PBRNs and ACTION: Accelerating the Implementation of Evidence-Based Healthcare

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PBRNs and ACTIONAccelerating the
Implementationof Evidence-Based Healthcare

• David Lanier, MD
• CP3
• Cynthia Palmer, MSc
• CDOM

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AHRQ Mission

• To improve the quality, safety, efficiency
• and effectiveness of healthcare
• for all Americans

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Increased emphasis on implementing evidence-based
healthcare
Translation
Scientific Evidence
Understandable and Usable Information
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Challenges

• Passive diffusion/implementation of evidence
  takes too long
• Lengthy time requirements of funding through
  traditional grant mechanisms
• Historical delays in passage of annual
  Congressional appropriations
• Traditional (AHC) research settings not ideally
  suited for implementation/translational work

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Ecology of Medical Care Updated Green, Yawn,
Lanier. N Engl J Med 20013442021-25
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New Funding Mechanism Required

• Easy access to healthcare sites where most
  Americans receive care
• Targeted activities related to implementation of
  research evidence into practice
• Shorten the cycle of soliciting and funding
  projects
• Include funding for dissemination and spread of
  project findings

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Master Task Order Contracts

• Identify/define groups eligible to carry out
  rapid turn-around task orders
• Award master contracts through open competition
• Awardees are pre-qualified to compete for
  specific task order work
• Each master contractor assured of being awarded
  at least one task order over life of contract

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Task Orders

• Master contractor reports interests/strengths of
  network
• AHRQ defines the work to be done and the
  timeframe for completion (RFTO)
• Funding (ranging from 150,000 to gt2 million)
  from AHRQ and/or our Federal (e.g., CDC) or
  private (e.g. RWJF) partners
• Master contractors usually have lt6 wks to respond
  to RFTO
• Responses peer-reviewed and award(s) made within
  3-6 wks
• Typical task order completed within 6-30 mos

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Two Master Contractor Programs Established

• Practice-Based Research Networks (PBRNs)
  networks composed of smaller (1-20 clinician)
  community-based primary care practices
• Accelerating Change and Transformation in
  Organizations and Networks (ACTION) composed of
  hospital systems, health plans, long-term care,
  other care-delivery systems

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PBRNs

• Groups of ambulatory practices devoted
• principally to the primary care of patients,
• affiliated with each other and academic
• researchers in order to investigate
• questions related to community-based
• practice and to improve the quality of
• primary care.

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Primary Care PBRNs

• Real-world primary care practices
• Clinicians include all primary care specialties
  (family medicine, general internal medicine,
  pediatrics, family nurse practitioners)
• Work with academic researchers to answer
  questions related to primary care practice or the
  delivery of primary care services
• Laboratories for effectiveness studies in office
  settings with competing demands for high quality
  care and greater efficiency/productivity
• Depend upon outside funding (grants, contracts)
  to support their work

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Capacity

• 28 PBRNs identified in 1994
• 177 PBRNs identified in 2005
• Headquartered in urban, suburban and rural areas
• 2,724 practices are affiliated with PBRNs located
  in all 50 states and Puerto Rico
• 16 million patients are affiliated with PBRNs
• Average of 198,112 patients per PBRN (range 1200
  to 2.7 million)

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Why Is Primary Care Important to AHRQ?

• Majority of daily patient/clinician interactions
  occur in ambulatory settings
• Majority of prescriptions for medications written
  in ambulatory settings
• While growth of HMOs and large integrated
  healthcare systems has been dramatic, gt50 of
  Americans still receive primary care services in
  smaller (3-10 clinician) practices
• Significant amount of care in these settings
  flies under radar of most national quality
  monitoring efforts

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Consortia of Networks

• North Carolina Network Consortium (NCNC) UNC,
  Duke, Adolescent Research, Mecklenburg, Robeson
  County
• PRIME Net RIOSNet, CaReNet, SERCN, SPUR-Net,
  CRN
• SNOCAP High Plains, CaReNet, BIGHORN, AAFP-NRN
• ePCRN Consortium MAFPRN, AAFP-NRN, Alabama, LA
  Net, OKPRN, Penn State, STARNet, South Florida,
  Buffalo

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Individual Networks

• ACORN (Virginia Commonwealth)
• Irene (Iowa)
• OKPRN (Oklahoma)
• ORPRN (Oregon)
• PeRC (Childrens, Philadelphia)
• PPRNet (Univ South Carolina)

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PBRN Task Order Contractors Practices
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PBRN Task Order Contractors Age-Range of
Patients
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PBRN Task Order Contractors Patient
Race/Ethnicity
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PBRN Task Order Contractors Physician Provider
Discipline
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PBRN Task Orders To Date

