Meeting Minutes, November 2020
(Virtual Meeting)
Contents
Summary
Call to Order and Approval of July 14, 2020, Meeting Summary
Overview and Recent AHRQ Accomplishments
AHRQ COVID-19 Update
Quality Measurement Enterprise Discussion
Feedback on the Strategic Plan for the PCOR Trust Fund
Public Comment
Chairman's Wrap-Up and NAC Input
Adjournment
Summary
NAC Members Present
Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Stanford University School of Medicine (NAC Chair)
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, University of Missouri
Karen S. Amstutz, M.D., M.B.A., FAAP, Indiana University Health
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital
Melinda B. Buntin, Ph.D., Vanderbilt University School of Medicine
Gretchen M. Dahlen, M.H.S.A., FACHE, Consumer Health Ratings
Beth Ann Daugherty, M.P.H., R.N.,Sparrow Clinton Hospital
Susan Edgman-Levitan, P.A., Massachusetts General Hospital
Peter J. Embi, M.D., M.S., FACP, FACMI, Regenstrief Institute
Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., FAAN, MedStar Health
Charles N. Kahn, III M.P.H., Federation of American Hospitals
Omar Lateef, D.O., Rush University Medical Center
Andrew L. Masica, M.D., M.S.C.I., Baylor Scott & White Health
Ramanathan Raju, M.D., M.B.A., CPE, FRCS, FACS, FACHE, Northwell Health
Edmondo J. Robinson, M.D., M.B.A., M.S., Christiana Care-Wilmington
Patrick S. Romano, M.D., M.P.H., University of California, Davis
Yanling Yu, Ph.D., Washington Advocates for Patient Safety
Ex Officio Members and Alternates Present
Ileana Arias,Ph.D., Centers for Disease Control and Prevention (for Chesley Richards)
David Atkins, M.D., M.P.H., Veterans Health Administration
Michael Lauer, M.D., National Institutes of Health
Shari M. Ling, M.D., Centers for Medicare & Medicaid Services
AHRQ Staff Members Present
David Meyers, M.D., FAAFP, Deputy Director and Chief Physician
Francis D. Chesley, Jr., M.D., Director, OEREP, and Director, Office of Minority Health
Lucie M. Levine, Chief Financial Officer
Therese Miller, Dr.P.H., Deputy Director, Center for Evidence and Practice Improvement
Kamila Mistry, Ph.D., M.P.H., Associate Director, OEREP
Mamatha Pancholi, M.S., Chief Data Officer and Senior Advisor
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of July 14, 2020, Meeting Summary
Tina Hernandez-Boussard, Ph.D., M.P.H., M.S., Stanford University School of Medicine and Chair of the National Advisory Council (NAC)
Dr. Hernandez-Boussard called the meeting to order at 10:00 a.m., welcoming the NAC members and other speakers, participants, and viewers. She noted that the meeting was being recorded and will be made available on the AHRQ website. She encouraged the NAC members to use Zoom technology to indicate that they have questions or comments during the meeting, and she encouraged non-NAC members to email any public comments.
Dr. Hernandez-Boussard noted that Chesley Richards, M.D., M.P.H., the ex officio NAC member from the Centers for Disease Control and Prevention (CDC), retired in October. His replacement is Ileana Arias, Ph.D., Associate Deputy Director for Public Health Science and Surveillance at the CDC. Dr. Hernandez-Boussard reported that, following this meeting, the following members would be rotating off the NAC: Karen Amstutz, M.D., M.B.A., Cathy J. Bradley, Ph.D., M.P.A., Beth Ann Daugherty, M.P.H., R.N., Charles N. Kahn III, M.P.H., Andrew L. Masica, M.D., M.S.C.I., and Dr. Hernandez-Boussard herself.
Dr. Hernandez-Boussard referred to the draft minutes of the previous NAC meeting (July 14, 2020) and asked for changes and approval. The NAC members voted unanimously to approve the July meeting minutes with no changes.
