Special Emphasis Notice: Research Priorities for the Agency for Healthcare Research and Quality--Research on Systems and Organizational Interventions for Improving Healthcare Quality for Low-income People served in Under-resourced Settings and Communities

Notice Number: NOT-HS-07-045

Key Dates
Release Date: November 22, 2006

Issued by
 Agency for Healthcare Research and Quality (AHRQ) (http://www.ahrq.gov)

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. AHRQ achieves this mission by supporting a broad program of health services research and by working with partners to promote improvements in clinical and health systems practices that benefit patients.

In FY2007, AHRQ plans to emphasize in its grants portfolio research on efforts to improve health care quality in under-resourced settings that predominantly serve low-income persons. The focus of the research will be on quality improvement interventions (QIIs) that target either or both health policy environments (Level D) and health care delivery organizations (Level C).  Quality improvement interventions may also target the clinical units of work that actually give the care that patients experience (e.g., outpatient clinics, emergency departments, hospitals and hospital units; Level B), but not this level alone. [Ref. 1,2,3,4.]   

While low-income patients across the board are affected by poor quality care, researching the effectiveness of implementation at the policy and organizational levels is essential. There is increasing evidence that disparities in care are at least partially attributable not only to who patients are (e.g., their socio-economic status, their racial/ethnic identification) but to where they get their care.  [Ref. 5,6,7,8,9,10.]  Without facilitative changes at policy and organizational levels, individual providers and small provider units in under-resourced settings are unlikely to be able to improve quality for their patients.

Further Guidance:

Research designs and methods. Research evaluations of the proposed QIIs may use alternatives to random assignment designs as long as they are rigorous enough to permit causal inferences.  Research incorporating Plan-Do-Study-Act approaches (small tests of change) in the context of a rigorous design are welcome. Sufficient information about the systems and/or organizational contexts of the interventions and the interventions’ nature, depth and intensity should be collected and linked to the intervention and findings so that the generalizability of findings to other systems and settings can be inferred and so that successful interventions can be replicated or adapted. Interventions that apply to more than one clinical condition are preferred. AHRQ uses the Institute of Medicine domains to define quality: safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness.4

Outcome measurement.  Improvements in health care quality should be measured using available consensus measures of quality at the appropriate levels of intervention.  Development and use of new measures must be justified by showing that consensus or widely used measures are not available.  

Inclusion of priority populations.  For purposes of this SEN, the “low-income” population includes low-income patients among AHRQ’s other priority populations (children, women, elderly, racial and ethnic minorities, individuals with special health care needs) and low-income populations in the priority areas of inner cities and rural areas, as stipulated by AHRQ’s Congressional authorizing legislation.

Limitation on grant funds.  Due to limitations on available grant funds for fiscal year 2007, AHRQ will maintain a limitation on grant funds on large research grant applications to $300,000 total costs (direct and indirect) per year and $100,000 total costs per year for large conference grant applications http://grants.nih.gov/grants/guide/notice-files/NOT-HS-04-007.html.

Application submission. With this notice, AHRQ provides information about the highest research priorities for unsolicited applications for fiscal year 2007. AHRQ will continue to provide regular updates of research priorities as research budget information becomes available. Applications focused on priority areas identified in this Special Emphasis Notice may be submitted on regular research and training grant application receipt dates and will be reviewed by standing AHRQ study sections. Application mechanisms currently accepted by AHRQ include R01, R03, R13, R18, K02, K08, F31, F32, and R36 applications.  Funding announcements for these mechanisms, as well as information about the grant application process, including e-grant applications, can be found at http://www.ahrq.gov/fund/.

Health policy environment level QII research includes, but need not be limited to, studies of the implementation of financial, regulatory or legislative changes that can arguably improve health care quality.    Health care delivery organization interventions can include team approaches to care, implementation of health information technology, and other changes that can be difficult to implement at the individual provider level.

Applicants are encouraged to contact AHRQ staff early in the process of preparing applications in order to clarify questions and discuss potential research projects. A listing of AHRQ staff contacts can be found at: http://www.ahrq.gov/fund/staffcon.htm.

1.  Berwick D. A user's manual for the IOM's 'Quality Chasm' Report. Health Affairs May/June 2002;21(3):80-90.
2.  Shortell S. Increasing value:  A research agenda for addressing the managerial and organizational challenges facing health care delivery in the United States. Medical Care Research and Review. September 2004;61(3 (Supplement)):12S-30S.
3.  Shojania K, McDonald K, Wachter R, Owens D. Closing the Quality Gap:  Volume 1--Series Overview and Methodology  Rockville, MD: AHRQ; July 2004. AHRQ Publication No. 04-0051-1.
4.  Institute of Medicine. Crossing the Quality Chasm:  A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
5.  Asch S, Baker D, Keesey J, et al. Does the collaborative model improve care for chronic heart failure? Medical Care. July 2005;43(7):667-675.
6.  Gillies R, Chenok K, Shortell S, Pawlson G, Wimbush J. The impact of health plan delivery system organization on clinical quality and patient satisfaction. HSR. Aug 2006;41(4 (Pt 1)):118-199.
7.     U.S. Department of Health and Human Services. National Healthcare Disparities Report 2005.  http://www.ahrq.gov/qual/nhdr05/nhdr05.htm. Accessed Aug. 28, 2006.
8.  Bach P, Pham H, Schrag D, Tate R, Hargraves J. Primary care physicians who treat blacks and whites. N Engl J Med. Aug 5 2004;351(6):575-584.
9.  Thompson J, Ryan K, Pinidiya S, Bost J. Quality of care for children in medicaid managed care:  Are differences between commercial and Medicaid beneficiaries inevitable? JAMA. Sep 17 2003;290(11):1486-1493.
10.  Lieu T, Finkelstein J, Lozano P, et al. Cultural competence policies and other predictors of asthma care quality for Medicaid-insured children. Pediatrics. Jul 2004;114(1):e102-110.


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