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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