Evidence-Based System Transformation: Research, Physician Education and New Models of Care

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Evidence-Based System Transformation Research,
Physician Education and New Models of Care
Carolyn M. Clancy, MD Director Agency for
Healthcare Research and Quality First Annual
Jewell and Carl Emswiller Interprofessional
Symposium Virginia Commonwealth
University Richmond, VA March 9, 2013
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What We Think We Know

• The truth is that for a large part of medical
  practice, we dont know what works. But we pay
  for it anyway.
• H. Gilbert Welch, MD
• Geisel School of Medicine
• at Dartmouth

Testing What We Think We Know. New York Times -
August 19, 2012
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Health System Transformation Current and Future
Current Future
Variable quality expensive, wasteful Consistently better quality lower cost, more efficient
Pay for volume Pay for quality
Pay for transactions Care-based episodes
Quality assessment based on provider and setting (process) Quality assessment based on patient experience (outcomes)
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And Big Questions Still
Need Answers

• Although health care reform has begun, these
  questions remain
• How is evidence on safety and quality improvement
  integrated into the new environment?
• How has the nature of evidence changed?
• How do these changes affect patients, providers,
  payers?
• How do we ensure that these changes are
  beneficial?
• How are improvements put into practice?

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So, Where Does That Leave Us?
Making progress, but our destination is in the
distance

• Progress in quality improvement and patient
  safety is taking place, but at a slow and uneven
  pace
• Payment based on quality and safety performance
  is not a passing fad role of teamwork is now
  valued
• Movement to patient-centered care also an
  evolving process

Institute of Medicine proposed 6 aims for the
health care system safe, effective,
patient-centered, timely, efficient, and
equitable. (Crossing the Quality Chasm, 2001)
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Evidence-Based System Transformation

• AHRQs New and Ongoing Priorities
• Why System Transformation is Needed in Quality
  and Safety Improvement
• Evidence-Based Interventions
• Patient-Centered Care in an Era of Transformation
  
• Q A

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AHRQ Priorities
Patient Safety

• Health IT
• Patient SafetyOrganizations
• Patient Safety Grants (incl. simulation)

Effective HealthCare Program
AmbulatoryPatient Safety

• Comparative Effectiveness Reviews
• Patient-Centered Outcomes Research
• Clear Findings for Multiple Audiences

• Safety Quality Measures,Drug Management,
  Patient-Centered Care
• Survey of Patient Safety Culture
• Diagnostic Error Research

Other Research Dissemination Activities
Medical ExpenditurePanel Surveys

• Quality Cost-Effectiveness, e.g.,Prevention
  PharmaceuticalOutcomes
• U.S. Preventive ServicesTask Force
• MRSA/HAIs

• Visit-Level Information on Medical Expenditures
• Annual Quality Disparities Reports

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AHRQs TOP 3 Focus Areas
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National Quality StrategyThree Broad Aims
Created Under the Affordable Care Act
Better Care
Improve the overall quality, by making health
care more patient-centered, reliable, accessible
and safe
Improve the health of the U.S. population by
supporting proven interventions to address
behavioral, social and environmental determinants
of health, in addition to delivering
higher-quality care
Healthy People/ Healthy Communities
Affordable Care
Reduce the cost of quality health care for
individuals, families, employers and government
www.healthcare.gov/center/reports/quality03212011a
.html
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With a Focus on Six Priorities
Making care safer by reducing harm caused in the
delivery of care
Ensuring that each person and family are engaged
as partners in their care
Promoting effective communication and
coordination of care
Promoting the most effective prevention and
treatment practices for the leading causes of
mortality, starting with cardiovascular disease
Working with communities to promote wide use of
best practices to enable healthy living
Making quality care more affordable for
individuals, families, employers, and governments
by developing and spreading new health care
delivery models
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Partnership for Patients HHS Public-Private
Initiative

• By end of 2013
• 40 decrease in instances of hospital
  patients acquiring preventable
  conditions, including
• Central line-associated bloodstream infections
• Catheter-associated urinary tract infections
• Surgical site infections
• Ventilator-associated pneumonia
• Pressure ulcers
• Adverse drug events
• Venous thromboembolisms
• Injuries from falls
• Injuries from obstetrical adverse events
• 20 decrease in preventable readmissions due to
  complications during a transition from one care
  setting to another

Funded by the Affordable Care Act
www.healthcare.gov/center/programs/partnership/ind
ex.html
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On The CUSP Stop BSIPart of HHS Action Plan

