Delivering information: AHRQ drives quality in context

In order to improve the quality, safety, efficiency and effectiveness of the healthcare system, the U.S. Agency for Healthcare Research and Quality (AHRQ) is tasked with a mission to gather research and disseminate valuable findings to those who can translate information into practice. In essence, AHRQ must pour an endless stream of intelligence into the right places, one bucket at a time.

Comparing Effectiveness

Dr. Clancy can cite examples in which research made its way into everyday practice, but she also notes that the industry lacks decisive knowledge in many areas. In cases where several treatment options are available, the value of one over another is too often undefined. AHRQ aims to shed some light in those areas with comparative-effectiveness studies. Its fiscal-year budgets in 2008 and in 2009 (estimated) each include $30 million earmarked for comparative-effectiveness research, which is double what it spent in each of the past several years.

AHRQ must establish a list of priority conditions and complete comprehensive effectiveness studies, as required by the Medicare Modernization Act of 2003. The Department of Health and Human Services moved the initiative even further earlier this year, expanding the list of priority health conditions to include those relevant not just to Medicare, but also Medicaid and SCHIP. Now, AHRQ's Effective Health Care Program is concentrating on 14 priority conditions-everything from dementia and cancer to obesity and substance abuse-to research quality treatments and best practices.

"Some of the priorities continue," Dr. Clancy says. "We started off with 10 and have expanded it [to 14] and expanded the population focus. One priority is obesity-boy, do we need better information . . . Another priority is developmental delays, attention deficit hyperactivity disorder, and autism. Another is disorders in pregnancy. And if you think about it for commercial insurers, this is one of the most common reasons they're paying for hospitalizations-and we have nothing for quality measures."

The science of comparing drugs, devices and procedures against each other is relatively new. Historically, treatments have been evaluated in a stand-alone manner, compared to placebo, or no treatment at all. With healthcare spending so dramatically outpacing inflation, health plans and politicians, among others, fully expect effectiveness reports to weigh choices among available treatments and to juxtapose the costs of each treatment as well.

Cost Vs. Quality

The question of whether a high-quality, effective treatment should be in some way devalued because of high cost continues to be the subject of great debate in healthcare. Most agree that cost cannot be completely separate from quality, but exactly how cost figures into the value equation remains the paramount issue. AHRQ is in a unique position because its legislative statute directs it to focus specifically on clinical effectiveness.

"To improve healthcare, AHRQ needs to address the ways healthcare can be delivered so that access and quality are improved without increasing costs," says Stephen D. Roberts, PhD, Professor of Industrial and Systems Engineering at N.C. State University, also part of the Healthcare Engineering Alliance. "This means that organization, financing and management of healthcare needs to be elevated as a research agenda."

Dr. Clancy agrees that cost and quality are not separate and says that information on costs can come from other sources if not from AHRQ.

For example, Consumer Reports Best Buy Drugs, a consumer resource, uses findings from the Effective Health Care Program to compare medications and adds the price data as well. The drug class reviews are downloaded at a rate of 110,000 per month, and more than 1 million reports have been downloaded thus far.

She also agrees with stakeholders who believe that great advances in medicine won't make Americans healthier if they are unaffordable.

"[Healthcare economist] Gail Wilensky and others believe we should focus on the clinical effectiveness first and then work on cost effectiveness," Dr. Clancy says. "I don't think anyone objects to it. There are other proposals that say-as insurers do-that that is absurd, and if we're not talking about [cost], why are we having the conversation?"