Comparative Effectiveness: Comparative Effectiveness: Moving from Research to PracticeMoving from Research to Practice

Carolyn M. Clancy, MDCarolyn M. Clancy, MD

DirectorDirectorAgency for Healthcare Research and QualityAgency for Healthcare Research and Quality

The 25The 25thth Annual Rosalynn Carter Annual Rosalynn Carter Symposium on Mental Health PolicySymposium on Mental Health Policy

The Carter Center – November 6, 2009The Carter Center – November 6, 2009

Treatment for Mental HealthTreatment for Mental Health

Nearly 30% of Nearly 30% of adults with mood, adults with mood, anxiety or impulse anxiety or impulse control disorders control disorders received minimally received minimally adequate treatmentadequate treatment

There were no There were no significant significant differences by agedifferences by age

Adults with a mood, anxiety or impulse control disorder in the last Adults with a mood, anxiety or impulse control disorder in the last 12 months who received minimally adequate treatment, 2001-200312 months who received minimally adequate treatment, 2001-2003

AHRQ 2008 National Healthcare Quality ReportAHRQ 2008 National Healthcare Quality Report

By Race & EducationBy Race & Education

% of adults who received % of adults who received minimally adequate minimally adequate treatment was lower among treatment was lower among Blacks and Hispanics, with Blacks and Hispanics, with Hispanics having the lowest Hispanics having the lowest % of all groups% of all groups

% was also lower among % was also lower among individuals with less than a individuals with less than a high school education and high school education and high school graduates, high school graduates, compared with those with compared with those with some college educationsome college education

AHRQ 2008 National Healthcare Disparities ReportAHRQ 2008 National Healthcare Disparities Report

Adults with a mood, anxiety or impulse control disorder in the last Adults with a mood, anxiety or impulse control disorder in the last 12 months who received minimally adequate treatment, 2001-200312 months who received minimally adequate treatment, 2001-2003

Treatment for DepressionTreatment for Depression

% of adults with major % of adults with major depressive episode who depressive episode who received treatment was received treatment was significantly lower for Blacks significantly lower for Blacks than for Whites (58.9% and than for Whites (58.9% and 71.1%) and lower for Hispanics 71.1%) and lower for Hispanics than for non-Hispanic Whites than for non-Hispanic Whites (51.8% and 73.3%) (51.8% and 73.3%)

There were no statistically There were no statistically differences by income or differences by income or education level education level

AHRQ 2008 National Healthcare Disparities ReportAHRQ 2008 National Healthcare Disparities Report

Adults with a major depressive episode in the last 12 months who received Adults with a major depressive episode in the last 12 months who received treatment for depression, by race, ethnicity, income and education, 2006treatment for depression, by race, ethnicity, income and education, 2006

Current ChallengesCurrent Challenges

Concerns about health spending – about $2.3 Concerns about health spending – about $2.3 trillion per year in the U.S. and growingtrillion per year in the U.S. and growing

Pervasive problems with the quality of care that Pervasive problems with the quality of care that people receive people receive

Translating scientific advances into actual Translating scientific advances into actual clinical practice clinical practice

Translating scientific advances into usable Translating scientific advances into usable information for clinicians and patientsinformation for clinicians and patients

A health care system that has been isolated for A health care system that has been isolated for people with mental health issues for far too longpeople with mental health issues for far too long

AHRQ: New Resources, AHRQ: New Resources, Ongoing PrioritiesOngoing Priorities

Comparative Effectiveness Comparative Effectiveness and The American and The American Reinvestment and Recovery Reinvestment and Recovery Act of 2009Act of 2009

Translating Science into Translating Science into Real-World ApplicationsReal-World Applications

CER: Moving from CER: Moving from Research to PracticeResearch to Practice

AHRQ’s MissionAHRQ’s Mission

Improve the quality, safety, efficiency and Improve the quality, safety, efficiency and effectiveness of health care for all Americanseffectiveness of health care for all Americans

AHRQ PrioritiesAHRQ Priorities

Effective HealthEffective HealthCare ProgramCare Program

Medical ExpenditureMedical ExpenditurePanel SurveysPanel Surveys

AmbulatoryAmbulatoryPatient SafetyPatient Safety

PatientPatient Safety Safety

Health IT Patient Safety

Organizations New Patient

Safety Grants Comparative Effectiveness Reviews

Comparative Effectiveness Research

Clear Findings for Multiple Audiences

Quality & Cost-Effectiveness, e.g.Prevention and PharmaceuticalOutcomes

U.S. Preventive ServicesTask Force

MRSA/HAIs

Visit-Level Information on Medical Expenditures

Annual Quality & Disparities Reports

Safety & Quality Measures,Drug Management andPatient-Centered Care

Patient Safety ImprovementCorps

Other Research & Other Research & Dissemination ActivitiesDissemination Activities