• First award made in July, 2007
• Twelve RFTOs released/funded to date
• Funding 4.7 million
• One project completed (12 month task order)

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PBRN Task Order Projects

• Integrating evidence-based clinical and community
  services
• Preparing primary care to respond to a pan-flu
  public health threat
• Assessing the costs to primary care of collecting
  and reporting quality-related data
• Assessing barriers to quality measurement and
  reporting in primary care
• Clinical impact of nurse-based care management
• Development of a health literacy universal
  precautions toolkit

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PBRN Task Order Projects

• Primary care management of sleep apnea
• Pediatric asthma hospitalizations and the quality
  of primary care
• Implementation and evaluation of electronic
  standing orders
• Primary care participation in health information
  exchanges
• Establishing benchmarks for the medical office
  survey on patient safety
• Management in primary care of patients suspected
  of having CA-MRSA infections

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ACTION Accelerating Change and Transformation
in Organizations and Networks

• 5-year model of field-based research
• 15 large partnerships
• Partnerships include over 150 collaborating
  organizations
• Partners located in all States

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Through ACTION, Partnering to Promote Knowledge
Transfer and Exchange

DECISION-MAKERS
RESEARCHERS
Info Tools
Info Tools
PUBLICATIONS
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ACTION Goals

• Be responsive to user, stakeholder and
  operational needs for innovation in health care
  delivery
• Accelerate the development, implementation,
  dissemination and uptake of evidence-based
  products, strategies and findings into practice
• Prioritize generalizable approaches to enable
  spread to other settings

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Current ACTION Partners?

• Health Services Research Organizations
• Abt Associates, Inc., Cambridge, MA
• American Institutes for Research, Silver Spring,
  MD
• RAND Corporation, Santa Monica, CA
• RTI International, Research Triangle Park, NC
• The CNA Corporation, Alexandria, VA
• Academic Institutions
• Boston University School of Public Health,
  Boston, MA
• Indiana University, Indianapolis, IN
• UCSF School of Medicine, San Francisco, CA
• University of Iowa Center for Health Policy and
  Research, Iowa City, IA
• Weill Medical College of Cornell University, New
  York, NY
• Yale New Haven Health Services Corporation, New
  Haven, CT
• Other Health Care Organizations
• American Association of Homes and Services for
  the Aging,  Washington, DC
• Aurora Health Care, Milwaukee, WI
• Denver Health, Denver, CO
• Health Research and Educational Trust, Chicago,
  IL

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Future ACTION Partners?

• Anticipate an open recompetion of ACTION by 2010

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ACTION Partnerships Include

• Hospital systems
• Ambulatory care practices
• Long-term care systems (nursing homes, home
  health, assisted living)
• Safety net systems
• Health plans
• University schools of medicine, nursing, public
  health, health policy, and management
• Health services and outcomes research
  organizations
• Veterans Integrated Delivery System Networks
• QIOs
• JCAHO, NCQA and other national organizations for
  healthcare quality assurance
• Associations of healthcare providers
• Consumer advocacy organizations

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Why ACTION?

• Because We Need To
• Quit describing problems, start solving them
• Partner to promote knowledge transfer and
  exchange
• Speed up getting project results
• Encourage uptake of innovation to improve health
  care delivery

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How Does Contract Process Work?

• Project concepts welcomed from all sources, any
  time
• Topics must be critical to AHRQ, health systems,
  sponsors
• Solicit proposals from closed pool of ACTION
  partnerships throughout the year
• ACTION partnerships submit proposals within 4-6
  weeks
• Proposal review by small ad hoc committee of
  experts
• 2-4 months from solicitation to award

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How Does Funding Work?

• 2006 - 2008 ? 58 awards totaling 30.2 million
• 78 competitive awards
• 22 sole source (most externally funded)
• Average award 520 K (range 120K to 3
  million)
• Average duration 23 months (range 9 to 36
  months)

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Amounts Awarded by Topic
Topic Millions
Patient Safety 12.2
Organization/Value 5.2
Public Health Preparedness 4.5
Healthcare Information Technology 3.8
Prevention 3.3
Long-term Care 1.2
Total 30.2
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External Sponsorship, 2006-2008

• 13 fully sponsored projects
• RWJF (1)
• CDC (6)
• HRSA (2)
• ASPR (4)
• 3 co-sponsored projects
• DoD
• ONC
• CMS

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Main Strategic Advantages

• Extensive depth and breadth of care settings,
  data and implementation capacity
• Huge diversity (geographic, demographic, payer)
  among gt100 million recipients of care
• Speed ? average project duration of 23 months
• Focus on knowledge transfer and exchange

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How Do We Encourage Knowledge Transfer and
Exchange?

