Meeting Minutes, March 2021
Virtual Meeting
Contents
Summary
Call to Order and Approval of November 10, 2020, Meeting Summary
Recent AHRQ Accomplishments
Update on AHRQ Budget and Transitions
Update on AHRQ Strategic Planning for the PCOR Trust Fund
Discussion on Health Equity
Public Comment
Chair's Wrap-Up and Final NAC Input
Adjournment
Summary
NAC Members Present
Edmondo J. Robinson, M.D., M.B.A., M.S., Moffitt Cancer Center (NAC Chair)
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, University of Missouri
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital
Gretchen M. Dahlen, M.H.S.A., FACHE, Consumer Health Ratings
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
Omar Lateef, D.O., Rush University Medical Center
Hoangmai Huu Pham, M.D., M.P.H., Anthem, Inc.
Ramanathan Raju, M.D., M.B.A., CPE, FRCS, FACS, FACHE, Northwell Health
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
Naomi Tomoyasu, Ph.D., Veterans Health Administration (for David Atkins)
Lee Fleisher, M.D., and Shari M. Ling, M.D., Centers for Medicare & Medicaid Services
AHRQ Staff Members Present
David Meyers, M.D., FAAFP, Acting Director
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement
Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
Kamila Mistry, Ph.D., M.P.H., Office of Extramural Research, Education, and Priority Populations
Karin Rhodes, M.D., M.S., Chief Implementation Officer, Office of the Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of November 10, 2020, Meeting Summary
David Meyers, M.D., FAAFP, Acting Director, AHRQ, and Edmondo J. Robinson, M.D., M.B.A., M.S., Moffitt Cancer Center, NAC Chair
Dr. Meyers welcomed the meeting attendees. He stated that the National Advisory Council (NAC) is AHRQ’s primary method for obtaining feedback from the health fields on the agency’s efforts to improve the quality, safety, equity, and value of healthcare. He introduced, with a brief bio, Edmondo J. Robinson, M.D., M.B.A., M.S., Senior Vice President and Chief Digital Innovation Officer at Moffitt Cancer Center, who had been appointed the new Chair of the NAC. Dr. Robinson also is Associate Professor of Medicine at Thomas Jefferson University’s Sidney Kimmel Medical College.
Dr. Robinson called the meeting to order at 10:05 a.m., welcoming the NAC members and other speakers, participants, and viewers. He noted that the meeting was being recorded and will be made available on the AHRQ website. He encouraged the NAC members to use Zoom online technology to indicate that they have questions or comments during the meeting, and he encouraged non-NAC members to email any public comments.
Dr. Robinson referred to the draft minutes of the previous NAC meeting (November 10, 2020) and asked for changes and approval. The NAC members voted unanimously to approve the November meeting minutes with no changes. Dr. Robinson reviewed the meeting agenda and introduced the first session.
Recent AHRQ Accomplishments
Health Systems Research
Jeffrey Brady, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ
Dr. Brady reported on recent AHRQ activities in health systems research:
- AHRQ awarded 26 research grants (a total of $17 million) to study questions about healthcare delivery during the COVID-19 pandemic. Areas of focus include the use of telehealth, best practices for rural care, emergency management in hospitals, and barriers to response and care for vulnerable populations in hospitals.
- AHRQ released, for researchers, a special emphasis notice on substance use disorder. This is in response to a continued rise in drug overdose deaths and morbidity. Rates of polysubstance and stimulant use are increasing. The notice seeks the dissemination and implementation of evidence-based, non-pharmacologic, behavioral therapies. It asks researchers to address social, environmental, psychological, and economic factors and whole-person health.
- In response to a request from Congress, the agency published a request for information on clinical algorithms that have the potential for introducing racial/ethnic bias. Such evidence will inform an Evidence-based Practice Center review to begin in May.
- AHRQ-supported research findings in comparative health system performance contributed to a special issue of Health Services Research (December 2020). One of the series of articles noted that perceived care integration was lower outside health system boundaries. Another reported no differences in racial/ethnic disparities in care when comparing health-system-affiliated and non-health-system-affiliated organizations.
- An AHRQ-supported study of acute care and antibiotic use in applying a safety program found antibiotic use to be reduced in 400 hospitals (reported in JAMA Network Open, February 2020). The improvement occurred even in the under-resourced hospitals.