Overview and Recent AHRQ Accomplishments
Words From Director Khanna
David Meyers, M.D., FAAFP, Deputy Director and Chief Physician, AHRQ
Dr. Meyers announced that AHRQ Director Gopal Khanna, M.B.A., could not join the meeting. Dr. Meyers shared the following introductory remarks from Director Khanna:
Good morning. Thank you to all NAC members and to the AHRQ staff in attendance. It is once again my honor and privilege to welcome you to the NAC meeting. As most of you can imagine, today’s meeting is extremely important, not only because it is the last of the year, but also because it comes as the United States heads into a winter with new record highs for COVID-19 cases. It also comes as AHRQ prepares to address upcoming transition issues, which I will support. Our staff has worked tirelessly during the past few weeks to put together a transition package for the U.S. Department of Health and Human Services (HHS) that demonstrates the tremendous value that AHRQ brings to the HHS family, especially through our work to address the COVID-19 pandemic. We have had great success contributing to Secretary Alex Azar’s whole-of-government COVID-19 effort, in large part due to the coronavirus strike team and rapid response team here at AHRQ. Through those two efforts, we have provided analysis and expertise to the Department within response activities. We launched the National Nursing Home COVID-19 Action Network [see below].
Thank you to the NAC members who are rotating off the council. Thank you especially, Tina, for what you have done to raise the profile of the NAC and to carry the message of our 21st Century Care Initiative. Your leadership has set a new standard for NAC member involvement. Some of you may note that Tina recently began co-authoring a forthcoming blog on telehealth safety and quality with Edmondo J. Robinson, M.D., M.B.A., M.S., Peter J. Embi, M.D., M.S., FACP, FACMI, and Karen S. Amstutz, M.D., M.B.A., FAAP. We are extremely grateful for this new type of participation by NAC members, as blogs become a regular forum. If any of you are interested in contributing to this AHRQ blog, please contact Jaime Zimmerman, M.P.H., PMP. One of the reasons I am so proud to have Tina and the others co-authoring the blog is that, to me, it represents a paradigm shift at AHRQ. Since becoming Director of AHRQ in 2017, I have made it a goal to change the way we communicate and think—toward better understanding the needs of stakeholders and the perspective of health system leaders.
We have so much to offer in the name of healthcare safety, quality, and value, and I firmly believe that changing the way we communicate our work will increase our impact significantly. This belief is one of the driving forces of my focus on AHRQ’s 21st Century Care Initiative. At its core, the initiative is a rallying cry for experts and researchers to come together under a central theme of dramatically improving the quality, safety, and value of healthcare services in the United States. You have heard me talk about 21st century care in the past, and your feedback has helped to shape our thinking. I have said that we need to take a step back and think differently about our work and about health services research as a whole. As I have said, cure and care are two sides of a coin. Two years ago, Congress’s 21st Century Cures Act was instituted to bring us to 21st century medicine. At the end of the day, 21st century care must take the best and brightest ideas from experts, front-line clinicians, and industry leaders and translate the ideas into research, evidence, best practices, and rapid-cycle, easily implemented, scalable, effective work. Each of you has a role to play in making this a reality. I hope today to solidify a commitment from each of you to help carry the message moving forward.
COVID-19 has brought healthcare quality in the United States into the spotlight and is fundamentally changing the way in which healthcare will be delivered in the future. We must be forward-thinking in our approach, must anticipate emerging needs, and must act. As we think about 21st century care, I urge you to be expansive in imagining what AHRQ can do as we address the issues that emerge regarding COVID-19. Thank you for your hard work and commitment. Let’s make this NAC meeting one of the best.
AHRQ Budget
Lucie M. Levine, Chief Financial Officer, AHRQ
Ms. Levine provided a brief update on the agency’s budget. The House Appropriations Subcommittee on Labor recommended a FY 2021 AHRQ budget of $343 million. That is an increase of $5 million over the previous year and an increase of $86 million over the President’s proposed budget. The Senate Appropriations Subcommittee has not yet made its recommendation. AHRQ is operating under a continuing resolution through December 11 (based on last year’s funding). It is possible that the Congress will pass a large omnibus bill to prevent a shutdown beginning December 11.
[Note: Later in this meeting Ms. Levine reported that the Senate subcommittee just released new information. It agreed that AHRQ should remain an independent agency rather than become an institute within the NIH. The Senate markup has agreed with the President’s proposed budget for AHRQ of $256.7 million. The Senate and House will come together subsequently to agree on a final budget for AHRQ in the omnibus bill.]
