quality improvement research carolyn clancy, md director agency for healthcare research and quality...
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Quality Improvement ResearchQuality Improvement Research
Carolyn Clancy, MDCarolyn Clancy, MD
DirectorDirector
Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality
Secretary’s Advisory Committee on Human Research Protections (SACHRP) Secretary’s Advisory Committee on Human Research Protections (SACHRP)
Washington, DC – March 27, 2008Washington, DC – March 27, 2008
Quality Improvement ResearchQuality Improvement Research
Health System Health System TransformationTransformation
Challenges in QI Challenges in QI ResearchResearch
What We Know So FarWhat We Know So Far
What We Need to Move What We Need to Move ForwardForward
AHRQ’s MissionAHRQ’s Mission
Improve the quality, safety, Improve the quality, safety, efficiency and effectiveness of efficiency and effectiveness of health care for all Americanshealth care for all Americans
The Quality ChallengeThe Quality Challenge
What Is Quality?What Is Quality?
Health carecosts up 6.7%
per year
Health care quality up
2.3%
A Quality DisconnectA Quality Disconnect
The Right Care
For The Right Person
At The Right Time
Health Care Quality and AccessHealth Care Quality and Access
Disparities in health care quality and access Disparities in health care quality and access are staying the same or increasingare staying the same or increasing
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QualityQuality AccessAccess
2007 National Healthcare Disparities Report2007 National Healthcare Disparities Report
The Confluence of The Confluence of Research and QIResearch and QI
ResearchResearch QIQI
The Complexity of QI ResearchThe Complexity of QI Research
Quality Improvement Research is complex Quality Improvement Research is complex
– Not an intervention in the way we understand Not an intervention in the way we understand clinical interventionsclinical interventions
– Can be multi-levelCan be multi-level
– Involves organizational and behavioral changes as Involves organizational and behavioral changes as part of implementationpart of implementation
– Context beyond the “it” is importantContext beyond the “it” is important Quality improvement is local (often single site), but Quality improvement is local (often single site), but
Federal, State, professional policies impactFederal, State, professional policies impact
– QI interventions may change over time and QI interventions may change over time and between sites between sites
– Potential for harm – to whom?Potential for harm – to whom?
From T1 to T2 to T3From T1 to T2 to T3
AHRQ Investments AHRQ Investments in QI Researchin QI Research
Since 1993, AHRQ (often in Since 1993, AHRQ (often in partnership with NIH, VA and partnership with NIH, VA and others) has generated research others) has generated research on topics including:on topics including:– CancerCancer
– DiabetesDiabetes
– AsthmaAsthma
– Health ITHealth IT
– Patient Safety Patient Safety
– Chronic Care ModelChronic Care Model
Using mechanisms ofUsing mechanisms of– GrantsGrants
– ContractsContracts
The Current Evidence BaseThe Current Evidence Base
Diabetes care: Diabetes care: No single strategy more effective than No single strategy more effective than anotheranother
Hypertension care: Hypertension care: All assessed strategies may be All assessed strategies may be beneficial under some circumstances, and in varying beneficial under some circumstances, and in varying combinations.combinations. There may be other useful strategies There may be other useful strategies that have not been studied that have not been studied
Reducing antibiotic prescribing: Reducing antibiotic prescribing: No individual QI No individual QI strategy (or combination of strategies) was more strategy (or combination of strategies) was more effectiveeffective
Reducing healthcare-associated infections: Reducing healthcare-associated infections: studies studies are of suboptimal quality. Some strategies may be are of suboptimal quality. Some strategies may be worth more study.worth more study.
