Subject: RFA AHCPR-9l-0l 2/l5/9l NIH Guide HC
From: Dot Baker <[email-masked]>
To: [email-masked]
Date: Thu, 14 Feb 91 14:34 EST

Hi Paul,
   Another one.  Please post to the NIH Listserver as:
RFAAHCPR-91-01.910215
                     Dottie
 ---------------------------- Text of forwarded message -----------------------
 
EFFECTIVE DISSEMINATION OF HEALTH SERVICES RESEARCH FINDINGS AND
MEDICAL PRACTICE GUIDELINES
 
RFA AVAILABLE:  AHCPR-91-01
 
P.T. 16; K.W. 0730050, 0730000, 0403004
 
Agency for Health Care Policy and Research
 
Application Receipt Dates:  April 26, June 1, October 1, 1991,
and February 1, 1992
 
BACKGROUND
 
The Agency for Health Care Policy and Research (AHCPR) invites
applications to conduct applied research on effective
dissemination of clinical knowledge and medical practice
guidelines to effect changes in practitioner and consumer
behavior, improve patient outcomes and, thereby, improve the
effectiveness, quality, and appropriateness of health care.  The
term "effective dissemination" encompasses the broader concept of
diffusion as well as the actual distribution of knowledge and new
information.  Additionally, the process through which target
groups become aware of, receive, accept, and utilize disseminated
information and knowledge is reflected in this term.
 
AHCPR has lead responsibility for the Medical Treatment
Effectiveness Program (MEDTEP), a program of the Department of
Health and Human Services.  Under MEDTEP, projects are supported
that systematically study the relationships between medical
treatments and procedures and its outcomes.  Research findings
will be an important part of the knowledge base that will be used
by non-Federal experts to develop medical practice guidelines, as
mandated by Sections 903 and 914(c) of the Omnibus Reconciliation
Act of 1989 (P.L. 101-239).
 
Research conducted under the MEDTEP program addresses fundamental
questions about what difference medical care makes:  Do patients
benefit?  What treatments work best?  Are health care resources
well spent?  MEDTEP research projects build on work that
documents numerous and substantial variations in patterns of care
that can neither be attributed to patient need nor clearly linked
to patient outcomes (Wennberg, 1987; Connell, 1981).  MEDTEP is
concerned with those practice variations that result from
uncertainty or controversy about the relative effectiveness or
appropriateness of alternative interventions, and those that
result from differences in the knowledge, skill, or "practice
styles" of health care providers.  When practice variations are
associated with disparate patient outcomes, or equivalent
outcomes but significant differences in resource use, serious
questions arise about the quality, appropriateness, and cost
effectiveness of health care.
 
A critical assumption is that inappropriate practice patterns can
be changed if relevant scientific evidence is effectively
disseminated to health care providers and patients.  There is
growing evidence that health care providers will voluntarily
change their practice patterns if they are made aware that the
patterns deviate markedly from local or national norms (Wennberg,
1977; Wennberg, 1984; McCormick, 1990).  For example, recent
reports from hospitals in all parts of the country indicate that
educational forums to disseminate research findings on quality
and costs of care have led to voluntary reductions in practice
patterns (McCormick, 1990).  A recent article that summarized the
literature on educational interventions to modify physician drug
prescribing behavior concluded that sustained change in physician
prescribing occurs, but only when information is provided to
physicians by physicians (Soumerai, 1990).
 
Although some health services research has occurred in the area
of dissemination of new knowledge, it has focused primarily on
the introduction of medical technology or the flow of new
information into practice.  A substantial amount of research has
examined the role of continuing medical education (CME) in
providing physicians with new information and knowledge.
Research findings suggest that traditional CME programs tend to
be ineffective in changing physician behavior over time (Haynes,
et.al., 1984).
 
Research has begun to accumulate in the area of physician
behavior change resulting from the diffusion of new information
or medical practice guidelines.  This literature has highlighted
the following:
 
o Studies examining the flow and utility of information to
physicians have emphasized:  the inability to keep abreast of the
volume of literature; the uncertainty associated with applying
particular clinical research findings to medical practice; and
the uncertainty associated with continually changing clinical
findings of new studies.  Peer review, journal articles,
interaction at professional meetings, and opinion leaders emerge
as key aspects of knowledge transfer and use and as potential
channels for dissemination (Backer, et. al., 1986; Backer and
Ohara, 1989; Greer, 1988; Lomas and Haynes, 1988).
 
