The outcome for AHCPR. Interview by Laura Lynn Brown

In late July, a House Appropriations Subcommittee voted to cut the Agency for Health Care Policy and Research (AHCPR) budget by 21 percent in fiscal year 1996. The six-year-old, $162 million agency has produced clinical practice guidelines for 10 of the 15 costliest conditions for which people are hospitalized. Their application has saved the health system far more than AHCPR costs, many experts believe. The agency's supporters say its work is a critical underpinning of the movement in value-based purchasing and quality assurance, while many Congressional Republicans believe the private sector could do AHCPR's work just as well. Health Systems REVIEW recently spoke with AHCPR administrator Clifton R. Gaus about the agency's mission and its strategy for survival.     

Linking evaluation and program development. The case of AHCPR-supported clinical practice guidelines

Within a research organization such as the Agency for Health Care Policy and Research (AHCPR), the process of evaluating program performance must often be integrated with a larger research and development agenda. The blending of evaluation and program development (research and development activities undertaken to build expertise and knowledge in a specific programmatic area) can both strengthen the quality of a program and enhance the science of evaluation research. This article describes AHCPR's evaluation strategy and highlights evaluation activities for the agency's clinical practice guideline program. A case study is presented to illustrate the unique methodological challenges in guideline evaluation, the creation of new tools and approaches for evaluating clinical quality, and the benefits of linking evaluation research with program development.     

National Practitioner Data Bank

The Health Care Quality Improvement Act of 1986 authorized the Department of Health and Human Services to establish a National Practitioner Data Bank to collect and release certain information relating to the professional competence and conduct of physicians, dentists and other health care practitioners. After a lengthy delay, the federal agency, on October 17, 1989, released detailed rules and regulations regarding reporting, disclosure and other requirements for the Data Bank. The following sets forth questions and answers covering significant aspects of the complex regulations.     

What is outcomes research and what can it tell us?

In 1989, Congress enacted P.L. 101-239, establishing the Agency for Health Care Policy and Research (AHCPR). Since then, practically every specialty society has developed practice guidelines for its practitioners, and every health care organization has embarked on some outcomes research. Outcomes research has become a fashion, meaning all things to all people, and runs the risk of becoming meaningless. This article attempts to reduce the confusion by clarifying what outcomes research is not delineating its several levels, along with the methods, tools, and examples appropriate to each level. The contributions of outcomes research to health care delivery innovation to date have been modest. Ultimately, we need community health information systems, which have not only the structural and process variables but also include the outcome results, to guide decision making with regard to the health of entire communities and the appropriate investment of resources to improve health.     

Effectiveness of a nationally implemented smoking cessation guideline on provider and patient practices

BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline outlines a set of recommendations for physicians to follow in daily practice. However, the effectiveness of this guideline has not been reported. The goal of this project was to evaluate the effect of the AHCPR smoking cessation guideline on provider practices with smokers and on patient smoking rates. METHODS: Patient survey and chart review data from 138 Veterans Administration (VA) acute care medical centers with outpatient facilities were examined. Data were available from both sources in 1996, 1997, and 1998. At the midpoint of this period (1997), the VA recommended the AHCPR smoking cessation clinical practice guideline for implementation throughout the VA healthcare system. RESULTS: From 1996 to 1998, both the chart audit and the patient survey showed a significant increase in the percentage of patients in the VA who were counseled about smoking and a significant decrease in the percentage of patients who smoke. CONCLUSIONS: Because the VA tied the guideline implementation to report cards and other performance-enhancing measures, guideline adherence may have been maximized in this setting. These findings suggest that healthcare systems should take an integrated approach to guideline implementation.     

Evaluating the use of the appropriateness method in the Agency for Health Care Policy and Research Clinical Practice Guideline Development process.

OBJECTIVE: To assess the feasibility of the appropriateness method in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Development process, and to compare the results of the appropriateness method with those obtained using evidence tables and an informal consensus method. SETTING: AHCPR Low Back Problems Clinical Practice Guideline. DESIGN: Two different group process methods with the same panel of experts were used in observational comparison of results of and satisfaction with guideline development. DATA COLLECTION: Practice guideline statements were created for topics using the conventional AHCPR method; then six months later new guideline statements for four topics were created using the appropriateness method. Panelist satisfaction with each process and resulting set of guideline statements was assessed. PRINCIPAL FINDINGS: Results of the appropriateness method for TENS, discography, and traction showed no disagreement among panel members and no appropriate indications for their use in the patient scenarios considered. These results are qualitatively similar to the guideline statements produced using evidence tables and informal consensus. Clinical practice guideline statements about electro-diagnostics created from appropriateness ratings were much more clinically specific than those created using evidence tables and informal consensus. Neither informal consensus building nor the appropriateness method was clearly preferred by a majority of panelists. CONCLUSIONS: It is feasible to use the appropriateness method in the AHCPR Clinical Practice Guideline Development process, and in some instances it produces more clinically specific guideline statements than does informal consensus.     