Recent AHRQ Accomplishments
David Meyers, M.D., FAAFP, Deputy Director and Chief Physician, AHRQ
Dr. Meyers presented a sampling of recent AHRQ accomplishments in four areas: health systems research, practice improvement, data/analytics, and operational excellence.
Health Systems Research
- The agency published the AHRQ Digital Healthcare Research 2019 Year in Review, describing its funded research and highlighting its significance and impact on improving care. It includes comments by the researchers regarding the impacts of their funded studies. It spotlights how AHRQ’s research initiatives in clinical decision support and patient-reported outcomes provide real-world demonstrations of interoperability, showing what is feasible and challenges that remain.
- In August, the agency awarded three, 3-year implementation grants to test models for improving the management of pain, opioids, and opioid use disorder in older adults. The first award is to create and implement a toolkit using academic detailing and practice facilitation in rural and tribal Oklahoma. The second award is to focus on the use of electronic health records and data relating to quality improvement to optimize prescribing, reduce adverse events, and manage opioid use disorder in rural Michigan and Ohio. The third award is to focus on patient-centered clinical decision support and shared decision making by using a toolkit to improve clinical outcomes for vulnerable older adults in Chicago.
- In September, the agency released Safer Together: A National Action Plan To Advance Patient Safety. The document collects insights from leading organizations that compose the National Steering Committee for Patient Safety. It provides directions for making advances toward safer care and reduced harm across the continuum of care. It offers background to support the creation of a future agenda.
Practice Improvement
- The AHRQ Safety Program for Improving Antibiotic Use achieved a reduction in antibiotic starts in more than 400 long-term care facilities, driven by a reduction in the use of quinolone. The program adapted principles of the Comprehensive Unit-Based Safety Program (CUSP). Those included engaging bedside clinicians to use the Four Moments of Antibiotic Decision Making. An educational toolkit for long-term care facilities will be released in 2021.
- The agency released an issue brief, Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis. It defines telediagnosis and describes how visits can support safe and effective care. It lists challenges and research needs.
Data/Analytics
- AHRQ’s Healthcare Cost and Utilization Project (HCUP) produced a statistical brief on State rates of emergency department visits related to suicidal ideation or attempt in 2017.
- HCUP data were used in a study of the numbers and types of emergency department visits by older adults during Hurricane Laura. The results can be used in a predictive manner for future events.
- The insurance component of AHRQ’s Medical Expenditure Panel Survey (MEPS) was used in a new chartbook to show trends in private insurance premiums from 2006 to 2019 (for enrolled employees).
- Data from AHRQ’s National Healthcare Quality and Disparities Report were used in “Data Spotlights” on the issues of courtesy and respect by home health providers and opioid-related deaths among Blacks.
Operational Excellence
- The agency’s social media messaging continued to expand, providing a wide range of content through Twitter, Facebook, and LinkedIn. The numbers of followers rose to 69,000 (Twitter), 16,500 (Facebook), and 86,000 (LinkedIn).
Discussion
Dr. Robinson asked whether the MEPS historical chartbook data regarding insurance premiums were adjusted for inflation. Dr. Meyers responded that they were not adjusted for inflation.
Yanling Yu, Ph.D., referred to the National Healthcare Quality and Disparities Report “Data Spotlights,” which looks at differences among ethnic groups regarding experienced courtesy and respect. She asked whether factors such as language or culture had been determined. Dr. Meyers responded that the reports include references to tools for determining such factors and that AHRQ’s Office on Priority Populations will be studying such. Susan Edgman-Levitan, PA, noted that home health has met large challenges during the COVID-19 pandemic, especially in light of workers coming into homes and the use of personal protective equipment.
Dr. Embi wondered about AHRQ’s role in the overall healthcare data activities of the Nation, noting that the agency has unique and important skills for working with healthcare data. Dr. Meyers noted that the environment is changing rapidly, especially with the pandemic. AHRQ must work as fast as it can and do as much as it can regarding data. It has hired Mamatha Pancholi, M.S., as its first Chief Data Officer and is beginning to look beyond MEPS and HCUP toward new programs in the future. The agency has been developing a data enterprise strategy that will include working in partnership with the private sector’s data efforts.
