1. Translating Research into Practice: Making Today’s Goals Tomorrow’s Reality
Carolyn Clancy, M.D.
Director
Agency for Healthcare Research and Quality
Oregon Health & Science University Grand Rounds
Portland – January 14, 2008

2. Excellence & Mediocrity
“A society which scorns excellence in plumbing simply because it is plumbing, but rewards mediocre philosophy simply because it is philosophy will soon become a society in which neither its pipes nor its theories will hold water.”
John W. Gardner (1961)

3. ‘Consider This Recent Case’

4. Social Workers Disease Management Nurses Physicians Medical Home PHRs
Coordination of Care
Care Managers
Physicians
Social Workers
Disease Management
Medical Home
Patients
PHRs
Family & Care Givers
Nurses

5. Making Today’s Goals Tomorrow’s Reality
Turning Evidence Into Action: AHRQ Resources and Priorities
Comparative Effectiveness: Effective Health Care
Current and Future Directions for Health IT
21st Century Health Care
Q&A

6. AHRQ’s Mission
Improve the quality, safety, efficiency and effectiveness of health care for all Americans

7. FY 2008 Funding $334.6 million FY 2008 appropriation includes:
FY 2008 Request – $329.6 million
FY 2007 Appropriation – $318.7 million
FY 2008 appropriation includes:
$30 million for comparative effectiveness research
Double the $15 million designated in FY 2007
$5 million for research and activities to reduce Methicillin Resistant Staphylococcus aureus (MRSA) and related infections
The first such federal grant to AHRQ for MRSA/HAIs
Congress also encouraged AHRQ to:
Consider proposals to detect medical errors and preemptively control injury via compact medical devices
Investigate the feasibility of an open-source, no-cost license computer model capable of predicting the effects of health care policy alternatives to improve quality and cost-effectiveness

8. FY 2008 Priorities Patient Safety Ambulatory Patient Safety
Health IT
Patient Safety Organizations
New Patient Safety Grants
Ambulatory Patient Safety
Effective Health Care Program
Comparative Effectiveness
Network of Research Centers
Clear Findings for Multiple Audiences
Safety & Quality Measures, Drug Management and Patient-Centered Care
Patient Safety Improvement Corps
Medical Expenditure Panel Surveys
Other Research & Dissemination Activities
Visit-Level Information on Medical Expenditures
Annual Quality & Disparities Reports
Quality & Cost-Effectiveness, e.g. Prevention and Pharmaceutical Outcomes
U.S. Preventive Services Task Force
MRSA/HAIs

9. The Promise of Genomics: Recent Activities
AHRQ is funding a Randomized Control Trial to clarify the added value of genetic testing to improve warfarin dosing.
AHRQ is funding a DEcIDE project to review databases focusing on utilization and outcomes of gene-based tests and therapies
EPC Reports:
Genomic testing in ovarian cancer (completed)
CYP450 testing in depression (completed)
HNPCC testing in colorectal patients (completed)
Horizon scan on cancer genetic tests for CMS (completed)
BRCA testing in breast and ovarian cancers (w/USPSTF recommendation)
HER-2-Neu testing in breast cancer (ongoing)
Expression profile tests in breast cancer (ongoing)
Family history in breast, ovarian, colorectal and prostate cancers (ongoing)
Screening for hemochromatosis (w/USPSTF recommendation)

10. Patient Involvement Campaign
AHRQ’s campaign with the Ad Council uses a series of TV, radio and print public service announcements
Web site features a “Question Builder” for patients to enhance their medical appointments

11. Transforming Hospitals: Designing for Safety and Quality
A DVD that demonstrates how evidence-based design can improve the quality and safety of hospital services while improving staff satisfaction and retention.
Case studies of three hospitals illustrate the benefit of incorporating evidence-based design principles into new construction or renovation projects.

