Methods for Quality Improvement Methods for Quality Improvement Research: AHRQ Introduction Research: AHRQ Introduction

Denise Dougherty, Ph.D.Denise Dougherty, Ph.D.Office of Extramural Research, Office of Extramural Research,

Education, and Priority PopulationsEducation, and Priority PopulationsJune 2004June 2004

AHRQ’s Mission StatementAHRQ’s Mission Statement

To improve the quality and safety, efficiency To improve the quality and safety, efficiency and effectiveness, of health care for all and effectiveness, of health care for all AmericansAmericans

Selected Quality Challenges in U.S. Selected Quality Challenges in U.S. Health CareHealth Care

Cancer – rate of women diagnosed at advanced stages has Cancer – rate of women diagnosed at advanced stages has not declined over last several years, while other cancer rates not declined over last several years, while other cancer rates havehave

Diabetes – Diabetes – – 1/5 of patients got all 5 recommended tests in 20001/5 of patients got all 5 recommended tests in 2000– No eye or foot exam for 1/3 of patientsNo eye or foot exam for 1/3 of patients

Heart disease –Heart disease –– Only 25% of people with high blood pressure have it under controlOnly 25% of people with high blood pressure have it under control– < 50% of acute heart attack patients are advised to quit smoking in < 50% of acute heart attack patients are advised to quit smoking in

the hospitalthe hospital– 69% of heart attack patients get beta blockers on admission69% of heart attack patients get beta blockers on admission

Quality Challenges (2)Quality Challenges (2)

HIV-AIDS – AIDS incidence increased in ’02HIV-AIDS – AIDS incidence increased in ’02 Mental health – 80% of adult patients diagnosed with Mental health – 80% of adult patients diagnosed with

depression do not have optimal levels of contact with a health depression do not have optimal levels of contact with a health care providercare provider

Respiratory disease – black children are nearly twice as likely Respiratory disease – black children are nearly twice as likely to be admitted to a hospital for asthma as white childrento be admitted to a hospital for asthma as white children

Children are nearly twice as likely as adults to get an Children are nearly twice as likely as adults to get an antibiotic for a common coldantibiotic for a common cold

Patient safety – HP2010 targets for hospital-acquired Patient safety – HP2010 targets for hospital-acquired infections are not being metinfections are not being met

Source: National Healthcare Quality Report, 2003. Source: National Healthcare Quality Report, 2003.

4 Interacting Levels for Changing the 4 Interacting Levels for Changing the SystemSystem

Public PolicyPublic Policy

Health systems and plansHealth systems and plans

Clinical microsystemsClinical microsystems

PatientPatient

Sources: Berwick; ShortellSources: Berwick; Shortell

AHRQ funding announcements AHRQ funding announcements Improvement/Implementation researchImprovement/Implementation research

REACHES (forthcoming)REACHES (forthcoming) THQIT RFAs (2004)THQIT RFAs (2004) PBRNS and TRIP PA PBRNS and TRIP PA

(2004)(2004) TRIP 2 RFAs and 2 PAs TRIP 2 RFAs and 2 PAs Innovations in Organization Innovations in Organization

and Financing to Improve and Financing to Improve Cost, Quality, Access PACost, Quality, Access PA

Partnerships for Quality Partnerships for Quality RFA (2002)RFA (2002)

Health Disparities Health Disparities Collaboratives Evaluation Collaboratives Evaluation (RFA—Chin and (RFA—Chin and Guadagnoli)Guadagnoli)

Quality Improvement RFA Quality Improvement RFA (1998)(1998)

Translational research in Translational research in diabetes PA (jointly with diabetes PA (jointly with NIH and CDC)NIH and CDC)

Other Agencies’ Improvement/Implementation Other Agencies’ Improvement/Implementation Announcements (Selected)Announcements (Selected)

NIMHNIMH– STATE IMPLEMENTATION OF EVIDENCE-BASED STATE IMPLEMENTATION OF EVIDENCE-BASED

PRACTICES PRACTICES (RFA 2002—NIMH AND SAMHSA)(RFA 2002—NIMH AND SAMHSA)

– DISSEMINATION AND IMPLEMENTATION RESEARCH DISSEMINATION AND IMPLEMENTATION RESEARCH IN MENTAL HEALTHIN MENTAL HEALTH (PA 2001-NIMH)(PA 2001-NIMH)

– EFFECTIVENESS, PRACTICE, AND EFFECTIVENESS, PRACTICE, AND IMPLEMENTATION IN CMHS’ CHILDREN’S SERVICE IMPLEMENTATION IN CMHS’ CHILDREN’S SERVICE SITES SITES (PA 2003 – NIMH)(PA 2003 – NIMH)

– IMPLEMENTATION OF INTERVENTION STRATEGIES IMPLEMENTATION OF INTERVENTION STRATEGIES FOR CHILDREN WITH DISRUPTIVE BEHAVIORS FOR CHILDREN WITH DISRUPTIVE BEHAVIORS (RFA 2000-NIMH)(RFA 2000-NIMH)

Other Selected (2)Other Selected (2)

OTHER NIH:OTHER NIH:– COMMUNITY IMPLEMENTATION OF HIV COMMUNITY IMPLEMENTATION OF HIV

PREVENTION INTERVENTIONS PREVENTION INTERVENTIONS (RFA 2001--NIMH, NIDA, NINR)(RFA 2001--NIMH, NIDA, NINR)

