Medicolegal Issues

AHRQ in the Lead


What exactly is the Agency for Healthcare Research and Quality (AHRQ), and why are hospitalists urged to increase its portion of the federal budget pie each year?

According to its mission statement, the AHRQ is “the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans.” This includes supporting high-quality, impartial research that specifically improves healthcare quality, reduces costs, advances patient safety, decreases medical errors, eliminates healthcare disparities, and broadens access to essential services.

“Supporting AHRQ is supporting an unbiased government organization that’s clearly on the side of patient safety, and that gets important information out fast,” says Andrew Fishmann, MD, FCCP, FACP, a member of AHRQ’s National Advisory Council and director of intensive care at Good Samaritan Hospital in Los Angeles. “Where’s the argument?”

Policy Points

Healthcare Reform Proposals

If you’re curious about which presidential candidates are proposing healthcare reform—and what type of reform they stand for—you can find the latest information through an online toolkit on the uninsured. The Alliance for Health Reform’s Web page at (click on “Presidential Candidates’ Reform Proposals”) provides links to half a dozen useful Web sites.

Self-referral Restrictions Postponed

In November, the Centers for Medicare and Medicaid Services announced it will delay a planned significant tightening of the Stark prohibitions against physician self-referral as they apply to academic medical centers and not-for-profit integrated health systems. The restrictions are now slated to go into effect in December.

The so-called “stand in the shoes” provision—because physicians are considered to stand in the shoes of their practice—was postponed partly because of arguments that it would be impossible to structure support payments that are routine in faculty-practice plans and not-for-profit systems while meeting the requirements of other Stark exceptions.


HIPAA appears to be hampering research. A survey of 1,527 epidemiology practitioners published in the Nov. 14 edition of Journal of the American Medical Association revealed that variability in the interpretation of HIPAA had slowed scientific research by making it more costly and time-consuming. In fact, some academic institutional review boards are closing down research.—JJ

Fight over Funding

The argument is over money, plain and simple. Each year, medical associations like SHM push for increased federal funding for AHRQ so the agency’s research can be expanded. And each year, Congress refuses those increases. Lawmakers have granted a slight boost in funding: Since 2002, AHRQ’s budget has increased by $2 million, or 6.7%.

Proponents of AHRQ believe precarious funding levels threaten the agency’s ability to achieve its essential mission. Last year, SHM lobbied for an increase in federal funding for AHRQ to $350 million in fiscal year 2008—$31 million more than the agency’s fiscal 2007 budget. By late 2007, Congress was weighing an increase of $329 million, plus $5 million targeted for comparative-effectiveness research.

“Think of AHRQ compared to the $28 billion that NIH gets,” says Dr. Fishmann. “[AHRQ’s] is a small budget relative to what they do.”

How much does AHRQ need to provide adequate research information? The answer is, apparently, as much as they can get. There are countless areas in healthcare the agency could address.

“If they got $500 million, could they spend it?” asks Dr. Fishmann. “Yes. They could look at the top 20 diseases instead of the top 10.”

What AHRQ Does

Regardless of the final budget amount they receive, AHRQ spends roughly 80% on grants and contracts focused on improving healthcare.

“AHRQ doesn’t do its own research or create its own data,” explains Dr. Fishmann. Rather, AHRQ conducts and supports health services research in leading academic institutions, hospitals, and other settings. In 2005, two hospitalists received separate grants for projects that have already had an effect on hospital medicine. Greg Maynard, MD, MS, division chief of hospital medicine at University of California San Diego School of Medicine, used AHRQ funds for an intervention project to prevent hospital-acquired venous thromboembolism (VTE). Dr. Maynard’s project continued to grow since that grant and has yielded key findings such as a risk-assessment model for VTE. Data and lessons learned are available in the VTE Resource Room on SHM’s Web site at

Asked why he went after AHRQ funding, Dr. Maynard explains: “AHRQ is one of the few [funding] agencies that focuses on the realm of implementation—that impact the patient immediately. It was a perfect marriage of what we wanted to do.” The other AHRQ-funded hospital medicine project was conducted by Mark V. Williams, MD, FACP, professor and chief, division of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago, and editor of the Journal of Hospital Medicine. Working for Emory University’s hospital medicine program in Atlanta at the time, Dr. Williams used the grant to create a “discharge bundle” of patient safety interventions such as medication reconciliation and patient-centered education to improve patient safety transitions out of the hospital setting.

“We would not have been able to conduct the study without the support of AHRQ,” says Dr. Williams. “We certainly need more research funds such as this. AHRQ is the primary federal agency funding health services research—however, they receive less than 5% of the funding that goes to NIH and fund more basic science-oriented research. As few as one in 10 grants submitted to AHRQ are actually funded.”

Like Dr. Maynard’s work on VTE prevention, the injection of AHRQ funds also allowed Dr. Williams’ project to continue and grow. “With support from the Society of Hospital Medicine, we have been quite fortunate to utilize the momentum from the AHRQ Patient Safe-[Discharge] grant to obtain a $1.4 million grant from the John A. Hartford Grant to develop a discharge toolkit and facilitate implementation of it at hundreds of hospital,” he explains. “The BOOST [Better Outcomes for Older adults through Safe Transitions] project aims to improve care delivery to older adults at hospitals across America as they transition from the hospital to home.”

Additional research is developed in AHRQ’s Centers for Education and Research in Therapeutics (CERTS). Each of the 11 CERTS has a specific charge and gathers data on the benefits, risks, and cost-effectiveness of therapeutic products such as drugs, medical devices, and biological products.

AHRQ disseminates current healthcare data quickly and more effectively than private channels. “They look at healthcare as a whole,” explains Dr. Fishmann. “For five years, they’ve published the annual National Quality Report and the National Disparity Report. They try to zero in on information to share with the public and with physicians, including all issues related to patient safety. They allow anyone access to the information: One market is hospitalists.”

AHRQ and Hospitalists

Of course, the research and information that AHRQ provides is vital to all physicians. But Dr. Fishmann believes hospitalists find the agency particularly valuable.

“SHM perceives AHRQ as their champion,” he says. “It’s a great partnership: AHRQ documents the value of having hospitalists. SHM provides an efficient way to disseminate new information relevant to hospitals.”

Many essential data and resources for physicians can be found on AHRQ’s Web site at

“The average hospitalist already uses this site, but I don’t think the average resident does,” says Dr. Fishmann. “I hope everyone knows about it.” TH

Jane Jerrard has written for The Hospitalist since 2005.

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