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Driving Change Through Research: Future Trends in Health Care Quality and Access


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Title: Driving Change Through Research: Future Trends in Health Care Quality and Access

Driving Change Through Research Future Trends in
Health Care Quality and Access
  • Carolyn M. Clancy, MD
  • Director
  • Agency for Healthcare Research and Quality
  • NAHSL 2008 50th Anniversary Conference
  • Lowell, MA October 21, 2008

Health Care Quality and Access
  • Disparities in health care quality and access are
    staying the same or increasing

nnumber of core measures
2007 National Healthcare Quality and Disparities
Quality and Access are Key
  • Vary A LOT NOT clearly related to dollars
  • Matter can be measured and improved
  • Measurement science is evolving
  • Structure, process and outcomes
  • Broad recognition that patient experience is
    essential component
  • Strong focus on public reporting is good
  • Motivates providers to improve
  • Not yet consumer friendly

Delivery As A Science
  • The fundamental problem with the quality of
    American medicine is that weve failed to view
    delivery of health care as a science. Thats a
    mistake, a huge mistake.
  • Peter Pronovost, MD
  • December 10, 2007

Coordination of Care
Social Workers
Disease Management
Medical Home
Insurance Programs
Family Care Givers
Care Managers
Opportunities for the Field
  • Using health IT to improve research
  • Building public/private partnerships that include
    representative stakeholders
  • Standardizing collection of race, ethnicity and
    language data, including priority populations and
  • Rewarding the leading edge and bringing others

Future Trends in Health Care Quality and Access
  • Knowledge Creation
  • Synthesis Dissemination
  • Translating Research Into Practice
  • 21st Century Health Care
  • Q A

AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
AHRQ Roles and Resources
  • Health IT Research
  • Funding
  • Support advances that improve patient
    safety/quality of care
  • Continue work in hospital settings
  • Step up use of Health IT to improve ambulatory
    patient care
  • Develop Evidence Base for Best Practices
  • Four key domains
  • Patient-centered care
  • Medication management
  • Integration of decision support tools
  • Enabling quality measurement
  • Promote Collaboration
  • and Dissemination
  • Support efforts of AHIC, ONC, HRSA and Centers
    for Medicare and Medicaid Services
  • Build on public and private partnerships
  • Use web tools to share knowledge and expertise

AHRQ Priorities
Patient Safety
  • Health IT
  • Patient SafetyOrganizations
  • New PatientSafety Grants

Effective HealthCare Program
AmbulatoryPatient Safety
  • Comparative Effectiveness Reviews
  • Comparative Effectiveness Research
  • Clear Findings for Multiple Audiences
  • Safety Quality Measures,Drug Management
    andPatient-Centered Care
  • Patient Safety ImprovementCorps

Medical ExpenditurePanel Surveys
Other Research Dissemination Activities
  • Visit-Level Information on Medical Expenditures
  • Annual Quality Disparities Reports
  • Quality Cost-Effectiveness, e.g.Prevention and
  • U.S. Preventive ServicesTask Force

Continuing Resolution Passed for FY 2009
Continues FY 2008 Funding through March 6, 2009
  • Continuation of 334.6 million
    appropriation, which includes
  • 30 million for comparative effectiveness
  • 5 million for research and activities to reduce
    Methicillin Resistant Staphylococcus aureus
    (MRSA) and related infections
  • 9.7 million for Value Research, including the
    Value-Driven Healthcare Initiative
  • 7.1 million for research related to prevention
    and care management

AHRQs National Reports on Quality and
  • The rate of improvement in quality between 1994
    and 2005 was 2.3 percent, down from 3.1 percent
    from 1994-2004
  • Measures of patient safety showed an average
    annual improvement of about 1
  • Areas where significant attention has been
    concentrated, such as appropriate timing of
    antibiotics for surgery and reducing medication
    errors, have shown progress

Key Findings
There were 45.7 million uninsured Americans in
  • Uninsurance is a major barrier to reducing
  • Uninsured individuals do worse than privately
    insured individuals on almost 90 of quality
    measures and on all access measures

Quality (9CRM)
Access (6CRM)
U.S. Bureau of the Census, August 2008
Usual Source of Care
Higher costs, poorer outcomes and greater
disparities are observed among individuals
without a usual source of care
  • Overall, the proportion of persons with a
    specific source of ongoing care is higher for
    females in all racial and ethnic groups
  • This proportion was significantly lower for the
    poor (78.1), near poor (81.4) and middle income
    (87.2) groups than for high income groups (92.3)

2007 National Healthcare Disparities Report
Massachusetts Overall Care Quality vs. All
States, One-Year Performance Change
Very Weak
Very Strong
Performance Meter All Measures
2007 National Healthcare Quality Report, State
Measuring MassachusettsHealth Care Quality
2007 National Healthcare Quality Report, State
Future Trends in Health Care Quality and Access
  • Knowledge Creation
  • Synthesis Dissemination
  • Translating Research Into Practice
  • 21st Century Health Care
  • Q A

