Tuesday, June 30, 2015

In Defense of AHRQ: A Key Component of Healthcare Delivery Science

The Agency for Healthcare Research & Quality (AHRQ) is an unheralded government agency that performs a great deal of healthcare-related research out of proportion to its small size. Just browsing through the AHRQ Web site makes it clear that agency does a great breadth of work for its annual $400 million budget. Yet AHRQ has somehow attracted its share of detractors, including those in control of the House of Representatives budgeting process who propose to abolish the agency in next fiscal year. A divide-and-conquer strategy of increasing federal medical research elsewhere is also concerning.

Eliminating AHRQ would be a profound mistake, especially with the emergence of the new discipline of healthcare delivery science [1], which the American Medical Association (AMA) calls the "third science" of medicine after basic and clinical sciences. It has been obvious for a long time that while the biomedical perspective of disease and its treatment by the healthcare system are important, larger questions loom around the most effective ways to transfer biomedical knowledge into effective, safe, and efficient healthcare delivery. Given the disease-oriented focus of most research from the National Institutes of Health (NIH), the large biomedical research agency of the US government, AHRQ is the main US government funder of research that would fall under the rubric of healthcare delivery science. The AMA has put its weight behind healthcare delivery science through its Accelerating Change in Medical Education Consortium.

AHRQ suffers from a number of challenges. One is that its research focuses on the healthcare system, including areas from healthcare delivery science such as patient safety, change management, and delivering high-value cost-conscious care. There are unfortunately elements of the healthcare system whose interests do not always align with the most effective or efficient care. By the same token, AHRQ also funds research on evidence-based medicine, which helps determine not only what works, but also identifies what does not work. EBM has its detractors, some (though not all) of whom may be invested (financially or otherwise) in specific tests and treatments for diseases. Furthermore, as AHRQ also focuses on patient safety and healthcare system issues, its research may be harder to sell than diseases such as cancer or Alzheimer’s Disease. It is more difficult for there to be "grateful patients" to celebrate a well-designed healthcare system avoiding an error or complication that a patient never knew he or she might suffer. All of these issues were explored well in a recent Washington Post article.

Another challenge for AHRQ is its being a standalone agency within the Department of Health and Human Services (HHS). As such, it is not protected under the umbrella of the larger health-related agencies, such as the NIH or Centers for Disease Control (CDC). A further difficulty for AHRQ is that has always been viewed as being associated with healthcare reform, including its political aspects. As such, it has tended to be viewed with suspicion by political conservatives. (Which to me is rather odd, since conservatives should be the first to point out that markets work best when consumers have information, and few federal agencies produce more high-quality, actionable information than AHRQ.)

One supporter of maintaining AHRQ is Michael Millenson, who recently blogged some criticism of AHRQ but nonetheless made the case for keeping it. I agree with Millenson that AHRQ needs to improve its messaging and perhaps change its name. But instead of Millenson’s suggestion to focus on "translational medicine," I believe that AHRQ should re-describe what it does as healthcare delivery science. Much of what AHRQ already does falls under the umbrella of healthcare delivery science, including areas such as value-based care, quality measurement and improvement, patient safety, and even informatics.

One of the news articles cited above notes that AHRQ comprises 0.1% of the HHS budget. As some of what AHRQ does would likely be transferred to other federal agencies, it is unlikely that eliminating AHRQ would save the government much money. Furthermore, the research AHRQ performs on comparative effectiveness and efficient care might save the government much larger amounts of money in other places, such as the Medicare system. I hope that wiser heads in Washington will prevail and maintain AHRQ and the valuable work it provides.

(Disclaimer: AHRQ funds research of myself and the department I lead at Oregon Health & Science University through its expansive health IT portfolio and its Evidence-Based Practice Center Program, which is part of its larger Effective Healthcare Program.)


1. Pronovost, PJ and Goeschel, CA (2010). Viewing health care delivery as science: challenges, benefits, and policy implications. Health Services Research. 45: 1508-1522.

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