Appendix C
Template for Submissions of Topics to the Agency for Healthcare Research and Quality

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Appendix C Template for Submissions of Topics to the Agency for Healthcare Research and Quality 9

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9 KNOWING WHAT WORKS IN HEALTH CARE Appendix Template for Submissions of Topics for AHRQ Evidence Reports or Technology Assessments Please complete the following information to nominate an AHRQ evidence report or technol- ogy assessment topic. Topic nominations should be submitted to Acting Director, Evidence- based Practice Centers (EPC) Program, Center for Outcomes and Evidence at AHRQ. Please e-mail this document to AHRQ will evaluate nominations based on: (a) the rationale and evidence of the importance of the topic; (b) plans for rapid translation of the resulting EPC report findings; (c) plans for dissemination of derivative products; and (d) plans for measuring the use and impact of an EPC report. Note: Please refer to the Federal Register Notice ( 27058.htm) for the due date of this topic nomination; topic nominations are typically due 50-60 days following the publication of the Federal Register Notice, for submittal of topics for consideration in the current fiscal year. However, topic nominations also can be submitted electronically to AHRQ on an ongoing basis. Nominating Organization Information Please provide contact information and an overview of the nominating organization, such as its mission, priorities, research agenda and/or interest or commitment to evidence analyses, etc. Organization Name: Contact Name: Title: Address: Phone: E-mail: Overview of Organization:

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9 APPENDIX C Proposed Evidence Assessment Topic and Evidence Questions Please provide a brief description of the proposed topic. Appropriate topics are those that focus on clinical or behavioral issues or those that address organization, financing or delivery of health care. Brief Name of Topic: Please provide 3 to 5 well-defined evidence questions to guide the evidence review or tech- nology assessment. (Additional well-defined evidence questions may be provided if neces- sary to address the topic.) An appropriate evidence question is one that can be addressed by a review of the available evidence by an EPC. Evidence questions should address, wherever applicable, particular indications, populations, interventions, care settings, and/or outcomes (e.g., effectiveness, safety, cost-effectiveness, etc.) of interest. Example 1 INSTEAD OF: What are the appropriate indications for [procedure X]? TRY: Does [procedure X] improve [certain outcomes] for [certain types of] patients? OR For what types of patients is there strong evidence that [procedure X] improves [certain outcomes]? Example 2 INSTEAD OF: What are the effects on health care of defined contribution models? TRY: How does utilization of previously covered health care services change when employers offer defined contribution models to their employees? In developing your evidence questions, please consider the guidance on framing evidence questions for AHRQ Topic Nominations outlined in the Partners Guide (see page 10). Evidence Question #1 Evidence Question #2 Evidence Question #3 Evidence Question #4 Evidence Question #5

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96 KNOWING WHAT WORKS IN HEALTH CARE Please complete the first box below for clinical and/or behavioral topics or the second box for organizational, financial and health care delivery topics. Defined Condition and Target Population of the Intervention (for clinical and/or behavioral topics) Nomination of clinical and behavioral topics should focus on specific aspects of screening, prevention, diagnosis, treatment, rehabilitation of a particular disease or condition; alterna- tive or complementary therapies; and/or on one or more procedures, interventions or other technologies used in the management of the disease or condition. Please provide below a description of the condition and/or disease and target population of the intervention to be assessed in the evidence review. Defined Organizational/Financial Arrangement or Structure (for organizational, finance and health care delivery topics) Nominations of organization, financing and delivery topics should focus on specific aspects of the organization, financing or delivery of health care. Among the broad range of potential topics are such examples as risk-adjustment methodologies, market performance measures, provider payment methodologies, insurance purchasing tools, etc. Please provide below a description of the organizational/financial arrangement or structure to be assessed in the evidence review.

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97 APPENDIX C Topic Rationale and Supporting Evidence Please provide a concise narrative justification for the topic to be nominated along with sup- porting evidence on the relevance and importance of the topic. This section is organized by key factors that will be considered in the selection of topics for AHRQ evidence reports and technology assessments. Please provide information under each selection factor that is applicable to the topic. It is not necessary to fill in each section. Description of the burden of disease, including severity, incidence and/or prevalence or relevance of organizational/financial topic to the general population and/or AHRQ’s priority populations (i.e., low-income groups, minority groups, women, children, el- derly, individuals with special health care needs) High costs associated with a condition, procedure, treatment, technology, organiza- tion/financial topic, taking into account the number of people needing such care, the unit cost of care and related or indirect costs Impact potential of an evidence report on this topic to improve patient and/or provider decision-making, improve health outcomes and/or reduce costs Availability of scientific and/or administrative data and bibliographies of studies on the topic to support the systematic review and analysis of the topic References to significant differences in practice patterns or results of health out- comes, alternative therapies and/or related controversies or uncertainties about the topic Relevance to the needs of the Medicare, Medicaid and other federal health care programs

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9 KNOWING WHAT WORKS IN HEALTH CARE Plans for Translation of the Evidence Report into Derivative Products EPCs take approximately one year to produce evidence reports/technology assessments. Organizations that nominate topics are responsible for translating the evidence reports and/or technology assessments into products that are useful for their memberships or other target groups. Please describe your plans for translating the evidence reports into quality improvement tools (e.g., clinical practice guidelines, performance measures), educational programs and/or coverage or reimbursement policies. Plans for Dissemination of These Derivative Products to its Membership Organizations nominating topics are responsible for disseminating the derivative prod- ucts to their memberships or other target groups, as appropriate. Please describe your organization’s plans for disseminating these quality improvement tools (e.g., clinical practice guidelines, performance measures), educational programs, etc. Please include a description of the target groups of these products (e.g., organizational members, health professionals, patient/consumer groups, regulators, etc.), proposed dissemination media (e.g., journal articles, print media, Internet), and timeframe for dissemination. How Organization will Measure Use of the Products and Impact of Such Use Organizations nominating topics are responsible for measuring the use of the derivative products and their impact. Please describe the process by which your organization will mea- sure the use of the products and the impact of such use on clinical care. In addition, briefly describe any barriers to use or implementation of the derivative products (e.g., lack of fund- ing, lack of patient compliance, professional resistance) and possible means to overcome these barriers (e.g., continuing education, changes in payment policies).