Presentation on theme: "“Update on PCORI: a new era in Research”"— Presentation transcript:
1“Update on PCORI: a new era in Research” Clyde W. Yancy, MD, MSc, FACC, FAHA, MACPMagerstadt Professor of MedicineAdjunct, Department of Medical Social SciencesChief of CardiologyNorthwestern University, Feinberg School of Medicine&Associate Medical DirectorBluhm Cardiovascular InstituteChicago, ILNow we would like to focus on the clinical case for Get With the Guidelines and take you through some of the literature and experience that we've had in our program.1
2DISCLOSURES Consultant/speaker/honoraria: none Editorial Boards: American Heart Journal, American Journal of Cardiology (associate editor); Circulation; Circulation-Heart Failure; Circulation- Quality Outcomes; Congestive Heart FailureGuideline writing committees: Chair, ACC/AHA, chronic HF; member, hypertrophic cardiomyopathy; member, ACC/AHA Guideline Taskforce, chair, methodology subcommitteeFederal appointments: FDA: Chair, Cardiovascular Device Panel; ad hoc consultant; NIH CICS study section; advisory committee to the Director; AHRQ- adhoc study section chair; NHLBI- consultant; PCORI- methodology committee memberVolunteer Appointments: American Heart Association- President, American Heart Association, ; American College of Cardiology, Founder- CREDO
3PCORI What is PCORI? What is different about PCORI? How will PCORI accomplish its work?What has PCORI done?
4PCORI Mission Statement The PCORIhelps people make informed health care decisions – and improves health care delivery and outcomes – by producing and promoting high integrity, evidence-based information – that comes from research guided by patients, caregivers and the broader health care community.PCORI is an independent, non-profit organization authorized by Congress committed to continuously seeking input from patients and a broad range of stakeholders to guide its work.
5Taking Patient-Centeredness Seriously Patient-DrivenResearchPatient EngagementDisseminationOne of PCORI’s earliest priorities is to distinguish itself from other entities that are, increasingly, sponsoring and conducting CER – NIH, AHRQ, the VA – to name 3. And if it does, it will do so in 3 areas: Engaging patients; this will likely be a major research focus, as well as a key day-to-day activity of PCORI. This will lead to a research agenda that is more closely aligned with the questions patients need answers and hopefully will involve more patients in the research itself. The result will be betterinformation to disseminate to support health decision-making for both patients and their providers.Understanding the choices patients faceAligning research questionsand methods withpatient needsProviding patients and providers with informationfor better decisions
6PCOR Definition Defining Patient-Centered Outcomes Research (PCOR) Helps people and their caregivers communicate and make informed health care decisions, allowing their voices to be heard in assessing the value of health care options. This research answers patient-centered questions such as:ExpectationsOptionsOutcomesDecisions“Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”“What are my options and what are the potential benefits and harms of those options?”“What can I do to improve the outcomes that are most important to me?”“How can clinicians and the care delivery systems help me make the best decisions about my health and healthcare?”Joe’s slideHere is a definition of patient-centered outcomes research that guides the work PCORI does.6
7In order to answer these patient-focused questions, PCOR: PCOR DefinitionIn order to answer these patient-focused questions, PCOR:Assesses the benefits and harms of preventive, diagnostic, therapeutic, palliative, or health delivery system interventions to inform decision making, highlighting comparisons and outcomes that matter to people;Is inclusive of an individual's preferences, autonomy and needs, focusing on outcomes that people notice and care about such as survival, function, symptoms, and health-related quality of life;Incorporates a wide variety of settings and diversity of participants to address individual differences and barriers to implementation and dissemination; andInvestigates (or may investigate) optimizing outcomes while addressing burden to individuals, resource availability, and other stakeholder perspectives.