12. AHRQ’s National Reports on Quality and Disparities
2007 editions pending
New efficiency chapter
Disability data added
More on health literacy

13. 2006 National Reports – The Good News
Good (but not perfect) news
6% of patients reported communication problems with doctors*
7% of patients reported communication problems with nurses
*CAHPS Hospital Survey, 2006 National Healthcare Disparities Report

14. Oregon: Overall Care Quality vs
Oregon: Overall Care Quality vs. All States, One-Year Performance Change
Average
Weak
Strong
Very Weak
Very Strong
Performance Meter
= Most Recent Year = Baseline Year
2006 National Healthcare Quality Report, State Snapshots

15. Oregon Snapshot
Measure
Performance
% of Medicare AMI patients administered aspirin within 24 hours of admission
Better than Average
% of Medicare AMI patients with beta blocker prescribed at discharge
Average
% of adults age 18 and over on Medicare managed care whose health providers always listened carefully, explained things clearly, showed respect for what they had to say and spent enough time with them
Lower than Average
National Healthcare Quality Report, State Snapshots, 2006

16. Making Today’s Goals Tomorrow’s Reality
Turning Evidence Into Action: AHRQ Resources and Priorities
Comparative Effectiveness: Effective Health Care
Current and Future Directions for Health IT
21st Century Health Care
Q&A

17. Comparative Effectiveness: Effective Health Care Program
Uses current, unbiased evidence in making head-to-head comparisons to show which health interventions:
Add Value
Offer minimal benefit above current choices
Fail to reach their potential
Work for some patients, but not others
Builds on years of experience gained through AHRQ’s Evidence-based Practice Centers
Goal: to develop and disseminate better evidence about benefits and risks of alternative choices

18. CERTs Centers Brigham and Women’s Hospital Health IT
NEW
Brigham and Women’s Hospital
Health IT
Children’s Hospital - Cincinnati
Pediatric care
Duke University Medical Center
Therapies for heart and blood vessel disorders
HMO Research Network
Multiple population-based delivery systems
Houston Area CERT
Consumer education and patient adherence
KP Ctr for Health Research, Portland
Coordinating Center
Rutgers University
Mental health therapeutics
University of Alabama - Birmingham
Musculoskeletal disorders
University of Arizona & C-Path
Drug interactions/Women’s health
University of Chicago
Clinical, economic issues in hospital settings
University of Illinois - Chicago
Prescribing tools, including formularies
University of Iowa
Elderly and aging
University of Pennsylvania
Anti-infective use and resistance
Vanderbilt University
Therapeutic issues in Medicaid and VA system
Weill Medical College - Cornell
Therapeutic medical devices
The Scientific Resource Center supports the Effective Health Care Program as a whole, with specific responsibilities to:
Communicate with stakeholders.
Assist with the development of key questions and research topics.
Coordinate peer review and public input for comparative effectiveness reviews.
Support the methodological work of effectiveness reviews and research projects.
The Scientific Resource Center is located at the Oregon EPC (a collaboration of Oregon Health and Science University, the Portland Veterans Affairs Medical Center, and the Kaiser Permanente Center for Health Research) and directed by Mark Helfand, M.D.

19. DEcIDE Research Network
Outcome Science Cambridge, MA
Brigham & Women’s Hospital Boston, MA
U of Colorado Aurora, CO
U of Pennsylvania Philadelphia, PA
Harvard Pilgrim Boston, MA
Acumen, LLC Palo alto, CA
U of Illinois Chicago
Duke University Durham, NC
U of Maryland Baltimore, MD
Vanderbilt U Nashville, TN
U of North Carolina Chapel Hill, NC
RTI International RTP, NC
Johns Hopkins Baltimore, MD
Network of institutions and partner organizations with access to de-identified data of some 50 million patients

20. Evidence-Based Practice Centers
AHRQ Created the EPC Program in 1997
Blue Cross and Blue Shield Association, Technology Evaluation Center (TEC), Chicago, IL
Duke University, Durham, NC
ECRI, Plymouth Meeting, PA
Johns Hopkins University, Baltimore, MD
McMaster University, Hamilton, Ontario
Oregon Evidence-Based Practice Center
RTI International-University of North Carolina at Chapel Hill, NC
Southern California Evidence-based Practice Center-RAND, Santa Monica, CA
Tufts University-New England Medical Center, Boston, MA
University of Alberta
University of Connecticut
Minnesota Evidence-based Practice Center
University of Ottawa
Vanderbilt University
Promote evidence-based practice and decision-making
Generate comparative effectiveness reviews on medications, devices and other interventions
User-driven, with public and private-sector partners

21. Effective Health Care Program: Reviews to Date
Nine comparative effectiveness reviews released to date, including:
ACEIs or ARBS: These two common classes of blood pressure pills are equally effective at controlling high blood pressure, November 2007
PCI vs. CABG: Bypass surgery is more likely than balloon angioplasty (with or without a stent) to bring relief from angina in patients with mid-range coronary artery disease, October 2007
All reviews available at: effectivehealthcare.ahrq.gov

