Exploring
p
g Public Capacity
p
y for
Evidence-Based Decision Making
Thomas Workman,
Th
W k
PhD
John M Eisenberg Center for Clinical Decisions and Communications Science
Baylor College of Medicine
AcademyHealth Annual Research Meeting Boston, MA June 29, 2010
What Is the Effective Health Care Program?
What Is the Effective Health Care Program?
 Section 1013 of the 2003 Medicare Prescription Drug,
Improvement, and
d Modernization
d
i i A
Act authorized
h i d the
h A
Agency ffor
Healthcare Research and Quality (AHRQ) to improve the quality,
effectiveness, and efficiency of health care delivered through
Medicare, Medicaid, and State Children’s Health Insurance
programs.

AHRQ started
d the
h Eff
Effective
i H
Health
l hC
Care P
Program iin 2005 upon
appropriation of funds.
 In 2009,
2009 the American Recovery and Reinvestment Act (ARRA)
awarded additional funding to AHRQ to:

broaden comparative
p
effectiveness research,,

build an infrastructure to support the expanded efforts, and

invest in innovative mechanisms to disseminate findings of research to
health care decisionmakers.
AHRQ Task Order Officers
Develop, coordinate, and monitor
Scientific Resource Center
coordinates topic selection/peer review/public input,
provides support
p
pp
Evidence based Practice Centers
Evidence-based
Evidence Synthesis and
Evidence Need Identification
Stakeholders
N i t topics,
Nominate
t i
provide input on
questions,
reviews, and
program
DEcIDE, CERTs, Grantees
Evidence Generation
Eisenberg
Ei
b Center
C t
Evidence Translation and Dissemination
Patients, health care providers, and policymakers make better health care decisions
The John M. Eisenberg Center for Clinical Decisions and Communications Science
Decisions and Communications Science
 The nation’s translation and dissemination unit for
AHRQ’s Effective Health Care Program
 Translates and disseminates effectiveness and
comparative effectiveness reviews for consumers,
clinicians, and policymakers
 Actionable
A i
bl summary guides
id
 Continuing medical education units
 Decision aids
 Other Products
 Coordinated with other AHRQ efforts such as
Healthcare 411
Key Focus: Adoption of EBDM Practices
Key Focus: Adoption of EBDM Practices
 Clarifying the Concepts
Evidence-based Medicine
 Patient-Centered Medicine
 Consumer Adoption of EBDM

 Initial Assessment: Internal and External
 Considerations for Capacity Building
 Suggested Next Research Steps
Conceptualizing EBM
Conceptualizing EBM
 Evidence-based medicine and patient-centered
medicine are distinctly different concepts with
research that has not connected the two (Bensing,
2000).
2000)
 Evidence based medicine is the conscientious,
conscientious
explicit, and judicious use of current best evidence
in making decisions about the care of individual
patients. The practice of evidence based medicine
means integrating individual clinical expertise with
the best available external clinical evidence from
systematic research (Sackett, 1996).
Conceptualizing Adoption Capacity: PCM
Conceptualizing Adoption Capacity: PCM
 In a patient-centered model, patients become
active
ti participants
ti i
t iin th
their
i own care and
d receive
i
services designed to focus on their individual needs
and preferences,
preferences in addition to advice and counsel
from health professionals (Stanton, 2002).
 Patient-centered medicine involves multiple
p
concepts:







Shared decision making
Patient involvement
Health information seeking
Health literacyy
Patient activation
Self-efficacy
Patient satisfaction
Conceptualizing Adoption Capacity: Adoption
p
g
p
p
y
p
 Context-based evidence-based decision-making
(Dobrow et al., 2004)
 Focus has been on evidence base and not the
d i i
decision-making
ki context
t t
 Both evidence and context are integral components
 Internal
I
l and
d externall contextuall factors
f
must be
b
considered
 Internal: Purpose,
Purpose process
process, participants
 External: Disease, jurisdiction, politics
Dobrow (et. al) Conceptual Framework
p
Changes to the External Context of EBDM
Changes to the External Context of EBDM
 Formation of the Agency for Healthcare Research and Quality






