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AHRQAHRQ’’ss Effective Health Care Program: Effective Health Care Program: Integrating Comparative Effectiveness Integrating Comparative Effectiveness

Research into Everyday PracticeResearch into Everyday Practice

Tuesday, October 12, 2010Tuesday, October 12, 20102:002:00--3:30 p.m. ET3:30 p.m. ET

Questions Questions

To submit a question: To submit a question:

–– Press the Press the ““Ask a QuestionAsk a Question”” button located at the button located at the bottom of the screen. bottom of the screen.

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–– Once completed, press the Once completed, press the ““SendSend”” button. button.

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AgendaAgenda

IntroductionIntroduction-- Stephanie Chang, M.D. (Facilitator)Stephanie Chang, M.D. (Facilitator)

Integrating Comparative Effectiveness Research into Practice Integrating Comparative Effectiveness Research into Practice --Carolyn M. Clancy, M.D. Carolyn M. Clancy, M.D.

Q&A from Audience Q&A from Audience

PatientPatient--Centered Outcomes Research and the Effective Health Care Centered Outcomes Research and the Effective Health Care Program Program -- Jean Slutsky, P.A., M.S.P.H.Jean Slutsky, P.A., M.S.P.H.

Q&A from Audience Q&A from Audience

Physician ImplementationPhysician Implementation-- Amir Qaseem, M.D., Ph.D., M.H.A., FACP Amir Qaseem, M.D., Ph.D., M.H.A., FACP –– American College of PhysiciansAmerican College of Physicians

Nurse Practitioner ImplementationNurse Practitioner Implementation-- Mary Jo Goolsby, Mary Jo Goolsby, Ed.DEd.D., M.S.N., ., M.S.N., ANPANP--C C –– American Association of Nurse PractitionersAmerican Association of Nurse Practitioners

Patient ImplementationPatient Implementation-- Nilay Shah, M.S., Ph.D. Nilay Shah, M.S., Ph.D. -- Mayo ClinicMayo Clinic

Q&A from AudienceQ&A from Audience 33

Questions Questions

To submit a question: To submit a question:

–– Press the Press the ““Ask a QuestionAsk a Question”” button located at the button located at the bottom of the screen. bottom of the screen.

–– When you click on the button, a box will appear at the When you click on the button, a box will appear at the bottom of your screen requesting that you to enter bottom of your screen requesting that you to enter your eyour e--mail address and your question. mail address and your question.

–– Once completed, press the Once completed, press the ““SendSend”” button. button.

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Integrating Comparative Integrating Comparative Effectiveness Research into Effectiveness Research into

PracticePractice

Carolyn M. Clancy, Carolyn M. Clancy, M.D.M.D.

AHRQ DirectorAHRQ Director

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AHRQAHRQ’’s Missions Mission

Improve the quality, safety, efficiency and Improve the quality, safety, efficiency and effectiveness of health care for effectiveness of health care for allall AmericansAmericans

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AHRQ PortfoliosAHRQ Portfolios

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Keeping the Patient at the CenterKeeping the Patient at the Center

Patients are more Patients are more involved in their involved in their carecare

Each patient is Each patient is differentdifferent

Patients need Patients need reliable, relevant, reliable, relevant, and and understandable understandable informationinformation

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Comparative Effectiveness Research Comparative Effectiveness Research

BenefitsHarms

Focuses on Focuses on patientpatient--centered outcomescentered outcomes

Unbiased and practical, evidenceUnbiased and practical, evidence--based based information information

Compares drugs, devices, tests and surgeries, Compares drugs, devices, tests and surgeries, and approaches to health care and approaches to health care –– benefits and harms benefits and harms –– what is known and what isnwhat is known and what isn’’tt

Descriptive, not prescriptiveDescriptive, not prescriptive

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What can comparative effectiveness What can comparative effectiveness research do for you?research do for you?