8. National Priorities for Research and Research Agenda Assessment of Options for Prevention, Diagnosis, and TreatmentComparisons of alternative clinical options to support personalized decision-making and self-careIdentifying patient differences in response to therapyStudies of patient preferences for various outcomesImproving Healthcare SystemsImproving support of patient self-managementFocusing on coordination of care for complex conditions and improving access to careComparing alternative strategies for workforce deploymentCommunication & Dissemination ResearchUnderstanding and enhancing shared decision-makingAlternative strategies for dissemination of evidenceExploring opportunities to improve patient health literacyAddressing DisparitiesUnderstanding differences in effectiveness across groupsUnderstanding differences in preferences across groupsReducing disparities through use of findings from PCORAccelerating PCOR and Methodological ResearchImproving study designs and analytic methods of PCORBuilding and improving clinical data networksMethods for training researchers, patients to participate in PCOREstablishing methodology for the study of rare diseases.What is the purpose of the Research Agenda?The Research Agenda describes the types of research questions that can be addressed under each of the five priorities. The agenda also outlines nine criteria, taken from PCORI’s establishing legislation, which will be used to evaluate research proposals. Studies that meet most or all of these criteria will be those most likely to be funded.Why doesn’t the Research Agenda name specific conditions or treatments that PCORI is interested in funding or studying?PCORI believes there are important comparative clinical effectiveness research questions to be answered across a wide range of conditions. Focusing on a narrower set of diseases or conditions at the start of PCORI’s research funding would mean that some patients and health care issues might have no chance of benefitting from PCORI’s existence. Also, there are issues that affect patients across a variety of conditions. For example, we have heard from the patient focus groups about challenges with communication and interaction with their providers. These are problems that are not specific to one condition, but have been identified by a variety of patients as being important to them. Involving patients and other stakeholders in a meaningful process of considering which conditions or questions deserve more PCORI funding is important and will begin immediately and continue throughout PCORI’s lifetime.However, it will take time to hear all views on these issues, to weigh the input, and to begin making these choices. This must be done in a transparent manner so that all can understand how we reached the narrower, targeted set of research questions we focus on. Over time, PCORI’s research portfolio will become more focused, but PCORI will continue to reserve a portion of its funding for addressing the broader set of possible questions that patients, researchers and stakeholders may raise.8
9Criteria for Research Outlined by Law Impact on Health of Individuals and PopulationsAddresses Current Gaps in Knowledge/ Variation in CarePatient-CenterednessImprovability through ResearchImpact on Health Care System PerformanceRigorous Research MethodsInclusiveness of Different PopulationsPotential to Influence Decision-MakingEfficient Use of Research Resources8
10PCORI What is PCORI? What is different about PCORI? How will PCORI accomplish its work?What has PCORI done?
11“This is going to be research done differently!” PCORI Board Member Harlan Krumholz, MDNational Patient and Stakeholder Dialogue National Press Club, Washington, DCFebruary 27,2012
12What Makes PCORI Funding Different? Special features include:Patient & Stakeholder Engagement PlanDissemination and Implementation AssessmentReproducible and Transparent Research PlanPCORI Criteria Outlined by StatuteComplies with Methodology StandardsUser-friendly announcements to encourage broader range of applicants12Source: PCORI PFA Application Guidelines
13Stakeholder Engagement in PCORI-funded Research Key stakeholders are engaged early and throughout the research process.PCORI will score applications on how meaningfully patients and stakeholders are engaged.Key stakeholders include those for whom the results of the research will be relevant:PatientsNonprofessional CaregiversClinicians (e.g. Physicians, Nurses, Pharmacists, Counselors, and other providers of care and support services)Patient-Advocacy GroupsCommunity GroupsResearchersHealth-Related AssociationsPolicy MakersInstitutions, Including Organizational Providers, Purchasers, Payers, and IndustryA key goal of patient engagement in research is to present information that best supports health decisions through generation of evidence relevant to patients, their caregivers, and clinicians. Patients and other key stakeholders should be meaningfully involved in the research team. The specific members of the team will vary from study to study.13
14The engagement of patients and stakeholders should include: What roles should patients and stakeholders play in research teams?The engagement of patients and stakeholders should include:Participation in formulation of research questions;Defining essential characteristics of study participants, comparators, and outcomes;Monitoring of study conduct and progress; andDissemination of research results.A key goal of patient engagement in research is to present information that best supports health decisions through generation of evidence relevant to patients, their caregivers, and clinicians. Patients and other key stakeholders should be meaningfully involved in the research team. The specific members of the team will vary from study to study.14Source: PCORI PFA Application Guidelines (Sec )
15Patient and Stakeholder Engagement 2012 (placeholder slide)Building communities of patients and stakeholders – using website, social media, face-to-face meetingsStrengthening ties with advocacy associations, professional clinician organizations, purchaser organizations, research communityRefining the PCORI Research AgendaConvening multi-stakeholder workshops focused on each of the National PrioritiesForming multi-stakeholder Advisory panelsUsing social media, surveys to obtain broad input
16PCORI What is PCORI? What is different about PCORI? How will PCORI accomplish its work?What has PCORI done?
17The First Methodology Committee Report Lori to introduce webinar and welcome listeners.
