H lth Services
Health
S i
Research
R
h Funding:
F di
Cross Institution Perspectives and
Di l
Dialogue
Ab
Aboutt P
Priorities
i iti
Carolyn M
M. Clancy
Clancy, MD
Director
Agency for Healthcare Research and Quality
AcademyHealth Annual Research Meeting
Boston – June 27, 2010
The Essence of Change
“Die when I may, I want
it said of me by
y those
who knew me best, that
y plucked
p
a
I always
thistle and planted a
flower where I thought
g
a flower would grow.”
Abraham Lincoln
Health System Change
“It's one thing to say you
support change, to add
your logo to the bottom of
an open letter, to put out a
press release. It's another
thing to participate in
change – to help drive it.”
HHS Secretary Kathleen Sebelius
April 26, 2010
The Change/Evolution of AHRQ
FY 1990
Budget:
$97 million
1989
A
Agency
ffor
Health Care
Policy and
Research
(AHCPR) iis
established
FY 1995
Budget:
$154 million
1995
AHRQ
begins
sponsorship
of U.S.
Preventive
Services
Task Force
activities
1998
President’s
FY 2011
AHRQ
budget
proposal:
$611
FY 2010 million
Budget:
$397
million
FY 2003
Budget:
$318.7
million
2000
AHCPR
“Near-death
“NearEffective
experience” becomes the
Health Care
Agency for
(EHC)
Healthcare
Program
Research
created
and Quality
(AHRQ)
2005
2010
Recovery
Act
EHC Program Funding in
launched
launched,
2009:
includes
$300
dissemination million to
and application AHRQ
function by the
Eisenberg
Center
Health Services Research Funding
 AHRQ Resources and
Priorities
 Transforming Research
into Action
 21st Century Health Care
 Q&A
AHRQ Priorities
Patient Safety
 Health IT
 Patient Safety
Organizations
 New Patient
 Safety & Quality Measures, Safety Grants
Drug Management and
Patient-Centered Care
 Patient Safety Improvement
Corps
Ambulatory
Patient Safety
Medical Expenditure
Panel Surveys
Effective Health
Care Program
 Comparative
Effectiveness Reviews
 Comparative Effectiveness
Research
 Clear Findings for
Multiple Audiences
Other Research &
Dissemination Activities
 Visit-Level Information on  Quality & Cost-Effectiveness, e.g.
Medical Expenditures
 Annual Quality &
Disparities Reports
Prevention and Pharmaceutical
Outcomes
 U.S.
U S Preventive Services
Task Force
 MRSA/HAIs
AHRQ’s Fiscal 2011
Budget
B d t Proposal
P
l
 Obama Administration proposed FY 2011
budget includes
c udes $6
$611 million
o for
o AHRQ
Q – up
from $397 million in FY 2010:
– $286 million for patientpatient-centered health
research, up $261 million over the FY 2010
budget
– $32 million for health information technology
research, a $4 million increase from FY 2010
– $65 million for patient safety research, including
$34 million to reduce and prevent healthcarehealthcareassociated infections
AHRQ and Comparative
Eff ti
Effectiveness
Research
R
h
 AHRQ’s Effective Health Care Program created
by Medicare Modernization Act of 2003
 From
F
2005-2009,
20052009 received
i d $129 million
illi ffrom
Congress for CER
 The American Recovery and Reinvestment Act of
2009 included $1.1 billion for comparative
g $300 million to
effectiveness research,, including
AHRQ
 The President’s FY 2011 budget proposal for
AHRQ includes
