**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 technology 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 epc@ahrq.gov.

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
(http://edocket.access.gpo.gov/2005/04-27058.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.

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  **Organization                                                                
  Name:**                                                                       

  **Contact                                                **Title:**           
  Name:**                                                                       

  **Address:**                                                                  

                                                                                

  **Phone:**                                 **E-mail:**                        
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**Overview of Organization:**

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**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.

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  **Brief Name   
  of Topic:**    

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Please provide 3 to 5 *well-defined* evidence questions to guide the
evidence review or technology assessment. (Additional well-defined
evidence questions may be provided if necessary 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**

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> **Evidence Question #2**

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> **Evidence Question #3**

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> **Evidence Question #4**

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> **Evidence Question #5**

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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; alternative 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.**

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**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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**Topic Rationale and Supporting Evidence**

Please provide a concise narrative justification for the topic to be
nominated along with supporting 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, elderly, individuals
> with special health care needs)**

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> **High costs associated with a condition, procedure, treatment,
> technology, organization/financial topic, taking into account the
> number of people needing such care, the unit cost of care and related
> or indirect costs**

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> **Impact potential of an evidence report on this topic to improve
> patient and/or provider decision-making, improve health outcomes
> and/or reduce costs**

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> Availability of scientific and/or administrative data and
> bibliographies of studies on the topic to support the systematic
> review and analysis of the topic

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> **References to significant differences in practice patterns or
> results of health outcomes, alternative therapies** and/or related
> controversies or uncertainties about the topic

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> ***Relevance to the needs of the Medicare, Medicaid and other federal
> health care programs***

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**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.

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**Plans for Dissemination of These Derivative Products to its
Membership**

**Organizations nominating topics are responsible for disseminating the
derivative products 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.**

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**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 measure 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 funding, lack of patient compliance, professional resistance) and
possible means to overcome these barriers (e.g., continuing education,
changes in payment policies).

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**Appendices**

Please attach any relevant appendices to this document in your e-mail to
AHRQ.