18Methodology Report Chapter 1. Introduction Chapter 2. How the Methodology Committee Developed the Recommended StandardsChapter 3.Overview of the StandardsChapter 4.Methodological Standards for Patient- Centeredness of Research Proposals and ProtocolsChapter 5.Methods for Prioritizing Patient-Centered Outcomes ResearchChapter 6.Choosing Data Sources, Research Design, and Analysis Plan: Translation Framework and Development of a Translation TableChapter 7.General and Cross-Cutting Research MethodsChapter 8. Design-Specific MethodsChapter 9. Next Steps
19Methodology ReportThe mandate for PCORI’s Methodology Committee is to define methodological standards, recommended actions and a translation table to guide health care stakeholders towards the best methods for patient-centered outcomes research (PCOR).Rigorous methods are essential to building trust in research findings.The report is the necessary catalyst for scientifically rigorous, patient-centered outcomes research that can inform decision- making.Once Report is revised and accepted by the PCORI Board of Governors, future PCORI funding applicants will be expected to reference the Standards in their applications and use the Standards in their PCORI funded research.Robin:The mandate for the Methodology Committee of PCORI is to define methodological standards and develop a translation table to guide health care stakeholders towards the best methods for patient-centered outcomes research (PCOR).The MC has four specific roles:Provide guidance about the appropriate use of methods in patient-centered outcomes researchEstablish priorities to address gaps in research methods or their applicationRecommend actions to support standardsMap research methods to specific research questions via Translation TableThe methodology report is the first deliverable to address PCOR methods.The report includes the first set of methodological standards and a translation table to guide health care stakeholders towards the best methods for patient-centered outcomes research (PCOR).Use of these standards will promote Rigorous methods that are essential to building trust in research findings. Using scientifically rigorous methods will produce patient-centered outcomes research results that can inform decision-making. Once the Report is revised and accepted by the PCORI Board of Governors, future PCORI funding applicants will be expected to reference the Standards in their applications and use the Standards in their PCORI funded research.1919
20NEJM Article and AdsDigital Ads released in Annals of Internal Medicine; Science Translational Medicine; JAMA; NEJM; Nature; and Health AffairsBill
21Selected Milestones in Health Care Interventions and Delivery Strategies and in Research Methods. Gabriel SE, Normand ST. N Engl J Med 2012;367:
22Information Gathering Methodology Report DevelopmentMethods SelectionWorking groups identified and prioritized major research methods questions to be addressedResearchers contracted to address selected topicsContractors developed research materials (e.g., reports, summary templates for proposed standard)MC solicited for external feedback on the translation table (RFI)Workshops held to discuss contractor findings, with invited experts in attendanceInformation GatheringCommittee ExpertiseInternal ReviewMC conducted in-depth internal review of materials developed by contractors, and support staffMC independently submitted preliminary votes on proposed standardsMC deliberated to reach consensus on recommendations to be endorsed in the reportRobinThe process for developing the first methodology report over our first year together as the methodology committee involved four phases: method selection, information gathering, internal review, and report generation.Method selection involve working in groups to prioritize the major research methods questions to be addressed.Second, we entered an Information gathering phase in which request for proposals were publicly solicited for selected topics, contractors were selected and completed their reports with summary templates of proposed standards. In addition to methodology committee solicited external feedback on the translation table through a request for information. Workshops were held to discuss contractor findings with invited experts in attendance.Third, the methodology committee began a phase of internal review. The committee conducted an in-depth internal review of the materials that were developed by the contractors and support staff. We then independently submitted are pulmonary votes on the proposed standards and then met in person to deliberate and reach consensus on the recommendations to be endorsed in the report.The report was then generated and refined based on committee of evaluations and discussions.Report GenerationRefined recommendations and report content per committee evaluations and discussions22
23Methodology Report – Information Gathering 17 reports* addressing 15 topics, from MC-led contracted research, informed 1st Methodology ReportTopicsDesign, Conduct, and Evaluation of Adaptive Randomized Clinical TrialsConduct of Registry StudiesDesign of Patient-Reported Outcomes Measures (PROMS)Use of Collaborative or Distributed Data NetworksPrevention and Handling of Missing DataDesign, Conduct and Evaluation of Diagnostic TestingCausal Inference Methods in Analyses of Data from Observational and Experimental StudiesAddressing Heterogeneity of Treatment Effects: Observational and Experimental PCOR*Reports are available on PCORI’s website (www.pcori.org)
