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

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)

‘Consider This Recent Case’

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

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

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

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

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

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)

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 www.ahrq.gov/questionsaretheanwser

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. http://www.ahrq.gov/qual/transform.htm

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

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

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

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

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

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

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.

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

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

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

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

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 http://effectivehealthcare.ahrq.gov/reports/med-care-report.cfm

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

Program Outputs Research Reports Consumer Guides Systematic Reviews

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

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

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

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

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

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

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

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

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

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

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. 8-10 awards

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

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

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

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

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

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

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

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

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,

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”

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

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