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 Department of Health and Human Services Agency for Healthcare Research and Quality
 AGENCY: Agency for Healthcare Research and Quality, HHS.
 ACTION: Notice.
 SUMMARY: This notice announces the intention of the Agency for Healthcare Research and Quality (AHRQ) to request that the Office of Management and Budget (OMB) approve the proposed information collection project: “Coordinating Care across Primary Care and Specialty Care Practices.” In accordance with the Paperwork Reduction Act of 1995, 44 U.S.C. 3506(c)(2)(A), AHRQ invites the public to comment on this proposed information collection.
 DATES: Comments on this notice must be received by May 4, 2009.
 ADDRESSES: Written comments should be submitted to: Doris Lefkowitz, Reports Clearance Officer, AHRQ, by e-mail at 
                        *doris.lefkowitz@ahrq.hhs.gov*. Copies of the proposed collection plans, data collection instruments, and specific details on the estimated burden can be obtained from the AHRQ Reports Clearance Officer.
 FOR FURTHER INFORMATION CONTACT: Doris Lefkowitz, AHRQ Reports Clearance Officer, (301) 427-1477, or by e-mail at 
                        *doris.lefkowitz@ahrq.hhs.gov*.


SUPPLEMENTARY INFORMATION: Proposed Project “Coordinating Care Across Primary Care and Specialty Care Practices” AHRQ proposes an evaluation of the redesign of the transitions of care between primary care and specialty care services. The purpose of the redesign is to remedy inefficiencies in the current referral processes that threaten care quality and safety, and system efficiency. This redesign is being implemented at the Boston Medical 
                    ( print page 9614)
                    Center (BMC), and two affiliated health centers. The evaluation will be conducted for AHRQ by its contractor, the Boston University School of Public Health (BUSPH). Care coordination has been identified by the Institute of Medicine (IOM) as a key strategy with potential to improve the effectiveness, safety and efficiency of the health care system. At the same time, care coordination, particularly in transitions among sites of care, is often lacking. Research shows that problems in coordination of care and common failures in patients' transitioning between and among systems typically create serious quality concerns in many settings. Individuals moving across systems of care and between care providers are vulnerable to fragmented and disjointed care (Coleman et al., 2004). Uncoordinated and fragmented transitions can lead to a wide range of costly problems and threats to patient safety including greater use of hospital and emergency services (Coleman et al., 2004), ordering and completion of redundant tests (Coleman & Berenson, 2004), prescription and medication errors and use of poly-pharmacy by multiple providers (Coleman & Berenson, 2004). The end result is often confusion about conflicting care plans and lack of follow-up care. The aim of this evaluation is to address this confusion and fragmentation by expanding knowledge of how to improve the experience and outcomes for patients in transitions of care between primary care and specialty practices. The initial focus is on referrals between primary care and two specialties: gastroenterology (GI) and obstetrics (OB). The redesigned referral system will be tested by implementing it in three participating primary care sites and two specialty clinics. We expect that the lessons learned from this evaluation will provide a model and tools that can later easily be tested and applied to other sites and specialties in the BMC system and provide lessons learned to other systems seeking to sustainably improve their referral systems. This project is being conducted pursuant to AHRQ's statutory authority to conduct research and evaluations on health care and systems for the delivery of such care, including activities with respect to: the quality, effectiveness, efficiency, appropriateness and value of health care services; clinical practice, including primary care and practice-oriented research; and health care costs, productivity, organization, and market forces. See 42 U.S.C. 299a(a)(l), (4) and (6). The overall aims of the evaluation are to provide a rigorous assessment of the success of the redesigned referral system in meeting its improvement goals and to gain an understanding of the implementation of the redesigned system. Method of Collection This evaluation will include the following data collections: ☐ Medical record data will be used to analyze aspects of the referral process, such as percentage of items on referral forms filled in, proportion of specialty appointments made, time between referral and initial specialty appointment. Patients' personal health data will not be analyzed. The medical record data will be used to measure both the fidelity of the redesigned system within the practices and success in meeting redesign improvement goal (outcome) indicators. The medical record data will be extracted by project staff and will not impose a burden on the participating health care sites. ☐ Patient satisfaction survey will be administered to selected patients twice during the project. The questionnaire will be designed to assess patient experience in the referral system. Only patients with referrals to obstetrics or gastroenterology specialists will receive the questionnaire. These two questionnaires are essentially identical and vary only by the type of specialist seen; for the purpose of this clearance request they are treated as identical. Results from the first survey will provide baseline data; results from the second survey will provide the basis for assessing change over time and fidelity to the new system design. ☐ Focus groups with providers, clinical staff and administrative staff will be conducted in each primary care site and in each specialty practice. The group sessions will pursue three topics: the extent to which the new system is being used as intended; the perceived effectiveness of the new system as implemented; and the organization and culture of the clinical setting. Themes from the focus groups will be used to assess fidelity of implementation, performance outcomes and factors affecting fidelity and outcomes. ☐ Implementation logs and meeting notes kept by the project team throughout the redesign implementation will document the implementation process, including factors affecting the process, challenges encountered, and strategies for dealing with the challenges. This component of the evaluation will not impose a burden on the participating health care sites. Estimated Annual Respondent Burden Exhibit 1 shows the estimated annualized burden hours for the respondents' time to participate in this two year evaluation. The patient satisfaction survey questionnaire will be completed by a total of 600 patients prior to the referral process redesign and 600 patients after the completion of the redesign (Exhibit 1 shows 300 per year). The questionnaire is estimated to take 6 minutes to complete. Focus groups will be conducted with about 21 clinical staff at each of the 3 primary care sites and 2 specialty care sites (Exhibit 1 shows 2.5 sites per year). Each focus group session will last about 45 minutes. The total annualized burden is estimated to be 99 hours. Exhibit 2 shows the estimated annualized cost burden associated with the respondents' time to participate in this project. The total annualized cost burden is estimated to be $2,620. Exhibit 1—Estimated Annualized Burden Hours
Form name
Number of
                             respondents
Number of
                             responses per 
                             respondent
Hours per
                             response
Total burden hoursPatient satisfaction survey
300
2
6/60
60Focus groups
2.5
21
45/60
39Total
302.5
na
na
99
 
