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Driving Change Through Research: Future Trends in Health Care Quality and Access Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality.

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Presentation on theme: "Driving Change Through Research: Future Trends in Health Care Quality and Access Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality."— Presentation transcript:

1 Driving Change Through Research: Future Trends in Health Care Quality and Access Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality NAHSL th Anniversary Conference Lowell, MA – October 21, 2008

2 Health Care Quality and Access Disparities in health care quality and access are staying the same or increasing n=number of core measures QualityAccess 2007 National Healthcare Quality and Disparities Reports

3 Quality and Access are Key Vary – A LOT; NOT clearly related to dollars spent Vary – A LOT; NOT clearly related to dollars spent Matter – can be measured and improved Matter – can be measured and improved Measurement science is evolving: Measurement science is evolving: – Structure, process and outcomes – Broad recognition that patient experience is essential component Strong focus on public reporting is good Strong focus on public reporting is good – Motivates providers to improve – Not yet ‘consumer friendly’

4 Delivery As A Science “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. … That’s a mistake, a huge mistake.” Peter Pronovost, MD December 10, 2007

5 Coordination of Care

6 Opportunities for the Field Using health IT to improve research Using health IT to improve research Building public/private partnerships that include representative stakeholders Building public/private partnerships that include representative stakeholders Standardizing collection of race, ethnicity and language data, including priority populations and sub-groups Standardizing collection of race, ethnicity and language data, including priority populations and sub-groups Rewarding the ‘leading edge’ and bringing others along Rewarding the ‘leading edge’ and bringing others along

7 Future Trends in Health Care Quality and Access Knowledge Creation Knowledge Creation Synthesis & Dissemination Synthesis & Dissemination Translating Research Into Practice Translating Research Into Practice 21 st Century Health Care 21 st Century Health Care Q & A Q & A

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

9 AHRQ Roles and Resources Health IT Research Funding Support advances that improve patient safety/quality of careSupport advances that improve patient safety/quality of care Continue work in hospital settingsContinue work in hospital settings Step up use of Health IT to improve ambulatory patient careStep up use of Health IT to improve ambulatory patient care Develop Evidence Base for Best Practices Four key domains: Patient-centered carePatient-centered care Medication managementMedication management Integration of decision support toolsIntegration of decision support tools Enabling quality measurementEnabling quality measurement Promote Collaboration and Dissemination Support efforts of AHIC, ONC, HRSA and Centers for Medicare and Medicaid ServicesSupport efforts of AHIC, ONC, HRSA and Centers for Medicare and Medicaid Services Build on public and private partnershipsBuild on public and private partnerships Use web tools to share knowledge and expertiseUse web tools to share knowledge and expertise

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

11 Funding Continuation of $334.6 million appropriation, which includes: Continuation of $334.6 million appropriation, which includes: – $30 million for comparative effectiveness research – $5 million for research and activities to reduce Methicillin Resistant Staphylococcus aureus (MRSA) and related infections Continuing Resolution Passed for FY 2009 Continues FY 2008 Funding through March 6, 2009 – $9.7 million for Value Research, including the Value-Driven Healthcare Initiative – $7.1 million for research related to prevention and care management

12 AHRQ’s National Reports on Quality and Disparities – The rate of improvement in quality between 1994 and 2005 was 2.3 percent, down from 3.1 percent from – Measures of patient safety showed an average annual improvement of about 1% – Areas where significant attention has been concentrated, such as appropriate timing of antibiotics for surgery and reducing medication errors, have shown progress

13 Key Findings  Uninsurance is a major barrier to reducing disparities  Uninsured individuals do worse than privately insured individuals on almost 90% of quality measures and on all access measures 0 25% 50% 75% 100% Quality(9CRM)Access(6CRM) 1BetterSame Worse 86 There were 45.7 million uninsured Americans in 2007* *U.S. Bureau of the Census, August 2008

14 Usual Source of Care Overall, the proportion of persons with a specific source of ongoing care is higher for females in all racial and ethnic groups Overall, the proportion of persons with a specific source of ongoing care is higher for females in all racial and ethnic groups This proportion was significantly lower for the poor (78.1%), near poor (81.4%) and middle income (87.2%) groups than for high income groups (92.3%) This proportion was significantly lower for the poor (78.1%), near poor (81.4%) and middle income (87.2%) groups than for high income groups (92.3%) 2007 National Healthcare Disparities Report Higher costs, poorer outcomes and greater disparities are observed among individuals without a usual source of care

15 Massachusetts: Overall Care Quality vs. All States, One-Year Performance Change = Most Recent Year = Baseline Year Performance Meter: All Measures Very Weak Weak Average Strong Very Strong 2007 National Healthcare Quality Report, State Snapshots

