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Agency for Healthcare Research and Quality Advancing Excellence in Health Care • www.ahrq.gov Advancing Excellence in Health Care Carolyn M. Clancy, MD Director Advancing Excellence in Health Care Case Presentation - 1 Paul, a 54 yo patient with diabetes and hypertension visits a primary care clinician for abdominal pain of 2-3 days duration. Prior to his visit, he and his pc team leader have reviewed his symptoms and history by email, and have examined possible causes by going to the PC Navigator, a system that has been developed to improve diagnosis and management of patients with undifferentiated symptoms. Advancing Excellence in Health Care Case Presentation - 2 Paul’s pc team has also reviewed Paul’s recent entries to the jointly held electronic medical record. A diabetic for 10 years, Paul manages his condition with diet and exercise, after several bumpy years on insulin. His self-management is supplemented by email consultations prn. Advancing Excellence in Health Care Case Presentation - 3 When Paul and his clinician meet -- at his convenience -- they discuss his options and agree on a diagnostic test, after reviewing possible outcomes of the test and options. The test is scheduled for that day. Before leaving the practice, Paul leads a group visit at which there are several medical students -- required to attend to learn from patients about chronic illness management. Advancing Excellence in Health Care Case Presentation - 4 The patients in the group visit provide feedback to the students about how they can enhance patients’ skills in self management. Paul then gets his diagnostic test, and before the end of the day his primary care clinician has e-mailed the results and suggested next steps. Advancing Excellence in Health Care Overview About AHRQ: The Evidence Agency Health Care 2005: Current Context Recent Findings and Directions Future Challenges Advancing Excellence in Health Care Mission Statement: AHRQ The mission of the Agency for Healthcare Research and Quality is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Advancing Excellence in Health Care Advancing Excellence in Health Care AHRQ RESEARCH FOCUS: HOW IT DIFFERS Patient-centered, not disease-specific Dual Focus -- Services + Delivery Systems Effectiveness research focuses on actual daily practice, not ideal situations (“efficacy”) AHRQ mission includes production and use of evidence-based information Advancing Excellence in Health Care Ten Roles of Government in Health Care Quality Purchase health care Provide health care Assure access for vulnerable populations Monitor health care quality Regulate health care markets Inform health care decision- makers Support acquisition of new knowledge Support development of health technologies and practices Develop the health care workforce Convene stakeholders Advancing Excellence in Health Care AHRQ RESEARCH AND HIT 20+ year history of supporting evaluation of use of HIT to improve care (IHC; Regenstrief; Brigham and Women’s) Provide and update content: e.g., National Guideline Clearinghouse Critical component of research efforts across business lines (patient safety**) New: supporting change efforts – real time evaluation and learning Advancing Excellence in Health Care Work in Progress Randomized trials of e-prescribing to reduce errors – With substantial hand-holding, 46% of physicians will use – Functionality challenges – both the applications and their use Multiple reporting demonstrations for patient safety Multiple studies to improve care using one or more applications of HIT as an intervention Advancing Excellence in Health Care Overview About AHRQ: The Evidence Agency Health Care 2005: Current Context Recent Findings and Directions Future Challenges Advancing Excellence in Health Care Driving Forces Rising health care expenditures Aging and increasingly diverse population Consumerism Biomedical advances: public and professional expectations Growing influence of purchasers Advancing Excellence in Health Care Current Environment Unprecedented opportunities and innovations Rising health care costs Consumer and purchaser demand for value Limited information on performance – and how to improve Numerous initiatives to address one piece of the puzzle Advancing Excellence in Health Care Percent of Americans Saying “I Have A Chronic Condition” 66% 70% 58% 60% 50% 35% 40% 30% 20% 24% 15% 10% 0% 18-29 30-39 40-49 Age 50-64 Source: Chronic Illness and Caregiving Survey, Harris 2000 65+ Advancing Excellence in Health Care New York Times, December 18, 2002 Public Perceptions Advancing Excellence in Health Care Percent who say they are dissatisfied with the quality of health care in this country… 2004 2000* Has the quality of health care in this country… Gotten worse Stayed about the same 55% 40% 44% 38% 4% 17% Don’t Know Gotten better * Gallup Poll conducted September 11-13, 2000 with 1,008 U.S. adults. Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005). Personal Experience Advancing Excellence in Health Have you Care been personally involved in a situation where a preventable medical error was made in your own medical care or that of a family member? No 65% 34% Did the error have serious health consequences, minor health consequences, or no health consequences at all? 21% Serious health consequences 10% Minor health consequences Yes 3% 1% Don’t Know No health consequences Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005). Role Of IT In Reducing Medical Errors Advancing Excellence in Health Care Percent who say… The coordination among the different health professionals that they see is a problem 69% Have you or a family member ever created your own set of medical records to ensure that you and all of your health care providers have all of your medical information? Yes They have seen a health care professional and noticed that they did not have all of their medical information They had to wait or come back for another appointment because the provider did not have all their medical information 48% 32% 1% 32% Don’t know 67% No Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005). Pace of Change Varies Across Care Settings Advancing Excellence in Health Care Median percent change Median change in performance by setting, 2003 NHQR vs 2004 NHQR 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 17.7% 5.4% 3.0% 1.4% Hospital care Ambulatory care Home health care Nursing home care Setting (24 measures) (49 measures) (12 measures) (3 measures) Of 98 measures with trend data, 88 can be mapped to care settings Some improvement seen in all settings However, change in performance varies across settings Major Opportunities for Improvement Advancing Excellence in Health Care Percentage of patients Quality of Pneumonia Treatment for Elderly, 2002 100 90 80 70 60 50 40 30 20 10 0 81% of Medicare 81 63.1 67.9 29.6 Received 1st Received Have blood Received all dose of recommended cultures recommended antibiotic within antibiotics collected before treatment 4 hours of consistent with antibiotics are regimens hospital arrival current administered guidelines Measure Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2002. pneumonia patients get blood cultures before antibiotics 68% get the right antibiotics 63% get their first antibiotic in a timely manner Yet, only 30% get all of three recommended interventions Advancing Excellence in Health Care The proportion of adults with diabetes who received all five recommended diabetic services (MEPS, 2000-2001) Advancing Excellence in Health Care 40% 30% 2000 2001 20% 10% or N ea M rP id oo dl e r In co H m ig e h In co m e Po te H is pa ni c W hi -H is pa ni c B la ck N on W hi te 0% Advancing Excellence in Health Care Environmental Change “In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves.” Advancing Excellence in Health Care Context Structural measures do not reliably predict quality Growing demand for evidence of performance and public reporting of same (Process) Outcomes considered best – but outcomes are not actionable, and require substantial adjustment for fair comparison Advancing Excellence in Health Care Categories of Care Activities Technical care – Application of science and technology of medicine to manage personal health problems Interpersonal care – Interaction between the patient/consumer and the health care system arrange and receive care Advancing Excellence in Health Care HHS: Recent Developments Nursing Home Initiative Home Health Care Initiative* AHA-JCAHO-VHA …. Hospital reporting initiative* Patient experience in hospitals* Bar coding IT standards (*) Advancing Excellence in Health Care Advancing Excellence in Health Care Patient Safety: Achieving A New Standard For Care “Americans should be able to count on receiving health care that is safe……..This requires, first, a commitment by all stakeholders to a culture of safety, and, second, improved information systems.” Institute of Medicine, 2003 Advancing Excellence in Health Care Issues Will public reporting improvements? Paying for quality – YES, but HOW?? Pay for quality – OR use of HIT? How to align measurement and improvement efforts? Advancing Excellence in Health Care Overview About AHRQ: The Evidence Agency Health Care 2005: Current Context Recent Findings and Directions Future Challenges AHRQ Research Study: Identifying Successful Hospital Quality Improvements Advancing Excellence in Health Care Major finding: Hospitals that were more likely to prescribe beta-blockers shared similar characteristics: – – – – Solid support from their hospital administration Strong physician leadership Shared goals of improving medical practice Effective way of monitoring progress Conducted by Yale University School of Medicine E Bradley, E Holmboe, J Mattera, et al., A Qualitative Study of Increasing B-Blocker Use After Myocardial Infarction, Journal of Advancing Excellence in Health Care AHRQ Research Study: Sleep Deprivation and Safety Major Finding: Serious medical errors fell significantly when medical interns’ work schedule was reduced from 30-hour-in-a-row shifts and when continuous work schedules were limited to 16 hours 36% more serious medical errors 21% more serious medication errors CP Landrigan, JM Rothschild, J W Cronin, et al., Effective of reducing interns’ work hours on serious medical errors in intensive care units, NEJM, October 28, 2004 AHRQ Research Study: Outpatient Prescription Drug-Related Injuries in Elderly Advancing Excellence in Health Care Major Finding: Outpatient Medicare patients suffered as many as 1.9 