Comparative Effectiveness: Moving from Research to Practice

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Comparative Effectiveness Moving from
Research to Practice

• Carolyn M. Clancy, MD
• Director
• Agency for Healthcare Research and Quality
• The 25th Annual Rosalynn Carter Symposium on
  Mental Health Policy
• The Carter Center November 6, 2009

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Treatment for Mental Health
Adults with a mood, anxiety or impulse control
disorder in the last 12 months who
received minimally adequate treatment, 2001-2003

• Nearly 30 of adults with mood, anxiety or
  impulse control disorders received minimally
  adequate treatment
• There were no significant differences by age

AHRQ 2008 National Healthcare Quality Report
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By Race Education
Adults with a mood, anxiety or impulse control
disorder in the last 12 months who
received minimally adequate treatment, 2001-2003

• of adults who received minimally adequate
  treatment was lower among Blacks and Hispanics,
  with Hispanics having the lowest of all groups
• was also lower among individuals with less than
  a high school education and high school
  graduates, compared with those with some college
  education

AHRQ 2008 National Healthcare Disparities Report
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Treatment for Depression
Adults with a major depressive episode in the
last 12 months who received treatment for
depression, by race, ethnicity, income and
education, 2006

• of adults with major depressive episode who
  received treatment was significantly lower for
  Blacks than for Whites (58.9 and 71.1) and
  lower for Hispanics than for non-Hispanic Whites
  (51.8 and 73.3)
• There were no statistically differences by income
  or education level

AHRQ 2008 National Healthcare Disparities Report
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Current Challenges

• Concerns about health spending about 2.3
  trillion per year in the U.S. and growing
• Pervasive problems with the quality of care that
  people receive
• Translating scientific advances into actual
  clinical practice
• Translating scientific advances into usable
  information for clinicians and patients
• A health care system that has been isolated for
  people with mental health issues for far too long

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CER Moving from Research to
Practice

• AHRQ New Resources, Ongoing Priorities
• Comparative Effectiveness and The American
  Reinvestment and Recovery Act of 2009
• Translating Science into Real-World Applications

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AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
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AHRQ Priorities
Patient Safety

• Health IT
• Patient SafetyOrganizations
• New PatientSafety Grants

Effective HealthCare Program
AmbulatoryPatient Safety

• Comparative Effectiveness Reviews
• Comparative Effectiveness Research
• Clear Findings for Multiple Audiences

• Safety Quality Measures,Drug Management
  andPatient-Centered Care
• Patient Safety ImprovementCorps

Medical ExpenditurePanel Surveys
Other Research Dissemination Activities

• Visit-Level Information on Medical Expenditures
• Annual Quality Disparities Reports

• Quality Cost-Effectiveness, e.g.Prevention and
  PharmaceuticalOutcomes
• U.S. Preventive ServicesTask Force
• MRSA/HAIs

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New Mental Health Research Findings

• Compendium of recent mental health research
  projects funded by AHRQ
• Expanded funding for improving mental health care
  through health IT and primary care delivery
• The Agency has also developed a new focus on the
  complex patient

http//www.ahrq.gov/research/mentalhth.pdf
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Recent Legislation for Parity in
Mental Health

• The Paul Wellstone and Pete Domenici Mental
  Health Parity and Addiction Equity Act of 2008
• Effective January 1, 2010, designed to produce
  parity in private employer-sponsored health plans
  for organizations with more than 50 employees
  (passed as part of the American Reinvestment and
  Recovery Act of 2009)
• The Medicare Improvements for Patients and
  Providers Act of 2008
• Mental health parity is gradually phased in
  between 2010 and 2014
• Children's Health Insurance Program
  Reauthorization Act of 2009 (CHIPRA)
• Requires mental health parity for states that
  offer mental health or substance abuse services
  in CHIP plans

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AHRQ 2009 New Resources, Ongoing Priorities

• 372 million for AHRQ in FY 09 budget
• 37 million more than FY 2008
• 46 million more than Administration request
• FY 2009 appropriation includes
• 50 million for comparative effectiveness
  research, 20 million more than FY 2008
• 49 million for patient safety activities
• 45 million for health IT

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AHRQs Role in Comparative
Effectiveness
Using Information to Drive Improvement
Scientific Infrastructure to Support Reform
Lead federal funding

• Aggregate best evidence to inform complex
  learning and implementation challenges

Engage private sector
Increase knowledge base to spur high-value
care
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CER Outputs at AHRQ

• Research reviews Comprehensive reports that draw
  on scientific studies to make head-to-head
  comparisons of treatments
• Summary guides Short, plain-language guides that
  summarize research reviews and are tailored to
  different audiences clinicians, consumers and
  policymakers
• New research reports Fast-turnaround reports
  that draw on health care databases, electronic
  patient registries and other resources to explore
  practical questions

http//effectivehealthcare.ahrq.gov
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Comparative Effectiveness
and the Recovery Act

• The American Recovery and Reinvestment Act of
  2009 includes 1.1 billion for comparative
  effectiveness research
• AHRQ 300 million
• NIH 400 million (appropriated to AHRQ and
  transferred to NIH)
• Office of the Secretary 400 million (allocated
  at the Secretarys discretion)

Federal Coordinating Council appointed to
coordinate comparative effectiveness research
across the federal government
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Definition Federal Coordinating Council

• CER is the conduct and synthesis of research
  comparing the benefits and harms of various
  interventions and strategies for preventing,
  diagnosing, treating, and monitoring health
  conditions in real-world settings. The purpose of
  this research is to improve health outcomes by
  developing and disseminating evidence-based
  information to patients, clinicians, and other
  decision makers about which interventions are
  most effective for which patients under specific
  circumstances.