AHRQ COVID-19 Update
David Meyers, M.D., FAAFP, Deputy Director and Chief Physician, AHRQ, and Mamatha Pancholi, M.S., Chief Data Officer and Senior Advisor, AHRQ
Dr. Meyers stated that the primary efforts of AHRQ relating to COVID-19 are in the areas of health systems research, practice improvement, data/analytics, and new broad initiatives.
In the area of health systems research, the agency is offering COVID revision supplements, with 15 applications from existing grantees working in the field being considered for additional funding to consider aspects of COVID-19. Topics will include safety, patient-centeredness, and learning health systems. The investigators have been asked to share meaningful results within 3 months. In addition, 14 new applications for new COVID research are being considered for funding within AHRQ portfolios. Topics will include quality, safety, telehealth, and disparities. These will be 3-year grants, and the investigators have been asked to share results during the time period.
Evidence-based Practice Center (EPC) reports recently produced the following reviews:
- Masks for Prevention of COVID-19 in Community and Healthcare Settings.
- Safety and Vaccines Used for Routine Immunization in the United States.
- Resource Allocation and Pandemic Response: An Evidence Synthesis To Inform Decision-Making.
- No-Touch Modalities for Disinfecting Patient Rooms in Acute Care Settings.
- Immunity After COVID-19 Infection: Research Protocol.
In the area of practice improvement, AHRQ produced the following four patient safety-net resources (how-to guides):
- Long-Term Care and the Response to COVID-19.
- COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care.
- Coronavirus Disease 2019 (COVID-19) and Diagnostic Error.
- Technology Responses to COVID-19: Special Edition Perspective.
AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) produced two new surveys/tools:
- Clinician & Group Visit Survey 4.1 (experience with telehealth).
- CAHPS Health Plan Survey 5.1 (adapted to the use of telehealth).
In the area of data and analytics, AHRQ supported the following publications:
- “Employment and the Risk of Severe COVID-19 Among Workers and Their Household Members”, JAMA Internal Medicine (in press).
- “The Risk of Severe COVID-19 Within Households of School Employees and School- Age Children,” Health Affairs, November 2020.
- “COVID-19 and Racial/Ethnic Disparities in Health Risk, Employment, and Household Composition,” Health Affairs, September 2020.
- “Hospital Ward Adaptation During the COVID-19 Pandemic: A National Survey of Academic Medical Centers,” Journal of Hospital Medicine, August 2020.
Dr. Meyers announced two new initiatives that AHRQ will support. The first is a convening, by AHRQ’s National Primary Care Learning Community, of organizations that work directly with primary care practices to help them adapt to new methods of care delivery and to address new and ongoing needs during COVID and beyond. The second is AHRQ’s creation of the ECHO National Nursing Home COVID-19 Action Network.
AHRQ ECHO National Nursing Home COVID-19 Action Network
Dr. Meyers began a presentation describing AHRQ’s new initiative to address nursing home deaths due to COVID-19. The virus has led to the deaths of more than 60,000 nursing home residents and staff during the past year. Nursing homes have lacked personal protective equipment (PPE), access to rapid testing, and stable staffing. In response, HHS is making available $5 billion in a multipronged effort to improve nursing home COVID-19 safety. The Health Resources and Services Administration (HRSA) recently distributed $2.5 billion of that amount to 14,000 nursing homes to support testing, ensure adequate PPE, and maintain workforces.
Ms. Pancholi stated that AHRQ’s contribution to the program is the AHRQ ECHO National Nursing Home COVID-19 Action Network, established through a contract with the University of New Mexico’s ECHO Institute and with an award to the Institute for Healthcare Improvement (contracts of about $237 million with a duration of 6 months). The Network will provide training and mentorship to about 15,000 nursing homes across the country to increase the implementation of evidence-based safety practices, with the following goals:
- Preventing the virus from entering nursing homes.
- Identifying early residents and staff who have been infected.
- Preventing the spread among staff, residents, and visitors.
- Providing care to residents with mild or asymptomatic cases.
- Ensuring that staffs have knowledge, skills, and confidence to implement best-practice safety measures.
- Reducing social isolation for residents, families, and staff.
