Meeting Minutes, November 7, 2014

Contents

Summary
Call to Order and Approval of July 25, 2014, Meeting Summary
Director's Update
Update on AHRQ's Efforts to Make Health Care Safer
Reducing Health Care Disparities
Update on the Quality and Disparities Reports
Public Comment
Chairman's Wrap-Up and Final Thoughts
Adjournment

Summary

NAC Members Present

Bruce Siegel, M.D., M.P.H., Essential Hospitals Institute (NAC Chair)
Gregory Baker, R.Ph., Take Care Employer Solutions Group
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health (by phone)
Francis J. Crosson, M.D., American Medical Association
Jane Durney Crowley, Catholic Health Partners
Shari Davidson, National Business Group on Health
Mary Fermazin, M.D., M.P.A., Health Services Advisory Group, Inc.
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Caritas Family of Companies
Ann L. Hendrich, Ph.D., R.N., FAAN, Ascension Health (by phone)
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
Henry H. Ng, M.D., M.P.H., FAAP, FACP, MetroHealth Medical Center
Jean Rexford, Connecticut Center for Patient Safety
Harry P. Selker, M.D., M.S.P.H., Tufts Medical Center
Paul E. Sherman, M.D., M.H.A., CPE, FAAP, Group Health Physicians
Jed Weissberg, M.D., Kaiser Permanente

Alternates Present

Robert W. O'Brien, Ph.D., U.S. Department of Veterans Affairs (for David Atkins)
Shari M. Ling, M.D., Centers for Medicare & Medicaid Services (CMS) (for Patrick Conway)
Charles J. Rothwell, M.S., M.B.A., National Center for Health Statistics, Centers for Disease Control and Prevention

AHRQ Staff Members Present

Richard Kronick, Ph.D., Director
Sharon Arnold, Ph.D., Deputy Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator

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Call to Order and Approval of July 25, 2014, 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 8:30 a.m. and welcomed the NAC members, invited speakers, visitors, and viewers of the Webcast. He noted that seven members would be rotating off the council following this meeting: Jane Durney Crowley; Michael P. Johnson, P.T., Ph.D., OCS; Newell E. McElwee III, Pharm.D., M.S.P.H.; Henry H. Ng, M.D., M.P.H., FAAP, FACP; David F. Penson, M.D., M.P.H.; Harry P. Selker, M.D., M.S.P.H.; and himself. He asked the NAC members to introduce themselves.

Dr. Siegel referred to the draft minutes of the previous NAC meeting and asked for changes and approval. The NAC members unanimously approved the July 25, 2014, meeting minutes.

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Director's Update

Richard Kronick, Ph.D., AHRQ Director

General Updates

Dr. Kronick welcomed the NAC members, speakers, and other attendees and viewers. He noted the following transitions for NAC members and AHRQ personnel:

• Gregory Baker, R.Ph., has become Vice President, Pharmacy, at Take Care Employer Solutions Group.
• Leon L. Haley, M.D., M.H.S.A., CPE, FACEP, has become the Emory University School of Medicine Executive Associate Dean of Clinical Services for Grady Health System and Chief Medical Officer of the Emory Medical Care Foundation.
• Henry H. Ng, M.D., M.P.H., FAAP, FACP, has become Interim Center Director, Internal Medicine and Pediatrics, MetroHealth Medical Center and President, GLMA: Health Professionals Advancing LGBT Equality.
• Irene Fraser, Ph.D., Director of AHRQ's Center for Delivery, Organization, and Markets, announced that she will be retiring. She has been with AHRQ since 1995. Her work has included the creation and management of the Healthcare Cost and Utilization Project and the development of quality indicators.
• Richard Ricciardi, Ph.D., N.P., was appointed AHRQ's new Senior Nursing Advisor in the Center for Evidence and Practice Improvement. He will serve as a liaison between AHRQ and nursing groups.

AHRQ Budget

Dr. Kronick reported that AHRQ is operating under a continuing resolution that extends to December 11, 2014. This features (on an annual basis) $371 million in appropriated funds and $105.6 million from the Patient-Centered Outcomes Research (PCOR) Trust Fund, about $45.9 million in support grants for investigator-initiated research, about $32.8 million in support grants for patient safety, and about $32.8 million in support grants for prevention and care management. Of the PCOR Trust Fund contribution, about $65.7 million is directed to grants.

