Advancing Excellence in Health Care

1. Advancing Excellence in Health Care Carolyn M. Clancy, MD Director January 21, 2005

2. Case Presentation - 1 • Paul, a 54 yo patient with diabetes and hypertension visits a primary care clinician for abdominal pain of 2-3 days duration. • Prior to his visit, he and his pc team leader have reviewed his symptoms and history by e-mail, and have examined possible causes by going to the PC Navigator, a system that has been developed to improve diagnosis and management of patients with undifferentiated symptoms.

3. Case Presentation - 2 • Paul’s pc team has also reviewed Paul’s recent entries to the jointly held electronic medical record. • A diabetic for 10 years, Paul manages his condition with diet and exercise, after several bumpy years on insulin. His self-management is supplemented by e-mail consultations prn.

4. Case Presentation - 3 • When Paul and his clinician meet -- at his convenience -- they discuss his options and agree on a diagnostic test, after reviewing possible outcomes of the test and options. The test is scheduled for that day. • Before leaving the practice, Paul leads a group visit at which there are several medical students -- required to attend to learn from patients about chronic illness management.

5. Case Presentation - 4 • The patients in the group visit provide feedback to the students about how they can enhance patients’ skills in self management. • Paul then gets his diagnostic test, and before the end of the day his primary care clinician has e-mailed the results and suggested next steps.

6. Overview • About AHRQ: The Evidence Agency • Health Care 2005: Current Context • Recent Findings and Directions • Future Challenges

7. Mission Statement: AHRQ The mission of the Agency for Healthcare Research and Quality is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

9. AHRQ RESEARCH FOCUS:HOW IT DIFFERS • Patient-centered, not disease-specific • Dual Focus -- Services + Delivery Systems Effectiveness research focuses on actual daily practice, not ideal situations (“efficacy”) • AHRQ mission includes production and use of evidence-based information

10. Purchase health care Provide health care Assure access for vulnerable populations Monitor health care quality Regulate health care markets Inform health care decision- makers Support acquisition of new knowledge Support development of health technologies and practices Develop the health care workforce Convene stakeholders Ten Roles of Government in Health Care Quality

11. Overview • About AHRQ: The Evidence Agency • Health Care 2005: Current Context • Recent Findings and Directions • Future Challenges

12. Driving Forces • Rising health care expenditures • Aging and increasingly diverse population • Consumerism • Biomedical advances: public and professional expectations • Growing influence of purchasers

13. Current Environment • Unprecedented opportunities and innovations • Rising health care costs • Consumer and purchaser demand for value • Limited information on performance – and how to improve • Numerous initiatives to address one piece of the puzzle

14. 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 Don’t 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).

15. Personal Experience Did the error have serious health consequences, minor health consequences, or no health consequences at all? Have you been personally involved in a situation where a preventable medical error was made in your own medical care or that of a family member? Serious health consequences Yes No Minor health consequences No health consequences Don’t Know 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).

16. Role Of IT In Reducing Medical Errors Percent who say… Have you or a family member ever created your own set of medical records to ensure that you and all of your health care providers have all of your medical information? The coordination among the different health professionals that they see is a problem Yes They have seen a health care professional and noticed that they did not have all of their medical information They had to wait or come back for another appointment because the provider did not have all their medical information Don’t know No 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).

17. Pace of Change VariesAcross Care Settings • Of 98 measures with trend data, 88 can be mapped to care settings • Some improvement seen in all settings • However, change in performance varies across settings

18. Major Opportunities for Improvement • 81% of Medicare pneumonia patients get blood cultures before antibiotics • 68% get the right antibiotics • 63% get their first antibiotic in a timely manner • Yet, only 30% get all of three recommended interventions

20. The proportion of adults with diabetes who received all five recommended diabetic services (MEPS, 2000-2001)

21. HHS: Recent Developments • Nursing Home Initiative • Home Health Care Initiative* • AHA-JCAHO-VHA …. Hospital reporting initiative* • Patient experience in hospitals* • Bar coding • IT standards (*)

22. Patient Safety: Achieving A New Standard For Care “Americans should be able to count on receiving health care that is safe……..This requires, first, a commitment by all stakeholders to a culture of safety, and, second, improved information systems.” Institute of Medicine, 2003

23. Issues • Will public reporting  improvements? • Paying for quality – YES, but HOW?? • Pay for quality – OR use of HIT? • How to align measurement and improvement efforts?

24. Overview • About AHRQ: The Evidence Agency • Health Care 2005: Current Context • Recent Findings and Directions • Future Challenges

25. AHRQ Research Study: Identifying Successful Hospital Quality Improvements • Major finding: Hospitals that were more likely to prescribe beta-blockers shared similar characteristics: • Solid support from their hospital administration • Strong physician leadership • Shared goals of improving medical practice • Effective way of monitoring progress • Conducted by Yale University School of Medicine E Bradley, E Holmboe, J Mattera, et al., A Qualitative Study of Increasing B-Blocker Use After Myocardial Infarction, Journal of the American Medical Association, May 23, 2001