Participation in the program by nursing homes is voluntary. The Network will use the model developed within Project ECHO, an interactive, case-based approach based on adult-learning principles. It will feature weekly training sessions, lectures about best practices, and sessions that feature peer-to-peer learning, with expert consultation. The nursing homes will have a 16-week facilitated training program in groups of 25-35 people. The program will provide nursing homes with access to national and local experts in infection control, patient safety, quality improvement, and operations. There is a standard curriculum of topics for the 16 weeks. As of November 6, a total of 69 Network training centers had been established, 54 cohorts were launched, and about 1,200 people were receiving training. The recruitment of nursing homes continues. AHRQ also will be seeking to engage national stakeholders and considering the development of tools and other resources. More information can be found at https://www.ahrq.gov/nursing- home/index.html
Discussion
Dr. Hernandez-Boussard reminded any NAC members who would like to contribute content to her new blog to contact Ms. Zimmerman at AHRQ.
Asaf Bitton, M.D., M.P.H., asked about goals and outcome measures as they relate to an implementation of the ECHO Network. Ms. Pancholi responded that AHRQ is collecting feedback from the nursing homes. That will result in an understanding of whether the participants feel the program is useful. Outcome measures will be trickier. Any connection to decreases in infection rates or mortality rates will be soft. In the next few weeks, AHRQ will be trying to identify mechanisms and sources of data. We are discussing with CDC a use of the National Healthcare Safety Network data and talking with CMS to obtain additional data. We hope to get to a quantitative assessment. We are not conducting a primary data collection from nursing homes regarding infection rates and changes. Dr. Bitton urged AHRQ to consider using measures of safety culture—the agency might use them to identify dynamics among the key staffs. Ms. Pancholi added that her group is in the beginning stages of designing a project evaluation.
Ms. Edgman-Levitan asked how much funding the nursing homes receive to engage in the program and whether AHRQ had considered using the Survey of Patient Safety Culture. Ms. Pancholi responded that AHRQ compensates the nursing homes about $6,000 each. The nursing homes also can submit requests from the relief fund directly. AHRQ will be considering using its Survey of Patient Safety Culture tool for some primary data collection.
Ms. Pancholi noted that AHRQ staff used a tiered approach in seeking nursing home representation across the country and began by identifying academic institutions that had experience with the ECHO model and could be supportive. It has been important to find partners who can supply staff and to do so rapidly. Dr. Amstutz reminded the group that health plans have relationships with skilled nursing facilities and, through contacts, have provider-relations staff that could be helpful.
Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., FAAN, noted that her operation has some nursing home consortiums that are contributing and have revealed interest regarding data collection. They may be able to help AHRQ in that area.
Gretchen M. Dahlen, M.H.S.A., FACHE, noted that the issue of social isolation reduces the interest in becoming a staff member in nursing homes. How might the isolation be reduced, and
what measures can be used? Dr. Meyers responded that two of the training units focus on social isolation effects. It is hoped that the bidirectional approach to learning can cause solutions to emerge, with experiences being recalled.
David Atkins, M.D., M.P.H., stated that the VA experience with ECHO has shown that it can be a good tool, but only if providers are available to participate in the training. Has full participation been obtained? Ms. Pancholi responded that there have been challenges, yet there is enthusiasm as well. Dr. Meyers added that a couple of early pilots found participation rising in training weeks 4, 5, and 6.
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, noted his experience in finding that participants learn from each other, especially regarding telehealth. How is the program sharing the knowledge? Ms. Pancholi responded that the program is collecting lessons learned and distilling them into a form that can be disseminated. There will be a resource site. Ms. Edgman- Levitan suggested obtaining data by using Paul O’Neill’s Three Questions about workplace experience. She also suggested using the IHI open school platform to document and broadcast the sessions.
In response to a question by Dr. Yu, Dr. Meyers noted that AHRQ is attempting to enlist State programs in the Network and model.