Dr. Kronick reported on the following recent AHRQ-supported activities, research, and publications:

• Data in AHRQ's 2013 State Snapshots of health care quality indicators revealed that no States performed well or poorly on all quality measures. As always, the data pointed to areas within States that need improvement.
• An AHRQ-supported study published in the September New England Journal of Medicine found that the broader use of ultrasound may be as effective as computed tomography scans for the initial diagnosis of kidney stones.
• AHRQ offered grants for the dissemination of PCOR to small- and medium-sized primary care practices, with a focus on the Million Hearts™ project to prevent heart attacks and strokes (through aspirin use, blood pressure and cholesterol control, and smoking cessation).
• AHRQ offered grants of up to $10.5 million per year for 5 years to support up to three Centers of Excellence on Comparative Health System Performance for the implementation of PCOR. The program will seek to understand the characteristics of high-performing systems.
• AHRQ's new Center for Evidence and Practice Improvement moved forward, naming directors for its operating divisions. The divisions developed mission statements and spending plans. AHRQ began a search for the center director.
• The U.S. Preventive Services Task Force released five final recommendations on the following topics: behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors, behavioral counseling to prevent sexually transmitted infections, low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia, screening for chlamydia, and screening for gonorrhea. The Task Force is currently reviewing the evidence on breast cancer screening.
• AHRQ recently initiated its Director's Lecture Series, featuring speaker David Cella, Ph.D., Chair of the National Institutes of Health Patient Reported Outcomes Measurement Information System. Dr. Cella's talk will eventually be placed on the AHRQ Web site.
• AHRQ released the “2014 Consumer Assessment of Healthcare Providers and Systems Health Plan Survey Chartbook,” featuring responses by enrollees about recent experiences with health plan services and care. The data indicated a slow but steady improvement in most measures.
• The National Quality Strategy 2014 Annual Progress Report was published September 26, 2014. It describes communities, health systems, and organizations that have achieved improvements and notes efforts in alignment.
• The Robert Wood Johnson Foundation awarded AHRQ a $2 million grant to include a Linked Medical Organizations Survey within the Medical Expenditure Panel Survey. The new survey will provide data on provider organizational characteristics, policies, and treatment protocols relating to ambulatory care.
• AHRQ-supported research, presented in a statistical brief, revealed a further increase in U.S. hospitalizations for opioid overuse. The release presented data broken down by age groups and geographical regions.
• AHRQ is supporting the Horizon Scan Project, which will feature a process to identify and monitor targeted technologies and innovations in health care. The project will help to anticipate coverage issues.
• AHRQ's collaborative efforts in patient safety have included the Partnership for Patients program, conducted with CMS, the Centers for Disease Control and Prevention, the American Hospital Association, and others. The project will soon release data showing reductions in rates of hospital-acquired conditions.
• AHRQ's Technology Assessment Program has provided evidence to inform CMS coverage decisions and questions about policy. Current topics include catheter ablation for atrial fibrillation and the effectiveness of hyaluronic acid in the treatment of severe degenerative joint disease of the knee.
• A U.S. Department of Health and Human Services (HHS) initiative in delivery system reform seeks to find new ways to coordinate and integrate care, engage patients in decisionmaking, and support prevention in communities. AHRQ will support the initiative, focusing on improving information for clinicians and patients and measuring performance.
• The National Business Group on Health has developed 11 purchaser guides based on AHRQ comparative effectiveness reviews. AHRQ works with the Group's national committee to identify relevant systematic reviews to translate into employer guides.
• AHRQ will cosponsor the seventh Annual Conference on the Science of Dissemination and Implementation, with the theme “Transforming Health Systems to Optimize Individual and Population Health.” It will be held December 8–9, 2014, in Bethesda, Maryland.
• A series of papers focused on issues in paying for value were published. AHRQ will convene a meeting of authors to provide feedback and identify research gaps.
• In its role of disseminating findings in PCOR, AHRQ has supported various topic reviews by Evidence-based Practice Centers.
• Working with leadership at the Patient-Centered Outcomes Research Institute (PCORI), AHRQ is managing a $20 million project centered at Duke University to create a registry and evaluate effectiveness of treatment options for uterine fibroids. AHRQ is also offering a series of grants for training and career development of researchers in PCOR.

