In May, as Andrew B. Bindman, MD, began his tenure as director of the Agency for Healthcare Research and Quality (AHRQ), the agency had recently survived the threat of a congressional spending bill for fiscal year (FY) 2016 that proposed to eliminate its funding. Although AHRQ endured, it was with a substantial budget cut, from $364 million to $334 million. As of press time, the agency was waiting to see if a proposed cut for FY 2017 that would decrease its discretionary budget by 16% would be in the final bill.
Andrew B. Bindman, MD
Before joining AHRQ, Bindman, a primary care physician who was trained as a Robert Wood Johnson Clinical Scholar, spent more than 3 decades practicing, teaching, and conducting health services research at the University of California, San Francisco, and San Francisco General Hospital, an urban safety net hospital. He has also been active in the policy arena, working with congressional staff on federal health care reform as a Robert Wood Johnson Health Policy Fellow.
AHRQ’s mission is “to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services [HHS] and with other partners to make sure that the evidence is understood and used.” Bindman recently spoke with JAMA about fulfilling that mission amid the challenges of heading an agency that has been buffeted by political storms over the years. The following is an edited version of that conversation.
JAMA:What are your top priorities for AHRQ?
Dr Bindman:An important emphasis I want to bring to our work is moving evidence into practice, to enable frontline clinicians and health care providers to quickly access the most up-to-date evidence and apply it. Currently, it takes about 17 years for research evidence to move into clinical practice. It’s critical that AHRQ step up to this challenge to better understand how effectively we’re doing this and to speed up that process. We’ve been a little more advanced in the work at AHRQ in pushing safety into the front line of practice. I’d like to see that happen with other areas of practice where we’ve done a good job of synthesizing the evidence but haven’t quite finished that last mile, getting it in the hands of physicians at the time they need it.
JAMA:What are some specific ways you’re considering to advance toward that goal?
Dr Bindman:I see opportunities around things like computer-supported clinical decision tools. We’re communicating with colleagues at the Office of the National Coordinator for Health Information Technology and others within HHS about how to accelerate the development of computer-supported clinical decision tools that can make evidence surrounding diagnosis, prevention, and treatment more visible to a provider at the time when decisions are being made about care. At AHRQ, we have been synthesizing the evidence and capturing guidelines in a repository, but we haven’t fully automated the connection between these resources with electronic health records systems and other forms of information technology that providers are using in their management of patients.AHRQ is also looking to support the science around dissemination and implementation. How do we make sure that the clinicians are getting that evidence-based information? Computer-supported clinical decision tools provide a means to do that.But it’s not always about simply knowing the evidence. For example, it’s rare that primary care physicians wouldn’t know that they should be lowering their patients’ blood pressure or helping patients to quit smoking. But they may not have the systems in place to identify who among their patients have modifiable cardiovascular risk factors, or have a strategy to use their personnel to systematically address those abnormal risk factors among all of their patients.We have a program under way called EvidenceNOW that is working with several thousand primary care practices to improve their ability to address cardiovascular risk factors. This program is providing coaches to primary care physicians in small- and medium-sized practices in 7 regions across the United States to help them think about reorganizing their workforce in a way that can allow them to more efficiently take advantage of information from AHRQ and other places to make better use of evidence.
JAMA:What do you see as one of the more pressing issues in our health care system that AHRQ is equipped to address?
Dr Bindman:One pressing issue is health care safety. AHRQ continues to focus on both researching potential harms and then developing tools and strategies to improve health care safety. We do that through research, through having a monitoring system to see what impact we’re having, and by having tools that are given to frontline clinicians. We’ve had great success in the ICU and hospital setting in reducing infections from urinary catheters and from central lines, but we have to continue to push the agenda to improve health care safety beyond the hospital and into ambulatory care, nursing homes, and other settings.Diagnostic error is also a very significant contributor to patient safety issues, and [we had] a research summit in September focused on improving diagnosis. We’re going to need different kinds of data, monitoring systems, and to think about what the right kind of interventions are to address [diagnostic error].
