MEASURES OF QUALITY OF CARE FOR VULNERABLE POPULATIONS

Release Date: December 22, 1998

RFA:  HS-99-001

P.T.

Agency for Health Care Policy and Research

Letter of Intent Receipt Date:  January 29, 1999
Application Receipt Date:  March 15, 1999

PURPOSE

The Agency for Health Care Policy and Research (AHCPR) invites applications to
stimulate and support research to develop measures of quality of care for
vulnerable populations, including those whose vulnerability is due to demographic
characteristics (such as age or race/ethnicity) or economic status, illness,
disability, or place of residence.

This Request for Applications (RFA) is one in a series of RFAs to support
research on quality of health care being issued by AHCPR over the next several
weeks.  These initiatives respond to the report, Quality First, The President's
Commission on Consumer Protection and Quality in the Health Care Industry
(Commission), which called for a significant investment in the further
development of research, tools, and information for patients, practitioners,
purchasers, and payers.

The three RFAs are:  1) Quality Measurement for Vulnerable Populations- to
develop and test new quality measures which can be used in the purchase or
improvement of health care services for populations identified as vulnerable in
the Commission report; 2) Translating Research into Practice- to generate new
knowledge about approaches, both innovative and established, which are effective
and cost-effective in promoting the use of rigorously derived evidence in
clinical settings and lead to improved health care practice and sustained
practitioner behavior change (with particular interest in studies that implement
AHCPR-supported evidence-based tools and information); and 3) Assessment of
Quality Improvement Strategies in Health Care- to rigorously evaluate strategies
for improving health care quality which are currently in widespread use by
organized quality improvement systems (projects that would expand the conceptual
and methodological basis for improving clinical quality and analyze the relative
utility and costs of various approaches to quality improvement).

In addition to their common context and theme, these three initiatives are also
designed to help build capacity in the field of health services research.  This
is accomplished through the inclusion of specific incentives to attract
applications from qualified minority and junior faculty health services
researchers.

Vulnerable populations, for the purposes of this RFA, are those made vulnerable
by their financial circumstances or place of residence; heath, age or functional
or developmental status; ability to communicate effectively; presence of chronic
or terminal illness or disability; or personal characteristics.  These
populations may be less able than others to safeguard their own needs and
interests adequately during this period of rapid health system change.  These
populations may incur different health outcomes traceable to unwarranted
disparities in their care or stemming from special needs for care or barriers to
care.  Measurement efforts designed for the general population may be unable to
detect deficiencies in quality of care for these groups.  Measures applicable to
the performance of health plans or institutional or clinical providers of care
with respect to these groups may provide new insight into problems that might
otherwise go undetected, and may provide the information necessary to devise
interventions to improve care.

AHCPR notes that, although productive researchers are engaged in quality
measurement research, they tend to be concentrated at a small number of
institutions.  Few of these researchers have focused on ethnic minorities or
people with disabilities.  Because capacity for study of these groups is
important in order to improve the effective use of measures determining their
quality of care, the Agency is particularly interested in receiving applications
from investigators not currently conducting research in this area.  AHCPR
encourages minority institutions to apply for funding under this solicitation and
encourages collaboration on projects between minority institutions and majority
institutions.  Minority institutions have had a significant role in delivering
health care to underserved communities and represent a valuable resource to
facilitate collaboration with those communities, while majority institutions may
bring greater experience in research on quality of care measurement.

AHCPR is committed to achieving the goals of the President's Race and Health
Disparities Initiative:  Eliminating by the year 2010 the differences in outcomes
and health status for racial and ethnic minority populations in six clinical
areas (infant mortality, cancer screening and management, cardiovascular disease,
diabetes, HIV infection, and child and adult immunization).  Many of these
disparities are not due to gaps in knowledge regarding disease processes but are
largely the result of provider factors, patient factors, and organizational
factors which impair the implementation of existing knowledge.  AHCPR seeks
research projects which will develop and validate measures that will assist in
achieving this ambitious goal.  For further information on this Initiative, see:
http://www.raceandhealth.hhs.gov.

