Introduction to Translating Evidence into Practice Epi 245 Ralph Gonzales, MD, MSPH Professor Medicine; Epidemiology & Biostatistics Sept 24, 2009
Introduction to Translating Evidence into Practice
Epi 245
Ralph Gonzales, MD, MSPH
Professor Medicine; Epidemiology & Biostatistics
Sept 24, 2009
EVID
ENCE
PRACTICE HEALTH
COMMUNITYHealth Care Delivery Systems
Providers
Patients
Public
GovernmentPayors
Prof. SocietiesAcademia
Translating Evidence Into Practice, Policy and Public HealthConceptual Framework
STAKEHOLDERS
EVID
ENCE
PRACTICE HEALTH
COMMUNITYHealth Care Delivery Systems
Providers
Patients
Public
GovernmentPayors
Prof. SocietiesAcademia
Epi 247:System-Centered Implementation
Strategies
Epi 248:Translating Practice Into Evidence:
Community Engagement Strategies
Epi 249:Advocacy & Policy Strategies
Epi 246:Individual-Centered
Implementation Strategies
Epi 245:Introduction to Translating
Evidence into Practice: Theory, Evidence & Design
Translating Evidence Into Practice, Policy and Public Health:UCSF Implementation and Dissemination Sciences Courses
STAKEHOLDERS
Course Goals
• Course Goals– Learn how to design & evaluate interventions– Learn some of the evidence base for specific types of
interventions– Develop and refine an intervention protocol
• Deconstruct Interventions– Population/Community/Public– Patients– Providers– Systems/Organizations
Course Schedule• Week 1: overview; making your case
• Week 2: translational tool box
• Week 3-6: public/patient, clinician and system
• Week 7: community engagement
• Week 8: study design; program evaluation
• Week 9: analytical designs and power
• Week 10: final protocol presentations
– 15 minutes to pitch to funders
Where You Will Learn• Website
– See supplementary reading list
• Class Presentations– Slide Sets and Notes
• Homework– Required Reading before class– Protocol development
• Exercise assigned after each class• Due following Sunday night (earlier is better)
• Pitching Session– Present your final protocol to potential funders
• Grades– Based on homework; participation in seminars; final protocol and final
presentation (equally-weighted)
TICR Professional Conduct Statement
• I will maintain the highest standards of academic honesty
• I will neither give nor receive aid in examinations or assignments unless such cooperation is expressly permitted by the instructor
• I will conduct research in an unbiased manner, report results truthfully, and credit ideas developed and work done by others
• I will write answers in my own words, and, when collaboration is permitted, acknowledge collaborators when answers are jointly formulated
Case Study
• In 1994, a 30 yo medicine resident is frustrated by patients’ antibiotic prescription requests when he moonlights at Kaiser urgent care.
• Inspired by the AHCPR Clinical Practice Guidelines, he wants to develop a practice guideline to reduce overuse of antibiotics for acute bronchitis.
Translating Evidence Into Practice: The Birth of T2
T1 T2
“I think that we have to ask ourselves whether much of the output of biomedical science is getting
lost in translation?” –C.Lenfant, NEJM 2003;349:868-74. Former Director NHLBI.
NIH Roadmap Initiative-translating discoveries into health
When Is Evidence Ready for Translation?
• Efficacy vs. effectiveness– Tests– Treatments– Procedures– Interventions
The Evidence-Based Medicine Movement (1990 → )
Rating the Evidence: Systematic Reviews• The Cochrane Collaboration (www.cochrane.org)
• Cochrane Effective Practice and Organisation of Care (EPOC) Group (www.epoc.cochrane.org)
– Systematic reviews of health care interventions• National Cancer Institute (www.cancer.gov)
Making Recommendations: Guidelines• USPSTF (www.ahrq.gov/CLINIC/uspstfix.htm)
• CDC (www.cdc.gov)
• Professional Societies
Practice Guidelines
• National Guidelines Clearinghouse (US)– www.guideline.gov
• National Institute for Health and Clinical Excellence (UK)– http://www.nice.org.uk
• The Guidelines International Network– http://www.g-i-n.net
Comparative Effectiveness Researchaka “How to spend $1.1 B”
“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”
-Institute of Medicine, 6/09
Case Study (cont)
“Antibiotics are never indicated for adults with acute bronchitis”
-Merle Sande, SFGH, 1994
“You first need to prove that there’s a problem. Are doctor’s really prescribing antibiotics for acute bronchitis?”
-Julie Gerberding, SFGH, 1994
A Pause for the Cause… Making Your Case
√ Is the evidence ready for translation?
#1. What is the current Quality of Care?
#2. What is the Quality Gap?
#3. What is the Outcome Gap?
Making Your Case…
Step #1
Measure Quality & Understand its Determinants
Quality of Health Care-c. 1980s
• Donabedian A. JAMA 1988;260:1743-8
Structure Process Outcomes
Community Characteristics
Delivery System Characteristics
Provider Characteristics
Population Characteristics
Health Care Providers-Technical Processes-Interpersonal Processes
Public & Patients-Access-Acceptance-Adherence
Health Status
Functional Status
Satisfaction
Mortality
Cost
EVID
ENCE
PRACTICE OUTCOME
COMMUNITYHealth Care Delivery Systems
Providers
Patients
Public
GovernmentPayors
Prof. SocietiesAcademia
Institute of Medicine Dimensions of Quality-c. 1990s
STAKEHOLDERS
-Effective
-Efficient
-Patient-Centered
-Safe
-Equitable
-Timely
“Quality Indicators”The Many Faces of Quality
• Outcomes• Structure
– Access to care, tests, treatments, procedures
• Processes… Things you can influence!– Performance Measures
• System and Clinician Oriented– Testing; treatment; referrals; counseling; communication
• Patient and Public Oriented– Adherence; testing; self-care; office visits; lifestyle; healthy
behaviors
Condition (n=25) Recommended Care, %Senile Cataract 79%Breast Cancer 76%Prenatal Care 73%….Dyspepsia/Ulcer Disease 33%Atrial Fibrillation 25%Hip Fracture 23%Alcohol Dependence 11%Overall Average 55%
CMS/JCAHO & Hospital Compare-Hospital Quality Measures
• Management of AMI– Aspirin on arrival and discharge– Beta-blockers on arrival and discharge– Lysis within 30 min of arrival– PCI within 90 min of arrival– ACE or ARB for LVSD– Management of CHF– ACE-inhibitor at discharge
• Management of CHF– ACE or ARB for LVSD– LVSD evaluation (echo)– Discharge counseling– Tobacco cessation
• Management of Pneumonia• Surgical Care Improvement
– Antibiotics within 1 hour of surgery; appropriate abx; d/c after 24 hours– DVT prophylaxis
Measure Quality Yourself-National Surveys/Reports
Behavior Data Sources–Public/Patient BRFSS; NHIS; NHANES;
MEPS
–Provider NAMCS; NHAMCS
–Delivery system NHDS
Measure Quality Yourself-Administrative Claims Data
Administrative data collected as a result of “claims” submitted by physicians/practices for reimbursement.
• Medicare (UB-92)– No pharmacy data
• Medicaid (Drug Utilization Review; OSHPD)– Enrollment rollercoaster
• Integrated Delivery Systems (Kaiser; Geisinger; etc)– Generalizability
• Hospital Networks (Premier)• Managed Care Organizations
Computerized health records are becoming a new resource for quality and outcome measurement…
Case Study (cont)
Antibiotic Prescription Rates-Sinusitis 56%-Bronchitis 66%-URI 53%
Making Your Case…
Step #2
Determine the Quality Gap
Quality Indicators and Benchmarks
• When guidelines exist
• When guidelines don’t exist
• When a benchmark is not available
National Committee for Quality Assurancewww.ncqa.org
HEDIS Effectiveness of Care Measures 2003, comm
• Beta-blocker post MI 94%• Cancer screening
– Breast 75%– Cervical 82%– Colorectal 47%
• Chlamydia screening 30%• Cholesterol screening 79%• HbA1c testing 85%• Eye exams in diabetes 49%• Controlling hypertension (<140/90) 62%• LDL < 100 after 60 days of MI 48%
Case Study (cont.)Measuring the Quality Gap
Condition Visits Rx Rate Bact. Prev Abx Excess
Otitis Media 13 x 106 76% 65% 1.1 million
Sinusitis 11 x 106 70% 40% 3.5 million
Pharyngitis14 x 106 62% 25% 5.2 million
Bronchitis 13 x 106 59% 10% 6.5 million
URI/cold 25 x 106 30% 5% 6.2 million
TOTAL 76 x 106 54% 25% 22.5 million
Gonzales R, et al. JAMA, 1997;278:901-904
Gonzales R, et al. Clinical Infectious Diseases, 2001, 33:757-62
Making Your Case…
Step #3
Link Quality Gap to
Outcome Gap
EVID
ENCE
QUALITY OF CARE OUTCOME
COMMUNITYHealth Care Delivery Systems
Providers
Patients
Public
GovernmentPayors
Prof. SocietiesAcademia
Linking Quality Gap to Outcome GapSTAKEHOLDERS
-Safe
-Effective
-Efficient
-Equitable
-Patient-Centered
-Timely
The Public Health and Business Case
RAND Health Insurance Experiment (1974-1982)
• Only RCT of health insurance in US• "Does free medical care lead to better health than co-
pay insurance plans?“• Results
– Free care induces demand/utilization of health care services– Cost-sharing reduces appropriate as well as inappropriate
health care utilization (patient behavior); but little effect on the cost of the encounter (provider behavior)
– Little effect on outcomes/health status• Except among poor with comorbidities (eg, hypertension)
Not a No-BrainerLinking Quality Gap with Outcomes.Werner R, 2006
CMS P4P Evaluation.Glickman SW, 2007
IOM Priority Areashttp://www.iom.edu/?id=19752
Asthma
Care coordination
Children with special health care needs
Diabetes
End of life
Cancer screening
Frailty associated with old age
Hypertension
Immunization
Ischemic heart disease
Major depression
Medication management
Nosocomial infections
Obesity (emerging area)
Pain control in advanced cancer
Pregnancy and childbirth
Self-management/health literacy (cross-cutting area)
Severe/persistent mental illness
Stroke
Tobacco-dependence treatment in adults
CASE STUDY (cont)Antibiotic Utilization = Antibiotic Resistance
Helping Change Happen…
Continuous Quality Improvementand PDSA Cycles
Don Berwick; Institute for Healthcare Improvement
Weeks 2-10EPI 245 modified PDSA…
• Needs Assessment of Your Problem (plan)– Understanding the Problem within a
Theoretical Framework
• Designing Multifaceted Intervention within a Theoretical Framework (do)
• Process and Outcome Evaluation of Intervention’s Impact (study)
• Refine and Repeat (act)
Improving Screening• Providing tools to help women
participate with their physicians in making informed decisions about screening (Phillips et al. 1998; Walter and Covinsky 2001).
• Ensuring access to primary care providers and the availability of mammography facilities with reminder systems (Phillips et al. 1998).
• Improving women's experiences with mammography through supportive care by the mammography technician (Carney et al. 2002).