i l d $286 million
illi ffor patientpatient
ti t-centered
t d
health research, up $261 million over the FY 2010
budget
Effective Health Care Program
 Has published more
than 45 products
products,
including guides for
clinicians,
li i i
consumers
and policymakers
– Research Reviews
– Summary Guides
– New Research
R
Reports
t
AHRQ FY 2008 – 2010
I
Investments
t
t in
i CER
Includes Recovery Act Investments
3%
3%
6%
13%
57%
12%
6%
An Unprecedented Investment
All
Allocations
ti
for
f the
th $1
$1.1
1 billi
billion iin
comparative effectiveness research
f di iin th
funding
the A
American
i
R
Recovery and
d
Reinvestment Act of 2009:
 Research
 Data Infrastructure
 Dissemination and
Adoption
 Administrative
support, inventory,
evaluation
 $681M (62%)
 $268M ((24%))
 $132M (12%)
 $19M (2%)
Recovery Act: Care
at the Front Line
 Addressing barriers that limit
dissemination of current evidence
evidence-based, patientpatient-centered
information for health care
providers, consumers and patients
–
–
M lti l proposals
Multiple
l d
designed
i
d tto b
bring
i
innovative, effective and useruserfriendly methods to advance the
dissemination of comparative
effectiveness concepts and content
Focus: “Evaluating and
recommending methods beyond
academic settings, to engage
consumers and providers where
yp
y made”
decisions are typically
HHS Framework for CER
Evidence
Generation
Horizon
Scanning
Evidence
Need
Identification
Evidence
Synthesis
Strategies
Interventions
Conditions
Populations
Dissemination
Translation
Research Platform
Infrastructure – Methods Development – Training
Improvements
in
Health Care
FCC and IOM Recommendations
Guide ARRA Funding
FCC--CER
FCC
• Data infrastructure
• Dissemination and translation
• Human and scientific capital
• Real
Real--world settings
g for
subpopulations, priority
conditions and interventions
IOM
• 100 top priority CER topics
– 50% focus on health care
delivery systems
– Only three of the topics are
narrowly focused on drug vs.
drug
Select examples of AHRQ funding
• Enhanced State Data for Analysis and Tracking of Comparative Effectiveness Impact:
Improved Clinical Content and Race-Ethnicity Data
• Registry of Patient Registries
Select examples of OS funding
• Electronic Data Methods (EDM) Forum for Comparative Effectiveness Research
• Enhanced Registries for Quality Improvement and Comparative Effectiveness Research
Data Infrastructure Investments:
S
Secretary’s
t ’ Spend
S
d Plan
Pl ($210.5M)
($210 5M)
Medicare Claims
Medicaid Claims
Clinically Enhanced State Data
Design and Implementation
Distributed Networks
Community Health Applied Research
Network
Patient Registries
g
Cancer Registries
Registry of Registries
FDA: Medication and Device CER
Data and Research: Chronic Conditions
Pediatric Care Networks
CMS
CMS
$35 million
$19.5 million
AHRQ
$8 million
ASPE/CMS
AHRQ
HRSA
$19 million
$25 million
$10 million
AHRQ
$20 million
$
CDC
$20 million
AHRQ
TBD
FDA
$20 million
AHRQ/IHS
$27 million
HRSA
$7 million
Recovery Act CER
Applications
A li ti
att HHS
 FDA: methods overlap with postpost-market





surveillance; additional policy applications?
CMS: making CMS data easily available for
researchers; Example: chronic disease
warehouse
CDC: CER for communitycommunity-based prevention;
enhancing cancer registries for research
Office of Minority Health: working with National
Institute for Minority Health and Health Disparities
Assistant Secretary for Planning and Evaluation
Integration/coordination: “CER“CER-CIT”
Translating the Science into
R
Real
Reall-World
W ld Applications
A li ti
 Examples of Recovery Act
Act--funded Evidence
Generation Projects by AHRQ:
– Clinical and Health Outcomes Initiative in Comparative
Effectiveness (CHOICE): First coordinated national
effort to establish a series of pragmatic
g
clinical
comparative effectiveness studies ($100M)
– Request for Registries: Up to five awards to create or
enhance
h
national
ti
l patient
ti t registries,
i ti
with
ith a primary
i
focus on the 14 priority conditions ($48M)
– DEcIDE Consortium Support: Advancing methods and
applications for taking advantage of increased
availability of clinically detailed electronic data ($24M)
Citizen’s Forum for Comparative
Eff ti
Effectiveness
Research
R
h
 ARRA funding will support the Citizens’ Forum
Initiative to develop new mechanisms and refine
existing approaches to eliciting public input ($10M)
 The Forum will increase our use of public input to
inform health care policy, especially involving
comparative
ti effectiveness
ff ti
research
h for
f AHRQ’s
AHRQ’
Effective Health Care Program
 It will expand AHRQ’s
AHRQ s efforts to obtain professional
and consumer input, build methods and capacity
for obtaining public input and allow the program
to obtain guidance and insight from a
broader public
New Resource on Comparative
Eff ti
Effectiveness
R
Research
hM
Methods
th d
 June 2010 supplement to Medical Care on
CER Methods
 22 original
i i l articles,
ti l
special
i l ffocus on:
–
Ways to enhance the inclusion of clinically heterogeneous
populations in clinical and comparative effectiveness studies
–
Methods for implementing longitudinal investigations that
capture longer term health outcomes, including patientpatientreported outcomes
 Printed copies available free of charge
thro gh the AHRQ Publications
through
P blications
Clearinghouse
www.effectivehealthcare.ahrq.gov
AHRQ publication number: OM10OM10-0067
Patient Protection and Affordable
Care Act (P
(Public
blic Law 111111-148)
 Patient
Patient--Centered Outcomes Research Institute
– Independent, nonprofit Institute with public
public-- and
private--sector funding
private
f
– Sets priorities and coordinates with existing agencies
that support CER
– Prohibits findings to be construed as mandates on
practice g
p
guidelines or coverage
g decisions and contains
patient safeguards
– Provides funding for AHRQ to disseminate research
findings
fi di
off the
th Institute
I tit t and
d other
th GovernmentGovernment
G
t-funded
f d d
research, and to train researchers on CER and build
capacity for research
PCORI Board of Governors
 Members of the board collectively must represent a
broad range of perspectives
 AHRQ and NIH Directors will serve on the Institute’s
Institute s
21--member board and it’s methodology committee
21
 At least three board members must represent patients
and consumers, with seven representing providers – all
stakeholders are encouraged
g to “cultivate” nominees
 The Comptroller General must appoint board members
by
y September
p
23,, 2010
Notice p
published in the Federal Register
g
on May
y 7th calls for
nominations to be submitted by June 30th
PCORI@gao.gov
21st Century Health Care: Training
 AHRQ has allocated $20 million in Recovery Act
funding for career development of clinicians and
research
hd
doctorates
t t ffocusing
i on comparative
ti
effectiveness research. Examples:
– NRSA Postdoctoral
P td t
l Comparative
C
ti Effectiveness
Eff ti
Development Training Award (T32)
 Two years of supervised study and research for two
cohorts of clinical and research doctorates
– Mentored Clinical Scientists Comparative
p
Effectiveness Development Award (K12)
 Three years of supervised study and research for one
cohort of clinical and research doctorates
21st Century Health Care: Data
Enhancements in the 2010 Quality and Disparities Reports
 Alignment of National
P i it P
Priority
Partnership
t
hi
Priorities with report
measures and chapters
–
End of life care →
Supportive & Palliative
Care
–
Safety → Patient Safety
–
Patient
P ti t selfself
lfmanagement &
decision--making →
decision
Patient Centeredness
 New Sections
–
–
–
Care coordination
Health System
Infrastructure
State Summaries
 New Findings
–
–
–
Achievable Benchmark
Time to Benchmark