Quality Measurement Enterprise Discussion
Mamatha Pancholi, M.S., Chief Data Officer and Senior Advisor, AHRQ, and Jaime Zimmerman, M.P.H., PMP, Senior Program Advisor and Designated Management Official, AHRQ
Ms. Pancholi began a discussion of a new quality measurement initiative by stating that, in June 2019, a Presidential executive order called for a program to empower patients to make fully informed decisions about their healthcare by facilitating the availability of appropriate and meaningful price and quality information. The order required the secretaries of HHS, U.S. Department of Defense, and U.S. Department of Veterans Affairs to establish a health quality roadmap outlining a vision for the future of a Federal healthcare quality measurement enterprise (QME).
Subsequent meetings convened by HHS brought focus on a need to evaluate and make improvements in three areas—governance, data, and measures. The Department seeks to establish coordinated governance and oversight, to modernize approaches to data collection, reporting, and sharing, and to reform how measures are used in Federal health quality programs. A resulting quality roadmap provided an approach to align Federal health quality programs that support and enhance patient health outcomes in those three areas.
Ms. Zimmerman stated that AHRQ is developing a subcommittee of the NAC to provide an analysis of AHRQ’s policies and programs relating to the QME. The subcommittee, or SNAC, will develop an integrated, cross-stakeholder, longitudinal vision for improving the QME. It will identify options for a process and an infrastructure that support the agency as it governs its own measurement development and deployment to achieve goals of a quality roadmap.
The subcommittee will identify options for a process and governance body to oversee AHRQ measure development and deployment. It will provide analysis of AHRQ’s policies and measurement programs relating to the Federal QME and make recommendations to the NAC. It will identify ways in which the agency’s governance structure could be taken to scale by HHS. The subcommittee will serve for 6 months, with an option to serve for an additional 6 months. It will report out at the spring NAC meeting.
Discussion
Dr. Robinson suggested that the subcommittee consider how CMS currently addresses quality impact reporting. Ms. Pancholi responded that a Federal group devoted to creating the roadmap has included participation by CMS and other HHS agencies. One goal of AHRQ is to determine its own role in the broader enterprise, leveraging its strengths while avoiding duplication.
Dr. Yu wondered about AHRQ’s eventual role. Will it be to develop measures, collect measures, implement measures, create a central source? Ms. Pancholi responded that AHRQ hopes that the subcommittee will consider that question and develop recommendations in light of the agency’s particular competencies.
Omar Lateef, D.O., noted that HHS convened, in the past, other groups to consider aligning measures. It might be necessary to align the groups that have addressed alignment. Perhaps the new AHRQ subcommittee could be the engine of the analytics for alignment. Ms. Pancholi responded that AHRQ has participated in those past efforts, which will inform the new initiative. Ms. Zimmerman added that there will be a report-out in the spring NAC meeting, when the NAC members will be able to comment and advise.
Dr. Hernandez-Boussard asked whether AHRQ would be embracing some of the newer measures, for example electronic quality measures. Ms. Pancholi responded that, so far, the agency’s role has been restricted to recognizing where such new measures are being used. AHRQ’s role could change in light of the ongoing discussions.
Dr. Alexander stated that the National Academies of Sciences, Engineering, and Medicine is convening a consensus panel on the quality of care in nursing homes, which will run through next year. The panel will be developing a document on the topic and conclusions.
Patrick S. Romano, M.D., M.P.H., asked whether other HHS agencies have similar advisory committees and whether they also were asked to create subcommittees. Will there be an alignment? In shifting to an HHS focus, how might other departments—DOD, VA, others—fit into the effort? Ms. Pancholi responded that those departments will be part of the HHS governance body and will play active roles. It is not known how they will proceed in their individual work, but they will bring the results to the HHS table. The actions within those other departments will fall under the rules of their authorizations. Coordination will occur using results at the department level. Issues of alignment will be considered at that final level.
Dr. Hernandez-Boussard called for a vote to form the subcommittee. The NAC members voted unanimously to form the subcommittee, or SNAC.
Feedback on the Strategic Plan for the PCOR Trust Fund
David Meyers, M.D., Deputy Director and Chief Physician, AHRQ, Francis D. Chesley, Jr., M.D., Director, Office of Extramural Research, Education, and Priority Populations, AHRQ, Therese Miller, Dr.P.H., Deputy Director, Center for Evidence and Practice Improvement, AHRQ, and Kamila Mistry, Ph.D., M.P.H., Associate Director, Office of Extramural Research, Education, and Priority Populations, AHRQ
Dr. Meyers began a session on the development of a strategic framework for AHRQ’s future investments of funds from the Patient-Centered Outcomes Research Trust Fund (PCORTF).
