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EvidenceEvidence--Based Care: Based Care: The New Imperative in QualityThe New Imperative in Quality

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDi tDi tDirectorDirector

Agency for Healthcare Research and QualityAgency for Healthcare Research and QualityNCSL Legislative Summit 2011NCSL Legislative Summit 2011

San Antonio, TX San Antonio, TX –– August 9, 2011August 9, 2011

All Health Care is LocalAll Health Care is Local

“Until a community “Until a community f t h tf t h tconfronts what goes on confronts what goes on

in its own population in its own population ——to the point of actually to the point of actually seeking the data and seeking the data and engaging those who engaging those who can solve the problemcan solve the problemcan solve the problem can solve the problem —— nothing will change.”nothing will change.”

AtulAtul GawandeGawande

10 Steps to Better Health Care10 Steps to Better Health Care, A , A GawandeGawande, D Berwick, E Fisher, M McClellan. New York Times, 08/13/2009, D Berwick, E Fisher, M McClellan. New York Times, 08/13/2009

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Putting the Patient Putting the Patient at the Center of Careat the Center of Care

PatientPatient--centeredness:centeredness:The final frontier?The final frontier?

PatientPatient--centeredness may centeredness may be the most challenging of be the most challenging of all six domains of quality, all six domains of quality, because it is so difficult to because it is so difficult to define and measuredefine and measureBut, it is also likely the most But, it is also likely the most important, because it important, because it includes elements of all includes elements of all other domainsother domains

EvidenceEvidence--Based Care: Based Care: The New Imperative in QualityThe New Imperative in Quality

AHRQ Resources andAHRQ Resources andAHRQ Resources and AHRQ Resources and PrioritiesPrioritiesQuality and Disparities Quality and Disparities OverviewOverview2121stst Century HealthCentury Health2121 Century Health Century Health CareCareQ & AQ & A

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HHS Organizational FocusHHS Organizational Focus

NIHNIHBiomedicalBiomedical

CDCCDCPopulation healthPopulation health

AHRQAHRQLongLong--term &term &Biomedical Biomedical

research to research to prevent, prevent, diagnose & treat diagnose & treat diseasesdiseases

Population health Population health & the role of & the role of communitycommunity--based based interventions to interventions to improve healthimprove health

LongLong term & term & systemsystem--wide wide improvement of improvement of health care quality health care quality & effectiveness& effectiveness

AHRQ’s Focus and AHRQ’s Focus and Strategic GoalsStrategic Goals

QualityQuality:: Deliver the right care at the right time Deliver the right care at the right time to the right patient to the right patient SafetySafety:: Reduce the risk of harm by promoting Reduce the risk of harm by promoting delivery of the best possible health caredelivery of the best possible health careEfficiencyEfficiency:: Enhance access to effective health Enhance access to effective health care services and reduce unnecessary costscare services and reduce unnecessary costsEffectivenessEffectiveness:: Improve health care outcomes Improve health care outcomes by encouraging the use of evidence to make by encouraging the use of evidence to make more informed health care decisionsmore informed health care decisions

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Medicaid Medical Directors Medicaid Medical Directors Learning Network (MMDLN)Learning Network (MMDLN)

Senior clinical leaders from 42 states whose Senior clinical leaders from 42 states whose primary responsibility is quality and costprimary responsibility is quality and costprimary responsibility is quality and cost primary responsibility is quality and cost effectiveness of their Medicaid programseffectiveness of their Medicaid programsEmbraces a mission that focuses on:Embraces a mission that focuses on:–– Development and use of evidenceDevelopment and use of evidence--based based

medicinemedicine–– Measurement and improvement of health care Measurement and improvement of health care

litlitqualityquality–– Redesign of health care delivery systemsRedesign of health care delivery systems

Now developing and conducting multiNow developing and conducting multi--state state projects comparing data and policy projects comparing data and policy interventionsinterventions

MMDLN ProjectsMMDLN Projects

Antipsychotic Medication Use in Antipsychotic Medication Use in Medicaid Children and AdolescentsMedicaid Children and AdolescentsMedicaid Children and AdolescentsMedicaid Children and Adolescents–– Documented state variation in Medication Documented state variation in Medication

use, produced a data dictionary and use, produced a data dictionary and highlighted state efforts to modify utilizationhighlighted state efforts to modify utilization