Legislative Trends

Jim Esquea, Assistant Secretary for Legislation, HHS, spoke about the recent national election results and their potential effects on the AHRQ budget. He noted that Congress would reconvene in the following week and work for 17 legislative days, ending the session on December 12. It is not known whether a new continuing budget resolution will result (either short- or long-term). Appropriation bills are being written. Topics to be addressed during the session include the Ebola virus crisis, tax issues, a defense authorization bill, and presidential nominations. The January 2015 session could see yet another vote to repeal the Affordable Care Act. Mr. Esquea suggested that the new era of divided government could lead to large legislative strides, which has happened in the past.

Discussion

Andrea Gelzer, M.D., M.S., FACP, raised the issue of differences between AHRQ's and PCORI's work in comparative effectiveness research. Dr. Kronick noted that PCORI began with broad funding announcements but has recently moved toward targeted approaches. Dr. Selker suggested that AHRQ support a focus on innovative work—such as research on the off-label use of drugs—that PCORI does not address.

Dr. Kronick emphasized that AHRQ's main purpose is dissemination, as in supporting the work of the Evidence-based Practice Centers and working with organizations to develop guidelines. Sharon Arnold, Ph.D., added that AHRQ can work with payers to provide evidence that supports changes in the health care delivery system. Jean Rexford called for more research on how care is delivered and where it is delivered. Dr. Kronick noted that the AHRQ portfolio features a large component devoted to care management. He added that PCORI at times collaborates in AHRQ's dissemination efforts.

Carol Matyka, M.A., encouraged AHRQ to develop different messages for different audiences in its dissemination efforts. Dr. Kronick stated that PCORI is open to public input and its board of directors is publicly available.

Dr. Johnson stressed that, for the issue of patient engagement, we should consider both patient and provider engagement and the importance of social science research (which examines habits and behaviors). Dr. Kronick suggested that these issues might be outside the scope of AHRQ's focus on dissemination and implementation.

Paul E. Sherman, M.D., M.H.A., CPE, FAAP, encouraged AHRQ, in considering PCOR, to look at where improved care has occurred. Dr. McElwee, in referring to the Horizon Scan Project, encouraged AHRQ to consider it as one step in a much larger project involving, for example, technology assessment.

Ms. Crowley referred to the issues of rating systems, tools, and health system performance, noting that science does not always resonate with the public, a fact that AHRQ should consider. Dr. Kronick added that we need to define health systems. Shari M. Ling, M.D., stated that we need measures for specific provider types. Dr. Selker proposed that AHRQ consider the quality of the metrics for quality. How do we define value?

Dr. Johnson stressed that we cannot assume that providers will act on data. He called for studies and reports on how providers do what they do. Dr. Kronick added that patient narratives are important, suggesting aspects that might be addressed. Dr. Johnson noted that sharing patient experiences with providers has the effect of putting positive pressure on providers.

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Update on AHRQ's Efforts to Make Health Care Safer

Jeffrey Brady, M.D., M.P.H., Center for Quality Improvement and Patient Safety (CQuIPS), AHRQ

Dr. Brady reviewed AHRQ's efforts in the area of health care safety. He stated that AHRQ seeks to:

• Produce and use evidence to make health care safer.
• Promote improvement in health care delivery.
• Support local solutions and national goals.

AHRQ's primary safety programs are CQuIPS, general patient safety, healthcare–associated infections, and Patient Safety Organizations (PSOs). The CQuIPS program is mentioned in the Affordable Care Act. Producing evidence to make health care safer is an agency priority.

Dr. Brady stressed that AHRQ's programs address a continuum spanning research, testing/demonstration, and implementation. He cited the examples of two major programs that have made strong impacts—CUSP and TeamSTEPPS. The former has been implemented in more than 1,000 hospitals, helping to reduce the number of central line–associated bloodstream infections. The latter has been implemented to train health care professionals in more than 1,500 hospitals.

Dr. Brady noted that the President's 2015 budget request features $72.6 million for patient safety research. AHRQ will serve to focus on primary care and nursing homes, developing evidence about risks, hazards, and prevention strategies; piloting and evaluating strategies; and providing data and measures to track success.

Other work includes developing guides for preventing falls, preventing pressure ulcers, and responding to venous thromboembolism. A safety program for perinatal care builds upon the CUSP and TeamSTEPPS programs and features the implementation of safety bundles in clinics. An adverse drug event program was just launched. It will engage leaders to implement evidence-based guidelines and adopt strategies and specific actions. Areas of focus include anticoagulants, diabetes agents, and opioids.