o Issues related to the adoption of innovations by physicians in
hospital settings have been studied, focusing on the use of
computerized medical records in quality assurance programs to
provide feedback to physicians and other hospital staff (Lomas
and Haynes, 1988; McDonald, 1990).  However, research is needed
on structural and process variables within a wide variety of
provider settings and how these variables can facilitate or
hinder the dissemination of new information and knowledge.  These
variables include:  multifaceted organizational relationships
within provider organizations; administrative governance; medical
direction; type of medical equipment available within an
institution; degree of compliance with recommended guidelines;
and level of internal communication.  These variables are often
important considerations when examining outcomes of care, and
they can be critical factors affecting the capacity to
disseminate clinical information and medical practice guidelines.
 
o More recent literature has focused on changes in physician
behavior as a result of dissemination of medical guidelines and
diffusion of new medical information and related research
findings.  An assessment of the Consensus Development Program
conducted by the National Institutes of Health found that despite
relative success in disseminating information from that program,
physician practice often remained unaffected.  The evidence
suggests that either simply disseminating clinical
recommendations or offering them in a didactic manner has not
demonstrated substantial impact in changing physician behavior.
Thus, there is a need for innovative strategies that utilize
multiple mechanisms in conjunction with one another (Backer,
1988; Kanouse and Jacoby, 1988; Lomas and Haynes, 1988; Lomas,
et. al., 1989).
 
Patients' expectations regarding their health and their health
care can also be influenced by salient information that is
effectively presented.  Clearly, desired changes in practice are
not automatic, and more empirical evidence is needed on ways to
bring changes about.
 
MEDTEP generates and evaluates scientific information to expand
and strengthen the information base for decisions by health care
providers and patients regarding choice of health care services
and procedures.  To accomplish this, information must be
delivered in a form and manner that encourages its acceptance and
use by providers and its comprehension by patients and other
members of the public.  Health care providers need methods to
explain treatment options to patients and then, to incorporate
patients' preferences and values into their professional
judgments.  Policymakers and planners need good science to make
more informed decisions about incentives and the use of health
care resources under public and private programs.
 
PURPOSE AND OBJECTIVES
 
This Request for Applications (RFA) describes the range of studies that
AHCPR encourages and intends to support at this time in the field
of dissemination research.  The objective is to stimulate new
grant applications on issues dealing with the ways in which
scientific information can be presented and disseminated to
foster its assimilation and use by health care providers and
patients and, ultimately, to improve the effectiveness, quality,
and appropriateness of medical care.
 
The process and structural factors influencing dissemination and
assimilation need to be examined.  This RFA
encourages studies that evaluate the dissemination of, and
outcomes associated with, clinical practice guidelines or
parameters assisted by AHCPR and other public and private
entities.  It also encourages the assessment and use of
particular models and techniques that effectively disseminate
clinical information and clinical practice guidelines.
 
Broad and timely dissemination of MEDTEP research findings is
critical.  Research, however, is needed to identify the relative
effectiveness of various ways to disseminate findings to diverse
audiences and to evaluate the effect of alternative dissemination
strategies.  Research is required to explore innovative methods
to assess audience needs and to translate the findings of patient
outcomes research into formats that will be most useful to
different target groups.  The effectiveness of dissemination is a
measure of the speed and completeness with which information is
assimilated and adopted, and the degree to which dissemination
activities motivate and sustain voluntary changes in provider or
patient behavior.
 
The following questions are illustrative examples of the research
issues and questions concerning dissemination of research
findings that merit investigation at this time.
 
How do factors such as timeliness of dissemination, acceptability
and retention of information, and appropriateness of the format
affect its assimilation and use by health care providers?
 
How can communication and computer technologies be designed to
affect assimilation and retention of information by health care
providers?
 
What is the comparative effectiveness of existing or new models
and techniques in disseminating clinical information and clinical
practice guidelines to providers?
 
What is the profile of the characteristics of successful
dissemination efforts in the health care sector or in other
industries that can serve as models or strategies for use in the
dissemination of clinical practice guidelines or other research-
related knowledge?
 
How do cultural, socioeconomic, and access factors affect the
assimilation of clinical information by providers and patients
within special population or target groups and geographic areas
(e.g., rural and minority)?
 
What is the effect of process and structural variables (e.g.,
organizational, personnel mix, work environment, and roles and
incentives) on the relationship between the assimilation of
practice guidelines by the health care provider and patient
outcomes?
 
How does type of provider organization (e.g., HMO, fee-for-
service sector) affect assimilation and retention of new
information and what is the effect of this on patient outcomes?
 
How do economic and regulatory incentives affect the timing and
nature of decisions to adopt and utilize medical practice
guidelines?
 
