Evidence-Based Medicine: Making Evidence-Based Medicine: Making Today’s Goals Tomorrow’s RealityToday’s Goals Tomorrow’s Reality

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDirectorDirector

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

Washington, DC Health Policy SeminarWashington, DC Health Policy Seminar

Washington, DC – April 21, 2009Washington, DC – April 21, 2009

Current ChallengesCurrent Challenges

Concerns about health spending – about $2.3 trillion per Concerns about health spending – about $2.3 trillion per year in the U.S. and growingyear in the U.S. and growing

Large variations in clinical careLarge variations in clinical care A lot of uncertainty about best practices involving A lot of uncertainty about best practices involving

treatments and technologies treatments and technologies Pervasive problems with the quality of care that people Pervasive problems with the quality of care that people

receive receive Translating scientific advances into actual clinical practice Translating scientific advances into actual clinical practice Translating scientific advances into usable information for Translating scientific advances into usable information for

clinicians and patientsclinicians and patients

According to Yogi BerraAccording to Yogi Berra

““If you don't know If you don't know where you are where you are going, you might going, you might wind up someplace wind up someplace else.” else.”

Comparative Effectiveness Comparative Effectiveness and the American Recovery and the American Recovery Reinvestment Act of 2009 Reinvestment Act of 2009 (ARRA)(ARRA)

AHRQ’s Role in Comparative AHRQ’s Role in Comparative EffectivenessEffectiveness

How Can We Further How Can We Further Enhance Our Efforts?Enhance Our Efforts?

Q&AQ&A

Evidence-Based MedicineEvidence-Based Medicine

AHRQ PrioritiesAHRQ Priorities

Effective HealthEffective HealthCare ProgramCare Program

Medical ExpenditureMedical ExpenditurePanel SurveysPanel Surveys

AmbulatoryAmbulatoryPatient SafetyPatient Safety

PatientPatient Safety Safety

Health IT Patient Safety

Organizations New Patient

Safety Grants Comparative Effectiveness Reviews

Comparative Effectiveness Research

Clear Findings for Multiple Audiences

Quality & Cost-Effectiveness, e.g.Prevention and PharmaceuticalOutcomes

U.S. Preventive ServicesTask Force

MRSA/HAIs

Visit-Level Information on Medical Expenditures

Annual Quality & Disparities Reports

Safety & Quality Measures,Drug Management andPatient-Centered Care

Patient Safety ImprovementCorps

Other Research & Other Research & Dissemination ActivitiesDissemination Activities

AHRQ FY 2009 FundingAHRQ FY 2009 Funding

$372 million$372 million– $37 million more than FY 2008$37 million more than FY 2008

– $46 million more than the president’s $46 million more than the president’s requestrequest

FY 2009 appropriation includes:FY 2009 appropriation includes:– $50 million for comparative effectiveness $50 million for comparative effectiveness

research, $20 million more than FY 2008 research, $20 million more than FY 2008

– $49 million for patient safety activities$49 million for patient safety activities

– $45 million for health IT$45 million for health IT

Comparative Effectiveness Comparative Effectiveness and the Recovery Actand the Recovery Act

The American Recovery and Reinvestment The American Recovery and Reinvestment Act of 2009 includes $1.1 billion for Act of 2009 includes $1.1 billion for comparative effectiveness research:comparative effectiveness research:– AHRQ: $300 millionAHRQ: $300 million

– NIH: $400 million (appropriated to AHRQ and NIH: $400 million (appropriated to AHRQ and transferred to NIH)transferred to NIH)

– Office of the Secretary: $400 million (allocated Office of the Secretary: $400 million (allocated at the Secretary’s discretion)at the Secretary’s discretion)

Funding for health IT, prevention and other areas Funding for health IT, prevention and other areas could have implications for the Agency could have implications for the Agency