Patient-centered outcomes research (PCOR) compares the impact of two or more preventive, diagnostic, treatment, or healthcare delivery approaches on health outcomes. As such, it offers options to patients and providers. AHRQ was a pioneer in supporting such research beginning in the early 2000s. In 2010, Congress established, under the Affordable Care Act, the PCORTF as well as the Patient-Centered Outcomes Research Institute (PCORI). In that legislation, AHRQ was called on to fund research-evidence dissemination and training (not research itself).
Authorization was for 10 years. The PCORTF has now been reauthorized for FY2020-2029.
Dr. Chesley stressed again that AHRQ was charged with disseminating findings from PCORI- and other government-funded entities that sponsor research on comparative clinical effectiveness. It also was charged with developing a publicly available resource that collects government-funded evidence, supporting the incorporation of research findings into clinical decision support technologies, and funding the training of researchers to build capacity for comparative effectiveness research. AHRQ funded and continues to fund grants for training programs. At the K-award stage, more than 100 scholars have been trained and more than 500 manuscripts have been authored or co-authored. At the R-award stage, 24 research projects and 31 pilot studies have been supported, and thousands of participants completed courses, webinars, and workshops.
Dr. Miller stated that AHRQ has worked to ensure that PCOR findings are known, understood, and used by synthesizing research evidence and developing tools, training, and outreach. It has funded more than 80 systematic evidence reviews of PCOR findings since 2012. The agency maintains an open nomination process allowing researchers, PCOR funders, professional societies, healthcare providers, and members of the public to identify promising findings for dissemination and implementation in the clinic. Examples of resulting projects conducted or upcoming include the EvidenceNOW project for heart health, the TAKEheart project for cardiac rehabilitation, a project to reduce unhealthy alcohol use, and a project to improve nonsurgical treatment of urinary incontinence in women. AHRQ has learned and demonstrated that dissemination must be followed by active, multilevel implementation to cause change in health system practices.
AHRQ has been advancing the transfer of evidence into practice by supporting the development of clinical decision support (CDS). It has been engaging a stakeholder community, creating prototype infrastructure, and funding research. It seeks to make CDS more shareable, standards- based, and available. It developed CDS Connect, an online platform that allows CDS users to discover shared CDS, to share CDS artifacts, and to obtain tools/software. The agency recognizes a need to implement standards-based, patient-centered CDS in health IT systems and is supporting the priorities for action established by the National Academy of Medicine.
Dr. Meyers noted that, in 2017, AHRQ began planning for a possible ending to the PCORTF support. It has sought to ensure that funds for completing projects will be available, that funds for disseminating later findings will be available, and that there will be appropriate ramp-down and evaluation. However, Congress reauthorized the PCORTF to the year 2029, with the same funding formula and same charge to AHRQ. The agency will receive about $1 billion over the decade, which allows it to conduct long-term strategic planning. It is targeting goals of creating an overarching strategic framework to guide its work, of investing in infrastructure, of establishing governance, and of ensuring stakeholder engagement.
Dr. Meyers stated that the strategic framework being developed will include components of a main goal, areas of focus, sub-goals, a model of how projects are connected, and an outline for creating an evaluation process and measuring success.
Dr. Mistry described the effort to address training and dissemination/implementation in the strategic framework. For the training area, she noted that the framework will feature key inputs (evaluation findings, environmental scanning, planning with stakeholders, using the Learning Health System Learning Collaborative), a broad strategy (blending traditional and innovative models), and strategic goals (focusing on researchers and scientists, leveraging AHRQ and PCORI authorizations, filling gaps).
For the dissemination and implementation area, Dr. Miller noted that key inputs will include PCOR findings and assessments of strength of evidence. The broad strategy will include dissemination and implementation of PCOR findings in diverse clinical practices, for example, building implementation capacity for digital tools. Strategic goals will include causing healthcare delivery systems, practices, and providers to use PCOR findings in clinical practice, for example, by engaging the stakeholders.
