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The State of Primary Care Research at AHRQ: Past, Present and Future
Bob McNellis, MPH, PA Senior Advisor for Primary Care September 8, 2017 ENSW: Collaborative Learning Session Denver, CO
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Learning Objectives At the end of this session, the participant should be able to: Describe AHRQ’s primary care research priorities. Develop ideas to guide future proposals for primary care research efforts. Discuss the contributions of practice-based research to AHRQ’s past, present and future research endeavors.
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Disclaimers and Disclosures
Disclaimer: The views and opinions expressed in this presentation are my own, and do not necessarily represent those of AHRQ or HHS. Disclosure: I wish I had financial relationships to disclose. Caveat: I was born inside the Beltway, so I only speak in acronyms, forgive me.
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About AHRQ The Agency for Healthcare Research and Quality's (AHRQ) mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable; And, to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.
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AHRQ’s Areas of Focus AHRQ invests in research and evidence to make health care safer and improve quality. AHRQ creates materials to teach and train health care systems and professionals to help them improve care for their patients. AHRQ generates measures and data used to track and improve performance and evaluate progress of the U.S. Health system.
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The State of Primary Care Research at AHRQ is…
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I am confident that the State of Primary Care Research at AHRQ is Strong!
Despite ongoing zeroing out of AHRQ’s budget, despite our move from a building named after John and offices for all to a glass office building with cubes for most, despite four directors in five years, and despite lack of understanding by congress about what we do, and an uncertain future integration to NIH
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Questions to guide discussion
What can we learn from the past? How can we build on the present? Where are we going in the future? Where do you think we should go in the future? How can we best support your work?
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Testing your knowledge
Which of the following was the earliest predecessor agency for AHRQ? A. National Center for Health Services Research and Development B. Bureau of Health Services Research C. National Center for Health Services Research D. National Center for Health Services Research and Health Care Technology Assessment E. Agency for Health Care Policy and Research F. National Institute for Research on Safety and Quality
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What do you know about the Past?
Which of the following was the earliest predecessor agency for AHRQ? A. National Center for Health Services Research and Development ( ) B. Bureau of Health Services Research ( ) C. National Center for Health Services Research ( ) D. National Center for Health Services Research and Health Care Technology Assessment ( ) E. Agency for Health Care Policy and Research ( )
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Health Services Research: U.S. Timeline
U.S. Public Health Service conducts investigations into the relationship between health and poverty NCHSRD conference to develop provisional guidelines for “automated multiphasic health testing and services” Focus increases on synthesizing the government’s role in addressing the quality gap Public Health Service establishes the Health Services Research Study Section Federal guidelines are developed Congress authorizes collection of infectious disease information 1883 1893 1914 1927 1959 1968 1970 1989 1998 Michigan among the first states to require reporting of certain infectious diseases Groundwork laid for establishment of the Committee on the Cost of Medical Care Agency for Health Care Policy and Research is established AHCPR becomes AHRQ The National Center for Health Services Research and Development is established (NCHSRD) Dr. Ernest Codman pioneers empirical studies of the quality of medical care in hospitals Dr. John Wennberg publishes technique that eventually comes to be known as outcomes research
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The Past – NCHSR&D, 1968 “Health services in the United States are expensive and complex. The result is that providers of health services face demands that exceed the capacity of traditional ideas, methods and institutions. NCHSR&D will provide a central focus for this kind of research and act as a catalyst for new ideas and methods. It will work with universities, industry, hospitals, practitioners and research institutions to seek new ways to improve the delivery of health care.” -Wilbur Cohn, Sec HEW, May 2, 1968 Three critical points of work – evaluation research, programs for the disadvantaged, automated multiphasic screening Medical Care. March-April 1969, Vol. VII, No. 2.
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In 1990, there was excitement about primary care research at the new AHCPR…
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Highlights from the primary care research agenda of 1990-91
“It must be remembered that primary care [research] is a very young field, less than 20 years old, with few established research programs or experienced mentors.” Harvey Estes reflected on the role of primary care and primary care research at AHCPR. Discussants highlighted commonalities and differences between family medicine, pediatrics and internal medicine research. Fitz Mullan discussed the Federal investment in primary care research ($15 million by NIH in 1989). Green & Lutz described PBRNs and ASPN, specifically Other topics on the agenda: prevention, changing provider behavior, disadvantaged populations, COPC, AIDS, substance abuse, and rural health. [Sound familiar?]