ReadmissionsReadmissions1717 State project to collect stateState project to collect state levellevel–– 1717--State project to collect stateState project to collect state--level level readmission data for children, pregnant readmission data for children, pregnant women and Medicaidwomen and Medicaid--only covered adultsonly covered adults

–– Initial results showed state readmission Initial results showed state readmission rates ranged from 7.5% to 22.9% rates ranged from 7.5% to 22.9%

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AHRQ 2010 National Healthcare AHRQ 2010 National Healthcare Quality and Disparities ReportQuality and Disparities Report

Health care quality, access are Health care quality, access are suboptimal, especially for minority suboptimal, especially for minority and lowand low income Americansincome Americansand lowand low--income Americansincome AmericansQuality is improving by 2.3% per Quality is improving by 2.3% per year; access and disparities are notyear; access and disparities are notUrgent attention is needed to Urgent attention is needed to improve quality and reduce improve quality and reduce disparities for:disparities for:

Cancer screening diabetesCancer screening diabetes–– Cancer screening, diabetes Cancer screening, diabetes managementmanagement

–– States in central U.S. States in central U.S. –– InnerInner--city, rural areas city, rural areas –– Disparities in preventive service and Disparities in preventive service and

access to care access to care

www.ahrq.gov/qual/qrdr10.htmwww.ahrq.gov/qual/qrdr10.htm

Washington: Overall Care Washington: Overall Care Quality vs. All StatesQuality vs. All States

WeakWeakAverageAverage

Very Very WeakWeak

WeakWeak StrongStrong

Very Very StrongStrong

== Most Recent Year Most Recent Year = Baseline Year= Baseline Year

Performance Meter: All MeasuresPerformance Meter: All Measures

2010 2010 National Healthcare Quality Report, State SnapshotsNational Healthcare Quality Report, State Snapshots

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Washington Snapshot: Overall Washington Snapshot: Overall Health Care Quality MeasuresHealth Care Quality Measures

Measure Measure PerformancePerformance

% adults who needed care right away % adults who needed care right away for an illness, injury, or condition in the for an illness, injury, or condition in the last 12 months and got it as soon as last 12 months and got it as soon as wanted, Medicare managed carewanted, Medicare managed care

Better than Better than averageaverage

All cancer deaths per 100,000 All cancer deaths per 100,000 populationpopulation

AverageAveragepopulationpopulation

% of hospital patients with heart failure % of hospital patients with heart failure who were given complete written who were given complete written discharge instructionsdischarge instructions

Worse than Worse than average average

National Healthcare Quality Report, State SnapshotsNational Healthcare Quality Report, State Snapshots

Patient StoriesPatient Stories

People who improved their care by asking questions and People who improved their care by asking questions and exploring their treatment optionsexploring their treatment options

Annie Randolph lived with high blood pressure for Annie Randolph lived with high blood pressure for years, but she only got the upper hand on it when she years, but she only got the upper hand on it when she found good information about the sofound good information about the so--called “silent called “silent killer” and her treatment optionskiller” and her treatment options–– The Decatur, GA, resident was diagnosed with the The Decatur, GA, resident was diagnosed with the

condition by her doctor during a checkup in 1991 condition by her doctor during a checkup in 1991 –– She didn’t pay much attention to her condition until She didn’t pay much attention to her condition until

about five years ago, after she was hospitalized for a about five years ago, after she was hospitalized for a second timesecond time

–– “We didn’t really have much information in the past,” “We didn’t really have much information in the past,” she says. “Today, information is really easy for she says. “Today, information is really easy for consumers to find”consumers to find”

www.effectivehealthcare.gov/options/stories/www.effectivehealthcare.gov/options/stories/

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EHC Summary GuidesEHC Summary Guides

PolicymakersPolicymakers CliniciansClinicians ConsumersConsumers

Summarize research review findings on theSummarize research review findings on the benefits and harmsbenefits and harms of different treatment of different treatment options. Provide useful background on health conditions. Medication guides contain options. Provide useful background on health conditions. Medication guides contain basic wholesale price information. basic wholesale price information. Consumer Guides available in Spanish.Consumer Guides available in Spanish.

