RAND Study: Quality of Health Care
Often Not Optimal
„ Doctors provide appropriate health care only
about half the time
DemandDemand-Driven Research: Working
through DeliveryDelivery-Based Networks
Irene Fraser, PhD, Director, CDOM
AcademyHealth Annual Research Meeting
June 8, 2004
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,
McGlynn, S. Asch,
Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults
Adults
in the United States, N Engl J Med,
Med, 2003
To Improve Health Care, DecisionDecision-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
0.3 year
Poyer, 1982
Koren, 1989
Acceptance
Negative
results
Publication
35%
Balas, 1995
Lack of
numbers
17:14
Expert
opinion
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
patient care
A Particular Problem for
EvidenceEvidence-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
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Identifying Need: What Do DecisionDecisionMakers Want?
„ Six useruser-centered meetings
– Small (20(20-30) groups
– Combination of industry leaders, purchasers,
policymakers, researchers
„ Discussion at several NAC meetings
„ Focus on both content and dissemination/use
#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
„ Five lessons for HOW we do our work:
#2: Present Findings in DecisionDecisionMakers’ 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
#4: Build UserUser-Researcher
Collaborations and Dialogue
„ ProviderProvider-based networks
„ Challenge grants
„ Organizational researchers with management
experience
„ Managers with research training
„ Practitioners in classrooms
#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
#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
2
Bonus Tip: Don’t OverOver-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“drive-onon-thethe-leftleft-sideside-ofof-thethe-road”
day
„ Subdivide time zones into 60 parts, observing local
times to the minute
„ Alphabetize phone books by first names
SUPPLYSUPPLY-DRIVEN MODEL
RESEARCHERS
•
•
•
•
•
•
SUPPLYSUPPLY-DRIVEN MODEL WITH
MARKETING
Questions
Hypotheses
Grant Applications
Study
Writing
Re-writing
DECISION-MAKERS
PUBLICATIONS
Leadership
Politics
Evidence
Culture
DEMANDDEMAND-INFORMED MODEL
User Needs Assessment
“Knowledge transfer”
RESEARCHERS
•
•
•
•
•
•
Questions
Hypotheses
Grant Applications
Study
Writing
Re-writing
DECISION-MAKERS
“Knowledge transfer”
PUBLICATIONS
Leadership
Politics
Evidence
Culture
DEMANDDEMAND-DRIVEN NETWORK MODEL
DECISION-MAKERS
RESEARCHERS
RESEARCHERS
•
•
•
•
•
•
Questions
Hypotheses
Grant Applications
Study
Writing
Re-writing
DECISION-MAKERS
PUBLICATIONS
Leadership
Politics
Evidence
Culture
3 Examples of Research Networks
„ Integrated Delivery System Research Network
„ Center for Health Management Research
„ HIV Research Network
Info +
Tools
Info +
Tools
PUBLICATIONS
3
What is the IDSRN?
Strategic Advantage: Size and Breadth
„ 9 practicepractice-based research partners:
–
–
–
–
–
–
–
–
–
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
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: Population
Diversity
Size and Breadth: Persons
Served Located in All States
„ Payer mix: privately insured, Medicare (3
million), Medicaid (2 million), uninsured (0.5
million)
„ Geographic mix: urban, innerinner-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
NationallyNationally-recognized academic and fieldfield-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 rapidrapid-cycle work:
–
–
–
–
data availability
expertise in data manipulation, methods
established partner collaborations
want solutions for own delivery system issues
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Examples of Products in 2003
Impact: 830 Downloads of Weill’s BTP Model
from AHA Web Site; AHA TA Provided
„ Presentations to IDS Operational Leadership (12)
„ Presentations at live/weblive/web-assisted conferences (50)
„ Scalable, scenarioscenario-appropriate models (for local to
international adaptation) (~15)
„ Training session and workshop tools (47)
„ “How to” guides, workbooks (many!)
„ Publications in peerpeer-reviewed journals (12)
„ Press releases, briefings and briefs (10)
„ National conference (1)
Impact: IDSRN Results Influence Users’
Practice or Policy Decisions
IDSRN: Three Types of Impact
„ 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
Home Page
http://www.AHRQ.gov
http://www.AHRQ.gov
Center for Delivery, Org. & Markets
http://www.AHRQ.gov
/about/cods
http://www.AHRQ.gov/about/cods
Irene Fraser:
ifraser@ahrq.gov
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