million drug-related injuries a year due to medical error or adverse drug events (ADE) not caused by errors Why did preventable ADEs occur? – 58% prescribing medications – 61% monitoring medications – 20% patients adhering to medication instructions Advancing Excellence in Health Care AHRQ Case Study: Computerized ICU System and Nursing Care Computerized medical information management system in hospital intensive care units (ICU) significantly reduced time ICU nurses spent on documentation 12 Nurses were able to complete more tasks without interruption 1 11 2 10 3 9 4 8 52 minutes saved in an 8hr shift 7 6 5 D. Wong, Y. Gallegos, M. Weinger, et al., Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system, Critical Care Medicine, 2003 Advancing Excellence in Health Care HIT + Systems approach Can Make a Difference Proportions of patients receiving the appropriate discharge prescriptions Intermountain Health Care QI effort on CVD Results: – 90% prescription rates – 27% decrease in unadjusted absolute death rates Lappe JM et. al., Ann Intern Med 2004;141:446-453 Advancing Excellence in Health Care AHRQ Recent Research Findings Systematic review of randomized clinical trials of computer-assisted interventions in diabetes care – significantly improved patients' glycated hemoglobin and blood glucose levels – substantially improved physician compliance with diabetes care guidelines in six of eight studies compliance with recommended diabetes care procedures was 71% to 227% higher among doctors prompted by computer systems to perform the procedures compared with doctors who did not receive the prompts Balas, Krishna, Kretschmer, et al., Computerized knowledge management in diabetes care (2004). Medical Care 42(6), pp. 610-621. Advancing Excellence in Health Care Hospital Survey on Patient Safety Culture New tool helps hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units Includes survey guide, survey, and feedback report template to customize reports AHRQ partnership with Premier, Inc., Department of Defense, and American Hospital Association www.ahrq.gov/qual/hospcult ure/ or e-mail to [email protected] Advancing Excellence in Health Care AHRQ WebM&M Web-Based Medical Journal Online medical journal and forum on patient safety and health care quality Features expert analysis of medical errors reported anonymously by readers, interactive learning modules on patient safety, and forums for online discussion CME credit available http://webmm.ahrq.gov Advancing Excellence in Health Care Key Implementation Activities – QualityTools Advancing Excellence in Health Care National Health Plan Learning Collaborative to Reduce Disparities and Improve Quality Public/private partnership to reduce disparities in health care for people with diabetes and other conditions Over next 3 years, collaborative will test ways to improve collection and analysis of data on race and ethnicity and match data to existing quality measures to close gap in care Sponsored by nine of Nation’s largest health insurance plans, and other organizations Advancing Excellence in Health Care Ambulatory Care Quality Develop strategy for moving forward effectively and efficiently: – Measuring performance at the provider level – Collecting and aggregating data in least burdensome way – Reporting meaningful information to consumers, physicians and other stakeholders to inform choices and improve outcomes Advancing Excellence in Health Care Overview About AHRQ: The Evidence Agency Health Care 2005: Current Context Recent Findings and Directions Future Challenges Advancing Excellence in Health Care The Future Delivery System: Baseline Assumptions Today’s students will encounter a dramatically different health care system Basic premise of health insurance is evolving System fragmentation will increase Consumer-directed options will increase increased price sensitivity and need for information “Disruptive challenges” (BT, SARS, ???) a daily reality: the “new normal” Advancing Excellence in Health Care What We Have Learned 2005 Knowing the right thing to do is NOT = doing it! Improvement must be based on science Patients as participants are far more effective than patients as ‘recipients’ Sutton’s Law: improving chronic illness care is essential Safety in health care delivery is critical Advancing Excellence in Health Care Improving Quality and Safety “We need to make the right thing the easy thing…” Mark Chassin, MD October 12, 2000 Advancing Excellence in Health Care Advancing Excellence in Health Care Advancing Excellence in Health Care If HIT is Such a Great Idea ….. Generalizability of promising findings open to question Even successful hospitals use multiple vendors – and have internal interoperability challenges Implementation is “challenging” Physicians are independent contractors Advancing Excellence in Health Care The Costs/Value of IT Significant capital investment for the purchase and installation Limited data on return of investment for IT -- is there a “business case for quality?” The "opportunity cost" of physician time and use of IT have not been determined. Economic impact uncertain -- hard to track all costs and savings following IT adoption (diffuse and indirect) FY04: Transforming Healthcare Quality through IT Advancing Excellence in Health Care