PBRNs and ACTION: Accelerating the Implementation of Evidence-Based Healthcare

1. PBRNs and ACTION:Accelerating the Implementationof Evidence-Based Healthcare David Lanier, MD CP3 Cynthia Palmer, MSc CDOM

2. AHRQ Mission To improve the quality, safety, efficiency and effectiveness of healthcare for all Americans

3. Image is of a linear series of boxes showing progression from scientific evidence, to translation of the evidence into understandable and usable information, to the use of that information to facilitate health care decisions.Image is of a linear series of boxes showing progression from scientific evidence, to translation of the evidence into understandable and usable information, to the use of that information to facilitate health care decisions.

4. Challenges Passive diffusion/implementation of evidence takes too long Lengthy time requirements of funding through traditional grant mechanisms Historical delays in passage of annual Congressional appropriations Traditional (AHC) research settings not ideally suited for implementation/translational work

5. Ecology of Medical Care Updated Green, Yawn, Lanier. N Engl J Med 2001;344:2021-25 The Ecology of Medical Care by Green, Yawn, and Lanier, published in issue 344 of the New England Journal of Medicine in 2001, analyzes the place of care from a community perspective. The above image depicts a series of boxes representing data. Each box represents a subgroup of the largest box, which comprises 1000 persons of all ages. Population at risk: 1000 Persons reporting one or more health-related symptoms: 800 Persons who consider seeking health care: 327 Persons who visit a physician�s office: 217 Persons who visits a CAM provider: 65 Persons who visit a hospital outpatient clinic: 21 Persons who receive home health care: 17 Persons who visit an emergency department: 13 Persons who are in a hospital: 8 Persons who are in an academic health center: less than 1 The Ecology of Medical Care by Green, Yawn, and Lanier, published in issue 344 of the New England Journal of Medicine in 2001, analyzes the place of care from a community perspective. The above image depicts a series of boxes representing data. Each box represents a subgroup of the largest box, which comprises 1000 persons of all ages. Population at risk: 1000 Persons reporting one or more health-related symptoms: 800 Persons who consider seeking health care: 327 Persons who visit a physician�s office: 217 Persons who visits a CAM provider: 65 Persons who visit a hospital outpatient clinic: 21 Persons who receive home health care: 17 Persons who visit an emergency department: 13 Persons who are in a hospital: 8 Persons who are in an academic health center: less than 1

6. New Funding Mechanism Required Easy access to healthcare sites where most Americans receive care Targeted activities related to implementation of research evidence into practice Shorten the cycle of soliciting and funding projects Include funding for dissemination and spread of project findings

7. Master Task Order Contracts Identify/define groups eligible to carry out rapid turn-around task orders Award master contracts through open competition Awardees are pre-qualified to compete for specific task order work Each master contractor assured of being awarded at least one task order over life of contract

8. Task Orders Master contractor reports interests/strengths of network AHRQ defines the work to be done and the timeframe for completion (RFTO) Funding (ranging from $150,000 to >$2 million) from AHRQ and/or our Federal (e.g., CDC) or private (e.g. RWJF) partners Master contractors usually have <6 wks to respond to RFTO Responses peer-reviewed and award(s) made within 3-6 wks Typical task order completed within 6-30 mos

9. Two Master Contractor Programs Established Practice-Based Research Networks (PBRNs): networks composed of smaller (1-20 clinician) community-based primary care practices Accelerating Change and Transformation in Organizations and Networks (ACTION): composed of hospital systems, health plans, long-term care, other care-delivery systems

10. PBRNs Groups of ambulatory practices devoted principally to the primary care of patients, affiliated with each other and academic researchers in order to investigate questions related to community-based practice and to improve the quality of primary care.

11. Primary Care PBRNs Real-world primary care practices Clinicians include all primary care specialties (family medicine, general internal medicine, pediatrics, family nurse practitioners) Work with academic researchers to answer questions related to primary care practice or the delivery of primary care services Laboratories for effectiveness studies in office settings with competing demands for high quality care and greater efficiency/productivity Depend upon outside funding (grants, contracts) to support their work

12. Capacity 28 PBRNs identified in 1994 177 PBRNs identified in 2005 Headquartered in urban, suburban and rural areas 2,724 practices are affiliated with PBRNs located in all 50 states and Puerto Rico 16 million patients are affiliated with PBRNs Average of 198,112 patients per PBRN (range 1200 to 2.7 million)

13. The image depicted in the slide is a map of the Unite States of America showing the geographic distribution of PBRN and Practice locations. Each states has a certain number of red or blue dots. Each blue dot represents one PBRN and each red dot represents one practice affiliated with a PBRN. There are 2209 total practices. A full list of the PBRNs can be found at http://pbrn.ahrq.gov. The image depicted in the slide is a map of the Unite States of America showing the geographic distribution of PBRN and Practice locations. Each states has a certain number of red or blue dots. Each blue dot represents one PBRN and each red dot represents one practice affiliated with a PBRN. There are 2209 total practices. A full list of the PBRNs can be found at http://pbrn.ahrq.gov.