Dr. Meyers stated that, in the 10-year period, AHRQ will be able to invest in staffing, communication support for dissemination (e.g., digital platforms), and evaluations. In light of the authorized longer time period, AHRQ will consider establishing budget allocations within the PCORTF that allow teams to conduct longer strategic planning and project development. To stimulate a discussion, Dr. Meyers presented slides that encouraged the NAC members to consider these issues: Financial allocation, infrastructure, programmatic investments, strategic framework topics, internal governance, and stakeholder engagement.
Discussion
Dr. Robinson called for a consideration of policy levers, especially at the State level, in the strategic framework around dissemination and implementation. This could include leveraging relationships with professional societies.
Dr. Masica suggested that AHRQ use data obtained from early phases of training grants, especially about where trainees are heading, to learn whether the training is becoming embedded in health systems (as when trainees train others). He emphasized a need to prioritize the question of how to get things done.
Ms. Dahlen asked about the allocation of effort in the strategic plan, suggesting that responding to national priorities should outweigh supporting nominated projects. There should be flexibility in determining the size of efforts.
Dr. Embi, regarding training, cited a need to define roles for those being trained and how they fit into healthcare systems to provide value. Perhaps a formal study should be conducted. Dr. Hernandez-Boussard noted the importance of integrating into the training programs efforts to address systematic bias that relate to the diverse trainees. Perhaps the use of supplements could be affirmed in the strategy. Dr. Chesley noted that AHRQ’s Learning Health System program includes a learning collaborative that is updating the core curriculum, which addresses disparities. One of AHRQ’s centers of excellence has developed a pilot module focusing on systemic racism, which will become available.
Dr. Amstutz encouraged AHRQ to include a focus on integrating the training with other areas of education, such as management. The training needs to be in a language that will translate into a business setting (the healthcare system). Dr. Chesley responded that the agency has been avoiding the word “researcher” and has sought to describe the trainees in a broader way. Working groups, in addressing the core curriculum, are addressing this fact of the broader skills required for the trainees. The institutions might have joint degree programs that help in this way.
Dr. Yu wondered how many PCORI guidelines have been implemented in clinics. Dr. Meyers responded that the number is not known. Dr. Yu suggested that the agency study the implementation of the many guidelines from societies and task forces to help inform its implementation efforts.
Dr. Robinson encouraged AHRQ to consider informatics in terms of implementation in the provider’s workflow. It was noted that there are clinical informatics training programs underway that could be engaged.
Ms. Edgman-Levitan emphasized the growing interest in creating learning health systems. AHRQ could consider partnering with organizations that are investing in that area. It could identify health systems to be sponsors for its “innovators” (a title perhaps to be preferred over “researchers”).
Public Comment
There were no public comments.
Chairman's Wrap-Up and NAC Input
Dr. Meyers again thanked the NAC members who are rotating off the council and encouraged them to continue to be in contact with the agency. He encouraged all NAC members to contact the office with any suggestions for making future NAC meetings more useful.
Dr. Masica expressed gratitude for the concise information and good discussion about AHRQ’s efforts relating to COVID-19. He encouraged the agency to consider how to engage healthcare systems and delivery organizations to advance connections with the agency’s work. Dr. Amstutz expressed appreciation for the council, with its thought-provoking dynamic and capacity for learning. Ms. Daugherty expressed her thanks for including considerations of the perspectives and needs of rural communities.
Dr. Hernandez-Boussard thanked AHRQ for the opportunity to chair the council for the past 2 years. She praised the team at AHRQ that supports the NAC, suggesting that the agency could leverage their talents even more, especially in efforts to disseminate the AHRQ message. She urged the team to engage and leverage further with the many national groups, such as those represented by the NAC members. She expressed hope for the continuing work to address AHRQ’s vision to address the challenges in healthcare delivery and to advance 21st century care.
Adjournment
Ms. Zimmerman thanked Dr. Hernandez-Boussard for her great help in the past years. Dr. Hernandez-Boussard thanked the NAC members, presenters, and AHRQ staff. She noted that the next NAC meeting will take place on March 18, 2021. She adjourned the meeting at 2:00 p.m.
Respectfully submitted,
Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Chair
National Advisory Council
Agency for Healthcare Research and Quality