Help make decisions more consistent, Help make decisions more consistent, transparent and rationaltransparent and rational

Clarify nature of disputes over practice Clarify nature of disputes over practice and policyand policy

Help inform quality improvement Help inform quality improvement effortsefforts

Help patients make decisions about Help patients make decisions about their own caretheir own care

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An Unprecedented Investment in An Unprecedented Investment in Comparative Effectiveness ResearchComparative Effectiveness Research

20052005--2009 2009 -- AHRQ received $129 million from AHRQ received $129 million from Congress for comparative effectiveness researchCongress for comparative effectiveness research

2009 2009 -- The American Recovery and Reinvestment Act The American Recovery and Reinvestment Act contained $1.1 billion for comparative effectiveness contained $1.1 billion for comparative effectiveness research, including $300 million to AHRQresearch, including $300 million to AHRQ–– Stakeholder Input and InvolvementStakeholder Input and Involvement–– Horizon ScanningHorizon Scanning–– Evidence SynthesisEvidence Synthesis–– Evidence Gap IdentificationEvidence Gap Identification–– Evidence GenerationEvidence Generation–– Research Training and Career Research Training and Career

DevelopmentDevelopment1313

Patient Protection and Patient Protection and Affordable Care ActAffordable Care Act

Section 6301: PatientSection 6301: Patient--Centered Outcomes ResearchCentered Outcomes Research

Name change: Comparative Effectiveness Research = Name change: Comparative Effectiveness Research = PatientPatient--Centered Outcomes ResearchCentered Outcomes Research

PatientPatient--Centered Outcomes Research InstituteCentered Outcomes Research Institute

–– Independent, nonprofit Institute with publicIndependent, nonprofit Institute with public--and privateand private--sector fundingsector funding

–– Sets priorities and coordinates with existing Sets priorities and coordinates with existing agencies that support patientagencies that support patient--centered outcomes research centered outcomes research

Prohibits findings to be construed as mandates on Prohibits findings to be construed as mandates on practice guidelines or coverage decisions and contains practice guidelines or coverage decisions and contains patient safeguardspatient safeguards

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Improving Health Care is a Improving Health Care is a Team SportTeam Sport

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Questions Questions

To submit a question: To submit a question:

–– Press the Press the ““Ask a QuestionAsk a Question”” button located at the button located at the bottom of the screen. bottom of the screen.

–– When you click on the button, a box will appear at the When you click on the button, a box will appear at the bottom of your screen requesting that you to enter bottom of your screen requesting that you to enter your eyour e--mail address and your question. mail address and your question.

–– Once completed, press the Once completed, press the ““SendSend”” button. button.

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PatientPatient--Centered Outcomes Centered Outcomes Research and the Effective Research and the Effective

Health Care ProgramHealth Care Program

Jean Slutsky, P.A., M.S.P.H.Jean Slutsky, P.A., M.S.P.H.Director, Director, AHRQAHRQ’’ss Center for Center for

Outcomes and EvidenceOutcomes and Evidence

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AHRQAHRQ’’ssEffective Health Care ProgramEffective Health Care Program

Created in 2005, authorized by Section 1013 of Created in 2005, authorized by Section 1013 of the Medicare Prescription Drug, Improvement, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and Modernization Act (MMA) of 2003

To improve the quality, effectiveness, and To improve the quality, effectiveness, and efficiency of health care delivered through efficiency of health care delivered through Medicare, Medicaid, and childrenMedicare, Medicaid, and children’’s programs s programs by focusing onby focusing on–– What is known What is known now now –– What research What research gapsgaps are critical to fillare critical to fill–– Clinical effectivenessClinical effectiveness

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Horizon Horizon ScanningScanning

EvidenceEvidenceNeedNeed

IdentificationIdentification

Evidence Evidence SynthesisSynthesis

EvidenceEvidenceGenerationGeneration

StrategiesStrategiesInterventionsInterventionsConditionsConditionsPopulationsPopulations

TranslationTranslation

DisseminationDissemination

ImplementationImplementation

ImprovementsImprovementsinin

Health CareHealth Care

Research PlatformResearch PlatformInfrastructure Infrastructure –– Methods Development Methods Development –– Training Training

A Framework for A Framework for PatientPatient--Centered Outcomes ResearchCentered Outcomes Research

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Research Focus: Research Focus: 14 Priority Conditions14 Priority Conditions

Arthritis and nonArthritis and non--traumatic joint disorderstraumatic joint disorders

CancerCancer

Cardiovascular disease, Cardiovascular disease, including stroke and including stroke and hypertensionhypertension

