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HSR and the Imperative for Health Care Transformation

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Title: HSR and the Imperative for Health Care Transformation


1
HSR and the Imperative for Health Care
Transformation
  • Carolyn M. Clancy, MD
  • Director
  • October 7, 2003

2
Overview
  • The imperative to improve
  • The challenges of creating applying Useable
    Knowledge
  • Opportunities and Challenges
  • Final thoughts

3
State of Quality in the U.S.
  • The American health care delivery system is in
    need of fundamental change.the care delivered is
    not, essentially, the care we should
    receiveBetween the health care we have and the
    care we could have lies not just a gap, but a
    chasm
  • The need for leadership in health care has never
    been greater.
  • IOM, Crossing the Quality Chasm, 2001

4
New York Times, December 18, 2002
5
RAND Study Quality of Health Care Often Not
Optimal
Medical errors corrode quality of healthcare
system
Medical Care Often Not Optimal Failure to Treat
Patients Fully Spans Range of What Is Expected of
Physicians and Nurses
Study U.S. Doctors are not following the
guidelines for ordinary illnesses
The American healthcare system, often touted as a
cutting-edge leader in the world, suddenly finds
itself mired in serious questions about the
ability of its hospitals and doctors to
deliver quality care to millions.
.
6
RAND Study Quality of Health Care Often Not
Optimal
  • Doctors provide appropriate health care only
    about half the time

Alcohol dependence
11
23
Hip fracture
Peptic ulcer
33
Diabetes
45
Low back pain
69
Prenatal care
73
Breast cancer
76
Cataracts
79
Percentage of time
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
7
  • The one question I still cant answer is WHY
    the gap between evidence-based and actual
    practice?
  • Earl Steinberg, M.D., M.P.P., 2003

8
Pick Your Condition .
  • Diabetes
  • Hypertension
  • Aspirin post MI
  • Beta blockers post MI
  • Anticoagulation
  • Hypercholesterolemia

9
The Chasm in Asthma Care
  • What percent of people in managed care get
    appropriate medications for asthma?

Children 5-9 60.0 Adolescents
10-17 58.7 Adults 18-65 65.1
10
Clarifying National Aims for Improvement
  • Safety
  • Effectiveness -- Matching care to science
    avoiding overuse of ineffective care and underuse
    of effective care
  • Patient Centeredness
  • Timeliness
  • Efficiency
  • Equity

11
Reperfusion Therapy in Medicare Beneficiaries
with Acute MI
Eligible
receiving reperfusion
Group
White men White women Black men Black women
59 56 50 44
Canto JG Allison JJ Kiefe CI Fincher C Farmer
R, Sekar P Person S Weissman NW. Relation of
rave and sex to the use of reperfusion therapy in
Medicare beneficiaries with acute myocardial
infarction. N Engl J Med 2000 Apr
13342(15)1094-100.
12
Context
  • Investments in biomedical science ? growing
    demand for products of HSR
  • Greater recognition among decision makers of the
    potential value of HSR
  • Growing impatience with the leisurely pace of
    translation of knowledge into practice
  • Growing recognition of patients as partners and
    agents of change -- rather than recipients

13
Manifestations
  • Public Library of Science (PLOS Harold Varmus)
  • Landmark lecture in US focuses on clinical
    research lost in translation
  • Multiple entities established, disbanded and
    reinvented to focus on research uptake (all
    Nations)
  • Health care challenges are page 1 news
  • Focus on HIT as the answer

14
What We Have Learned 2003
  • Knowing the right thing to do is NOT doing it!
  • Improvement must be based on science
  • Patients as participants are far more effective
    than patients as recipients
  • Suttons Law improving chronic illness care is
    essential
  • Safety in health care delivery is critical

15
Potential for HSR
  • From describing problems to solving them
  • Getting to TRIPP
  • Creating and nurturing receptor sites for our
    work
  • Back to the Future

16
Potential is what you have when you havent done
it yet Darrel Royall University
of Texas Football coach
17
Overview
  • The imperative to improve
  • The challenges of creating applying Useable
    Knowledge
  • Opportunities and Challenges
  • Final thoughts

