Presentation is loading. Please wait.

Presentation is loading. Please wait.

HSR and the Imperative for Health Care Transformation Carolyn M. Clancy, MD Director October 7, 2003.

Similar presentations


Presentation on theme: "HSR and the Imperative for Health Care Transformation Carolyn M. Clancy, MD Director October 7, 2003."— Presentation transcript:

1 HSR and the Imperative for Health Care Transformation Carolyn M. Clancy, MD Director October 7, 2003

2 Overview The imperative to improve The imperative to improve The challenges of creating & applying “Useable Knowledge” The challenges of creating & applying “Useable Knowledge” Opportunities and Challenges Opportunities and Challenges Final thoughts Final thoughts

3 State of Quality in the U.S. “ The American health care delivery system is in need of fundamental change….the care delivered is not, essentially, the care we should receive… … Between the health care we have and the care we could have lies not just a gap, but a chasm…” “The need for leadership in health care has never been greater.” IOM, Crossing the Quality Chasm, 2001 IOM, Crossing the Quality Chasm, 2001

4 New York Times, December 18, 2002

5 RAND Study: Quality of Health Care Often Not Optimal Patients’ care often deficient, study says. Proper treatment given half the time. On average, doctors provide appropriate health care only half the time, a landmark study of adults in 12 U.S. metropolitan areas suggests. Medical Care Often Not Optimal Failure to Treat Patients Fully Spans Range of What Is Expected of Physicians and Nurses Study: U.S. Doctors are not following the guidelines for ordinary illnesses. The American healthcare system, often touted as a cutting-edge leader in the world, suddenly finds itself mired in serious questions about the ability of its hospitals and doctors to deliver quality care to millions. Medical errors corrode quality of healthcare system

6 RAND Study: Quality of Health Care Often Not Optimal Doctors provide appropriate health care only about half the time Doctors provide appropriate health care only about half the time Percentage of time Alcohol dependence Hip fracture Peptic ulcer Diabetes Low back pain Prenatal care Breast cancer Cataracts 11% 23% 33% 45% 69% 73% 76% 79% E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults in the United States, N Engl J Med, 2003

7 “ The one question I still can’t answer is: WHY the gap between evidence- based and actual practice?” Earl Steinberg, M.D., M.P.P., 2003

8 Pick Your Condition …. Diabetes Diabetes Hypertension Hypertension Aspirin post MI Aspirin post MI Beta blockers post MI Beta blockers post MI Anticoagulation Anticoagulation Hypercholesterolemia Hypercholesterolemia

9 The Chasm in Asthma Care What percent of people in managed care get appropriate medications for asthma?* What percent of people in managed care get appropriate medications for asthma?* Children % Adolescents % Adults %

10 Clarifying National Aims for Improvement Safety Safety Effectiveness -- Matching care to science; avoiding overuse of ineffective care and underuse of effective care Effectiveness -- Matching care to science; avoiding overuse of ineffective care and underuse of effective care Patient Centeredness Patient Centeredness Timeliness Timeliness Efficiency Efficiency Equity Equity

11 Reperfusion Therapy in Medicare Beneficiaries with Acute MI White men White women Black men Black women 59% 56% 50% 44% Canto JG; Allison JJ; Kiefe CI; Fincher C; Farmer R, Sekar P; Person S; Weissman NW. Relation of rave and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. N Engl J Med 2000 Apr 13;342(15): % Eligible receiving reperfusion Group

12 Context Investments in biomedical science  growing demand for products of HSR Investments in biomedical science  growing demand for products of HSR Greater recognition among decision makers of the potential value of “HSR” Greater recognition among decision makers of the potential value of “HSR” Growing impatience with the leisurely pace of translation of knowledge into practice Growing impatience with the leisurely pace of translation of knowledge into practice Growing recognition of patients as partners and agents of change -- rather than ‘recipients’ Growing recognition of patients as partners and agents of change -- rather than ‘recipients’

13 Manifestations Public Library of Science (PLOS; Harold Varmus) Public Library of Science (PLOS; Harold Varmus) Landmark lecture in US focuses on “clinical research lost in translation” Landmark lecture in US focuses on “clinical research lost in translation” Multiple entities established, disbanded and reinvented to focus on research uptake (all Nations) Multiple entities established, disbanded and reinvented to focus on research uptake (all Nations) Health care challenges are page 1 news Health care challenges are page 1 news Focus on HIT as “the answer” Focus on HIT as “the answer”

