1. 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

2. 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.

3. 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.

4. 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.

5. 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.

6. The State of Primary Care Research at AHRQ is…

7. 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

8. 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?

9. 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

10. 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 ( )

11. 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

12. 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.

13. In 1990, there was excitement about primary care research at the new AHCPR…

14. 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?]

15. 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

16. The Past – funding grows
~$320M
Near death
Start of MEPS

17. A legacy of the Past
One last reflection on a significant event from AHRQ’s past – from 1999:

18. The Past is Prologue…
The Tempest – Shakespearan = the past is meaningless or Napoleonic = learn from the past to not repeat its mistakes

19. 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

20. 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:

21. The Expanded Care Model

22. 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

23. 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

24. 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.

25. 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

27. 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

28. 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

29. 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

31. 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.

32. 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.

33. 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)

34. Quality Improvement Services
Engineering intersections

35. Timeline
We are here!
More this afternoon…

36. 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

37. 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.

38. 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

39. 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

40. 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

41. 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

42. Primary care research grants

43. Primary care research funded

44. Appropriation History (FY2004 - FY2017)
+ARRA $300M

45. AHRQ’s budget and primary care research, 2007-2017
NEW

46. 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

47. 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

48. “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

49. Puzzle pieces of the future

50. 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

51. 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.

52. 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

53. 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

54. Puzzle pieces of the future

55. 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?

56. 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?

58. Are you confident that the State of Primary Care Research at AHRQ is Strong? You are uniquely positioned to help keep it strong!

59. 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

60. 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…

61. About transformations
Helping you go from this…
…to this!

62. Thank you for your participation, engagement and commitment to this project!
You are part of something big