Comparative Effectiveness: Moving from Research to Practice

1. Comparative Effectiveness: Moving from Research to Practice Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality The 25th Annual Rosalynn Carter Symposium on Mental Health Policy The Carter Center – November 6, 2009

2. Treatment for Mental Health Adults with a mood, anxiety or impulse control disorder in the last 12 months who received minimally adequate treatment, 2001-2003 • Nearly 30% of adults with mood, anxiety or impulse control disorders received minimally adequate treatment • There were no significant differences by age AHRQ 2008 National Healthcare Quality Report

3. By Race & Education Adults with a mood, anxiety or impulse control disorder in the last 12 months who received minimally adequate treatment, 2001-2003 • % of adults who received minimally adequate treatment was lower among Blacks and Hispanics, with Hispanics having the lowest % of all groups • % was also lower among individuals with less than a high school education and high school graduates, compared with those with some college education AHRQ 2008 National Healthcare Disparities Report

4. Treatment for Depression Adults with a major depressive episode in the last 12 months who received treatment for depression, by race, ethnicity, income and education, 2006 • % of adults with major depressive episode who received treatment was significantly lower for Blacks than for Whites (58.9% and 71.1%) and lower for Hispanics than for non-Hispanic Whites (51.8% and 73.3%) • There were no statistically differences by income or education level AHRQ 2008 National Healthcare Disparities Report

5. Current Challenges • Concerns about health spending – about $2.3 trillion per year in the U.S. and growing • Pervasive problems with the quality of care that people receive • Translating scientific advances into actual clinical practice • Translating scientific advances into usable information for clinicians and patients • A health care system that has been isolated for people with mental health issues for far too long

6. CER: Moving from Research to Practice • AHRQ: New Resources, Ongoing Priorities • Comparative Effectiveness and The American Reinvestment and Recovery Act of 2009 • Translating Science into Real-World Applications

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

8. 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

9. New: Mental Health Research Findings • Compendium of recent mental health research projects funded by AHRQ • Expanded funding for improving mental health care through health IT and primary care delivery • The Agency has also developed a new focus on the complex patient http://www.ahrq.gov/research/mentalhth.pdf

10. Recent Legislation for Parity in Mental Health • The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 • Effective January 1, 2010, designed to produce parity in private employer-sponsored health plans for organizations with more than 50 employees (passed as part of the American Reinvestment and Recovery Act of 2009) • The Medicare Improvements for Patients and Providers Act of 2008 • Mental health parity is gradually phased in between 2010 and 2014 • Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) • Requires mental health parity for states that offer mental health or substance abuse services in CHIP plans

11. AHRQ 2009: New Resources, Ongoing Priorities • $372 million for AHRQ in FY ‘09 budget • $37 million more than FY 2008 • $46 million more than Administration request • FY 2009 appropriation includes: • $50 million for comparative effectiveness research, $20 million more than FY 2008 • $49 million for patient safety activities • $45 million for health IT

12. 21st Century Health Care AHRQ’s Role in Comparative Effectiveness Using Information to Drive Improvement: Scientific Infrastructure to Support Reform Lead federal funding Aggregate best evidence to inform complex learning and implementation challenges Engage private sector Increase knowledge base to spur high-value care

13. CER Outputs at AHRQ • Research reviews: Comprehensive reports that draw on scientific studies to make head-to-head comparisons of treatments • Summary guides: Short, plain-language guides that summarize research reviews and are tailored to different audiences – clinicians, consumers and policymakers • New research reports: Fast-turnaround reports that draw on health care databases, electronic patient registries and other resources to explore practical questions http//:effectivehealthcare.ahrq.gov

14. Comparative Effectiveness and the Recovery Act • The American Recovery and Reinvestment Act of 2009 includes $1.1 billion for comparative effectiveness research: • AHRQ: $300 million • NIH: $400 million (appropriated to AHRQ and transferred to NIH) • Office of the Secretary: $400 million (allocated at the Secretary’s discretion) Federal Coordinating Council appointed to coordinate comparative effectiveness research across the federal government

15. Definition: Federal Coordinating Council • CER is the conduct and synthesis of research comparing the benefits and harms of various interventions and strategies for preventing, diagnosing, treating, and monitoring health conditions in real-world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers about which interventions are most effective for which patients under specific circumstances.

