www.ahrq.gov

The mission of AHRQ is to improve the quality,

safety, efficiency, and effectiveness of health

care by:

• Using evidence to improve health care.

• Improving health care outcomes through

research.

• Transforming research into practice.

Background

The Institute of Medicine’s (IOM)

2003 report, Priority Areas for National

Action: Transforming Health Care

Quality, identifies 20 diseases and

clinical conditions that may be

significantly improved or effectively

managed by using best practice

treatment guidelines. Scientific studies

have proven that following best practice

guidelines reduces suffering and patient

mortality, while improving quality of

life and clinical outcomes.

The IOM report and other, much older

literature note that the rate of adoption

for best practice guidelines has been

frustratingly low. As a result, many

thousands of American lives are lost

each year to medical conditions that

can be treated successfully.

New and more effective health care

treatment practices often do not

quickly find their way into clinical

practice, despite attention garnered in

professional journals and at medical

conferences. Recent studies indicate an

average of 17 years is needed before

new knowledge generated through

research, such as randomized clinical

trials, is incorporated into widespread

clinical practice—and even then the

application of the knowledge is very

uneven.

The disturbing gap in quality—the

difference between present treatment

success rates and those thought to be

achievable using best practice

guidelines—led the Agency for

Healthcare Research and Quality

(AHRQ) to examine the issues

surrounding the adoption of improved

clinical practices.

In an effort to determine which

strategies are more effective than others

for introducing proven treatment

methods, AHRQ commissioned

researchers at the Stanford University

–University of California at San

Francisco EPC1 to study the quality

improvement literature for a number of

the priority conditions identified in the

Closing the Quality Gap:

A Critical Analysis of

Quality Improvement

Strategies

FACT SHEET

U.S. Department of Health 

and Human Services

Public Health Service

Agency for Healthcare Research and Quality

1The Agency oversees 12 Evidence-based Practice Centers (EPCs), tasked with analyzing and

synthesizing the scientific literature related to medical conditions/issues that consume a significant share

of health care resources and affect large numbers of Medicare or Medicaid users. The contractor

organizations operating the EPCs include universities, nonprofit research organizations, and health care

organizations (http://www.ahrq.gov/clinic/epc/).

Advancing Excellence in Health Care
IOM report. These studies, to be

undertaken and published over a 2-year

period, will be diverse in their focus

and are intended to address best

practice implementation issues across

the full spectrum of health care—from

wellness and prevention, to chronic and

acute disease treatment, to end-of-life

care.

The EPC studies will be published as a

series of AHRQ Technical Reviews

called Closing the Quality Gap: A

Critical Analysis of Quality Improvement

Strategies, and will explore the human

and organizational factors influencing

various quality improvement strategies. Many reasons exist for the quality gap

between the best, evidence-based

models of patient treatment and the

actual care received by patients. Chief

among them are increased treatmentrelated expenses, a lag in the spread of

knowledge concerning an improved

treatment technique, skepticism regarding the observed increase in

effectiveness, and insufficient staffing or

equipment resources. There is also the

possibility that a practice shown to be

highly effective in a specialized research

setting is not practical for some clinical

settings.

Moreover, the coordinated delivery of

health care has become so complex that

physicians, nurses, and other providers

with responsibilities for patient care

often find they can no longer devote

the time necessary to assimilate the

ever-expanding numbers of clinical

studies and emerging treatment

advances.

The Closing the Quality Gap series will

address many of the IOM-identified

treatment priorities, and it is AHRQ’s

hope that the series will stimulate ideas

for further quality improvement across

a broad range of users; for example:

• Policymakers can use the detailed

evidence review to prioritize quality

improvement strategies and choose

how best to narrow the quality gaps

in their organizations.

• Researchers can find detailed

information about well-studied areas

of treatment, while learning of areas

in need of greater exploration.

• Clinicians and trainees can see a

broad spectrum of approaches to

improving the quality of care. Some

of these approaches fall within the

control of individual practitioners,

while others will require major

systemic changes at the local level or

beyond.

• Patients can learn quality

improvement strategies that they

can help to promote, while gaining

a deeper understanding of the

nature and extent of quality gaps, as

well as the systemic changes

necessary to close them.