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A rocky road, a pain in the back and a charismatic leader
Notable observations: “The Agency for Health Care Policy and Research has had a turbulent history.” “Health services research, an AHSR lobbyist once said, was as difficult to sell as a dead fish wrapped in newspaper.” “Funding is more forthcoming for a research agency if plausible arguments are made that it can do something to address real world problems.” Health Affairs, June 25, 2003
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The Past – funding grows
~$320M Near death Start of MEPS
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A legacy of the Past One last reflection on a significant event from AHRQ’s past – from 1999:
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The Past is Prologue… The Tempest – Shakespearan = the past is meaningless or Napoleonic = learn from the past to not repeat its mistakes
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AHRQ believes… Revitalizing the nation’s primary care system is foundational to achieving our mission of improving the quality, safety, accessibility, equity and affordability of health care for all Americans The present approach began with a belief, evidence, a conceptual model and an approach
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The Ecology of Medical Care, 2001
Kerr White did the first nesting boxes in 1961 Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The Ecology of Medical Care Revisited. New England Journal of Medicine 2001;344:
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The Expanded Care Model
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Primary Care Renewal Embrace the basics
Comprehensive (address the majority of needs including mental health) Continuous (long term relationships) Coordinated (links to the community) First contact (accessible) Whole person orientation (not just organ systems) New structures and infrastructure Teams (intraclinic and extraclinic) Information systems (health IT) New processes Care coordination Ongoing quality and safety improvement Self management support Population health management Linking to community resources and public health
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Primary Care: Too Important to Fail
Meyers and Clancy lay out the functions of a community-based health care extension service: Professional services Connectors QI technical assistance Practice-based research Annals of Internal Medicine, Feb 2009
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Focus on the PCMH A medical home is not simply a place but a model of primary care that delivers care that is: Patient-Centered Comprehensive Coordinated Accessible, and Continuously improved through a systems-based approach to quality and safety AHRQ believes that health IT, workforce development, and payment reform are foundational to achieving the potential of the medical home.
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Primary Care Research Areas
Research and evaluation of the PCMH Guidance on practice facilitation as a tool for practice improvement Investments in primary care practice-based research networks Integration of primary care and behavioral health Care coordination Self management support Utilizing heath IT for quality improvement Team-based care and team training
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Targeted research programs
Transformation of Primary Care 14 Transforming Primary Care grants (2010) 4 IMPaCT cooperative agreements (2011) 15 Costs of Transformation grants (2013) Optimizing Care for People Living With Multiple Chronic Conditions – MCC Research Network (2008, 2010) New Models of Primary Care Workforce and Financing Rural Opioid Abuse Disorder Testing ability of telehealth to overcome knowledge, workforce shortages to provide MAT MAT training, behavioral health support Builds on investment in Project ECHO
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Annals of Family Medicine, June 2013
Lessons Learned A strong foundation is needed for successful redesign The process of transformation can be a long and difficult journey Approaches to transformation vary Visionary leadership and a supportive culture can ease the way for transformation Contextual factors are inextricably linked to outcome One other resource that I’d like to highlight is a paper that presents lessons learned from AHRQ-supported research on the quality improvement and the transformation to the PCMH, lessons which can perhaps smooth the road out a bit for practices and Practice Facilitators that are just starting this journey. This paper, which was published in 2012, is publically available from the Annals of Family Medicine. Annals of Family Medicine, June 2013
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Targeted research programs
Transformation of Primary Care 14 Transforming Primary Care grants 4 IMPaCT cooperative agreements 15 Costs of Transformation grants Optimizing Care for People Living With Multiple Chronic Conditions – MCC Research Network New Models of Primary Care Workforce and Financing Rural Opioid Abuse Disorder Testing ability of telehealth to overcome knowledge, workforce shortages to provide MAT MAT training, behavioral health support Builds on investment in Project ECHO
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Help practices implement evidence to improve health care quality
Goals are to: Help practices implement evidence to improve health care quality Focus on heart health (ABCS) Help practices identify ways to build their capacity to receive and incorporate other patient-centered outcomes research findings in the future Study how external QI support helps primary care practices improve the way they work, improve the health of their patients Build and disseminate a blueprint of what works to transform care The goal of EvidenceNOW is to ensure that primary care practices have the latest evidence on cardiovascular health and that they use it to help their patients live healthier and longer lives.