26. AHRQ Research Study: Sleep Deprivation and Safety • Major Finding: Serious medical errors fell significantly when medical interns’ work schedule was reduced from 30-hour-in-a-row shifts and when continuous work schedules were limited to 16 hours 36% more serious medical errors 21% more serious medication errors CP Landrigan, JM Rothschild, J W Cronin, et al., Effective of reducing interns’ work hours on serious medical errors in intensive care units, NEJM, October 28, 2004

27. AHRQ Research Study: OutpatientPrescription Drug-Related Injuries in Elderly • Major Finding: Outpatient Medicare patients suffered as many as 1.9 million drug-related injuries a year due to medical error or adverse drug events (ADE) not caused by errors • Why did preventable ADEs occur? • 58% prescribing medications • 61% monitoring medications • 20% patients adhering to medication instructions

28. Intermountain Health Care QI effort on CVD Results: 90% prescription rates 27% decrease in unadjusted absolute death rates HIT + Systems approach Can Make a Difference Proportions of patients receiving the appropriate discharge prescriptions Lappe JM et. al., Ann Intern Med 2004;141:446-453

29. Hospital Survey on Patient Safety Culture • New tool helps hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units • Includes survey guide, survey, and feedback report template to customize reports • AHRQ partnership with Premier, Inc., Department of Defense, and American Hospital Association • www.ahrq.gov/qual/hospculture/ or e-mail to ahrqpubs@ahrq.gov

30. Key Implementation Activities – QualityTools

31. National Health Plan Learning Collaborative to Reduce Disparities and Improve Quality • Public/private partnership to reduce disparities in health care for people with diabetes and other conditions • Over next 3 years, collaborative will test ways to improve collection and analysis of data on race and ethnicity and match data to existing quality measures to close gap in care • Sponsored by nine of Nation’s largest health insurance plans, and other organizations

32. Overview • About AHRQ: The Evidence Agency • Health Care 2005: Current Context • Recent Findings and Directions • Future Challenges

33. The Future Delivery System:Baseline Assumptions • Today’s students will encounter a dramatically different health care system • Basic premise of health insurance is evolving • System fragmentation will increase • Consumer-directed options will increase  increased price sensitivity and need for information • “Disruptive challenges” (BT, SARS, ???) a daily reality: the “new normal”

34. What We Have Learned • 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

35. Implementation of Research Findings: Debunked Assumption Question Hypothesis Study Publications Changes in practice

36. A Flawed Model • Receptor sites are “assumed” • Decisionmaking is not-linear: evidence is only part of the “solution” • Broad dissemination  modest effects

37. Improving Quality and Safety “We need to make the right thing the easy thing…” Mark Chassin, MD October 12, 2000

40. If HIT is Such a Great Idea ….. • Generalizability of promising findings open to question • Even successful hospitals use multiple vendors – and have internal interoperability challenges • Implementation is “challenging” • Physicians are independent contractors

41. FY04: Transforming Healthcare Quality through IT • Planning : up to $7M • assist healthcare systems and their partners in planning for activities that will lead to successful HIT implementation • Implementation : up to $24M • support organizational and community-wide implementation and diffusion of HIT • Value : up to $10M • assess the value derived from the adoption, diffusion, and utilization of HIT

42. State and Regional Demonstrations in Health IT • Identify and support statewide data sharing and interoperability activities on a discrete state or regional level. • Approximately 5 states • $25M over 5 years • “Test Beds” to produce demonstrable improvements • Improvements must be sustainable beyond end of contract and applicable to other states or regions

43. Critical Challenges • Common data elements and definitions; build capacity to make improvements • Linking implementation to requisite clinical transformation • Avoiding the “NIH” syndrome • Aligning incentives and rewarding success • Making it easy

44. Contemporary Challenges • Scientific basis for safe and appropriate use of diagnostic, therapeutic and preventive interventions -- from and to the point of care • Quality improvement as science • Translating promising educational models into large-scale improvements in care and outcomes

45. What is Section 1013? • To improve the quality, effectiveness and efficiency of health care delivered through Medicare, Medicaid and the S-CHIP programs • $50 million is authorized in Fiscal Year 2004 for the Agency for Healthcare Research and Quality (AHRQ) to conduct and support research with a focus on outcomes, comparative clinical effectiveness and appropriateness of health care items and services (including pharmaceutical drugs), including strategies for how these items and services are organized, managed and delivered

46. What is Section 1013? • By June 2004, the Secretary shall establish an initial list of research priorities (including those related to prescription drugs) • Priorities may include health care items and services which impose a high cost on Medicare, Medicaid or S-CHIP, including those that may be underutilized or over utilized

47. SHARED DECISION MAKING:DECISIONS AND OUTCOMES Patient Alternative 1 Alternative 2

48. PREQUISITES FOR CHANGE • Integrating strategy to make existing information accessible with requisite data collection • Expected differences in patient experiences (e.g., disparities associated with race, ethnicity and SES) • How to present information in usable formats (different versions of “the answers” will be more effective for different audiences)

49. Focus: Research and Policy • Describing problems – policy window • Developing and testing solutions to problems • Evaluating solutions • Interaction with stakeholders and decision makers is not optional

50. Supply-Side Research Paradigm • Research world: • Questions • Hypothesis • Study • Userworld: • Many needs • Beliefs & interests • Decision processes Publication 34 c2 The winding road to a receptor site