18
Health Services Research
  • Health services research is a multidisciplinary
    field of inquiry, both basic and applied, that
    examines the use, costs, quality, accessibility,
    delivery, organization, financing, and outcomes
    of health care services to increase knowledge and
    understanding of the structure, processes, and
    effects of health services for individuals and
    populations.
  • Institute of Medicine, 1995

19
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20
The Challenge
  • What we really want to get at is not how many
    reports have been done, but how many people's
    lives are being bettered by what has been
    accomplished. In other words, is it being used,
    is it being followed, is it actually being given
    to patients?What effect is it having on
    people?
  • Congressman John Porter, 1998
  • Chairman, House Appropriations Subcommittee on
  • Labor, HHS, and Education

21
Research Impact
Improves Access, Outcomes,
Efficiency
Level 4
Improves Delivery and Practice
Level 3
Improves Processes and Policies
Level 2
Level 1
Improves Other Research
22
Levels of ImpactADHD
23
  • A real lack is what is known as translational
    research -- The translation of great basic
    science into practical clinical realities for
    patients.
  • -- Steve Case, AOL Time Warner Chairman at Senate
    Appropriations Labor HHS Subcommittee, June 4,
    2002

24
Bridging the Quality Chasm
Where We
Where We Are
Want To Be
Implementation
Innovation
Education
Diffusion
Adoption
TRIP
25
This is Not a New ProblemThe Case of Scurvy
  • 1601- Lancaster shows that lemon juice supplement
    eliminates scurvy among sailors
  • 1747- Lind shows that citrus juice supplement
    eliminates scurvy
  • 1795- (194 years after discovery) British Navy
    implements citrus juice supplement

26
Original research
18
variable
Negative results
Dickersin, 1987
Submission
46
0.5 year
Kumar, 1992
Koren, 1989
Acceptance
Negative results
0.6 year
Kumar, 1992
Publication
1714
Expert opinion
35
0.3 year
Poyer, 1982
Balas, 1995
Lack of numbers
Bibliographic databases
50
6. 0 - 13.0 years
Antman, 1992
Poynard, 1985
Reviews, guidelines, textbook
9.3 years
Inconsistent indexing
Implementation
It takes 17 years to turn 14 per cent of original
research to the benefit of patient care
27
Debunked Assumption I Supply Side Research
Question
Hypothesis
Study
Publications
Changes in practice
28
Debunked Assumption IIImproved Packaging
Publications (multiple)
Evidence synthesis
???
Guidelines, Performance Measures
Changes in Practice
29
A Flawed Model
  • Receptor sites are assumed
  • Decisionmaking is not-linear evidence is only
    part of the solution
  • Broad dissemination ? modest effects

30
Selected Models of Change
  • Rogerss diffusion of innovation
  • Gladwell the tipping point
  • Economics incentives and rewards
  • Regulation sanctions
  • Individual PRECEDE
  • One or more of the above
  • Other?

31
Diffusion of Innovation
  • Invention is hard dissemination is much more
    difficult (Berwick 2003)
  • A problem for all industries
  • Influences on rate of diffusion
  • Perception of innovation
  • Characteristics of individuals who adopt change
  • Contextual and managerial factors
  • Source Mosteller, Science l981221881

32
The Tipping Point (M. Gladwell)
  • Small changes can have big effects
  • The law of the few -- individual actions can be
    amplified by social connections, energy,
    enthusiasm and personality (connectors, mavens
    and salesmen)
  • The stickiness factor-- simple changes in the
    presentation and structuring of information can
    make a big difference in its impact
  • The power of context -- individual behavior is
    markedly affected by the environment

33
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34
Joint Production
  • Priority setting for research
  • Joint design of research (CBPR)
  • Results interpretation and synthesis
  • Improved formatting and new vehicles for
    communication
  • Receptor capacity
  • Identifying brokers and champions
  • Clarifying shortcomings and impact

35
Potential Barriers to Implementation
  • Knowledge- lack of awareness of what is being
    implemented (generally or specifically), unable
    to access the information at the time of need
  • Attitudes- lack of agreement with objective, lack
    of self-efficacy, lack of outcomes expectancy,
    inability to overcome inertia
  • Behavior- unable to reconcile with others
    preferences, ongoing conflicting actions,
    conflicting environmental factors
  • -- Adapted from Cabana, et al., JAMA 1999