Dr. Brady referred to the Partnership for Patients public/private initiative, which seeks to reduce the number of hospital patients who acquire preventable conditions. AHRQ has been developing a communication and resolution program toolkit, which features adverse event reporting and issues of communication and disclosure. Dr. Brady described AHRQ's healthcare–associated infections program, which involves research and the implementation of proven methods for prevention. It works to implement the CUSP strategy in a variety of circumstances. Dr. Brady also described AHRQ's programs to address antimicrobial-resistant bacteria.

The Patient Safety and Quality Improvement Act of 2005 authorized the creation of PSOs. Today there are 84 active PSOs in 31 States. Dr. Brady profiled the PSOs by type of business and clinical specialty. He noted that the Affordable Care Act mandates that hospitals institute a patient safety evaluation system, working with a PSO, as part of a qualified health plan participating in a health insurance exchange.

Discussion

In response to a question, Dr. Brady stated that it is difficult to attribute improvements in healthcare–associated infections to the Partnership for Patients initiative. Jed Weissberg, M.D., asked about statutory protections and challenges regarding PSO data. Challenges have occurred, and PSOs have successfully protected their data. Dr. Weissberg noted that efforts to improve diagnostic performance will rely on health information technologies.

Ms. Crowley stated the need to do even better in reducing healthcare–associated conditions. Dr. Brady suggested that capacity is a large part of the problem (for example, the time involved). Ms. Crowley suggested that 50 percent of harms are associated with frailty. Robert W. O'Brien, Ph.D., proposed the leveraging of funds, such as partnering with the U.S. Department of Veterans Affairs. Dr. Selker called for the investigation of levers in the area of malpractice that could help to promote a reduction in healthcare–associated conditions.

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Reducing Health Care Disparities

Rashida Dorsey, Ph.D., M.P.H., Office of Minority Health (OMH), HHS

Dr. Dorsey reported on efforts by HHS to address health care disparities. OMH was created in 1986 and is dedicated to improving the health of racial and ethnic minority populations through the development of health policies and programs that eliminate health disparities. The Office was reauthorized by the Affordable Care Act of 2010. It supports the development and implementation of the provisions of the Act that address disparities and equity. It also leads the implementation of the HHS action plan to reduce racial and ethnic health disparities and coordinates a national partnership for action to end health disparities and a national stakeholder strategy for achieving health equity.

The Affordable Care Act cites the following goals:

• To end insurance discrimination.
• To make health insurance more affordable.
• To make preventive services more affordable and accessible.
• To increase the number of health care providers in underserved communities.
• To enhance the diversity and cultural competency of the workforce.
• To enhance health disparities research.
• To improve data collection and reporting standards.
• To strengthen the HHS minority health infrastructure.

HHS published an Action Plan to Reduce Racial and Ethnic Health Disparities, which features, as one priority, assessing and heightening the impact of all HHS policies, programs, processes, and resource decisions to reduce health disparities. Grant applicants, where applicable, are required to submit health disparity impact statements as part of their applications.

As part of the goal of strengthening the Nation's health and human services infrastructure and workforce, HHS employs the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare (CLAS). OMH supports the publication, promotion, and evaluation of enhanced national CLAS standards. In 2015, two new questions about awareness of the CLAS standards will be added to the National Ambulatory Care Medical Survey.

Dr. Dorsey stressed two additional goals for the Office—increasing the availability and quality of collected data on racial and ethnic minorities (mandated by the Affordable Care Act) and supporting research to inform initiatives for the reduction of disparities. She noted that AHRQ's PCOR grant portfolio can fund research to identify strategies to reduce racial and ethnic disparities. AHRQ itself has an Office of Minority Health.

Discussion

In response to a question, Dr. Dorsey stated that OMH will work with HHS partners and communicate with organizations to assess the adoption of CLAS standards. Dr. Ng noted the intersections that occur in the large realm of minority status and disparities, and he encouraged the collection and distribution of data on not only sexual orientation but also gender identity. Dr. Dorsey agreed but noted that OMH is not a data collection agency. It can only report data from other agencies. Charles Rothwell cautioned that such data collection is an evolving science, as society changes.

Ms. Matyka raised the issue of increasing the participation of minorities in clinical trials to strengthen evidence. Dr. Dorsey responded that OMH has discussed that issue with the U.S. Food and Drug Administration. It has also discussed issues in adverse event reporting. Francis J. Crosson, M.D., encouraged OMH to consider disparities of process. Dr. Siegel noted that the Affordable Care Act is an income redistribution vehicle and, as such, may be a powerful force for health change.

