EBM12: Feedback is ‘missing link’ in evidence-based medicine cycle
CHICAGO—While changes to the overall U.S. healthcare system and payment models are inevitable, a key component to these changes is communicating proper goals and expectations to providers and patients, said Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), on Oct. 4 at the CMIO Summit on Transforming Healthcare through Evidence-Based Medicine.
Healthcare reform, including payment reform, has already begun. “We are slowly, clumsily, awkwardly, but step-by-step making our way through payment reforms,” she said. “We are getting to a place for quality and results, as opposed to how much stuff we do. But the transitional path won’t be that smooth.”
In this new environment, Clancy questioned: How is evidence integrated in? How has the nature of evidence changed? How do these changes affect providers, payers and patients? How do we make sure that these changes are beneficial?
Evidence is being produced at an extremely rapid rate, but its incorporation into clinical practice happens much more slowly, said Clancy, pointing to the widespread adoption of beta-blockers taking 25 years, after the initial landmark clinical trial. “Transparency efforts don’t offer enough usable data for decisions regarding a specific disease and selection of a treatment option, and remain a maddening challenge,” she added. “We face an underperforming healthcare system and untenable cost forecasts.”
Three contemporary areas of healthcare focus—patient-centered care, population health and advanced modern medicine (such as genomics and nanotechnology)—call for organizing care around the patient rather than around systems of care, which is the focus of the AHRQ.
Annual AHRQ reports have found significant and statistical improvements in the overall quality of care. However, the 2011 “National Healthcare Disparities Report” concluded that the overall improvement in the quality of care remains suboptimal and access to care is not improving.
“Few disparities in quality are getting smaller and almost no disparities in access are getting smaller,” Clancy reported. “Quality of care varies not only across types of care but also across parts of the U.S.” Also, the report found healthcare quality and access are suboptimal, particularly for minority and low-income groups.
The report also concluded that urgent attention is needed to ensure continued improvement in quality and progress on reducing disparities for services, geographic areas and populations. That includes:
Patient-centeredness may be the most challenging of all six domains of quality within the AHRQ, according to Clancy, because it is difficult to define and measure. “But, it is also likely the most important, because it includes elements of all other domains,” she added.
AHRQ is working to: translate scientific advances into actual clinical practice; translate scientific advances into usable information for clinicians and also for patients; and deliver information in the right place at the right time.
“It’s surprising how difficult it is for the patient to get the information that they need,” she said. Step one, Clancy explained, is producing the appropriate information, and step two, is making that information available when people need it.
“Patient-centered outcomes research informs decisions by providing evidence and information on effectiveness, benefits and harms,” she said.
Currently, the Patient-Centered Outcomes Research Institute 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 percent of the Patient-Centered Outcomes Research Trust Fund can be used to support research capacity building and dissemination activities.
Despite all the information that healthcare agencies and researchers produce, there are still many assumptions in healthcare about how information gets translated to providers and patients, according to Clancy. “One, we’ve always assumed flawless execution, and two, we’ve also always assumed that any issues that arise are caused by a knowledge problem—neither is true,” she said.
An example of success on the provider side can be found with healthcare-associated infections (HAIs) that patients get in the course of medical care, and affect up to one in 20 patients in hospitals at any one time. AHRQ issued $34 million in support of goals of the Partnership for Patients and HHS Action Plan to Prevent HAIs. The projects include:
Since that time, CUSP has cut central line-associated bloodstream infections by 40 percent in 1,100 hospital units in a Johns Hopkins patient safety project in Michigan, from 1.903 infections per 1,000 central line days to 1.137 per 1,000 days.
However, engaging patients is consistently problematic. Clancy points to asking two questions at patient discharge as integral components of ensuring he or she is going to comply: Tell me your goals. Tell me what you heard.
“We will develop a more intuitive grasp of the power of data over time,” she said. “Young physicians tend to be first adopters of health IT, and new practice arrangements are increasingly offering more alternatives to physicians entering practice.” Clancy said that someday, health IT will make data collection, reporting and updating of quality measures easy, but “not today.”
Currently, quality assessment is based on the provider and setting, or processes, but in the future, it will be based on patient experience, or outcomes. However, assessing and understanding those outcomes will be integral in the changes to the healthcare system, and communication is the "missing link" in this process, according to Clancy.
