment

There were no public comments.

Return to Contents

Chairman's Wrap-Up and NAC Input

Dr. Siegel asked the NAC members for final comments and suggestions for the next meeting agenda.

• Dr. Siegel announced the formation of a subcommittee to discuss and provide strategic direction for AHRQ. The subcommittee will include volunteers from the NAC.
• Dr. Selker asked for a description of links to AHRQ funding for the systematic reviews and Michigan programs (the final presentations). Such support should be facilitated.
• Dr. Montori emphasized the issue of combining patient-centered care and multiple morbidities. The Agency could lead in developing collaborations.
• Dr. Gelzer emphasized the integration of issues of physical health and behavior.
• Dr. Johnson encouraged followup on the issue of social determinants of health.
• Dr. Atkins noted that much research targets high-risk groups. How are they defined? He also raised the issue of patient activation. What is the correlation between patient activation and health care costs?
• Ms. Rexford raised the issue of patient engagement in general. We need longer term studies, and we need to know long-term effects.
• Dr. Haley raised the issue of transferring new information to medical students. How do we incorporate such information?
• Dr. McElwee reminded the group of issues that were raised at the conclusion of the last NAC meeting.

Return to Contents

Adjournment

Dr. Siegel stated that the next NAC meeting will take place July 26, 2013. He thanked the NAC members, invited speakers, and guests and adjourned the meeting at 3:15 p.m.

Return to Contents