– INTERVENTIONS TO IMPROVE INTERVENTIONS TO IMPROVE HYPERTENSION CONTROL RATES IN HYPERTENSION CONTROL RATES IN AFRICAN AMERICANS AFRICAN AMERICANS (RFA 2004—NHLBI)(RFA 2004—NHLBI)

NIH Implementation/Improvement NIH Implementation/Improvement AwardsAwards

– NHLBI Guideline Implementation RCTs NHLBI Guideline Implementation RCTs (Diette, Cloutier, Cabana, Crabtree)(Diette, Cloutier, Cabana, Crabtree)

– Improving Use of ADHD guidelines Improving Use of ADHD guidelines (Bickman, NIMH grant) (Bickman, NIMH grant)

– Quality Improvement School Mental Health Quality Improvement School Mental Health Services Services (Kataoka-Endo, NIMH K award)(Kataoka-Endo, NIMH K award)

– Quality improvement for Depression Quality improvement for Depression (Rubinstein, NIMH award)(Rubinstein, NIMH award)

NIH Awards (2)NIH Awards (2)

Pathways to overcoming disparities in depression Pathways to overcoming disparities in depression – (Wells, NIMH award)(Wells, NIMH award)

Improving Diabetes by Primary Care Translation Improving Diabetes by Primary Care Translation (IMPACT) (IMPACT) – (Peterson, DK project)(Peterson, DK project)

Improving Palliative Care for Patients with Cancer Improving Palliative Care for Patients with Cancer – (Ahles, CA project)(Ahles, CA project)

Selected publications from AHRQ-Selected publications from AHRQ-supported QI/TRIP researchsupported QI/TRIP research

Glasgow, R.E., Bull, S.S. (2001). "Making a difference with Glasgow, R.E., Bull, S.S. (2001). "Making a difference with interactive technology: considerations in using and evaluating interactive technology: considerations in using and evaluating computerized aids for computerized aids for diabetes self-management diabetes self-management educationeducation." ." Diabetes SpectrumDiabetes Spectrum, Vol. 14, pp. 99-106, Vol. 14, pp. 99-106

Scribano, P.V., Lerer, T., Kennedy, D., Cloutier, M.M. (2001). Scribano, P.V., Lerer, T., Kennedy, D., Cloutier, M.M. (2001). "Provider adherence to a clinical practice guideline for "Provider adherence to a clinical practice guideline for acute acute asthma in a pediatric emergency departmentasthma in a pediatric emergency department." ." Academic Academic Emergency MedicineEmergency Medicine, Vol. 8, pp. 1147-1152 , Vol. 8, pp. 1147-1152

Margolis P, et al., Practice based education to improve Margolis P, et al., Practice based education to improve delivery systems for delivery systems for prevention in primary careprevention in primary care: : randomised trial.randomised trial.BMJ. 2004 Feb 14;328(7436):388. Epub 2004 Feb 06. BMJ. 2004 Feb 14;328(7436):388. Epub 2004 Feb 06.

Selected publications (continued)Selected publications (continued)

Shafer MA, et al., Effect of a clinical practice improvement Shafer MA, et al., Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls.intervention on Chlamydial screening among adolescent girls.JAMA. 2002 Dec 11;288(22):2846-52. JAMA. 2002 Dec 11;288(22):2846-52.

Casebeer, et al., Designing tailored Web-based instruction to Casebeer, et al., Designing tailored Web-based instruction to improve practicing physicians' preventive practices.improve practicing physicians' preventive practices.J Med Internet Res. 2003 Jul-Sep;5(3):e20. J Med Internet Res. 2003 Jul-Sep;5(3):e20.

Upcoming PAs—What Will AHRQ Be Upcoming PAs—What Will AHRQ Be Looking for?Looking for?

InterventionsInterventions Reach and generalizabilityReach and generalizability Beyond direct attempts in single settings to “change Beyond direct attempts in single settings to “change

provider behavior”provider behavior” Sample questions:Sample questions:

– Interventions that demonstrate the forces and Interventions that demonstrate the forces and processes that will support adoption of promising processes that will support adoption of promising innovations and system changes and development of innovations and system changes and development of routines that sustain improvements? routines that sustain improvements?

– Which interventions work best when they are bundled Which interventions work best when they are bundled with other practices to create systemic change? with other practices to create systemic change?

Solid research designs Solid research designs – Difficult to do; we are working on itDifficult to do; we are working on it

Suggestions/CaveatsSuggestions/Caveats

Suggestion: work with colleagues who Suggestion: work with colleagues who understand organizational behavior and understand organizational behavior and systems systems

Caveat: Appropriate single-setting research Caveat: Appropriate single-setting research on limited innovative interventions may still be on limited innovative interventions may still be necessary and appropriate. Make the case!necessary and appropriate. Make the case!

For more information about AHRQ For more information about AHRQ fundingfunding

Debbie Rothstein, Ph.D.Debbie Rothstein, Ph.D.– Senior Advisor, Extramural ResearchSenior Advisor, Extramural Research– Office of Extramural Research, Education, and Office of Extramural Research, Education, and

Priority Populations (OEREP)Priority Populations (OEREP)– drothste@ahrq.govdrothste@ahrq.gov

Francis Chesley, MDFrancis Chesley, MD– Director, OEREPDirector, OEREP– fchesley@ahrq.govfchesley@ahrq.gov

http://www.ahrq.gov/fund/http://www.ahrq.gov/fund/