1. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Provision of Preventive Services in the Complex Patient AHRQ Annual Meeting September 9, 2008

2. Advancing Excellence in Health Care The Issue Aging American population Aging American population  prevalence and burden of chronic illnesses  prevalence and burden of chronic illnesses Most quality metrics designed for the uncomplicated case Most quality metrics designed for the uncomplicated case

3. Advancing Excellence in Health Care Goals of the Funding Opportunity Inform prioritization of guidelines, whether for prevention or disease management, in order to: Inform prioritization of guidelines, whether for prevention or disease management, in order to: – Maximize effective care – Avoid inappropriate incentives for clinicians – Respect patient autonomy and choice in the setting of a limited life span

4. Advancing Excellence in Health Care Three Study Types Envisioned 1. Descriptive Epidemiology 2. Analytic Epidemiology 3. Modeling

5. Advancing Excellence in Health Care Descriptive Epidemiology  Large data set analyses (population surveys, medical databases, EHR, insurance claims)  Chronic illnesses needing  Natural history  Impact on quality of life over time  Life expectancy  Cumulative burden of therapies over time  Number and types of medications  Other recommended treatments  Services for tertiary prevention

6. Advancing Excellence in Health Care Analytic Epidemiology  Retrospective cohort designs  Assess benefits and harms of preventive or therapeutic interventions  In “real world” settings for patients who have multiple chronic co-morbid conditions  Require sufficient clinical data and innovative statistical techniques to determine the relative positive and negative impacts of prevention/therapy in a populations with co-morbid illness

7. Advancing Excellence in Health Care Modeling studies  Decision models and cost-effectiveness analysis  Project impact of recommended therapies and preventive services on patients with two or more co-morbid chronic conditions  Models sufficiently comprehensive to model the impact of the co-morbid illness on  issues of competing morbidity and/or mortality  benefits and harms of the intervention

8. Advancing Excellence in Health Care R21 Grant Program 2008 funds $ 3.7 million 2008 funds $ 3.7 million 18 awards 18 awards R21 : exploratory research R21 : exploratory research Second phase planned for 2010 to build on results Second phase planned for 2010 to build on results

9. Advancing Excellence in Health Care Today’s Presenters ‘Complex Patient’ R21 grantees ‘Complex Patient’ R21 grantees – Laura M. De Castro MD; Duke U. “Relationship of Depression to Sickle Cell Disease Severity, Health Care Utilization and Quality of Life” “Relationship of Depression to Sickle Cell Disease Severity, Health Care Utilization and Quality of Life” – Maureen Smith MD; U. Wisconsin “Guideline Adherence and Health Outcomes in Medicare FFS Patients with Diabetes” “Guideline Adherence and Health Outcomes in Medicare FFS Patients with Diabetes” Expert commentary Expert commentary – Barbara J. Turner MD, MSED, MA Professor of Medicine Division of General Internal Medicine University of Pennsylvania School of Medicine