 
 Exhibit 2—Estimated Annualized Cost Burden
Form name
Number of
                             respondents
Total burden hours
Average
                             hourly wage 
                             rate*
Total cost
                             burdenPatient satisfaction survey
300
60
$19.29
$1,157Focus groups
2.5
39
37.50
1,463Total
302.5
99
na
2,620* The hourly wage for the patient surveys is based on the national average wage. The hourly wage for the focus groups is based upon the weighted mean of the average wages for physicians ($58.76, n=45), clinical administrative staff ($17.64, n=30) and other clinical staff ($25.48, n=30). National Compensation Survey: Occupational Wages in the United States, U.S. Department of Labor, Bureau of Labor Statistics. June 2007, Summary 07-03, 
                        *http://www.bls.gov/​ncs/​ocs/​sp/​ncblO9lO.pdf*. Accessed December 10, 2008.
 Estimated Annual Costs to the Federal Government Exhibit 3 shows the estimated total and annualized cost for this two-year evaluation. The total cost is $155,110 and includes $23,267 for project development, $32,573 for data collection activities, $31,022 for data processing and analysis, $15,511 for the publication of results, $12,408 for project management and $40,329 for overhead. Exhibit 3—Estimated Total and Annualized Cost
Cost component
Total cost
Annualized costProject Development
$23,267
$11,633Data Collection Activities
32,573
16,287Data Processing and Analysis
31,022
15,511Publication of Results
15,511
7,756Project Management
12,408
6,204Overhead
40,329
20,164Total
155,110
77,555
 Request for Comments In accordance with the above-cited Paperwork Reduction Act legislation, comments on AHRQ's information collection are requested with regard to any of the following: (a) Whether the proposed collection of information is necessary for the proper performance of AHRQ health care research, quality improvement and information dissemination functions, including whether the information will have practical utility; (b) the accuracy of AHRQ's estimate of burden (including hours and costs) of the proposed collection(s) of information; (c) ways to enhance the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information upon the respondents, including the use of automated collection techniques or other forms of information technology. Comments submitted in response to this notice will be summarized and included in the Agency's subsequent request for OMB approval of the proposed information collection. All comments will become a matter of public record. Dated: February 24, 2009. Carol M. Clancy, Director.


[FR Doc. E9-4515 Filed 3-4-09; 8:45 am] BILLING CODE 4160-90-M