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the health promotion
and disease prevention objectives of "Healthy People 2000," a PHS-led national
activity for setting priority areas.  AHCPR encourages applicants to submit grant
applications with relevance to the specific objectives of this initiative. 
Potential applicants may obtain a printed copy of "Healthy People 2000" (Full
Report: Stock No. 017-001-00474-0 or Summary Report: Stock No. 017-001-00473-1)
through the Superintendent of Documents, Government Printing Office, Washington,
DC 20402-9325, telephone 202-512-1800.

ELIGIBILITY REQUIREMENTS

Applications may be submitted by public or private non-profit organizations,
including universities, clinics, units of State and local governments, non-profit
firms, and non-profit foundations. For-profit entities may participate as members
of consortia or subcontractors if the applicant is non-profit.  Organizations
described in section 501(c)4 of the Internal Revenue Code that engage in lobbying
are not eligible.

AHCPR encourages investigators who are women, members of minority groups, and
persons with disabilities to apply as Principal Investigators.

MECHANISM OF SUPPORT

The RFA mechanism of support is the research project grant (R01).  Responsibility
for the planning, direction, and execution of the proposed project will be solely
that of the applicant. The earliest anticipated award date is September 1, 1999.

AHCPR is interested in funding 1 to 2-year projects but will consider projects
of up to 5 years.

This RFA is a one-time solicitation.  Future unsolicited applications, including
competing continuation applications, will compete with all other investigator-
initiated applications and be reviewed according to customary peer review
procedures.

FUNDS AVAILABLE

AHCPR expects to award up to $3 million in fiscal year 1999 to support the first
year of up to 10 projects under this RFA.  AHCPR will set aside approximately $1
million of that $3 million to support projects that address quality measures for
racial and ethnic minority population groups regarding the six clinical areas
identified in the President's Race and Health Disparities Initiative.

The number of awards is dependent on the number of high quality applications and
their individual budget requirements; it is not the intent of AHCPR that the
awards be equal in size. Funding beyond the initial budget period will depend
upon annual progress reviews by AHCPR and the availability of funds.

RESEARCH OBJECTIVES

Background

The rapid spread of managed health care over the past half-dozen years has raised
concerns that the search for efficiency may have mixed effects.  The various
systems that take shape may be beneficial to the society as a whole and perhaps
even to the majority of patients receiving care.  Yet they may ignore or be
ineffective for some population subgroups less able to demand and enforce demands
for the best quality care.  Even prior to the transformation of the health care
system via managed care, however, it was well known that some groups of people
consistently fared better than others in terms of their health and their health
care. There is no reason to believe that recent system changes have produced
remedies in most of these imbalances.  A discussion of some of these differences,
their sources, and recommendations for remedies can be found in the Final Report
of The President's Advisory Commission on Consumer Protection and Quality in the
Health Care Industry (Quality First, 1998).  The Report recognizes as vulnerable
population groups those "made vulnerable by their financial circumstances or
place of residence; health, age, or functional or developmental status; or
ability to communicate effectively...[and] personal characteristics, such as
race, ethnicity, and sex."  This RFA uses the same definition, which encompasses
those populations who are vulnerable due to chronic or terminal disease or
disability.

AHCPR has an interest in enhancing the availability of scientifically valid
measures of quality of care for these vulnerable populations.  Such measures are
needed to determine the performance of health plans, provider institutions, and
clinicians in providing care to these groups.  Measures of interest would be
those that lend themselves to use in designing and evaluating interventions--in
other words, they should be feasible, believable, and actionable.  Measures may
be those useful to conduct quality improvement initiatives, or to select
providers, as might be done by a health care plan or by a consumer or patient
with access to a full range of options.  They may be most useful in describing
best practices or benchmarks of care, or in some other feedback mode.  They also
may be the key to some other intervention using a scientifically based measure
in bringing about improved quality of care for these vulnerable populations.

Measurement strategies and methods are particularly challenging for vulnerable
populations because: (1) numbers of subgroup members in any single data set may
be too small for significant differences to be detected; (2) identifying the
groups through existing data systems may be difficult;  and (3) qualitative
information may be lacking about quality problems these groups face.  Research
addressing these methodologic issues is also of interest under this solicitation. 
(For example, an empirical question is the extent to which there are common
characteristics shared by multiple racial and ethnic minority groups, yet
distinct from other groups, for the purposes of assessing and improving quality
of care.)

