Demand-Driven Research: Working through Delivery-Based Networks Irene Fraser, PhD, Director, CDOM AcademyHealth Annual Research Meeting June 8, 2004

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

To Improve Health Care, Decision-Makers Need and Want Evidence Clinical decisions - EB Medicine Clinical decisions - EB Medicine – What to include in drug formularies – How to define medical necessity Management decisions -- EB Management Management decisions -- EB Management – How to pay hospitals, physicians, nurses – How many/what kind of staff to recruit – With whom to merge, affiliate, contract – How to organize processes of care – What kinds of IT systems to purchase Policy Decisions – EB Policy Policy Decisions – EB Policy

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 17 yrs to turn 14% of original research 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

A Particular Problem for Evidence-Based Management EB Medicine More targeted goal (improve practice) More targeted goal (improve practice) Researchers and users are both scientists Researchers and users are both scientists Read common journals Read common journals Patients the unit of analysis Patients the unit of analysis EB Management Multiple goals (quality, efficiency, profit) Multiple goals (quality, efficiency, profit) Managers not scientists Managers not scientists Managers and scientists read different things Managers and scientists read different things Organizations the unit of analysis (N problem) Organizations the unit of analysis (N problem)

Lessons from Marketing First rule of marketing: First rule of marketing: – Build product to fit the need Second rule of marketing: Second rule of marketing: – To have the right product, may need to change the way you make it

Identifying Need: What Do Decision- Makers Want? Six user-centered meetings Six user-centered meetings – Small (20-30) groups – Combination of industry leaders, purchasers, policymakers, researchers Discussion at several NAC meetings Discussion at several NAC meetings Focus on both content and dissemination/use Focus on both content and dissemination/use Five lessons for HOW we do our work: Five lessons for HOW we do our work:

#1: Design Studies that Answer User Questions Move from description to prediction and explanation Move from description to prediction and explanation Focus on independent variables that are modifiable Focus on independent variables that are modifiable Provide details on HOW to implement Provide details on HOW to implement

#2: Present Findings in Decision- Makers’ Time and Space Define “evidence” as they do Define “evidence” as they do Perhaps redefine when something is ready for “prime time” Perhaps redefine when something is ready for “prime time” Limit caveats Limit caveats Be willing to generalize to broader universe Be willing to generalize to broader universe Add “tools” to our list of products Add “tools” to our list of products

#3: Change Incentive Systems for Researchers Currently, researchers Get tenure by publishing in journals managers don’t read Get tenure by publishing in journals managers don’t read Get credit for teaching other researchers, not managers Get credit for teaching other researchers, not managers Get grants for “academic” research, not applied, translational research Get grants for “academic” research, not applied, translational research Find it easier to publish quantitative, not qualitative, research Find it easier to publish quantitative, not qualitative, research

#4: Build User-Researcher Collaborations and Dialogue Provider-based networks Provider-based networks Challenge grants Challenge grants Organizational researchers with management experience Organizational researchers with management experience Managers with research training Managers with research training Practitioners in classrooms Practitioners in classrooms

#5: Change Dissemination Let early adopters, not researchers, educate next wave of users Let early adopters, not researchers, educate next wave of users Give presentations at trade association meetings, not just research meetings Give presentations at trade association meetings, not just research meetings Collaborate with, mimic, or work through consultants Collaborate with, mimic, or work through consultants Find or create equivalent of Harvard Business Review for health care Find or create equivalent of Harvard Business Review for health care Expand funding for implementation research Expand funding for implementation research

Bonus Tip: Don’t Over-Complicate Findings Winners of Washington Post Contest on Ways to Make Life Harder Supermarkets arrange goods alphabetically: lettuce, lamb and lysol are now contiguous Supermarkets arrange goods alphabetically: lettuce, lamb and lysol are now contiguous Thursdays become “drive-on-the-left-side-of-the-road” day Thursdays become “drive-on-the-left-side-of-the-road” day Subdivide time zones into 60 parts, observing local times to the minute Subdivide time zones into 60 parts, observing local times to the minute Alphabetize phone books by first names Alphabetize phone books by first names

SUPPLY-DRIVEN MODEL PUBLICATIONS DECISION-MAKERSRESEARCHERS Questions Hypotheses Grant Applications Study Writing Re-writing Culture Leadership Politics Evidence

SUPPLY-DRIVEN MODEL WITH MARKETING “Knowledge transfer” PUBLICATIONS DECISION-MAKERSRESEARCHERS Questions Hypotheses Grant Applications Study Writing Re-writing Culture Leadership Politics Evidence

