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Implementation of evidence based medicine in practice


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  • 1. Implementation of Evidence- Based Medicine in Practice Carolyn M. Clancy, MD DirectorAgency for Healthcare Research and Quality CMIO Leadership Forum: Transforming Healthcare through Evidence-based Medicine Chicago, IL – October 4, 2012
  • 2. Understanding a Changing Landscape Health care reform, including payment reform, has already begun – How is evidence integrated into the new environment? – How has the nature of CHANGE evidence changed? AHEAD – How do these changes affect providers, payers and patients? How do we ensure that these changes are beneficial?
  • 3. Maintaining the Status Quo is Not an Option Evidence is being produced at an extremely rapid rate, but its incorporation into clinical practice is happening much more slowly Transparency efforts don’t offer enough usable data for decisions regarding a specific disease and selection of a treatment option We face an underperforming health care system and untenable cost forecasts Too often, the patient is an afterthought
  • 4. Aiming for the Sweet Spot There is an overlap among patient-centered care, population health, and advanced modern medicine All three call for organizing care around the patient rather than around systems of care All three call for a fresh examination of how we conduct and disseminate research
  • 5. Implementation ofEvidence-Based Medicine  Making the Case: AHRQ and Its Role in Advancing High-Quality Health Care  Patient-Centered Outcomes Research: The Collection of Modern Evidence to Enable Modern Medicine  Putting the Patient at the Center of Care  21st Century Health Care
  • 6. AHRQ’s Mission Improve the quality, safety, efficiency, andeffectiveness of health care for all Americans
  • 7. AHRQ’s Focus and Strategic Goals Quality: Deliver the right care at the right time to the right patient Safety: Reduce the risk of harm by promoting delivery of the best possible health care Efficiency: Enhance access to effective health care services and reduce unnecessary costs Effectiveness: Improve health care outcomes by encouraging the use of evidence to make more informed health care decisions
  • 8. HHS Organizational Focus NIH CDC AHRQ Biomedical Population health Long-term and Research to and the role of system-wideprevent, diagnose community based improvement ofand treat disease interventions to health care quality improve health and effectiveness
  • 9. AHRQ Priorities Patient Safety  Health IT  Patient Safety Organizations Ambulatory  Patient Safety Effective Health Patient Safety Grants (incl. Care Program simulation)  Comparative Safety & Quality Measures, Effectiveness Reviews Drug Management, & Patient-Centered Care  Patient-Centered Survey of Patient Safety Culture Outcomes Research Diagnostic Error Research  Clear Findings for Multiple Audiences Other Research & Medical Expenditure Dissemination Activities Panel Surveys  Quality & Cost-Effectiveness, e.g.,  Visit-Level Information on Prevention & Pharmaceutical Medical Expenditures Outcomes  Annual Quality &  U.S. Preventive Services Disparities Reports Task Force  MRSA/HAIs
  • 10. AHRQ 2011 National Healthcare Quality and Disparities Reports 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 Quality of care varies not only across types of care but also across parts of the country
  • 11. 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 inNational Quality Strategy and HHS Plan to Reduce Racial and Ethnic Health Disparities
  • 12. Quality Is Improving Slowly Quality measures that are improving, not changing or worsening, overall and for select populations  Nearly 60 percent of health care quality measures tracked showed improvement  However, the median rate of change was 2.5 percent per yearAHRQ 2011 National Healthcare Quality and Disparities Reports
  • 13. Few Disparities in Quality of Care Are Getting Smaller Quality measures for which disparities related toage, race, ethnicity and income are improving, not changing or worsening  Few disparities in quality showed significant improvement.  The number of disparities that were getting smaller exceeded the number that were getting larger AHRQ 2011 National Healthcare Quality and Disparities Reports
  • 14. Illinois: Overall Quality of Care Compared with All States Average Weak StrongVery VeryWeak Strong Performance Meter: All Measures = Most Recent Year = Baseline Year National Healthcare Quality Report, State Snapshots
  • 15. Illinois Snapshot: Quality MeasuresMeasure PerformanceESRD: Renal failure – received a Better thantransplant averageDiabetes: Diabetes eye exams AverageCancer: Prostate cancer deaths Worse than average National Healthcare Quality Report, State Snapshots
  • 16. Implementation ofEvidence-Based Medicine  Making the Case: AHRQ and Its Role in Advancing High-Quality Health Care  Patient-Centered Outcomes Research: The Collection of Modern Evidence to Enable Modern Medicine  Putting the Patient at the Center of Care  21st Century Health Care
  • 17. What We Know ―The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway.‖ H. Gilbert Welch, MD Geisel School of Medicine at DartmouthTesting What We Think We Know. New York Times - August 19, 2012
  • 18. Research that Addresses Patient Outcomes Patient-Centeredness: The final frontier? Patient-centeredness may be the most challenging of all 6 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
  • 19. Until Recently, Few Tools toGet From Evidence to Practice  AHRQ is working to: – Translate scientific advances into actual clinical practice – Translate scientific advances into usable information for clinicians and for patients – Deliver information in the right places at the right time
  • 20. Effective Health Care Program Summaries Policymakers Clinicians ConsumersSummarize research review findings on the benefits and harms of different treatmentoptions. Provide useful background on health conditions. Medication guides contain basic wholesale price information.
