Introduction to Translating Evidence into Practice

Epi 245

Ralph Gonzales, MD, MSPH

Professor Medicine; Epidemiology & Biostatistics

Sept 24, 2009

EVID

ENCE

PRACTICE HEALTH

COMMUNITYHealth Care Delivery Systems

Providers

Patients

Public

GovernmentPayors

Prof. SocietiesAcademia

Translating Evidence Into Practice, Policy and Public HealthConceptual Framework

STAKEHOLDERS

EVID

ENCE

PRACTICE HEALTH

COMMUNITYHealth Care Delivery Systems

Providers

Patients

Public

GovernmentPayors

Prof. SocietiesAcademia

Epi 247:System-Centered Implementation

Strategies

Epi 248:Translating Practice Into Evidence:

Community Engagement Strategies

Epi 249:Advocacy & Policy Strategies

Epi 246:Individual-Centered

Implementation Strategies

Epi 245:Introduction to Translating

Evidence into Practice: Theory, Evidence & Design

Translating Evidence Into Practice, Policy and Public Health:UCSF Implementation and Dissemination Sciences Courses

STAKEHOLDERS

Course Goals

• Course Goals– Learn how to design & evaluate interventions– Learn some of the evidence base for specific types of

interventions– Develop and refine an intervention protocol

• Deconstruct Interventions– Population/Community/Public– Patients– Providers– Systems/Organizations

Course Schedule• Week 1: overview; making your case

• Week 2: translational tool box

• Week 3-6: public/patient, clinician and system

• Week 7: community engagement

• Week 8: study design; program evaluation

• Week 9: analytical designs and power

• Week 10: final protocol presentations

– 15 minutes to pitch to funders

Where You Will Learn• Website

– See supplementary reading list

• Class Presentations– Slide Sets and Notes

• Homework– Required Reading before class– Protocol development

• Exercise assigned after each class• Due following Sunday night (earlier is better)

• Pitching Session– Present your final protocol to potential funders

• Grades– Based on homework; participation in seminars; final protocol and final

presentation (equally-weighted)

TICR Professional Conduct Statement

• I will maintain the highest standards of academic honesty

• I will neither give nor receive aid in examinations or assignments unless such cooperation is expressly permitted by the instructor

• I will conduct research in an unbiased manner, report results truthfully, and credit ideas developed and work done by others

• I will write answers in my own words, and, when collaboration is permitted, acknowledge collaborators when answers are jointly formulated

Case Study

• In 1994, a 30 yo medicine resident is frustrated by patients’ antibiotic prescription requests when he moonlights at Kaiser urgent care.

• Inspired by the AHCPR Clinical Practice Guidelines, he wants to develop a practice guideline to reduce overuse of antibiotics for acute bronchitis.

Translating Evidence Into Practice: The Birth of T2

T1 T2

“I think that we have to ask ourselves whether much of the output of biomedical science is getting

lost in translation?” –C.Lenfant, NEJM 2003;349:868-74. Former Director NHLBI.

NIH Roadmap Initiative-translating discoveries into health

When Is Evidence Ready for Translation?

• Efficacy vs. effectiveness– Tests– Treatments– Procedures– Interventions

The Evidence-Based Medicine Movement (1990 → )

Rating the Evidence: Systematic Reviews• The Cochrane Collaboration (www.cochrane.org)

• Cochrane Effective Practice and Organisation of Care (EPOC) Group (www.epoc.cochrane.org)

– Systematic reviews of health care interventions• National Cancer Institute (www.cancer.gov)

Making Recommendations: Guidelines• USPSTF (www.ahrq.gov/CLINIC/uspstfix.htm)

• CDC (www.cdc.gov)

• Professional Societies

Practice Guidelines

• National Guidelines Clearinghouse (US)– www.guideline.gov

• National Institute for Health and Clinical Excellence (UK)– http://www.nice.org.uk

• The Guidelines International Network– http://www.g-i-n.net

Comparative Effectiveness Researchaka “How to spend $1.1 B”

“CER is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care”

“The purpose of CER is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels”

-Institute of Medicine, 6/09

Case Study (cont)

“Antibiotics are never indicated for adults with acute bronchitis”

-Merle Sande, SFGH, 1994

“You first need to prove that there’s a problem. Are doctor’s really prescribing antibiotics for acute bronchitis?”

