Advancing Excellence in Health Care

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Advancing Excellence in Health Care

• Carolyn M. Clancy, MD
• Director
• January 21, 2005

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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.

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Case Presentation - 2

• Pauls pc team has also reviewed Pauls 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.

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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.

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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.

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Overview

• About AHRQ The Evidence Agency
• Health Care 2005 Current Context
• Recent Findings and Directions
• Future Challenges

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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.

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AHRQ RESEARCH FOCUSHOW 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

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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

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Overview

• About AHRQ The Evidence Agency
• Health Care 2005 Current Context
• Recent Findings and Directions
• Future Challenges

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Driving Forces

• Rising health care expenditures
• Aging and increasingly diverse population
• Consumerism
• Biomedical advances public and professional
  expectations
• Growing influence of purchasers

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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

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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
2004
2000
Gotten worse
Stayed about the same
Dont 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).
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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
Yes
No
Minor health consequences
No health consequences
Dont 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).
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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
Yes
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
Dont know
No
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).
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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

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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

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The proportion of adults with diabetes who
received all five recommended diabetic services
(MEPS, 2000-2001)
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HHS Recent Developments

• Nursing Home Initiative
• Home Health Care Initiative
• AHA-JCAHO-VHA . Hospital reporting initiative
• Patient experience in hospitals
• Bar coding
• IT standards ()

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Patient Safety Achieving A New Standard For Care

• 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

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Issues

• Will public reporting ? improvements?
• Paying for quality YES, but HOW??
• Pay for quality OR use of HIT?
• How to align measurement and improvement efforts?

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Overview

• About AHRQ The Evidence Agency
• Health Care 2005 Current Context
• Recent Findings and Directions
• Future Challenges

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AHRQ Research Study Identifying 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
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AHRQ Research Study Sleep Deprivation and Safety

• 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
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AHRQ Research Study OutpatientPrescription
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

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HIT Systems approach Can Make a Difference
Proportions of patients receiving the appropriate
discharge prescriptions

• Intermountain Health Care QI effort on CVD
• Results
• 90 prescription rates
• 27 decrease in unadjusted absolute death rates

Lappe JM et. al., Ann Intern Med 2004141446-453
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Hospital Survey on Patient Safety Culture

• 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
• www.ahrq.gov/qual/hospculture/ or e-mail to
  ahrqpubs_at_ahrq.gov

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Key Implementation Activities QualityTools
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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 Nations largest health
  insurance plans, and other organizations

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Overview

• About AHRQ The Evidence Agency
• Health Care 2005 Current Context
• Recent Findings and Directions
• Future Challenges

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The Future Delivery SystemBaseline Assumptions

• Todays 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

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What We Have Learned

• 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
• Suttons Law improving chronic illness care is
  essential
• Safety in health care delivery is critical

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Implementation of Research Findings Debunked
Assumption
Question
Hypothesis
Study
Publications
Changes in practice
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A Flawed Model

• Receptor sites are assumed
• Decisionmaking is not-linear evidence is only
  part of the solution
• Broad dissemination ? modest effects

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Improving Quality and Safety
We need to make the right thing the easy
thing Mark Chassin, MD October 12, 2000
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If HIT is Such a Great Idea ..

• 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

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FY04 Transforming Healthcare Quality through IT

• 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

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State and Regional Demonstrations in Health IT

• 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

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Critical Challenges

• 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

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Contemporary Challenges

• 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

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What is Section 1013?

• 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

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What is Section 1013?

• 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

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SHARED DECISION MAKINGDECISIONS AND OUTCOMES
Patient
Alternative 1
Alternative 2
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PREQUISITES FOR CHANGE

• 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)

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Focus Research and Policy

• Describing problems policy window
• Developing and testing solutions to problems
• Evaluating solutions
• Interaction with stakeholders and decision makers
  is not optional

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Supply-Side Research Paradigm

• Research world
• Questions
• Hypothesis
• Study

• User world
• Many needs
• Beliefs interests
• Decision processes

Publication
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c2
The winding road to a receptor site
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Demand/Supply Side Model

• Research world
• Questions
• Hypothesis
• Study

• User world
• Many needs
• Beliefs interests
• Decision processes

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c2
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Approaching Knowledge Gaps
?

• 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

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Essential Issues to be Addressed

• 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)

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Questions in Search of Answers

• 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?

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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