• Examples of project deliverables
• Workshops, webcasts, training programs, technical
  assistance in care delivery settings
• DVDs, how to guides, workbooks
• Presentations to healthcare operational
  leadership
• Live/web-assisted conferences
• Tested scalable, scenario-appropriate models
• Publications in peer-reviewed and trade journals
• Ready access to Steering Committee members
  organizations (e.g., AHA, MGMA, NBGH, RWJF) for
  rapid dissemination (member webcasts, listserves,
  annual meetings, journals)

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PBRN Task Order Example 1Pandemic Flu
Management in Primary Care

• How to manage
• patient surges
• during pandemic flu?
• HIT-assisted
• systems to
• faciliate patient self-management.

• Development of enhanced interactive phone systems
• Interactive website with patient education
  materials
• University of Oklahoma (OKPRN)
• 12 month project

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PBRN Example 2Measuring costs to primary care
practices of collecting/reporting quality data

• Policy issue What is the cost to a primary care
  practice of collecting/reporting quality-related
  data? Who should bear the financial burden?
• Task Order Awards One Task Order to North
  Carolina (NCNC) to measure costs of
  collecting/reporting global quality measures
  Second Task Order to Univ Colorado (SNOCAP) to
  measure costs of collecting/reporting
  diabetes-specific measures
• Results anticipated November, 2008 (14 month
  projects)

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PBRN Example 3Management of Suspected CA-MRSA

• Congressional appropriation to AHRQ in December,
  2007
• CDC has established evidence-informed principles
  for ambulatory management but feasibility/actual
  outcomes unknown
• Three task orders awarded August, 2008

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ACTION Is 2 ½ Years Old

• Some early task orders are completed and others
  have interim results.
• How are we doing?

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Example 1 60 MRSA Infection Reduction in
Indianapolis Hospitals

• Problem
• gt126,000 MRSA infections per yr in hospitals
• gt5,000 patients die as a result
• Over 2.5 billion excess healthcare costs
• Products and Results
• Indiana University developed and implemented a
  novel approach to reduce MRSA in ICUs in
  hospital systems in Indianapolis
• improved surveillance, hand hygiene, contact
  isolation
• Avg 60 reduction in MRSA infections in
  intervention units 20 reduction in control
  units
• Other hospitals in the Indianapolis area and
  elsewhere eager to adopt this approach
• Congress funding AHRQ to further enhance and
  spread successful approaches to reduce MRSA and
  other healthcare associated infections

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Example 2 National Spread of TeamSTEPPS

• Problem
• Poor communication and lack of teamwork among
  health care professionals contribute to errors in
  patient safety
• Products and Results
• AHRQ, DoD and American Institutes for Research
  built national training and support network for
  TeamSTEPPS, an evidence-based teamwork system
• TeamSTEPPS National Implementation program fully
  operational nationwide
• 1200 Master Trainers/Change Agents being trained
  (including in ACTION partnerships)
• Other spread e.g., all Maine hospitals using
  TeamSTEPPS

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Example 3 10 Million in Reduced Waste at Denver
Health Hospital

• Problem
• Estimates of overuse, underuse, and misuse of
  resources range from 30 (Midwest Business Group
  on Health) to 50 (Intermountain Health Care) of
  all healthcare expenses in the US
• Products and Results
• Denver Health trained all hospital middle
  managers in waste reduction using Lean
• Examples
• Better organized respiratory therapy equipment ?
  40 reduction in time spent searching (estimated
  9,220/year saved)
• Disposal of 75 dumpsters of old files, equipment,
  supplies, hazardous materials ? 300,000 in
  capital improvement and improved safety
• Switch from paper to electronic forms ? cost
  savings of 7,500/yr

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Example 4 Improved Health Care Planning in
Disasters

• Problem
• Lack of planning for emergencies
• Example Hurricane Katrina
• Products and Results (3 of many examples)
• Alternate Site Locator to help State and local
  officials quickly locate appropriate alternate
  health care sites if existing ones are
  overwhelmed
• Emergency Preparedness Resource Inventory to help
  local/regional planners inventory equipment,
  personnel, and supplies in advance
• Staffing for Disaster Preparedness Response Model
  to improve antibiotic dispensing and vaccination
  campaigns for disease outbreaks

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Questions? Comments?
Contacts

• ACTION Program Officer Cynthia.Palmer_at_ahrq.hhs.go
  v
• ACTION Fact Sheet at www.ahrq.gov/research/action
  .pdf
• PBRN Program Officer David.Lanier_at_ahrq.hhs.gov
• PBRN website www.ahrq.gov/research/primarix.htm