Dementia, including Dementia, including AlzheimerAlzheimer’’s Diseases Disease

Depression and other Depression and other mental health disordersmental health disorders

Developmental delays, Developmental delays, ADHD and autismADHD and autism

Diabetes mellitusDiabetes mellitus

Functional limitations and Functional limitations and disabilitydisability

Infectious disease Infectious disease including HIV/AIDSincluding HIV/AIDS

ObesityObesity

Peptic ulcer disease and Peptic ulcer disease and dyspepsiadyspepsia

Pregnancy including Pregnancy including preterm birthpreterm birth

Pulmonary Pulmonary disease/asthmadisease/asthma

Substance abuseSubstance abuse2020

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Research Focus: Research Focus: Priority PopulationsPriority Populations

LowLow--income groups income groups

Minority groups Minority groups

Women Women

Children Children

The elderly The elderly

Individuals with special healthIndividuals with special health--care needs, such as care needs, such as those with disabilities, those who need chronic care or those with disabilities, those who need chronic care or endend--ofof--life care, or those who live in innerlife care, or those who live in inner--city and city and rural areas rural areas 2121

Since 2005Since 2005……–– 25 Research Reviews25 Research Reviews–– 16 Research Reports16 Research Reports–– 36 Methods Research 36 Methods Research

Reports and Guidance Reports and Guidance documentsdocuments

–– 36 Consumer, Clinician 36 Consumer, Clinician GuidesGuides

and countingand counting……

Effective Health Care Program Effective Health Care Program ResearchResearch

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Effective Health Care Program Effective Health Care Program Translation ProductsTranslation ProductsExecutive Summary

Web Site

ClinicianGuide

ConsumerGuide Policymaker

Summary

Interactive Case Study

CE Modules

Faculty Slides

Patient Decision Aid(available soon)

Systematic Review Report

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Consumer GuidesConsumer Guides

Paired with clinician guides Paired with clinician guides to promote shared decision to promote shared decision makingmakingGuides available in Guides available in –– PrintPrint–– OnlineOnline–– Audio podcastsAudio podcasts–– Spanish translationsSpanish translations

http://effectivehealthcare.ahrq.gov/ 2424

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Get involved!Get involved!

–– Nominate topics onlineNominate topics online

–– Comment via the Web on draft key Comment via the Web on draft key questions and reportsquestions and reports

–– Share with colleagues and patientsShare with colleagues and patients

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Spreading the WordSpreading the Word

Get updates about the Get updates about the Effective Health Care Program Effective Health Care Program and alerts when new reports or and alerts when new reports or guides are available.guides are available.

Share the reports, Share the reports, guides, or other tools guides, or other tools with your colleagues with your colleagues

and patients.and patients.

Add buttons or widgets Add buttons or widgets to your website.to your website.

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Focus on the FindingsFocus on the Findings

Comparative Effectiveness of Comparative Effectiveness of ACEIsACEIs or or ARBsARBs Added Added to Standard Medical Therapy for Treating Stable to Standard Medical Therapy for Treating Stable Ischemic Heart DiseaseIschemic Heart Disease

Comparative Effectiveness and Safety of Oral Comparative Effectiveness and Safety of Oral Diabetes Medications for Adults with Type 2 DiabetesDiabetes Medications for Adults with Type 2 Diabetes

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The comparative effectiveness of different The comparative effectiveness of different combination treatments:combination treatments:

ACEI or ARB + Standard Therapy ACEI or ARB + Standard Therapy vsvs Standard Therapy AloneStandard Therapy AloneACEI + ARB + Standard Therapy ACEI + ARB + Standard Therapy vsvs ACEI + Standard TherapyACEI + Standard TherapyACEI or ARB + Standard Therapy ACEI or ARB + Standard Therapy vsvs Standard Therapy Alone Close Standard Therapy Alone Close to a Revascularization Procedureto a Revascularization Procedure

The benefits and harms associated with each The benefits and harms associated with each treatment modality.treatment modality.

The differences in the benefits or harms between The differences in the benefits or harms between various subpopulations of patients.various subpopulations of patients.

Key Questions for Evidence Synthesis: Key Questions for Evidence Synthesis: ACEI and ACEI and ARBsARBs for Stable Ischemic Heart Disease for Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Functionand Preserved Left Ventricular Systolic Function

Coleman CI, et al. AHRQ Comparative Effectiveness Review No. 18. October 2009. 2828

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Adding an Adding an ACEIACEI or an or an ARBARB can provide additional can provide additional clinical benefits for some patients. clinical benefits for some patients.

