Session I | Session II
Testimony before the House Subcommittee on Labor-HHS-Education Appropriations
Carolyn Clancy, M.D.
Deputy Assistant Secretary, Budget
March 5, 2008
Mr. Chairman and Members of the Committee, I am pleased to be here today to discuss with you health issues and opportunities at AHRQ. As you may know,
AHRQ’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. We do this by supporting research to improve the quality of health care, reduce its cost, improve patient safety and address medical errors,
Our mission is driven by the needs of the people who use our research -- patients, clinicians, health system leaders, and policymakers. A major focus for us is to translate the findings of our research into practice and policy. We work closely with our partner agencies in Department of Health and Human Services to achieve this objective.
The agency's research agenda is broad and spans from promoting health care information technology to reducing medical errors; from supporting comparative effectiveness research to enhancing Americans’ health care quality.
Today, I would to like to first highlight for the Committee our work in the area of comparative effectiveness research, which has recently received a lot of interest.
Comparative Effectiveness Research
10 Priority Conditions for Comparative Effectiveness Research
- Arthritis and non-traumatic joint disorders (Muscle, bone, and joint conditions)
- Cancer (Cancer)
- Chronic obstructive pulmonary disease and asthma (Breathing conditions)
- Dementia including Alzheimer's disease (Brain and nerve conditions)
- Depression and other mood disorders (Mental health)
- Diabetes mellitus (Diabetes)
- Ischemic heart disease (Heart and blood vessel conditions)
- Peptic ulcer disease and dyspepsia (Digestive system conditions)
- Pneumonia (Breathing conditions)
- Stroke and hypertension (Heart and blood vessel conditions)
Mr. Chairman, AHRQ was authorized to perform comparative effectiveness research under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. MMA authorizes AHRQ to conduct and support research with a focus on outcomes, comparative clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. The focus of this research is based on the top ten conditions (see table) that are common and costly among those whose health care is funded by Medicare, Medicaid, and the State Children’s Health Insurance Program. The list of priority conditions was developed with substantial input from the public and stakeholders.
The comparative effectiveness research program was established using an existing infrastructure of our Evidence-based Practice Centers and created capacity for rapid-cycle comparative effectiveness research, and translation of comparative effectiveness findings for patients, clinicians, and policy makers.
Since 2005, the Effective Health Care Program has released 14 comparative effectiveness reviews. These reviews ranged from diagnostic evaluation of technologies for abnormal breast cancer screening to comparative effectiveness of drugs for depression to treatments for prostate cancer. As an example, one review found that drugs can be as effective as surgery in the management of gastro esophageal reflux disease (GERD), better known as heartburn. GERD is one of the most common health conditions in older Americans and results in $10 billion annually in direct health care costs.
We are beginning to see an impact from AHRQ’s comparative effectiveness research. It is used by a variety of groups who make decisions about health care. For example, Consumer Reports Best Buy Drugs, a public education project of Consumers Union, uses these findings to help health care professionals and patients determine which drugs and other medical treatments work best for certain health conditions. The National Business Group on Health uses this research to provide employers and their employees’ best available evidence for designing benefits and making treatment choices. Medscape, an online medical information and education tool for specialists, primary care physicians, and other health professionals, uses the reports for clinicians to get continuing education. In addition, most of the reports are published concurrently in one of the Annals of Internal Medicine, one of the premier medical journals.
A recent Congressional Budget Office report indicates that only a limited amount of evidence is available about which treatments work best for which patients and whether the
added benefits of more-effective and more-expensive services are sufficient to warrant their added costs. The CBO report suggests that comparative effective research could help reduce health care spending without affecting health overall. The bottom line is that “doing the right thing” – using comparative effectiveness to improve the quality of health care – will enhance the value of our investments in health care.
Mr. Chairman, I would like to thank the Committee for its continued support for comparative effectiveness research, and in particular, for doubling the Agency’s funding in this critical area from $15 million to $30 million in FY 2008. With this increase the number of comparative effectiveness reviews and technical briefs, and other products will double. New research studies will include surgical interventions, prescription drugs, heart disease, infectious diseases, and obesity. Continued investments in comparative effectiveness research at AHRQ will help us fill the evidence gap identified by CBO and provide better health care value for Medicare beneficiaries and all Americans.