Recovery Act Timeline: AHRQRecovery Act Timeline: AHRQ

20092009

March 19: March 19: Establishment of Establishment of

Federal Federal Coordinating Coordinating Council for Council for

Comparative Comparative Effectiveness Effectiveness

ResearchResearch

February 17: February 17: The American The American Recovery and Recovery and Reinvestment Reinvestment Act of 2009 is Act of 2009 is

signed into lawsigned into law

JanuaryJanuary AprilApril JulyJuly

June 30: Due June 30: Due date for IOM date for IOM

submission of a submission of a list of national list of national

priority priority conditionsconditions**

May 1: Due May 1: Due date for Agency date for Agency

wide and wide and program-program-specific specific

Recovery Act Recovery Act plansplans

OctoberOctober

November 1: November 1: AHRQ AHRQ

FY ‘10 FY ‘10 operations operations

plan dueplan due

July 30: July 30: AHRQ to AHRQ to submit submit

FY ’09 FY ’09 Operations Operations

PlanPlan

20102010

December December 31, 2010: All 31, 2010: All

Recovery Recovery Act funding Act funding

to be to be obligatedobligated

* * Stakeholder input requiredStakeholder input required

Federal Coordinating CouncilFederal Coordinating Council

Established by the Office of the Secretary to Established by the Office of the Secretary to offer guidance and coordination to achieve offer guidance and coordination to achieve maximum use of the fundingmaximum use of the funding– Members include representatives from agencies Members include representatives from agencies

involved in comparative effectiveness researchinvolved in comparative effectiveness research

– The Council will consider the needs of populations The Council will consider the needs of populations served by federal programs and opportunities to served by federal programs and opportunities to build and expand on current investments and build and expand on current investments and prioritiespriorities

– The Council will not recommend clinical guidelines The Council will not recommend clinical guidelines for payment, coverage or treatment for payment, coverage or treatment

Other Aspects of Other Aspects of the Recovery Act the Recovery Act

Includes significant funding for health IT, Includes significant funding for health IT, prevention and other activitiesprevention and other activities

HHS-wide Recovery Act Implementation Team HHS-wide Recovery Act Implementation Team to address all aspects of implementing billto address all aspects of implementing bill

Specific subgroups for comparative Specific subgroups for comparative effectiveness research, health IT and prevention; effectiveness research, health IT and prevention; AHRQ and NIH co-lead comparative AHRQ and NIH co-lead comparative effectiveness workgroupeffectiveness workgroup

Detailed reporting requirements as outlined by Detailed reporting requirements as outlined by the Office of Management and Budget and the Office of Management and Budget and Health & Human Services Health & Human Services

Effective Health Care ProgramEffective Health Care Program

A.A. Evidence synthesis (EPC program)Evidence synthesis (EPC program)– Systematically reviewing, synthesizing, comparing existing Systematically reviewing, synthesizing, comparing existing

evidence on treatment effectivenessevidence on treatment effectiveness– Identifying relevant knowledge gapsIdentifying relevant knowledge gaps

B.B. Evidence generation (DEcIDE, CERTs)Evidence generation (DEcIDE, CERTs)– Development of new scientific knowledge to address Development of new scientific knowledge to address

knowledge gaps. knowledge gaps. – Accelerate practical studiesAccelerate practical studies

C.C. Evidence communication/translation Evidence communication/translation (Eisenberg Center)(Eisenberg Center)– Translate evidence into improvements Translate evidence into improvements – Communication of scientific information in plain language Communication of scientific information in plain language

to policymakers, patients, and providersto policymakers, patients, and providers

The FutureThe Future

Public-private funding and participation likely a Public-private funding and participation likely a necessitynecessity

More effort to get better conditional More effort to get better conditional reimbursement study designs/protocolsreimbursement study designs/protocols

Patients should be engaged as partners at the Patients should be engaged as partners at the local and national levelslocal and national levels

Need to tackle important issuesNeed to tackle important issues– EthicalEthical– When to know when the evidence is sufficientWhen to know when the evidence is sufficient– TransparencyTransparency– Setting prioritiesSetting priorities

Evidence of ProgressEvidence of Progress

Wal-MartWal-Mart– Plans to sell electronic Plans to sell electronic

medical records to doctorsmedical records to doctors Geisinger Health SystemsGeisinger Health Systems

– Building the capability to Building the capability to push specific types of push specific types of information to select patient information to select patient populationspopulations

MarriottMarriott– Launched a preventive Launched a preventive

health campaign to help health campaign to help address multiple languages address multiple languages and diverse backgrounds of and diverse backgrounds of employeesemployees

Progress (Cont.)Progress (Cont.)

