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

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Advancing excellence in health care

Advancing Excellence in Health Care

Carolyn M. Clancy, MD


January 21, 2005

Case presentation 1
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.

Case presentation 2
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.

Case presentation 3
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.

Case presentation 4
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.


  • About AHRQ: The Evidence Agency

  • Health Care 2005: Current Context

  • Recent Findings and Directions

  • Future Challenges

Mission statement ahrq
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.

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

Ten roles of government in health care quality

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


  • About AHRQ: The Evidence Agency

  • Health Care 2005: Current Context

  • Recent Findings and Directions

  • Future Challenges

Driving forces
Driving Forces

  • Rising health care expenditures

  • Aging and increasingly diverse population

  • Consumerism

  • Biomedical advances: public and professional expectations

  • Growing influence of purchasers

Current environment
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

Advancing excellence in health care

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…



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).

Advancing excellence in health care

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



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).

Advancing excellence in health care

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


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


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).

Pace of change varies across care settings
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

Major opportunities for improvement
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

Advancing excellence in health care
The proportion of adults with diabetes who received all five recommended diabetic services (MEPS, 2000-2001)

Hhs recent developments
HHS: Recent Developments recommended diabetic services (MEPS, 2000-2001

  • Nursing Home Initiative

  • Home Health Care Initiative*

  • AHA-JCAHO-VHA …. Hospital reporting initiative*

  • Patient experience in hospitals*

  • Bar coding

  • IT standards (*)

Patient safety achieving a new standard for care
Patient Safety: Achieving A New Standard For Care recommended diabetic services (MEPS, 2000-2001

“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

Issues recommended diabetic services (MEPS, 2000-2001

  • Will public reporting  improvements?

  • Paying for quality – YES, but HOW??

  • Pay for quality – OR use of HIT?

  • How to align measurement and improvement efforts?

Overview recommended diabetic services (MEPS, 2000-2001

  • About AHRQ: The Evidence Agency

  • Health Care 2005: Current Context

  • Recent Findings and Directions

  • Future Challenges

Ahrq research study identifying successful hospital quality improvements
AHRQ Research Study: Identifying recommended diabetic services (MEPS, 2000-2001 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

Ahrq research study sleep deprivation and safety
AHRQ Research Study: Sleep Deprivation and Safety recommended diabetic services (MEPS, 2000-2001

  • 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

Ahrq research study outpatient prescription drug related injuries in elderly
AHRQ Research Study: Outpatient recommended diabetic services (MEPS, 2000-2001Prescription 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

Hit systems approach can make a difference

Intermountain Health Care QI effort on CVD recommended diabetic services (MEPS, 2000-2001


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

Hospital survey on patient safety culture
Hospital Survey on Patient Safety Culture recommended diabetic services (MEPS, 2000-2001

  • 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

  • or e-mail to

Key implementation activities qualitytools
Key Implementation Activities – QualityTools recommended diabetic services (MEPS, 2000-2001

National health plan learning collaborative to reduce disparities and improve quality
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

Overview Disparities and Improve Quality

  • About AHRQ: The Evidence Agency

  • Health Care 2005: Current Context

  • Recent Findings and Directions

  • Future Challenges

The future delivery system baseline assumptions
The Future Delivery System: Disparities and Improve QualityBaseline 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”

What we have learned
What We Have Learned Disparities and Improve Quality

  • 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

Implementation of research findings debunked assumption
Implementation of Research Findings: Debunked Assumption Disparities and Improve Quality





Changes in practice

A flawed model
A Flawed Model Disparities and Improve Quality

  • Receptor sites are “assumed”

  • Decisionmaking is not-linear: evidence is only part of the “solution”

  • Broad dissemination  modest effects

Improving quality and safety
Improving Quality and Safety Disparities and Improve Quality

“We need to make the right thing

the easy thing…”

Mark Chassin, MD

October 12, 2000

If hit is such a great idea
If HIT is Such a Great Idea ….. Disparities and Improve Quality

  • 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

Fy04 transforming healthcare quality through it
FY04: Transforming Healthcare Quality through IT Disparities and Improve Quality

  • 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

State and regional demonstrations in health it
State and Regional Demonstrations in Health IT Disparities and Improve Quality

  • 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

Critical challenges
Critical Challenges Disparities and Improve Quality

  • 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

Contemporary challenges
Contemporary Challenges Disparities and Improve Quality

  • 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

What is section 1013
What is Section 1013? Disparities and Improve Quality

  • 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

What is section 10131
What is Section 1013? Disparities and Improve Quality

  • 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

Shared decision making decisions and outcomes


Alternative 1

Alternative 2

Prequisites for change
PREQUISITES FOR CHANGE Disparities and Improve Quality

  • 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)

Focus research and policy
Focus: Research and Policy Disparities and Improve Quality

  • Describing problems – policy window

  • Developing and testing solutions to problems

  • Evaluating solutions

  • Interaction with stakeholders and decision makers is not optional

Supply side research paradigm
Supply-Side Research Paradigm Disparities and Improve Quality

  • Research world:

  • Questions

  • Hypothesis

  • Study

  • Userworld:

  • Many needs

  • Beliefs & interests

  • Decision processes




The winding road to a receptor site

Demand supply side model
Demand/Supply Side Model Disparities and Improve Quality

  • Research world:

  • Questions

  • Hypothesis

  • Study

  • Userworld:

  • Many needs

  • Beliefs & interests

  • Decision processes



Approaching knowledge gaps
Approaching Knowledge Gaps Disparities and Improve Quality

  • Not always head to head

  • Need to be creative

  • Explore new methodologies

  • Examine existing or forthcoming data sources

  • Reserve most expensive approaches for the most important and controversial questions

Essential issues to be addressed
Essential Issues to be Addressed Disparities and Improve Quality

  • Ethics and Quality Improvement: (when is it research?

  • Identification of subgroups most likely to benefit

  • Identifying critical intervention points (“teachable moments”)

  • Conceptual blueprint for practical clinical trials

  • Integration of disease management with clinical decision support – “knowledge engineering”

  • Patient engagement (including the pre-contemplative)

Questions in search of answers
Questions in Search of Answers Disparities and Improve Quality

  • Linking knowledge development to policy levers (e.g., payment; regulation): role of ‘demonstrations’

  • When is “good enough”?

  • Vocabulary and pathways for translation of knowledge-based interventions under-developed

  • Concurrent -- or sequential -- evaluation and translation?

Advancing excellence in health care

“It is not enough just to develop new insights into the fundamental nature of disease and its prevention. It is not enough to test that fundamental knowledge in rigorously controlled clinical trials. We must also improve the distribution of that knowledge so that it reaches everyone in the world -- so that everyone will benefit from it.”

Robert H. Brook, M.D., Sc.D., remarks to Research! America, March 20, 2001