JAMA:One of the challenges AHRQ has taken on is learning how to improve opioid treatment in rural areas. What efforts are under way there?
Dr Bindman:Early on in my time here, AHRQ had a call for supporting rural primary care providers to deliver medication-assisted treatment for opioid abuse. We were able to fund 3 states, Oklahoma, Pennsylvania, and Colorado. AHRQ was given only $9 million to invest in supporting rural primary care physicians in caring for people who need treatment for opioid addition, so we’re trying to be strategic in identifying promising models and evaluating them in a way that we hope can spread to all the states that have this need.One big piece of what these 3 states are doing is applying a “hub-and-spoke” model to use in their efforts. This model was [initially] used in Project Echo, an AHRQ-funded program in New Mexico to support rural primary care providers who each care for a relatively small number of cases of hepatitis C. The University of New Mexico set up a “hub” with a specialist who would “meet” online with those primary care providers on a regular basis. Patients with hepatitis C managed in primary care using the telehealth model did as well as, or in many cases better than, the patients who went to the specialty clinic at the University of New Mexico.And so, an early investment that AHRQ made has echoed itself in spinoffs through new applications, such as applying it to opioid treatment. It’s an exciting example of how AHRQ, by making strategic investments, can really move the needle on how care is provided.
JAMA:Are you planning any new initiatives for the agency?
Dr Bindman:We have a new initiative, Comparative Health System Performance, to systematically characterize all of the health systems in the United States in terms of their size and the characteristics of the physicians associated with them, as well as to understand organizational differences among these health systems and how those differences impact their capacity to incorporate evidence into the ways that they practice. Because health systems are taking on an increasingly important role as intermediaries between payers and patients, we want to understand these systems and their contributions to quality and safety. So, for example, we’re looking to characterize their use of IT systems, their team approaches to care, and the way they pay their practitioners.Our goal is to develop a foundational database on these health systems and to make it public so the health services research community can study important questions, such as the relationships of these organizational characteristics to important health outcomes or measures of performance. We anticipate having at least some of the information publicly available by the end of the year.
JAMA:A House subcommittee recently marked up its FY 2017 spending bill and specified new cuts that would decrease AHRQ’s discretionary budget by 16%. How would this affect the work at AHRQ?
Dr Bindman:It’s the first time in 4 years that the House of Representatives did not propose to give us a zero budget, so we’re going to take that as a small moral victory. I’m very hopeful; Congress has not finalized these bills yet, and we’re still early in that process. Were these budget cuts to occur, however, it would result in the real loss of programs that can be valuable for improving the health care system.Last year, AHRQ had an 8% budget cut that resulted in a loss of an HIV research network that has been very successful for many years for studying patterns in HIV care and supporting improvements in care. It also resulted in the elimination of a robust research enterprise we had for studying therapeutics, so we are limited now in our capacity to look at, for example, questions around the growth in the costs of medications.
JAMA:Why do you think an agency with a mission of promoting higher quality and safer care while lowering costs has been such a target?
Dr Bindman:With new entities and changes among some of the agencies, some members of Congress have had questions about the unique functions of AHRQ today. As an example, comparative effectiveness research was first developed as an idea at AHRQ, but under the Affordable Care Act, comparative effectiveness research moved to the Patient-Centered Outcomes Research Institute, so some questioned if AHRQ was still needed. But of course, comparative effectiveness research is just one element of AHRQ. Similarly, AHRQ has talked about translating research findings into practice, and the NIH has talked about “translational research,” which can lead to misunderstandings about whether similar work is going on in 2 places.So I’m trying to make sure that members of Congress and their staffs understand AHRQ’s unique contributions. There is no other federal agency that has AHRQ’s mission to improve quality and safety, to think about equity and access and affordability. This is really AHRQ’s unique function, so I feel being able to communicate about that is very important and hopefully will contribute to members of Congress feeling more confident they are not funding a redundant agency.
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Stephenson J. AHRQ Director Sets Course for Agency’s Health Services Research. JAMA. 2016;316(16):1632-1634. doi:10.1001/jama.2016.12702