Patients at the Center:Guidelines for Effectiveness

Carolyn M. Clancy, MD

Director

Agency for Healthcare Research and Quality

New York Academy of Medicine Conference on E-GAPPS

New York, NY – December 10, 2012

What We Know

“The truth is that for a large part of medical practice, we don’t know what works. But we pay for it anyway.”

H. Gilbert Welch, MDGeisel School of Medicine

at Dartmouth

Testing What We Think We Know. New York Times - August 19, 2012

Health System Transformation: Current and Future

Current Future

Variable quality; expensive, wasteful

Consistently better quality; lower cost, more efficient

Pay for volume Pay for quality

Pay for transactions Care-based episodes

Quality assessment based on provider and setting (process)

Quality assessment based on patient experience (outcomes)

Patients at the Center:Guidelines for Effectiveness

Making the Case: Health Care Quality and Disparities

Learning More about What We Know

The Role of Guidelines Questions

CDC

Population health and the role of

community based interventions to improve health

NIH AHRQ

Long-term and system-wide

improvement of health care quality and effectiveness

Biomedical Research to

prevent, diagnose and treat disease

HHS Organizational Focus

AHRQ 2011 National Healthcare Quality and Disparities Reports

Overall, improvement in the quality of care remains suboptimal

Few disparities in quality are getting smaller

Quality of care varies not only across types of care but also across parts of the country

Progress is Uneven Toward National Priority Areas

2011 Findings: – Health care quality and access are suboptimal,

especially for minority and low-income groups– Quality is improving; access and disparities are not– Urgent attention needed to ensure continued

improvement in quality and progress on reducing disparities for services, geographic areas and populations, including: Diabetes care and adverse events Disparities in cancer screening and access to care States in the South

Reports include evidence of progress toward priorities identified in National Quality Strategy and HHS Plan to Reduce Racial and Ethnic

Health Disparities

Quality Is Improving Slowly

Nearly 60 percent of health care quality measures tracked showed improvement

However, the median rate of change was 2.5 percent per year

AHRQ 2011 National Healthcare Quality and Disparities Reports

Quality measures that are improving, not changing or worsening, overall and for select populations

Few Disparities in Quality of Care Are Getting Smaller

Few disparities in quality showed significant improvement.

The number of disparities that were getting smaller exceeded the number that were getting larger

AHRQ 2011 National Healthcare Quality and Disparities Reports

Quality measures for which disparities related to age, race, ethnicity and income are improving, not changing or

worsening

New York: OverallQuality vs. All States

= Most Recent Year = Baseline Year

Performance Meter: All Measures

Very Weak

Weak

Average

Strong

Very Strong

National Healthcare Quality Report, State Snapshots

New York Snapshot:Quality Measures

Measure Performance

Adult admissions—diabetes, short-term complications

Better than average

CABG deaths in hospital Average

Deaths per 1,000 admissions in low-mortality DRGs

Worse than average

National Healthcare Quality Report, State Snapshots

National Quality Strategy:Three Broad Aims

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

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

Healthy People/Healthy Communities

Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health, in addition to delivering higher-quality care

Affordable CareReduce the cost of quality health care for individuals, families, employers and government

Created Under the Affordable Care Act

There Has Been Considerable Progress: For Example…

Unprecedented national investment in health care research, access, delivery

Funding for data infrastructure, new evidence, dissemination of best practices

Wider opportunities for patient-centered outcomes research and quality improvement

Patients at the Center:Guidelines for Effectiveness

Making the Case: Health Care Quality and Disparities

Learning More about What We Know

The Role of Guidelines Questions

Research that Addresses Patient Outcomes

Patient-centeredness may be the most challenging of all 6 domains of quality, because it is so difficult to define and measure

But, it is also likely the most important, because it includes elements of all other domains

Patient-Centeredness: The final frontier?

Implementing Evidence-Based Treatment Decisions

Which treatments work, for which patients, and what are the trade-offs? – Patient-centered outcomes research informs

decisions by providing evidence and information on effectiveness, benefits and harms

How can evidence-based improvements be translated and shared with providers, patients?– Effective Health Care Clinician and Consumer

Summaries– Continuing Medical Education – Center for Medicare and Medicaid Innovation; AHRQ

Innovation Exchange

Until Recently, Few Tools to Get From Evidence to Practice

AHRQ is working to:– Translate scientific

advances into actual clinical practice

– Translate scientific advances into usable information for clinicians and for patients

– Deliver information in the right places at the right time

The Patient-Centered Outcomes Research Trust Fund and AHRQ

Provides funding for AHRQ to disseminate research findings of the Institute and other government-funded research, train and build capacity for research – Up to 20% of Patient-Centered

Outcomes Research Trust Fund can be used to support research capacity building and dissemination activities

Patients at the Center:Guidelines for Effectiveness

Making the Case: Health Care Quality and Disparities

Learning More about What We Know

The Role of Guidelines Questions

National Guideline Clearinghouse

Originally a public/private partnership with the American Medical Association and American Association of Health Plans

Emphasis on transferring evidence-based knowledge to health care professionals

NGC went live 12/15/98

http://guideline.gov

Facts About NGC

More than 2,300 guideline summaries from 275 organizations

More than 30 guideline comparisons (syntheses)

More than 6,500 citations in the annotated bibliography

More than 63,000 subscribers to the “What’s New” email service

http://guideline.gov

New, Updated, and Withdrawn Guidelines

IOM Reports

What’s In a Definition?