Mary Fermazin, M.D., M.P.A., raised the issue of risk adjustment in outcome measures. She wondered whether any research has examined the effects of adjusting for (or not adjusting for) class issues. What is the proper way to adjust risk when dealing with disparities? Would transparency help? Perhaps disparity rates could be considered in stratification. Dr. Kronick stated that AHRQ is doing some work in this area.

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Update on the Quality and Disparities Reports

Ernest Moy, M.D., M.P.H., CQuIPS, AHRQ

Dr. Moy described the genesis and productions of the "National Quality Report" and "National Disparities Report." The reports were mandated by Congress's 1999 Healthcare Research and Quality Act, and the first reports were released in 2003. The reports were to provide “national trends in the quality of health care provided to the American people” and "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations." AHRQ has assembled the reports based on input from the HHS National Quality Strategy, the HHS Disparities Action Plan, an HHS interagency workgroup, the NAC, and AHRQ centers.

Dr. Moy presented highlights of the 2013 reports and described a planned redesign for 2014. A goal of the redesign is to make the reports more useful and actionable. For the 2014 release, a brief summary for policymakers will feature key stories and data summaries. It will combine the quality and disparities elements yet remain only about 20 pages in length. A larger version featuring integrated statistical documents will combine the quality and disparities elements, linking them to the National Quality Strategy priorities, and will be available on the Web only (http://nhqrnet.ahrq.gov/inhqrdr).

The revised format will continue to feature the State Snapshots, with some changes. Dr. Moy presented visuals of the State Snapshots and other graphical presentations that will be featured. He encouraged the NAC members to offer suggestions for priority population products that the 2014 report might offer.

Dr. Moy summarized the content/changes within the 2014 Quality Report/Disparities Report as follows:

• There will be a combined highlights report for policymakers of about 20 pages, with a focus on some key stories and a summary of data.
• There will be a larger online statistical document providing findings for both quality and disparities relating to each of the National Quality Strategy priorities, to which data on access and priority populations will be added. It will possibly feature a chartbook format, with graphs placed above bulleted points.
• These items will be part of an integrated Web site, which will be refined on a continual basis.

Discussion

NAC members encouraged the report writers to be clear in their descriptions of the States that fail to achieve benchmarks (as in the State Snapshots). Dr. Siegel suggested that the reports may have uses that are not recognized. Dr. Gelzer stated that her organization uses the reports as a rallying cry. She suggested that the revised reports contain some analysis and recommendations. Perhaps new data sources could be used, providing greater depth and insight into the issues.

Dr. Crosson proposed that multiple chronic conditions be one of the priority topics. Dr. Selker added the topic of military personnel, who suffer from unique health conditions. Dr. Ling wondered whether there might be a way to indicate populations and where advances are needed. Dr. Kronick suggested that there is a need to make improvements in the measures used for disparities, allowing for better linkage of quality and disparities. Dr. Fermazin proposed that the reports provide data on communities (with more granularity), if possible. Charles J. Rothwell, M.S., M.B.A., encouraged AHRQ to communicate with the National Center for Health Statistics in developing the report.

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Public Comment

Michael Duenas, O.D., Chief Public Health Officer of the American Optometric Association, stated his opinion that the quality and disparities reports have been important tools. He cited concern about a vision disparity measure, which seemed to underestimate disparities in vision care. He suggested including a survey question such as "Has the person received an eye examination by an eye doctor, optometrist, or ophthalmologist in the past 12 months?"

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Chairman's Wrap-Up and Final Thoughts

NAC members noted changes on the horizon for the Medicare and Medicaid programs—for example, the Medicaid Primary Care bump will expire soon. Dr. Kronick thanked the retiring NAC members for their input through the years, and he presented Dr. Siegel with a gift in appreciation of his years of service as NAC chair. He encouraged the NAC members to consider questions that need to be answered, to consider applicants for Dr. Fraser's position, to suggest new potential collaborations, and to encourage applications for a new R01 grant program focused on health care affordability and accessibility.

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Adjournment

Dr. Siegel stated that the next NAC meeting will take place on March 27, 2015. He thanked the NAC members and other participants and adjourned the meeting.

Respectfully submitted,

Elizabeth A. McGlynn, Ph.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality

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