  • 21. AHRQ’s EffectiveHealth Care Program
  • 22. Implementing Evidence- Based Treatment Decisions Which treatments work, for which patients, and what are the trade-offs? – Patient-centered outcomes research informs decisions by providing evidence and information on effectiveness, benefits and harms How can evidence-based improvements be translated and shared with providers, patients? – Effective Health Care Clinician and Consumer Guides – Continuing Medical Education – Center for Medicare and Medicaid Innovation; AHRQ Innovation Exchange
  • 23. The Patient-Centered Outcomes Research Institute and AHRQ Provides funding for AHRQ to disseminate research findings of the Institute and other government-funded research, train and build capacity for research – Up to 20% of Patient-Centered Outcomes Research Trust Fund can be used to support research capacity building and dissemination activities
  • 24. Implementation ofEvidence-Based Medicine  Making the Case: AHRQ and Its Role in Advancing High-Quality Health Care  Patient-Centered Outcomes Research: The Collection of Modern Evidence to Enable Modern Medicine  Putting the Patient at the Center of Care  21st Century Health Care
  • 25. Assumptions We’ve always assumed flawless execution We’ve also always assumed that any issues that arise are caused by a knowledge problem Neither is always true A case in point…
  • 26. Sometimes,It’s The Little Things
  • 27. AHRQ HAI Research Portfolio  Healthcare-associated infections (HAIs) are infections that patients get in the course of medical care  HAIs affect up to 1 in 20 patients in hospitals at any one time  $34 million in support of goals of Partnership for Patients and HHS Action Plan to Prevent  Projects include: – Three new modules for the Comprehensive Unit-based Safety Program (CUSP) – Research on ways to reduce MRSA and Clostridium difficile (C-diff) – Use of health system facility design to reduce HAIs
  • 28. CUSP Cuts CLABSIs by 40 Percent in 1,100 Hospital Units Nationwide patient safety project – Developed at Johns Hopkins, tested in Michigan – Implemented in more than 1,100 hospital units  Results: – CLABSIs reduced from 1.903 infections per 1,000 central line days to 1.137 per 1,000 days – Savings: more than 500 lives, $34 million in costs New toolkit for implementation AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent. Press Release, September 10, 2012.