24Methodology Report – Information Gathering Contracted Research Reports (Cont’d)TopicsInvolving Patients in Topic GenerationValue-of-Information in Research PrioritizationPeer Review as a Method for Research PrioritizationExamination of Research Gaps in Systematic Reviews for Research PrioritizationIntegrating Patients' Voices in Study Design Elements with a Focus on Hard to-Reach PopulationsEliciting Patient PerspectivePCORI Expert Interviews*Reports are available on PCORI’s website (www.pcori.org)
25Methods for Involving Patients in Topic Generation for Patient-Centered Comparative Effectiveness Research – An International PerspectivePetra Nass, Susan Levine, Clyde Yancy
26Project Framework Discuss the levels of engagement Summarize qualitative research strategies and methodsProvide specific examplesDiscuss facilitators of public engagementDescribe three types of scientific research data as part of the engagement processPropose a process of engagement
28Public Engagement as Research Is the objective study of the individual experienceUses mostly qualitative research strategies and methods
29Scientific Strategies the Framework of Engagement Phenomenologythe study of experiencesEthnographythe study of cultural phenomenaGrounded theorythe study of theory through analysis of dataAction researchthe study of focused problem solvingSurvey
30Methods and ProcessesInterviews (one-on-one or group interviews, photovoice)ObservationDocumentsQuestionnairesPublic-physician partnershipsConsultationCollaboration
31Views, Opinions, Experience as Research Data Generates mostly textual dataCan be categorized into themesAnd can be translated into research areas and topics
32Case 1 In-depth one-on-one interviews and focus group interviews 40 patients with ulcerative colitisPatients identified 9 research areasOnly during in-depth interview patients asked about prenatal genetic testing for a possible termination of pregnancy if the fetus was affected
33Case 2Public-Clinician Partnership to develop research topics for urinary incontinence (James Lind Alliance)Lay members and clinicians consult with their peers to include diverse viewsSystematic reviews are used to generate additional topics and to avoid duplication of researchNominal Group Technique to reach a consensus and prioritize topicsE.g., creating a“Top 10” list of research questions
34Case 3Advisory patient/stakeholder panel to identify research topics and research priorities related to urinary incontinence in womenWhat can researchers study to make your life better?What should we measure to see if your life is better?E.g., Patients considered quality of life the most important outcome measures.
35Facilitators that Overcome the Barriers to Public Engagement Creating a patient-centered organizational structureSupporting members of the publicCommunicating clear expectationsProvide trainingUsing processes that give an equal voice to professional and lay participantsUsing a variety of engagement methods
37PCORI What is PCORI? What is different about PCORI? How will PCORI accomplish its work?What has PCORI done?
38PCORI Awards The first experience – cycle 1 “Title Slide” format
394 9 6 6 25 Slate includes all applications scoring 30 or better. Addressing disparities(6% of PFA total)9Assessing options(4% of PFA total)6Communication & dissemination(7% of PFA total)We want to mainly focus on 2, 4 and 76Improving healthcare systems(6% of PFA total)25Total(5% of total)% of total means of those applications deemed responsive
40Addressing Disparities ConditionsAddressing DisparitiesComm. & Dissem.We want to mainly focus on 2, 4 and 7Assessing OptionsImproving Systems“Other” typically indicates a non-condition response to the question. Responses include: insurance coverage, primary care, surgical decision making, clinical management, comprehensive health systems., etc.
41Populations OverallWe want to mainly focus on 2, 4 and 7Other Population includes women, disabled persons, and veterans.
43Project Titles: Assessing Options A Comparison of Non-Surgical Treatment Methods for Patients with Lumbar Spinal Stenosis.Cognitive AED Outcomes in Pediatric Localization Related Epilepsy (COPE)Comparative effectiveness of adolescent lipid screening and treatment strategiesComparative Effectiveness of Intravenous v. Oral Antibiotic Therapy for Serious Bacterial InfectionsComparative effectiveness of rehabilitation services for survivors of an acute ischemic strokeEvaluation of a Patient-Centered Risk Stratification Method for Improving Primary Care for Back PainImproving Psychological Distress Among Critical Illness Survivors and Their Informal CaregiversSelection of Peritoneal Dialysis or Hemodialysis for Kidney Failure: Gaining Meaningful Information for Patients and CaregiversShared Decision Making in the Emergency Department: The Chest Pain Choice TrialWe want to mainly focus on 2, 4 and 7
44Improving Palliative and End-of-Life Care in Nursing Homes Project Titles: Improving Healthcare SystemsCreating a Clinic-Community Liaison Role in Primary Care: Engaging Patients and Community in Health Care InnovationImproving Palliative and End-of-Life Care in Nursing HomesInnovative Methods for Parents And Clinics to Create Tools (IMPACCT) for Kids' CareOptimizing Behavioral Health Homes by Focusing on Outcomes that Matter Most for Adults with Serious Mental IllnessRelative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitionsThe Family VOICE Study (Value Of Information, Community Support, and Experience): a randomized trial of family navigator services versus usual care for young children treated with antipsychotic medicationWe want to mainly focus on 2, 4 and 7
