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PRACTICE GUIDELINES

Question. One of AHCPR's mandates is developing clinical practice guidelines, which we hope will provide information about what treatments are effective and which ones don't work.

Can you give us an update on what your agency has done so far in this area, and what practice guidelines will be developed in FY 1992?

Answer, The Agency for Health Care Policy and Research (AHCPR) currently has seven panels in process and is initiating an eighth panel on HIV treatment. The

panels are: prediction, prevention, and early treatment of pressure sores in adults; management of acute post operative pain; diagnosis and treatment of depressed outpatients in primary care settings; urinary incontinence in the adult; visual impairment due to cataracts in the aging eye; delivery of comprehensive care in sickle cell disease; and diagnosis and treatment of benign prostatic hyperplasia (BPH).

Two of the of the panels, pain management and benign prostatic hyperplasia, are beginning the peer review process of their draft guidelines. The panel on urinary incontinence has completed the peer review process. The peer review process consists of the panels sending drafts of the guidelines they have developed and the supporting evidence to external reviewers with a wide range of relevant backgrounds to review critically all aspects of the development process. This process takes approximately one month and is followed by pilot testing of the guidelines by various types of practitioners who utilize them in their own setting in patient management for two to three months. The feedback from pilot testing will be utilized by the panels in making any necessary changes in the guidelines prior to release and dissemination. The urinary incontinence, pain management and BPH panels should finish their guidelines in the Fall and the other four guideline panels are expected to complete their guidelines before the end of the calendar year.

The AHCPR has prepared a request for proposal to develop guidelines under contract with public or nonprofit entities. We also are in the process of developing mechanisms for the creation of standards, performance measures and review criteria based on the developed guidelines.

The AHCPR is considering the possible development of guidelines in FY 1992 for cancer pain management, low back pain, otitis media in children, congestive heart failure in the adult, management of Alzheimer's disease, management of cerebral vascular accident, and quality determinants of mammography. We will make final decisions on these conditions shortly and publish the appropriate notices in the Federal Register.

Question. Where I come from, there are quite a few solo practitioners, small hospitals, and other health care settings that are not university-based or even physician-based.

I am concerned that these health care providers are most vulnerable to professional isolation, and may have the hardest time keeping up with current medical findings.

How will AHCPR ensure that the practice guidelines are disseminated to these health providers?

Answer. The Journal of the American Medical Association (JAMA) has agreed to publish all the practice guidelines. The National Library of Medicine will use its outreach efforts also for dissemination. In addition, AHCPR is developing a dissemination strategy to work with medical and allied health specialty groups, American Association of Retired Persons (AARP) and other consumer groups, business groups, and a variety of publications and the media to ensure that the guidelines reach practitioners and their patients regardless of their residence.

SOURCE OF FUNDS FOR AHCPR

Question. Dr. Clinton, one aspect of your budget request is very troubling to me. It's not the end so much as the means of getting funding. I'm sure you know that we had a lot of trouble last year over whether to use funds from the 1% evaluation setaside (Section 2711) for the Agency for Health Care Policy and Research.

I had hoped the budget request would take into account the conflict over that funding method, and seek another or seek a change in the authorization, which specifies the current tap on 1% funds. Unfortunately, this isn't the case.

Knowing of the trouble we had last year, and the trouble that may lie ahead, will the Administration seek any change in the AHCPR funding authorization?

Answer. The authority for AHCPR and its major programs expires in FY 1993. The question of the funding authorization is currently under review as the administration develops its policy and legislative plans for next year. At the present time, a decision has not been made about whether the administration will seek a change in funding methods in the FY 1993 AHCPR reauthorization legislation.

RANGE OF RESEARCH

Question. I have advocated in the past for a "larger gene pool" of researchers and research topics, including women, minorities, and those from more rural institutions. From the start, this Subcommittee has advocated that research topics should, to the extent possible, provide a broad base of knowledge relevant to current questions of health policy. And last year, we suggested that AHCPR should establish a Small Grants program in order to bring more new researchers into the field.

Dr. Clinton, please describe to the Committee what steps you will be taking to increase research activity on rural health issues, problems of minorities, and the question of low-income individuals gaining access to quality health care.

Answer. We have been very active within the primary care research community, specifically to increase the capacity for high quality research dealing with rural health issues, problems of

minorities, and the question of low-income individuals gaining access to quality health care.

We have recently published a research agenda for primary care, deriving in large part from our first national conference on primary care research. Research on issues related to health care of underserved, vulnerable, and minority populations are prominent in this document. On February 7, 1991 we published a program note together without the National Center for Nursing Research, reaffirming our continuing interest in supporting research targeted toward the problems of the most vulnerable rural population.

In addition, we have collaborated with the Office of Rural Health Policy within the Health Resources and Services Administration to establish a series of regional research capacity building workshops. By the end of the current fiscal year, we will have held workshops in Chapel Hill, NC, Seattle, WA, Bismarck, ND, and Tucson, AZ and Marshfield, WI. We are organizing workshops on rural and undeserved populations research at meetings of major national health organizations including the National Rural Health Association and the Association of University Programs in Hospital Administration (AUPHA).