Disparities in Care:

There is considerable and fairly consistent evidence that members of some groups,
such as ethnic minority groups and women, do not receive the same level of care
in some important situations as their male or majority-group counterparts
(Ayanian and others, 1991; Johnson, 1993).  Examples of some of these situations
are cardiac surgery and hypertension treatment.  People from certain
neighborhoods (that is, with high proportions of poor and black residents) have
been shown to get care of lesser quality than others in a given type of hospital
(Kahn and others, 1994).  Elderly people undergoing heart attacks or strokes may
not be receiving interventions that might benefit them because of excessive fears
about adverse outcomes (Rich, 1998).  To date, there is little systematic
understanding of the extent to which stereotypical thinking or misinformation on
the part of clinicians may be responsible for disparities of this kind.  Clearly
there are other factors involved, such as patient preference, insurance coverage,
and clinical indications.  Measures of the probable etiology, nature, extent, and
consequences of such problems are necessary in order to develop and test
interventions to enhance equity in medical decision making for such groups. 
Purely descriptive studies of inequities are not of interest under this
solicitation unless they are essentially linked to development and validation of
a quality measure.

Despite gains which have occurred in the overall health of Americans, significant
disparities persist in the burden of illness and death experienced by racial and
ethnic minority populations.  The health of these groups increasingly will affect
the health of the entire nation because of their projected growth as a proportion
of the U.S. population.  The challenge of improving the health of the nation
increasingly is becoming the challenge of eliminating health disparities
experienced by these populations.  One purpose of this solicitation is to fund
research projects which address quality of care measures for one or more of the
six conditions (infant mortality, cancer screening and management, cardiovascular
disease, diabetes, HIV infection, and child and adult immunization) identified
in the President's Race and Health Disparities Initiative.  Quality measures
developed through this solicitation will support the Initiative by providing
tools to improve interactions and interventions in minority communities.

Different or Disproportionate Needs for Care or Barriers to Care:

There are many well-known differences among populations in their needs for care
and the barriers they encounter in seeking care.  For example, despite the fact
that AHCPR-supported clinical guidelines on acute and chronic pain were published
in 1992 and 1994 respectively(see References below), many persons still are not
receiving adequate pain management (Brockopp and others, 1998). Many of these
patients would fit the definition of a vulnerable population because of chronic
or terminal disease conditions.  Among their special needs would be pain control. 
Given that pain control is well established as an evidence-based process of care,
measures of pain control that are tested and validated in one or more vulnerable
populations would be appropriate products of research under this solicitation.

Similarly, the vulnerability of children as a group stems from their differences
from adults in their care needs.  These differences often are not recognized; for
example, ambulances and emergency facilities may not be equipped or staffed
properly to provide the most effective emergency care to children (IOM, 1993). 
Prenatal care is understood to be a critical determinant in the birth of healthy
infants, but process measures of prenatal care are not well identified. 
Adolescents frequently receive care in facilities such as school health, STD or
family-planning centers.  Research on some conditions that are important problems
for children and adults, such as asthma, has not yielded good measures for
children.  For others that are problems principally of childhood, such as otitis
media, measures are sparse.

Patients with chronic conditions or disabilities may find their needs unmet, as
reported by a recent Harris poll(American Health Line, 1998).  This is especially
true when this source of vulnerability is compounded by another.  Children with
disabilities, for example, are undoubtedly at a particular disadvantage.  Low
income, ethnicity, or chronic illness may have especially severe effects on
subgroups such as women, members of ethnic minorities, or the elderly. 
Particular categories of chronic disease and disability have been especially
under-researched in terms of quality measurement, such as prevention and care of
dental or mental health conditions.  A population that has not been under-
researched, in comparison with others, is the general Medicare population, for
whom data availability has been an attraction.  Within this group, however, may
be special subgroups and circumstances (for example, the frail elderly or
cognitively impaired patients) that would be justifiable as a focus for
measurement development.  In addition, studies of broadly defined groups such as
Hispanics might be of less interest than studies of specific subgroups (e.g.,
Mexican-Americans, Cubans).