14. Why Is Primary Care Important to AHRQ? Majority of daily patient/clinician interactions occur in ambulatory settings Majority of prescriptions for medications written in ambulatory settings While growth of HMOs and large integrated healthcare systems has been dramatic, >50% of Americans still receive primary care services in smaller (3-10 clinician) practices Significant amount of care in these settings flies under radar of most national quality monitoring efforts

15. Consortia of Networks North Carolina Network Consortium (NCNC): UNC, Duke, Adolescent Research, Mecklenburg, Robeson County PRIME Net: RIOSNet, CaReNet, SERCN, SPUR-Net, CRN SNOCAP: High Plains, CaReNet, BIGHORN, AAFP-NRN ePCRN Consortium: MAFPRN, AAFP-NRN, Alabama, LA Net, OKPRN, Penn State, STARNet, South Florida, Buffalo

16. Individual Networks ACORN (Virginia Commonwealth) Irene (Iowa) OKPRN (Oklahoma) ORPRN (Oregon) PeRC (Children�s, Philadelphia) PPRNet (Univ South Carolina)

17. PBRN Task Order Contractors: Practices The image in the slide is a pie chart depicting the settings of the 2209 practice participating in networks. The breakdown is as follows: 34.6% of the practices are in urban settings 34.4% of the practices are in rural settings 31% of the practices are in suburban settings The image in the slide is a pie chart depicting the settings of the 2209 practice participating in networks. The breakdown is as follows: 34.6% of the practices are in urban settings 34.4% of the practices are in rural settings 31% of the practices are in suburban settings

18. PBRN Task Order Contractors: Age-Range of Patients The image in the slide is a box with 2 pie charts inside of it. The first pie chart is a breakdown of the 11,877,396 patients that are cared for by the PBRN, by age group. The second pie chart is a breakdown of the 281,421,906 people living in the Unite States as determined by the 2000 census, by age group. The purpose of the slide is to compare the 2 charts. Out of the PBRN patients 30% are young adults, 28% are older adults, 22% are children, and 20% are elderly. In the United Stated 36.9% of the population are young adults, 28.6% are children, 22% are older adults, and 12.4% are elderly. The image in the slide is a box with 2 pie charts inside of it. The first pie chart is a breakdown of the 11,877,396 patients that are cared for by the PBRN, by age group. The second pie chart is a breakdown of the 281,421,906 people living in the Unite States as determined by the 2000 census, by age group. The purpose of the slide is to compare the 2 charts. Out of the PBRN patients 30% are young adults, 28% are older adults, 22% are children, and 20% are elderly. In the United Stated 36.9% of the population are young adults, 28.6% are children, 22% are older adults, and 12.4% are elderly.

19. PBRN Task Order Contractors: Patient Race/Ethnicity The image in the slide is a box with 2 pie charts inside of it. The first pie chart is a breakdown of the 11,877,396 patients that are cared for by the PBRN, by race/ethnicity. The second pie chart is a breakdown of the 281,421,906 people living in the Unite States as determined by the 2000 census, by race/ethnicity. The purpose of the slide is to compare the 2 charts. Out of the PBRN patients 65% of them are Caucasian, 16% are Hispanic, 15% are African American, 4% are Native American, and 1% are categorized as other. In the United States 72% of the population is Caucasian, 12.5% is Hispanic, 12.3% is African American, .0.9% is Native American, and 3.6% are categorized as other. The image in the slide is a box with 2 pie charts inside of it. The first pie chart is a breakdown of the 11,877,396 patients that are cared for by the PBRN, by race/ethnicity. The second pie chart is a breakdown of the 281,421,906 people living in the Unite States as determined by the 2000 census, by race/ethnicity. The purpose of the slide is to compare the 2 charts. Out of the PBRN patients 65% of them are Caucasian, 16% are Hispanic, 15% are African American, 4% are Native American, and 1% are categorized as other. In the United States 72% of the population is Caucasian, 12.5% is Hispanic, 12.3% is African American, .0.9% is Native American, and 3.6% are categorized as other.