How do the socioeconomic, demographic, and professional
characteristics of providers affect the assimilation and
retention of new scientific information about health care
practices?
 
What are the barriers to the assimilation and adoption of medical
practice guidelines and how can these be overcome?
 
ELIGIBILITY
 
Applicants must be public entities or nonprofit organizations and
institutions.  Proposed Principal Investigators must have
demonstrated expertise in dissemination of health services
research findings, clinical research findings, or medical
practice guidelines.  Applicants must also have demonstrated (1)
capability to conduct and manage applied research or
demonstration and evaluation projects in the area(s) that will be
the subject of the dissemination project; and (2) expertise in
communications.  Eligibility is restricted to U.S. institutions.
Project staff will need a combination of clinical, research, and
administrative expertise.
 
LENGTH OF SUPPORT
 
It is anticipated that projects will vary from one to three years
in length.  Project lengths could be up to five years in rare
cases in which the complexity or breadth of the subject area so
mandated, or in areas proposing to research the longer term
effects of particular forms of dissemination.
 
MECHANISM OF SUPPORT
 
All projects will be funded as research grants (RO1).  The start date
for funded projects with under $250,000 total direct costs will
be September 30, 1991.  The start date for funded projects with
total direct costs greater than $250,000 will be December 1,
1991.
 
Approximately four to ten grant awards will be issued during FY
1991 and FY 1992 depending upon the number and cost of approved
applications.  It is expected that $4 million will be spent.
Applications for dissemination research grants in
subsequent years will compete equally for funding with other
applications to AHCPR.
 
PREPARATION OF APPLICATIONS
 
Each application will be submitted in accordance with the
instructions of form PHS 398 (rev. 10/88).  State and local
governments using form DHHS 5161 must submit an original and two
copies of the application.  The following requirements must be
discussed in the Project narrative in addition to the
requirements specified in the application kit:
 
Specific Aims
 
o Where appropriate, the long-term objectives of the project must
specify the product(s) to be disseminated and the audiences to be
targeted.
 
o The dissemination methods and questions to be addressed should
be discussed in terms of ascertaining the effects of
dissemination on behavior change, characteristics or
effectiveness of dissemination techniques, or the development of
an innovative dissemination model.
 
Progress Report/Preliminary Studies
 
o Prior studies conducted by the Principal Investigator pertaining
to dissemination, health services research (especially in the
areas where AHCPR has ongoing work) or communications research
that will contribute to the proposed project should be described.
 
Experimental Design and Methods
 
o The specific dissemination model that will be used or developed
in the project should be explicitly addressed in terms of:
audiences; type of product or the knowledge to be disseminated;
technique of dissemination; characteristics or variables of
dissemination to be used and/or examined; and the relationship of
the project to the structure of the health care system, clinical
management, health care outcomes, and health status.
 
REVIEW PROCEDURES AND CRITERIA
 
Applications must be submitted to:
 
Application Receipt Office
Division of Research Grants
Westwood Building, Room 240
Bethesda, MD  20892**
 
Applications will be referred to an AHCPR study section for
initial review.  Applications requesting total direct costs in
excess of $250,000 will also be reviewed by the National Advisory
Council for Health Care Policy, Research, and Evaluation.
 
Applications will be reviewed in accordance with the standard
AHCPR peer review procedures.  The review criteria for these
applications are the considerations of scientific and technical
excellence, which include:  adequacy of the method to carry out
the project; availability of data or the proposed plan to collect
data required for the project; qualifications and experience of
the Principal Investigator and proposed staff; adequacy of the
plan for organizing and carrying out the project; reasonableness
of the proposed budget; and adequacy of the facilities and
resources available to the grantee.  In addition, the following
criteria will be considered:  ability of the project's results to
be applied to the dissemination of AHCPR products now and in the
future; adherence of the project approach to accepted principles
of communication and dissemination; and ability to analyze the
effects of dissemination on behavior change among practitioners
and consumers.
 
APPLICATION PROCEDURES
 
Those considering an application to this RFA are strongly
encouraged to discuss their project with AHCPR program
administrators in advance of formal submission.
 
Applications must address all requirements as presented in this
RFA.
 
Use application form PHS 398 (rev.  10/88).  State and local
governments may use form DHHS 5161.  These forms may be secured
from the Office of Scientific Review, Agency for Health Care
Policy and Research, Room 18A-20, Parklawn Building, 5600 Fishers
Lane, Rockville, Maryland 20857 (telephone 301-443-3091) and from
most institutional business offices.
 
Type in line 2 of the face page of the application the words "RFA
AHCPR-91-01:  AHCPR Dissemination Effectiveness" and use the RFA label
in the application package.
 
