Informing DecisionMaking Through Comparative Effectiveness

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Informing Decision-Making Through Comparative
Effectiveness
Ronda G. Hughes, PhD, MHS, RN Senior Health
Scientist Administrator Agency for Healthcare
Research Quality University of Oklahoma,
Health Science Center Wednesday, September 16,
2009
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Today

• Health Policy
• Health Services Research
• Driving Forces of Change Research
• Opportunities

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Improving Health Care for All
Americans

• AHRQ Focus Goals
• Health Services Research Theory
• Resources Research
• Future Research

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HHS Organizational Focus
NIH Biomedical research to prevent, diagnose
treat diseases
CDC Population health the role of
community-based interventions to improve health
AHRQ Long-term system-wide improvement of
health care quality effectiveness
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AHRQ Roles Resources

• Health IT Research
• Funding
• Support advances that improve patient
  safety/quality of care
• Continue work in hospital settings
• Step up use of HIT to improve ambulatory patient
  care

• Develop Evidence Base for Best Practices
• Four key domains
• Patient-centered care
• Medication management
• Integration of decision support tools
• Enabling quality measurement

• Promote Collaboration
• and Dissemination
• Support efforts of AHIC, ONC, HRSA Centers for
  Medicare Medicaid Services
• Build on public private partnerships
• Use web tools to share knowledge expertise

Source FY 2007 Budget Summary for HHS and BNA
Health Care Policy Report 2-13-06
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AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
www.ahrq.gov
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AHRQs Focus 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 reduce unnecessary costs
• Effectiveness Improve health care outcomes by
  encouraging the use of evidence to make more
  informed health care decisions

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Value-Driven Health Care Principles Drive
Chartered Value Exchanges

• Health care is local national quality
  improvement will occur one community at a time
• Transparency accurate meaningful information on
  quality cost is key to provider improvement
  consumer engagement
• Collaboratives involving key stakeholder groups
  public private payers, providers, plans
  consumer organizations hold promise to foster
  requisite reforms

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Health Services Research

• HSR is a multidisciplinary field of inquiry,
  both basic applied, that examines the use,
  costs, quality, accessibility, delivery,
  organization, financing, outcomes of health
  care services to increase knowledge
  understanding of the structure, processes,
  effects of health services for individuals
  populations.

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Cornerstones of
Value-Driven Health Care
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AHRQ Comparative Effectiveness Research
http//effectivehealthcare.ahrq.gov
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Effective Health Care Program

• Evidence synthesis (EPC program)
• Systematically review, synthesize, compare
  existing evidence on treatment effectiveness
• Identify relevant knowledge gaps
• Evidence generation (DEcIDE, CERTs)
• Develop new scientific knowledge to address
  knowledge gaps
• Accelerate practical studies
• Evidence communication/translation (Eisenberg
  Center)
• Translate evidence into improvements
• Communicate scientific information in plain
  language to policymakers, patients, and providers

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AHRQs Role in Comparative Effectiveness

• Lead USA national agency for comparative
  effectiveness research
• HTA at the request of CMS
• Analyze data/options for CED and post CED data
  collection
• Provide translation of comparative effectiveness
  findings
• Promote and fund comparative effectiveness
  methods research
• Fund training grants focused on comparative
  effectiveness

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Effective Health Care Program

• To improve the quality, effectiveness, and
  efficiency of health care delivered through
  Medicare, Medicaid, and S-CHIP programs
• Focus is on what is known now ensuring programs
  benefit from past investments in research and
  what research gaps are critical to fill
• Focus is on clinical effectiveness

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Conceptual Framework
Stakeholder Input Involvement
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Priority Conditions

• Arthritis and non-traumatic joint disorders
• Cancer
• Cardiovascular disease, including stroke and
  hypertension
• Dementia, including Alzheimer Disease
• Depression and other mental health disorders
• Developmental delays, attention-deficit
  hyperactivity disorder and autism

• Diabetes Mellitus
• Functional limitations and disability
• Infectious diseases including HIV/AIDS
• Obesity
• Peptic ulcer disease and dyspepsia
• Pregnancy including pre-term birth
• Pulmonary disease/Asthma
• Substance abuse

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Selection Criteria

• Appropriateness

• 3 criteria
• 7 criteria
• 1 criterion
• 1 criterion
• 6 criteria

Importance
Duplication
Feasibility
Potential Impact
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The Future of CER

