Transcript 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
Access
n=number of core measures
Quality
2007 National Healthcare Quality and Disparities Reports
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’
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
Coordination of Care
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
Future Trends in Health Care
Quality and Access
 Knowledge Creation
 Synthesis & Dissemination
 Translating Research Into
Practice
 21st Century Health Care
 Q&A
AHRQ’s 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
Promote Collaboration
and Dissemination
Four key domains:
• Patient-centered care
• Medication management
• Integration of decision
support tools
• Enabling quality
measurement
• 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 Safety
Ambulatory
Patient Safety
Organizations
 New Patient
 Safety & Quality Measures, Safety Grants
Drug Management and
Patient-Centered Care
 Patient Safety Improvement
Corps
Medical Expenditure
Panel Surveys
Effective Health
Care Program
 Comparative
Effectiveness Reviews
 Comparative Effectiveness
Research
 Clear Findings for
Multiple Audiences
Other Research &
Dissemination Activities
 Visit-Level Information on  Quality & Cost-Effectiveness, e.g.
Medical Expenditures
 Annual Quality &
Disparities Reports
Prevention and Pharmaceutical
Outcomes
 U.S. Preventive Services
Task Force
 MRSA/HAIs
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
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 19942004
– 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 2007*
 Uninsurance is a major
barrier to reducing
disparities
100%
Better
Same
Worse
1
75%
 Uninsured individuals
do worse than privately
insured individuals on
almost 90% of quality
measures and on all
access measures
50%
8
6
Quality
(9CRM)
Access
(6CRM)
25%
0
*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
Average
Weak
Strong
Very
Weak
Very
Strong
Performance Meter: All Measures
= Most Recent Year
= Baseline Year
2007 National Healthcare Quality Report, State Snapshots
Measuring Massachusetts
Health Care Quality
Performance
Measure
% of heart attack patients administered a
beta-blocker within 24 hours of admission,
all payers
% of adults age 18 and over who reported
that they always got appointment for
illness/injury as soon as they wanted,
Medicaid
% of Cancer deaths per 100,000 population
per year
Better than
average
Average
Worse than
average
2007 National Healthcare Quality Report, State Snapshots
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
A. Evidence synthesis (EPC program)
–
–
Systematically reviewing, synthesizing, comparing existing
evidence on treatment effectiveness
Identifying relevant knowledge gaps
B. Evidence generation (DEcIDE, CERTs)
–
–
Development of new scientific knowledge to address
knowledge gaps.
Accelerate practical studies
C. Evidence communication/translation
(Eisenberg Center)
–
–
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
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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
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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
Brigham and Women’s Hospital
Health IT
Children’s Hospital - Cincinnati
Pediatric care
Duke University Medical Center
Therapies for heart and blood vessel disorders
HMO Research Network
Multiple population-based delivery systems
Houston Area CERT
Consumer education and patient adherence
KP Ctr for Health Research, Portland
Coordinating Center
Rutgers University
Mental health therapeutics
University of Alabama - Birmingham
Musculoskeletal disorders
University of Arizona & C-Path
Drug interactions/Women’s health
University of Chicago
Clinical/economic issues in hospital settings
University of Illinois - Chicago
Prescribing tools, including formularies
University of Iowa
Elderly and aging
University of Pennsylvania
Anti-infective use and resistance
Vanderbilt University
Therapeutic issues in Medicaid and VA system
Weill Medical College - Cornell
Therapeutic medical devices
DEcIDE Research Network*
U of Illinois
Chicago
U of Pennsylvania
Philadelphia, PA
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
*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
RTI International
RTP, NC
U of North Carolina
Chapel Hill, NC
Vanderbilt U
Nashville, TN
New Solicitations through
the DEcIDE Network
1) 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
2) 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)
3) 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 information
 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 (CDCfunded)
– BRCA Testing in Breast and Ovarian Cancers, and Screening for
Hereditary Hemochromatosis (USPSTF recommendations)
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
AHRQ Health IT
Investment: $260
Million
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
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 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
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
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
• 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 evidencebased practice and
decision-making
 Generate comparative
effectiveness reviews
on medications, devices
and other interventions
 User-driven, with public
and private-sector
partners
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
New USPSTF
Clinical Recommendations
– Screening for Prostate Cancer
– Screening for Hearing Loss in all Newborns
– Screening for Bacterial Vaginosis in
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–
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Pregnancy
Screening for Illicit Drug Use
Screening for Chronic Obstructive
Pulmonary Disease
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 groups:
– Consumers
– Health care providers
– Policymakers
AHRQ Comparative
Effectiveness Research
http//:effectivehealthcare.ahrq.gov
Effective Health Care Program:
Comparative Effectiveness
Reviews in Progress
Condition
Topic
Diabetes
Comparative Effectiveness, Safety, and
Indications of Insulin Analogues in Premixed
Formulations for Adults with Type 2 Diabetes
Heart and Blood
Vessel
Conditions
Cancer
Comparative Effectiveness of Medical
Therapies for Stable Ischemic Heart Disease
Breathing
Conditions
Comparative Effectiveness of Anticholinergic
Medications in Patients with Chronic
Obstructive Pulmonary Disease (COPD)
Research
Methodology
A Qualitative Study to Understand Barriers to
Conducting Cluster Randomized Trials
Core Needle Breast Biopsy and Surgical
Excision Biopsy for Diagnosing Breast Lesions
Emerging Methods in
Comparative Effectiveness & Safety
 Variation in methods among
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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
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
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
(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
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
Quality Standards
Price Standards
Design systems to collect quality
of care information and define
what constitutes quality health care
Aggregate claims information to
enable cost comparisons between
specific doctors and hospitals
Interoperability
Incentives
Set common technical standards
for quick and secure
communication and data exchange
Reward those who provide and
purchase high-quality and
competitively priced 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 measurement
– 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, patientfocused enterprises
Evidence is
continually refined
as a by-product of
care delivery
21st Century
Health Care
Information and
evidence transform
interactions from
reactive to
proactive (benefits
and harms)
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 “3T’s” Road Map to Transforming U.S. Health Care
Basic biomedical
science
T1
Clinical efficacy
knowledge
Key T1 activity to test
what care works
Clinical efficacy research
T2
Clinical effectiveness
knowledge
Key T2 activities to test
who benefits from
promising care
Outcomes research
Comparative effectiveness
Research
Health services research
T3
Improved health
care quality and
value and
population health
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.”
Pronovost Study
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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
Connecting ‘Achievability’
and Reliability…
 A robust health care
system must include
capacity for:
– Rapid translation of
beneficial advances or
breakthroughs
– 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