Transcript National Quality Measures Clearinghouse

HSR and the Imperative for
Health Care Transformation
Carolyn M. Clancy, MD
Director
October 7, 2003
Overview
 The imperative to improve
 The challenges of creating &
applying “Useable Knowledge”
 Opportunities and Challenges
 Final thoughts
State of Quality in the U.S.
“The American health care delivery system is in
need of fundamental change….the care
delivered is not, essentially, the care we
should receive……Between the health care
we have and the care we could have lies
not just a gap, but a chasm…”
“The need for leadership in health care has
never been greater.”
IOM, Crossing the Quality Chasm, 2001
New York Times, December 18, 2002
RAND Study: Quality of Health
Care Often Not Optimal
Patients’ care often deficient, study says.
Proper treatment given half the time.
On average, doctors provide appropriate health care only half the
time, a landmark study of adults in 12 U.S. metropolitan areas suggests.
Medical Care
Often Not
Optimal
.Failure to Treat
Patients Fully Spans
Range of What Is
Expected of
Physicians and Nurses
Medical errors corrode
quality of healthcare system
The American healthcare system,
often touted as a cutting-edge
leader in the world, suddenly
finds itself mired in serious
questions about the ability of its
hospitals and doctors to deliver
quality care to millions.
RAND Study: Quality of Health
Care Often Not Optimal
 Doctors provide appropriate health
care only about half the time
Alcohol dependence
Hip fracture
Peptic ulcer
Diabetes
Low back pain
Prenatal care
Breast cancer
Cataracts
11%
23%
33%
45%
69%
73%
76%
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
“The one question I still can’t answer
is: WHY the gap between evidencebased and actual practice?”
Earl Steinberg, M.D., M.P.P., 2003
Pick Your Condition ….
 Diabetes
 Hypertension
 Aspirin post MI
 Beta blockers post MI
 Anticoagulation
 Hypercholesterolemia
The Chasm in Asthma Care
 What percent of people in managed care get
appropriate medications for asthma?*
Children 5-9
60.0%
Adolescents 10-17
58.7%
Adults 18-65
65.1%
Clarifying National Aims for
Improvement
 Safety
 Effectiveness -- Matching care to
science; avoiding overuse of ineffective care
and underuse of effective care
 Patient Centeredness
 Timeliness
 Efficiency
 Equity
Reperfusion Therapy in Medicare
Beneficiaries with Acute MI
Group
% Eligible
receiving reperfusion
White men
59%
White women
56%
Black men
50%
Black women
44%
Canto JG; Allison JJ; Kiefe CI; Fincher C; Farmer R, Sekar P; Person S; Weissman NW. Relation of rave
and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. N
Engl J Med 2000 Apr 13;342(15):1094-100.
Context
 Investments in biomedical science  growing
demand for products of HSR
 Greater recognition among decision makers of
the potential value of “HSR”
 Growing impatience with the leisurely pace of
translation of knowledge into practice
 Growing recognition of patients as partners
and agents of change -- rather than
‘recipients’
Manifestations
 Public Library of Science (PLOS; Harold
Varmus)
 Landmark lecture in US focuses on “clinical
research lost in translation”
 Multiple entities established, disbanded and
reinvented to focus on research uptake (all
Nations)
 Health care challenges are page 1 news
 Focus on HIT as “the answer”
What We Have Learned 2003
 Knowing the right thing to do is NOT =




doing it!
Improvement must be based on science
Patients as participants are far more
effective than patients as ‘recipients’
Sutton’s Law: improving chronic illness
care is essential
Safety in health care delivery is critical
Potential for HSR
 From describing problems to solving
them:
 Getting to “TRIPP”
 Creating and nurturing ‘receptor sites’ for
our work
 “Back to the Future”
“Potential is what you have
when you haven’t done it yet”
Darrel Royall
University of Texas
Football coach
Overview
 The imperative to improve
 The challenges of creating &
applying “Useable Knowledge”
 Opportunities and Challenges
 Final thoughts
Health Services Research
“Health services research is a
multidisciplinary field of inquiry, both basic
and applied, that examines the use,
costs, quality, accessibility, delivery,
organization, financing, and outcomes of
health care services to increase
knowledge and understanding of the
structure, processes, and effects of health
services for individuals and populations.