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
  • Translate evidence into improvements
  • Communication of scientific information in plain
    language to policymakers, patients, and providers

New Priority Conditions for the Effective Health
Care Program
  • Arthritis and non-traumatic joint disorders
  • Cancer
  • Cardiovascular disease, including stroke and
  • 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

CERTs Centers
DEcIDE Research Network
Network of institutions and partner
organizations with access to de-identified data
of 50 million patients generates evidence and
analytic tools in practical, accelerated format
New Solicitations through the
DEcIDE Network
  • Computer-based Clinical Decision Support (CDS)
    Tools for Gene-based Tests Used in Breast Cancer
  • Developing clinical decision support (CDS) tools
    for gene-based tests that are used in the
    prevention and treatment of breast cancer
  • Multicenter Research Cooperatives for Clinical
    Comparative Effectiveness Studies
  • Creating multi-center research cooperatives to
    coordinate and conduct studies on clinical
    effectiveness and comparative effectiveness in
    selected priority health conditions (diabetes and
  • Pilot Studies For Evaluating the Safety and
    Effectiveness of Prescription Drugs, Biologics
    and Vaccines Using Medicare Part D
  • Conducting pilot studies which evaluate the
    safety and effectiveness of prescription drugs,
    biologics and vaccines using Medicare Part D data

Proposed information and not final information
Advances in Genomics
  • A recent DEcIDE report identified major gaps in
    our ability to generate evidence on utilization
    and outcomes of genomic testing
  • The American Health Information Community (AHIC)
    has called on AHRQ to help develop standards to
    code and exchange pharmacogenomics-relevant EHR
  • Reports
  • Genomic Testing in Ovarian Cancer, Breast Cancer,
    Colorectal Cancer and Depression Patients
  • Horizon Scans on Cancer and non-Cancer Genetic
    Tests (for CMS)
  • Collection, and Use of Cancer Family History in
    Primary Care (CDC-funded)
  • BRCA Testing in Breast and Ovarian Cancers, and
    Screening for Hereditary Hemochromatosis (USPSTF

Health IT and Patient Safety
  • Long-term agency priority
  • Since 2004, AHRQ has supported more than 200
    projects and demonstrations to improve the
    safety, quality and efficiency of health care in
    virtually every state
  • Special attention to best practices that can
    improve quality of care in rural, small
    community, safety net and community health center
    care settings
  • New focus on ambulatory safety and quality

Evidence-Based Guidelines
  • NGC is a comprehensive database of evidence-based
    clinical practice guidelines and related
  • NQMC is a database and Web site for information
    on specific evidence-based health care quality
    measures and measure sets
  • The goal of both is to promote the dissemination,
    implementation and use in order to inform health
    care decisions

Coming Soon MEADERS
Medication Error and Adverse Drug Event Reporting
System (MEADERS)
  • Designed to help doctors in small practices
    quantify medication errors and ADEs
  • Web-based system for documenting and reporting in
    ambulatory settings
  • Information fed back to practices for QI purposes
  • Voluntary and confidential

AHRQ Health Care
Innovations Exchange
Web-based Repository of Cutting-Edge Service
  • National electronic learning hub for sharing
    health care service innovations, bringing
    innovators and adopters together
  • Searchable database featuring innovation
    successes and failures, expert commentaries,
    lessons learned, etc.,
  • Designed to help health care Agents of Change
    improve quality

AHRQ Encourages Consumers to Get Involved with
their Care
  • AHRQs campaign with the Ad Council uses a series
    of TV, radio and print public service
  • Web site features a Question Builder for
    patients to enhance their medical appointments
  • www.ahrq.gov/questionsaretheanwser

Future Trends in Health Care Quality and Access
  • Knowledge Creation
  • Synthesis Dissemination
  • Translating Research Into Practice
  • 21st Century Health Care
  • Q A

Evidence-Based Practice Centers
  • Created in 1997 promotes evidence-based practice
    and decision-making
  • Generate comparative effectiveness reviews on
    medications, devices and other interventions
  • User-driven, with public and private-sector
  • Blue Cross and Blue Shield Association,
    Technology Evaluation Center (TEC), Chicago, IL
  • Duke University, Durham, NC
  • ECRI, Plymouth Meeting, PA
  • Johns Hopkins University, Baltimore, MD
  • McMaster University, Hamilton, Ontario
  • Oregon Evidence-Based Practice Center
  • RTI International-University of North Carolina at
    Chapel Hill, NC
  • Southern California Evidence-based Practice
    Center-RAND, Santa Monica, CA
  • Tufts University-New England Medical Center,
    Boston, MA
  • University of Alberta
  • University of Connecticut
  • Minnesota Evidence-based Practice Center
  • University of Ottawa
  • Vanderbilt University

