Evidence-Based System Transformation: Research, Physician Education and New Models of Care

Evidence-Based System Transformation: Research, Physician Education and New Models of Care Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality 6th Annual JPS Research Day JPS Health Network Via Videoconference – June 1, 2012

Research that Focuseson Patient Outcomes Patient-centeredness: The final frontier? Patient-centeredness may be the most challenging of all six domains of quality, because it is so difficult to define and measure But, it is also likely the most important, because it includes elements of all other domains

Innovation in an Era of Reform:Implications for Research AHRQ Overview The Quality and Disparities Conundrum Projects to Improve Quality The Right Treatment for the Right Person at the Right Time Recent Legislation 21st Century Health Care

HHS Organizational Focus NIH AHRQ CDC Long-term and system-wide improvement of health care quality and effectiveness Population health and the role of community-based interventions to improve health Biomedical research to prevent, diagnose, and treat disease

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

AHRQ Priorities Patient Safety • Health IT • Patient SafetyOrganizations • Patient Safety Grants (incl. simulation) AmbulatoryPatient Safety Effective HealthCare Program • Comparative Effectiveness Reviews • Patient-Centered Outcomes Research • Clear Findings for Multiple Audiences • Safety & Quality Measures, Drug Management & Patient-Centered Care • Survey of Patient Safety Culture • Diagnostic Error Research Other Research & Dissemination Activities Medical ExpenditurePanel Surveys • Quality & Cost-Effectiveness, e.g.,Prevention & PharmaceuticalOutcomes • U.S. Preventive ServicesTask Force • MRSA/HAIs • Visit-Level Information on Medical Expenditures • Annual Quality & Disparities Reports

Priority Populations • Inner city and rural areas (including frontier areas) • Racial and ethnic minority groups • Low income groups • Women and children • The elderly • Individuals with special health care needs, including individuals with disabilities and those who need chronic care or end-of-life health care

2011 Reports:Quality and Disparities • Overall, improvement in the quality of care remains suboptimal and access to care is not improving • Few disparities in quality are getting smaller and almost no disparities in access are getting smaller • Particular problem areas include cancer screening and management of diabetes • Quality of care varies not only across types of care but also across parts of the country

Progress is Uneven Toward National Priority Areas • 2011 Findings: • Health care quality and access are suboptimal, especially for minority and low-income groups • Quality is improving; access and disparities are not • Urgent attention needed to ensure continued improvement in quality and progress on reducing disparities for services, geographic areas and populations, including: • Diabetes care and adverse events • Disparities in cancer screening and access to care • States in the South Reports include evidence of progress toward priorities identified in National Quality Strategy and HHS Plan to Reduce Racial and Ethnic Health Disparities

From the First NHDR Until Now,What Has Changed? Inequality in quality exists Disparities come at a personal and societal price Differential access may lead to disparities in quality Opportunities to provide preventive care are frequently missed Improvement is possible • Key findings in the first Disparities Report “Perhaps the most important limitation of this first NHDR is the scarcity of information about why disparities in health care exist.”

Disparities in Health Care: Determinants Socioeconomic status Discrimination Culture Violence Education Employment Social Determinants Health Care Determinants • Access • Availability • Quality • Insurance • Cost

Suboptimal Quality and Access, Especially for Minority and Low Income Groups • Disparities are common • Adults over age 65 received worse care than adults ages 18-44 for 39% of measures • Blacks received worse care than Whites for 41% of quality measures • Poor people received worse care than high-income people for 47% of quality measures Fig H. 1. Number and proportion of all quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Improvements in Acute Treatment, Work Remains on Prevention, Chronic Disease • Quality improvement is uneven • About 60% of process measures and half of outcome measures showed improvement • 77% of measures related to treatment of acute illness or injury improved. However, only half of measures related to prevention/chronic disease management got better Fig. H. 7. Number and proportion of measures that are improving, not changing, or getting worse

