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. Facilitate Informed Health Care Decisions by: • Patients • Providers • Policymakers Increased emphasis on implementing evidence-based healthcare Scientific Evidence Translation Understandable and Usable Information

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. Population at risk (including children) 1000 Report one or more health-related symptoms 800 327 Consider seeking health care 217 Visit a physician’s office Visit a CAM provider Visit a hospital outpatient clinic (21) 65 Receive home health care (17) Visit an E.D. (13) Are in a hospital (8) Are in an academic health center (<1) Ecology of Medical Care UpdatedGreen, Yawn, Lanier. N Engl J Med 2001;344:2021-25

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)

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

18. PBRN Task Order Contractors: Age-Range of Patients

19. PBRN Task Order Contractors: Patient Race/Ethnicity

20. PBRN Task Order Contractors: Physician Provider Discipline

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. Through ACTION, Partnering to Promote Knowledge Transfer and Exchange RESEARCHERS DECISION-MAKERS Info+ Tools Info + Tools PUBLICATIONS

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 solvingthem • 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. 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 PBRN Task Order Example #1:Pandemic Flu Management in Primary Care

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. 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 PBRN Example #3:Management of Suspected CA-MRSA

40. ACTION Is 2 ½ 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 Locatortohelp State and local officials quickly locate appropriate alternate health care sites if existing ones are overwhelmed • Emergency Preparedness Resource Inventoryto help local/regional planners inventory equipment, personnel, and supplies in advance • Staffing for Disaster Preparedness Response Modelto 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 Contacts