1. Agency for Healthcare Research and Quality
Building a Bridge Over the Quality Chasm: The Role of AHRQ and the UT System
Carolyn M. Clancy, MD
Director
Agency for Healthcare Research and Quality
UT Clinical Safety and Effectiveness Inaugural Conference
Austin, TX – October 15, 2009

2. The Fundamental Problem
“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

3. Challenges
Concerns about health spending – about $2.3 trillion per year in the U.S. and growing
Pervasive problems with the quality of care that people receive
Large variations and inequities in clinical care
Uncertainty about best practices involving treatments and technologies
Translating scientific advances into actual clinical practice and usable information both for clinicians and patients

4. Building a Bridge at the Quality Chasm
AHRQ’s Role
The Quality Chasm
Getting There from Here
Q&A

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

6. HHS Organizational Focus
NIH
Biomedical research to prevent, diagnose and treat diseases
CDC
Population health and the role of community-based interventions to improve health
AHRQ
Long-term and system-wide improvement of health care quality and effectiveness

7. AHRQ Priorities Patient Safety Ambulatory Patient Safety
Health IT
Patient Safety Organizations
New Patient Safety Grants
Ambulatory Patient Safety
Effective Health Care Program
Comparative Effectiveness Reviews
Comparative Effectiveness Research
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

8. AHRQ Roles and Resources
Health IT Research
Funding
Support advances that improve safety and quality
Continue work in hospital settings
Step up use of HIT to improve ambulatory care
Develop Evidence Base for Best Practices
Patient-centered care
Medication management
Integration of decision support tools
Enabling quality measurement
Promote Collaboration
and Dissemination
Support efforts of other federal agencies (e.g., CMS, HRSA)
Build on public and private partnerships
Use web tools to share knowledge and expertise

9. Plus: significant ARRA funding (more on that later)
AHRQ FY 2009 Funding
$372 million
$37 million more than FY 2008
$46 million more than the president’s request
FY 2009 appropriation includes:
$50 million for comparative effectiveness research, $20 million more than FY 2008
$49 million for patient safety activities
$45 million for health IT
Plus: significant ARRA funding (more on that later)

10. Building a Bridge at the Quality Chasm
AHRQ’s Role
The Quality Chasm
Getting There from Here
Q&A

11. The Quality Chasm: The STEEEP Challenge
In 1999, in To Err is Human, Institute of Medicine estimated that 44,000 to 98,000 patients die each year in the United States as a result of medical error
In 2001, IOM observed that a “quality chasm” exists between the care that should be provided and care that actually is provided
IOM defined quality care as care that is safe, timely, effective, efficient, equitable, and patient centered

12. 2008 Healthcare Quality Report
Key Themes
Health care quality is suboptimal and improves at a slow pace (1.8% annually for core measures; 1.4% for all measures)
Reporting of hospital quality is spurring improvement, but patient safety is lagging
Health care quality measurement is evolving but much work remains

13. 2008 Healthcare Disparities Report
Key Themes:
Disparities persist in health care quality and access
Magnitude and pattern of disparities are different within subpopulations
Some disparities exist across multiple priority populations

14. Texas: Dashboard on Overall Health Care Quality vs. All States
Average
Weak
Strong
Very Weak
Very Strong
Performance Meter: All Measures
= Most Recent Year = Baseline Year
2008 National Healthcare Quality Report, State Snapshots

15. Texas Snapshot
Measure
Performance
% of hospital patients age 65 and over with pneumonia who received pneumococcal screening or vaccination
Better than average
% of hospital patients with heart attack who received aspirin within 24 hours of admission
Average
% of adult surgery patients who received appropriate timing of antibiotics
Worse than average
2008 National Healthcare Quality Report, State Snapshots

16. Tools to Address the Chasm
Health IT (efficiency, timeliness)
Comparative effectiveness research (safety, effectiveness)
Direct engagement with consumers (equity, patient-centeredness)

17. AHRQ Health IT Research Funding
AHRQ Health IT Investment: $260 Million
Long-term agency priority
AHRQ has invested more than $260 million in contracts and grants
More than 150 communities, hospitals, providers, and health care systems in 48 states

18. AHRQ Health IT Initiative
State and regional demonstrations
Health IT grants
Privacy and security solutions for interoperable health information exchange
ASQ Initiative
E-prescribing pilots
CDS demonstrations
Technical assistance for Medicaid and CHIP agencies

19. AHRQ National Resource Center for Health IT
Established in 2004
Central national source of information and assistance for advancing health IT goals
Maintains operation of the AHRQ health IT Web site
Direct technical assistance to AHRQ grantees
Repository for lessons learned from AHRQ’s health IT initiative

20. Health IT EPC Report
First synthesis of existing evidence on factors influencing the usefulness, usability, barriers and drivers to use, and effectiveness of consumer applications
The top factor associated with use by patients was the perception of a health benefit
Patients prefer systems tailored to them that incorporate familiar devices

21. AHRQ National Resource Center for Health IT Web Site
Features AHRQ’s portfolio of health IT projects
Funding opportunities
News releases
Emerging lessons and best practices
Meetings and events