16 Measuring Massachusetts Health Care Quality MeasurePerformance % of heart attack patients administered a beta-blocker within 24 hours of admission, all payers Better than average % of adults age 18 and over who reported that they always got appointment for illness/injury as soon as they wanted, Medicaid Average % of Cancer deaths per 100,000 population per year Worse than average 2007 National Healthcare Quality Report, State Snapshots

17 Future Trends in Health Care Quality and Access Knowledge Creation Knowledge Creation Synthesis & Dissemination Synthesis & Dissemination Translating Research Into Practice Translating Research Into Practice 21 st Century Health Care 21 st Century Health Care Q & A Q & A

18 Effective Health Care Program A. Evidence synthesis (EPC program) – Systematically reviewing, synthesizing, comparing existing evidence on treatment effectiveness – Identifying relevant knowledge gaps B. Evidence generation (DEcIDE, CERTs) – Development of new scientific knowledge to address knowledge gaps. – Accelerate practical studies C. Evidence communication/translation (Eisenberg Center) – Translate evidence into improvements – Communication of scientific information in plain language to policymakers, patients, and providers

19 New Priority Conditions for the Effective Health Care Program Arthritis and non- traumatic joint disorders Arthritis and non- traumatic joint disorders Cancer Cancer Cardiovascular disease, including stroke and hypertension Cardiovascular disease, including stroke and hypertension Dementia, including Alzheimer Disease Dementia, including Alzheimer Disease Depression and other mental health disorders Depression and other mental health disorders Developmental delays, attention-deficit hyperactivity disorder and autism Developmental delays, attention-deficit hyperactivity disorder and autism Diabetes Mellitus Diabetes Mellitus Functional limitations and disability Functional limitations and disability Infectious diseases including HIV/AIDS Infectious diseases including HIV/AIDS Obesity Obesity Peptic ulcer disease and dyspepsia Peptic ulcer disease and dyspepsia Pregnancy including pre-term birth Pregnancy including pre-term birth Pulmonary disease/Asthma Pulmonary disease/Asthma Substance abuse Substance abuse

20 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 CERTs Centers

21 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 50 million patients; generates evidence and analytic tools in practical, accelerated format

22 New Solicitations through the DEcIDE Network * Proposed information and not final information 1) Computer-based Clinical Decision Support (CDS) Tools for Gene- based Tests Used in Breast Cancer Developing clinical decision support (CDS) tools for gene-based tests that are used in the prevention and treatment of breast cancer Developing clinical decision support (CDS) tools for gene-based tests that are used in the prevention and treatment of breast cancer 2) Multicenter Research Cooperatives for Clinical & Comparative Effectiveness Studies* Creating multi-center research cooperatives to coordinate and conduct studies on clinical effectiveness and comparative effectiveness in selected priority health conditions (diabetes and cancer) Creating multi-center research cooperatives to coordinate and conduct studies on clinical effectiveness and comparative effectiveness in selected priority health conditions (diabetes and cancer) 3) Pilot Studies For Evaluating the Safety and Effectiveness of Prescription Drugs, Biologics and Vaccines Using Medicare Part D* Conducting pilot studies which evaluate the safety and effectiveness of prescription drugs, biologics and vaccines using Medicare Part D data Conducting pilot studies which evaluate the safety and effectiveness of prescription drugs, biologics and vaccines using Medicare Part D data

23 Advances in Genomics A recent DEcIDE report identified major gaps in our ability to generate evidence on utilization and outcomes of genomic testing A recent DEcIDE report identified major gaps in our ability to generate evidence on utilization and outcomes of genomic testing The American Health Information Community (AHIC) has called on AHRQ to help develop standards to code and exchange pharmacogenomics-relevant EHR information The American Health Information Community (AHIC) has called on AHRQ to help develop standards to code and exchange pharmacogenomics-relevant EHR information Reports: Reports: – Genomic Testing in Ovarian Cancer, Breast Cancer, Colorectal Cancer and Depression Patients – Horizon Scans on Cancer and non-Cancer Genetic Tests (for CMS) – Collection, and Use of Cancer Family History in Primary Care (CDC- funded) – BRCA Testing in Breast and Ovarian Cancers, and Screening for Hereditary Hemochromatosis (USPSTF recommendations)

24 Health IT and Patient Safety Long-term agency priority Long-term agency priority – Since 2004, AHRQ has supported more than 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 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: $260 Million