Adding an Adding an ACEIACEI may increase the risk of cough, may increase the risk of cough, syncope, or syncope, or hyperkalemiahyperkalemia..

Adding an Adding an ARBARB may increase the risk of may increase the risk of hyperkalemiahyperkalemia..

Adding an Adding an ACEIACEI does not impact cardiovascular does not impact cardiovascular mortality in patients with endmortality in patients with end--stage renal disease stage renal disease and left ventricular hypertrophy.and left ventricular hypertrophy.

Results of Evidence Synthesis: Results of Evidence Synthesis: ACEI and ACEI and ARBsARBs for Stable Ischemic Heart Disease for Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Functionand Preserved Left Ventricular Systolic Function

Coleman CI, et al. AHRQ Comparative Effectiveness Review No. 18. October 2009 2929

Comparative Effectiveness Review: Comparative Effectiveness Review: Oral Diabetes Medications for Adults Oral Diabetes Medications for Adults

With Type 2 DiabetesWith Type 2 Diabetes

Major Finding:Major Finding: MetforminMetformin, a blood , a blood glucose drug prescribed for type 2 glucose drug prescribed for type 2 diabetes, is less likely to cause weight diabetes, is less likely to cause weight gain and may be more likely than gain and may be more likely than other treatments to decrease bad other treatments to decrease bad cholesterolcholesterol

First analysis to summarize evidence First analysis to summarize evidence on the effectiveness and adverse on the effectiveness and adverse events for all approved oral events for all approved oral medications commonly used in the medications commonly used in the U.S. for type 2 diabetesU.S. for type 2 diabetes

AHRQ Comparative Effectiveness Review No. 8, Comparative EffectiAHRQ Comparative Effectiveness Review No. 8, Comparative Effectiveness and Safety of Oral Diabetes Medications for veness and Safety of Oral Diabetes Medications for Adults with Type 2 Diabetes, July 2007, Available at Adults with Type 2 Diabetes, July 2007, Available at www.effectivehealthcare.ahrq.govwww.effectivehealthcare.ahrq.gov 3030

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In the PipelineIn the Pipeline

More than 100 topicsMore than 100 topics–– Evidence Synthesis Evidence Synthesis –– Future Research NeedsFuture Research Needs–– Original ResearchOriginal Research–– Methods ResearchMethods Research

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How to Access ProductsHow to Access Products

AHRQ Website: AHRQ Website: www.effectivehealthcare.ahrq.govwww.effectivehealthcare.ahrq.gov

Full reports and summary guides for patients and cliniciansFull reports and summary guides for patients and cliniciansOpportunities to nominate research topics or comment on researchOpportunities to nominate research topics or comment on researchquestions and draft reportsquestions and draft reportsAudio files Audio files Spanish translations for consumer guidesSpanish translations for consumer guidesCE Activities CE Activities Faculty slides Faculty slides

AHRQ Publications ClearinghouseAHRQ Publications Clearinghouse: : (800) 358(800) 358--92959295

Requests for Requests for FREEFREE, printed summary guides, printed summary guides3232

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How to Stay InformedHow to Stay Informed

EHC Program website: EHC Program website: www.effectivehealthcare.ahrq.govwww.effectivehealthcare.ahrq.gov

EE--mail notices: mail notices: http://www.effectivehealthcare.ahrq.gov/index.cfm/http://www.effectivehealthcare.ahrq.gov/index.cfm/joinjoin--thethe--emailemail--list1/list1/

EHC Program newsletter, EHC Program newsletter, Comparative Comparative Effectiveness NewsEffectiveness News

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Questions Questions

To submit a question: To submit a question:

–– Press the Press the ““Ask a QuestionAsk a Question”” button located at the button located at the bottom of the screen. bottom of the screen.

–– When you click on the button, a box will appear at the When you click on the button, a box will appear at the bottom of your screen requesting that you to enter bottom of your screen requesting that you to enter your eyour e--mail address and your question. mail address and your question.

–– Once completed, press the Once completed, press the ““SendSend”” button. button.