The original and 6 copies of the application should be submitted
to DRG as directed in the application instructions.  State and
local governments using form DHHS 5161 must submit an original
and two copies of the application.
 
Applications must be received at DRG by the close of business
April 26, June 1, October 1, 1991, and February 1,
1992.  Applications submitted after the deadline date will be
considered in the next review cycle.
 
INQUIRIES
 
For further assistance and consultation on program requirements,
contact:
 
Margaret VanAmringe
Director, Center for Research Dissemination and Liaison
Parklawn Building, Room 18A-10
5600 Fishers Lane
Rockville, MD  20857
Telephone:  (301) 443-2904
 
For information regarding budgetary/administrative issues
contact:
 
Ralph Sloat
Grants Management Officer
Agency for Health Care Policy and Research
Parklawn Building, Room 18A-27
5600 Fishers Lane
Rockville, MD  20857
Telephone:  (301) 443-4033
 
This program is described in the Catalog of Federal Domestic
Assistance No. 93.180 and 93.226.
 
Executive Order 12372 does not apply to AHCPR grant programs.
 
REFERENCES
 
Backer, TE, "Research Utilization and Managing Utilization in
Rehabilitative Organizations," Journal of Rehabilitation, Vol.
54, No. 2, pp 18-22, 1988.
 
Backer, TE, Liberman, RP, and Kuehnel, TG, "Dissemination and
Adoption of Innovative Psychosocial Interventions,"  Journal of
Consulting and Clinical Psychology, Vol. 54, No. 1, pp 111-118,
1986.
 
Backer, TE, and Ohara, KB, Knowledge Transfer and Utilization in
Health Care:  A Review for the National Emergency Medical
Services for Children Program, Human Interaction Research
Institute, December, 1989.
 
Connell, FA, Day, RW, and Logerfo, JP, "Hospitalization of
Medicaid Children:  Analysis of Small Area Variations in
Admission Rates," American Journal of Public Health, Vol. 71, No.
6, pp 606-613.
 
Greer, AL, "The State of the Art Versus the State of the Science
-- the Diffusion of New Medical Technologies into Practice,"
International Journal of Technology Assessment in Health Care,
Vol. 4, pp 5-26, 1988.
 
Haynes, RB, Davis, DA, McKibbon, DA, and Tugwell, P, "A Critical
Appraisal of the Efficacy of Continuing Medical Education,"
Journal of the American Medical Association, Vol. 251, pp 61-64,
1984.
 
Kanouse, DE and Jacoby, I, "When Does Information Change
Behavior?" International Journal of Technology Assessment in
Health Care, Vol. 4, pp 27-33, 1988.
 
Lomas, J, "Holding Back the Tide of Cesareans -- Publishing
Recommendations is Not Enough," British Medical Journal, Vol 297,
pp 569-570, 1988 (editorial).
 
Lomas, J, Anderson, GM, Domnick-Pierre, K, Vayda, E, Enkin, MW,
and Hannah, WJ, "Do Practice Guidelines Guide Practice?  The
Effect of a Consensus Statement on the Practice of Physicians,"
New England Journal of Medicine, Vol. 321, No. 19, pp 1306-1311,
1989.
 
Lomas, J and Haynes, RB, "A Taxonomy and Critical Review of
Tested Strategies for the Application of Clinical Practice
Recommendations:  From "Official" to "Individual" Clinical
Policy," American Journal of Preventive Medicine, Vol 4 (Suppl),
pp 77-84, 1988.
 
McCormick, B, "Can Research Change the Way MDs Practice
Medicine?" Hospitals, October 5, pp 32-38, 1990.
 
McDonald, C, "Effect of Computer Feedback on Physician Test-
Ordering," New England Journal of Medicine, Vol. 322, pp 1499-
1504, 1990.
 
Soumerai, SB, and Avorn, J, "Principles of Educational Outreach
('Academic Detailing') to Improve Clinical Decision Making,"
Journal of the American Medical Association, Vol. 263, No. 4, pp
549-556, 1990,
 
Wennberg, JE, Blowers, L, Parker, R, and Gittelsohn, A, "Changes
in Tonsillectomy Rates Associated with Feedback and Review,"
Pediatrics, Vol. 59, pp 821-826, 1977.
 
Wennberg, JE, "Dealing With Medical Practice Variations:  A
Proposal for Action," Health Affairs, Vol. 3, pp 6-32, 1984.
 
Wennberg, JR, Freeman, JL, and Culp, WJ, "Are Hospital Services
Rationed in New Haven or Over-Utilized in Boston?" Lancet, pp
1185-1189, 1987.