20. PBRN Task Order Contractors: Physician Provider Discipline The image in the slide is two pie charts comparing the disciplines of physicians enrolled in primary care PBRNs to disciplines of primary care physicians included in the AMA Masterfile. Family physicians make up a much larger percentage of PBRN physicians vs all primary care physicians (80% vs 43%). A lower percentage of general internal medicine physicians (9% vs 36.7%) and pediatricians (7% vs 20.1%) are represented in PBRNs compared to all primary care physicians in the U.S.The image in the slide is two pie charts comparing the disciplines of physicians enrolled in primary care PBRNs to disciplines of primary care physicians included in the AMA Masterfile. Family physicians make up a much larger percentage of PBRN physicians vs all primary care physicians (80% vs 43%). A lower percentage of general internal medicine physicians (9% vs 36.7%) and pediatricians (7% vs 20.1%) are represented in PBRNs compared to all primary care physicians in the U.S.

21. PBRN Task Orders To Date First award made in July, 2007 Twelve RFTOs released/funded to date Funding $4.7 million One project completed (12 month task order)

22. PBRN Task Order Projects Integrating evidence-based clinical and community services Preparing primary care to respond to a pan-flu public health threat Assessing the costs to primary care of collecting and reporting quality-related data Assessing barriers to quality measurement and reporting in primary care Clinical impact of nurse-based care management Development of a health literacy universal precautions toolkit

23. PBRN Task Order Projects Primary care management of sleep apnea Pediatric asthma hospitalizations and the quality of primary care Implementation and evaluation of electronic standing orders Primary care participation in health information exchanges Establishing benchmarks for the medical office survey on patient safety Management in primary care of patients suspected of having CA-MRSA infections

24. ACTION = Accelerating Change and Transformation in Organizations and Networks 5-year model of field-based research 15 large partnerships Partnerships include over 150 collaborating organizations Partners located in all States

25. Image is of two over-lapping circles, one representing researchers, the other decision-makers, indicating how information, tools and publications are actively generated at the interface of these two groups.Image is of two over-lapping circles, one representing researchers, the other decision-makers, indicating how information, tools and publications are actively generated at the interface of these two groups.

26. ACTION Goals Be responsive to user, stakeholder and operational needs for innovation in health care delivery Accelerate the development, implementation, dissemination and uptake of evidence-based products, strategies and findings into practice Prioritize generalizable approaches to enable spread to other settings

27. Current ACTION Partners? Health Services Research Organizations: Abt Associates, Inc., Cambridge, MA American Institutes for Research, Silver Spring, MD RAND Corporation, Santa Monica, CA RTI International, Research Triangle Park, NC The CNA Corporation, Alexandria, VA Academic Institutions: Boston University School of Public Health, Boston, MA Indiana University, Indianapolis, IN UCSF School of Medicine, San Francisco, CA University of Iowa Center for Health Policy and Research, Iowa City, IA Weill Medical College of Cornell University, New York, NY Yale New Haven Health Services Corporation, New Haven, CT Other Health Care Organizations: American Association of Homes and Services for the Aging, �Washington, DC Aurora Health Care, Milwaukee, WI Denver Health, Denver, CO Health Research and Educational Trust, Chicago, IL

28. Future ACTION Partners? Anticipate an open recompetion of ACTION by 2010

29. ACTION Partnerships Include� Hospital systems Ambulatory care practices Long-term care systems (nursing homes, home health, assisted living) Safety net systems Health plans University schools of medicine, nursing, public health, health policy, and management Health services and outcomes research organizations Veterans Integrated Delivery System Networks QIOs JCAHO, NCQA and other national organizations for healthcare quality assurance Associations of healthcare providers Consumer advocacy organizations

30. Why ACTION? Because We Need To� Quit describing problems, start solving them Partner to promote knowledge transfer and exchange Speed up getting project results Encourage uptake of innovation to improve health care delivery

31. How Does Contract Process Work? Project concepts welcomed from all sources, any time Topics must be critical to AHRQ, health systems, sponsors Solicit proposals from closed pool of ACTION partnerships throughout the year ACTION partnerships submit proposals within 4-6 weeks Proposal review by small ad hoc committee of experts ~2-4 months from solicitation to award

32. How Does Funding Work? 2006 - 2008 ? 58 awards totaling $30.2 million 78% competitive awards 22% sole source (most externally funded) Average award = $520 K (range: $120K to $3 million) Average duration = 23 months (range: 9 to 36 months)