Institute of Medicine, 1995
The Challenge
“What we really want to get at is not how
many reports have been done, but how
many people's lives are being bettered by
what has been accomplished. In other
words, is it being used, is it being
followed, is it actually being given to
patients?…[W]hat effect is it having on
people?”
Congressman John Porter, 1998
Chairman, House Appropriations Subcommittee on
Labor, HHS, and Education
Research Impact
Level 4
Level 3
Level 2
Level 1
Improves
Access, Outcomes,
Efficiency
Improves Delivery and
Practice
Improves Processes and Policies
Improves Other Research
Levels of Impact:
ADHD
Level 1: Impact on
knowledge base future
research
Level 2: Impact on
policies, change
agents
Level 3: Impact on
clinical practice
Level 4: Impact on
patient outcomes
Evidence Report on the
Management of ADHD
Findings led to new AAP
guidelines, ADHD toolbox,
eQUIPP module
NICHQ Collaborative;
NICHQ/AAP/CHADD
applied for Partnerships
for Quality funding from
AHRQ
TBD
“A real
lack is what is known as
‘translational research’ -- The
translation of great basic science
into practical clinical realities for
patients.”
-- Steve Case, AOL Time Warner Chairman at Senate Appropriations
Labor HHS Subcommittee, June 4, 2002
Bridging the Quality Chasm
Where We
Are
Where We
Want To Be
Implementation
Innovation
Diffusion
Adoption
This is Not a New Problem:
The Case of Scurvy
 1601- Lancaster shows that lemon juice
supplement eliminates scurvy among
sailors
 1747- Lind shows that citrus juice
supplement eliminates scurvy
 1795- (194 years after discovery) British
Navy implements citrus juice
supplement
Original research
18%
Negative
results
variable
Dickersin, 1987
Submission
46%
0.5 year
Kumar, 1992
0.6 year
Kumar, 1992
Koren, 1989
Acceptance
Negative
results
Publication
35%
Lack of
numbers
Balas, 1995
17:14
0.3 year
Poyer, 1982
Expert
opinion
Bibliographic databases
50%
6. 0 - 13.0 years
Antman, 1992
Poynard, 1985
Reviews, guidelines, textbook
Inconsistent
indexing
9.3 years
Implementation
It takes 17 years to turn 14 per cent of original research
to the benefit of patient care
Debunked Assumption I:
Supply Side Research
Question
Hypothesis
Study
Publications
Changes in practice
Debunked Assumption II:
Improved Packaging
Publications (multiple)
Evidence synthesis
Guidelines, Performance Measures
???
Changes in Practice
A Flawed Model
 Receptor sites are “assumed”
 Decisionmaking is not-linear:
evidence is only part of the
“solution”
 Broad dissemination  modest
effects
Selected Models of Change
 Rogers’s diffusion of innovation
 Gladwell: the “tipping point”
 Economics: incentives and rewards
 Regulation: sanctions
 Individual: PRECEDE
 One or more of the above
 Other?
Diffusion of Innovation
 “Invention is hard; dissemination is much
more difficult” (Berwick; 2003)
 A problem for all industries
 Influences on rate of diffusion:
– Perception of innovation
– Characteristics of individuals who adopt
change
– Contextual and managerial factors
The Tipping Point (M.
Gladwell)
Small changes can have big effects
 The law of the few -- individual actions can be
amplified by social connections, energy,
enthusiasm and personality (connectors,
mavens and salesmen)
 The stickiness factor-- simple changes in the
presentation and structuring of information can
make a big difference in its impact
 The power of context -- individual behavior is
markedly affected by the environment
“Joint Production”
 Priority setting for research
 Joint design of research (“CBPR”)*
 Results interpretation and synthesis
 Improved formatting and new vehicles
for communication
 “Receptor capacity”**
 Identifying brokers and champions**
 Clarifying shortcomings and impact**
Potential Barriers to
Implementation
 Knowledge- lack of awareness of what is being
implemented (generally or specifically), unable to
access the information at the time of need
 Attitudes- lack of agreement with objective, lack
of self-efficacy, lack of outcomes expectancy,
inability to overcome inertia
 Behavior- unable to reconcile with others’
preferences, ongoing conflicting actions,
conflicting environmental factors
-- Adapted from Cabana, et al., JAMA 1999
Acute Cardiac Ischemia- Time
Insensitive Predictive Instrument
10
6
0
0
-10
10
0
-16
-20
-30
-40
-50
-50
CCU Admissions
Pts. without cardiac ischemia
Pts with unstable angina or AMI
ED Discharges
Pts. with stable angina
The Two Faces of “TRIPP”
 Funding research on transferring research
into practice
versus
 Embedding the transfer of research into
practice within the culture of universities,
healthcare organizations and research
funders
Overview
 The imperative to improve
 The challenges of creating &
applying “Useable Knowledge”
 Opportunities and Challenges
 Final thoughts
Back to the Future - 1
 Infomedicine now understood as
essential complement to biomedicine
 Boundaries between “QI” and “research”
have disappeared
 Data collection is purposeful, strategic
and oriented to patients’ and clinicians’
needs for information
 NO research is initiated without a clear
plan for sustained implementation
Challenges 1
 Evaluation of translation research
 Career paths for individuals focused on
improvement: metrics for success?