Clinical practice guidelines. The Agency for Health Care Policy and Research fosters the development of evidence-based guidelines

As medical technology increases rapidly and becomes more complex, clinical practice guidelines can help healthcare providers assess current practices and integrate technological advances. Through the Agency for Health Care Policy and Research (AHCPR), the federal government has begun to facilitate the development of clinical practice guidelines. Expert or contract panels, authorized by the AHCPR, develop guidelines on specific clinical conditions. The AHCPR guideline methodology is designed to produce evidence-based guidelines that are valid, clinically applicable, and clinically flexible. Each panel spends a year or more developing the guideline, beginning with an extensive literature search and review. The panel prepares evidence tables, statistically analyzes aggregate data (where appropriate), conducts harm and benefit analyses, and prepares health policy analyses (or cost-impact studies). During this process, the panel holds an open forum to solicit comments on the guideline topic. After this public discussion, the panel prepares a final draft of the guideline. Several hundred individuals review the guideline. Some policymakers believe clinical practice guidelines can lead to better healthcare outcomes. Guidelines can provide information in a useful format for clinicians to use at the bedside or the point of decision making in patient care. Guidelines also provide information that can be used in continuing education and professional education programs.     

Job-based health insurance, 1977-1998: the accidental system under scrutiny

This paper highlights changes in employer-based health insurance from 1977 to 1998, based on national household surveys conducted by the Agency for Health Care Policy and Research (AHCPR) in 1977, 1987, and 1996; and surveys of employers by the AHCPR in 1977, by the Health Insurance Association of America in 1988, and by KPMG Peat Marwick/Kaiser Family Foundation in 1998. During the study years, in 1998 dollars, the cost of job-based insurance increased 2.6-fold, and employees' contributions for coverage increased 3.5-fold. The percentage of nonelderly Americans covered by job-based insurance plummeted from 71 percent to 64 percent. This decline occurred exclusively among non-college-educated Americans. An information-based global economy is likely to produce not only greater future wealth but also greater inequalities in income and health benefits.     

Health care practitioners' motivation for tobacco-dependence counseling

Smoking cessation counseling by practitioners occurs at low rates in spite of strong evidence that counseling increases quit rates and reduces patient mortality. In a preliminary study, 1060 New York State physicians completed a survey concerning use of the Agency for Health Care Policy and Research (AHCPR) Guidelines, perceived autonomy and perceived competence for counseling, perceived autonomy support from insurers, and barriers to counseling. Considered together, perceived autonomy, perceived competence and perceived autonomy support predicted time devoted to counseling and use of the AHCPR guidelines. The primary, longitudinal study of 220 health care practitioners who attended a smoking cessation workshop predicted change in the practitioners' perceived autonomy and perceived competence for counseling as a function of the degree to which they experienced the workshop instructor as autonomy-supportive. In turn, change in perceived autonomy predicted change in time spent counseling and change in use of the AHCPR guidelines.     

Book review

Making Research: Work Edited by Dorota twaniec and fohn Pinkerton, John Wiley & Sons 1998 Reviewed by Una Lernihan, Social Services Trainer North and West Belfast Health and Social Services Trust (Currently on secondment to the Centre for Child Care Reseach)

Child Care Law: A Comparative Review Of The New Legislation In Northern Ireland and Scotland The Children (N.I.) Order 1995 and The Children (Scotland) Act 1995 Conducted by Kay Tisdall, Ruth Lavery and Patrick McCrystal Published by: The Centre for Child Care Research Queen's University, Belfast Reviewed by Berni Kelly, University of Ulster     

Is the methodological quality of guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research (AHCPR) guidelines with those published subsequently

Objective: To determine whether North American guidelines published subsequent to and in the same topic areas as those developed by the US Agency for Health Care Policy and Research (AHCPR) meet the same methodological criteria.

