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

1. 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

2. Health Care Quality and Access Disparities in health care quality and access are staying the same or increasing Quality Access n=number of core measures 2007 National Healthcare Quality and Disparities Reports

3. Quality and Access are Key • Vary – A LOT; NOT clearly related to dollars spent • 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’

4. Delivery As A Science “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. … That’s a mistake, a huge mistake.” Peter Pronovost, MD December 10, 2007

5. Coordination of Care Social Workers Disease Management Patients Nurses Physicians Medical Home Insurance Programs PHRs Family & Care Givers Care Managers

6. 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 sub-groups • Rewarding the ‘leading edge’ and bringing others along

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

8. AHRQ’s Mission Improve the quality, safety, efficiency and effectiveness of health care for all Americans

9. 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

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

11. Funding 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 research • $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

12. AHRQ’s National Reports on Quality and Disparities • 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

13. Better Same Worse Key Findings There were 45.7 million uninsured Americans in 2007* • Uninsurance is a major barrier to reducing disparities • Uninsured individuals do worse than privately insured individuals on almost 90% of quality measures and on all access measures 100% 1 75% 8 6 50% 25% 0 Quality (9CRM) Access (6CRM) *U.S. Bureau of the Census, August 2008

14. 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

15. =Most Recent Year = Baseline Year Massachusetts: Overall Care Quality vs. All States, One-Year Performance Change Average Weak Strong Very Weak Very Strong Performance Meter: All Measures 2007 National Healthcare Quality Report, State Snapshots

16. Measuring MassachusettsHealth Care Quality 2007 National Healthcare Quality Report, State Snapshots

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

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

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

20. CERTs Centers

21. U of Pennsylvania Philadelphia, PA U of Illinois Chicago Johns Hopkins Baltimore, MD Brigham & Women’s Hospital Boston, MA Outcome Science Cambridge, MA Harvard Pilgrim Boston, MA U of Maryland Baltimore, MD Acumen, LLC Palo Alto, CA Duke University Durham, NC U of Colorado Aurora, CO RTI International RTP, NC U of North Carolina Chapel Hill, NC Vanderbilt U Nashville, TN 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

22. 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 cancer) • PilotStudies 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

23. 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 information Reports: Advances in Genomics • 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 recommendations)

24. AHRQ Health IT Investment: $260 Million 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

25. Evidence-Based Guidelines • NGC is a comprehensive database of evidence-based clinical practice guidelines and related documents • 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

26. 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

27. AHRQ Health Care Innovations Exchange Web-based Repository of Cutting-Edge Service Innovations • 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 www.innovations.ahrq.gov

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

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

30. Evidence-Based Practice Centers • 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 • 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 partners

31. Support for U.S. Preventive Services Task Force (USPSTF) • 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 Force

32. 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 Disease • Screening for Phenylketonuria • Screening for Congenital Hypothyroidism

33. 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 groups: • Consumers • Health care providers • Policymakers

34. AHRQ Comparative Effectiveness Research http//:effectivehealthcare.ahrq.gov

35. Effective Health Care Program: Comparative Effectiveness Reviews in Progress

36. Emerging Methods in Comparative Effectiveness & Safety • Variation in methods among systematic reviews undercuts transparency • Methods reduce the likelihood of scientific impartiality • Methods help minimize misclassification of data • Methods must continue to evolve and not remain stagnant • AHRQ has and will continue to make investments in improving methods

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

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

39. Health Care in 2058(NAHSL’s 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

40. 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

41. Quality Standards Design systems to collect quality of care information and define what constitutes quality health care Incentives Reward those who provide and purchase high-quality and competitively priced health care Price Standards Aggregate claims information to enable cost comparisons between specific doctors and hospitals Interoperability Set common technical standards for quick and secure communication and data exchange Cornerstones of Value-Driven Health Care

42. Chartered Value Exchanges

43. 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 measurement • MAeHC is working to encourage implementation of EHRs and HIEs in Massachusetts • Priorities: Health IT & consumer engagement

44. 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”

45. 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

46. T1 T2 T3 How Do We Enhance Our Efforts? The “3T’s” Road Map to Transforming U.S. Health Care 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 research 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 “3T’s Roadmap to Transform U.S. Health Care: The ‘How’ of High-Quality Care.”

47. 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 baseline • 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

48. A robust health care system must include capacity for: Rapid translation of beneficial advances or breakthroughs Connectivity with the biomedical enterprise Connecting ‘Achievability’ and Reliability… Achievability: What can work under ideal circumstances for some people Reliability: Getting it right for all patients every time – the first time

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