 “Alignment of incentives” for researchers
and funders
 “Research findings are ‘not ready to
use’”
Back to the Future - 2
 Learning from clinical encounters is a
critical component of knowledge
development
 Patients understand and SEE incentives
for participation in routine clinical
evaluation and improvement
 Throughout the world, the question
“What is the evidence?” is as routine as
vital signs or budget numbers
Challenges 2
 Taking promising findings “to scale”: metrics
for ‘promising’ and ‘readiness to implement’?
 Science of change: validation before and/or
during implementation?
 Moving beyond “1000 flowers blooming”
 Involving users throughout the research cycle
 Redefining “core focus” of HSR
Back to the Future - 3
 Policymakers “get it”: the return on investment
in biomedical research is significantly
enhanced by a robust investment in outcomes
research
 Target quality improvement efforts have
completely replaced “special” studies on
disparities (we now know that disparities in
health care = a critical QI opportunity)
 Continuous focus on measurement and
evaluation -- for improvement
Contemporary Challenges
 Scientific basis for safe and
appropriate use of diagnostic,
therapeutic and preventive
interventions – the case for
“practical clinical trials”
 Quality improvement as science
 Translating promising models into
large-scale improvements in care
and outcomes
The Evolution of TRIP
Research
 1999 - TRIP I RFA
– New knowledge about approaches that are
effective and cost-effective in promoting the
use of research evidence in clinical settings
and lead to improved health care practice and
sustained practitioner behavior change
 2000 - TRIP II RFA
– Strategies for translating research into
practice through the development of
partnerships between researchers and health
care systems and organizations
AHRQ Research Study: Outcomes of Beta
Blocker Use Before Bypass Surgery
3.4%
2.8%
Patients who took beta blockers before
bypass surgery had lower rates of death
in and out of the hospital within 30 days
of surgery
compared to those who did not
Use of beta blockers also improved
outcomes in patients at higher risk, e.g.,
those with heart failure, older age, lung
disease, and diabetes
With
Without
Beta Blocker
TB Ferguson, L Coombs, E Peterson, Preoperative B-Blocker Use and Mortality
and Morbidity Following CABG Surgery in North American, JAMA, May 2002
Team Approach to Testing for
Chlamydia
65%
 Team-oriented approach to testing
for chlamydia increased screening
rate of sexually active 14- to 18-year
old female patients from 5% to 65%
in a large California HMO study
 New screening system may help
reduce estimated $4 billion annual
treatment cost
5%
M Shafer, The effect of clinical practice improvement
intervention on chlamydia screening among sexually
active adolescent girls, JAMA, December 11, 2002
Effectiveness of Inpatient and Outpatient
Treatment for Women With PID
 1.2 Million women are treated each year for pelvic
inflammatory disease (PID)
 Major Finding: Treating PID in outpatient settings
rather than in a hospital does not cause harm to
women
100,000
women
hospitalized
for PID
15%
85%
Acute & serious PID
requires inpatient treatment
Mild to moderate PID
may be treated as outpatients
May save about $500 million each year
R. Ness, D. Soper, R. Holley, et al., Effectiveness of inpatient and outpatient treatment strategies for
women with pelvic inflammatory disease: results from the PID evaluation and clinical health (PEACH)
randomized trial, AJOG, May 2002
The Evolution of TRIP
Research
 2002 - TRIP PA
¯
Supporting research that can bridge the chasm
between promising prototypes and generalizable
knowledge that can be used in multiple settings
and lead to systematic improvement on a large
scale.
