Richard Kronick is Director of the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, Maryland.
Find articles by Richard KronickRichard Kronick is Director of the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Rockville, Maryland.
Corresponding author.Address correspondence to: Richard Kronick, PhD, U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, 5600 Fishers Ln., 7th Fl., Rockville, MD 20857, Phone: 301-427-1100, vog.shh.qrha@kcinork.drahcir.
Copyright © 2016 Association of Schools and Programs of Public HealthThe Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency charged with improving the quality and safety of America's health-care system. AHRQ develops the knowledge, tools, and data needed to improve health system performance and help patients, health-care professionals, and policy makers make informed health decisions. The research, tools and training, and data and measures that AHRQ produces enable close collaboration with U.S. Department of Health and Human Services (HHS) agencies and other partners to ensure that the evidence produced is understood and used to achieve the goals of better care, smarter spending of health-care dollars, and healthier people.
The 2010 Patient Protection and Affordable Care Act has made great strides in transforming American health care, with an estimated 17.6 million additional Americans receiving health-care coverage 1 compared with 49.9 million uninsured in 2010. 2 Although expansion of the Affordable Care Act's coverage has garnered the most attention, the law's quality and safety provisions may have even more impact on U.S. health system performance in the long term. The latest evidence is shown in an HHS report released in December 2015 on hospital-acquired conditions (HACs). 3
According to the report, from 2010 to 2014, hospital patients had an estimated 2.1 million fewer HACs than they would have had if rates of adverse events had remained at the 2010 level of 145 HACs per 1,000 hospital discharges. Fewer HACs resulted in 87,000 fewer patients dying in hospitals and a reduction of nearly $20 billion in health-care costs. 3 These findings build on results reported in December 2014, which showed that 50,000 fewer patients died in hospitals and $12 billion in health-care costs were saved from 2010 to 2013. 4 Overall, from 2010 to 2014, the number of adverse events declined by 17%, dropping from 145 adverse events per 1,000 hospital discharges to 121 adverse events per 1,000 hospital discharges. 3
Improving patient safety requires efforts from many actors. Clinicians and staff members in hospitals across the United States were fundamental to this progress. The Affordable Care Act also played a key role in these efforts through the HHS Partnership for Patients initiative, a public-private collaboration of health-care providers, employers, patients, and federal and state governments. The initiative, launched in 2011, focused on improving health-care safety by lowering the rate of HACs and decreasing preventable complications that can result in hospital readmissions. 5 Progress was further incentivized by changes in Medicare payment, which galvanized the attention of hospital leaders. For example, under the Affordable Care Act, Medicare reduced payments to the 25% of hospitals whose rate of HACs fell within the highest quartile. 6 Translating HHS's policy aims of better care, smarter spending, and healthier people into practice requires strong, diverse public-private partnerships, including frontline clinicians, institutions, and patients and families. In addition to the Partnership for Patients initiative, these efforts include hospital engagement networks, quality improvement organizations, and many other public and private partners.
Tools, resources, and data from AHRQ are essential to these efforts. The tools, knowledge, and data that AHRQ develops and funds are foundational to creating a health-care system that is safe, timely, effective, efficient, equitable, and patient-centered. 7 AHRQ contributes to creating a higher-performing health system in three major ways.
AHRQ supports research to improve U.S. health system performance. AHRQ generated much of the basic evidence about how to improve the safety of hospital care, starting with evidence on how to reduce central line-associated bloodstream infections. 8 Central line-associated bloodstream infections can occur when bacteria or other germs enter a central line or catheter placed in a patient's large vein to facilitate medical treatment. These infections can lead to death and add billions of dollars in health-care costs each year. Until the mid-2000s, it was generally accepted by physicians that central line infections were a cost of doing business in the intensive care unit (ICU). Some ICU patients needed central lines, and some of those central lines would become infected, leading to bloodstream infections that contributed to longer hospital stays and high mortality rates. AHRQ-funded research demonstrated that central line infections could be prevented, and data from a 2015 report on HACs showed a 72% reduction in central line infections nationwide from 2010 to 2014. The 2010 baseline measure for central line infections was 18,000; by 2014, it had decreased to 5,000, fueled by national education and outreach through Partnership for Patients and with tools and resources, many of which were based on AHRQ-funded research. 9
Other AHRQ-funded projects include our Evidence-based Practice Centers, 13 academic and research organizations that review scientific literature on a wide spectrum of clinical and health services topics 10 and provide evidence for the U.S. Preventive Services Task Force. AHRQ also supports investigator-initiated research. One example of this AHRQ-funded research is an innovative model for training and supporting primary clinicians in rural communities in New Mexico to provide specialized care for their patients. 11
AHRQ has credibility and an excellent ongoing relationship with the health-care provider community. Tools and resources such as the Surveys on Patient Safety Culture 12 and TeamSTEPPS ® training materials, an evidence-based teamwork system aimed at improving communication and teamwork skills among health-care professionals, 13 are widely used in hospitals, physician practices, and other settings of care. These materials vary widely in scope but together translate the latest evidence from bench to bedside.