Support for U.S. Preventive Services Task Force
  • Evidence-Based Practice Centers support The Guide
    to Clinical Preventive Services Recommendations
    of the U.S. Preventive Services Task Force
  • Prepare systematic evidence reviews and evidence
    summaries for topics under consideration by Task

New USPSTF Clinical Recommendations
  • Screening for Prostate Cancer
  • Screening for Hearing Loss in all Newborns
  • Screening for Bacterial Vaginosis in Pregnancy
  • Screening for Illicit Drug Use
  • Screening for Chronic Obstructive Pulmonary
  • Screening for Phenylketonuria
  • Screening for Congenital Hypothyroidism

AHRQ Evidence Translation/ Communication
(Eisenberg Center)
  • Translates knowledge about effective health care
    into clear, actionable summaries to assess
  • Treatments
  • Medications
  • Technologies
  • Develops information summaries for 3 key audience
  • Consumers
  • Health care providers
  • Policymakers

AHRQ Comparative Effectiveness Research
Effective Health Care Program Comparative
Effectiveness Reviews in Progress
Emerging Methods in Comparative
Effectiveness Safety
  • Variation in methods among systematic reviews
    undercuts transparency
  • Methods reduce the likelihood of scientific
  • Methods help minimize misclassification of data
  • Methods must continue to evolve and not remain
  • AHRQ has and will continue to make investments in
    improving methods

  • An NAHL favorite
  • A free gateway to reliable consumer HHS
  • Includes links to 6,000 health information
  • Access to myhealthfinder
  • Updated version launched in September

Future Trends in Health Care Quality and Access
  • Knowledge Creation
  • Synthesis Dissemination
  • Translating Research Into Practice
  • 21st Century Health Care
  • Q A

Health Care in 2058(NAHSLs 100th Anniversary)
  • What will it look like?
  • There is no way to tell. In the meantime, goals
    to be addressed include
  • Determining what can be done to improve the
    system right now
  • A continuing sense of urgency for long-term
    solutions involving innovation, enhanced risk
    taking and new delivery system approaches

Getting to Value-Driven Health Care
  • "Every American should have access to a full
    range of information about the quality and cost
    of their health care options."

Michael O. Leavitt, Secretary US Dept. of
Health and Human Services November 5, 2007
Cornerstones of
Value-Driven Health Care
Chartered Value Exchanges
Massachusetts Chartered Value Exchange
  • The Massachusetts Health Quality Partners and the
    Massachusetts eHealth Collaborative came together
    to form the Chartered Value Exchange
  • MHQP anticipates the Value Exchange will help
    further advance quality by integrating timely
    information into claims data for performance
  • MAeHC is working to encourage implementation of
    EHRs and HIEs in Massachusetts
  • Priorities Health IT consumer engagement

21st Century Health Care
Improving quality by promoting a culture of
safety through Value-Driven Health Care
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
Scope of the Opportunity in Health Care
  • A major challenge in 21st Century health care is
    evaluating all innovations and determining which
  • Represent added value
  • Offer minimal enhancements over existing choices
  • Fail to reach their potential
  • Work for some patients and not for others

How Do We Enhance Our Efforts?
The 3Ts Road Map to Transforming U.S. Health
Improved health care quality and value
and population health
Basic biomedical science
Clinical efficacy knowledge
Clinical effectiveness knowledge
Key T1 activity to test what care
works Clinical efficacy research
Key T2 activities to test who benefits from
promising care Outcomes research Comparative
effectiveness Research Health services
Key T3 activities to test how to deliver
high-quality care reliably and in all
settings Measurement and accountability of
health care quality and cost Implementation of
Interventions and health care system
redesign Scaling and spread of effective
interventions Research in above domains
Source JAMA, May 21, 2008 D. Dougherty and
P.H. Conway, pp. 2319-2321. The 3Ts Roadmap to
Transform U.S. Health Care The How of
High-Quality Care.
Pronovost Study
  • Settings Volunteer MI hospital ICUs for adults
    (108 intention to treat)
  • Primary hypothesis Rate of CABSIs would be
    reduced during first 3 months of intervention v
  • Multiple interventions (sequential and parallel)
  • Outcome measure Incidence-rate ratios for CABSIs

New Yorker, December 2007
  • Analytic approach Generalized linear latent and
    mixed model with robust variance estimation and
    random effects to account for clustering within
    hospitals and hospitals within regions, adjusted
    for hospital teaching status and number of beds

Pronovost et al., NEJM 355(26) Dec. 28, 2006
Connecting Achievability and
  • A robust health care system must include capacity
  • Rapid translation of beneficial advances or
  • Connectivity with the biomedical enterprise

Achievability What can work under ideal
circumstances for some people Reliability
Getting it right for all patients every time
the first time
Future Trends in Health Care Quality and Access
  • Knowledge Creation
  • Synthesis Dissemination
  • Translating Research Into Practice
  • 21st Century Health Care
  • Q A
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