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AgendaAgendaIntroductionIntroduction-- Stephanie Chang, M.D. (Facilitator)Stephanie Chang, M.D. (Facilitator)

Integrating Comparative Effectiveness Research into Practice Integrating Comparative Effectiveness Research into Practice --Carolyn M. Clancy, M.D. Carolyn M. Clancy, M.D.

Q&A from Audience Q&A from Audience

PatientPatient--Centered Outcomes Research and the Effective Health Care Centered Outcomes Research and the Effective Health Care Program Program -- Jean Slutsky, P.A., M.S.P.H.Jean Slutsky, P.A., M.S.P.H.

Q&A from Audience Q&A from Audience

Physician ImplementationPhysician Implementation-- Amir Qaseem, M.D., Ph.D., M.H.A., FACP Amir Qaseem, M.D., Ph.D., M.H.A., FACP –– American College of PhysiciansAmerican College of Physicians

Nurse Practitioner ImplementationNurse Practitioner Implementation-- Mary Jo Goolsby, Mary Jo Goolsby, Ed.DEd.D., M.S.N., ., M.S.N., ANPANP--C C –– American Association of Nurse PractitionersAmerican Association of Nurse Practitioners

Patient ImplementationPatient Implementation-- Nilay Shah, M.S., Ph.D. Nilay Shah, M.S., Ph.D. -- Mayo ClinicMayo Clinic

Q&A from Audience Q&A from Audience 3535

Physician Implementation: Physician Implementation: Clinical Practice GuidelinesClinical Practice Guidelines

Amir Qaseem, M.D., Ph.D., M.H.A., FACPAmir Qaseem, M.D., Ph.D., M.H.A., FACPDirector, Clinical PolicyDirector, Clinical Policy

American College of PhysiciansAmerican College of Physicians

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Who We AreWho We Are

Largest medical specialty organization in the US130,000 members

InternistsInternal medicine sub-specialistsResidents/fellows training in internal medicine or its subspecialtiesMedical students

Headquarters in Philadelphia and an office in Washington, D.C.

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History of ACP Clinical GuidelinesHistory of ACP Clinical Guidelines

Program was established in 1981Early ACP guidelines addressed diagnostic tests and technologiesScreening, Dx, and Rx

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ACP Clinical PoliciesACP Clinical Policies

Clinical PoliciesClinical GuidelinesGuidance StatementsHigh-Value Cost Conscious Care Advice

Evidence ReviewsACP sponsoredAHRQ’s Evidence-based Practice Centers (EPC)-Nation’s top medical schools, universities, or medical centers that conduct AHRQ’s research reviews. Collaboration with other societies

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ACP & AHRQACP & AHRQ

Working together since1999AHRQ Evidence-based Practice Centers (EPC) & Effective Health Care Program66% of our guidelines based on EPC evidence reports

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ACPACP’’ss Guidelines CoverageGuidelines Coverage

Top 3 most valued productsMost common reason to visit ACP’s website25 of the top 100 most read articles ever in the Annals of Internal MedicineTop most read article in Internal Medicine on MedscapeAll ACP Guidelines are regularly covered by print, TV, radio, and online stories

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ACP Guidelines CoverageACP Guidelines CoverageACP Guideline Print/

InternetTV Coverage

Downloads Total Audience

ED (11/2009) 121 N/A 18,500 52 MillionRx of Depression (11/2008)

141 17 76,000 27 Million

Rx of Osteoporosis (9/2008)

65 N/A 95,000 10 Million

Screening for Osteoporosis (5/2008)

167 153 47,000 32 Million

Rx of Dementia (3/2008)

92 N/A 86,500 17 Million

Palliative Care (1/2008)

140 N/A 102,500 7 Million

COPD (11/2007) 166 102 113,000 48 Million

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AHRQ ReportsAHRQ ReportsComparative Effectiveness of Treatments To Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis

Comparative Effectiveness of Second- Generation Antidepressants in the Pharmacologic Treatment of Adult Depression

Diagnosis and Treatment of Erectile Dysfunction

Pharmacological Treatment of Dementia

Use of Spirometry for Case Finding, Diagnosis, and Management of COPD

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ACP Membership FeedbackACP Membership Feedback