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Definition IOM

• Comparative effectiveness research (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.
• National Priorities for Comparative Effectiveness
  Research
• Institute of Medicine Report Brief
• June 2009

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Conceptual Framework
Stakeholder Input Involvement
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AHRQs Priority Conditions for the Effective
Health Care Program

• Arthritis and non-traumatic joint disorders
• Cancer
• Cardiovascular disease, including stroke and
  hypertension
• Dementia, including Alzheimer Disease
• Depression and other mental health disorders
• Developmental delays, attention-deficit
  hyperactivity disorder and autism

• Diabetes Mellitus
• Functional limitations and disability
• Infectious diseases including HIV/AIDS
• Obesity
• Peptic ulcer disease and dyspepsia
• Pregnancy including pre-term birth
• Pulmonary disease/Asthma
• Substance abuse

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IOMs 100 Priority Topics

• Initial National Priorities for Comparative
  Effectiveness Research (June 20, 2009)
• Topics in 4 quartiles groups of 25.
• Includes several priorities for mental health,
  including
• Treatment approaches, such as integrating mental
  health care and primary care
• Training of primary care physicians in primary
  care mental health and co-location systems of
  primary care and mental health care on outcomes
  including depression, anxiety and cost
• Patient decision support tools on informing
  diagnostic and treatment decisions, and
  including patients with mental health
  problems

Report Brief Available At http//www.iom.edu
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AHRQ Operating Plan for Recovery Acts CER Funding

• Stakeholder Input and Involvement To occur
  throughout the program
• Horizon Scanning Identifying promising
  interventions
• Evidence Synthesis Review of current research
• Evidence Generation New research with a focus on
  under-represented populations
• Research Training and Career Development Support
  for training, research and careers

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Translating the Science into
Real-World Applications

• Examples of Recovery Act Evidence Generation
  projects with funding available/pending
• Clinical and Health Outcomes Initiative in
  Comparative Effectiveness (CHOICE) First
  coordinated national effort to establish a series
  of pragmatic clinical comparative effectiveness
  studies (100M)
• Request for Registries Up to five awards for the
  creation or enhancement of national patient
  registries, with a primary focus on the 14
  priority conditions (48M)
• DEcIDE Consortium Support Expansion of
  multi-center research system and funding for
  distributed data network models that use
  clinically rich data from electronic health
  records (24M)

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Additional Proposed Investments

• Supporting AHRQs long-term commitment to
  bridging the gap between research and practice
• Dissemination and Translation
• Between 20 and 25 two-three-year grants (29.5M)
• Eisenberg Center modifications (3 years, 5M)
• Citizen Forum on Effective Health Care
• Formally engages stakeholders in the entire
  Effective Health Care enterprise
• A Workgroup on Comparative Effectiveness will be
  convened to provide formal advice and guidance
  (10M)

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Health IT and Comparative Effectiveness Research

• As with comparative effectiveness research,
  health IT is a useful tool in a much larger
  toolkit
• AHRQ has invested more than 260 million in
  health IT contracts and grants

• More then 150 communities, hospitals, providers
  and health care systems in 48 states

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AHRQ Health IT Initiatives

• Examples, Ambulatory Safety and Quality (ASQ)
  Program
• Pharmaceutical Safety Tracking Childrens
  Research Institute, Columbus, OH
• Monitoring medication adherence in an urban
  mental health system serving a primarily Medicaid
  population
• Improving Outcomes through Ambulatory Care
  Coordination Nebraska Behavioral Health
  Information Network
• An HIE focused on coordination of care for
  individuals with chronic mental illness
• A Personal Health Record (PHR) for Mental Health
  Consumers Emory University
• Adapts existing electronic PHR for needs of
  people with a serious mental disorder and one or
  more chronic conditions

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CER and Innovation

• CER will enhance the best and most innovative
  strategies
• Can open up new populations for which something
  can be useful in
• Can bring early attention to potential issues

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Comparative Effectiveness Challenges/Opportunities

• Anticipating downstream effects of policy
  applications
• Eliminating uncertainty about best practices
  involving treatments and technologies
• Making sure that comparative effectiveness is
  "descriptive, not prescriptive
• Creating a level playing field among all
  stakeholders, including patients and consumers
• Adopting a more integrated approach to achieving
  high quality health care
• Using the same evidence-based information to make
  different care decisions based on the
  characteristics, needs, etc., of the individual

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Where to From Here?

• Timing Significant support for and interest in
  comparative effectiveness research
• The mission Address gaps in quality and resolve
  conflicting or lack of evidence about most
  effective treatment approaches
• Words of wisdom In theory, there is no
  difference between theory and practice. In
  practice, there is. Yogi Berra

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Thank You
www.ahrq.gov
http//effectivehealthcare.ahrq.gov
www.hhs.gov/recovery