22. Oregon Evidence-based Practice Center
The Center supports The Guide to Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task Force by preparing systematic evidence reviews and evidence summaries as resources on topics under consideration by the Task Force

23. Emerging Methods in Comparative Effectiveness & Safety
A series of 23 articles by AHRQ researchers on new approaches in comparative effectiveness methods are compiled in a special October edition of Medical Care
A valuable new resource for scientists committed to advancing the comparative effectiveness and safety research
The Resource Center in Oregon led the development process, helped draft the document and manage work groups, and handled public comment
DEcIDE program

24. Eisenberg Clinical Decisions and Communications Center
Presents evidence synthesized by the Evidence-Based Practice Centers and generated by the DeCIDE Network in actionable formats for stakeholders including patients, providers, policymakers and the public
Oregon Health & Sciences University
The knowledge is used to maximize the benefits of health care, minimize harm and optimize the use of health care resources

25. Program Outputs
Research Reports
Consumer Guides
Systematic Reviews

26. AHRQ Research from the Grants On-line Database (GOLD)
Oregon Health & Science University
Findings published January ‘08 in Medical Care show a “concerning association” between privately insured parents and uninsured children
Overall, the findings suggest that even when parents successfully gain employment with private health coverage and raise their families out of poverty, health care for their children remains out of reach
A study of how gaps in health insurance coverage for low-income Oregon children affect their medical, prescription and dental health
The findings are scheduled to be published in the March/April issue of Ambulatory Pediatrics

27. Making Today’s Goals Tomorrow’s Reality
Turning Evidence Into Action: AHRQ Resources and Priorities
Comparative Effectiveness: Effective Health Care
Current and Future Directions for Health IT
21st Century Health Care
Q&A

28. Health IT: Where We’ve Been; Where We’re Going
Long-term agency priority
Since 2004, AHRQ has supported about 200 projects and demonstrations to improve the safety, quality and efficiency of health care in virtually every state
Special attention to best practices that can improve quality of care in rural, small community, safety net and community health center care settings
New focus on ambulatory safety and quality
AHRQ Health IT Investment: $216 Million

29. Ambulatory Safety and Quality Program (ASQ)
Over 60 Grants (in 29 states and the District of Columbia) and Task Orders in 3 areas:
Enabling Quality Measurement through Health IT
Improving Quality through Clinician Use of Health IT
Enabling Patient-Centered Care through Health IT
Health IT CERT awarded to Brigham & Women’s
EPC Report on the Elderly, Chronically Ill and Underserved’s use of health IT
Consumer Engagement Focus Groups
Contract for Technical Assistance for Medicaid and SCHIP programs

30. Impact of Health IT on Outcomes in Ambulatory Settings and Across High-Risk Transitions of Care
Using Precision Performance Measurement to Conduct Focused Quality Improvement – Northwestern University
Type of health IT: Quality of Care Decision Support, Vocabulary/Coding Standards
Designed to create systems that improve quality data and seamlessly link it to practice-level quality improvement programs and point of care interventions
Estimated Total Funding – $1.2 million
Project Start – Sept. 30, 2007
Project End – Sept. 29, 2010

31. The Relationship Between Health IT and Workflow Design
Medication Safety in Primary Care Practice: Translating Research into Practice – Medical University of South Carolina
The project will develop a set of medication safety measures relevant for primary care, incorporate them in quarterly practice performance reports and assess the impact of the intervention on the incidence of medication errors
Type of Health IT: Quality of Care Decision Support
Estimated Total Funding: $1.2 million
Project Start – Sept. 30, 2007
Project End – Sept. 29, 2010

32. Care for Patients with Multiple Chronic Conditions
RxSafe: Shared Medication Management and Decision Support for Rural Clinicians – Oregon Health & Science University
Oregon Health & Science University is using previously developed technology to support shared medication management for persons with chronic conditions.
Type of Health IT: Clinical/Operational Decision Support (provider-focused)
Oregon Health & Science University
Estimated Total Funding: $1.2 million
Project Start – Sept. 30, 2007
Project End – Sept. 29, 2010

33. Women
Harnessing Health IT to Prevent Medication-Induced Birth Defects – University of Pittsburgh
This project will develop and evaluate ways computers may be able to help doctors counsel women about preventing birth defects caused by use of certain medications.
Type of Health IT: Clinical Decision Support (provider-focused), Human/Machine Interface
Estimated Total Funding: $1.19 million Project Start – Sept. 30, 2007
Project End – Sept. 29, 2010