16. Definition: IOM • Comparative effectiveness research (CER) is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers and policy makers to make informed decisions that will improve health care at both the individual and population levels. National Priorities for Comparative Effectiveness Research Institute of Medicine Report Brief June 2009

17. Horizon Scanning Research Training Evidence Synthesis Evidence Need Identification Evidence Generation Career Development Dissemination & Translation Conceptual Framework Stakeholder Input & Involvement

18. 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 AHRQ’s Priority Conditions for the Effective Health Care Program

19. IOM’s 100 Priority Topics • Initial National Priorities for Comparative Effectiveness Research(June 20, 2009) • Topics in 4 quartiles; groups of 25. • Includes several priorities for mental health, including: • Treatment approaches, such as integrating mental health care and primary care • Training of primary care physicians in primary care mental health and co-location systems of primary care and mental health care on outcomes including depression, anxiety and cost • Patient decision support tools on informing diagnostic and treatment decisions, and including patients with mental health problems Report Brief Available At http://www.iom.edu

20. AHRQ Operating Plan for Recovery Act’s CER Funding • Stakeholder Input and Involvement: To occur throughout the program • Horizon Scanning: Identifying promising interventions • Evidence Synthesis: Review of current research • Evidence Generation: New research with a focus on under-represented populations • Research Training and Career Development: Support for training, research and careers

21. Translating the Science into Real-World Applications • Examples of Recovery Act Evidence Generation projects with funding available/pending: • Clinical and Health Outcomes Initiative in Comparative Effectiveness (CHOICE): First coordinated national effort to establish a series of pragmatic clinical comparative effectiveness studies ($100M) • Request for Registries: Up to five awards for the creation or enhancement of national patient registries, with a primary focus on the 14 priority conditions ($48M) • DEcIDE Consortium Support: Expansion of multi-center research system and funding for distributed data network models that use clinically rich data from electronic health records ($24M)

22. Additional Proposed Investments • Supporting AHRQ’s long-term commitment to bridging the gap between research and practice: • Dissemination and Translation • Between 20 and 25 two-three-year grants ($29.5M) • Eisenberg Center modifications (3 years, $5M) • Citizen Forum on Effective Health Care • Formally engages stakeholders in the entire Effective Health Care enterprise • A Workgroup on Comparative Effectiveness will be convened to provide formal advice and guidance ($10M)

23. Health IT and Comparative Effectiveness Research • As with comparative effectiveness research, health IT is a useful tool in a much larger toolkit • AHRQ has invested more than $260 million in health IT contracts and grants • More then 150 communities, hospitals, providers and health care systems in 48 states

24. AHRQ Health IT Initiatives • Examples, Ambulatory Safety and Quality (ASQ) Program • Pharmaceutical Safety Tracking: Children’s Research Institute, Columbus, OH • Monitoring medication adherence in an urban mental health system serving a primarily Medicaid population • Improving Outcomes through Ambulatory Care Coordination: Nebraska Behavioral Health Information Network • An HIE focused on coordination of care for individuals with chronic mental illness • A Personal Health Record (PHR) for Mental Health Consumers: Emory University • Adapts existing electronic PHR for needs of people with a serious mental disorder and one or more chronic conditions

25. CER and Innovation • CER will enhance the best and most innovative strategies • Can open up new populations for which something can be useful in • Can bring early attention to potential issues

26. Comparative Effectiveness Challenges/Opportunities Anticipating downstream effects of policy applications Eliminating uncertainty about best practices involving treatments and technologies Making sure that comparative effectiveness is "descriptive, not prescriptive” Creating a level playing field among all stakeholders, including patients and consumers Adopting a more integrated approach to achieving high quality health care Using the same evidence-based information to make different care decisions based on the characteristics, needs, etc., of the individual

27. Where to From Here? • Timing:Significant support for and interest in comparative effectiveness research • The mission:Address gaps inquality and resolve conflicting or lack of evidence about most effective treatment approaches • Words of wisdom:“In theory, there is no difference between theory and practice. In practice, there is.” – Yogi Berra

28. Thank You www.ahrq.gov http//:effectivehealthcare.ahrq.gov www.hhs.gov/recovery