Patients with literacy or language problems or those who have impairments of
hearing or vision may not properly receive or fully understand a clinician's
explanations or instructions or may have problems accessing care in the first
place.  Their particular characteristics as patients and consumers may not be
well understood, as many clinical and health services research studies have
excluded people with limited ability to speak or read English (Frayne and others,
1996), and other-language versions of standard instruments are rare and of
uncertain reliability and validity.  Culturally determined beliefs or practices
may be at odds with practices and assumptions of U.S. health care, or with the
practices of individual organizations or clinicians, to such an extent that
patients do not seek or do not receive the full benefit of necessary health
services.  Language and cultural issues may affect groups such as relatively
recent immigrants of Asian/Pacific Island, African, Hispanic, or Eastern European
origin, indigenous groups such as Native Americans, or long-established Hispanic-
origin communities.  Cultural issues may also affect relationships between
providers belonging to one ethnic population and patients belonging to another.

Access to care at any level, or access to specialty and referral care, may be of
particular concern for some groups.  Examples are rural/wilderness populations;
the uninsured; members of Medicaid or Medicare managed care plans now
experiencing financial difficulties; or the poor who lack transportation to
sources of care, or lack sources of care available outside their working hours. 
To the extent that access at any point in the continuum of care becomes, in
practice, a denial of necessary care, this becomes a quality issue.  Again, the
burden is on the applicant to show how measures developed will be of use in
improving quality of care; scenarios will be considered on the basis of immediacy
and specificity.

Illustrative Research Questions

o  What is the relationship between measures of cultural competence (based, for
example, on translation and interpretation services) and the quality of health
services delivery?

o  What are the most efficient process measures to serve as indicators of quality
for the widest variety of vulnerable populations?

o  What structural measures of quality of care for a vulnerable population can
be linked either to validated process measures (that is, measures with evidence
of linkage to outcomes) or to outcomes?  For example, is the presence of minority
ethnic staff related to reduced disparities in care?  Does use of clinical
guidelines or protocols reduce disparities in care?  Does presence of
interpreters improve patient adherence to treatment plans?

o  Are there useful process measures of quality or outcome measures that have
been validated for adults but not for children, or for adults that excluded older
age groups that can be validated for these previously excluded age groups?

o  Are there specific indicators of (1) disparities in care or (2) special care
needs or barriers for persons with chronic disease or disabilities that can be
used to identify and remedy more general problems in quality of care for these
subsets of patients or plan members?  For example, might problems related to
diabetic care also reflect problems in care of hypertension or another chronic
condition?

o  What additional information is gained by stratified application of quality
measures?

o  How do measures of health status perform in various minority ethnic
populations, and how does that performance compare with that in majority
populations?  How do outcome measures perform in minority populations?  Are
different measures of health status or health outcome required for minority as
compared with majority populations?  How do various risk adjustment methodologies
based on patient outcomes (rather than cost or utilization) perform among
minority populations?

o  To what extent are quality measures requiring patient report impaired by low
response rates among, or exclusion of, vulnerable subgroups?  What can be done
to improve response rates and ensure inclusion of vulnerable subgroups?

o  Are quality of care instruments which have been validated for the general
population or majority population also valid for racial/ethnic minority
populations?

AHCPR DATA

To the extent feasible, AHCPR applicants are encouraged to submit projects that
build on available data, will generate early results, and are modest in time,
scale, and cost.

AHCPR encourages research applications that will use data from the Medical
Expenditure Panel Survey (MEPS), the Healthcare Cost and Utilization Project
(HCUP-3), and other AHCPR data.

The MEPS is a rich data source for health care utilization, expenditure, and
insurance information, directly linking data about persons and their families
with information obtained from their employers, insurers, and health care
providers.  It is the third in a series of nationally representative surveys of
medical care use and expenditures in the U.S.  The 1996 MEPS updates previous
survey data to reflect the changes that have occurred over the past decade.  MEPS
collects data on the specific health services that Americans use, how frequently
they use them, the cost and source of payment for services, and information on
the types and costs of private health insurance held by and available to the U.S.
population.  It provides a foundation for estimating the impact of changes in
sources of payment and insurance coverage on different economic groups or special
populations of interest, such as the poor, elderly, uninsured, and racial and
ethnic minorities.