• As part of Action Plan, AHRQ funded 18 million
  national effort
• Goal Reduce CLABSI rates to lt 1 per 1,000
  central line days across all hospitals in project
• Partnership with JHU Quality and Safety Group,
  Health Research and Educational Trust (AHA
  affiliate), and Michigan Hospital Assn.s
  Keystone Center

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On the CUSP
Stop BSI Project Update

• To date, 45 state hospital associations and 1
  other umbrella group have committed to leading
  project in their states
• Groups have recruited more than 1,100 hospitals
  and 1,800 hospital teams to participate
• Twenty-three states began project in 2009, 14
  states and District of Columbia began during
  2010, and 9 States and Puerto Rico began efforts
  in 2011

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CUSP Cuts CLABSIs by 40 Percent in 1,100 Hospital
Units

• Nationwide patient safety project
• Developed at Johns Hopkins, tested in Michigan
• Implemented in more than 1,100 hospital units
• Results
• CLABSIs reduced from 1.903 infections per 1,000
  central line days to 1.137 per 1,000 days
• Savings more than 500 lives, 34 million in
  costs
• New toolkit for implementation

AHRQ Patient Safety Project Reduces Bloodstream
Infections by 40 Percent. Press Release,
September 10, 2012. www.ahrq.gov/news/press/pr2012
/pspclabsipr.htm
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Evidence-Based System Transformation

• AHRQs New and Ongoing Priorities
• Why System Transformation is Needed in Quality
  and Safety Improvement
• Evidence-Based Interventions
• Patient-Centered Care in an Era of Transformation
  
• Q A

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2012 National Healthcare Quality and Disparities
Reports New Features

• AHRQs National Quality and National Disparities
  Reports
• 2012 will be 10th in series
• Addition of more NQS measures reflecting
  population need
• Focus on long-term trends
• Focus on new HHS race/ethnicity standards
• NHQRDRnet
• Addition of function to generate customized
  graphics

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2011 National Healthcare Quality and Disparities
Reports

• Overall health care quality in the US is
  improving slowly
• Access to health care not improving for most
  racial and ethnic groups
• On average, Americans receive appropriate
• Acute care services 80 of the time
• Recommended chronic disease management services
  70 of the time
• Preventive care services 60 of the time

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Quality is Improving Slowly
Quality measures that are improving, not changing

or worsening, overall and for select populations

• Across all measures of health care quality
  tracked in the reports, almost 60 showed
  improvement
• However, median rate of change was only 2.5 per
  year
• Improvement included all groups defined by age,
  race, ethnicity, and income

AHRQ 2011 National Healthcare Quality and
Disparities Reports
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Quality Measures Most Rapidly Improving or
Worsening
Quality Improving Quality Worsening
Adult surgery patients who received prophylactic antibiotics w/in 1 hr before surgical incision Postoperative pulmonary embolism or DVT per 1,000 surgical hospital discharges, adults 18 or over
Adult surgery patients who had prophylactic antibiotics discontinued w/in 24 hours after surgery end time Hospital admissions for short-term complications of diabetes per 100,000 population
Hospital patients with heart attack who received percutaneous coronary intervention w/in 90 minutes of arrival Maternal deaths per 100,00 live births
AHRQ 2011 National Healthcare Quality Report
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Making Care Safer

• Improvements in safety are lagging
• The reports track 26 safety measures related to
  HAIs and other hospital-related adverse events
• Of these measures, 38 showed improvement
• By comparison, among 16 hospital quality measures
  not related to safety, almost all showed
  improvement over time

2011 AHRQ National Health Care Quality and
Disparities Reports
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Virginia Snapshot Overall Health Care Quality
Measures
Measure Performance
of adults age 18 and over who have had their blood cholesterol checked within the last 5 years Better than average
Adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision Average
All cancer deaths per 100,000 population Worse than average
National Healthcare Quality Report, State
Snapshots
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Evidence-Based System Transformation

• AHRQs New and Ongoing Priorities
• Why System Transformation is Needed in Quality
  and Safety Improvement
• Evidence-Based Interventions
• Patient-Centered Care in an Era of Transformation
  
• Q A

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Medical Liability and Patient Safety
Initiative

• Part of Affordable Care Act
• Supports implementation and evaluation of
  evidence-based patient safety and medical
  liability projects
• Seven AHRQ-funded demonstration grants have been
  awarded to test models that
• Reduce preventable harm
• Inform injured patients promptly and making
  efforts to provide prompt compensation
• Promote early disclosures and settlements,
  through court-directed alternate dispute
  resolution model