Care Coordination:Care Coordination: Evidence about key intervention Evidence about key intervention components is lackingcomponents is lacking
http://www.ahrq.gov/clinic/epcindex.htm#qualityhttp://www.ahrq.gov/clinic/epcindex.htm#quality
Pronovost StudyPronovost Study
Settings: Volunteer MI hospital Settings: Volunteer MI hospital ICUs for adults (108 intention to ICUs for adults (108 intention to treat)treat)
Primary hypothesis: Rate of Primary hypothesis: Rate of CABSIs would be reduced during CABSIs would be reduced during first 3 months of intervention v first 3 months of intervention v baselinebaseline
Multiple interventions (sequential Multiple interventions (sequential and parallel)and parallel)
Outcome measure: Incidence-Outcome measure: Incidence-rate ratios for CABSIs rate ratios for CABSIs
Pronovost et al., NEJM 355(26); Dec. 28, 2006Pronovost et al., NEJM 355(26); Dec. 28, 2006
Analytic approach: Generalized linear latent and mixed Analytic approach: Generalized linear latent and mixed model with robust variance estimation and random effects model with robust variance estimation and random effects to account for clustering within hospitals and hospitals to account for clustering within hospitals and hospitals within regions, adjusted for hospital teaching status and within regions, adjusted for hospital teaching status and number of bedsnumber of beds
New Yorker, December 2007New Yorker, December 2007
Northern New England Northern New England Cardiovascular Disease Study GroupCardiovascular Disease Study Group
Regional Voluntary ConsortiumRegional Voluntary Consortium– Maintains registries for CABG, PCI & heart Maintains registries for CABG, PCI & heart
valve replacementvalve replacement
– Databases & data collection tools track Databases & data collection tools track outcomes and help develop risk-adjusted outcomes and help develop risk-adjusted modelsmodels
The Promise of Quality ImprovementThe Promise of Quality Improvement
National studyNational study 46 primary care practices 46 primary care practices
(public & private)(public & private) 181 primary care clinicians181 primary care clinicians 1,356 depressed patients1,356 depressed patients Patient outcomes measured Patient outcomes measured
over five yearsover five years
Kenneth B. Wells, MD, UCLA Neuropsychiatric Institute & RandKenneth B. Wells, MD, UCLA Neuropsychiatric Institute & Rand
Partners in Care (PIC)Partners in Care (PIC)
PIC Clinics Were RandomizedPIC Clinics Were Randomized
Kenneth B. Wells, MD, UCLA Neuropsychiatric Institute & RandKenneth B. Wells, MD, UCLA Neuropsychiatric Institute & Rand
Design Design Unit of AnalysisUnit of Analysis Potential for Use Potential for Use Level of difficulty in Level of difficulty in current environmentcurrent environment
Randomized Randomized Controlled Controlled Trial (RCT)Trial (RCT)
Individual patient Individual patient level level
RareRare High High
--applies to few interventions--applies to few interventions
RCTRCT Providers/delivery Providers/delivery systems/policy systems/policy
RareRare HighHigh
--Refusal to be randomized--Refusal to be randomized
Cluster RCTCluster RCT Clinical practices, Clinical practices, States, etc.States, etc.
When more than one When more than one site can be randomized site can be randomized
High High
--single site studies the norm--single site studies the norm
--criteria for randomization --criteria for randomization unknownunknown
Quasi-Quasi-experimentsexperiments
(ITS)(ITS)
AllAll Frequent Frequent HighHigh
--academic acceptance--academic acceptance
--acceptance in practice--acceptance in practice
--funding--funding
QualitativeQualitative All?All? ?? HighHigh
--above, plus cost--above, plus cost
Research Designs and Research Designs and Methods for Internal ValidityMethods for Internal Validity
Some Provisional DefinitionsSome Provisional Definitions
Quality improvement InterventionQuality improvement Intervention– An effort to enhance the extent to which health care is An effort to enhance the extent to which health care is
safe, timely, effective, efficient, equitable, and patient-safe, timely, effective, efficient, equitable, and patient-centered and results in the best possible patient centered and results in the best possible patient outcomes. It can occur at the policy, delivery system, outcomes. It can occur at the policy, delivery system, or clinical microsystems levels (or all of these) and will or clinical microsystems levels (or all of these) and will enhance the way care delivery is structured, organized, enhance the way care delivery is structured, organized, and operationalized to ensure that patients receive and operationalized to ensure that patients receive care based on the best available evidence.care based on the best available evidence.
Implementation researchImplementation research– The scientific study of how specific sets of activities The scientific study of how specific sets of activities
and strategies are used to integrate evidence-based or and strategies are used to integrate evidence-based or evidence-informed policy-, organizational-, or provider-evidence-informed policy-, organizational-, or provider-oriented interventions within specific settings toward a oriented interventions within specific settings toward a goal of improving the quality of health caregoal of improving the quality of health care
What We Need to Move What We Need to Move Forward in QI ResearchForward in QI Research
DefinitionsDefinitions ConstructsConstructs Frameworks Frameworks Methods appropriate to answering QI Methods appropriate to answering QI
questionsquestions Methods for synthesizing resultsMethods for synthesizing results ResourcesResources
– ResearchersResearchers– Research Participants (policymakers, delivery Research Participants (policymakers, delivery
systems, providers)systems, providers)– FundingFunding
ConclusionConclusion
We need researchers and research We need researchers and research participants in order to learnparticipants in order to learn
We need to focus on resolving research We need to focus on resolving research ethics issues to enhance research capacity ethics issues to enhance research capacity
Implementation of effective QI interventions Implementation of effective QI interventions can and should proceed unfetteredcan and should proceed unfettered
QI researchers should understand the QI researchers should understand the flexibility provided by the Common Rule – flexibility provided by the Common Rule – both in terms of allowable exemptions and both in terms of allowable exemptions and waivers of informed consentwaivers of informed consent
Questions?Questions?
HTTP://WWW.AHRQ.GOVHTTP://WWW.AHRQ.GOV