25 Evidence-Based Guidelines NGC is a comprehensive database of evidence-based clinical practice guidelines and related documents NGC is a comprehensive database of evidence-based clinical practice guidelines and related documents NQMC is a database and Web site for information on specific evidence-based health care quality measures and measure sets NQMC is a database and Web site for information on specific evidence-based health care quality measures and measure sets The goal of both is to promote the dissemination, implementation and use in order to inform health care decisions The goal of both is to promote the dissemination, implementation and use in order to inform health care decisions

26 Coming Soon: MEADERS Designed to help doctors in small practices quantify medication errors and ADEs Designed to help doctors in small practices quantify medication errors and ADEs Web-based system for documenting and reporting in ambulatory settings Web-based system for documenting and reporting in ambulatory settings Information fed back to practices for QI purposes Information fed back to practices for QI purposes Voluntary and confidential Voluntary and confidential Medication Error and Adverse Drug Event Reporting System (MEADERS)

27 AHRQ Health Care Innovations Exchange National electronic learning hub for sharing health care service innovations, bringing innovators and adopters together National electronic learning hub for sharing health care service innovations, bringing innovators and adopters together Searchable database featuring innovation successes and failures, expert commentaries, lessons learned, etc., Searchable database featuring innovation successes and failures, expert commentaries, lessons learned, etc., Designed to help health care “Agents of Change” improve quality Designed to help health care “Agents of Change” improve quality Web-based Repository of Cutting-Edge Service Innovations

28 AHRQ Encourages Consumers to Get Involved with their Care AHRQ’s campaign with the Ad Council uses a series of TV, radio and print public service announcements 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 Web site features a “Question Builder” for patients to enhance their medical appointments –

29 Future Trends in Health Care Quality and Access Knowledge Creation Knowledge Creation Synthesis & Dissemination Synthesis & Dissemination Translating Research Into Practice Translating Research Into Practice 21 st Century Health Care 21 st Century Health Care Q & A Q & A

30 Evidence-Based Practice Centers Created in 1997; promotes evidence- based practice and decision-making Created in 1997; promotes evidence- based practice and decision-making Generate comparative effectiveness reviews on medications, devices and other interventions Generate comparative effectiveness reviews on medications, devices and other interventions User-driven, with public and private-sector partners User-driven, with public and private-sector partners 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

31 Support for U.S. Preventive Services Task Force (USPSTF) Evidence-Based Practice Centers support The Guide to Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task Force Evidence-Based Practice Centers support The Guide to Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task Force Prepare systematic evidence reviews and evidence summaries for topics under consideration by Task Force Prepare systematic evidence reviews and evidence summaries for topics under consideration by Task Force

32 New USPSTF Clinical Recommendations – Screening for Prostate Cancer – Screening for Hearing Loss in all Newborns – Screening for Bacterial Vaginosis in Pregnancy – Screening for Illicit Drug Use – Screening for Chronic Obstructive Pulmonary Disease – Screening for Phenylketonuria – Screening for Congenital Hypothyroidism

33 AHRQ Evidence Translation/ Communication (Eisenberg Center) Translates knowledge about effective health care into clear, actionable summaries to assess: Translates knowledge about effective health care into clear, actionable summaries to assess: – Treatments – Medications – Technologies Develops information summaries for 3 key audience groups: Develops information summaries for 3 key audience groups: – Consumers – Health care providers – Policymakers

34 AHRQ Comparative Effectiveness Research http//:effectivehealthcare.ahrq.gov

35 Effective Health Care Program: Comparative Effectiveness Reviews in Progress ConditionTopic Diabetes Comparative Effectiveness, Safety, and Indications of Insulin Analogues in Premixed Formulations for Adults with Type 2 Diabetes Heart and Blood Vessel Conditions Comparative Effectiveness of Medical Therapies for Stable Ischemic Heart Disease Cancer Core Needle Breast Biopsy and Surgical Excision Biopsy for Diagnosing Breast Lesions Breathing Conditions Comparative Effectiveness of Anticholinergic Medications in Patients with Chronic Obstructive Pulmonary Disease (COPD) Research Methodology A Qualitative Study to Understand Barriers to Conducting Cluster Randomized Trials

36 Emerging Methods in Comparative Effectiveness & Safety Variation in methods among systematic reviews undercuts transparency Variation in methods among systematic reviews undercuts transparency Methods reduce the likelihood of scientific impartiality Methods reduce the likelihood of scientific impartiality Methods help minimize misclassification of data Methods help minimize misclassification of data Methods must continue to evolve and not remain stagnant Methods must continue to evolve and not remain stagnant AHRQ has and will continue to make investments in improving methods AHRQ has and will continue to make investments in improving methods