Some data from the Household and Nursing Home Components of the 1996 MEPS became
available for use by researchers beginning in March 1997.  The release schedule
for other data through calendar year 1998 is available from the MEPS section of
the AHCPR Web site (See below).

HCUP includes two data bases covering 1988-1996, with 1996 data available early
in 1999.  These all-payer databases were created through a Federal-state-industry
partnership to build a multistate health care data system.  Both data bases
contain patient-level information for inpatient hospital stays in a uniform
format with privacy protections.  The State Inpatient Database (SID), available
from the partner states, contains inpatient records for all community hospitals
in 19 states, and ambulatory surgery data from five states.  The Nationwide
Inpatient Sample (NIS) is drawn from the SID to approximate a national sample of
950 hospitals and includes all inpatient records (6.5 million) from these
institutions.  These data bases can be directly linked to county-level data from
the Health Resources and Services Administrations Area Resource File and to
hospital-level data from the Annual Survey of the American Hospital Association.
Fourteen of the 19 states include information on race-ethnicity on the patient
record.  HCUP data can be used to assess disparities among population subgroups
in conditions, treatments, and outcomes.

Information on MEPS AND HCUP-3 is available from the Data and Methods section of
the AHCPR Web site, and AHCPR staff (See INQUIRIES).

CONDITIONS OF AWARD

In addition to other applicable grants policies and requirements, the following
conditions apply to all AHCPR grant awards.  Applicants should also be familiar
with the agency's grant regulation, 42 CFR Part 67 Subpart A, and particularly
sections 67.18-67.22.

Data Privacy

Information obtained in the course of this study that identifies an individual
or entity must be treated as confidential in accordance with section 903(c) of
the Public Health Service Act.  Applicants must describe in the Human Subjects
section of the application procedures for ensuring the confidentiality of
identifying information.  The description of the procedures should include a
discussion of who will be permitted access to the information, both raw data and
machine readable files, and how personal identifiers will be safeguarded.

Rights in Data

AHCPR grantees may copyright or seek patents, as appropriate, for final and
interim products and materials including, but not limited to, methodological
tools, measures, software with documentation, literature searches, and analyses,
which are developed in whole or in part with AHCPR funds.  Such copyrights and
patents are subject to a Federal Government license to use these products and
materials for AHCPR purposes.  In accordance with its legislative dissemination
mandate, AHCPR purposes may include, subject to statutory confidentiality
protections, making research materials, data bases, and algorithms available for
verification or replication by other researchers; and subject to AHCPR budget
constraints, final products may be made available to the health care community
and the public by AHCPR, or its agents, if such distribution would significantly
increase access to a product and thereby produce public health benefits. 
Ordinarily, to accomplish distribution, AHCPR publicizes research findings but
relies on grantees to publish in peer-reviewed journals and to market grant-
supported products.

INCLUSION OF WOMEN, MINORITIES, AND CHILDREN IN RESEARCH STUDY POPULATIONS
INVOLVING HUMAN SUBJECTS

It is the policy of AHCPR that women and members of minority groups be included
in all AHCPR-supported research projects involving human subjects, unless a clear
and compelling rationale and justification are provided that inclusion is
inappropriate with respect to the health of the subjects or the purpose of the
research.

All investigators proposing research involving human subjects should read the
"NIH Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical
Research," which was published in the Federal Register of March 28, 1994 (FR 59
14508-14513), and printed in the NIH GUIDE FOR GRANTS AND CONTRACTS of March 18,
1994.  AHCPR follows the NIH Guidelines, as applicable.

Investigators may obtain copies from those sources or from the AHCPR contractor,
Equals Three Communications, Inc., listed under INQUIRIES.

AHCPR is also encouraging investigators to consider including children in study
populations, as appropriate.  AHCPR announced in the NIH Guide of May 9, 1997,
that it is developing a policy and implementation plan on the inclusion of
children in health services research.  This Notice is available through the AHCPR
Web site http://www.ahcpr.gov (Funding Opportunities) and InstantFAX (see
instructions under INQUIRIES).

AHCPR program staff may also provide information concerning these policies (See
INQUIRIES).

Special Inclusion Requirement

All investigators are expected to make provisions to include non-English speakers
or those with limited English facility as appropriate.  To the extent that a
specific ethnic minority constitutes 10 per cent or more of the population of
interest in a study, the application should provide detailed information on how
translation, interpretation and/or culturally-sensitive methods will be employed
to include those among that group with limited ability to read, understand, or
speak English.

LETTER OF INTENT

Prospective applicants are asked to submit, by January 29, 1999, a letter of
intent that includes the name, address, and telephone number of the proposed
Principal Investigator and other key personnel; a descriptive title of the
application; and the number and title of this RFA.  Although a letter of intent
is not required, is not binding, and does not enter into the consideration of any
subsequent application, the information allows AHCPR to estimate the potential
review workload and avoid conflicts of interest in the review.  AHCPR will not
provide responses to letters of intent.

The letter of intent is to be addressed to:

Elinor Walker
Center for Quality Measurement and Improvement
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 502
Rockville, MD  20852-4908
FAX:  (301) 594-2155
Email: [email protected]

APPLICATION PROCEDURES

The research grant application form PHS 398 (rev. 4/98) is to be used in applying
for these grants.  State and local government applicants may use form PHS-5161-1,
Application for Federal Assistance (rev. 5/96), and follow those requirements for
copy submission.  Application kits are available at most institutional offices
of sponsored research and may be obtained from the Division of Extramural
Outreach and Information Resources, National Institutes of Health, 6701 Rockledge
Drive, MSC 7910, Bethesda, MD  20892-7910, telephone 301/710-0267, E-mail:
[email protected].

AHCPR applicants should obtain application materials from the AHCPR contractor:
Equals Three Communications, Inc., 7910 Woodmont Avenue, Suite 200, Bethesda, MD 
20814-3015; telephone 301/656-3100 or FAX 301/652-5264

The RFA label available in the form PHS 398 (rev. 4/98) must be affixed to the
bottom of the face page of the original application.  Failure to do so could
result in delayed processing of the application such that it may not reach the
review committee in time for review.  In addition, the RFA title and number must
be typed on line 2 of the face page of the application form and YES must be
marked.

The PHS 398 type size requirements (p.6) will be enforced rigorously and non-
compliant applications returned.

Submit a signed, typewritten original of the application, including the
Checklist, and three signed photocopies, in one package to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040, MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for express/courier service)

Applications submitted under this RFA must be received in the CSR, NIH, no later
than March 15, 1999.  If an application is received later than that it will be
returned to the applicant without review.

At the time of submission, two additional copies of the application, labeled
"Advance Copy," must be sent to:

Lisa Krever
Center for Quality Measurement and Improvement
Agency for Health Care Quality and Research
2101 E. Jefferson Street, Suite 502
Rockville, MD  20852-4908

Application Preparation (for Using HCFA Data)

For applications that propose to use Medicare or Medicaid data that are
individually identifiable, applicants should state explicitly in the "Research
Design and Methods" section of the Research Plan (form PHS 398) the specific
files, time periods, and cohorts proposed for the research.  In consultation with
the Health Care Financing Administration (HCFA), AHCPR will use this information
to develop a cost estimate for obtaining the data.  This estimate will be
included in the estimated total cost of the grant at the time funding decisions
are made.

Applicants should be aware that for individually identifiable Medicare and
Medicaid data, Principal Investigators and their grantee institutions will be
required to enter into a Data Use Agreement (DUA) with HCFA to protect the
confidentiality of data in accordance with OMB Circular A-130, Appendix III--
Security of Federal Automated Information Systems.  The use of the data is
restricted to the purposes and time period specified in the DUA.  At the end of
this time period, the grantee is required to return the data to HCFA or certify
that the data have been destroyed.  Grantees must also comply with the
confidentiality requirements of Section 903(c) of the PHS Act.

REVIEW CONSIDERATIONS

Applications that are complete and responsive to the RFA will be evaluated for
scientific and technical merit by an appropriate peer review group convened in
accordance with AHCPR peer review procedures.  If the application is not
responsive to the RFA, Referral staff may contact the applicant to determine
whether to return the application to the applicant or submit it for review in
competition with unsolicited applications at the next review cycle.  As part of
the merit review, all applications will receive a written critique, and also may
undergo a process in which only those applications deemed to have the highest
scientific merit will be discussed and assigned a priority score.

