Upload
phillip-mcdonald
View
225
Download
0
Tags:
Embed Size (px)
Citation preview
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