2121stst Century Health CareCentury Health Care

Unprecedented national Unprecedented national investment in health careinvestment in health careFunding for data infrastructure, Funding for data infrastructure, new evidence, spread of best new evidence, spread of best practicespracticesExpanded opportunities for Expanded opportunities for p ppp pppatientpatient--centered outcomes centered outcomes research and quality research and quality improvementimprovement

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Recovery Act Grant: WashingtonRecovery Act Grant: Washington

Comparative Effectiveness of LipidComparative Effectiveness of Lipid--Lowering and Lowering and Antihypertensive Medications Among HIVAntihypertensive Medications Among HIV--InfectedInfectedAntihypertensive Medications Among HIVAntihypertensive Medications Among HIV--Infected Infected Individuals Individuals –– Washington State UniversityWashington State University–– Decrease in mortality through improvements in Decrease in mortality through improvements in

antiretroviral therapy has been accompanied by antiretroviral therapy has been accompanied by increases in complications such as hypertensionincreases in complications such as hypertension

–– Project will analyze cardiovascular disease risk factors Project will analyze cardiovascular disease risk factors associated with treating HIV patientsassociated with treating HIV patients

–– The Centers for AIDS Research Network of Integrated The Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) database will be the primary Clinical Systems (CNICS) database will be the primary source of clinical datasource of clinical data

Prioritization and Message DevelopmentPrioritization and Message DevelopmentExample:Example:

New Diabetes CERNew Diabetes CER

•• Media campaignMedia campaign

Patient Centered Outcomes Research Dissemination Framework

National awareness of CER and specific findingsNational awareness of CER and specific findings

Deeper awareness of CER and findings at Deeper awareness of CER and findings at regional, local, or system levelregional, local, or system level

Publicity CenterPublicity Center

Regional OfficesRegional Offices

EvaluatEvaluat

•• Media campaignMedia campaign•• Outreach to national orgs (i.e. Outreach to national orgs (i.e. 

ADA, AADE, Endocrine Society, ADA, AADE, Endocrine Society, AACE)AACE)

•• Outreach to consumersOutreach to consumers

•• Integrate message into Integrate message into Diabetes packageDiabetes package

•• Promote via regional/State Promote via regional/State chapters of national orgs, local chapters of national orgs, local advocacy orgs, and regional advocacy orgs, and regional h lth  th lth  t

Individual clinician Individual clinician education and practiceeducation and practice‐‐level implementationlevel implementation

Academic DetailingAcademic Detailing& & 

Online CEOnline CE

tiontionhealth systemshealth systems

•• Integrate clinical message into Integrate clinical message into Diabetes AD packageDiabetes AD package

•• Promote/discuss in individual Promote/discuss in individual practice settingspractice settings

•• Create and promote CE Create and promote CE modules based on individual modules based on individual findings findings 

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Partnership for Patients: Partnership for Patients: Better Care Lower CostsBetter Care Lower Costs

New opportunity to improve New opportunity to improve

Up to $1 billion in funding provided from the Affordable Care ActUp to $1 billion in funding provided from the Affordable Care Act

the safety of health care the safety of health care through publicthrough public--private private collaborationcollaborationOpen to hospitals, doctors, Open to hospitals, doctors, nurses, pharmacists and other nurses, pharmacists and other health professionals, health professionals, employers unions patientemployers unions patientemployers, unions, patient employers, unions, patient advocates, health plans and advocates, health plans and othersothersMore than 1,500 have already More than 1,500 have already signed the pledgesigned the pledge

www.healthcare.gov/center/programs/partnershipwww.healthcare.gov/center/programs/partnership

National Quality Strategy:National Quality Strategy:Three Broad AimsThree Broad Aims

Improve the overall quality by makingImprove the overall quality by making

Created Under the Affordable Care ActCreated Under the Affordable Care Act

Better CareBetter CareImprove the overall quality, by making Improve the overall quality, by making health care more patienthealth care more patient--centered, centered, reliable, accessible and safereliable, accessible and safe