•Groups and individuals charged

with funding research will be able to

identify high-yield areas of concern

that warrant future research support.

Theories on creating positive change in

the behaviors of patients, clinicians, and

organizations often draw from studies

that try to determine the o

verall effect

of changing a single factor, or

combinations of factors, in otherwise

controlled situations. Other studies

focus on the clinical setting, on

particular treatment interventions, or

on specific targets for change. Researchers studying the literature must

accurately interpret a diverse range of

journal articles and analyze the overall

statistical findings, as well as the

circumstances unique to each included

study.

2 Advancing Excellence in Health Care
Methodology

To help users assess the validity of the

studies presented in each volume of the

series, the EPC researchers restricted

their review of quality improvement

strategies to those studies most likely to

produce scientifically valid results.

These include randomized controlled

trials—considered the gold standard of

experiment designs—as well as other

high quality studies. They did so with

the knowledge that the relatively strict

study criteria may have excluded some

possibly relevant results. Findings from

the most valid studies were analyzed

using accepted statistical tools; further

analyses of combined data also were

performed when studies were found to

be consistent in their design and

population, and had comparable

outcomes.

Nine quality improvement strategies

were evaluated for their effectiveness in

the priority condition reports. The

researchers defined a quality

improvement (QI) strategy as any tool or

process aimed at reducing the quality

gap for a group of patients typical of

those seen in routine practice.

The following QI strategies were used

in the priority condition studies as a

measure of potential gains in best

practice adherence:

1. Physician reminder systems (such as

prompts in paper charts or

computer-based reminders).

2.Facilitated relay of clinical data to

providers (patient data transmitted

by telephone call or fax, from

outpatient specialty clinics to

primary care physicians).

3.Audit and feedback (physician

performance tracking and reviews,

using quality indicators and reports,

comparisons with national/State

quality report cards, publicly

released performance data, and

benchmark outcomes data).

4. Physician education (workshops and

professional conferences,

educational outreach visits,

distribution of educational

materials).

5. Patient education (classes, parent

and family education, pamphlets

and other media, etc.).

6. Promotion of disease selfmanagement (workshops, materials

such as blood pressure or glucose

monitoring devices).

7.Patient reminder systems (telephone

calls or postcards from physicians to

their patients).

8. Organizational changes (Total

Quality Management or

Continuous Quality Improvement

programs, multidisciplinary teams,

shifting from paper-based to

computer-based recordkeeping,

long-distance case discussion

between professional peers).

9.Financial incentives, regulation, and

policy (performance-based bonuses

and alternative reimbursement

systems for physicians, positive or

negative financial incentives for

patients, and changes in professional

licensure requirements).

Looking Ahead

The first volume in the Closing the

Quality Gap series outlines the

challenges inherent to the process of

translating research into clinical

practice, as well as the methodology

used by the EPC staff to review the

included studies. 

Volumes 2 and 3 are

devoted to improving treatment for

patients suffering from conditions that

adversely affect the lives of millions:

diabetes and hypertension. Other

3

Advancing Excellence in Health Care
www.ahrq.gov

AHRQ Pub No. 04-P014

March 2004

volumes in the series will examine the

relation of quality improvement

strategies to broader issues, such as

medication management and care

coordination.

While medicine has a long history of

investigating what works and why, the

behavioral mechanisms that spur the

adoption and widespread

implementation of new and more

effective treatment practices are not

entirely understood. Remarkably—and

despite the millions of lives at stake—

relatively little information exists on the

most effective ways for translating

research into clinical practice.

It is AHRQ’s hope that the Closing the

Quality Gap series will advance the

knowledge of best practice guideline

implementation, and will help to reduce

the numbers of lives lost each year to

painful, debilitating, and all-too-often

fatal medical conditions.

For More Information

For additional information on AHRQ’s

projects involving evidence-based

treatment practices and quality

improvements in the delivery of health

care, visit the AHRQ Website

www.ahrq.gov or contact:

Kenneth Fink, M.D., M.G.A., M.P.H.

Director

AHRQ Evidence-based Practice Centers

Program

Phone: 301-427-1617

E-mail: kfink@ahrq.gov