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Reforming Medical Liability Seven Pillars
Project

• Launched in 2006 at University of
  Illinois-Chicago by Dr. Timothy McDonald focuses
  on transparency and disclosure to eliminate
  patient harms and learn from safety events.
• Seven Pillars components
• Patient safety incident reporting
• Investigation
• Communication and disclosure
• Apology and remediation, including waiver of
  hospital and professional fees
• System process and performance improvement
• Data tracking and performance evaluation
• Education and training

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Improving Hospital Safety Culture TeamSTEPPS

• TeamSTEPPS
• Evidence-based teamwork system to improve
  communications and teamwork among health care
  professionals
• Provides higher-quality, safer care by
• Increasing team awareness and clarifying team
  roles and responsibilities
• Resolving conflicts and improving information
  sharing
• Eliminating barriers to quality and safety
• Rooted in more than 25 years of research and
  lessons from application of teamwork principles
• Developed by Department of Defense and AHRQ

www.teamstepps.ahrq.gov
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Optimizing TeamSTEPPS for Simulation Training
and Rapid Response Systems

• TeamSTEPPS includes instruction modules applied
  to simulation-based training rapid response
  systems
• Simulation modules integrate critical teamwork,
  interpersonal, and communication skills into
  simulation-based training
• Rapid response modules provide insight into
  teamwork concepts applied to rapid response
  protocols

http//ahrq.gov/teamsteppstools
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Evidence-Based System Transformation

• AHRQs New and Ongoing Priorities
• Why System Transformation is Needed in Quality
  and Safety Improvement
• Evidence-Based Interventions
• Patient-Centered Care in an Era of Transformation
  
• Q A

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Research that Addresses Patient Outcomes
Patient-Centeredness The final frontier?

• Patient-centeredness may be the most challenging
  of all 6 domains of quality, because it is so
  difficult to define and measure
• But, it is also likely the most important,
  because it includes elements of all other domains

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Implementing Evidence-Based Treatment Decisions

• Which treatments work, for which patients, and
  what are the trade-offs?
• Patient-centered outcomes research informs
  decisions by providing evidence and information
  on effectiveness, benefits and harms
• How can evidence-based improvements be translated
  and shared with providers, patients?
• Effective Health Care Clinician and Consumer
  Summaries
• Continuing Medical Education
• Center for Medicare and Medicaid Innovation AHRQ
  Health Care Innovations Exchange

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AHRQs Effective Health Care Program

• AHRQs Effective Health Care Program, created by
  the Medicare Modernization Act of 2003
• Program has published more than 100 products,
  including summaries for clinicians, consumers and
  policymakers, with plans for at least 75 more
  over two-year period
• Emphasis on synthesis of existing evidence and
  creation of new evidence

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EHC Products Developed By the Eisenberg
Center
www.effectivehealthcare.ahrq.gov
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Recently Released Translation Products

• ADHD in Children
• ANA and RF tests for
  Musculoskeletal
  Complaints in
  Children
• Chronic Pelvic Pain
• Mechanical Thrombectomy
• Pain Management in Hip Fracture
• Preventing Fractures in Low Bone Density
• Urinary Incontinence in Women

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AHRQs Guide to Patient and Family Engagement
Environmental Scan

• AHRQ-funded environmental scan conducted to serve
  as evidence-based foundation for development of
  Guide to Patient and Family Engagement.
• Highlights
• Quality and Safety Both patients and providers
  think that the quality of care they receive or
  give is generally good they do not share same
  views on what constitutes quality or safety
• Engagement In theory, patients and providers
  support patient and family involvement and
  recognize it can lead to better patient
  experience and outcomes. Support is more
  uncertain when patient engagement includes higher
  level of involvement, i.e. making diagnosis or
  treatment decisions.