Study design: A guideline appraisal instrument containing 30 criteria was used to evaluate the methodological quality of the AHCPR guidelines, "updates" of the AHCPR guidelines authored by others, and guidelines that referenced or were adapted from the AHCPR guidelines. The frequency with which the criteria appeared in each guideline was compared and an analysis was performed to determine guidelines with two key features of the ACHPR guidelines—multidisciplinary guideline development panels and systematic reviews of the literature. Data were extracted from the guidelines by one investigator and then checked for accuracy by the other.

Results: Fifty two guidelines identified by broad based searches were evaluated. 50% of the criteria were present in every AHCPR guideline. The AHCPR guidelines scored 80% or more on 24 of the 30 criteria compared with 14 for the "updates" and 11 for those that referenced/adapted the AHCPR guidelines. All of the 17 AHCPR guidelines had both multidisciplinary development panels and systematic reviews of the literature compared with five from the other two categories (p<0.05).

Conclusions: North American guidelines developed subsequent to and in the same topic areas as the AHCPR guidelines are of substantially worse methodological quality and ignore key features important to guideline development. This finding contrasts with previously published conclusions that guideline methodological quality is improving over time.

     

Requests pouring in for AHCPR's new practice guidelines

Since the early March release of the first practice guideline by the Agency for Health Care Policy and Research, on postoperative pain management, the agency's clearinghouse has received more than 110,000 telephone calls and letters requesting copies. The agency also has issued guidelines on urinary incontinence and pressure ulcers. It has mailed 615,000 pieces of literature on the guidelines, and more requests are being filled daily.     

Agency-Based Empowerment Interventions: Efforts to Enhance Decision-Making and Action in Health and Development

The Journal of Behavioral Health Services & Research - This paper outlines the critical role of personal agency in influencing health and development outcomes and presents a framework for...     

Adoption of the AHCPR Clinical Practice Guideline for Smoking Cessation: a survey of California's HMOs

OBJECTIVE: Our objective was to assess the degree to which health maintenance organizations (HMOs) and Medicaid managed care (MMC) plans in California have adopted the 1996 AHCPR Clinical Practice Guideline for Smoking Cessation. (AHCPR [U.S. Agency for Health Care Policy and Research] was renamed AHRQ [Agency for Healthcare Research and Quality] in 1999.) METHODS: A fax survey of 13 licensed HMOs and 21 MMC plans operating in California in 1999 with up to 10 follow-up contacts by telephone, mail, fax, and/or electronic mail. RESULTS: Awareness of the AHCPR guideline is widespread, and all HMOs in California in 1999 offered coverage for at least one treatment for smoking cessation. We found that 77% of the HMOs in California were aware of the AHCPR guideline, but less than half had used it to design benefits or distribute treatment guidelines to medical care providers in their networks. While only 23% of California HMOs covered the nicotine patch or gum, 69% covered at least one form of the pharmacotherapy and one type of counseling to treat tobacco dependence. In addition, a majority of the HMOs and MMC plans inform their members about coverage for smoking cessation treatments and inform providers about their role in helping smokers to quit. CONCLUSION: Considerable progress has been made in increasing access to effective smoking cessation treatments in California's managed care organizations over the last 10 years. Future efforts and research must concentrate on: (1) adopting the 2000 Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence, (2) increasing purchaser demand for coverage of tobacco dependence treatments, (3) increasing health plan documentation and monitoring of member smoking status, and (4) increasing provider provision of effective tobacco dependence treatments.     

Using a computerized patient database to evaluate guideline adherence and measure patterns of care for major depression

This study examined the translation of recommendations from the Agency for Health Care Policy and Research (AHCPR) guidelines for major depression into measures derived from a computerized database to assess guideline conformance and patterns of care for major depression. Patients (n = 208) were identified who were hospitalized for major depression and had two or more outpatient mental health appointments within 6 months of discharge from an academically affiliated Veterans Affairs Medical Center. Measures were based on AHCPR guideline recommendations or developed independently. Conformance could be measured for three guideline recommendations. Of patients on single-agent antidepressant therapy, 87% received dosages within the recommended range. Sixty-nine percent received the recommended number of follow-up visits. Specific condition-related treatment interventions were identified in 32% of patients with concurrent alcoholism. Dual diagnoses of depression and drug or alcohol abuse were not deterrents to prescribing benzodiazepines. Despite its limitations, computerized database analyses provided efficient measures of guideline adherence.     

After the Affordable Care Act: the Effects of the Health Safety Net and the Medicaid Expansion on Latinxs’ Use of Behavioral Healthcare in the US

The Journal of Behavioral Health Services & Research - This study investigated the association between the implementation of the Affordable Care Act (ACA) and Latinxs’ use of behavioral...