14 What We Have Learned 2003 Knowing the right thing to do is NOT = doing it! Knowing the right thing to do is NOT = doing it! Improvement must be based on science Improvement must be based on science Patients as participants are far more effective than patients as ‘recipients’ Patients as participants are far more effective than patients as ‘recipients’ Sutton’s Law: improving chronic illness care is essential Sutton’s Law: improving chronic illness care is essential Safety in health care delivery is critical Safety in health care delivery is critical

15 Potential for HSR From describing problems to solving them: From describing problems to solving them: Getting to “TRIPP” Getting to “TRIPP” Creating and nurturing ‘receptor sites’ for our work Creating and nurturing ‘receptor sites’ for our work “Back to the Future” “Back to the Future”

16 “Potential is what you have when you haven’t done it yet” Darrel Royall University of Texas Football coach

17 Overview The imperative to improve The imperative to improve The challenges of creating & applying “Useable Knowledge” The challenges of creating & applying “Useable Knowledge” Opportunities and Challenges Opportunities and Challenges Final thoughts Final thoughts

18 Health Services Research “Health services research is a multidisciplinary field of inquiry, both basic and applied, that examines the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services to increase knowledge and understanding of the structure, processes, and effects of health services for individuals and populations. Institute of Medicine, 1995

19

20 The Challenge “What we really want to get at is not how many reports have been done, but how many people's lives are being bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients?…[W]hat effect is it having on people?” Congressman John Porter, 1998 Chairman, House Appropriations Subcommittee on Labor, HHS, and Education

21 Research Impact Improves Access, Outcomes, Efficiency Improves Other Research Improves Processes and Policies Improves Delivery and Practice Level 4 Level 3 Level 2 Level 1

22 Levels of Impact: ADHD

23 A real lack is what is known as ‘translational research’ -- The translation of great basic science into practical clinical realities for patients.” “ A real lack is what is known as ‘translational research’ -- The translation of great basic science into practical clinical realities for patients.” -- Steve Case, AOL Time Warner Chairman at Senate Appropriations Labor HHS Subcommittee, June 4, 2002

24 Bridging the Quality Chasm Where We Where We Are Want To Be TRIP Implementation Diffusion Adoption Education Innovation

25 This is Not a New Problem: The Case of Scurvy Lancaster shows that lemon juice supplement eliminates scurvy among sailors Lancaster shows that lemon juice supplement eliminates scurvy among sailors Lind shows that citrus juice supplement eliminates scurvy Lind shows that citrus juice supplement eliminates scurvy (194 years after discovery) British Navy implements citrus juice supplement (194 years after discovery) British Navy implements citrus juice supplement

26 Publication Bibliographic databases Submission Reviews, guidelines, textbook Negative results variable 0.3 year years 50% 46% 18% 35% 0.6 year 0.5 year 9.3 years It takes 17 years to turn 14 per cent of original research to the benefit of patient care to the benefit of patient care Dickersin, 1987 Koren, 1989 Balas, 1995 Poynard, 1985 Kumar, 1992 Poyer, 1982 Antman, 1992 Negative results Lack of numbers Expert opinion Inconsistent indexing 17:14 Original research Acceptance Implementation

27 Debunked Assumption I: Supply Side Research Question Hypothesis Study Publications Changes in practice

28 Debunked Assumption II: Improved Packaging Publications (multiple) Evidence synthesis Guidelines, Performance Measures Changes in Practice ???

29 A Flawed Model Receptor sites are “assumed” Receptor sites are “assumed” Decisionmaking is not-linear: evidence is only part of the “solution” Decisionmaking is not-linear: evidence is only part of the “solution” Broad dissemination  modest effects Broad dissemination  modest effects

30 Selected Models of Change Rogers’s diffusion of innovation Rogers’s diffusion of innovation Gladwell: the “tipping point” Gladwell: the “tipping point” Economics: incentives and rewards Economics: incentives and rewards Regulation: sanctions Regulation: sanctions Individual: PRECEDE Individual: PRECEDE One or more of the above One or more of the above Other? Other?