Healthcare reform, including payment reform, has already begun. “We are slowly, clumsily, awkwardly, but step-by-step making our way through payment reforms,” she said. “We are getting to a place for quality and results, as opposed to how much stuff we do. But the transitional path won’t be that smooth.”
In this new environment, Clancy questioned: How is evidence integrated in? How has the nature of evidence changed? How do these changes affect providers, payers and patients? How do we make sure that these changes are beneficial?
Evidence is being produced at an extremely rapid rate, but its incorporation into clinical practice happens much more slowly, said Clancy, pointing to the widespread adoption of beta-blockers taking 25 years, after the initial landmark clinical trial. “Transparency efforts don’t offer enough usable data for decisions regarding a specific disease and selection of a treatment option, and remain a maddening challenge,” she added. “We face an underperforming healthcare system and untenable cost forecasts.”
Three contemporary areas of healthcare focus—patient-centered care, population health and advanced modern medicine (such as genomics and nanotechnology)—call for organizing care around the patient rather than around systems of care, which is the focus of the AHRQ.
Annual AHRQ reports have found significant and statistical improvements in the overall quality of care. However, the 2011 “National Healthcare Disparities Report” concluded that the overall improvement in the quality of care remains suboptimal and access to care is not improving.
“Few disparities in quality are getting smaller and almost no disparities in access are getting smaller,” Clancy reported. “Quality of care varies not only across types of care but also across parts of the U.S.” Also, the report found healthcare quality and access are suboptimal, particularly for minority and low-income groups.
The report also concluded that urgent attention is needed to ensure continued improvement in quality and progress on reducing disparities for services, geographic areas and populations. That includes:
- Diabetes care and adverse events;
- Disparities in cancer screening and access to care; and
- States in the South.
Patient-centeredness may be the most challenging of all six domains of quality within the AHRQ, according to Clancy, because it is difficult to define and measure. “But, it is also likely the most important, because it includes elements of all other domains,” she added.
AHRQ is working to: translate scientific advances into actual clinical practice; translate scientific advances into usable information for clinicians and also for patients; and deliver information in the right place at the right time.
“It’s surprising how difficult it is for the patient to get the information that they need,” she said. Step one, Clancy explained, is producing the appropriate information, and step two, is making that information available when people need it.
“Patient-centered outcomes research informs decisions by providing evidence and information on effectiveness, benefits and harms,” she said.
Currently, the Patient-Centered Outcomes Research Institute 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 percent of the Patient-Centered Outcomes Research Trust Fund can be used to support research capacity building and dissemination activities.
Despite all the information that healthcare agencies and researchers produce, there are still many assumptions in healthcare about how information gets translated to providers and patients, according to Clancy. “One, we’ve always assumed flawless execution, and two, we’ve also always assumed that any issues that arise are caused by a knowledge problem—neither is true,” she said.
An example of success on the provider side can be found with healthcare-associated infections (HAIs) that patients get in the course of medical care, and affect up to one in 20 patients in hospitals at any one time. AHRQ issued $34 million in support of goals of the Partnership for Patients and HHS Action Plan to Prevent HAIs. The projects include:
- Three new modules for the Comprehensive Unit-based Safety Program (CUSP);
- Research on ways to reduce methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C-diff); and
- Use of health system facility design to reduce HAIs.
Since that time, CUSP has cut central line-associated bloodstream infections by 40 percent in 1,100 hospital units in a Johns Hopkins patient safety project in Michigan, from 1.903 infections per 1,000 central line days to 1.137 per 1,000 days.
However, engaging patients is consistently problematic. Clancy points to asking two questions at patient discharge as integral components of ensuring he or she is going to comply: Tell me your goals. Tell me what you heard.
“We will develop a more intuitive grasp of the power of data over time,” she said. “Young physicians tend to be first adopters of health IT, and new practice arrangements are increasingly offering more alternatives to physicians entering practice.” Clancy said that someday, health IT will make data collection, reporting and updating of quality measures easy, but “not today.”
Currently, quality assessment is based on the provider and setting, or processes, but in the future, it will be based on patient experience, or outcomes. However, assessing and understanding those outcomes will be integral in the changes to the healthcare system, and communication is the "missing link" in this process, according to Clancy.