34. Chronic Illness
The BLUES Project: Improving Diabetes Outcomes in Mississippi with Health IT – Delta Health Alliance, Jackson, MS
Demonstrating the effects of diabetes management practices at several ambulatory clinics throughout Mississippi when utilizing well-designed, comprehensive health IT
Type of Health IT: Electronic Medical Record
Estimated Total Funding: $1.16 million Project Start – Sept. 30, 2007
Project End – Sept. 29, 2010

35. Other ASQ Grants in Oregon
Automating Assessment of Asthma Car Quality – Kaiser Foundation Research Institute
Type of Health IT: Quality of care decision support, data electronic transform & load
Estimated total funding: $871,711 from 9/30/2007 – 9/29/2009
Improving Quality in Cancer Screening: The Excellence Report for Colonoscopy – Oregon Health & Science University
Type of Health IT: Operational decision support – quality of care
Estimated total funding: $616,207 from 9/30/2007 – 9/29/2009

36. New ASQ RFA
AHRQ has published an RFA soliciting research projects that focus on using health IT to improve the quality of management for people with complex health care needs
Application deadline of February 21 for submissions that address linkages across service providers, as well as those that focus on the affected individual
Tools and processes to be implemented in a variety of settings, including small and rural practices, in a cost-effective manner
Projects may be funded for a period of up to three years
$3M in funding, approx awards

37. Making Today’s Goals Tomorrow’s Reality
Turning Evidence Into Action: AHRQ Resources and Priorities
Comparative Effectiveness: Effective Health Care
Current and Future Directions for Health IT
21st Century Health Care
Q&A

38. Getting to Value-Driven Health Care
“The mantra of competition based on value is that there is no such thing as a national health care market. What we have is a network of local markets."
Michael O. Leavitt, Secretary
US Dept. of Health and Human Services
November 5, 2007

39. Cornerstones of Value-Driven Health Care
Quality Standards
Design systems to collect quality of care information and define what constitutes quality health care
Price Standards
Aggregate claims information to enable cost comparisons between specific doctors and hospitals
Interoperability
Set common technical standards for quick and secure communication and data exchange
Incentives
Reward those who provide and purchase high-quality and competitively priced health care

40. Value-Driven Health Care: Core Principles
All healthcare is local
Broad access to information will improve value by:
stimulating provider improvement
engaging consumers in provider selection, treatment choices
enabling purchasers to align consumer, provider incentives
Nationwide learning network will foster market-based health care reform

41. Value-Driven Health Care and Health IT
How does Health IT affect patient safety culture?
Adopting and using Health IT remains a huge cultural change for many clinicians
Change requires commitment to achieving and sustaining evolution in culture

42. What’s Missing in Health Care
Delivery System Design
Real-time information
Clinical effectiveness
Delivery to patients
Impact on patients
Evidence-based management
Shared attention to data
Shared strategies for improvement
Policy adjustments for improvement

43. Growing Demand for Comparative Information
Potential Benefits
Potential Drawbacks
Comparative effectiveness information can help establish the value of medicines, procedures and services
It can also stimulate the development of important advances in health care, and enhance value and transparency
Better comparative information will not address issues such as aging populations and increases in chronic disease
Studies could be used to limit treatment options rather than help target the right treatments to the right patients

44. How Can We Enhance Our Efforts?
The Evolution of Translational Research

45. The Social Case: Potential lives saved through quality improvement
Drug could save 20,000 lives if 100% of population received it. If only 80% receive it, only 16,000 lives are saved. To save 20,000 lives reaching only 80% of the patient population, the efficacy of the drug would have to increase by 25%.
Woolf and Johnson,

46. 21st Century Health Care
Improving quality by promoting a culture of safety through Value-Driven Health Care
Information-rich, patient-focused enterprises
Information and evidence transform interactions from reactive to proactive (benefits and harms)
Evidence is continually refined as a by-product of care delivery
21st Century Health Care
Actionable information available – to clinicians AND patients – “just in time”

47. Connecting ‘Achievability’ and Reliability…
A robust health care system must include capacity for:
Rapid translation of beneficial advances or breakthroughs
Connectivity with the biomedical enterprise
Achievability: What can work under ideal circumstances for some people
Reliability: Getting it right for all patients every time – the first time

48. Making Today’s Goals Tomorrow’s Reality
Turning Evidence Into Action: AHRQ Resources and Priorities
Comparative Effectiveness: Effective Health Care
Current and Future Directions for Health IT
21st Century Health Care
Q&A