-Julie Gerberding, SFGH, 1994

A Pause for the Cause… Making Your Case

√ Is the evidence ready for translation?

#1. What is the current Quality of Care?

#2. What is the Quality Gap?

#3. What is the Outcome Gap?

Making Your Case…

Step #1

Measure Quality & Understand its Determinants

Quality of Health Care-c. 1980s

• Donabedian A. JAMA 1988;260:1743-8

Structure Process Outcomes

Community Characteristics

Delivery System Characteristics

Provider Characteristics

Population Characteristics

Health Care Providers-Technical Processes-Interpersonal Processes

Public & Patients-Access-Acceptance-Adherence

Health Status

Functional Status

Satisfaction

Mortality

Cost

EVID

ENCE

PRACTICE OUTCOME

COMMUNITYHealth Care Delivery Systems

Providers

Patients

Public

GovernmentPayors

Prof. SocietiesAcademia

Institute of Medicine Dimensions of Quality-c. 1990s

STAKEHOLDERS

-Effective

-Efficient

-Patient-Centered

-Safe

-Equitable

-Timely

“Quality Indicators”The Many Faces of Quality

• Outcomes• Structure

– Access to care, tests, treatments, procedures

• Processes… Things you can influence!– Performance Measures

• System and Clinician Oriented– Testing; treatment; referrals; counseling; communication

• Patient and Public Oriented– Adherence; testing; self-care; office visits; lifestyle; healthy

behaviors

Condition (n=25) Recommended Care, %Senile Cataract 79%Breast Cancer 76%Prenatal Care 73%….Dyspepsia/Ulcer Disease 33%Atrial Fibrillation 25%Hip Fracture 23%Alcohol Dependence 11%Overall Average 55%

CMS/JCAHO & Hospital Compare-Hospital Quality Measures

• Management of AMI– Aspirin on arrival and discharge– Beta-blockers on arrival and discharge– Lysis within 30 min of arrival– PCI within 90 min of arrival– ACE or ARB for LVSD– Management of CHF– ACE-inhibitor at discharge

• Management of CHF– ACE or ARB for LVSD– LVSD evaluation (echo)– Discharge counseling– Tobacco cessation

• Management of Pneumonia• Surgical Care Improvement

– Antibiotics within 1 hour of surgery; appropriate abx; d/c after 24 hours– DVT prophylaxis

Measure Quality Yourself-National Surveys/Reports

Behavior Data Sources–Public/Patient BRFSS; NHIS; NHANES;

MEPS

–Provider NAMCS; NHAMCS

–Delivery system NHDS

Measure Quality Yourself-Administrative Claims Data

Administrative data collected as a result of “claims” submitted by physicians/practices for reimbursement.

• Medicare (UB-92)– No pharmacy data

• Medicaid (Drug Utilization Review; OSHPD)– Enrollment rollercoaster

• Integrated Delivery Systems (Kaiser; Geisinger; etc)– Generalizability

• Hospital Networks (Premier)• Managed Care Organizations

Computerized health records are becoming a new resource for quality and outcome measurement…

Case Study (cont)

Antibiotic Prescription Rates-Sinusitis 56%-Bronchitis 66%-URI 53%

Making Your Case…

Step #2

Determine the Quality Gap

Quality Indicators and Benchmarks

• When guidelines exist

• When guidelines don’t exist

• When a benchmark is not available

National Committee for Quality Assurancewww.ncqa.org

HEDIS Effectiveness of Care Measures 2003, comm

• Beta-blocker post MI 94%• Cancer screening

– Breast 75%– Cervical 82%– Colorectal 47%

• Chlamydia screening 30%• Cholesterol screening 79%• HbA1c testing 85%• Eye exams in diabetes 49%• Controlling hypertension (<140/90) 62%• LDL < 100 after 60 days of MI 48%