Texas: Overall Care Quality vs. All States Average Weak Strong Very Weak Very Strong Performance Meter: All Measures =Most Recent Year = Baseline Year 2010 National Healthcare Quality Report, State Snapshots

Texas Snapshot: Overall Health Care Quality Measures 2010 National Healthcare Quality Report, State Snapshots

The Journey from Knowledge to Practice • What we know: • A long journey • Holds unexpected surprises • Not just one way to get there • Bottom line: Implementing best practices requires investigating how clinical findings can be most effectively understood, adapted and used to improve patient care

Partnership for Patients: HHS Public-Private Initiative By end of 2013: • Goal: 40% decrease in instances of hospital patients acquiring preventable conditions, including: • Central line-associated bloodstream infections • Catheter-associated urinary tract infections • Surgical site infections • Ventilator-associated pneumonia • Pressure ulcers • Adverse drug events • Venous thromboembolisms • Injuries from falls • Injuries from obstetrical adverse events • Goal: 20% decrease in preventable readmissions due to complications during a transition from one care setting to another Funded by the Affordable Care Act www.healthcare.gov/center/programs/partnership/index.html

On The CUSP: Stop BSIPart of HHS Action Plan • As part of Action Plan, AHRQ funded $18 million national effort • Goal: Reduce CLABSI rates to < 1 per 1,000 central line days across all hospitals in project • Partnership with JHU Quality and Safety Group, Health Research and Educational Trust (AHA affiliate), and Michigan Hospital Assn.’s Keystone Center

Changing Clinical PracticeOn the CUSP: Stop BSI Project • To date, 45 state hospital associations and 1 other umbrella group have committed to leading project in their states • Groups have recruited more than 1,100 hospitals and 1,800 hospital teams to participate • Twenty-three states began project in 2009, 14 states and District of Columbia began during 2010, and 9 States and Puerto Rico began efforts in 2011

Changing Clinical PracticeOn the CUSP: Stop BSI Project • Among hospital units that began the protocol in 2009 and 2010, CLABSI rates have decreased by an average of 41% (from 1.94 to 1.18 infections per 1,000 central line days)* • Improvement occurred in the 10 to 12 months following introduction of the protocol • Hospitals that reported zero CLABSI rates increased from 29% at baseline to 68% at 1 year following intervention *Eliminating CLABSI: A National Patient Safety Imperative: National On the CUSP: Stop BSI Project Report, September 2011

New Resource for Care Coordination Measures • Identifies more than 60 measures for assessing care coordination • Includes perspectives of patients and caregivers, health care professionals and health system managers • Also useful as a tool for locating gaps in existing measures that can be addressed in future work www.ahrq.gov/qual/careatlas

AHRQ Health IT Strategic Goals • Improved health care decision-making • Support patient-centered care

AHRQ Health IT Investment: $300 Million AHRQ Health ITResearch Funding • Long-term agency priority • AHRQ has invested more than $300 million in contracts and grants • More than 200 communities, hospitals, providers, and health care systems in 48 states

Patient-Focused Care:The Challenge of Many Options

The Only Questions That Matter Is this treatment right? Is this treatment right for me?

Patient-Centered Outcomes Research AHRQ’s Effective Health Care Program created by Medicare Modernization Act of 2003 From 2005-2009, AHRQ received $129 million from Congress for patient-centered outcomes research plus $300 million from ARRA Program has published more than 100 products, including guides for clinicians and consumers, with plans for 75 more over the next two years Emphasis on user-driven synthesis of existing evidence and creation of new evidence

EHC Summary Guides Consumers Policymakers Clinicians Summarize research review findings on the benefits and harms of different treatment options. Provide useful background on health conditions. Medication guides contain basic wholesale price information.