DEMAND-INFORMED MODEL User Needs Assessment “Knowledge transfer” PUBLICATIONS DECISION-MAKERSRESEARCHERS Questions Hypotheses Grant Applications Study Writing Re-writing Culture Leadership Politics Evidence

DEMAND-DRIVEN NETWORK MODEL DECISION-MAKERS RESEARCHERS PUBLICATIONS Info + Tools Tools

3 Examples of Research Networks Integrated Delivery System Research Network Integrated Delivery System Research Network Center for Health Management Research Center for Health Management Research HIV Research Network HIV Research Network

What is the IDSRN? 9 practice-based research partners: 9 practice-based research partners: – Abt Associates Inc. – Center for Health Care Policy and Evaluation – Denver Health – Emory Center on Health Outcomes and Quality – – HMO Research Network – Marshfield Clinic IDS Research Consortium – Research Triangle Institute - UNC Network – University of Minnesota Consortium – Weill Medical College of Cornell University 40 collaborators 40 collaborators Work through task orders Work through task orders

Strategic Advantage: Size and Breadth IDSRN includes: Over 50 million patients Over 50 million patients Majority of US physicians Majority of US physicians Majority of acute inpatient facilities Majority of acute inpatient facilities 2,250 outpatient clinics 2,250 outpatient clinics 450 long term care facilities 450 long term care facilities 56 rehabilitation facilities 56 rehabilitation facilities 30 home health agencies 30 home health agencies 63 dental facilities 63 dental facilities

Size and Breadth: Persons Served Located in All States

Strategic Advantage: Population Diversity Payer mix: privately insured, Medicare (3 million), Medicaid (2 million), uninsured (0.5 million) Payer mix: privately insured, Medicare (3 million), Medicaid (2 million), uninsured (0.5 million) Geographic mix: urban, inner-city, suburban and rural (6.3 million) residents Geographic mix: urban, inner-city, suburban and rural (6.3 million) residents Demographic mix: ethnic and racial minorities (>5.8 million), children and adolescents (>14 million), persons aged 65+ (~7 million) Demographic mix: ethnic and racial minorities (>5.8 million), children and adolescents (>14 million), persons aged 65+ (~7 million)

Strategic Advantage: Data, Research, Implementation Capacity Large, robust databases (e.g., administrative, clinical, registries) Large, robust databases (e.g., administrative, clinical, registries) Clinical, demographic, geographic data diversity Clinical, demographic, geographic data diversity Nationally-recognized academic and field-based researchers Nationally-recognized academic and field-based researchers Expertise in data manipulation, methods, emerging IDS policy/management issues Expertise in data manipulation, methods, emerging IDS policy/management issues Operational leadership involved in setting agenda and using findings Operational leadership involved in setting agenda and using findings

Strategic Advantage: Speed From request for proposals to award : ~9 weeks From request for proposals to award : ~9 weeks Average project completed in 16 months Average project completed in 16 months Excellent mechanism for rapid-cycle work: Excellent mechanism for rapid-cycle work: – data availability – expertise in data manipulation, methods – established partner collaborations – want solutions for own delivery system issues

Examples of Products in 2003 Presentations to IDS Operational Leadership (12) Presentations to IDS Operational Leadership (12) Presentations at live/web-assisted conferences (50) Presentations at live/web-assisted conferences (50) Scalable, scenario-appropriate models (for local to international adaptation) (~15) Scalable, scenario-appropriate models (for local to international adaptation) (~15) Training session and workshop tools (47) Training session and workshop tools (47) “How to” guides, workbooks (many!) “How to” guides, workbooks (many!) Publications in peer-reviewed journals (12) Publications in peer-reviewed journals (12) Press releases, briefings and briefs (10) Press releases, briefings and briefs (10) National conference (1) National conference (1)

Impact: 830 Downloads of Weill’s BTP Model from AHA Web Site; AHA TA Provided

Impact: IDSRN Results Influence Users’ Practice or Policy Decisions Providence Health System hired “transition pharmacist” to reduce errors using an electronic medication list CMS/OMH using CLAS guides as training tools in M+CO workshops nationwide CMS/OMH using CLAS guides as training tools in M+CO workshops nationwide Findings influenced Aetna’s decision to begin collecting race/ethnicity data Findings influenced Aetna’s decision to begin collecting race/ethnicity data Evercare CEO making NP staffing decisions for nursing homes based on pneumonia care findings Evercare CEO making NP staffing decisions for nursing homes based on pneumonia care findings

IDSRN: Three Types of Impact

Center for Delivery, Org. & Markets Irene Home Page