Patients at the Center: Guidelines for Effectiveness

1. Patients at the Center:Guidelines for Effectiveness Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality New York Academy of Medicine Conference on E-GAPPS New York, NY – December 10, 2012

2. What We Know “The truth is that for a large part of medical practice, we don’t 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

3. Health System Transformation: Current and Future

4. Patients at the Center:Guidelines for Effectiveness Making the Case: Health Care Quality and Disparities Learning More about What We Know The Role of Guidelines Questions

5. HHS Organizational Focus NIH AHRQ CDC Population health and the role of community based interventions to improve health Long-term and system-wide improvement of health care quality and effectiveness Biomedical Research to prevent, diagnose and treat disease

6. AHRQ 2011 National Healthcare Quality and Disparities Reports • Overall, improvement in the quality of care remains suboptimal • Few disparities in quality are getting smaller • Quality of care varies not only across types of care but also across parts of the country

7. Progress is Uneven Toward National Priority Areas • 2011 Findings: • Health care quality and access are suboptimal, especially for minority and low-income groups • Quality is improving; access and disparities are not • Urgent attention needed to ensure continued improvement in quality and progress on reducing disparities for services, geographic areas and populations, including: • Diabetes care and adverse events • Disparities in cancer screening and access to care • States in the South Reports include evidence of progress toward priorities identified in National Quality Strategy and HHS Plan to Reduce Racial and Ethnic Health Disparities

8. Quality Is Improving Slowly Quality measures that are improving, not changing or worsening, overall and for select populations • Nearly 60 percent of health care quality measures tracked showed improvement • However, the median rate of change was 2.5 percent per year AHRQ 2011 National Healthcare Quality and Disparities Reports

9. Few Disparities in Quality of Care Are Getting Smaller Quality measures for which disparities related to age, race, ethnicity and income are improving, not changing or worsening • Few disparities in quality showed significant improvement. • The number of disparities that were getting smaller exceeded the number that were getting larger AHRQ 2011 National Healthcare Quality and Disparities Reports

10. New York: OverallQuality vs. All States =Most Recent Year = Baseline Year Average Weak Strong Very Weak Very Strong Performance Meter: All Measures National Healthcare Quality Report, State Snapshots

11. New York Snapshot:Quality Measures National Healthcare Quality Report, State Snapshots

12. National Quality Strategy:Three 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

13. There Has Been Considerable Progress: For Example… Unprecedented national investment in health care research, access, delivery Funding for data infrastructure, new evidence, dissemination of best practices Wider opportunities for patient-centered outcomes research and quality improvement

14. Patients at the Center:Guidelines for Effectiveness Making the Case: Health Care Quality and Disparities Learning More about What We Know The Role of Guidelines Questions

15. 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 Research that Addresses Patient Outcomes Patient-Centeredness: The final frontier?

16. 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 Innovation Exchange

17. Until Recently, Few Tools to Get From Evidence to Practice • AHRQ is working to: • Translate scientific advances into actual clinical practice • Translate scientific advances intousable information for clinicians and for patients • Deliver information in the right places at the right time

18. The Patient-Centered Outcomes Research Trust Fundand 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

19. Patients at the Center:Guidelines for Effectiveness Making the Case: Health Care Quality and Disparities Learning More about What We Know The Role of Guidelines Questions

20. National Guideline Clearinghouse • Originally a public/private partnership with the American Medical Association and American Association of Health Plans • Emphasis on transferring evidence-based knowledge to health care professionals • NGC went live 12/15/98 http://guideline.gov

21. Facts About NGC • More than 2,300 guideline summaries from 275 organizations • More than 30 guideline comparisons (syntheses) • More than 6,500 citations in the annotated bibliography • More than 63,000 subscribers to the “What’s New” email service http://guideline.gov

22. New, Updated, and Withdrawn Guidelines

23. IOM Reports

24. What’s In a Definition? IOM 2009 IOM 2011 Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options • Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances

25. NGC: Next Steps & Time Estimates – IOM Trustworthiness Timeline for AHRQ and NGC actions involving IOM Standards for Developing Trustworthy Guidelines Announce Revised Inclusion Criteria Inclusion Criteria Apply Inclusion Criteria to New and Updated Guidelines (“Grandfather”) 6 Months 1Q 2015 3Q 2014 4Q 2014 2Q 2014 1Q 2013 3Q 2013 4Q 2013 2Q 2013 1Q 2014 Calendar Year Extent Adherence to IOM Begin Phased Implementation of Approach Develop, Test Approach to Indicating Extent to Which Guidelines Adhere to IOM Standards

26. A Matter of Trust Measures of CPG Trustworthiness • Systematic review of the existing evidence • Developed by multidisciplinary panel of experts • Consider patient subgroups and preferences • Explicit and transparent process • Clear explanation of relationships between alternative care options and health outcomes • Reconsidered and revised as appropriate

27. Eight Standards for Developing Trustworthy CPGs • Establishing transparency • Management of conflict of interest • Guideline development group composition • Clinical practice guideline–systematic review intersection • Establishing evidence foundations for and rating strength of recommendations • Articulation of recommendations • External review • Updating

28. Implications for Clinical Practice Guidelines • CPGs must comprise actionable statements • Future CPGs will be embedded in information systems  collaborations with human factors, engineers, others • CPGs are about both ‘what’ – and ‘how’ • Improved quality supply chain links CPGs, quality measures and data sources

29. Eisenberg Center Symposium:September 2012 • What do we do when new evidence challenges conventional wisdom? • When evidence challenges established clinical practice • Consumers receiving mixed messages • Media focus on emerging research, conflict rather than established practice • Conclusions • Clear and concise messages! • Transparency in generating evidence and recommendations • Ongoing stakeholder input; work with trusted sources • “Meeting people where they are at”

30. The “Quality Supply Chain” • Significant activity recently on provider performance measurement • Less clear is the basis for existing measures • Health IT sometimes considered a silver bullet • Digitized data “self-assembles” • Clinical decision support

31. USPSTF: New Steps Designed to Increase Transparency • The Task Force now requests public comment throughout the recommendation process • USPSTF is also developing stakeholder groups • Organizations and individuals are encouraged to sign up for the Task Force listserv to receive updates on the latest activities New Product for Consumers www.uspreventiveservicestaskforce.org/index.html

32. Recommendation Process Public CommentOpportunity Develop Research Plan Develop Evidence Report Public Comment Opportunity Task Force members work with researchers from an Evidence-based Practice Center (EPC) to create a draft Research Plan that guides the recommendation process. The draft Research Plan isposted on the USPSTF Web site for public comment. The Task Force and EPC review all comments, address them as appropriate, and create a final Research Plan. Using the final Research Plan,the research team at the EPC independently gathers and reviewsthe available published evidenceand creates a draft Evidence Report. The draft Evidence Report is critiqued by external national subject matter experts. The draft Evidence Reportis posted on the USPSTF Web site for public comment. (Future Step in 2013) The EPC reviews all comments, addresses them as appropriate, and creates a final Evidence Report. The Task Force reviews all comments, addresses them as appropriate, and creates a final Recommendation. Members vote to ratify the final Recommendation. Public CommentOpportunity Publish & Disseminate Final Recommendation Develop Recommendation Finalize Recommendation Task Force members discuss the Evidence Report and deliberate on the effectiveness of the service. Based on the discussion, Task Force members create a draft Recommendation. The draft Recommendation is posted on the USPSTF Web site for public comment. The Evidence Report is finalized and published. The final Recommendation and supporting Evidence Report are posted on the Task Force Web site. Final Recommendations also are made available through electronic tools, peer-reviewed journals, and consumer guides.

33. Key Considerations • Guidelines will remain central to the provision of safe, high-quality care • Much of the measurement enterprise is “evolving” • Collective interest in using guidelines that reflect the profession’s knowledge and authority • Disparate stakeholders must be engaged • The patient always comes first!

34. Questions? 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