Thursday, April 11, 2013

Politics and practice guidelines: a volatile mix

Health services research in the United States has historically been the "poor cousin" of biomedical research in federal funding and support. The annual budget for the National Institutes of Health, for example, is typically around 100 times that of the Agency for Healthcare Research and Quality (AHRQ). In last month's Georgetown University Health Policy seminar, we discussed the financial and political challenges that AHRQ and its predecessor, the Agency for Health Care Policy and Research (AHCPR) have faced while trying to improve outcomes and effectiveness of medical care since the latter's founding during the first Bush Administration.

Citing John Wennberg's pioneering geographic analyses of medical practice variations and potentially inappropriate use of health services across the U.S., AHCPR's supporters wanted the new agency to produce practice guidelines to promote evidence-based care. However, when one of those guidelines suggested that spinal fusion surgery was unnecessary for most patients with acute low back pain, AHCPR found its budget under attack. It didn't help that the agency was also identified with the failed Clinton health reform plan and had few defenders left in a Republican Congress after the 1994 elections. Although the agency survived, this experience eventually drove it out of the guideline-producing business for good. When AHRQ was reauthorized in 1999, the word "policy" was removed from its name.

From 2010 AHRQ Annual Conference presentation by Dr. Francis Chesley, Jr.

It's understandable that this episode made future AHRQ leaders reluctant to wade into explosive scientific controversies, especially regarding sacred cows of medicine such as mammography and prostate cancer screening. When the AHRQ-supported U.S. Preventive Services Task Force chose to do so, the political fallout again put the agency in an uncomfortable position. Distancing itself from the USPSTF's recommendation against routine mammography in women younger than 50 and repeatedly delaying the release of another that advised clinicians to stop prostate-specific antigen testing altogether, AHRQ still found itself under heavy fire from health reform opponents on Capitol Hill. In July 2012, it was deja-vu all over again as AHRQ's budget was singled out for elimination by an appropriations subcommittee in the House of Representatives. Supporters of health services research in the U.S. lined up to defend the agency. The bill was not taken up by the Senate, and of this writing, AHRQ appears to have survived another "near death experience."


The above post first appeared on The Health Policy Exchange. Note: I was employed as a medical officer at AHRQ from October 2006 through December 2010.