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Scope of the project $112 million investment over 4 years Reach:
Seven grants to establish regional Cooperatives One grant for an independent, external evaluation Creation of a Technical Assistance Center (TAC) Reach: Over 1,500 small- to medium-sized primary care practices Over 5,000 primary care professionals 8,000,000 patients Employs over 500 people Cooperatives will recruit small- to medium-sized practices (10 or fewer clinical staff in a practice). Cooperatives will provide quarterly updates on outcomes, which will be made available via the AHRQ website. Cooperatives also intend to disseminate results and findings in journal publications or a possible journal supplement.
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The EvidenceNOW Community
Healthy Hearts in the Heartland (Midwest Cooperative) HealthyHearts NYC (New York City Cooperative) Heart Health NOW! (North Carolina Cooperative) Healthy Hearts Northwest (Northwest Cooperative) Healthy Hearts for Oklahoma (Oklahoma Cooperative) EvidenceNOW Southwest (Southwest Cooperative) Heart of Virginia Healthcare (Virginia Cooperative) The EvidenceNOW initiative establishes seven regional cooperatives across 12 States that deliver health care in a range of metropolitan and rural settings and serve diverse populations. The cooperatives are composed of multidisciplinary teams of experts. Each cooperative is recruiting and engaging small- and medium-sized, independent primary care practices and providing quality improvement services typically not available to the practices because of their size. List of seven R18’s and PI’s that serve across 12 States: Healthy Hearts in the Heartland (Midwest Cooperative) – PI: Abel Kho HealthyHearts NYC (New York City Cooperative) – PI: Donna Shelly Heart Health Now! (North Carolina Cooperative) – PI: Samuel Cykert Healthy Hearts Northwest (Northwest Cooperative) – PI: Michael Parchman Healthy Hearts for Oklahoma (H2O) (Oklahoma Cooperative) – PI: Dan Duffy Evidence Now Southwest (Southwest Cooperative) – PI: Perry Dickinson Heart of Virginia Healthcare (Virginia Cooperative) – PI: Anthony Kuzel Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES) (National Evaluation) – PI/Lead: Debbie Cohen ESCALATES (National Evaluation Team) TAC (Technical Assistance Center)
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Quality Improvement Services
Engineering intersections
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Timeline We are here! More this afternoon…
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ENSW helping guide AHRQ
Perry Dickinson, PI ENSW Deb Cohen, PI ESCALATES Sharon Arnold, Deputy Director Beth McGlynn, Chair of NAC McGlynn’s NEJM: The quality of health care delivered to adults in the United States has 4932 citations, McNellis cited 42 times Gopal Khanna, AHRQ’s new Director
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Home for Primary Care at AHRQ
The NCEPCR is AHRQ's main point of contact with the primary care community, communicating the evidence from AHRQ's research—and how this evidence can be used to improve health and primary health care—to researchers, primary care professionals, health care decisionmakers, and patients and families.