New: Mental Health New: Mental Health Research FindingsResearch Findings

Compendium of recent Compendium of recent mental health research mental health research projects funded by AHRQprojects funded by AHRQ

Expanded funding for Expanded funding for improving mental health improving mental health care through health IT and care through health IT and primary care deliveryprimary care delivery

The Agency has also The Agency has also developed a new focus on developed a new focus on the complex patientthe complex patient

http://www.ahrq.gov/research/mentalhth.pdfhttp://www.ahrq.gov/research/mentalhth.pdf

Recent Legislation for Recent Legislation for Parity in Mental HealthParity in Mental Health

The Paul Wellstone and Pete Domenici Mental Health The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008Parity and Addiction Equity Act of 2008– Effective January 1, 2010, designed to produce parity in Effective January 1, 2010, designed to produce parity in

private employer-sponsored health plans for organizations private employer-sponsored health plans for organizations with more than 50 employees (passed as part of the with more than 50 employees (passed as part of the American Reinvestment and Recovery Act of 2009)American Reinvestment and Recovery Act of 2009)

The Medicare Improvements for Patients and The Medicare Improvements for Patients and Providers Act of 2008Providers Act of 2008– Mental health parity is gradually phased in between 2010 Mental health parity is gradually phased in between 2010

and 2014and 2014

Children's Health Insurance Program Reauthorization Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA)Act of 2009 (CHIPRA)– Requires mental health parity for states that offer mental Requires mental health parity for states that offer mental

health or substance abuse services in CHIP plans health or substance abuse services in CHIP plans

AHRQ 2009: New Resources, AHRQ 2009: New Resources, Ongoing PrioritiesOngoing Priorities

$372 million for AHRQ in FY ‘09 budget$372 million for AHRQ in FY ‘09 budget– $37 million more than FY 2008$37 million more than FY 2008

– $46 million more than Administration $46 million more than Administration requestrequest

FY 2009 appropriation includes:FY 2009 appropriation includes:– $50 million for comparative $50 million for comparative

effectiveness research, $20 million effectiveness research, $20 million more than FY 2008more than FY 2008

– $49 million for patient safety activities$49 million for patient safety activities

– $45 million for health IT$45 million for health IT

AHRQ’s Role in AHRQ’s Role in Comparative EffectivenessComparative Effectiveness

Using Information to Drive Improvement: Using Information to Drive Improvement: Scientific Infrastructure to Support ReformScientific Infrastructure to Support Reform

Lead federal fundingLead federal funding

Engage private sectorEngage private sectorAggregate best Aggregate best evidence to inform evidence to inform complex learning complex learning and implementation and implementation challengeschallenges

Increase knowledge base Increase knowledge base to spur high-value careto spur high-value care

21st Century Health Care

CER Outputs at AHRQCER Outputs at AHRQ

Research reviewsResearch reviews: Comprehensive : Comprehensive reports that draw on scientific studies reports that draw on scientific studies to make head-to-head comparisons to make head-to-head comparisons of treatmentsof treatments

Summary guides:Summary guides: Short, plain- Short, plain-language guides that summarize language guides that summarize research reviews and are tailored to research reviews and are tailored to different audiences – clinicians, different audiences – clinicians, consumers and policymakersconsumers and policymakers

New research reports:New research reports: Fast- Fast-turnaround reports that draw on turnaround reports that draw on health care databases, electronic health care databases, electronic patient registries and other resources patient registries and other resources to explore practical questionsto explore practical questions

http//:effectivehealthcare.ahrq.govhttp//:effectivehealthcare.ahrq.gov

Comparative Effectiveness Comparative Effectiveness and the Recovery Act and the Recovery Act

The American Recovery and The American Recovery and Reinvestment Act of 2009 includes Reinvestment Act of 2009 includes $1.1 billion for comparative $1.1 billion for comparative effectiveness research:effectiveness research:

– AHRQ: $300 millionAHRQ: $300 million

– NIH: $400 million (appropriated to NIH: $400 million (appropriated to AHRQ and transferred to NIH)AHRQ and transferred to NIH)

– Office of the Secretary: $400 million Office of the Secretary: $400 million (allocated at the Secretary’s discretion)(allocated at the Secretary’s discretion)

Federal Coordinating Council appointed to coordinate comparative Federal Coordinating Council appointed to coordinate comparative effectiveness research across the federal governmenteffectiveness research across the federal government

Definition: Federal Definition: Federal Coordinating CouncilCoordinating Council

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

Definition: IOMDefinition: IOM

Comparative effectiveness research (CER) is the Comparative effectiveness research (CER) is the generation and synthesis of evidence that compares generation and synthesis of evidence that compares the benefits and harms of alternative methods to the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical prevent, diagnose, treat and monitor a clinical condition or to improve the delivery of care. The condition or to improve the delivery of care. The purpose of CER is to assist consumers, clinicians, purpose of CER is to assist consumers, clinicians, purchasers and policy makers to make informed purchasers and policy makers to make informed decisions that will improve health care at both the decisions that will improve health care at both the individual and population levels.individual and population levels.