Health Information Technology
However, simply producing comparative effectiveness research isn’t sufficient to improve the quality and value of health care services. Creating the means and capacity will put the findings of research quickly at the fingertips of health care professionals and patients. For that, we need “smart” health IT, health information technology
AHRQ's unique contribution to health information technology (health IT) is a key element in achieving this goal and bringing to health care into the 21st century. Since 2004, AHRQ has invested $199 million in grant and contracts in 48 states to support and stimulate investment in health IT, especially in rural and underserved areas.
Increased investments in this area would foster a collaborative effort between AHRQ’s health IT research and comparative effectiveness programs to develop a way of quickly and efficiently delivering the findings of research to health care professionals and patients. For example, comparative effectiveness research shows that a certain drug is best to treat high blood pressure. As soon as the health care professional enters a diagnosis of high blood pressure into a patient’s electronic medical record, a prescription for that drug is generated automatically. The electronic medical record would generate a warning against using that drug if the patient is allergic or shouldn’t take it for some other reason. In this case, it would offer alternatives. Similarly, the same system can collect information on unexpected patient harms to patients from treatments.
We also would work to create a system that would, with the right Federal, State, and private sector partnerships, help implement electronic prescribing throughout the health care system in a way that improved quality, rather than the haphazard way that it is currently occurring.
Health IT has breathtaking potential to change dramatically how patients receive health care services. Currently, we need to go to a doctor’s office or clinic for health care information and services that are tailored to our individual needs and preferences. Under the concept of a health IT-enabled “medical home,” anywhere with a computer and Internet access – one’s home, a library, a school – can be a place where people can connect with their health care providers for this type of service.
To ensure that we harness the power that health IT has to offer, we need to develop an evidence-based strategy to help clinicians and health care leaders decide which health IT innovations we should be adopted and how they should be implemented to maximize value – both to clinicians and patients today and to the public health and research enterprises.
We know that health IT is not a magic bullet for improving the quality, safety and value of health care. We also need a change in the culture of health care that takes a systematic approach to eliminating medical errors and improving overall quality.
Just last month, we published a proposed rule implementing the Patient Safety and Quality Improvement Act. This proposed rule improves the quality and safety of health care for all Americans by fostering the establishment of patient safety organizations – private entities recognized by the Secretary of Health and Human Services to collect and analyze patient
safety events reported by health care providers. They are new and separate from all currently existing entities that are addressing health care quality.
The new rule provides us with an opportunity for an important future investment in efforts to reduce avoidable harms to patients. With additional funding, we could accelerate the development of patient safety event reporting systems as well as other provisions in The Patient Safety and Quality Improvement Act.
Another opportunity would be for AHRQ to expand the Patient Safety Improvement Corps – a group of health care professionals from state government and hospitals especially trained in strategies to reduce medical errors. We could expand the Corps to include other professionals in a greater number of communities.
Additional opportunities exist to accelerate the development and implementation of evidence-based tools to health care professionals nationwide. This would include the development of assessment tools that could be used to gauge the culture of safety in health care settings such as dialysis centers, nursing homes, physicians’ offices and free-standing clinics.
Our investments in patient safety have already shown improvements in care and have increased the commitment to patient safety in many health care settings. For example,
AHRQ supported research at Johns Hopkins University that developed a program that instituted a simple five-step checklist designed to prevent certain hospital infections in intensive care units (ICU) throughout Michigan. Among other things, the check list reminds doctors to wash their hands and put on a sterile gown and gloves before putting intravenous (IV) lines into patients. As a result of taking this simple step, the rate of bloodstream infections from IV lines was reduced by two-thirds within three months. In addition, the average ICU decreased its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million. One leader in critical care medicine described these results as one of the most important developments in a generation.
This is just one example of how our investments in patient safety have made improvements in care. We recognize that our health care system is massive, with over $2 trillion spent annually on care, and that our investments are only the tip of the iceberg. There is a lot more that needs to be done.
Value in Health Care
Mr. Chairman, so far I have raised a number of opportunities that we see as critical steps toward improving the quality of health care. I would now like to highlight steps that we can take to help ensure that we are getting value in our investments.
As we are all aware, growth in health care costs is placing a tremendous burden on federal and state budgets, threatening employer capacity to provide health insurance, and straining personal finances. Through research that we have supported, we know that a large part of this cost can be attributed to the use of inappropriate use of resources.