37 healthfinder.gov An NAHL favorite An NAHL favorite A free gateway to reliable consumer HHS information A free gateway to reliable consumer HHS information Includes links to 6,000+ health information resources Includes links to 6,000+ health information resources Access to myhealthfinder Access to myhealthfinder Updated version launched in September Updated version launched in September

38 Future Trends in Health Care Quality and Access Knowledge Creation Knowledge Creation Synthesis & Dissemination Synthesis & Dissemination Translating Research Into Practice Translating Research Into Practice 21 st Century Health Care 21 st Century Health Care Q & A Q & A

39 Health Care in 2058 (NAHSL’s 100 th Anniversary) What will it look like? What will it look like? – There is no way to tell. In the meantime, goals to be addressed include: Determining what can be done to improve the system right now Determining what can be done to improve the system right now A continuing sense of urgency for long-term solutions involving innovation, enhanced risk taking and new delivery system approaches A continuing sense of urgency for long-term solutions involving innovation, enhanced risk taking and new delivery system approaches

40 Getting to Value-Driven Health Care "Every American should have access to a full range of information about the quality and cost of their health care options." "Every American should have access to a full range of information about the quality and cost of their health care options." Michael O. Leavitt, Secretary US Dept. of Health and Human Services November 5, 2007

41 Quality Standards Design systems to collect quality of care information and define what constitutes quality health care Incentives Reward those who provide and purchase high-quality and competitively priced 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 Cornerstones of Value-Driven Health Care

42 Chartered Value Exchanges

43 Massachusetts Chartered Value Exchange The Massachusetts Health Quality Partners and the Massachusetts eHealth Collaborative came together to form the Chartered Value Exchange The Massachusetts Health Quality Partners and the Massachusetts eHealth Collaborative came together to form the Chartered Value Exchange – MHQP anticipates the Value Exchange will help further advance quality by integrating timely information into claims data for performance measurement – MAeHC is working to encourage implementation of EHRs and HIEs in Massachusetts – Priorities: Health IT & consumer engagement

44 21 st Century Health Care Improving quality by promoting a culture of safety through Value-Driven Health Care 21 st Century 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 Actionable information available – to clinicians AND patients – “just in time”

45 Scope of the Opportunity in Health Care A major challenge in 21 st Century health care is evaluating all innovations and determining which: A major challenge in 21 st Century health care is evaluating all innovations and determining which: – Represent added value – Offer minimal enhancements over existing choices – Fail to reach their potential – Work for some patients and not for others

46 How Do We Enhance Our Efforts? Key T1 activity to test what care works what care works Clinical efficacy research Key T2 activities to test who benefits from who benefits from promising care Outcomes research Comparative effectiveness Research Health services research Key T3 activities to test how to deliver high-quality how to deliver high-quality care reliably and in care reliably and in all settings all settings Measurement and accountability of health care quality and cost care quality and cost Implementation of Interventions and health care system redesign care system redesign Scaling and spread of effective interventions Research in above domains T1T2T3 Basic biomedical science Clinical efficacy knowledge Clinical effectiveness knowledge Improved health care quality and value and population health Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp The “3T’s Roadmap to Transform U.S. Health Care: The ‘How’ of High-Quality Care.” The “3T’s” Road Map to Transforming U.S. Health Care

47 Pronovost Study Settings: Volunteer MI hospital ICUs for adults (108 intention to treat) Settings: Volunteer MI hospital ICUs for adults (108 intention to treat) Primary hypothesis: Rate of CABSIs would be reduced during first 3 months of intervention v baseline Primary hypothesis: Rate of CABSIs would be reduced during first 3 months of intervention v baseline Multiple interventions (sequential and parallel) Multiple interventions (sequential and parallel) Outcome measure: Incidence-rate ratios for CABSIs Outcome measure: Incidence-rate ratios for CABSIs Pronovost et al., NEJM 355(26); Dec. 28, 2006 Analytic approach: Generalized linear latent and mixed model with robust variance estimation and random effects to account for clustering within hospitals and hospitals within regions, adjusted for hospital teaching status and number of beds Analytic approach: Generalized linear latent and mixed model with robust variance estimation and random effects to account for clustering within hospitals and hospitals within regions, adjusted for hospital teaching status and number of beds New Yorker, December 2007

48 Connecting ‘Achievability’ and Reliability… A robust health care system must include capacity for: 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

49 Future Trends in Health Care Quality and Access Knowledge Creation Knowledge Creation Synthesis & Dissemination Synthesis & Dissemination Translating Research Into Practice Translating Research Into Practice 21 st Century Health Care 21 st Century Health Care Q & A Q & A


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