National Priorities for Comparative National Priorities for Comparative Effectiveness ResearchEffectiveness Research

Institute of Medicine Report BriefInstitute of Medicine Report BriefJune 2009June 2009

Conceptual FrameworkConceptual Framework

Dissemination& Translation

HorizonScanning

Evidence Need Identification

Evidence Synthesis

EvidenceGeneration

Career DevelopmentCareer Development

Research TrainingResearch Training

Stakeholder Input Stakeholder Input & Involvement& Involvement

AHRQ’s Priority Conditions for AHRQ’s Priority Conditions for the Effective Health Care Programthe Effective Health Care Program

Arthritis and non-Arthritis and non-traumatic joint disorderstraumatic joint disorders

CancerCancer Cardiovascular disease, Cardiovascular disease,

including stroke and including stroke and hypertensionhypertension

Dementia, including Dementia, including Alzheimer DiseaseAlzheimer Disease

Depression and other Depression and other mental health disordersmental health disorders

Developmental delays, Developmental delays, attention-deficit attention-deficit hyperactivity disorder hyperactivity disorder and autism and autism

Diabetes MellitusDiabetes Mellitus Functional limitations Functional limitations

and disabilityand disability Infectious diseases Infectious diseases

including HIV/AIDSincluding HIV/AIDS ObesityObesity Peptic ulcer disease Peptic ulcer disease

and dyspepsiaand dyspepsia Pregnancy including Pregnancy including

pre-term birthpre-term birth Pulmonary Pulmonary

disease/Asthmadisease/Asthma Substance abuseSubstance abuse

IOM’s 100 Priority TopicsIOM’s 100 Priority Topics

Initial National Priorities for Comparative Initial National Priorities for Comparative Effectiveness ResearchEffectiveness Research (June 20, 2009)(June 20, 2009)

Topics in 4 quartiles; groups of 25. Topics in 4 quartiles; groups of 25. Includes several priorities for mental health, Includes several priorities for mental health,

including:including:– Treatment approaches, such as integrating mental Treatment approaches, such as integrating mental

health care and primary carehealth care and primary care– Training of primary care physicians in primary care Training of primary care physicians in primary care

mental health and co-location systems of primary care mental health and co-location systems of primary care and mental health care on outcomes including and mental health care on outcomes including depression, anxiety and costdepression, anxiety and cost

– Patient decision support tools on informing Patient decision support tools on informing diagnostic and treatment decisions, and including diagnostic and treatment decisions, and including patients with mental health problemspatients with mental health problems

Report Brief Available At Report Brief Available At http://www.iom.eduhttp://www.iom.edu

AHRQ Operating Plan for AHRQ Operating Plan for Recovery Act’s CER FundingRecovery Act’s CER Funding

Stakeholder Input and Involvement:Stakeholder Input and Involvement: To occur throughout the programTo occur throughout the program

Horizon Scanning:Horizon Scanning: Identifying promising Identifying promising interventionsinterventions

Evidence Synthesis:Evidence Synthesis: Review of current Review of current research research

Evidence Generation:Evidence Generation: New research with a New research with a focus on under-represented populationsfocus on under-represented populations

Research Training and Career Research Training and Career Development:Development: Support for training, research Support for training, research and careers and careers

Translating the Science into Translating the Science into Real-World Applications Real-World Applications

Examples of Recovery Act Evidence Generation Examples of Recovery Act Evidence Generation projects with funding available/pending:projects with funding available/pending:– Clinical and Health Outcomes Initiative in Comparative Clinical and Health Outcomes Initiative in Comparative

Effectiveness (CHOICE): First coordinated national effort Effectiveness (CHOICE): First coordinated national effort to establish a series of pragmatic clinical comparative to establish a series of pragmatic clinical comparative effectiveness studies ($100M)effectiveness studies ($100M)

– Request for Registries: Up to five awards for the creation Request for Registries: Up to five awards for the creation or enhancement of national patient registries, with a or enhancement of national patient registries, with a primary focus on the 14 priority conditions ($48M)primary focus on the 14 priority conditions ($48M)