31 Diffusion of Innovation “Invention is hard; dissemination is much more difficult” (Berwick; 2003) “Invention is hard; dissemination is much more difficult” (Berwick; 2003) A problem for all industries A problem for all industries Influences on rate of diffusion: Influences on rate of diffusion: – Perception of innovation – Characteristics of individuals who adopt change – Contextual and managerial factors Source: Mosteller, Science l981;221:881

32 The Tipping Point (M. Gladwell) Small changes can have big effects The law of the few -- individual actions can be amplified by social connections, energy, enthusiasm and personality (connectors, mavens and salesmen) The law of the few -- individual actions can be amplified by social connections, energy, enthusiasm and personality (connectors, mavens and salesmen) The stickiness factor-- simple changes in the presentation and structuring of information can make a big difference in its impact The stickiness factor-- simple changes in the presentation and structuring of information can make a big difference in its impact The power of context -- individual behavior is markedly affected by the environment The power of context -- individual behavior is markedly affected by the environment

33

34 “Joint Production” Priority setting for research Priority setting for research Joint design of research (“CBPR”)* Joint design of research (“CBPR”)* Results interpretation and synthesis Results interpretation and synthesis Improved formatting and new vehicles for communication Improved formatting and new vehicles for communication “Receptor capacity”** “Receptor capacity”** Identifying brokers and champions** Identifying brokers and champions** Clarifying shortcomings and impact** Clarifying shortcomings and impact**

35 Potential Barriers to Implementation Knowledge- lack of awareness of what is being implemented (generally or specifically), unable to access the information at the time of need Knowledge- lack of awareness of what is being implemented (generally or specifically), unable to access the information at the time of need Attitudes- lack of agreement with objective, lack of self-efficacy, lack of outcomes expectancy, inability to overcome inertia Attitudes- lack of agreement with objective, lack of self-efficacy, lack of outcomes expectancy, inability to overcome inertia Behavior- unable to reconcile with others’ preferences, ongoing conflicting actions, conflicting environmental factors Behavior- unable to reconcile with others’ preferences, ongoing conflicting actions, conflicting environmental factors -- Adapted from Cabana, et al., JAMA 1999

36 Acute Cardiac Ischemia- Time Insensitive Predictive Instrument

37 The Two Faces of “TRIPP” Funding research on transferring research into practice Funding research on transferring research into practiceversus Embedding the transfer of research into practice within the culture of universities, healthcare organizations and research funders Embedding the transfer of research into practice within the culture of universities, healthcare organizations and research funders

38 Overview The imperative to improve The imperative to improve The challenges of creating & applying “Useable Knowledge” The challenges of creating & applying “Useable Knowledge” Opportunities and Challenges Opportunities and Challenges Final thoughts Final thoughts

39 Back to the Future - 1 Infomedicine now understood as essential complement to biomedicine Infomedicine now understood as essential complement to biomedicine Boundaries between “QI” and “research” have disappeared Boundaries between “QI” and “research” have disappeared Data collection is purposeful, strategic and oriented to patients’ and clinicians’ needs for information Data collection is purposeful, strategic and oriented to patients’ and clinicians’ needs for information NO research is initiated without a clear plan for sustained implementation NO research is initiated without a clear plan for sustained implementation

40 Challenges 1 Evaluation of translation research Evaluation of translation research Career paths for individuals focused on improvement: metrics for success? Career paths for individuals focused on improvement: metrics for success? “Alignment of incentives” for researchers and funders “Alignment of incentives” for researchers and funders “Research findings are ‘not ready to use’” “Research findings are ‘not ready to use’”

41 Back to the Future - 2 Learning from clinical encounters is a critical component of knowledge development Learning from clinical encounters is a critical component of knowledge development Patients understand and SEE incentives for participation in routine clinical evaluation and improvement Patients understand and SEE incentives for participation in routine clinical evaluation and improvement Throughout the world, the question “What is the evidence?” is as routine as vital signs or budget numbers Throughout the world, the question “What is the evidence?” is as routine as vital signs or budget numbers

42 Challenges 2 Taking promising findings “to scale”: metrics for ‘promising’ and ‘readiness to implement’? Taking promising findings “to scale”: metrics for ‘promising’ and ‘readiness to implement’? Science of change: validation before and/or during implementation? Science of change: validation before and/or during implementation? Moving beyond “1000 flowers blooming” Moving beyond “1000 flowers blooming” Involving users throughout the research cycle Involving users throughout the research cycle Redefining “core focus” of HSR Redefining “core focus” of HSR

43 Back to the Future - 3 Policymakers “get it”: the return on investment in biomedical research is significantly enhanced by a robust investment in outcomes research Policymakers “get it”: the return on investment in biomedical research is significantly enhanced by a robust investment in outcomes research Target quality improvement efforts have completely replaced “special” studies on disparities (we now know that disparities in health care = a critical QI opportunity) Target quality improvement efforts have completely replaced “special” studies on disparities (we now know that disparities in health care = a critical QI opportunity) Continuous focus on measurement and evaluation -- for improvement Continuous focus on measurement and evaluation -- for improvement