How Can We Further How Can We Further Enhance Our Efforts? Enhance Our Efforts?

Key T1 activity to testKey T1 activity to test what care workswhat care works

Clinical efficacy researchClinical efficacy research

Key T2 activities to testKey T2 activities to test who benefits from who benefits from

promising carepromising care

Outcomes researchOutcomes researchComparative effectivenessComparative effectiveness

ResearchResearch

Health services researchHealth services research

Key T3 activities to testKey T3 activities to test how to deliver high-qualityhow to deliver high-quality

care reliably and incare reliably and in all settingsall settings

Measurement and Measurement and accountability of healthaccountability of health care quality and costcare quality and cost

Implementation of Implementation of Interventions and healthInterventions and health care system redesigncare system redesign

Scaling and spread of Scaling and spread of effective interventionseffective interventions

Research in above domainsResearch in above domains

T1 T2 T3Basic biomedical

scienceClinical efficacy

knowledgeClinical effectiveness

knowledge

Improved health care quality and

value andpopulation health

Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp. 2319-2321. The “3T’s Roadmap to Transform U.S. Health Care: The ‘How’ of High-Quality Care.” Source: JAMA, May 21, 2008: D. Dougherty and P.H. Conway, pp. 2319-2321. The “3T’s Roadmap to Transform U.S. Health Care: The ‘How’ of High-Quality Care.”

The “3T’s” Road Map to Transforming U.S. Health CareThe “3T’s” Road Map to Transforming U.S. Health Care

Future ChallengesFuture Challenges

Downstream effects of policy applicationsDownstream effects of policy applications Making sure that comparative effectiveness Making sure that comparative effectiveness

is “descriptive, not prescriptive”is “descriptive, not prescriptive” Creating a level playing field among all Creating a level playing field among all

stakeholdersstakeholders Ensuring that information is presented to Ensuring that information is presented to

clinicians and consumers so they can clinicians and consumers so they can actually use itactually use it

Funding OpportunitiesFunding Opportunities

Opportunities for the field to become Opportunities for the field to become involved will be made available as soon involved will be made available as soon as possible:as possible:– To sign up for updates, visit To sign up for updates, visit

http://effectivehealthcare.ahrq.gov

– To review AHRQ’s standing program and To review AHRQ’s standing program and training award announcements training award announcements http://www.ahrq.gov/fund/grantix.htm

2009 AHRQ Annual Conference2009 AHRQ Annual Conference

““Research to Reform: Research to Reform: Achieving Health System Change”Achieving Health System Change”

September 13-16, 2009 September 13-16, 2009 Bethesda North Marriott Convention Center Bethesda North Marriott Convention Center

Bethesda, MDBethesda, MD

Sessions on topics including the following:Sessions on topics including the following:

- Increased Funding for Comparative Effectiveness Increased Funding for Comparative Effectiveness

- AHRQ’s Rapidly Expanding Health IT PortfolioAHRQ’s Rapidly Expanding Health IT Portfolio

- Implementation of Research Findings into Changes Implementation of Research Findings into Changes in Practice and Policyin Practice and Policy

MARK YOUR CALENDARS!

Comparative Effectiveness and the Comparative Effectiveness and the American Recovery Reinvestment American Recovery Reinvestment Act of 2009 (ARRA)Act of 2009 (ARRA)

AHRQ’s Role in Comparative AHRQ’s Role in Comparative EffectivenessEffectiveness

Comparative Effectiveness Comparative Effectiveness Research and IT: The Future?Research and IT: The Future?

Q&AQ&A

Health Policy Research Health Policy Research in the 21in the 21stst Century Century