Integrated Quality
Report, Disparities
Report and Priority
Populations findings
21st Century Health Care:
New Models of Collaboration
 Medicaid
M di id M
Medical
di l Di
Directors
t
Learning Network
– Forum for clinical leaders of
state Medicaid programs to
discuss their most pressing
needs as policymakers
 Community Quality
C ll b ti
Collaboratives
– Community based
organizations of multiple
stakeholders that are
working together to
t
transform
f
health
h lth care att the
th
local level
21st Century Health Care:
Innovations
Web--based Repository of CuttingWeb
Cutting-Edge Service Innovations
 National electronic learning
hub for sharing health care
service innovations, bringing
innovators and adopters
together
g
 Searchable database
featuring innovation
successes and failures
failures,
expert commentaries,
lessons learned, etc.,
 Designed to help health care
“Agents of Change” improve
quality
www.innovations.ahrq.gov
21st Century Health Care:
Prevention
 Collaboration with CDC
CDC, CMS
CMS,
OS and other federal agencies to
launch p
projects
j
that p
prevent and
reduce HAIs
 Expansion of CUSP/Central LineLine-
Associated Blood Stream
Infections Project to all 50 States,
and expansion from the ICU
setting
 Interagency Steering Committee
will develop a national action
plan to significantly reduce HAIs
within five years
Central Venous CatheterCatheter-related Blood
Stream Infection Rates from the 2009 NHQR
R t per 1000 select
Rates
l t di
discharges
h
3
25
2.5
R t per 1000 CVC iinsertions
Rates
ti
3
Rate increasing
2
25
2.5
2
No change
1
1
05
0.5
05
0.5
0
0
Source: HCUP 2000-2006
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
1.5
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
1.5
Source: MPSMS, 2002-2007
Keystone ICU Project Update:
Low
L
CLABSI R
Rates
t S
Sustained
t i d
 More than 100 participating ICUs in Michigan
have maintained nearnear-zero rates beyond initial
18--month target
18
target, for an additional 18 months
 Key factors to sustainability, as noted by
participating ICU teams:
– Continued feedback of infection data
– Improvements in safety culture as a result of the
project
– Reducing infections rates was a shared goal
rather
th than
th a statewide
t t id competition
titi
– “An Unremitting belief in the preventability of
bloodstream infections”
infections
Pronovost et al., BMJ, 2010;340:c309 doi:10.1136/bmj.c309
What Does It Really Mean
t B
to
Be P
Patient
Patientti t-Centric?’
C t i ?’
Where to From Here?

Identify synergies – methods and
infrastructure – between CER and
post--marketing surveillance:
post
identification of signals and
investigations of causes

M k sure allll activities
Make
ti iti
enhance
h
quality, safety, efficiency and
effectiveness at the front line

Operationalize the expanded
definition of CER (i.e. the 'care
delivery interventions'
interventions piece)

Ensure that more informed means
better informed
Future Directions for Quality – 1
 We are MUCH better at measuring than
improving
 Growing list of successful ‘prototypes’ – but
only one clear home run
 Government has multiple roles
– Pay for care / provide incentives
– Support research
– Regulate; provide; monitor
Future Directions for Quality - 2
 Transition from settingsetting-specific approach to
patient focused,
focused, taking advantage of health IT
 Transparency and financial levers are important
but NOT the onlyy levers for change
g
 “At the end of the day, only those who provide
care can improve that care”
care
 Incredible opportunity to leverage ARRA and
other
th iinvestments
t
t
Challenges and Opportunities
 Identify
Id tif synergies
i – methods
th d and
d iinfrastructure
f t t
– between CER and post
post--marketing
surveillance: identification of signals and
investigations of causes
 Make sure activities/investments enhance
quality, safety, efficiency and effectiveness at
the front line
 Operationalize the expanded definition of CER
(i
(i.e.
e the 'care
care delivery interventions
interventions' piece)
 Ensure that more informed means better
informed
We Can’t
Can t Do It Without You!




Not about us without us
Participate in CER: input
on priorities
priorities, topics
topics,
comment on draft reports;
www.effectivehealthcare.
ahrq.gov
h
Participate on expert
panels
Funding opportunities:
qg
www.ahrq.gov/fund/
Thank You
AHRQ Mission
To
o improve
p o e tthe
e qua
quality,
ty, sa
safety,
ety,
efficiency, and effectiveness of
health care for all Americans
AHRQ Vision
As a result of AHRQ's
AHRQ s efforts,
American health care will
provide services of the highest
quality with the best possible
quality,
outcomes, at the lowest cost
www.ahrq.gov