Planning : up to $7M – assist healthcare systems and their partners in planning for activities that will lead to successful HIT implementation Implementation : up to $24M – support organizational and community-wide implementation and diffusion of HIT Value : up to $10M – assess the value derived from the adoption, diffusion, and utilization of HIT Advancing Excellence in Health Care State and Regional Demonstrations in Health IT Identify and support statewide data sharing and interoperability activities on a discrete state or regional level. Approximately 5 states $25M over 5 years “Test Beds” to produce demonstrable improvements Improvements must be sustainable beyond end of contract and applicable to other states or regions Advancing Excellence in Health Care Critical Challenges Common data elements and definitions; build capacity to make improvements Linking implementation to requisite clinical transformation Avoiding the “NIH” syndrome Aligning incentives and rewarding success Making it easy Advancing Excellence in Health Care Errors As a Systems Problem “We must stop blaming people and start looking at our systems. We must look at how we do things that cause errors and keep us from discovering them...before they cause an injury.” - Leape 1994 Advancing Excellence in Health Care AHRQ Research Study: Timing of Surgery for Hip Fracture and Outcomes Major Finding: Hip fracture surgery performed within 24 hours of hospital admission results in positive outcomes for the patient: – Reduces pain – Shortens hospital stays – May limit probability of major complications, such as pneumonia and arrhythmias GM Orosz, J. Magaziner, EL Hannan, et. al., The association of timing of surgery for hip fracture and patient outcomes, JAMA, April 14, 2004 Advancing Excellence in Health Care Contemporary Challenges Scientific basis for safe and appropriate use of diagnostic, therapeutic and preventive interventions -- from and to the point of care Quality improvement as science Translating promising educational models into large-scale improvements in care and outcomes Advancing Excellence in Health Care PREQUISITES FOR CHANGE Integrating strategy to make existing information accessible with requisite data collection Expected differences in patient experiences (e.g., disparities associated with race, ethnicity and SES) How to present information in usable formats (different versions of “the answers” will be more effective for different audiences) Advancing Excellence in Health Care What is Section 1013? To improve the quality, effectiveness and efficiency of health care delivered through Medicare, Medicaid and the S-CHIP programs $50 million is authorized in Fiscal Year 2004 for the Agency for Healthcare Research and Quality (AHRQ) to conduct and support research with a focus on outcomes, comparative clinical effectiveness and appropriateness of health care items and services (including pharmaceutical drugs), including strategies for how these items and services are organized, managed and delivered Advancing Excellence in Health Care What is Section 1013? By June 2004, the Secretary shall establish an initial list of research priorities (including those related to prescription drugs) Priorities may include health care items and services which impose a high cost on Medicare, Medicaid or S-CHIP, including those that may be underutilized or over utilized Advancing Excellence in Health Care SHARED DECISION MAKING: DECISIONS AND OUTCOMES Patient Alternative 1 Alternative 2 Advancing Excellence in Health Care All We Need Is….. Payment changes: p4p + FFS = ?? Smart Policies People who get it “Pull” – demand for change; urgency Advancing Excellence in Health Care How has practice changed? Agency for Healthcare Research and Quality Advancing Excellence in Health Care • www.ahrq.gov www.ahrq.gov AHRQ’s Publications Clearinghouse 800-358-9295 (weekdays, 9 - 5 eastern time) Advancing Excellence in Health Care The End Please continue to the post test Download the post test Complete the post test Return the post test to Dr. Sandra Oliver at TAMU II 407 I Advancing Excellence in Health Care Post test Question 1 The mission of the AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care : 1. for all Americans. 2. for underserved Americans. 3. through evidence based medicine. 4. through scientific exploration of diseases. Advancing Excellence in Health Care Post test Question 2 Which of the following is not a role of government in health care quality: 1. 2. 3. 4. 5. Purchase health care Provide health care Assure access for vulnerable populations Monitor health care quality Regulate health care decision makers Advancing Excellence in Health Care Post test Question 3 The NHQR quality measures of care settings, showed which of the following: 1. Change in performance was the same across settings. 2. Nursing homes showed the greatest change. 2. Hospitals showed the greatest change. 3. No change in one year in any setting. Advancing Excellence in Health Care Post test Question 4 Which of the following is true: 1. Knowing the right thing to do is equal to doing it! 2. Change must be based on practice patterns of physicians 3. Patients as participants are far more effective than patients as ‘recipients’ 4. Safety in health care delivery is irrelevant