Healthy People/Healthy People/Healthy CommunitiesHealthy Communities

Improve the health of the U.S. Improve the health of the U.S. population by supporting proven population by supporting proven interventions to address behavioral, interventions to address behavioral, social and environmental determinants social and environmental determinants

www.healthcare.gov/center/reports/quality03212011a.htmlwww.healthcare.gov/center/reports/quality03212011a.html

of health, in addition to delivering of health, in addition to delivering higherhigher--quality care quality care

Affordable CareAffordable CareReduce the cost of quality health care Reduce the cost of quality health care for individuals, families, employers and for individuals, families, employers and governmentgovernment

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FORCEFORCE--TJR: Centers and SitesTJR: Centers and Sites

Function and Outcomes Research for Comparative Effectiveness in total Joint Replacement (FORCE-TJR)

Collecting data Collecting data on 30,000 on 30,000 patients on patients on functions functions includingincludingDeveloping Developing t l ft l ftools for tools for patientpatient--centered centered outcomes outcomes researchresearch

Ad Campaign Encourages Patients Ad Campaign Encourages Patients To Explore Treatment OptionsTo Explore Treatment Options

AHRQ, Ad Council launch AHRQ, Ad Council launch multimedia ad campaign: multimedia ad campaign: “E l Y T t t“E l Y T t t“Explore Your Treatment “Explore Your Treatment Options”Options”–– Encourages patients to ask Encourages patients to ask

about all options before about all options before choosing a treatmentchoosing a treatment

–– Features patient stories that Features patient stories that demonstrate how researchdemonstrate how researchdemonstrate how research demonstrate how research leads to better treatmentleads to better treatment

–– Encourages patients to Effective Encourages patients to Effective Health Care Program summary Health Care Program summary guidesguides

www.effectivehealthcare.ahrq.gov/optionswww.effectivehealthcare.ahrq.gov/options

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PreguntasPreguntas Campaign: Campaign: AHRQ and the Ad CouncilAHRQ and the Ad Council

ConoceConoce laslas PreguntasPreguntas(Know the Questions), (Know the Questions), a new multimediaa new multimediaa new, multimedia a new, multimedia SpanishSpanish--language language campaigncampaignNational public service National public service campaign featuring campaign featuring television, radio, print television, radio, print and Web adsand Web adsSupports HHS plan to Supports HHS plan to reduce health reduce health disparities among disparities among racial and ethnic racial and ethnic minoritiesminorities

www.ahrq.gov/preguntaswww.ahrq.gov/preguntas

Future DirectionsFuture Directions

Promote value by seizing opportunities emerging Promote value by seizing opportunities emerging with the increasing attention being paid to with the increasing attention being paid to t t e c eas g atte t o be g pa d tot t e c eas g atte t o be g pa d totransforming the nation’s health care systemtransforming the nation’s health care system−− Form alliances, partnerships and Form alliances, partnerships and

other strategies that promote other strategies that promote collaborationcollaboration

−− Further Further promote the use of promote the use of comparative research into comparative research into the the broader health care transformationbroader health care transformationbroader health care transformation broader health care transformation efforteffort

−− Address the gaps that exist between Address the gaps that exist between our ability to generate data and our ability to generate data and having the capacity having the capacity for it to be used for it to be used “right now”“right now”

For AHRQ Funding Opportunities: For AHRQ Funding Opportunities: http://www.ahrq.gov/fund http://www.ahrq.gov/fund

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Thank YouThank You

AHRQ Mission AHRQ Mission To improve the quality, safety, To improve the quality, safety, efficiency, and effectiveness of efficiency, and effectiveness of health care for all Americanshealth care for all Americans

AHRQ VisionAHRQ VisionAs a result of AHRQ's efforts, As a result of AHRQ's efforts, American health care willAmerican health care will

www.ahrq.govwww.ahrq.gov

American health care will American health care will provide services of the highest provide services of the highest quality, with the best possible quality, with the best possible outcomes, at the lowest outcomes, at the lowest cost0cost0