  • 29. Keystone: Maintaining Improvement Practices Example of building improvement into the research – Partnership with grants from AHRQ and various commitments from Blue Cross Blue Shield of Michigan, the Michigan Hospital Association, Johns Hopkins University and others – Stakeholders, end users and others are able to use the data to monitor progress – Innovative methods of dissemination and communication – An ongoing effort to learn and improve
  • 30. AHRQ Health IT Research Portfolio AHRQ has invested more than $300 million since 2004 in contracts and grants More than 200 communities, hospitals, provi ders, and health care systems in 48 states AHRQ Health IT Investment: $300 Million
  • 31. Enabling Evidence-Based Medicine through Health IT Streamlining Information and Clinical Processes Faster and broader dissemination of new evidence Inclusion of new evidence and treatments into electronic quality reporting systems, EHRs, etc. Registries
  • 32. Who Benefits from AHRQ’s Health IT Work? Patients get the right treatment at the right time; and when their records are shared, tests don’t have to be repeated Doctors manage information in the office, and get decision support and helpful reminders Hospitals coordinate care among units and among each other Payers get faster, more accurate data States get real-time data on services statewide
  • 33. Preparing the Field for Innovation: Project ECHO Project ECHODevelops capacity to safely and effectively treat chronic, common, complex diseases in rural, underserved areas and monitor outcomes
  • 34. MEADERSMedication Error and Adverse Drug Event ReportingSystem (MEADERS) Web-based and downloadable reporting system for ambulatory care settings to document medication errors and adverse drug events ―Cloud‖ reporting system users can compare their results to national data Piloting testing underway at Cleveland Clinic and two sites that are part of the HRSA ―Patient Safety and Clinical Pharmacy Services Collaborative
  • 35. AHRQ Hip and Knee Registry Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) – Collecting data on 30,000 patients on functions including:  Longitudinal patient pain and function  Post-procedure complications and revisions  Characteristics of patients, procedure, physician and hospital – Developing tools for patient-centered outcomes research:  Establish consensus on the definition of ―functional failure‖  Construct, validate and refine prediction algorithms for patients at risk for early post-TJR functional failure  Develop and institute an integrated, brief TJR-specific physical function outcome measure
  • 36. Generating Information and Evidence with Registries Registries increasingly used to inform clinical decision- making – Revised AHRQ guide (2010) includes 4 new chapters:  When to Stop a Registry  Use of Registries in Product Safety Assessment  Linking Registry Data  Interfacing Registries and Electronic Health Records
  • 37. How Do We Engage Patients? Two requests to make of patients: – ―Tell me your goals.‖ – ―Tell me what you heard.‖
  • 38. A Decent Meal, Or a New Model of Care? The challenge: – Serving millions of people – Delivering a range of services – Keeping costs reasonable – Attaining a consistently high level of quality Can care be mechanized? Should it be? Are there models we can use?Gawande A. Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care? New Yorker. August 13, 2012
  • 39. Implementation ofEvidence-Based Medicine  Making the Case: AHRQ and Its Role in Advancing High-Quality Health Care  Patient-Centered Outcomes Research: The Collection of Modern Evidence to Enable Modern Medicine  Putting the Patient at the Center of Care  21st Century Health Care
  • 40. This is an Evolving Enterprise Evidence, quality assessment, and othertools are important—but only inasmuch as they improve care for patients
  • 41. Getting There will Be a New Learning Model We will develop a more intuitive grasp of the power of data over time – Young physicians tend to be first adopters of health IT – Older physicians generally experience more difficulty in adapting to the rapidly changing practice environment – New practice arrangements are increasingly offering more alternatives to physicians entering practice
  • 42. Key Considerations Interest in assessing clinician performance will continue Much of the measurement enterprise is ―evolving‖ Collective interest in using quality measures that reflect the profession’s knowledge and authority ―Some day‖ health IT will make data collection, reporting and updating of measures easy – but not today!
  • 43. How Will We Know We’re On Track? The quality enterprise adds value to clinical practice Care includes focus on missed opportunities and dropped balls: transitions; handoffs; anticipating errors Physicians say, ―we‖ rather than ―I‖ Patient activation and engagement is welcomed and encouraged ―Best doctors‖ are evaluated in terms of care for individual patients and leadership in health of population
  • 44. Health System Transformation: Current and Future Current FutureVariable quality; expensive, Consistently better quality; wasteful lower cost, more efficient Pay for volume Pay for quality Pay for transactions Care-based episodesQuality assessment based Quality assessment based on provider and setting on patient experience (process) (outcomes)
  • 45. The Journey:From Knowledge to Practice  System transformation is a long-term endeavor  It requires research, incentives, and desire to improve  Communication at every juncture is critical  So is measurement!  Change is not only possible, but it is inevitable if we are committed to it
  • 46. Thank You AHRQ Mission To improve the quality, safety, efficiency, and effectiveness of health care for all Americans AHRQ Vision As a result of AHRQs efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest