Carolyn M. Clancy, MD
Director
Agency for Healthcare Research and Quality
The 25 th Annual Rosalynn Carter
Symposium on Mental Health Policy
The Carter Center – November 6, 2009

Treatment for Mental Health
Adults with a mood, anxiety or impulse control disorder in the last
12 months who received minimally adequate treatment, 2001-2003
 Nearly 30% of adults with mood, anxiety or impulse control disorders received minimally adequate treatment
 There were no significant differences by age
AHRQ 2008 National Healthcare Quality Report

By Race & Education
Adults with a mood, anxiety or impulse control disorder in the last
12 months who received minimally adequate treatment, 2001-2003
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% of adults who received minimally adequate treatment was lower among
Blacks and Hispanics, with
Hispanics having the lowest
% of all groups
% was also lower among individuals with less than a high school education and high school graduates, compared with those with some college education
AHRQ 2008 National Healthcare Disparities Report

Treatment for Depression
Adults with a major depressive episode in the last 12 months who received treatment for depression, by race, ethnicity, income and education, 2006
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% of adults with major depressive episode who received treatment was significantly lower for Blacks than for Whites (58.9% and
71.1%) and lower for Hispanics than for non-Hispanic Whites
(51.8% and 73.3%)
There were no statistically differences by income or education level
AHRQ 2008 National Healthcare Disparities Report

Current Challenges
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Concerns about health spending – about $2.3 trillion per year in the U.S. and growing
Pervasive problems with the quality of care that people receive
Translating scientific advances into actual clinical practice
Translating scientific advances into usable information for clinicians and patients
A health care system that has been isolated for people with mental health issues for far too long

CER: Moving from
Research to Practice
 AHRQ: New Resources,
Ongoing Priorities
 Comparative Effectiveness and The American
Reinvestment and Recovery
Act of 2009
 Translating Science into
Real-World Applications

AHRQ’s Mission
Improve the quality, safety, efficiency and effectiveness of health care for all Americans

Patient Safety
Ambulatory
Patient Safety

Safety & Quality Measures,
Drug Management and

Health IT

Patient Safety
Organizations

New Patient
Safety Grants
Patient-Centered Care

Patient Safety Improvement
Corps
Effective Health
Care Program

Comparative
Effectiveness Reviews

Comparative Effectiveness
Research

Clear Findings for
Multiple Audiences
Medical Expenditure
Panel Surveys

Visit-Level Information on
Medical Expenditures

Annual Quality &
Disparities Reports
Other Research &
Dissemination Activities

Quality & Cost-Effectiveness, e.g.
Prevention and Pharmaceutical
Outcomes

U.S. Preventive Services
Task Force

MRSA/HAIs

New: Mental Health
Research Findings
 Compendium of recent mental health research projects funded by AHRQ
 Expanded funding for improving mental health care through health IT and primary care delivery
 The Agency has also developed a new focus on the complex patient http://www.ahrq.gov/research/mentalhth.pdf

Recent Legislation for
Parity in Mental Health
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The Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008
– Effective January 1, 2010, designed to produce parity in private employer-sponsored health plans for organizations with more than 50 employees (passed as part of the
American Reinvestment and Recovery Act of 2009)
The Medicare Improvements for Patients and
Providers Act of 2008
– Mental health parity is gradually phased in between 2010 and 2014
Children's Health Insurance Program Reauthorization
Act of 2009 (CHIPRA)
– Requires mental health parity for states that offer mental health or substance abuse services in CHIP plans

AHRQ 2009: New Resources,
Ongoing Priorities
 $372 million for AHRQ in FY ‘09 budget
–
–
$37 million more than FY 2008
$46 million more than Administration request
 FY 2009 appropriation includes:
– $50 million for comparative effectiveness research, $20 million more than FY 2008
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–
$49 million for patient safety activities
$45 million for health IT

AHRQ’s Role in
Comparative Effectiveness
Using Information to Drive Improvement:
Scientific Infrastructure to Support Reform
Lead federal funding
Aggregate best evidence to inform complex learning and implementation challenges
21 st Century
Health Care
Engage private sector
Increase knowledge base to spur high-value care

CER Outputs at AHRQ
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Research reviews : Comprehensive reports that draw on scientific studies to make head-to-head comparisons of treatments
Summary guides: Short, plainlanguage guides that summarize research reviews and are tailored to different audiences – clinicians, consumers and policymakers
New research reports: Fastturnaround reports that draw on health care databases, electronic patient registries and other resources to explore practical questions http//:effectivehealthcare.ahrq.gov

 The American Recovery and
Reinvestment Act of 2009 includes
$1.1 billion for comparative effectiveness research:
–
–
AHRQ: $300 million
NIH: $400 million (appropriated to
AHRQ and transferred to NIH)
– Office of the Secretary: $400 million
(allocated at the Secretary’s discretion)
Federal Coordinating Council appointed to coordinate comparative effectiveness research across the federal government

Definition: Federal
Coordinating Council
 CER is the conduct and synthesis of research comparing the benefits and harms of various interventions and strategies for preventing, diagnosing, treating, and monitoring health conditions in real-world settings. The purpose of this research is to improve health outcomes by developing and disseminating evidencebased information to patients, clinicians, and other decision makers about which interventions are most effective for which patients under specific circumstances.