Case Study (cont.)Measuring the Quality Gap

Condition Visits Rx Rate Bact. Prev Abx Excess

Otitis Media 13 x 106 76% 65% 1.1 million

Sinusitis 11 x 106 70% 40% 3.5 million

Pharyngitis14 x 106 62% 25% 5.2 million

Bronchitis 13 x 106 59% 10% 6.5 million

URI/cold 25 x 106 30% 5% 6.2 million

TOTAL 76 x 106 54% 25% 22.5 million

Gonzales R, et al. JAMA, 1997;278:901-904

Gonzales R, et al. Clinical Infectious Diseases, 2001, 33:757-62

Making Your Case…

Step #3

Link Quality Gap to

Outcome Gap

EVID

ENCE

QUALITY OF CARE OUTCOME

COMMUNITYHealth Care Delivery Systems

Providers

Patients

Public

GovernmentPayors

Prof. SocietiesAcademia

Linking Quality Gap to Outcome GapSTAKEHOLDERS

-Safe

-Effective

-Efficient

-Equitable

-Patient-Centered

-Timely

The Public Health and Business Case

RAND Health Insurance Experiment (1974-1982)

• Only RCT of health insurance in US• "Does free medical care lead to better health than co-

pay insurance plans?“• Results

– Free care induces demand/utilization of health care services– Cost-sharing reduces appropriate as well as inappropriate

health care utilization (patient behavior); but little effect on the cost of the encounter (provider behavior)

– Little effect on outcomes/health status• Except among poor with comorbidities (eg, hypertension)

Not a No-BrainerLinking Quality Gap with Outcomes.Werner R, 2006

CMS P4P Evaluation.Glickman SW, 2007

IOM Priority Areashttp://www.iom.edu/?id=19752

Asthma

Care coordination

Children with special health care needs

Diabetes

End of life

Cancer screening

Frailty associated with old age

Hypertension

Immunization

Ischemic heart disease

Major depression

Medication management

Nosocomial infections

Obesity (emerging area)

Pain control in advanced cancer

Pregnancy and childbirth

Self-management/health literacy (cross-cutting area)

Severe/persistent mental illness

Stroke

Tobacco-dependence treatment in adults

CASE STUDY (cont)Antibiotic Utilization = Antibiotic Resistance

Helping Change Happen…

Continuous Quality Improvementand PDSA Cycles

Don Berwick; Institute for Healthcare Improvement

Weeks 2-10EPI 245 modified PDSA…

• Needs Assessment of Your Problem (plan)– Understanding the Problem within a

Theoretical Framework

• Designing Multifaceted Intervention within a Theoretical Framework (do)

• Process and Outcome Evaluation of Intervention’s Impact (study)

• Refine and Repeat (act)

Improving Screening• Providing tools to help women

participate with their physicians in making informed decisions about screening (Phillips et al. 1998; Walter and Covinsky 2001).

• Ensuring access to primary care providers and the availability of mammography facilities with reminder systems (Phillips et al. 1998).

• Improving women's experiences with mammography through supportive care by the mammography technician (Carney et al. 2002).

Finding the Dollars: Feds

• AHRQ– Areas: health IT; complex patients; safety;

comparative effectiveness• K01, K02, K08, R01, R03, R13, R18, R36, U13• Co-Sponsored with NIH

– Women’s mental health in pregnancy and the post-partum period

– Emergency medical services for children– Cancer surveillance using health claims-based data– Understanding and promoting health literacy– Improving Health Care for Obese Patients

Finding the Dollars: Feds

• NIH– Areas: check with each institute, and don’t call

it “health services research”

• HRSA– Current MCHB: newborn screening;

congenital conditions; sickle cell treatment; traumatic brain injury

– Health Professions; Rural Health; Primary Care Centers

Finding the Dollars: Feds• CDC- National Centers (or Offices) for…

– Public Health Informatics; Public Health Genomics– Terrorism Preparedness and Emergency Response– Chronic Disease Prevention and Health Promotion– Preparedness, Detection and Control of Infectious Diseases– Zoonotic, Vector-Borne, and Enteric Disease– Immunization and Respiratory Diseases– Birth Defects and Developmental Disabilities– Environmental Health– Global Health– Global AIDS Program– HIV/Viral Hepatitis/STD/AIDS– Injury Prevention– Occupational Safety (NIOSH)