General Review Criteria

Review criteria for AHCPR grant applications are: significance and originality
from a scientific and technical viewpoint; adequacy of the method(s);
availability of data or proposed plan to collect data required for the project;
adequacy of the plan for organizing and carrying out the project; qualifications
and experience of the Principal Investigator and proposed staff; reasonableness
of the proposed budget; and adequacy of the facilities and resources available
to the applicant; the extent to which women, minorities and children (as
appropriate) are adequately represented in study populations; and where
applicable, the adequacy of the proposed means for protecting human subjects.

Special Review Criteria

1.  The significance of the project in addressing the needs of the target group
as a vulnerable population.

2.  The extent to which and immediacy with which the research findings and
products can be expected to be used to improve care for the vulnerable
population.  Evidence in this regard would be:

a.  Direct involvement and investment in the research by insurer, provider, or
advocacy groups whose participation heightens the probability of application in
practice;

b.  Presentation of a plan to implement measures to improve quality.

3.  The specificity and adequacy of methods proposed for including linguistic and
cultural minorities in the study.

Additional Review Criteria for Set-Aside Funds

In addition to the review criteria above, applications will be evaluated on the
following criteria to determine their eligibility for the $1 million set-aside
funds:

1. The significance of the project in addressing one or more of the six
conditions identified in the President's Race and Health Disparities Initiative
(infant mortality, cancer screening and management, cardiovascular disease,
diabetes, HIV infection, and child and adult immunization) in one or more of the
four identified racial/ethnic minority population groups (Black; Hispanic;
American Indian and Alaska Native; and Asian American and Pacific Islander).

2. The degree to which the project demonstrates a meaningful collaboration
between a minority institution and a majority institution.

AWARD CRITERIA

Applications will compete for available funds with all other applications under
this RFA.  Applications deemed eligible for set-aside funds will compete with
other eligible applications for set-aside funds, and if not funded, will then
compete with all other applications under this RFA.  The following will be
considered in making funding decisions:  quality of the proposed project as
determined by peer review, program balance, and availability of funds.

Special preference will be accorded to applications from investigators not
recently or currently funded as principal investigator of an AHCPR grant for
research in quality measurement.

In addition, the AHCPR is particularly interested in funding policy relevant
proposals that can be completed within one to two years.

Also considered will be the extent to which projects are complementary to and
build on AHCPR's ongoing quality initiatives (See INQUIRIES).  Projects that are
complementary to these initiatives, rather than overlapping, will be considered
as furthering program balance.  Applications directly overlapping with QSpan
projects will not be funded, or if overlap is partial, funds will not be awarded
for overlapping activities. The earliest anticipated date of award for
applications is September 1, 1999.

INQUIRIES

AHCPR wishes to assure that new applications build on existing research, as
appropriate, and are not unnecessarily redundant with currently supported
research. Applicants are encouraged to use AHCPR's Web site
(http://www.ahcpr.gov) to learn about AHCPR major initiatives, such as Q-Span
(Expansion of Quality of Care Measures) and CAHPS (Consumer Assessment of Health
Plans).  Information on these initiatives is also available from the AHCPR
Clearinghouse, 1-800-358-9295.

Copies of this RFA are available from AHCPR's Web site or from:

Equals Three Communications, Inc.
7910 Woodmont Avenue, Suite 200
Bethesda, MD  20814-3015
Telephone: 301/656-3100
FAX: 301/652-5264

This RFA is also available on AHCPR's Web site, http://www.ahcpr.gov (Funding
Opportunities) and through AHCPR InstantFAX at 301/594-2800.  To use InstantFAX,
you must call from a facsimile (FAX) machine with a telephone handset.  Follow
the voice prompt to obtain a copy of the InstantFAX table of contents, which has
the document order number (not the same as the RFA number).  The RFA will be sent
at the end of the ordering process.  AHCPR InstantFAX operates 24 hours a day,
7 days a week.  For questions about this service, call Judy Wilcox, Office of
Health Care Information, at 301/594-1364, ext. 1389.

AHCPR welcomes the opportunity to clarify any issues or questions from potential
applicants.  Written and telephone inquiries are encouraged.  Direct inquiries
regarding program matters to:

Elinor Walker
Center for Quality Measurement and Improvement
Agency for Health Care Policy and Research
2101 E. Jefferson Street, Suite 502
Rockville, MD  20852-4908
Telephone:  (301) 594-2049
FAX:  (301) 594-2155
Email:  [email protected]

For inquiries regarding AHCPR data sources:

MEPS Household Component
Nancy Krauss
Center for Cost and Financing Studies
Telephone:  (301) 594-1406, ext. 1489
Email: [email protected]

MEPS Nursing Home Component
Jeffrey Rhoades
Center for Cost and Financing Studies
Telephone:  (301) 594-1406, ext. 1473
Email: [email protected]

HCUP-3
Kelly Carper
Telephone:  (301) 594-1406, ext. 1520
Email: [email protected] or [email protected] or [email protected]

Direct inquiries regarding fiscal matters to:

Al Deal
Grants Management Specialist
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 601
Rockville, MD  20852-4908
Telephone:  (301) 594-1843
FAX:  (301) 594-3210
Email:  [email protected]

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance Number
93.226.  Awards are made under authorization of Title IX of the Public Health
Service Act (42 U.S.C. 299-299c-6) and Section 1142 of the Social Security Act
(42 U.S.C. 1320b-12) as applicable.  Awards are administered under the PHS Grants
Policy Statement and Federal regulations 42 CFR 67, Subpart A, and 45 CFR Parts
74 and 92.  This program is not subject to the intergovernmental review
requirements of Executive Order 12372 or Health Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a smoke-
free workplace and promote the non-use of all tobacco products.  In addition,
Public Law 103-227, The Pro-Children Act of 1994, prohibits smoking in  certain
facilities (or in some cases, any portion of a facility) in which regular or
routine education, library, day care, health care, or early childhood development
services are provided to children.  This is consistent with the PHS mission to
protect and advance the physical and mental health of the American people.

References

Agency for Health Care Policy and Research.  Acute Pain Management in Adults:
Operative Procedures. Quick Reference Guide for Clinicians, 22 pp. (AHCPR 92-
0019).

Agency for Health Care Policy and Research (1994).  Management of Cancer Pain:
Adults.  Quick Reference Guide for Clinicians, Number 9, 29 pp. (AHCPR 94-0593).

Ayanian, JZ; Epstein, AM (1991).  Differences in the Use of Procedures Between
Women and Men Hospitalized for Coronary Heart Disease, N Engl J Med, 325:226-230.

DeJong, G. (1997).  Primary Care for Persons with Disabilities.  Am J Phys Med
Rehabil, 76 (3Suppl): S2-8.

Disabled Lack Medical Care Compared to Non-Disabled (1998, October 15).  American
Health Line.

Emergency Medical Services for Children (1993).  Institute of Medicine, National
Academy Press, Washington, DC.

Frayne, SM; Burns, RB; Hardt, EJ; and others (1996).  The Exclusion of Non-
English-Speaking Persons from Research, J Gen Intern Med, 11:39-43.

Johnson, PA; Lee, TH; Cook, EF; and others (1993).  Effect of Race on the
Presentation and Management of Patients with Chest Pain, Ann Intern Med,
118:593-601.

Kahn, KL; Pearson, ML; Harrison, ER; and others (1994, April 20).  Health Care
for Black and Poor Hospitalized Patients, JAMA 271(15):1169-74.

Neff, JM and Anderson, G (1995, December 20).  Protecting Children with Chronic
Illness in a Competitive Marketplace,  JAMA  274(23):1866-9.

Quality First:  Better Health Care for All Americans (1998). Final Report of the
President's Advisory Commission on Consumer Protection and Quality in the Health
Care Industry.  Washington, DC:  U.S. Government Printing Office.

Rich, MW (1998, October).  A Therapy for Acute Myocardial Infarction in Older
Persons, J Am Geriatr Soc 46 (10):1302-7.

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