Finding the Dollars: Feds
• AHRQ– Areas: health IT; complex patients; safety;
comparative effectiveness• K01, K02, K08, R01, R03, R13, R18, R36, U13• Co-Sponsored with NIH
– Women’s mental health in pregnancy and the post-partum period
– Emergency medical services for children– Cancer surveillance using health claims-based data– Understanding and promoting health literacy– Improving Health Care for Obese Patients
Finding the Dollars: Feds
• NIH– Areas: check with each institute, and don’t call
it “health services research”
• HRSA– Current MCHB: newborn screening;
congenital conditions; sickle cell treatment; traumatic brain injury
– Health Professions; Rural Health; Primary Care Centers
Finding the Dollars: Feds• CDC- National Centers (or Offices) for…
– Public Health Informatics; Public Health Genomics– Terrorism Preparedness and Emergency Response– Chronic Disease Prevention and Health Promotion– Preparedness, Detection and Control of Infectious Diseases– Zoonotic, Vector-Borne, and Enteric Disease– Immunization and Respiratory Diseases– Birth Defects and Developmental Disabilities– Environmental Health– Global Health– Global AIDS Program– HIV/Viral Hepatitis/STD/AIDS– Injury Prevention– Occupational Safety (NIOSH)
Finding the Dollars: Feds• DOD
– Congressionally Directed Medical Research Programs
• ALS; Autism; Bone Marrow Failure; Breast Cancer; Deployment Related Medical; Gulf War Illness; Minority and Underserved Areas; Neurofibromatosis; Ovarian Cancer; Prostate Cancer; Psychological Health/Traumatic Brain Injury; Tuberous Sclerosis Complex; CML; Prions
– HIV/AIDS Prevention Program– Research and Technology Development
• Average award: $1.15 M
Finding the Dollars: Feds
• VA – Clinical Science Research and Development Service– Cooperative Studies Program– Health Services Research and Development Service
• QUERI; COE & REAPs; HSR & Pilot Program• Priority Areas: Access/Rural Health; Care of Complex,
Chronic Conditions; Equity and Health Disparities; Health Services Genomics; Healthcare Informatics; Implementation and Management Research; Long-Term Care and Caregiving; Mental Health; Post-Deployment Health; Research Methodology; Womens Health
– Rehabilitation Research and Development
Finding the Dollars: Foundations
• The Robert Wood Johnson Foundation– Areas: Building Human Capital; Childhood Obesity;
Coverage; Pioneer; Public Health; Quality/Equity; Vulnerable Populations
– Funding: Investigator-initiated; RFAs
• The Commonwealth Fund– Areas: Affordable Health Insurance; Payment System
Reform; Patient-Centered Coordinated Care Program; Health Care Quality Improvement and Efficiency; Quality of Care for Frail Elders; Commission on High Performance Health System;
Finding the Dollars: Foundations
• Pew Charitable Trusts– Areas: Public Health and Human Services Policy;
Family Financial Security; Science and Technology
– Funding: investigator-initiated
• Foundation for Informed Decision Making– Areas: decision support tools; primary care
integration; literacy and numeracy; communication sciences;
Finding the Dollars: Others
• State and Other Government– Medicaid– Departments of Public Health
• Professional Societies
• Industry– Insurers: eg, Anthem; Aetna– Delivery Systems: eg, Kaiser Permanente – Pharmaceutical Companies
Summary
• Translating evidence into practice, policy and public health depends on aligning attitudes and behaviors of stakeholders, delivery systems, providers, patients and the public.
• Stakeholders, health care providers and the public need to monitor health care quality, and inform the development of new evidence and translational activities.
Summary
• Quality of care is a function of the structure, processes and outcomes of care– Changes to the structure and processes of care
can lead to improved outcomes of care… in essence, the goal of T3 research
• Improving the quality of health care should maximize safety, effectiveness, efficiency, patient-centeredness, and timeliness and eliminate disparities in care.
Summary
• To Make Your Case for translating evidence into practice for a specific topic– Measure its quality, determine the quality gap,
and link the quality gap to an outcome gap
• To Help Change Happen, understand the behaviors that are critical to translating evidence into practice
Homework #1 TableEvidence Health Outcome Delivery System
BehaviorClinician Behavior
Patient Behavior Public Behavior Stakeholders
EXAMPLE:Acute bronchitis does not benefit from antibiotics
Morbidity and mortality from bacterial infections
Measure antibiotic prescription rates
Stop prescribing antibiotics for acute bronchitis
Stop expecting antibiotics for acute bronchitis
Make better health care seeking decisions for cough illness
CDCNCQA
EXAMPLE:Chlamydia screening programs reduce rates of infertility and PID
Female infertility and PID
Measure Chlamydia screening rates;Increase access to screening
Screen sexually active women 13-24 yrs at least annually
Accept Chlamydia screening;
Seek preventive health care services
CDCWomens HealthState Health
Homework #1
• Complete Table for you and your topic• What evidence are you proposing to translate into
practice?– Identify single key behavior change target for your
translational activity.• What is the current performance level of your target
behavior (ie, its quality)?– What is the quality gap?– What is the evidence that changing performance will
improve clinical outcomes?• Identify at least 3 potential funding sources