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Research on Advancing Primary Care and Health Care Delivery
How different configurations of primary care teams affect the effectiveness and efficiency of care and health outcomes; How different financing models for primary care affect the delivery of high quality care; How to integrate primary care into larger health care systems and public health to improve health outcomes; How different external supports, configurations of teams, delivery or financing models of primary care improve health equity across diverse populations and communities; How different external supports, configurations of teams, delivery or financing models of primary care improve patient and/or provider satisfaction; The development of quality measures that are applicable to the primary care setting. For example, how can concepts of primary care such as “comprehensiveness” or “team-ness” be measured. Highlight main areas of interest
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Funding for primary care research
What year did AHRQ provide the largest number of grant awards and provide the largest annual funding for primary care? A. 2008 B. 2010 C. 2012 D. 2015 E. 2016
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ARRA = American Recovery and Reinvestment Act of 2009
The Current Era What year did AHRQ provide the largest number of grant awards and provide the largest annual funding for primary care? A (109, $26M) B (144, $87M) The Era of ARRA C (109, $26M) D (96, $50M) E (117, $58M) ARRA = American Recovery and Reinvestment Act of 2009
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AHRQ’s Primary Care Grant Portfolio, 2007-2017
Searched our grants database for “primary care, primary care physician, or primary care setting” in abstract or title Applications: 3145 Awards: 1182 PIs: 1653/461 Orgs: 553/178 Total funds: $415,977,310
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Primary care research grants
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Primary care research funded
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Appropriation History (FY2004 - FY2017)
+ARRA $300M
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AHRQ’s budget and primary care research, 2007-2017
NEW
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Most common mechanisms
Research Demonstration and Dissemination Projects Research Project Exploratory/Developmental Small Research Project Mentored Clinical Scientist Development Conference Grant For all primary care applications National Research Service Award Dissertation Grant Research Demonstration/Cooperative Agreements Mentored Research Scientist Career Development Resource-related Research Project
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AHRQ’s PBRN Grant Portfolio, 2007-2017
Searched our grants database for “PBRN or practice-based research” in abstract or title Applications: 410 Awards: 212 PIs: 214 Orgs: 109 Total funds: $83,291,448
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“It’s tough to make predictions, especially about the future
“It’s tough to make predictions, especially about the future.” -Bohr, Berra, Einstein or Twain
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Puzzle pieces of the future
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Secretary Price’s priorities
Childhood obesity Substance abuse (especially opioid epidemic) Mental health (especially serious mental illness) Person-centered care Decreasing administrative burden on physicians
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What is a Learning Health Care System?
Systematically gathers and creates evidence Applies the most promising evidence-based practices to improve care Submitted slide: Learning Health Care Systems Organizations that can systematically gather and create evidence and apply the most promising evidence-based practices to improve care delivery are called Learning Health Care Systems.
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AHRQ’s/NIRSQ’s FY’18 budget priorities
Patient safety Enhancing research through technological advances (e.g., ECHO+) Quality improvement training Data for tracking changes in the health care system
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AHRQ staff musings and interests
Advancing telehealth and electronic care planning Relationship-centered care Narrative medicine Next phase of MCC work EvidenceNOW 2.0 and spin-offs Expanding practice facilitation and HIT support Shared decision making
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Puzzle pieces of the future
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Where do you think the future of primary care research lies?
Integration of behavioral health and primary care PCPs very nervous when providing behavioral health care for people. Helping to understand what Primary Care doctors can really use. Integrating public health and addressing social determinants of health Concrete, practical ways to address these things. Helping patients with community connections Linking primary care with community resources Understanding the roles of different staff in the PCP office. Who can (and is allowed) to do what based on license, etc. Can roles be expanded? Rural perspective is missing in most PC research (resource shortages and cultural issues) What does practice transformation mean now? [in the post-PCMH, post-ACA era] Examining the payment structures and align them with the services that are provided. How do we pay/bill for adding resources to our practices? Big data [versus small data] Data infrastructure for research and QI Health equity research Team training for true team-based care Patient engagement, community engagement Cross-border learning, esp US & Canada or Colorado and New Mexico Building partnerships with basic science, clinicians, patients and researchers Impact of practice consolidation, mergers and acquisitions T.S. Elliot’s Choruses from the Rock – where is the wisdom we have lost in knowledge, where is the knowledge we have lost in the information?
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Tell me what you think What can we learn from the past?
How can we build on the present? Where are we going in the future? Where do you think we should go in the future? How can we best support your work?
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Are you confident that the State of Primary Care Research at AHRQ is Strong? You are uniquely positioned to help keep it strong!
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One last quote “The fate of the new agency and primary care are closely linked together. If primary care research can assist AHCPR (or AHRQ or NIRSQ) in effectively addressing the problems of unmet health care needs in an era of restrained funding, its hand will be strengthened and improved health care in the future will be virtually assured.” - Harvey Estes, 1990 The story of AHRQ is the story of primary care – visionaries, turbulence, innovation, challenges, rejuvenation
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Recognize the team at AHRQ
David Meyers Arlene Bierman Tess Miller Jan Genevro Jan DelaMare Ted Ganiats Ric Ricciardi Chunliu Zhan Alaina Fournier And many more…
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About transformations
Helping you go from this… …to this!
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Thank you for your participation, engagement and commitment to this project!
You are part of something big
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