High quality guidelinesBased on scientific evidenceHelpful source of adviceNot rigid or difficult to applyNot difficult to understand or use

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Upcoming Guidelines based on Upcoming Guidelines based on EHC Research ReportsEHC Research ReportsManagement of Patients with Chronic Kidney DiseaseDiagnosis and Management of Obstructive Sleep ApneaDiagnosis and Management of Urinary IncontinenceCE & Safety of Oral Diabetes MedicationsOfflabel use of Atypical AntipsychoticsTreatments to Prevent Fractures in patients with Osteoporosis

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Nurse Practitioner Implementation: Nurse Practitioner Implementation: Continuing Education ProgrammingContinuing Education Programming

Mary Jo Goolsby, Mary Jo Goolsby, Ed.DEd.D., M.S.N., NP., M.S.N., NP--C, FAANPC, FAANPDirector of Research and EducationDirector of Research and Education

American Academy of Nurse PractitionersAmerican Academy of Nurse Practitioners

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Background

2009 AANP promoted awareness of the Effective Health Care (EHC) resources

– Goal to inform nurse practitioners (NPs) of resources to integrate comparative effectiveness research findings into clinical practice

Accredited CE identified as vehicle to enhance uptake of CER resourcesIntroduced select Clinician Guides as CE modules

– Summaries of research review findings comparing benefits/harms associated with treatment options

– Relevant, practice-oriented

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The NP Role

NPs are licensed independent practitionersNP Scope of Practice includes:

– Diagnosis and management of both acute and chronic conditions

– Emphasis of health promotion and disease prevention– Services include, but not limited to:

ordering, conducting, supervising, and interpreting diagnostic studiesprescription of pharmacologic and non-pharmacologic therapies

– Prescriptive authority in all 50 States/DC

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NPs Growing Resource for Healthcare Delivery

• Over 679 million annual visits to NPs in 2008

• In 20041:• 10.8% of adults had seen an

NP within the past year• 18.5% of seniors had seen an

NP within the past year

1Ferrer (2007) Pursuing Equity: Contact with Primary Care and Specialist Clinicians by Demographics, Insurance, and Health Status. Annals of Family Medicine.

2 AANP (2010) National NP Database.

NP Growth2

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AANP CE Center History

The mission of the American Academy of Nurse Practitioners includes promotion of excellence in NP practice, education, and researchCE is consistently rated by members as most valuable AANP service AANP CE Center launched mid-2007– Approximately 16,000 registered users– Approximately 65 programs available– 6,500 program “accesses” in August 2010

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Current Effective Health Care Clinician Guide CE Modules

ACEIs or ARBs for Adults with Hypertension

Premixed Insulin Analogues: A Comparison with Other Treatments for Type 2 Diabetes

Fracture Prevention Treatment for Postmenopausal Women with Osteoporosis

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Participation Rates

ACEIs or ARBS>1,700 accesses through August 2010

Premixed Insulin Analogues– >600 accesses through August 2010

Fracture Prevention Treatment– Newly launched

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Evaluations & Comments

Activities highly rated based on standard evaluations– Objectives achieved– Content relevant to practice– Related resources useful

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Survey of Participants

Recent brief online survey of 1,185 NPs who had completed at least one of the EHC program post-tests103 responses within one week:– Mainly family (57%) or adult (33%) NPs– 98% found discussions helpful in their clinical practice– 57% had reviewed related material (Full Report, Patient

Guide)– 29% had used other material from the site

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Comment Excerpts

Great way to learn about issues. . . Enjoy all extra material I can access

Specifically recalled the comparison of side effects cited in the ACEI vs ARB article. . . helpful to be reminded that the ACEI vs ARBs are similar in their RAAS/renal protective mechanism

Most simple and complete information is what I use day-to-day

Good resource for evidence-based practice

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Comment Excerpts

Working in surgical practice. . . look for these type of resources for patient follow-up which most of time is directed towards primary care

Satisfied with Effective Health Care Resources as CE offering, plus the opportunity to use the website

I was able to use this information in: lectures I prepared for the community, discussion with patients and colleagues, obtaining personal knowledge and resources

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Summary Slide

NPs are seeking evidence-based, practical resourcesOnline CE successful approach to enhancing awareness of and clinical integration of Effective Health Care resources