• A hot button topic in health care reform
• More effort to get more relevant and responsive
  research
• Methods, methods, methods
• Need to tackle important issues
• Ethical
• When to know when the evidence is sufficient
• Transparency
• Setting priorities and for whom
• Patient-centered, what is good for the public may
  not be good for the individual

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Sources of Evidence

• Research Studies
• Randomized clinical trials
• Cross-sectional studies
• Case series studies
• Case control studies
• Systematic Reviews
• Critical analysis of the quality research studies
• Qualitative or quantitative synthesis
• Clinical Guidelines Recommendations
• Expert opinion
• Clinical decision-making

SOURCE Haynes, Devereauxs, Guyatt. ACP J Club
2002 136A11-14.
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Source of Evidence
1000 people
800 have symptoms
327 consider seeking medical care
217 visit a physicians office 113 visit
primary care physicians office
65 visit CAM provider
21 visit a hospital OPD
14 receive home health care
13 visit an emergency department
8 in a hospital
lt1 in an academic health center
SOURCE NEJM 2000, Green et al.
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Evidence-based Clinical Decisions
Patient Preferences Actions
Clinical state, Setting Circumstances
Clinical Expertise
Research Evidence
Health Care Resources
SOURCE Haynes, Devereauxs, Guyatt. ACP J Club
2002 136A11-14.
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Evidence-Based Guideline Clearinghouses

• The National Guidelines Clearinghouse is a
  comprehensive database of evidence-based clinical
  practice guidelines related documents
• The National Quality Measures Clearinghouse is a
  database Web site for information on specific
  evidence-based health care quality measures
  measure sets
• The goal of both is to promote the dissemination,
  implementation use in order to inform health
  care decisions

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Research Priorities for Value Where We Need
Knowledge

• Measures of value, cost, efficiency within and
  across sites of care
• Methods, modeling, and data sources for measuring
  and tracking value and efficiency, projecting
  impact of policy, payment, organizational change
• Impact of consumer incentives on consumer
  behavior, costs and ROI for multiple stakeholders
• Impact of Federal and State regulatory and legal
  changes on organization, financing,
  accessibility, delivery, quality and cost of
  health care
• Impact of Medicare, Medicaid, SCHIP benefit
  provisions management on enrollment,
  utilization, costs, and quality
• Impact of public reporting strategies

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How Can We Enhance Our
Efforts?
The Evolution of Translational Research
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You Can Only Improve What You Can Measure
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(No Transcript)
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The 3Ts Road Map to Transforming U.S. Health
Care
Improved health care quality and value
and population health
Basic biomedical science
Clinical efficacy knowledge
Clinical effectiveness knowledge
Key T1 activity to test what care
works Clinical efficacy research
Key T2 activities to test who benefits from
promising care Outcomes research Comparative
effectiveness Research Health services
research
Key T3 activities to test how to deliver
high-quality care reliably and in all
settings Measurement and accountability of
health care quality and cost Implementation of
Interventions and health care system
redesign Scaling and spread of effective
interventions Research in above domains
Source JAMA, May 21, 2008 D. Dougherty and
P.H. Conway, pp. 2319-2321. The 3Ts Roadmap to
Transform U.S. Health Care The How of
High-Quality Care.
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Challenges

• Generating big impact research
• Building public/private partnerships that include
  representative stakeholders
• Developing the capacity to track long-term
  outcomes of training programs
• Ensuring that more informed actually means better
  informed
• Rewarding the leading edge and bringing others
  along

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Opportunities

• Use best available evidence for decision making
• Generate evidence for practice policy
• Compare evidence best practices

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Future Challenges

• Downstream effects of policy applications
• Diffusion of technology
• Effects on innovation
• Unintended consequences
• International collaboration
• Understanding the role of costs in the U.S.
• Determining where comparative effectiveness
  should reside

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Funding Opportunities

• Dissertation Grants
• Conference Grants
• AHRQ has funds available for convening
  professionals to effect change
• AHRQ Tools/Resources
• http//effectivehealthcare.ahrq.gov
• www.innovations.ahrq.gov
• http//psnet.ahrq.gov

http//www.ahrq.gov
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Ronda G. Hughes, PhD, MHS, RN Senior Health
Scientist Administrator Senior Advisor for
End-of-Life Care Center for Primary Care,
Prevention, Clinical Partnerships Agency for
Healthcare Research Quality 540 Gaither Road,
Suite 6000 Rockville, MD 20850 Phone (301)
427-1578 Fax [phone] E-Mail
Ronda.Hughes_at_ahrq.hhs.gov