Practice Improvement
Arlene S. Bierman, M.D., M.S., Center for Evidence and Practice Improvement, AHRQ
Dr. Bierman reported on activities in practice improvement:
- AHRQ has been partnering with the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI) to provide training to about 9,000 nursing homes in all States. As part of the National Nursing Home COVID-19 Action Network, this involves case-based learning and peer-to-peer mentoring.
- The agency placed its COVID-19 Resources Catalog for Nursing Homes online and is developing other resources and tools relating to COVID-19 vaccines, safety, and quality. These include a leadership learning guide, information on staffing strategies, a fact sheet on misinformation about vaccines, and videos about vaccine communications.
- AHRQ produced two new issue briefs on improving diagnostic safety and quality. These are “Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction” and “Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.”
- AHRQ has prepared a draft report to Congress on strategies to improve patient safety, including ways to reduce medical errors and ways to encourage the use of such strategies. The draft is now available for public comment.
- In the areas of dissemination and implementation, the agency’s EvidenceNOW and TAKEheart programs have continued to make progress. EvidenceNOW for advancing heart health created a practice recruitment and retention toolkit. It has a new 3-year, $18 million grant initiative to help primary care practices advance equity in heart health, using State-based cooperatives and developing in-State networks. The TAKEheart program created an interactive repository of resources for unhealthy alcohol use and developed resources and learning sessions addressing hospital cardiac rehabilitation services.
- The Center for Evidence and Practice Improvement’s Evidence Discovery and Retrieval (CEDAR) project is obtaining evidence from repositories with a goal of supporting progress in clinical decision support (CDS) systems. The Center also is supporting the CDS Connect program’s public-private initiative to achieve sustainability in CDS. It is offering R18 grants to demonstrate and disseminate shareable interoperable CDS systems. Another new funding opportunity (R21/R33) is titled “Using Innovative Digital Healthcare Solutions to Improve Quality at the Point of Care.”
Data and Analytics
Joel W. Cohen, Ph.D., Center for Financing, Access, and Cost Trends, AHRQ
Dr. Cohen reported on AHRQ activities in data and analytics:
- Responding to the issues of privacy and availability of data, AHRQ is developing synthetic healthcare data within a research database. The result will be a nationally represented database with details helpful to researchers. It will be used for tracking and studying rare diseases, exploring treatment patterns, exploring variation in utilization, payments, and access to care by payer, and assessing the influence of local area characteristics on care.
- The agency is developing a database for social determinants of health. Supported by the Patient-Centered Outcomes Research (PCOR) Trust Fund, the database will offer linkable data for research and will inform approaches that address emerging health issues. Dr. Cohen encouraged the NAC to provide input for the development of the database.
- A new statistical brief on COVID-19-related hospitalizations in nine States revealed significantly disproportionate rates of hospitalization for Hispanics and non-Hispanic Blacks during the period April-May-June 2020.
- The 2019 National Healthcare Quality & Disparities Report revealed that U.S. healthcare quality improved overall from 2000 to 2018, although with variations in areas, including some worsening. The related Chartbook on Patient Safety revealed improvement in patient safety overall, especially with regard to urinary tract infections and pressure ulcers for patients in nursing homes.
- An AHRQ evaluation found that participation in Medicaid increased following passage of the Affordable Care Act, especially in States that chose to expand programs and especially for persons with serious psychological distress and depression.
- A statistical brief on the concentration of healthcare expenditures for the U.S. population revealed that, in 2018, the 1 percent of people ranked with highest expenditures accounted for about 21 percent of the total healthcare expenditures in the United States. Such a skewed distribution has been the case for about 50 years.
Discussion
Hoangmai Huu Pham, M.D., M.P.H., raised the issue of disparities at the structural level, noting that there are health systems with better or worse care integration. Many large health systems are able to garner increasing shares of resources and can negotiate higher prices/payments from payers. Smaller systems suffer from a lack of such leverage. Dr. Bierman responded that AHRQ created a compendium of data on U.S. health systems, which can help researchers. There are plans to update it in the near future to include COVID-19 data.
Susan Edgman-Levitan, P.A., cited the challenges in nursing homes and encouraged AHRQ to develop advocacy around those issues and policy reform. Dr. Meyers noted that AHRQ’s role is one of research rather than advocacy and it will be offering research evidence to the national dialogue on nursing homes. Ms. Edgman-Levitan stated that it will be helpful to enlist the voices of the public in initiatives. Drs. Bierman and Meyers noted the ongoing use of focus groups and the enlistment of primary care practices in learning communities, supporting engagement.
Peter J. Embi, M.D., M.S., FACP, FACMI, encouraged the agency to advance the work on social determinants of health by supporting efforts to standardize approaches and promote coordination. Dr. Cohen responded that AHRQ is speaking with people across the U.S. Department of Health and Human Services (HHS) and coordinating their responses. The new database on determinants of health likely will lead to discussions. Dr. Embi suggested that AHRQ’s work in social determinants of health could be a marquee program.
Gretchen M. Dahlen, M.H.S.A., FACHE, encouraged AHRQ to evaluate effectiveness within nursing homes and their networks. Dr. Meyers noted that the agency is doing such work with training centers. However, it cannot get to the people/players who are not participating. There are serious issues, such as a feeling of isolation among nursing home staffs and resulting burnout.
Ramanathan Raju, M.D., M.B.A., stressed the idea of using Z-codes from the ICD-10 to obtain evidence regarding social determinants of health. The use of the codes can be tied to reimbursement. For nursing homes, AHRQ researchers could seek to improve the system of star-ratings for performance, leading to the creation of information on social determinants.
Yanling Yu, Ph.D., suggested that the agency measure the adoption of evidence-based practice guidelines by facilities. Dr. Bierman responded that AHRQ is doing that as its research programs support the use of guidelines. Dr. Brady added that the integration of measurement in the work is a key to good results and the use of guidelines in digital clinical support technologies can lead to both burdens and, hopefully, efficiencies. We need evidence and best practices for handling multiple chronic conditions.
Dr. Yu cautioned that, in some cases, telehealth is not appropriate and might be associated with increases in antibiotic prescribing. We need to establish standards of care and avoid diagnostic errors. Dr. Pham stated that we need new approaches/paradigms in developing digital applications in care delivery and for defining care delivery and entities. Dr. Brady responded that AHRQ’s digital healthcare research program is moving in such directions. .
Update on AHRQ Budget and Transitions
David Meyers, M.D., FAAFP, Acting Director, AHRQ
Dr. Meyers reported that the transition relating to a new administration has resulted in new attention to such topics as dealing with the recovery from the COVID-19 pandemic, health equity, healthcare access, and possible linkages between climate change and healthcare.
Dr. Meyers reported that AHRQ’s FY 2021 enacted budget is $338 million, equal to the FY 2020 budget. It provides an increase of $1.8 million for expanding the Medical Expenditure Panel Survey (MEPS) while reducing expenditures in other research portfolios by 0.915 percent. The budget bill maintains AHRQ as an independent agency. AHRQ also receives funding from the PCOR Trust Fund. Details about the FY 2022 budget are not yet available.
Dr. Meyers asked the NAC members to consider whether to continue the Subcommittee of the NAC (SNAC) focused on AHRQ’s Quality Measurement Enterprise. The members voted unanimously to extend the SNAC.
In response to a question from Patrick S. Romano, M.D., M.P.H., Dr. Meyers noted that the recently passed large stimulus bill ($1.9 trillion) did not specify any activities for AHRQ. Nevertheless, the agency will stand ready to offer support, for example, in the areas of data, measurement, and evaluation. Dr. Romano stated that there appear to be opportunities for AHRQ to work with sister agencies and to support research in disaster preparedness.
Update on AHRQ Strategic Planning for the PCOR Trust Fund
Karin Rhodes, M.D, M.S., Chief Implementation Officer, Office of the Director, AHRQ
Dr. Rhodes, new to the agency, provided a brief summary of her career, which has included community health programs and research, work in nursing and as an emergency room doctor, and work in healthcare-system and State government-level administrations. She then presented issues within AHRQ’s support for patient-centered outcomes research (PCOR), beginning with definitions:
- PCOR compares the impact of two or more preventive, diagnostic, treatment, or delivery approaches on meaningful health outcomes. It is comparative effectiveness research.
- The PCOR Institute (PCORI) supports clinical effectiveness research, helping patients, clinicians, purchasers, and policymakers make informed healthcare choices.
- The PCOR Trust Fund supports research. The money that it gives to AHRQ is used to support the particular areas of researcher training and the dissemination of research findings. The dissemination of findings includes work to incorporate findings into health information technologies associated with clinical decision support.
AHRQ’s PCOR training initiatives include deploying mechanisms such as educational projects, center grants, and cooperative agreements with emphases on studying operations, quality, and system improvement. AHRQ’s funding opportunity announcements support training and career development of PCOR researchers. It currently is conducting an evaluation of initiatives.
AHRQ’s efforts in dissemination link research with clinical practice, ensuring that PCOR findings are known, understood, and used. It supports the synthesis of research, the translation and communication of evidence, and implementation of evidence into practice. The agency’s EvidenceNOW program focuses on the dissemination of evidence in primary care practices. It will advance State capacities. The AHRQ Compendium of U.S. Health Systems identifies, classifies, and tracks healthcare delivery systems and supports dissemination of PCOR evidence.
AHRQ’s clinical decision support initiative seeks to move evidence into practice by making CDS shareable, interoperable, and publicly available. It includes the engagement of stakeholders, the development of prototype infrastructures, and advancement through grant-funded research. [Go to https://cds.ahrq.gov]
Next steps in the PCOR work at AHRQ include building on strategic planning and a framework, establishing priorities for investment, establishing transparent governance, investing in infrastructure/staff, clarifying and strengthening relationships, and ensuring stakeholder engagement.
Dr. Robinson asked the NAC members to consider the following three questions:
- What are the biggest issues health systems are dealing with today and will be for the next 10 years in trying to use evidence more effectively?
- How can we best track and inform new models of care (telehealth, home-based primary care, hospital-at-home, etc.)?
- How will AHRQ remain relevant during a time of rapid health system consolidation and changing models of care and payment?
Discussion
Dr. Yu referred to the first question and called for a stronger development and use of open notes (patient feedback and discussion) for tracking and performing analyses. AHRQ could support such an effort.
Also referring to the first question, Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, stressed the importance of advancing the use of technologies and improving interoperability. That will be especially important for long-term care. We need to develop new rules for information blocking. We must deal with the evolving new care delivery models (e.g., telehealth) and how they are being used. New quality measures and ways of using them will appear. AHRQ could help especially to support advancements in measurement.
Referring to the second and third questions, Dr. Pham encouraged the agency to develop new research partnerships and new sources for inquiry. She encouraged AHRQ to consider the use of predictive analytics to track new models of care.
Regarding the third question, Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., FAAN, suggested that the agency develop an army of advocates for its work. It should seek ways to create outreach and establish relevancy for CEOs, other senior leaders, medical students, and nursing students. Perhaps AHRQ could improve communication with consumers (patients and families). For example, the agency’s website could be improved to be more helpful.
Dr. Meyers stressed the need to examine stakeholder engagement using PCOR Trust Fund dollars. He raised the idea of creating another subcommittee to consider the possibilities for advancing engagement, and he asked for a motion to create such a subcommittee.
The NAC members voted unanimously to form the new SNAC, which will serve to develop ideas on stakeholder engagement, within the PCOR Trust Fund umbrella, to inform Dr. Rhodes and the agency in general.
Discussion on Health Equity
Kamila Mistry, Ph.D., M.P.H., Office of Extramural Research, Education, and Priority Populations, AHRQ
Dr. Mistry began a discussion on health equity by considering context. As defined in an executive order by President Biden, equity is the consistent, systematic, fair, just, and impartial treatment of all individuals. Health equity is the principle underlying a commitment to reduce and ultimately eliminate disparities in health and in its determinants, including social determinants. A health disparity means a higher burden of illness, injury, disability, or mortality experienced by one group relative to another. A healthcare disparity typically means differences between groups regarding health insurance coverage, access to and use of care, or quality of care.
The administrations have produced executive orders for ensuring an equitable pandemic response and recovery and, through the Federal government, advancing racial equity and support for underserved communities. A Public Health Service act gave AHRQ a mandate to address priority populations. The Affordable Care Act established an Office of Minority Health and an Office of Women’s Health.
Some current and recent AHRQ activities are the following:
- So-called “dashboard grants” to study social determinants of health data integration and analytics and the use of dashboards to guide clinicians.
- Support for a social determinants of health database.
- A study of COVID-19-related hospitalizations in nine States by race and ethnicity.
- An Evidence-based Practice Center’s report on bias in algorithms.
The agency created a health equity workgroup with a goal of defining a series of short-term actions (3 months) and long-term actions that the agency can take to advance health equity within three areas: ensuring a culture of equity at AHRQ, creating policies and procedures to advance equity, and identifying scientific priorities to advance health equity. Three sub-workgroups composed of a variety of AHRQ experts are addressing those areas. The agency also plans to develop a health equity communications plan and an evaluation plan.
Dr. Robinson asked the NAC members to consider the following questions:
- How should AHRQ focus its efforts to advance health equity using its current core competencies in research, practice improvement, and data/analytics?
- Are there opportunities to grow new competencies to maximize impact?
- Who are the new partners and stakeholders AHRQ should engage to maximize the impact?
Discussion
Dr. Raju stressed a need to consider overall social equity and suggested that efforts to obtain healthcare quality be conducted within a social equity lens. HHS must support work to integrate data, bringing together social data and health data from many agencies.
Dr. Robinson cited the phenomenon of efforts that increase healthcare quality overall yet widen certain disparities. It is important to understand individuals in a holistic way, even before they become patients. What are the underlying influences for social determinants? Might there be a role for AHRQ in studying them (education, food deserts)? How should we address racism?
Dr. Yu encouraged AHRQ to convene focus groups that feature minority individuals (patients and families) who can offer their perspectives for identifying priorities and policies.
Ms. Edgman-Levitan noted that the ABIM Foundation has an initiative to accumulate information about programs sponsored by health systems and organizations that could be regarded as models for addressing problems. The Foundation has engaged a wide group of stakeholders, including patient organizations. Perhaps AHRQ could consult or partner with it. The Foundation also is conducting a survey about patient trust and physician trust.
Ms. Dahlen cited as a model the work by the Institute for Healthcare Improvement (IHI) to engage hospitals with interventions to reduce medical error. The project has featured guides and tips for implementing the interventions and has been successful. Perhaps AHRQ could partner. Ms. Edgman-Levitan added that Kedar Mate at IHI has led much of the work, including efforts to improve equity. Perhaps AHRQ could partner there as well.
Dr. Robinson encouraged the NAC members to use the AHRQ blog to discuss further the issues of equity. Dr. Raju volunteered to begin and encourage such a blog discussion.
Dr. Yu raised the issue of how to grow competencies and suggested that the COVID-19 pandemic likely has produced much evidence of how to achieve that growth, as in the areas of equity and the use of public health. She encouraged AHRQ to consider such evidence.
Public Comment
There were no public comments.
Chair's Wrap-Up and Final NAC Input
In a final session, Dr. Robinson listed some key topics that had been brought up, including the influence of digital technology, advanced analytics, new care paradigms, new healthcare tools (digital, virtual, point-of-care), and the impact of health disparities. He stressed especially the potential for research involving digital technologies and advanced analytics.
Dr. Raju stated that, with regard to telemedicine and the virtual concept, we must be cautious. Healthcare disparities could continue and even increase. As we have seen with virtual teaching, there remains a digital divide, in which some people do not have Internet access or computers.
Dr. Romano noted that the Medicare trust fund is nearing insolvency. He encouraged AHRQ to support research that brings the idea of value back to the discussion of, for example, new digital technologies. Value is linked to both quality and safety. Dr. Meyers added that a recent report concluded that health services research has great importance yet is underfunded. We need to communicate the value of the research. Dr. Meyers suggested that the term “health systems research” might serve better than the term “health services research.” AHRQ will attempt to communicate to politicians the value of health services/systems research.
Dr. Embi noted challenges at the intersection of the area of the academic and the area of the operational in health services/systems research. For example, the languages tend to differ. AHRQ could perhaps support the development of models for collaboration.
Dr. Alexander noted the Senate’s Nursing Home Modernization Act, which is being developed. AHRQ could inform the legislators on issues such as quality measurement. The Journal of the American Medical Directors Association is calling for articles on “reimagining long-term care.” Perhaps AHRQ can contribute with an article focused on vision. The agency also could consider offering input to the National Academy of Medicine’s work on quality of care in nursing homes.
Adjournment
Dr. Robinson thanked the NAC members, presenters, and AHRQ staff. He stated that the next NAC meeting will occur on July 14, 2021 (again virtual). He adjourned the meeting.
Respectfully submitted,
Edmondo J. Robinson, M.D., M.B.A., M.S., Chair
National Advisory Council
Agency for Healthcare Research and Quality