Patient Protection and Affordable Care Act • Best kept secret: multiple quality provisions • Data collection, analysis and public reporting • Standardized approaches to data on race, ethnicity, disability status, and language • Focus on eliminating disparities • National Quality and Prevention strategies

Patient-Centered Outcomes Research Institute • Created by the Patient Protection and Affordable Care Act • Institute must include research that takes into account the potential for differences in the effectiveness of treatments, services, etc., within various subpopulations: • Racial and ethnic minorities • Gender, age • Individuals with chronic conditions • Genetic and molecular sub-types • Quality of life preferences • These subpopulations must be included as research subjects

National Quality Strategy:Three Broad Aims Created Under the Affordable Care Act Better Care Improve the overall quality, by making health care more patient-centered, reliable, accessible and safe Improve population health by supporting proven interventions to address behavioral, social and environmental determinants of health, in addition to delivering higher-quality care Healthy People/ Healthy Communities Affordable Care Reduce the cost of quality health care for individuals, families, employers and government www.healthcare.gov/center/reports/quality03212011a.html

National Quality Strategy:Six Priorities • Making care safer by reducing harm caused in the delivery of care • Ensuring that each person and family is engaged as partners in their care • Promoting effective communication and coordination of care • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease • Working with communities to promote wide use of best practices to enable healthy living • Making quality care more affordable for individuals, families, employers and governments by developing and spreading new health care delivery models

NQS 2012 Annual Progress Report to Congress • Released April 30th • Details the implementation of the National Quality Strategy over the past year • Establishes key measures and goals to measure progress in improving quality

Translating the Science intoReal-World Applications • Examples of Recovery Act-funded Evidence Generation Projects by AHRQ: • Clinical and Health Outcomes Initiative in Comparative Effectiveness (CHOICE):First coordinated national effort to establish a series of pragmatic clinical comparative effectiveness studies • Request for Registries:Up to five awards to create or enhance national patient registries, with a primary focus on the 14 priority conditions • 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

National Action Plan to Improve Health Literacy • Launched in May 2010 to engage organizations, professions, policymakers, communities, consumers and others. Calls for: • Increased use of plain language in patient handouts, medical forms, health web sites and recommendations to the public • Improved patient-provider communication • Better access to information to help low health literacy individuals make evidence-based health care decisions www.health.gov/communication/hlactionplan

AHRQ Health Care Innovations Exchange Web-based Repository of Cutting-Edge Service Innovations • Electronic learning hub for sharing innovations, bringing innovators and adopters together • Searchable database featuring successes and failures, expert commentaries, lessons learned • Designed to help “Agents of Change” improve quality www.innovations.ahrq.gov

AHRQ Training Objectives • Goal 1: Individuals: Foster the growth of the next generation of researchers and knowledgeable users of research • Goal 2: Diversity: Foster the institutional and individual diversity in the field of health services research • Goal 3: Science: Foster the development of an integrated science of health services research and refine its foundation

21st Century Health Care: Training • AHRQ allocated $20 million in Recovery Act funding alone for career development. Examples of AHRQ-funded training: • Ruth L. Kirschstein National Research Service Awards for Individual Predoctoral Fellowships to Promote Diversity in Health-Related Research • Mentored Research Scientist Development Awards • Mentored Clinical Scientist Development Awards • Summer Research Intern Program

Training and Education Opportunities • Education and career development grants and opportunities in health services research: • Mentored career enhancement in PCOR • PCOR infrastructure development • Institutional training • Health Services Research training • Individual post-doc fellowship awards

What Does It Really MeanTo Be ‘Patient-Centric?’

We Can See the Possibilities But We’re Not There Yet • Success means: • Learning from what we do every day • Putting that learning to work • Not assuming that learning more means we’re getting smarter and that will lead to improved quality

Thank You AHRQ Mission To improve the quality, safety, efficiency, and effectiveness of health care for all Americans AHRQ Vision As a result of AHRQ's efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest cost www.ahrq.gov

Evidence-Based System Transformation: Research, Physician Education and New Models of Care