IOM 2009 Clinical practice

guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances

IOM 2011 Clinical practice

guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options

NGC: Next Steps & Time Estimates – IOM Trustworthiness

1Q 2013

Announce Revised Inclusion Criteria

2Q 2013

Apply Inclusion Criteria to New and Updated Guidelines

(“Grandfather”)

3Q 2013 4Q 2013 1Q 2014 2Q 2014 3Q 2014 4Q 2014 1Q 2015

6 Months

Develop, Test Approach to Indicating Extent to Which

Guidelines Adhere to IOM Standards

Inclusion Criteria

Begin Phased Implementation

of Approach

Extent Adherence to

IOM

Calendar Year

Timeline for AHRQ and NGC actions involving IOM Standards for Developing Trustworthy Guidelines

A Matter of Trust

Systematic review of the existing evidence

Developed by multidisciplinary panel of experts

Consider patient subgroups and preferences

Explicit and transparent process Clear explanation of relationships

between alternative care options and health outcomes

Reconsidered and revised as appropriate

Measures of CPG Trustworthiness

Eight Standards for Developing Trustworthy CPGs

Establishing transparency Management of conflict of

interest Guideline development group

composition Clinical practice guideline–

systematic review intersection Establishing evidence

foundations for and rating strength of recommendations

Articulation of recommendations External review Updating

Implications for Clinical Practice Guidelines

CPGs must comprise actionable statements

Future CPGs will be embedded in information systems collaborations with human factors, engineers, others

CPGs are about both ‘what’ – and ‘how’

Improved quality supply chain links CPGs, quality measures and data sources

Eisenberg Center Symposium:September 2012

What do we do when new evidence challenges conventional wisdom?– When evidence challenges established

clinical practice– Consumers receiving mixed messages– Media focus on emerging research,

conflict rather than established practice

Conclusions– Clear and concise messages!– Transparency in generating evidence and

recommendations– Ongoing stakeholder input; work with

trusted sources– “Meeting people where they are at”

The “Quality Supply Chain”

Significant activity recently on provider performance measurement

Less clear is the basis for existing measures

Health IT sometimes considered a silver bullet– Digitized data “self-

assembles”– Clinical decision

support

USPSTF: New Steps Designed to Increase Transparency

The Task Force now requests public comment throughout the recommendation process

USPSTF is also developing stakeholder groups

Organizations and individuals are encouraged to sign up for the Task Force listserv to receive updates on the latest activities

New Product for Consumers

www.uspreventiveservicestaskforce.org/index.html

The final Recommendation and supporting Evidence Report are posted on the Task Force Web site.

Final Recommendations also are made available through electronic tools, peer-reviewed journals, and consumer guides.

The Task Force reviews all comments, addresses them as appropriate, and creates a final Recommendation.

Members vote to ratify the final Recommendation.

The draft Recommendation is posted on the USPSTF Web site for public comment.

The Evidence Report is finalized and published.

The draft Evidence Reportis posted on the USPSTF Web site for public comment. (Future Step in 2013)

The EPC reviews all comments, addresses them as appropriate, and creates a final Evidence Report.

Using the final Research Plan,the research team at the EPC independently gathers and reviewsthe available published evidenceand creates a draft Evidence Report.

The draft Evidence Report is critiqued by external national subject matter experts.

The draft Research Plan isposted on the USPSTF Web site for public comment.

The Task Force and EPC review all comments, address them as appropriate, and create a final Research Plan.

Task Force members work with researchers from an Evidence-based Practice Center (EPC) to create a draft Research Plan that guides the recommendation process.

Develop Research PlanPublic Comment

Opportunity Develop Evidence Report Public Comment Opportunity

Task Force members discuss the Evidence Report and deliberate on the effectiveness of the service.

Based on the discussion, Task Force members create a draft Recommendation.

Develop RecommendationPublic Comment

Opportunity Finalize RecommendationPublish & Disseminate Final

Recommendation

Recommendation Process

Key Considerations

Guidelines will remain central to the provision of safe, high-quality care

Much of the measurement enterprise is “evolving”

Collective interest in using guidelines that reflect the profession’s knowledge and authority

Disparate stakeholders must be engaged

The patient always comes first!

Questions?

www.ahrq.gov

AHRQ Mission

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

AHRQ Vision

As a result of AHRQ's efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest cost