Advancing Excellence in Health Care: Complexities of Co-Occurring Conditions

1. Advancing Excellence in Health Care: Complexities of Co-Occurring Conditions Helen Burstin, MD, MPH Director, Center for Primary Care, Prevention, and Clinical Partnerships CCC Conference June 24, 2004

2. Overview • About AHRQ: The Evidence Agency • Improving Quality and Reducing Disparities • Mental Health and Substance Abuse at AHRQ • Opportunities and Challenges

3. 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

4. New AHRQ Mission Statement To improve the quality, safety, efficiency, and effectiveness of health care for all Americans

5. AHRQ Research and Knowledge Transfer • Building the knowledge base: • The Effectiveness Question: What works? • Clinical • Organizational • How do we get people/systems/policymakers to do or use what works? • How do we support the widespread implementation of what works? • How do we sustain evidence based practice?

6. Involving Users in Research Cycle Partnering for Translation and Dissemination Partnering for Implementation and Evaluation Research Networks Research Collaboratives Focus on Results Measuring impact Systematic evaluations Knowledge Transfer Strategies

7. Evidence-based Practice Centers • Systematically reviews scientific literature on clinical, behavioral, and organization and financing topics • Conducts research on methodologies and the effectiveness of their implementation • Requires nomination by an organization who will use the reports to support quality improvement

8. Examples of EPC Topics • Impact of financial incentives on the delivery of clinical preventive services • Rating systems for strength of scientific evidence • Best practices for priority conditions • MH/SA: pharmacologic therapy for alcoholism, depression, ADHD, and dementia

9. The National Guideline Clearinghouse www.guideline.gov • Emphasis on transferring evidence-based knowledge to health care professionals • Structured summaries of guidelines • Includes “syntheses,” guideline comparisons, and annotated bibliographies • Numerous guidelines on approximately 20 different MH/SA diagnoses.

10. Overview • About AHRQ: The Evidence Agency • Improving Quality and Reducing Disparities • Mental health and substance abuse at AHRQ • Opportunities and Challenges

11. Patients’ care often deficient, study says. Proper treatment given half the time. On average, doctors provide appropriate health care only half the time, a landmark study of adults in 12 U.S. metropolitan areas suggests. RAND Study: Quality of Health Care Often Not Optimal Medical errors corrode quality of healthcare system Medical Care Often Not Optimal Failure to Treat Patients Fully Spans Range of What Is Expected of Physicians and Nurses Study: U.S. Doctors are not following the guidelines for ordinary illnesses The American healthcare system, often touted as a cutting-edge leader in the world, suddenly finds itself mired in serious questions about the ability of its hospitals and doctors to deliver quality care to millions. .

12. Healthcare Research and Quality Act (PL. 106-129) • “Beginning in fiscal year 2003, the Secretary, acting through the Director, shall submit to Congress an annual report on national trends in the quality of health care provided to the American people.” • Annual report to the Congress on “prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations.”

13. NHQR/NHDR: Key Findings • Only 20.9% of patients with diabetes receive all recommended tests • 90% of adults are screened for high blood pressure – but only 25% are controlled • Nearly 1/3 of adults and children with asthma do NOT receive effective Rx • Almost 80% of patients diagnosed with depression do not have optimal levels of contact with their health care provider.

14. NHQR/NHDR: Mental Health Data Limitations: • Need additional measures for mental disorders other than depression • Need better data on vulnerable populations • Insufficient data to track the quality of mental health treatment for young adults or the elderly

15. Getting to Improvement • Making research findings usable – now: www.qualitytools.ahrq.gov • Partnerships with professional organizations, federal agencies, communities and patients • New links to SAMHSA (National Mental Health Information Center) and NIMH (Health Information) information

16. Overview • About AHRQ: The Evidence Agency • Improving Quality and Reducing Disparities • Mental health and substance abuse at AHRQ • Opportunities and Challenges

17. How has practice changed?

18. Percent of Americans Saying “I Have A Chronic Condition” Chronic Illness and Caregiving Survey, Harris 2000

19. Beneficiaries With 5 or More Chronic Conditions Account for Two-Thirds of Medicare Spending Source: Medicare 5% Sample, 2001 Gerry Anderson, JHU

20. Most Adults Have Multiple Chronic Conditions Source: Medical Expenditure Panel Survey, 2000 Gerry Anderson, JHU

21. Depression and Utilization • For 8 common conditions, depression increases odds: • 2.1-3.2 of ER visit • 2.6-3.7 of hospitalization • 1.7-2.7 of preventable hospitalization Gerry Anderson, JHU

23. Practice-Based Research Networks (PBRNs) 36 new PBRN grants awarded in 2002 19 PBRN grants awarded in 2000

24. Practice-based Research Networks • Groups of primary care providers that work together to study questions related to community-based practice • Provide strategies to translate research into practice • 45 regional/national networks of community health centers, clinics, practices, and HMOs • Support from NIMH

25. PBRNs and Study of MH/SA* * PBRN Resource Center Survey of 83 PBRNs

26. Prescription for Health: RWJ-AHRQ Initiative • PBRNs develop creative, practical strategies to promote healthy behaviors that can be easily adopted by other primary care practices. • $9 million research/QI initiative • 4 health risk behaviors: smoking, risky drinking, sedentary lifestyle; and unhealthy diet • 7/17 projects: interventions to reduce risky drinking

27. US Preventive Services Task Force • Independent panel of experts in primary care and prevention • Evaluates the scientific evidence for a range of preventive services (i.e. counseling, screening, and preventive medications) • Makes recommendations on whether a clinical preventive service should be routinely delivered

28. USPSTF and MH/SA • Recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. • Screening improves the accurate identification of depressed patients in primary care settings • Treatment of depressed adults identified in primary care settings decreases clinical morbidity. • Insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population.

29. USPSTF and MH/SA • Recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings • Insufficient evidence to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care settings. • Insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse.

30. Overview • About AHRQ: The Evidence Agency • Improving Quality and Reducing Disparities • Mental Health and Substance Abuse at AHRQ • Opportunities and Challenges

31. Bridging the Quality Chasm Where Where We We Are Want To Be Implementation Innovation Health IT Diffusion Adoption TRIP

32. Diffusion of Innovation • “Invention is hard; dissemination is much more difficult”. • A problem for all industries. • Influences on rate of diffusion: • Perception of innovation • Characteristics of individuals who adopt change • Contextual and managerial factors

33. Where is US Health Care and IT?

34. The “CPR Adoption Gap”:The United States Versus Others Primary Care Physician Office CPR Use by Country, 2002 Source: "European Physicians Especially in Sweden, Netherlands, and Denmark, Lead U.S. in Use of Electronic Medical Records." Harris Interactive Health Care News 2(16).

35. Health Information Technology • AHRQ Investment: $60M • $26M: to implement proven technologies in small and rural communities where HIT penetration has been low • $24M: targeted for developing, implementing, and evaluating the use of new and innovative technologies to improve patient safety and quality of care in diverse health care settings • $10M: targeted for clinical data standards and interoperability

36. Questions in Search of Answers • Linking knowledge development to policy levers (e.g., payment; regulation): role of ‘demonstrations’ • When is “good enough”? • Vocabulary and pathways for translation of knowledge-based interventions under-developed • Concurrent -- or sequential -- evaluation and translation?

38. For additional questions, please contact: Dr. Helen Burstin, hburstin@ahrq.gov