¯
Emphasizing projects that introduce changes at
the clinical, organization/health care systems,
and/or public policy levels […] and then measure
the impact of these efforts.
AHRQ Strategy Components
 Building the knowledge base:
– The Effectiveness Question: What works?
 Clinical
 Organizational
– The TRIP Question: How do we get
people/systems/policymakers to do or use
what works?
 How do we support the widespread
implementation of what works?
 How do we sustain evidence based practice?
Practice-Based Research Networks
(PBRNs)
36 new PBRN grants awarded in 2002
19 PBRN grants awarded in 2000
Strategic Advantages: Size and
Breadth
IDSRN’s 9 consortia
include:
 Over 50 million patients
 Majority of US
physicians and acute
inpatient facilities
 >2000 outpatient clinics
 Long-term care, rehab,
dental facilities
 Home health agencies
Priority Areas in Both Reports - 1
 Cancer
 Chronic kidney disease
 Diabetes
 Heart disease
 HIV/AIDS
 Maternal and child health
 Mental illness-depression
 Respiratory illness (e.g., asthma, flu)
Priority Areas in Both Reports - 2
 Nursing home and home health
 Patient safety
 Timeliness
 Patient centeredness
 Resource consumption
What Will Be the Response
to the First Reports?
 WOW!! Extensive media coverage
 We need more – measures
 WHAT NOW??
Issues
 Will public reporting  improvements?
 Literature to date suggests modest albeit
growing impact on consumers’ decisions
 Apparently tangible impact on providers
 “Paying for quality” – YES, but HOW??
 If quality improvement is local, what is
Federal role?
Improving Quality and Safety
“We need to make the right thing
the easy thing…”
Mark Chassin, MD
October 12, 2000
Outline
 The imperative to improve
 The challenges of creating &
applying “Useable Knowledge”
 Opportunities and challenges
 Final thoughts
Growing Impatience ….
 Precision and consensus regarding
management of (‘X’) greatly exceeds
translation into practice
 Most clear successes of translating research
into practice have focused on underuse of
effective treatments; less focus on misuse
and overuse
 Next frontiers: linking incentives with
improvement; IT; leadership
HSR: The Future
 Increased emphasis on research input to
health care transformation
 Clear focus on value for health care $$
 Positioned as science partner for
change
 Active promotion of quality improvement,
innovation and learning
How HSR Could Evolve
 Proposed studies that do not involve all
stakeholders are considered ‘amusing’
 Proposed studies that do not include an
explicit and compelling plan for
incorporation into practice are not
funded
 Patients are central to conduct and
review of research: “Nothing about me
without me”
We Need YOU
“Physician-Researchers
Needed to
Get Cures Out of Rat’s Cage”
Begley S. (Science Journal) 2003, April 25. Wall St.
Journal
Practice and Organizational
Challenges
 Information problems
 Variation in individual clinical




decisions
Stress
Inertia
Readiness to change
Need for clinical policies
Questions in Search of Answers
 Linking knowledge development to
policy levers (e.g., payment;
regulation): role of ‘demonstrations’
 When is “good enough”?
 Vocabulary and pathways for
translation of knowledge-based
interventions under-developed
 Concurrent -- or sequential -evaluation and translation?
Percent of Americans Saying
“I Have A Chronic Condition”
66%
70%
58%
60%
50%
35%
40%
30%
20%
24%
15%
10%
0%
18-29
30-39
40-49
Age
50-64
65+
Source: Chronic Illness and Caregiving Survey, Harris 2000
Intellectual Challenges
 Different kinds of research questions and
methods
–
–
–
–
–
–
–
Research synthesis
Clinical quality improvement
Moving systems
Provider-centered
Systems-centered
“Spread”/diffusion
If NOT secondary analysis of data sets or (often)
RCTs – then what?
 Different measures of success
Implications for Academic
Medical Centers
 Imperative to improve: challenging




definitions of « research »
Tension between "1000 flowers
blooming", a strategic approach to
research, and academic rewards
Career Paths
Education of students and residents
Academic Medical Centers as drivers of
change (?)