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Expanding Research and Evaluation Designsfor QII

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Title: Expanding Research and Evaluation Designsfor QII


1
Expanding Research and Evaluation Designs…for QII
  • Carolyn M. Clancy, MD
  • Director, AHRQ
  • September 13, 2005

2
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3
Are We Making Any Progress?
  • Second annual reports focus on quality of and
    disparities in health care in America
  • Quality Report finds that quality is improving
    and identifies areas which are in need of major
    improvements
  • Disparities Report indicates that there are
    pervasive disparities related to race, ethnicity,
    and socioeconomic status

4
Preliminary NHQR Highlights 2005
  • Health Care Quality Continues To Improve at a
    Modest Pace Across Most Measures of Quality
  • 101 ratio of measures improved to declined
  • Overall improvement rate 2.8
  • Health Care Quality Improvement Is Variable, With
    Notable Areas of High Performance
  • Patient safety 10.2
  • QIO Measures 9.2
  • Effectiveness measures 2.8
  • High improvement subset 5.4

5
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
6
Public Perceptions
Percent who say they are dissatisfied with the
quality of health care in this country…
Has the quality of health care in this country…
2004
2000
Gotten worse
Stayed about the same
Dont Know
Gotten better
Gallup Poll conducted September 11-13, 2000
with 1,008 U.S. adults.
Source Kaiser Family Foundation / Agency for
Healthcare Research and Quality / Harvard School
of Public Health National Survey on Consumers
Experiences with Patient Safety and Quality
Information, November 2004 (Conducted July 7
September 5, 2005).
7
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8
AHRQs Mission
  • To improve the safety and quality, efficiency and
    effectiveness of health care for all Americans

9
Answers must be
  • Timely
  • Valid
  • Convincing
  • Practical

10
Balas, 2002
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
35
0.3 year
Poyer, 1982
Balas, 1995
Lack of numbers
Bibliographic databases
Expert opinion
50
6. 0 - 13.0 years
Antman, 1992
Reviews, guidelines, textbook
Poynard, 1985
9.3 years
Inconsistent indexing
Implementation
It takes 17 years to turn 14 per cent of original
research to the benefit of patient care
11
Treatments Thought to Work but Shown Ineffective
  • Sulphuric acid for scurvy
  • Leeches for almost anything
  • Insulin for schizophrenia
  • Vitamin K for myocardial infarction
  • HRT to prevent cardiovascular disease
  • Flecainide for ventricular tachycardia
  • Routine blood tests prior to surgery
  • ABMT for late stage Breast CA
  • BMJFebruary 28 2004 324474-5.

12
Expanding Research and Evaluation Designs…for QII
  • Carolyn M. Clancy, M.D.
  • Director, AHRQ
  • September 13, 2005
  • DRAFT Denise D and David Atkins 9/7/05

13
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14
  • Health services research has not yet been
    sufficiently helpful in meeting the challenge of
    improving care in part because it has
    over-constrained both its methods and its
    favorite topics….HSR should become more
    effectively part of the solution. To do that
    will require that we enrich our portfolio of
    methods and broaden our area of inquiry.
  • --Berwick, HSR, 402 (April 2005)

15
Challenges to the RCT Paradigm
  • The intervention targets are not patients
    directly,
  • Interventions are complex
  • Interventions change, and
  • Where the setting is an essential component of
    the question and intervention.   

16
AHRQ Research Study Computerized Physician Order
Entry Systems
  • Major Finding While computerized physician order
    entry (CPOE) is expected to significantly reduce
    medication errors, systems must be implemented
    thoughtfully to avoid facilitating certain types
    of errors
  • Study looked at clinicians experience in using
    one CPOE system at a major urban teaching
    hospital
  • Implementation problems can be minimized through
    testing before products are marketed and through
    adaptation to meet the needs of individual
    clinical settings

R. Koppel, J. Metlay, A. Cohen, et al., Role of
computerized physician order entry systems in
facilitating medication errors, Journal of the
American Medical Association, March 9, 2005
17
Current QI evaluation questions AHRQ and others
are asking
  • Can a regional health information organization
    improve interoperability of health information
    technology systems and improve patient safety and
    quality of care?
  • Can pay for performance improve quality?
  • Do changes in hospital culture reduce medical
    errors?
  • What QI strategies work for reducing disparities?
  • Different strategies for different populations
    and settings?
  • Same strategies?

18
Current QI evaluation questions AHRQ and others
are asking - 2
  • When should coverage be linked with development
    of better evidence (decision-based evidence
    making)?
  • In an action-oriented world how to identify a
    control group?
  • Can evidence for the effectiveness of team
    training in obstetrics be developed as training
    is provided?
  • For which questions is a registry useful? What
    methods will help us take advantage of new
    sources of electronic data?

19
Galaxies of Evaluation Designs That May Inform
QII Evaluation Designs and Methods
Behavioral/Social Science Galaxy
Medical/clinical/ HSR Galaxy
RCT
Action Research K Lewin
GRT
ITS/MBS
Quasi-exp
QII Evaluation Research
HSR 2 data Analysis
RD
Case reports
Systems Science
RCT
Cohort study
Case- Control
Qualita- tive methods
Case studies
PDSA/SPC Deming/ Shewhart
1 For purposes of this chart, intervention
evaluation research is defined as studies
designed to Answer the Questions Does the
Intervention Work? For Whom or What? Under What
Conditions?
20
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21
Questions?
  • Contact
  • CCLANCY_at_AHRQ.GOV

22
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