Finding the Dollars: Feds• DOD

– Congressionally Directed Medical Research Programs

• ALS; Autism; Bone Marrow Failure; Breast Cancer; Deployment Related Medical; Gulf War Illness; Minority and Underserved Areas; Neurofibromatosis; Ovarian Cancer; Prostate Cancer; Psychological Health/Traumatic Brain Injury; Tuberous Sclerosis Complex; CML; Prions

– HIV/AIDS Prevention Program– Research and Technology Development

• Average award: $1.15 M

Finding the Dollars: Feds

• VA – Clinical Science Research and Development Service– Cooperative Studies Program– Health Services Research and Development Service

• QUERI; COE & REAPs; HSR & Pilot Program• Priority Areas: Access/Rural Health; Care of Complex,

Chronic Conditions; Equity and Health Disparities; Health Services Genomics; Healthcare Informatics; Implementation and Management Research; Long-Term Care and Caregiving; Mental Health; Post-Deployment Health; Research Methodology; Womens Health

– Rehabilitation Research and Development

Finding the Dollars: Foundations

• The Robert Wood Johnson Foundation– Areas: Building Human Capital; Childhood Obesity;

Coverage; Pioneer; Public Health; Quality/Equity; Vulnerable Populations

– Funding: Investigator-initiated; RFAs

• The Commonwealth Fund– Areas: Affordable Health Insurance; Payment System

Reform; Patient-Centered Coordinated Care Program; Health Care Quality Improvement and Efficiency; Quality of Care for Frail Elders; Commission on High Performance Health System;

Finding the Dollars: Foundations

• Pew Charitable Trusts– Areas: Public Health and Human Services Policy;

Family Financial Security; Science and Technology

– Funding: investigator-initiated

• Foundation for Informed Decision Making– Areas: decision support tools; primary care

integration; literacy and numeracy; communication sciences;

Finding the Dollars: Others

• State and Other Government– Medicaid– Departments of Public Health

• Professional Societies

• Industry– Insurers: eg, Anthem; Aetna– Delivery Systems: eg, Kaiser Permanente – Pharmaceutical Companies

Summary

• Translating evidence into practice, policy and public health depends on aligning attitudes and behaviors of stakeholders, delivery systems, providers, patients and the public.

• Stakeholders, health care providers and the public need to monitor health care quality, and inform the development of new evidence and translational activities.

Summary

• Quality of care is a function of the structure, processes and outcomes of care– Changes to the structure and processes of care

can lead to improved outcomes of care… in essence, the goal of T3 research

• Improving the quality of health care should maximize safety, effectiveness, efficiency, patient-centeredness, and timeliness and eliminate disparities in care.

Summary

• To Make Your Case for translating evidence into practice for a specific topic– Measure its quality, determine the quality gap,

and link the quality gap to an outcome gap

• To Help Change Happen, understand the behaviors that are critical to translating evidence into practice

Homework #1 TableEvidence Health Outcome Delivery System

BehaviorClinician Behavior

Patient Behavior Public Behavior Stakeholders

EXAMPLE:Acute bronchitis does not benefit from antibiotics

Morbidity and mortality from bacterial infections

Measure antibiotic prescription rates

Stop prescribing antibiotics for acute bronchitis

Stop expecting antibiotics for acute bronchitis

Make better health care seeking decisions for cough illness

CDCNCQA

EXAMPLE:Chlamydia screening programs reduce rates of infertility and PID

Female infertility and PID

Measure Chlamydia screening rates;Increase access to screening

Screen sexually active women 13-24 yrs at least annually

Accept Chlamydia screening;

Seek preventive health care services

CDCWomens HealthState Health

Homework #1

• Complete Table for you and your topic• What evidence are you proposing to translate into

practice?– Identify single key behavior change target for your

translational activity.• What is the current performance level of your target

behavior (ie, its quality)?– What is the quality gap?– What is the evidence that changing performance will

improve clinical outcomes?• Identify at least 3 potential funding sources