Demand-Driven Research: Working
through Delivery-Based Networks
Irene Fraser, PhD, Director, CDOM
AcademyHealth Annual Research Meeting
June 8, 2004
RAND Study: Quality of Health Care
Often Not Optimal
 Doctors provide appropriate health care only
about half the time
Alcohol dependence
Hip fracture
Peptic ulcer
Diabetes
Low back pain
Prenatal care
Breast cancer
Cataracts
11%
23%
33%
45%
69%
73%
76%
79%
Percentage of time
E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults
in the United States, N Engl J Med, 2003
To Improve Health Care, Decision-Makers
Need and Want Evidence
 Clinical decisions - EB Medicine
– What to include in drug formularies
– How to define medical necessity
 Management decisions -- EB Management
– How to pay hospitals, physicians, nurses
– How many/what kind of staff to recruit
– With whom to merge, affiliate, contract
– How to organize processes of care
– What kinds of IT systems to purchase
 Policy Decisions – EB Policy
Original research
18%
Negative
results
variable
Dickersin, 1987
Submission
46%
0.5 year
Kumar, 1992
0.6 year
Kumar, 1992
Koren, 1989
Acceptance
Negative
results
Publication
35%
Lack of
numbers
17:14
0.3 year
Balas, 1995
Expert
opinion
Poyer, 1982
Bibliographic databases
50%
6. 0 - 13.0 years
Antman, 1992
Poynard, 1985
Reviews, guidelines, textbook
Inconsistent
indexing
9.3 years
Implementation
17 yrs to turn 14% of original research to the benefit of patient care
A Particular Problem for
Evidence-Based Management
EB Medicine
 More targeted goal
(improve practice)
 Researchers and users
are both scientists
 Read common journals
 Patients the unit of
analysis
EB Management
 Multiple goals (quality,
efficiency, profit)
 Managers not scientists
 Managers and scientists
read different things
 Organizations the unit of
analysis (N problem)
Lessons from Marketing
 First rule of marketing:
– Build product to fit the need
 Second rule of marketing:
– To have the right product, may need to change the
way you make it
Identifying Need: What Do DecisionMakers Want?
 Six user-centered meetings
– Small (20-30) groups
– Combination of industry leaders, purchasers,
policymakers, researchers
 Discussion at several NAC meetings
 Focus on both content and dissemination/use
 Five lessons for HOW we do our work:
#1: Design Studies that Answer
User Questions
 Move from description to prediction and
explanation
 Focus on independent variables that are
modifiable
 Provide details on HOW to implement
#2: Present Findings in DecisionMakers’ Time and Space
 Define “evidence” as they do
 Perhaps redefine when something is ready for “prime
time”
 Limit caveats
 Be willing to generalize to broader universe
 Add “tools” to our list of products
#3: Change Incentive Systems
for Researchers
Currently, researchers
 Get tenure by publishing in journals managers don’t
read
 Get credit for teaching other researchers, not
managers
 Get grants for “academic” research, not applied,
translational research
 Find it easier to publish quantitative, not qualitative,
research
#4: Build User-Researcher
Collaborations and Dialogue
 Provider-based networks
 Challenge grants
 Organizational researchers with management
experience
 Managers with research training
 Practitioners in classrooms
#5: Change Dissemination
 Let early adopters, not researchers, educate next




wave of users
Give presentations at trade association meetings, not
just research meetings
Collaborate with, mimic, or work through consultants
Find or create equivalent of Harvard Business Review
for health care
Expand funding for implementation research
Bonus Tip: Don’t Over-Complicate
Findings
Winners of Washington Post Contest on Ways to
Make Life Harder
 Supermarkets arrange goods alphabetically: lettuce,
lamb and lysol are now contiguous
 Thursdays become “drive-on-the-left-side-of-the-road”
day
 Subdivide time zones into 60 parts, observing local
times to the minute
 Alphabetize phone books by first names
SUPPLY-DRIVEN MODEL
RESEARCHERS
•
•
•
•
•
•
Questions
Hypotheses
Grant Applications
Study
Writing
Re-writing
DECISION-MAKERS
PUBLICATIONS
Leadership
Politics
Evidence
Culture
SUPPLY-DRIVEN MODEL WITH
MARKETING
“Knowledge transfer”
RESEARCHERS
•
•
•
•
•
•
Questions
Hypotheses
Grant Applications
Study
Writing
Re-writing
DECISION-MAKERS
PUBLICATIONS
Leadership
Politics
Evidence
Culture
DEMAND-INFORMED MODEL
User Needs Assessment
“Knowledge transfer”
RESEARCHERS
•
•
•
•
•
•
Questions
Hypotheses
Grant Applications
Study
Writing
Re-writing
DECISION-MAKERS
PUBLICATIONS
Leadership
Politics
Evidence
Culture
DEMAND-DRIVEN NETWORK MODEL
DECISION-MAKERS
RESEARCHERS
Info +
Tools
Info +
Tools
PUBLICATIONS
3 Examples of Research Networks
 Integrated Delivery System Research Network
 Center for Health Management Research
 HIV Research Network
What is the IDSRN?