One prominent example of AHRQ's work with providers is the development and implementation of the Comprehensive Unit-based Safety Program (CUSP). CUSP is a customizable program that combines clinical best practices with the science of safety, improved safety culture, and an increased focus on teamwork. Developed by Johns Hopkins researchers with AHRQ funding, it has been a major force in reducing central line infections. 14 CUSP was later applied to catheter-associated urinary tract infections, reducing such infections in more than 950 hospitals by about 15% from 2011 to 2015. 15 The CUSP Toolkit brings together practical resources based on the experiences of thousands of hospitals that have used CUSP with learning materials that help providers understand key principles that increase safety. Add-on modules target safety issues and settings of care. 16
AHRQ's data products are the national gold standard in providing information to providers, patients, and policy makers to track progress, identify problem areas, and catalyze quality improvement. The Healthcare Cost and Utilization Project, a family of databases containing information extracted from administrative data, is the largest and most robust database available on the care provided to hospital patients in the United States. 17 The Medical Expenditure Panel Survey, which is a set of large-scale surveys of families and individuals, their providers, and employers in the United States, is the most complete source of data on the cost and use of health care and insurance. 18 The Consumer Assessment of Healthcare Providers and Systems surveys ask consumers to evaluate their experiences with health care. Survey topics focus on aspects of quality that consumers are best qualified to assess, such as the providers' communication skills and ease of access to health-care services. 19
These data resources and national surveys, along with products such as the annual National Healthcare Quality and Disparities Report 20 and AHRQ's Quality Indicators, 21 comprise a robust set of data sources that researchers and policy makers can use to identify trends and potential interventions. For example, AHRQ data highlighted a 153% increase in adult hospitalizations for overuse of opioids between 1993 and 2012, increasing from 117 opioid-related hospitalizations per 100,000 population in 1993 to 296 opioid-related hospitalizations per 100,000 population in 2012. These data helped prompt HHS's launch of a 2015 initiative to reduce opioid use. 22
AHRQ continues to explore ways to expand its efforts in patient safety into nonhospital settings. Initial efforts to improve safety focused on the sickest and most vulnerable patients (i.e., those treated in hospital settings). However, health care is increasingly provided in nonhospital settings, such as outpatient surgery centers and physician offices, albeit to less vulnerable patients. Efforts such as the opioid use reduction initiative 22 and the New Mexico rural physician training and support program 11 demonstrate AHRQ's commitment to assessing and improving the performance of health care wherever patients receive it.
High-performance health care, which is the goal of the Affordable Care Act's quality and safety provisions, means getting the right care delivered to the right patient at the right time, using resources wisely, respecting patients' and families' preferences, and reducing errors. The Affordable Care Act enables structural changes to the health-care system that reward these aims. The law is already keeping patients safer in hospitals, as evidenced by reductions in adverse events and thousands of lives saved. And that's just the beginning. AHRQ is building a health system informed by evidence, much of which is being generated by AHRQ. Researchers and scientists look forward to working within HHS and with other partners and stakeholders to fulfill the vision of a safer, high-quality health-care system that serves all people equally and efficiently.
1. Department of Health and Human Services (US), Office of the Assistant Secretary for Planning and Evaluation. Health insurance coverage and the Affordable Care Act. ASPE Data Point 2015 Sep 22 [cited 2016 Jan 15] Available from: https://aspe.hhs.gov/sites/default/files/pdf/111826/ACA%20health%20insurance%20coverage%20brief%2009212015.pdf.
2. Department of Health and Human Services (US), Office of the Assistant Secretary for Planning and Evaluation. ASPE Issue Brief: overview of the uninsured in the United States: a summary of the 2011 Current Population Survey. 2011 [cited 2016 Jan 28] Available from: https://aspe.hhs.gov/basic-report/overview-uninsured-united-states-summary-2011-current-population-survey.
3. Department of Health and Human Services (US), Agency for Healthcare Research and Quality. Rockville (MD): AHRQ; 2015. Dec, Saving lives and saving money: hospital-acquired conditions update: interim data from national efforts to make care safer, 2010–2014. Also available from: www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2014.html [cited 2016 Jan 15] [Google Scholar]
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7. Department of Health and Human Services (US), Agency for Healthcare Research and Quality. The six domains of health care quality [cited 2016 Jan 18] Available from: https://cahps.ahrq.gov/consumer-reporting/talkingquality/create/sixdomains.html.
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