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Notice Number: NOT-HS-13-009
Release Date: May 17, 2013
Agency for Healthcare Research and Quality (AHRQ)
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 system practices that benefit patients.
This Special Emphasis Notice (SEN) informs the research community that AHRQ intends to support research designed to improve diagnostic performance in ambulatory care settings. With this notice, AHRQ is providing information about one of its highest research priorities for investigator initiated applications. This includes gaining a better understanding of the incidence, cost, determinants, and strategies for preventing or mitigating diagnostic errors (i.e., misdiagnosis, missed diagnosis, delayed diagnosis). For the purposes of this SEN, ambulatory care refers to health care provided in emergency departments; clinicians' offices and practices, both large and small; outpatient clinics; community health centers; urgent care centers; and ambulatory surgery centers. Researchers from non-ambulatory settings with a strong interest in fostering safe, high quality diagnostic performance are welcome to apply, but must do so in partnership with an ambulatory care organization.
Diagnostic error comprises a significant and costly fraction of all medical errors and has resulted in devastating consequences for patients, families, and health care professionals. Diagnostic error encompasses a broad array of factors that converge and interact in time-constrained and dynamic clinical settings. The emerging literature has implicated cognitive, affective, and perceptual factors; systems-based factors; education and training; settings-of care; disease-specific entities; domain-specific concerns; laboratory-related processes; use of tools and technologies; and healthcare policy issues, among other factors.
Examples of cognitive issues include flawed reasoning, incomplete knowledge, faulty information gathering or interpretation, and inappropriate use of decision-making heuristics (i.e., cognitive shortcuts used in decision making that do not always hold true). System-related components include production pressures and high patient volumes, tools and technology that can improve or impede diagnostic performance, flawed workflow processes, lack of feedback mechanisms that enable recalibration of diagnostic performance, ineffective coordination and communication, and misaligned payment incentives, among other examples. At the same time, there is a need for innovative and improved education and training methods that can be reliably demonstrated. Laboratory-related failures entail the total testing process, including pre-analytic, analytic, and post-analytic phases. Performing and interpreting diagnostic tests can be more problematic in certain settings such as emergency departments, with certain diseases or conditions such as cancer or depression, and with diverse patient populations that can involve variations in language, health literacy, and cultural norms. Mental health diagnoses present another challenge for many ambulatory care settings. These are just a few areas of diagnostic vulnerability, but not all the areas, of potential interest to AHRQ. Applications addressing diagnostic challenges and issues not addressed above are welcomed.
Priority Populations. Diagnostic errors impact all populations regardless of age, gender, ethnicity, or socio-ethnic backgrounds. However, these factors may underlie missed diagnoses, diagnostic work-ups, and the level of care received. Priority populations continue to be an area of interest to AHRQ. For purposes of this SEN, priority populations include low-income patients and the uninsured along with AHRQ's other priority populations (children, women, elderly, racial and ethnic minorities, and individuals with special health care needs).
Use of Multiple Funding Mechanisms. AHRQ will use standing grant mechanisms such as the R01, R03, R18, and K08 funding mechanisms to support research on diagnostic errors. The relevant general AHRQ Funding Opportunity Announcements for R01, R18, R03, and K08 mechanisms can be found at: http://www.ahrq.gov/funding/research/announcements/index.html.
Limitations on Timelines and Funds. Due to limitations on available grant funds, AHRQ currently limits the total (direct plus indirect) costs for the R01 and R18 mechanisms to no more than $250,000 per year. The project period for large projects can be up to five years. R03 applications are limited to total (direct plus indirect) costs of no more than $100,000 for the duration of the project which may be up to two years.
Application Submission. Applicants should consider this SEN active until further notice. AHRQ will provide updates of new developments and research priorities as research budget information becomes available. Applications focused on areas identified in this SEN should be submitted on regular research grant receipt dates and will be reviewed by AHRQ's standing study sections. Information about the grant application process, including e-grant applications and the funding mechanisms noted above, can be found at http://www.ahrq.gov/funding/index.html.
The AHRQ designated contacts for this SEN are:
R01, R03, and R18 inquiries:
Kerm Henriksen, Ph.D.
Center for Quality Improvement and Patient Safety
Kay Anderson, Ph.D.
Office of Extramural Research, Education, and Priority Populations
Applicants are encouraged to contact the designated AHRQ staff early in the process of preparing applications in order to clarify questions and discuss potential research projects.