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

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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 focuses on patient outcomes

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

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

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

AHRQ’s Mission

Improve the quality, safety, efficiency, and effectiveness of health care for all Americans


Ahrq priorities

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

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


Innovation in an era of reform implications for research1

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


2011 reports quality and disparities

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

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

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

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

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

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

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

Texas Snapshot: Overall Health Care Quality Measures

2010 National Healthcare Quality Report, State Snapshots


Innovation in an era of reform implications for research2

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


The journey from knowledge to practice

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

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 bsi part of hhs action plan

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 practice on the cusp stop bsi project

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 practice o n the cusp stop bsi project

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

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

AHRQ Health IT Strategic Goals

  • Improved health care decision-making

  • Support patient-centered care


Ahrq health it research funding

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


Innovation in an era of reform implications for research3

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


Patient focused care the challenge of many options

Patient-Focused Care:The Challenge of Many Options


The only questions that matter

The Only Questions That Matter

Is this treatment right?

Is this treatment right for me?


Patient centered outcomes research

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

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.


Innovation in an era of reform implications for research4

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


Patient protection and affordable care act

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

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

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

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

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 into real world applications

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


Innovation in an era of reform implications for research5

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


National action plan to improve health literacy

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

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

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


21 st century health care training

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

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 mean to be patient centric

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


We can see the possibilities

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

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


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