33. Amounts Awarded by Topic

34. External Sponsorship, 2006-2008 13 fully sponsored projects: RWJF (1) CDC (6) HRSA (2) ASPR (4) 3 co-sponsored projects: DoD ONC CMS

35. Main Strategic Advantages Extensive depth and breadth of care settings, data and implementation capacity Huge diversity (geographic, demographic, payer) among >100 million recipients of care Speed ? average project duration of 23 months Focus on knowledge transfer and exchange

36. How Do We Encourage Knowledge Transfer and Exchange? Examples of project deliverables: Workshops, webcasts, training programs, technical assistance in care delivery settings DVDs, �how to� guides, workbooks Presentations to healthcare operational leadership Live/web-assisted conferences Tested scalable, scenario-appropriate models Publications in peer-reviewed and trade journals Ready access to Steering Committee members� organizations (e.g., AHA, MGMA, NBGH, RWJF) for rapid dissemination (member webcasts, listserves, annual meetings, journals)

37. PBRN Task Order Example #1:Pandemic Flu Management in Primary Care How to manage patient surges during pandemic flu? HIT-assisted systems to faciliate patient self-management. Development of enhanced interactive phone systems Interactive website with patient education materials University of Oklahoma (OKPRN) 12 month project

38. PBRN Example #2:Measuring costs to primary care practices of collecting/reporting quality data Policy issue: What is the cost to a primary care practice of collecting/reporting quality-related data? Who should bear the financial burden? Task Order Awards: One Task Order to North Carolina (NCNC) to measure costs of collecting/reporting global quality measures; Second Task Order to Univ Colorado (SNOCAP) to measure costs of collecting/reporting diabetes-specific measures Results anticipated: November, 2008 (14 month projects)

39. PBRN Example #3:Management of Suspected CA-MRSA Congressional appropriation to AHRQ in December, 2007 CDC has established evidence-informed principles for ambulatory management; but feasibility/actual outcomes unknown Three task orders awarded August, 2008

40. ACTION Is 2 � Years Old� Some early task orders are completed and others have interim results. How are we doing?

41. Example 1: 60% MRSA Infection Reduction in Indianapolis Hospitals Problem >126,000 MRSA infections per yr in hospitals >5,000 patients die as a result Over $2.5 billion excess healthcare costs Products and Results Indiana University developed and implemented a novel approach to reduce MRSA in ICUs in hospital systems in Indianapolis improved surveillance, hand hygiene, contact isolation Avg 60% reduction in MRSA infections in intervention units; 20% reduction in control units Other hospitals in the Indianapolis area and elsewhere eager to adopt this approach Congress funding AHRQ to further enhance and spread successful approaches to reduce MRSA and other healthcare associated infections

42. Example 2: National Spread of TeamSTEPPS Problem Poor communication and lack of teamwork among health care professionals contribute to errors in patient safety Products and Results AHRQ, DoD and American Institutes for Research built national training and support network for TeamSTEPPS, an evidence-based teamwork system TeamSTEPPS National Implementation program fully operational nationwide 1200 Master Trainers/Change Agents being trained (including in ACTION partnerships) Other spread: e.g., all Maine hospitals using TeamSTEPPS

43. Example 3: $10 Million in Reduced Waste at Denver Health Hospital Problem Estimates of overuse, underuse, and misuse of resources range from 30% (Midwest Business Group on Health) to 50% (Intermountain Health Care) of all healthcare expenses in the US Products and Results Denver Health trained all hospital middle managers in waste reduction using Lean Examples: Better organized respiratory therapy equipment ? 40% reduction in time spent searching (estimated $9,220/year saved) Disposal of 75 dumpsters of old files, equipment, supplies, hazardous materials ? ~ $300,000 in capital improvement and improved safety Switch from paper to electronic forms ? cost savings of $7,500/yr

44. Example 4: Improved Health Care Planning in Disasters Problem Lack of planning for emergencies Example: Hurricane Katrina Products and Results (3 of many examples) Alternate Site Locator to help State and local officials quickly locate appropriate alternate health care sites if existing ones are overwhelmed Emergency Preparedness Resource Inventory to help local/regional planners inventory equipment, personnel, and supplies in advance Staffing for Disaster Preparedness Response Model to improve antibiotic dispensing and vaccination campaigns for disease outbreaks

45. Questions? Comments? ACTION Program Officer: Cynthia.Palmer@ahrq.hhs.gov ACTION Fact Sheet at: www.ahrq.gov/research/action.pdf PBRN Program Officer: David.Lanier@ahrq.hhs.gov PBRN website: www.ahrq.gov/research/primarix.htm