Staff of AHCPR's extramural research Division of Primary Care are currently analyzing grant proposals submitted over the last five years to identify patterns of deficiency that have impeded successful review and funding. The results of this analysis will be incorporated into future workshops as well as ongoing technical assistance to potential investigators.

Finally, we are working closely with several minority health oriented academic institutions in increasing the capacity for research in primary care. We would expect specific strategies and institutional relationships to be identified this year for implementation during FY 1992.

Question. Do you think the "small grants" method is useful, or should we be looking at other ways of enhancing the research base and the opportunities for new researchers?

Answer. The "small grants” mechanism is one of several useful strategies for increasing opportunities for new researchers. As the Senate suggested last year, the AHCPR has expanded our small grants program. Soon we will be announcing four priority areas for funding under the small grants mechanism in FY 1991 and FY 1992. These include:

Research on health care services for
underserved/disadvantaged populations (e.g., women and
minority health issues, rural health issues, methods to
improve access; and costs, access, and quality of care for
the uninsured/underinsured);

Research on health care services for individuals with HIV infections, (e.g., including issues of costs, access, and quality of care);

Research on medical liability issues (e.g., determinants of or alternative approaches to reduce medical liability) and,

Clinical practice-oriented primary care research.

We expect to fund up to 20 proposals during FY 1991 as a result of this small grant announcement.

There are other strategies that also would enhance the research base for issues in primary care for vulnerable and underserved populations. Our National Research Service Awards (NRSA) and dissertation grants program currently support approximately 24 institutional and individual awards in health services research and 25 dissertation grants per year. Research evolving from these training investments will, in part, make noteworthy contributions to the underserved issues.

QUESTIONS SUBMITTTED BY SENATOR ARLEN SPECTER

MEDICAL TREATMENT EFFECTIVENESS

Question. Dr. Clinton, since fiscal year 1990 over $100,000,000 has been made available to your agency for research on medical treatment effectiveness. How will the information gleaned from this research be translated into practice by physicians, policy makers and the American consumers?

Answer. The Medical Treatment Effectiveness Program (MEDTEP) emphasizes the dissemination of findings to potential users of the information including physicians, private and public decisionmakers, researchers, third-party payers, educators, legislators, allied health professionals, and consumers.

Multiple and detailed dissemination strategies for each medical practice guideline are now being developed, with emphasis on their adoption and use. They will be disseminated via a variety of means including print, direct mail, computer search systems, video tape, the press, exhibits, presentations, and other formats. Dissemination activities will involve professional groups, governmental agencies, consumer groups, educational organizations, libraries and targeted marketing efforts in selected communities. In order to ensure that we adequately address the critical issue of translating research into medical practice, we are holding a workshop with dissemination experts to thoroughly explore what is currently known about effective dissemination. The input from these experts will be used to guide the development of our dissemination strategies.

The National Library of Medicine (NLM) has expanded its information services to retrieve research findings and practice guidelines from computer-based medical information systems. The NLM and AHCPR are updating the medical subject headings to increase access to research findings and guidelines and will continue activities to increase dissemination of information, Further, we have an intra-agency agreement with the NLM's National Technical Information Service to hold all of AHCPR's products. We will be working with them to develop full text retrieval of these products beginning with the clinical guidelines.

RESEARCH TRAINING

Question. Dr. Clinton, is there a sufficient number of trained health services researchers to carry out this important line of research? How much is the federal government investing in training for researchers in this field? Is there a need to expand this effort in order to ensure an adequate pool of trained scientists for the future?

Answer. We are concerned about there being a sufficient cadre of health services researchers to keep pace with current and future research needs. This is a well recognized problem exacerbated by shrinking private investments in training health services research students. The AHCPR administers a National Research Service Award (NRSA) program directed at training pre and post doctoral health services research trainees through both institutional awards and individual fellowships.

We are emphasizing areas in the field that are needed to support the medical effectiveness and outcomes research by encouraging applications in epidemiology, biostatistics, research methodology and behavioral research.

As mandated by the Public Health Service Act, the AHCPR receives 1/2 of 1% of the National Research Service Award monies appropriated to the National Institutes of Health (NIH) and the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). Also, Medical Treatment Effectiveness Program (MEDTEP) funds were used to supplement the NRSA monies in FY 1990 ($ 1 million) and FY 1991 ($1.35 million). This resulted in $2.59 million being allocated for training of health services researchers in FY 1990 and $2.65 million in FY 1991 through these two programs.

Additionally, AHCPR's Health Services Dissertation Research Grants support doctoral research on the organization, delivery, financing, and of effectiveness of health care services. In FY 1990, 20 dissertation research grants were awarded totalling $395,000. Approximately 25 dissertation grants will be awarded in FY 1991 from the $500,000 earmarked for this activity.

Finally, the AHCPR has announced its intent to make administrative supplemental grant funds available to increase involvement of minority health professionals in ongoing health services research. Presently, racial and ethnic minority health professionals are not adequately represented throughout the spectrum of health services research. Their inclusion in prominent and significant roles is critical to a better understanding of problems encountered in delivering and ensuring health care in minority populations. The professional involvement of racial and ethnic minorities in the conduct of the grant can add immeasurably to the cultural sensitivity, appropriateness, and credibility of such research.

Effective enhancement of careers for minorities in health services research will require focused attention to the

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