 9 practice-based research partners:
–
–
–
–
–
–
–
–
–
Abt Associates Inc.
Center for Health Care Policy and Evaluation
Denver Health
Emory Center on Health Outcomes and Quality
HMO Research Network
Marshfield Clinic IDS Research Consortium
Research Triangle Institute - UNC Network
University of Minnesota Consortium
Weill Medical College of Cornell University
 40 collaborators
 Work through task orders
Strategic Advantage: Size and Breadth
IDSRN includes:
 Over 50 million patients
 Majority of US physicians
 Majority of acute inpatient
facilities
 2,250 outpatient clinics
 450 long term care facilities
 56 rehabilitation facilities
 30 home health agencies
 63 dental facilities
Size and Breadth: Persons
Served Located in All States
Strategic Advantage: Population
Diversity
 Payer mix: privately insured, Medicare (3
million), Medicaid (2 million), uninsured (0.5
million)
 Geographic mix: urban, inner-city, suburban
and rural (6.3 million) residents
 Demographic mix: ethnic and racial minorities
(>5.8 million), children and adolescents (>14
million), persons aged 65+ (~7 million)
Strategic Advantage: Data, Research,
Implementation Capacity
 Large, robust databases (e.g., administrative,




clinical, registries)
Clinical, demographic, geographic data diversity
Nationally-recognized academic and field-based
researchers
Expertise in data manipulation, methods,
emerging IDS policy/management issues
Operational leadership involved in setting
agenda and using findings
Strategic Advantage: Speed
 From request for proposals to award : ~9
weeks
 Average project completed in 16 months
 Excellent mechanism for rapid-cycle work:
– data availability
– expertise in data manipulation, methods
– established partner collaborations
– want solutions for own delivery system issues
Examples of Products in 2003
 Presentations to IDS Operational Leadership (12)
 Presentations at live/web-assisted conferences (50)
 Scalable, scenario-appropriate models (for local to
international adaptation) (~15)
 Training session and workshop tools (47)
 “How to” guides, workbooks (many!)
 Publications in peer-reviewed journals (12)
 Press releases, briefings and briefs (10)
 National conference (1)
Impact: 830 Downloads of Weill’s BTP Model
from AHA Web Site; AHA TA Provided
Impact: IDSRN Results Influence Users’
Practice or Policy Decisions
 Providence Health System hired “transition
pharmacist” to reduce errors using an electronic
medication list
 CMS/OMH using CLAS guides as training tools in
M+CO workshops nationwide
 Findings influenced Aetna’s decision to begin
collecting race/ethnicity data
 Evercare CEO making NP staffing decisions for
nursing homes based on pneumonia care findings
IDSRN: Three Types of Impact
Home Page
http://www.AHRQ.gov
Center for Delivery, Org. & Markets
http://www.AHRQ.gov/about/cods
Irene Fraser:
ifraser@ahrq.gov