36
Acute Cardiac Ischemia- Time Insensitive
Predictive Instrument
37
The Two Faces of TRIPP
  • Funding research on transferring research into
    practice
  • versus
  • Embedding the transfer of research into practice
    within the culture of universities, healthcare
    organizations and research funders

38
Overview
  • The imperative to improve
  • The challenges of creating applying Useable
    Knowledge
  • Opportunities and Challenges
  • Final thoughts

39
Back to the Future - 1
  • Infomedicine now understood as essential
    complement to biomedicine
  • Boundaries between QI and research have
    disappeared
  • Data collection is purposeful, strategic and
    oriented to patients and clinicians needs for
    information
  • NO research is initiated without a clear plan for
    sustained implementation

40
Challenges 1
  • Evaluation of translation research
  • Career paths for individuals focused on
    improvement metrics for success?
  • Alignment of incentives for researchers and
    funders
  • Research findings are not ready to use

41
Back to the Future - 2
  • Learning from clinical encounters is a critical
    component of knowledge development
  • Patients understand and SEE incentives for
    participation in routine clinical evaluation and
    improvement
  • Throughout the world, the question What is the
    evidence? is as routine as vital signs or budget
    numbers

42
Challenges 2
  • Taking promising findings to scale metrics for
    promising and readiness to implement?
  • Science of change validation before and/or
    during implementation?
  • Moving beyond 1000 flowers blooming
  • Involving users throughout the research cycle
  • Redefining core focus of HSR

43
Back to the Future - 3
  • Policymakers get it the return on investment
    in biomedical research is significantly enhanced
    by a robust investment in outcomes research
  • Target quality improvement efforts have
    completely replaced special studies on
    disparities (we now know that disparities in
    health care a critical QI opportunity)
  • Continuous focus on measurement and evaluation --
    for improvement

44
Contemporary Challenges
  • Scientific basis for safe and appropriate use of
    diagnostic, therapeutic and preventive
    interventions the case for practical clinical
    trials
  • Quality improvement as science
  • Translating promising models into large-scale
    improvements in care and outcomes

45
The Evolution of TRIP Research
  • 1999 - TRIP I RFA
  • New knowledge about approaches that are effective
    and cost-effective in promoting the use of
    research evidence in clinical settings and lead
    to improved health care practice and sustained
    practitioner behavior change
  • 2000 - TRIP II RFA
  • Strategies for translating research into practice
    through the development of partnerships between
    researchers and health care systems and
    organizations

46
AHRQ Research Study Outcomes of Beta Blocker
Use Before Bypass Surgery
Patients who took beta blockers before bypass
surgery had lower rates of death in and out of
the hospital within 30 days of surgery compared
to those who did not Use of beta blockers also
improved outcomes in patients at higher risk,
e.g., those with heart failure, older age, lung
disease, and diabetes
With
Without
Beta Blocker
TB Ferguson, L Coombs, E Peterson, Preoperative
B-Blocker Use and Mortality and Morbidity
Following CABG Surgery in North American, JAMA,
May 2002
47
Team Approach to Testing for Chlamydia
  • Team-oriented approach to testing for chlamydia
    increased screening rate of sexually active 14-
    to 18-year old female patients from 5 to 65 in
    a large California HMO study
  • New screening system may help reduce estimated 4
    billion annual treatment cost

65
M Shafer, The effect of clinical practice
improvement intervention on chlamydia screening
among sexually active adolescent girls, JAMA,
December 11, 2002
5
48
Effectiveness of Inpatient and Outpatient
Treatment for Women With PID
  • 1.2 Million women are treated each year for
    pelvic inflammatory disease (PID)
  • Major Finding Treating PID in outpatient
    settings rather than in a hospital does not cause
    harm to women

Acute serious PID requires inpatient treatment
15
100,000 women hospitalized for PID
Mild to moderate PID may be treated as
outpatients May save about 500 million each year
85
R. Ness, D. Soper, R. Holley, et al.,
Effectiveness of inpatient and outpatient
treatment strategies for women with pelvic
inflammatory disease results from the PID
evaluation and clinical health (PEACH) randomized
trial, AJOG, May 2002
49
The Evolution of TRIP Research
  • 2002 - TRIP PA
  • Supporting research that can bridge the chasm
    between promising prototypes and generalizable
    knowledge that can be used in multiple settings
    and lead to systematic improvement on a large
    scale.
  • Emphasizing projects that introduce changes at
    the clinical, organization/health care systems,
    and/or public policy levels and then measure
    the impact of these efforts.