44 Contemporary Challenges Scientific basis for safe and appropriate use of diagnostic, therapeutic and preventive interventions – the case for “practical clinical trials” Scientific basis for safe and appropriate use of diagnostic, therapeutic and preventive interventions – the case for “practical clinical trials” Quality improvement as science Quality improvement as science Translating promising models into large-scale improvements in care and outcomes Translating promising models into large-scale improvements in care and outcomes

45 The Evolution of TRIP Research TRIP I RFA TRIP I RFA – New knowledge about approaches that are effective and cost-effective in promoting the use of research evidence in clinical settings and lead to improved health care practice and sustained practitioner behavior change TRIP II RFA TRIP II RFA – Strategies for translating research into practice through the development of partnerships between researchers and health care systems and organizations

46 2.8% 3.4% Patients who took beta blockers before bypass surgery had lower rates of death in and out of the hospital within 30 days of surgery compared to those who did not Use of beta blockers also improved outcomes in patients at higher risk, e.g., those with heart failure, older age, lung disease, and diabetes WithWithout AHRQ Research Study: Outcomes of Beta Blocker Use Before Bypass Surgery Blocker Use Before Bypass Surgery TB Ferguson, L Coombs, E Peterson, Preoperative B-Blocker Use and Mortality and Morbidity Following CABG Surgery in North American, JAMA, May 2002 Beta Blocker

47 Team Approach to Testing for Chlamydia Team-oriented approach to testing for chlamydia increased screening rate of sexually active 14- to 18-year old female patients from 5% to 65% in a large California HMO study Team-oriented approach to testing for chlamydia increased screening rate of sexually active 14- to 18-year old female patients from 5% to 65% in a large California HMO study New screening system may help reduce estimated $4 billion annual treatment cost New screening system may help reduce estimated $4 billion annual treatment cost 5% 65% M Shafer, The effect of clinical practice improvement intervention on chlamydia screening among sexually active adolescent girls, JAMA, December 11, 2002

48 Effectiveness of Inpatient and Outpatient Treatment for Women With PID 1.2 Million women are treated each year for pelvic inflammatory disease (PID) 1.2 Million women are treated each year for pelvic inflammatory disease (PID) Major Finding: Treating PID in outpatient settings rather than in a hospital does not cause harm to women Major Finding: Treating PID in outpatient settings rather than in a hospital does not cause harm to women R. Ness, D. Soper, R. Holley, et al., Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the PID evaluation and clinical health (PEACH) randomized trial, AJOG, May % 85% Acute & serious PID requires inpatient treatment Mild to moderate PID may be treated as outpatients May save about $500 million each year 100,000 women womenhospitalized for PID for PID

49 The Evolution of TRIP Research TRIP PA TRIP PA ¯ Supporting research that can bridge the chasm between promising prototypes and generalizable knowledge that can be used in multiple settings and lead to systematic improvement on a large scale. ¯ Emphasizing projects that introduce changes at the clinical, organization/health care systems, and/or public policy levels […] and then measure the impact of these efforts.

50 AHRQ Strategy Components Building the knowledge base : Building the knowledge base : – The Effectiveness Question: What works? Clinical Clinical Organizational Organizational – The TRIP Question: How do we get people/systems/policymakers to do or use what works? How do we support the widespread implementation of what works? How do we support the widespread implementation of what works? How do we sustain evidence based practice? How do we sustain evidence based practice?

51 Practice-Based Research Networks (PBRNs) 36 new PBRN grants awarded in PBRN grants awarded in 2000

52 Strategic Advantages: Size and Breadth IDSRN’s 9 consortia include: Over 50 million patients Over 50 million patients Majority of US physicians and acute inpatient facilities Majority of US physicians and acute inpatient facilities >2000 outpatient clinics >2000 outpatient clinics Long-term care, rehab, dental facilities Long-term care, rehab, dental facilities Home health agencies Home health agencies

53

54

55 Priority Areas in Both Reports - 1 Cancer Cancer Chronic kidney disease Chronic kidney disease Diabetes Diabetes Heart disease Heart disease HIV/AIDS HIV/AIDS Maternal and child health Maternal and child health Mental illness-depression Mental illness-depression Respiratory illness (e.g., asthma, flu) Respiratory illness (e.g., asthma, flu)

56 Priority Areas in Both Reports - 2 Nursing home and home health Nursing home and home health Patient safety Patient safety Timeliness Timeliness Patient centeredness Patient centeredness Resource consumption Resource consumption

57 What Will Be the Response to the First Reports? WOW!! Extensive media coverage WOW!! Extensive media coverage We need more – measures We need more – measures WHAT NOW?? WHAT NOW??