In an effort to create value for our health care investments, AHRQ is supporting efforts to measure, track, and report on health care quality and how health care services are used. These efforts give us a snapshot of the health care system and show us where we need to make improvements and adjustments.
For example, through a partnership with state hospital associations and state data agencies, AHRQ’s Healthcare Cost and Utilization Project or HCUP, has data on 90 percent of all the hospital discharges in the country, as well as emergency department and ambulatory data from about half the States.
HCUP provides a rich data source for Federal, State and local policy makers, as well as individual communities seeking to improve quality and reduce waste. For example, the National Institutes of Health has used the data from HCUP to determine that a questioned rotavirus vaccine was indeed safe, resulting in a go-ahead for immunizing children around the world. Also, Federal policymakers have used it to create benchmark data on influenza rates and MRSA. The future opportunity that many States see right now is linking administrative or billing data to smart HIT so that health care challenges can be rapidly
identified and addresses, and State leaders can assess the impact of changes in policy on health care and people’s health.
Finally, since we recognize that many value improvements require community-wide actions, we have recently launched Secretary Leavitt’s Value-Driven Health Care Initiative. The ultimate goal of the Initiative is to increase value and quality of care that Americans’ receive. AHRQ has recently launched 14 community- and state-wide collaboratives in 13 states. These multi-stakeholder groups will be working to track, publicly report, and improve quality across their communities. These 14 and additional communities to be selected later this year will be front-row customers for the products of comparative effectiveness research, greatly expanding the number of Americans who benefit from taxpayer-supported research investments. Clinicians and patients confront challenges in making the best decisions every day; our job is to make sure that evidence-based information is available when and where it is needed
Mr. Chairman, I want to thank you for the opportunity to discuss with the Committee how continued investments in AHRQ’s essential programs will improve quality and value in health care.
Agency for Healthcare Research and Quality (AHRQ)
Department of Health and Human Services
Carolyn M. Clancy, M.D., now serves as Director, Agency for Healthcare Research and Quality (AHRQ). Prior to her appointment as Director on February 5, 2003, Dr. Clancy had served as AHRQ's Acting Director since March 2002 and before that Director of AHRQ's Center for Outcomes and Effectiveness Research (COER).
Dr. Clancy is a general internist and health services researcher, and a graduate of Boston College and the University of Massachusetts Medical School. Following clinical training in internal medicine, Dr. Clancy was a Henry Kaiser Family Foundation Fellow at the University of Pennsylvania. She was also an assistant professor in the Department of Internal Medicine at the Medical College of Virginia in Richmond prior to joining AHRQ (then named the Agency for Health Care Policy and Research) in 1990.
Her major research interests include women's health, primary care, access to care, and the impact of financial incentives on physicians' decisions. She holds an academic appointment at George Washington University School of Medicine (Clinical Associate Professor, Department of Health Care Sciences) and serves as Senior Associate Editor, Health Services Research. Dr. Clancy is a member of multiple editorial boards (American Journal of Public Health; Journal of Evaluation in Clinical Practice; Journal of General Internal Medicine; and Medical Care Research and Review).
Dr. Clancy has published widely in peer-reviewed journals and has edited or contributed to five books. Her work in women's health was recognized by an award from the Women's Caucus of the American Public Health Association. Active in multiple professional organizations, she has been recognized as a leader within the Society of General Internal Medicine. Before becoming the Director of COER in 1997, Dr. Clancy served as Director of the Center for Primary Care Research. There she helped develop the U.S. Public Health Service Primary Care Policy Fellowship and led research initiatives on:
The interface of primary and specialty care.
- The impact of health care reforms on primary care.
- The evaluation of strategies to implement clinical practice guidelines in primary care practice.
Department of Health and Human Services
Office of Budget
Richard J. Turman
Mr. Turman is the Deputy Assistant Secretary for Budget, HHS. He joined federal service as a Presidential Management Intern in 1987 at the Office of Management and Budget, where he worked as a Budget Examiner and later as a Branch Chief. He has worked as a Legislative Assistant in the Senate, as the Director of Federal Relations for an association of research universities, and as the Associate Director for Budget of the National Institutes of Health. He received a Bachelor=s Degree from the University of California, Santa Cruz, and a Masters in Public Policy from the University of California, Berkeley