50
AHRQ Strategy Components
  • Building the knowledge base
  • The Effectiveness Question What works?
  • Clinical
  • Organizational
  • The TRIP Question How do we get
    people/systems/policymakers to do or use what
    works?
  • How do we support the widespread implementation
    of what works?
  • How do we sustain evidence based practice?

51
Practice-Based Research Networks (PBRNs)
36 new PBRN grants awarded in 2002
19 PBRN grants awarded in 2000
52
Strategic Advantages Size and Breadth
  • IDSRNs 9 consortia include
  • Over 50 million patients
  • Majority of US physicians and acute inpatient
    facilities
  • gt2000 outpatient clinics
  • Long-term care, rehab, dental facilities
  • Home health agencies

53
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55
Priority Areas in Both Reports - 1
  • Cancer
  • Chronic kidney disease
  • Diabetes
  • Heart disease
  • HIV/AIDS
  • Maternal and child health
  • Mental illness-depression
  • Respiratory illness (e.g., asthma, flu)

56
Priority Areas in Both Reports - 2
  • Nursing home and home health
  • Patient safety
  • Timeliness
  • Patient centeredness
  • Resource consumption

57
What Will Be the Response to the First Reports?
  • WOW!! Extensive media coverage
  • We need more measures
  • WHAT NOW??

58
Issues
  • Will public reporting ? improvements?
  • Literature to date suggests modest albeit growing
    impact on consumers decisions
  • Apparently tangible impact on providers
  • Paying for quality YES, but HOW??
  • If quality improvement is local, what is Federal
    role?

59
Improving Quality and Safety
We need to make the right thing the easy
thing Mark Chassin, MD October 12, 2000
60
Outline
  • The imperative to improve
  • The challenges of creating applying Useable
    Knowledge
  • Opportunities and challenges
  • Final thoughts

61
Growing Impatience .
  • Precision and consensus regarding management of
    (X) greatly exceeds translation into practice
  • Most clear successes of translating research into
    practice have focused on underuse of effective
    treatments less focus on misuse and overuse
  • Next frontiers linking incentives with
    improvement IT leadership

62
HSR The Future
  • Increased emphasis on research input to health
    care transformation
  • Clear focus on value for health care
  • Positioned as science partner for change
  • Active promotion of quality improvement,
    innovation and learning

63
How HSR Could Evolve
  • Proposed studies that do not involve all
    stakeholders are considered amusing
  • Proposed studies that do not include an explicit
    and compelling plan for incorporation into
    practice are not funded
  • Patients are central to conduct and review of
    research Nothing about me without me

64
We Need YOU
  • Physician-Researchers Needed to Get Cures Out of
    Rats Cage
  • Begley S. (Science Journal) 2003, April 25.
    Wall St. Journal

65
Practice and Organizational Challenges
  • Information problems
  • Variation in individual clinical decisions
  • Stress
  • Inertia
  • Readiness to change
  • Need for clinical policies

66
Questions in Search of Answers
  • Linking knowledge development to policy levers
    (e.g., payment regulation) role of
    demonstrations
  • When is good enough?
  • Vocabulary and pathways for translation of
    knowledge-based interventions under-developed
  • Concurrent -- or sequential -- evaluation and
    translation?

67
Percent of Americans Saying I Have A Chronic
Condition

Source Chronic Illness and Caregiving Survey,
Harris 2000
68
Intellectual Challenges
  • Different kinds of research questions and methods
  • Research synthesis
  • Clinical quality improvement
  • Moving systems
  • Provider-centered
  • Systems-centered
  • Spread/diffusion
  • If NOT secondary analysis of data sets or (often)
    RCTs then what?
  • Different measures of success

69
Implications for Academic Medical Centers
  • Imperative to improve challenging definitions of
     research 
  • Tension between "1000 flowers blooming", a
    strategic approach to research, and academic
    rewards
  • Career Paths
  • Education of students and residents
  • Academic Medical Centers as drivers of change (?)

70
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