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AHRQs Guide to Patient and Family Engagement
Environmental Scan

• Highlights
• Engagement Patients more likely to engage when
  goals relate to obtaining specific information
  about their care (asking questions about
  condition), but less likely to engage when faced
  with behaviors that seem new or confrontational
  (asking providers to mark surgical sites)
• Barriers and facilitators to engagement
• Patients and family members Fear, uncertainty,
  low health literacy and provider reactions.
  Facilitators include self-efficacy, information,
  invitations to engage, and other provider
  support.
• Health providers Professional norms and
  experiences, fear of litigation, perceived level
  of effort. Facilitators include leadership,
  occurrence of sentinel event, business case for
  quality and safety, patient stories, altruism

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AHRQs Guide to Patient and Family Engagement
Environmental Scan

• Key Findings to Inform Future Development of
  Patient and Family Engagement Guide
• Existing approaches to and resources for patient
  and family engagement lack strong evidence base
  of efficacy or effectiveness
• Gaps in content and topic areas include
• Strategies not attuned to patient and family
  member experience of hospitalization
• Lack of individual tools to support
  hospital-level strategies
• Lack of concrete, actionable support for
  individual users to engage in behaviors
• Dearth of materials for nurses on how to better
  communicate with patients

http//www.ahrq.gov/qual/ptfamilyscan/
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Innovations and Tools To Improve Quality, Reduce
Disparities

• AHRQ Health Care Innovations Exchange
• Find evidence-based innovations and quality tools
• View new innovations and tools
• Learn from experts through events and articles

http//Innovations.ahrq.gov
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Patient Centered Outcomes Research Dissemination
Framework
Prioritization and Message Development

• Example
• New Diabetes CER
• Media campaign
• Outreach to national orgs (i.e. ADA, AADE,
  Endocrine Society, AACE)
• Outreach to consumers
• Integrate message into Diabetes package
• Promote via regional/State chapters of national
  orgs, local advocacy orgs, and regional health
  systems
• Integrate clinical message into Diabetes AD
  package
• Promote/discuss in individual practice settings
• Create and promote CE modules based on individual
  findings

National awareness of CER and specific findings
Publicity Center
Deeper awareness of CER and findings at regional,
local, or system level
Evaluation
Regional Offices
Individual clinician education and practice-level
implementation
Academic Detailing Online CE
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The Patient-Centered Outcomes Research Trust Fund
and AHRQ

• Provides funding for AHRQ to disseminate research
  findings of the Institute and other
  government-funded research, train and build
  capacity for research
• Up to 20 of Patient-Centered Outcomes Research
  Trust Fund can be used to support research
  capacity building and dissemination activities

www.pcori.org
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Closing the Quality Gap Revisiting the State
of the Science

• Series of reports summarizing the evidence on
  quality improvement strategies for chronic
  conditions and other priorities
• Bundled Payment
• Health Disparities
• Patient-Centered Medical Home
• Public Reporting
• Medication Adherence

http//www.ahrq.gov/clinic/tp/gapbundtp.htm
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Prioritizing Future Research Needs
Identifying Research Needs for Improving Health
Care

• Article describes challenges and lessons learned
  in developing a systematic approach to
  identifying and prioritizing future research
  needs (FRN)
• Based on the approach initiated by EPCs in 2010
  to better define patient-centered research needs
  from selected systematic reviews
• Focuses on stakeholder involvement as an
  essential tenet in the process

Chang S, Carey T. Ann Inter Med. 2012157439-445
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A Decent Meal,Or a New Model of Care?

• The challenge
• Serving millions of people
• Delivering a range of services
• Keeping costs reasonable
• Attaining a consistently high level of quality
• Can care be mechanized? Should it be?
• Are there models we can use?
• Gawande A. Big Med Restaurant chains have
  managed to combine quality control, cost control,
  and innovation. Can health care? New Yorker.
  August 13, 2012

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What Should the New Model
Look Like?

• That remains to be determined, although overall
  factors to consider include
• Engaging stakeholders at the point when strategic
  decisions are being made
• Making evidence available earlier and during
  different intervals of a project
• Thinking of publication as one step in the
  continuing process to get results into the hands
  of those who need it rather than the end of the
  research cycle
• Testing multiple conclusions in the field rather
  than waiting until there is a right answer

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The Journey from Patient Safety Knowledge to
Practice

• What we know
• Its a long journey
• Holds unexpected surprises
• Not just one way to get there
• Bottom line Improving safety requires that we
  understand how patients and families perceive
  their care, recognize different degrees of
  engagement, and be willing to form partnerships
  to provide safer care

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Traveling Fast or Traveling to Get Somewhere?

• If you want to travel fast, you travel alone. If
  you want to go far, travel with others.
  

African Proverb
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Thank You
AHRQ Mission To improve the quality, safety,
efficiency, and effectiveness of health care for
all Americans AHRQ Vision As a result of AHRQ's
efforts, American health care will provide
services of the highest quality, with the best
possible outcomes, at the lowest cost
www.ahrq.gov