Definition: IOM
 Comparative effectiveness research (CER) is the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purchasers and policy makers to make informed decisions that will improve health care at both the individual and population levels.
National Priorities for Comparative
Effectiveness Research
Institute of Medicine Report Brief
June 2009

Stakeholder Input
& Involvement
Research Training
Horizon
Scanning
Evidence
Synthesis
Evidence Need
Identification
Evidence
Generation
Career Development
Dissemination
& Translation

AHRQ’s Priority Conditions for the Effective Health Care Program
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Arthritis and nontraumatic joint disorders
Cancer
Cardiovascular disease, including stroke and hypertension
Dementia, including
Alzheimer Disease
Depression and other mental health disorders
Developmental delays, attention-deficit hyperactivity disorder and autism
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Diabetes Mellitus
Functional limitations and disability
Infectious diseases including HIV/AIDS
Obesity
Peptic ulcer disease and dyspepsia
Pregnancy including pre-term birth
Pulmonary disease/Asthma
Substance abuse

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Initial National Priorities for Comparative
Effectiveness Research (June 20, 2009)
Topics in 4 quartiles; groups of 25.
Includes several priorities for mental health, including:
– Treatment approaches, such as integrating mental health care and primary care
– Training of primary care physicians in primary care mental health and co-location systems of primary care and mental health care on outcomes including depression, anxiety and cost
– Patient decision support tools on informing diagnostic and treatment decisions, and including patients with mental health problems
Report Brief Available At http://www.iom.edu

AHRQ Operating Plan for
Recovery Act’s CER Funding
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Stakeholder Input and Involvement:
To occur throughout the program
Horizon Scanning: Identifying promising interventions
Evidence Synthesis: Review of current research
Evidence Generation: New research with a focus on under-represented populations
Research Training and Career
Development: Support for training, research and careers

Translating the Science into
Real-World Applications
 Examples of Recovery Act Evidence Generation projects with funding available/pending:
– Clinical and Health Outcomes Initiative in Comparative
Effectiveness (CHOICE): First coordinated national effort to establish a series of pragmatic clinical comparative effectiveness studies ($100M)
– Request for Registries: Up to five awards for the creation or enhancement of national patient registries, with a primary focus on the 14 priority conditions ($48M)
– DEcIDE Consortium Support: Expansion of multi-center research system and funding for distributed data network models that use clinically rich data from electronic health records ($24M)

Additional Proposed Investments
 Supporting AHRQ’s long-term commitment to bridging the gap between research and practice:
– Dissemination and Translation
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Between 20 and 25 two-three-year grants ($29.5M)
Eisenberg Center modifications (3 years, $5M)
– Citizen Forum on Effective Health Care
 Formally engages stakeholders in the entire Effective
Health Care enterprise
 A Workgroup on Comparative Effectiveness will be convened to provide formal advice and guidance ($10M)

 As with comparative effectiveness research, health IT is a useful tool in a much larger toolkit
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AHRQ Health IT Initiatives
 Examples, Ambulatory Safety and
Quality (ASQ) Program
– Pharmaceutical Safety Tracking: Children’s
Research Institute, Columbus, OH
 Monitoring medication adherence in an urban mental health system serving a primarily Medicaid population
– Improving Outcomes through Ambulatory
Care Coordination: Nebraska Behavioral
Health Information Network
 An HIE focused on coordination of care for individuals with chronic mental illness
– A Personal Health Record (PHR) for Mental
Health Consumers: Emory University
 Adapts existing electronic PHR for needs of people with a serious mental disorder and one or more chronic conditions

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CER will enhance the best and most innovative strategies
Can open up new populations for which something can be useful in
Can bring early attention to potential issues

Comparative Effectiveness
Challenges/Opportunities
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Anticipating downstream effects of policy applications
Eliminating uncertainty about best practices involving treatments and technologies
Making sure that comparative effectiveness is
"descriptive, not prescriptive”
Creating a level playing field among all stakeholders, including patients and consumers
Adopting a more integrated approach to achieving high quality health care
Using the same evidence-based information to make different care decisions based on the characteristics, needs, etc., of the individual

Where to From Here?
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Timing: Significant support for and interest in comparative effectiveness research
The mission: Address gaps in quality and resolve conflicting or lack of evidence about most effective treatment approaches
Words of wisdom: “In theory, there is no difference between theory and practice. In practice, there is.” – Yogi Berra

Thank You www.ahrq.gov http//:effectivehealthcare.ahrq.gov
www.hhs.gov/recovery