Patient Implementation:Patient Implementation:Decision AidsDecision Aids

Nilay Shah, M.S., Ph.D.Nilay Shah, M.S., Ph.D.Division of Health Care Policy and Research andDivision of Health Care Policy and Research andKnowledge and Encounter Research (KER) UnitKnowledge and Encounter Research (KER) Unit

Mayo ClinicMayo Clinic

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Disclosure

Relevant Financial Relationships

Funded by the American Diabetes Association & the Agency for Healthcare Research and Quality (AHRQ) 

(R18HS018339)

Off Label Usage

None

Research Team: Victor Montori, Maggie Breslin, Barbara Yawn, Steven Smith, Jeanette Ziegenfuss, and numerous 

primary care clinicians

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Comparative Effectiveness and Safety of Oral Diabetes Medications

• Glycemic control

• Blood pressure / Lipids

• All cause mortality

• Cardiovascular morbidity and mortality

• Microvascular outcomes

• Functional status and quality of life

Source:  Bolen et. al. July 2007.  Comparative effectiveness and safety of oral diabetes medications for adults with type 2 diabetes.  Available at: http://effectivehealthcare.ahrq.gov 60

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Comparative Effectiveness Research

The Clinical Encounter

Coverage Decisions

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“Baseball Cards”63

“Narrative Cards” 64

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“Issue Cards” 66

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Summary• The use of decision aids in primary care practice was acceptable and efficient.

• Was the decision aid effective?– Patients found the tool helpful

– Improved knowledge

– Increased involvement

– Not on decisional conflict

– Not on the nature of choices made

– Videos of the encounters tells a different story:• Greater patient participation

• Different conversation ‐ patient‐centered concerns

– Not on adherence 68

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Next stepsDiverse populations

Longitudinal follow‐up (repeated use)

Another key consideration:  IMPLEMENTATION – Normalization Process Theory (NPT)

iADAPT RFA – Designing and testing a decision aid for Depression Medications (HS019214)

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Challenges for Translation

• Patient‐important outcomes

• Practice challenges

• “Costs”

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RESULTS OF THE PILOT TRIAL ARE AVAILABLE IN:  Mullan RJ, Montori VM, Shah ND, Christianson TJH, Bryant SC, GuyattGH, Perestelo‐Perez LI, Stroebel RJ, Yawn BP, Yapuncich V, Breslin MA, Pencille L, Smith SA.  The diabetes medication choice decision aid: a randomized trial.  Arch Int Med 2009 Sep;169:1560‐1568.

A VERSION OF THE DIABETES CARDS ARE AVAILABLE AT:

http://kercards.e‐bm.info

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Questions Questions

To submit a question: To submit a question:

–– Press the Press the ““Ask a QuestionAsk a Question”” button located at the button located at the bottom of the screen. bottom of the screen.

–– When you click on the button, a box will appear at the When you click on the button, a box will appear at the bottom of your screen requesting that you to enter bottom of your screen requesting that you to enter your eyour e--mail address and your question. mail address and your question.

–– Once completed, press the Once completed, press the ““SendSend”” button. button.

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For more information aboutFor more information about……

AHRQAHRQ’’s Effective Health Care Program:s Effective Health Care Program:www.effectivehealthcare.ahrq.govwww.effectivehealthcare.ahrq.gov

Access Access FREEFREE resources resources AHRQAHRQ’’ss Publications Clearinghouse: Publications Clearinghouse:

(800) 358(800) 358--92959295

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Sign up for eSign up for e--mail notices: mail notices: http://www.effectivehealthcare.ahrq.gov/ihttp://www.effectivehealthcare.ahrq.gov/index.cfm/joinndex.cfm/join--thethe--emailemail--list1/list1/

More questions? EMore questions? E--mail us: mail us: EHC_Clinicians@ahrq.hhs.govEHC_Clinicians@ahrq.hhs.gov

AlsoAlso……

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Thank you!Thank you!

Thank you for joining us today. Thank you for joining us today.

Please take a moment to provide feedback at Please take a moment to provide feedback at the end of this event. the end of this event.

A recording and transcript for todayA recording and transcript for today’’s event s event will be available at a later date at will be available at a later date at www.effectivehealthcare.ahrq.govwww.effectivehealthcare.ahrq.gov

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