(AHRQ) in 1999
Medicare Modernization Act of 2003 – established AHRQ’s
Effective Health Care Program
American Recovery and Reinvestment Act of 2009 – established the Federal Coordinating Council for Comparative
Effectiveness Research added funds
IOM and Federal Coordinating Council publish definitions and
national priorities
P ti t Protection
Patient
P t ti and
d Aff
Affordable
d bl Care
C
A
Actt off 2010 -established the Patient-Centered Outcomes Research Institute,
added additional research funds
EBDM being refocused as patient-centered research
USHHS creates new national action plan to improve health
literacy in 2010.
2010
Internal Context: What Do We Know?
Internal Context: What Do We Know?
 Most physicians are not engaging patients in the decisionmaking
process (Mauksch et
et. al
al., 2008)
 Patients rarely initiate conversations or questions during office
visits ((Tran,, et. al.,, 2008))
 Patient Decision Aids are underutilized (O’Connor, et.al., 2004)
 70 % of Patient Non
Non-adherence
adherence is intentional (Clifford, et.al.,
2008)
 Nearly 9 out of 10 adults have difficulty using everyday health
information (Kutner, et. al., 2006)
 62% of internet searches are health related (Heese, et. al.,
2005)
Internal Context: What Do We Know?
Internal Context: What Do We Know?
 DECISIONS study (2010)
82% considered at least one medical decision in the
past 2 years
 Highest
Hi h t percentage
t
iinvolved
l d cancer screening
i
 Individuals with a primary care provider
considered decisions more often than those who
did not.
 Women made decisions more often then men.
men
 Age, education, and availability of insurance were
all inconsistent factors across decision types

Internal Context: What Do We Know?
Internal Context: What Do We Know?
 AIR study
y ((Carman et. al.,, 2010))
Consumer confusion by terminology of medical
evidence
 Belief that all medical care meets minimum quality
standards
 Belief that medical guidelines are an inflexible,
bargain-basement approach
 Most Patients believe more care, newer care, and
more costly care is better
 Consumers
C
connecting
ti “
“evidence-based
id
b
d medical
di l
decisions” with political agendas and cost-saving
measures that ultimately deny them care

Considerations for Capacity Building
Considerations for Capacity Building
 Addressing Internal Contextual Barriers
Increase consumer desire and appreciation for
comparative evidence
 Patient
Patient-Provider
Provider interactions must support evidence
evidencebased decisionmaking across conditions
Q
Qualityy of evidence-based information p
products is
critical, but product testing may not identify or
address broader internal context influences
 Testing information comprehension versus “process”
outcomes
 Testing decision conclusions in light of contextual
influences within the clinical setting

Considerations
Considerations for Capacity Building
for Capacity Building
 Addressing External Contextual Barriers
Evidence-based
E
id
b dd
decisions
i i
mustt reflect
fl t actual
t l“
“power
of choice” across conditions and populations
 Patient choice-making
choice making must be separated from a
“Medical consumerism” frame
 Evidence
Evidence-based
based decisionmaking must be incentivized
across clinicians, consumers, and policymakers.
 EBDM must be de
de-politicized
politicized and separated from other
issues of health care reform

Possible steps for research
Possible steps for research
 Connecting decision science to broader issues of EBDM
 Determining the impact of literacy, agency, and
patient activation on the adoption of EBDM
 Exploring
E l i th
the role
l off interactive
i t
ti social
i l media
di iin th
the
evidence introduction, interpretation, and application
context
 Time to focus on medical choicemaking
representations in popular culture?
 Developing better assessment tools for EBDM uptake
and long-term
g
outcomes
 Exploring ways in which translation and dissemination
efforts can also build capacity