– DEcIDE Consortium Support: Expansion of multi-center DEcIDE Consortium Support: Expansion of multi-center research system and funding for distributed data network research system and funding for distributed data network models that use clinically rich data from electronic health models that use clinically rich data from electronic health records ($24M)records ($24M)

Additional Proposed InvestmentsAdditional Proposed Investments

Supporting AHRQ’s long-term commitment to Supporting AHRQ’s long-term commitment to bridging the gap between research and practice:bridging the gap between research and practice:– Dissemination and TranslationDissemination and Translation

Between 20 and 25 two-three-year grants ($29.5M)Between 20 and 25 two-three-year grants ($29.5M) Eisenberg Center modifications (3 years, $5M)Eisenberg Center modifications (3 years, $5M)

– Citizen Forum on Effective Health CareCitizen Forum on Effective Health Care Formally engages stakeholders in the entire Effective Formally engages stakeholders in the entire Effective

Health Care enterpriseHealth Care enterprise A Workgroup on Comparative Effectiveness will be A Workgroup on Comparative Effectiveness will be

convened to provide formal advice and guidance ($10M)convened to provide formal advice and guidance ($10M)

Health IT and Comparative Health IT and Comparative Effectiveness ResearchEffectiveness Research

As with comparative effectiveness As with comparative effectiveness research, health IT is a useful tool in a research, health IT is a useful tool in a much larger toolkitmuch larger toolkit

AHRQ has invested more than $260 AHRQ has invested more than $260 million in health IT contracts and million in health IT contracts and grantsgrants

More then 150 communities, More then 150 communities, hospitals, providers and health hospitals, providers and health care systems in 48 statescare systems in 48 states

AHRQ Health IT InitiativesAHRQ Health IT Initiatives

Examples, Ambulatory Safety and Examples, Ambulatory Safety and Quality (ASQ) ProgramQuality (ASQ) Program– Pharmaceutical Safety Tracking: Children’s Pharmaceutical Safety Tracking: Children’s

Research Institute, Columbus, OHResearch Institute, Columbus, OH Monitoring medication adherence in an urban Monitoring medication adherence in an urban

mental health system serving a primarily mental health system serving a primarily Medicaid populationMedicaid population

– Improving Outcomes through Ambulatory Improving Outcomes through Ambulatory Care Coordination: Nebraska Behavioral Care Coordination: Nebraska Behavioral Health Information NetworkHealth Information Network An HIE focused on coordination of care for An HIE focused on coordination of care for

individuals with chronic mental illnessindividuals with chronic mental illness

– A Personal Health Record (PHR) for Mental A Personal Health Record (PHR) for Mental Health Consumers: Emory UniversityHealth Consumers: Emory University Adapts existing electronic PHR for needs of Adapts existing electronic PHR for needs of

people with a serious mental disorder and people with a serious mental disorder and one or more chronic conditionsone or more chronic conditions

CER and InnovationCER and Innovation

CER will enhance CER will enhance the best and most the best and most innovative strategiesinnovative strategies

Can open up new Can open up new populations for populations for which something which something can be useful incan be useful in

Can bring early Can bring early attention to potential attention to potential issuesissues

Comparative Effectiveness Comparative Effectiveness Challenges/OpportunitiesChallenges/Opportunities

Anticipating downstream effects of policy applicationsAnticipating downstream effects of policy applications Eliminating uncertainty about best practices involving Eliminating uncertainty about best practices involving

treatments and technologiestreatments and technologies Making sure that comparative effectiveness is Making sure that comparative effectiveness is

"descriptive, not prescriptive”"descriptive, not prescriptive” Creating a level playing field among Creating a level playing field among all all stakeholders, stakeholders,

including patients and consumersincluding patients and consumers Adopting a more integrated approach to achieving Adopting a more integrated approach to achieving

high quality health carehigh quality health care Using the same evidence-based information to make Using the same evidence-based information to make

different care decisions based on the characteristics, different care decisions based on the characteristics, needs, etc., of the individualneeds, etc., of the individual

Where to From Here?Where to From Here?

Timing:Timing: Significant support for and interest Significant support for and interest in comparative effectiveness research in comparative effectiveness research

The mission:The mission: Address gaps inAddress gaps in quality and quality and resolve conflicting or lack of evidence about resolve conflicting or lack of evidence about most effective treatment approaches most effective treatment approaches

Words of wisdom:Words of wisdom: “In theory, there is no “In theory, there is no difference between theory and practice. In difference between theory and practice. In practice, there is.”practice, there is.” – – Yogi BerraYogi Berra

Thank You Thank You

www.ahrq.gov www.ahrq.gov

www.hhs.gov/recoverywww.hhs.gov/recovery

http//:effectivehealthcare.ahrq.govhttp//:effectivehealthcare.ahrq.gov