45Shared Medical Decision Making in Pediatric Diabetes Project Titles: Communications & DisseminationDecision Support for Parents Receiving Genetic Information about Child’s Rare DiseaseExtension Connection: Advancing Dementia Care for Rural and Hispanic PopulationsPatient-Identified Personal Strengths (PIPS) vs. Deficit-Focused Models of CarePresenting Patient-Reported Outcomes Data to Improve Patient and Clinician Understanding and UseRelapsed childhood neuroblastoma as a model for parental end-of-life decision-makingShared Medical Decision Making in Pediatric DiabetesWe want to mainly focus on 2, 4 and 7
46Project Titles: Addressing Disparities Cultural tailoring of educational materials to minimize disparities in HPV vaccinationLong-term outcomes of community engagement to address depression outcomes disparitiesReducing Disparities with Literacy-Adapted Psychosocial Treatments for Chronic Pain: A Comparative TrialReducing Health Disparities in Appalachians with Multiple Cardiovascular Disease Risk FactorsWe want to mainly focus on 2, 4 and 7
47Examples of Patient Centeredness in Funded Applications
48The Chest Pain CHOICE Trial Assessment of Prevention, Diagnosis and Treatment Options“We first developed a Web-based tool to reliably determine the future risk of a heart attack. Then, incorporating feedback from patients, doctors, and researchers, developed a patient education tool—Chest Pain Choice—to help patients better understand the tests that are being performed to determine the cause of their chest pain, what these tests might show, their individualized 45- day risk of a heart attack, and the available management options.”$2.03 million
49Assessment of Prevention, Diagnosis and Treatment Options Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information TechnologyAssessment of Prevention, Diagnosis and Treatment Options“Patient-led, health educator–moderated training sessions for nurses will promote improved communication about VTE with patients. Informational materials developed with partnering patient stakeholders, including self-monitoring tools, will be provided to all hospitalized patients as a part of the admission package, empowering patients to take an active role in VTE prevention”.$1.5 million
50Ovarian Cancer Patient-Centered Decision Aid Assessment of Prevention, Diagnosis and Treatment Options“The objective of this study is to develop and test a new decision aid—named Patient Centered Outcome Aid (PCOA)—that will allow patients to assimilate information and identify trade-offs about the impact of IP/IV therapy versus IV-only therapy on their QOL and survival, based on their own preferences and personal clinical characteristics, described in terms that are meaningful to them”.$1.9 million
51Improving Healthcare Systems The Family VOICE Study: A Randomized Trial of Family Navigator Services Versus Usual Care for Young Children Treated with Antipsychotic MedicationImproving Healthcare Systems“In this study, we are partnering with parents/family advocates, child-serving agencies, and health providers to develop a Family Navigator Service to link with this medication program. Family Navigators are individuals who have cared for their own child with mental illness. The navigators will support parents, provide information on psychosocial treatment options, and address barriers to using services”.$1.4 million
52PATient Navigator to rEduce Readmissions (PArTNER) Improving Health Care Systems“We propose to engage stakeholder groups at an MSI,(minority serving institution) including patients/caregivers, in an iterative process to develop a CHW-based Patient Navigator (CHW- Navigator- community health worker) toolkit tailored to their needs to augment the benefits of a QI program to reduce readmission. We will compare the effectiveness of an integrated CHW- Navigator on the patient experience, 30-day readmissions rates, and other outcomes”. $2.0 million
53Reverse Innovation and Community Engagement to Improve Quality of Care and Patient Outcomes Communication and Dissemination Research“We propose to adapt a World Health Organization community engagement approach to support Hospital Community Health Partnership (J-CHiP), an initiative targeting high-risk adults with chronic conditions who reside in surrounding ZIP codes. The overall goals are to improve the health of residents by enhancing communication and “co-developing” a community engagement partnership between hospitals and clinics, CBOs, and community”.$2.03 million
54Addressing Healthcare Disparities Reducing Health Disparities in Appalachians with Multiple Cardiovascular Disease Risk FactorsAddressing Healthcare Disparities“We will compare (a) the standard of care alone and referral to a primary care provider for management of CVD risk factors with (b) standard of care supplemented by patient- centered, culturally appropriate, self-care CVD risk reduction intervention (HeartHealth) designed to improve multiple CVD risk factors while overcoming barriers to success”.$2.09 million
55PCORI What is PCORI? What is different about PCORI? How will PCORI accomplish its work?What has PCORI done?