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Read Brad Gray's original paper, and related perspectives
by Jack Wennberg, and Clifton R. Gaus.

P E R S P E C T I V E : A H C P R
W E B  E X C L U S I V E   

25 June 2003  
  

Back To The Future

AHRQ’s current director provides an overview of the agency’s accomplishments
and challenges in “interesting times” for health services research.


by Carolyn M. Clancy

ABSTRACT:

The paper by Brad Gray and colleagues summarizes a decade of challenge, growth, and evolution within what is now called the Agency for Healthcare Research and Quality (AHRQ) and the field of health services research, and it gives new depth to the old saying, “May you live in interesting times.” Their assessment of the significance of the agency’s reauthorization and description of continued challenges for AHRQ and the field are insightful. This commentary focuses on continued maturation of AHRQ’s mission and focus, recent achievements, new external factors, and emerging policy dilemmas that AHRQ is uniquely poised to address.

The creation of AHCPR (the Agency for Health Care Policy and Research), now called AHRQ (the Agency for Healthcare Research and Quality), signaled policymakers’ emerging awareness of two related themes. The first, growing evidence of health care costs without obvious benefit, reflected policymakers’ increasing interest in understanding the return on investment for health care services. The second, impatience with the translation of research into tangible improvements in health care delivery, foreshadowed current frustration with the sometimes glacial pace with which investments in research are incorporated into practice and policy. Our experience with large outcomes research projects and facilitating clinical practice guidelines highlights several lessons: the need to involve the intended users of research from the outset; the need to link research on what works in health care with research on strategies for effective implementation; and the importance of AHRQ’s avoiding even the appearance of a regulatory role. It is now eminently clear that the agency must focus on both the production and synthesis of evidence as well as strategies to assure its use.

Risky Business?

Biomedical research and health services research share a common foundation in scientific rigor, supported by a peer review system that draws upon the best and brightest in the field. But they address very different portions of the research continuum, and, as Brad Gray and colleagues make clear, health services research is on the riskier end of that continuum. From bench science to clinical trials, investments in the National Institutes of Health (NIH) expand possibilities for the prevention, diagnosis, and treatment of disease, leading to the introduction of new drugs, devices, and procedures. By contrast, AHRQ uses clinical research to determine which patients benefit most from an intervention and whether the benefits warrant the additional cost. AHRQ’s delivery system research identifies how to most effectively apply biomedical knowledge to patient care in typical practice settings. In combination, this research capacity is unique and critical for ensuring value for our health care dollar. But as Gray and colleagues’ case study demonstrates, the findings can easily collide with the interests of those vested in existing patterns of care. As the nation’s investments in biomedical research continue to yield a greatly expanded array of diagnostic and therapeutic options, the relevance of AHRQ’s unique contributions to both public policy and private-sector decisionmakers can only increase. The Institute of Medicine’s (IOM’s) Clinical Research Roundtable, a forum for stakeholders to assess the relevance of the clinical research enterprise (broadly defined), reached a similar conclusion. As Donald Berwick recently noted, “Invention is hard, but implementation is much more difficult.”¹

The good news is that both AHRQ and the field of health services research (HSR) have continued to evolve. Upon receiving the prestigious Baxter Prize for sustained accomplishments in HSR in 1995, Stephen Shortell noted that the dominant logics of health care were shifting—from a focus on physical assets to knowledge assets and relationship management, from a focus on costs to quality and value—and that HSR was making a transition from describing problems to developing evidence-based options for addressing them.²

Addressing Health Care’s Challenges

A new program of research focused on assuring that Americans receive health care that is reliably safe is a clear example of AHRQ’s continued evolution. AHRQ’s investments in patient safety maintain an overarching focus on the systems in which health care is delivered and include support for centers of excellence, evaluation of new applications of information technology, new knowledge regarding the organization and work processes that facilitate the best efforts of health care professionals, and assessment of unintended harms attributable to therapeutic and diagnostic interventions. In addition, AHRQ is leading efforts to simplify adverse-event reporting and is developing evidence-based information for the public and all stakeholders to promote improvements even as current research continues. The relevance of the research is tested by involving our customers— from individual consumers to health plans, hospitals, purchasers, and federal partners—at all stages of the research cycle.

Similar to current and prior efforts to improve the quality of health care, AHRQ continues to develop evidence-based information and tools that are broadly applicable while developing new approaches to effective partnerships with those who will champion local implementation. Continued public support for evidence-based information to improve health care requires ensuring that HSR focuses on the most important issues facing those who purchase, provide, or receive services, as well as new strategies for accelerating the ongoing incorporation of evidence into policy and practice.

Since the mid-1990s the products of AHRQ’s data development have been released to researchers in an unprecedented short time frame, and Web-based applications have greatly simplified routine data queries. Clif Gaus (AHCPR administrator, 1994–1997) initiated a new model of research to develop and implement the Consumer Assessment of Health Plans (CAHPS), an enhanced approach to assessing consumers’ perceptions of care, by insisting that researchers collaborate in new ways and that their work is continuously informed by user input. John Eisenberg (AHCPR administrator, 1997–1999, and AHRQ director, 1999–2002) launched two new research networks, comprising integrated delivery systems and primary care practitioners, as a new type of “laboratory” to implement evidence-based improvements.

Building on this legacy, AHRQ has continued to evolve through closer working relationships with the Centers for Medicare and Medicaid Services (CMS) and community health centers. AHRQ and the CMS have recently collaborated on developing and implementing improvements in care provided in hospitals, nursing homes, and patients’ homes. Two research teams are now evaluating the components of efforts to improve quality and reduce disparities in care for those served by community health centers, with a clear focus on rapid export of lessons learned to newly established centers. In addition, a recent initiative intended to accelerate implementation yielded Partners for Quality, a series of grants awarded to a diverse group of health care professional, accreditation, purchasing, and community-based organizations to challenge prior expectations regarding the speed with which evidence- based improvements can occur.

In today’s policy environment, where all government programs are being more critically assessed, translation of research findings into improved patient outcomes has become a core part of AHRQ’s culture. As the nation struggles with rising costs, growing demands for evidence of quality and safety, and continued debates regarding the policies likely to yield the greatest improvements in health and health care, the need for a vigorous HSR enterprise is clear. A clear and continuous focus on the needs of its customers, close partnerships with those who direct or benefit from the products of health care, and health care’s ongoing transformation in the Information Age will assure both relevance and vitality for AHRQ in the coming years.

NOTES

1. D.M. Berwick, “Disseminating Innovations in Health Care,” Journal of the American Medical Association 289, no. 15 (2003): 1969–1975.
2. S.M. Shortell, “The Baxter Foundation Prize Address,” Journal of Health Administration Education 14, no. 3 (1996): 345–354.

Carolyn Clancy is the director of the Agency for Healthcare Research and Quality (AHRQ), in Rockville, Maryland. Health Affairs invited her response to the paper by Brad Gray and colleagues, which accompanies the Perspective on the Health Affairs Web site.

Read Brad Gray's original paper, and related perspectives by Jack Wennberg, and Clifton R. Gaus.

©2003 Project HOPE–The People-to-People Health Foundation, Inc.