58 Issues Will public reporting  improvements? Will public reporting  improvements? Literature to date suggests modest albeit growing impact on consumers’ decisions Literature to date suggests modest albeit growing impact on consumers’ decisions Apparently tangible impact on providers Apparently tangible impact on providers “Paying for quality” – YES, but HOW?? “Paying for quality” – YES, but HOW?? If quality improvement is local, what is Federal role? If quality improvement is local, what is Federal role?

59 Improving Quality and Safety “We need to make the right thing the easy thing…” Mark Chassin, MD October 12, 2000

60 Outline The imperative to improve The imperative to improve The challenges of creating & applying “Useable Knowledge” The challenges of creating & applying “Useable Knowledge” Opportunities and challenges Opportunities and challenges Final thoughts Final thoughts

61 Growing Impatience …. Precision and consensus regarding management of (‘X’) greatly exceeds translation into practice Precision and consensus regarding management of (‘X’) greatly exceeds translation into practice Most clear successes of translating research into practice have focused on underuse of effective treatments; less focus on misuse and overuse Most clear successes of translating research into practice have focused on underuse of effective treatments; less focus on misuse and overuse Next frontiers: linking incentives with improvement; IT; leadership Next frontiers: linking incentives with improvement; IT; leadership

62 HSR: The Future Increased emphasis on research input to health care transformation Increased emphasis on research input to health care transformation Clear focus on value for health care $$ Clear focus on value for health care $$ Positioned as science partner for change Positioned as science partner for change Active promotion of quality improvement, innovation and learning Active promotion of quality improvement, innovation and learning

63 How HSR Could Evolve Proposed studies that do not involve all stakeholders are considered ‘amusing’ Proposed studies that do not involve all stakeholders are considered ‘amusing’ Proposed studies that do not include an explicit and compelling plan for incorporation into practice are not funded Proposed studies that do not include an explicit and compelling plan for incorporation into practice are not funded Patients are central to conduct and review of research: “Nothing about me without me” Patients are central to conduct and review of research: “Nothing about me without me”

64 We Need YOU “ Physician-Researchers Needed to Get Cures Out of Rat’s Cage” Begley S. (Science Journal) 2003, April 25. Wall St. Journal

65 Practice and Organizational Challenges Information problems Information problems Variation in individual clinical decisions Variation in individual clinical decisions Stress Stress Inertia Inertia Readiness to change Readiness to change Need for clinical policies Need for clinical policies

66 Questions in Search of Answers Linking knowledge development to policy levers (e.g., payment; regulation): role of ‘demonstrations’ Linking knowledge development to policy levers (e.g., payment; regulation): role of ‘demonstrations’ When is “good enough”? When is “good enough”? Vocabulary and pathways for translation of knowledge-based interventions under-developed Vocabulary and pathways for translation of knowledge-based interventions under-developed Concurrent -- or sequential -- evaluation and translation? Concurrent -- or sequential -- evaluation and translation?

67 Percent of Americans Saying “I Have A Chronic Condition” Percent of Americans Saying “I Have A Chronic Condition” Source: Chronic Illness and Caregiving Survey, Harris 2000

68 Intellectual Challenges Different kinds of research questions and methods Different kinds of research questions and methods – Research synthesis – Clinical quality improvement – Moving systems – Provider-centered – Systems-centered – “Spread”/diffusion – If NOT secondary analysis of data sets or (often) RCTs – then what? Different measures of success Different measures of success

69 Implications for Academic Medical Centers Imperative to improve: challenging definitions of « research » Imperative to improve: challenging definitions of « research » Tension between "1000 flowers blooming", a strategic approach to research, and academic rewards Tension between "1000 flowers blooming", a strategic approach to research, and academic rewards Career Paths Career Paths Education of students and residents Education of students and residents Academic Medical Centers as drivers of change (?) Academic Medical Centers as drivers of change (?)

70


Download ppt "HSR and the Imperative for Health Care Transformation Carolyn M. Clancy, MD Director October 7, 2003."

Similar presentations


Ads by Google