22. Ambulatory Safety and Quality (ASQ) Program
Purpose: Improve safety and quality of ambulatory health care in the U.S. More than 60 grants
Sample types of health IT used in projects:
PHRs
Clinical/medication reminders
Clinical decision support
Telehealth
Human/machine interface

23. ASQ Grants: Texas
Using Electronic Records To Detect and Learn From Ambulatory Diagnostic Errors – University of Texas Health Science Center at Houston
Type of Health IT: Operational decision support (quality of care)
Duration of Project: 9/30/2007 – 9/29/2009
Using Information Technology To Provide Measurement-Based Care for Chronic Illness – Texas Southwest Medical Center at Dallas
Type of Health IT: CDS (provider-focused)
Duration of project: 9/3-/2007 – 9/29/2010

24. What is Comparative Effectiveness Research?

25. Essential Questions Posed by Comparative Effectiveness
The Effective Health Care Program engages in comparative effectiveness research. We’ve all heard a lot about comparative effectiveness research recently, some of it true, some of it not so much. So I think it’s important to step back and discuss what this endeavor is all about.
You’ll recall that one of the six aims of a quality health care system as designated by the Institute of Medicine is that health care should be effective. “Effectiveness” is often difficult to gauge. What do we mean by that? How do we measure that?
It would make everyone’s life so much easier if, when you had one patient, you had one treatment. Apply the one treatment, and the patient gets better.
Unfortunately that’s not how modern medicine works. Because every patient is different, and every set of circumstances is different, there are usually multiple options facing patients and clinicians. Even in cancer, where our courses of treatment often are pretty straightforward, there are gray areas—lots of them.
For instance, and I’ll have more to say about this in a moment, when you have a woman in her mid-40s with a family history of breast cancer, should we administer certain medications as a means of prophylaxis? If so, should we use tamoxifen, which is the most widely accepted? Or should we use other drugs that sometimes are used?

26. Essential Questions Posed by Comparative Effectiveness
So the essential nature of comparative effectiveness research is that it hits at the “effectiveness” aim that the IOM calls for. But it also gets at another critical IOM quality aim: patient-centeredness. Because every patient is different, not only in his or her diseases but also in his or her desires as a patient and as a human being.
Is this treatment right?
Is this treatment right for me?

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

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

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

30. Comparative Effectiveness and the Recovery Act
The American Recovery and Reinvestment Act of 2009 includes $1.1 billion for comparative effectiveness research:
AHRQ: $300 million
NIH: $400 million (appropriated to AHRQ and transferred to NIH)
Office of the Secretary: $400 million (allocated at the Secretary’s discretion)
Funding for health IT, prevention and other areas have implications for the Agency

31. Translating the Science into Real-World Applications
Examples of Recovery Act-funded Evidence Generation projects:
Clinical and Health Outcomes Initiative in Comparative Effectiveness (CHOICE): First coordinated national effort to establish a series of pragmatic clinical comparative effectiveness studies ($100M)
Request for Registries: Up to five awards for the creation or enhancement of national patient registries, with a primary focus on the 14 priority conditions ($48M)
DEcIDE Consortium Support: Expansion of multi-center research system and funding for distributed data network models that use clinically rich data from electronic health records ($24M)

32. The Bottom Line
“Patients’ ratings of hospital care are of interest because they are, in many ways, “the bottom line.”’
New England Journal of Medicine
Patients’ Perspectives of Care in the United States New England Journal of Medicine 359;18 October 30, 2008

33. AHRQ Patient Engagement Campaigns
Primary Campaign
Spanish-Language Campaign
Men’s Preventive Health Campaign
PSA by Fran Drescher

34. Plain Language Guides in English & Spanish

35. Hispanic Elderly Initiative
HHS pilot initiative aimed at improving the health and quality of life for Hispanic elders
Eight metropolitan communities selected to participate in the pilot: Chicago, Houston, Los Angeles, McAllen, Miami, New York, San Antonio, and San Diego
Medicare participation and diabetes care are target areas of work for each of the communities

36. Building a Bridge at the Quality Chasm
AHRQ’s Role
The Quality Chasm
Getting There from Here
Q&A

37. Future Challenges Downstream effects of policy applications
Using technology, but not letting technology determine our priorities
Care coordination: what can we learn from large integrated systems?
Public-private funding and participation likely a necessity
Patients should always be engaged as partners: it’s about them, not about you

38. What Does It Mean to Be ‘Patient-Centric?’

39. Technology and Consumers
We create tools that make care more efficient for clinicians
Consumers already are comfortable with the technology; they’re leading us, not the other way around
Consumers are demanding tools to make their care more about them; let’s satisfy the demand!

40. 21st Century Health Care
Using Information to Drive Improvement: Scientific Infrastructure to Support Reform
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”

41. According to Yogi Berra
“If you don't know where you are going, you might wind up someplace else.”
Yogi Berra

42. Funding Opportunities
Opportunities for the field to become involved are made available as soon as possible:
To sign up for updates, visit
To review AHRQ’s standing program and training award announcements

43. Building a Bridge at the Quality Chasm
AHRQ’s Role
The Quality Chasm
Getting There from Here
Q&A