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>> FS: Good morning. Pretty good. For a Monday morning. Just wait for a few more people to
take their seats. On behalf of the Office of Behavioral and Social Sciences Research
and the conference planning committee, it's my pleasure to welcome you to the Fourth Annual
NIH Conference on the Science of the Dissemination and Implementation. I think you can see by
the size of the room that we've had yet another record turnout for this year's meeting. And
I think it reflects a growing recognition of the need to address how best to insure
that scientific advances ultimately make a difference in improving health.
This year's conference theme, policy and practice, is intended to stimulate dialog on the connections
between public policy, practice, and health research. The health policy landscape has
changed a lot in recent years. Not just here in the U.S., but globally, and we believe
a focus on this is both timely and critical to closing the gap between research, evidence,
and policy. More and more we recognize that health is a global issue, and that many policies
that influence health are, in fact, made outside the healthcare arena. Population health is
intimately linked to a government's broader social, economic and environmental policies.
Appreciating this, we welcome the contributions of our international colleagues attending
this year's conference.
NIH is also particularly pleased to be joined this year by the Veterans Health Administration
and the Agency for Healthcare Research and Quality. And I know we'll benefit from their
increased presence at this year's conference.
I'd also like to acknowledge the people on our planning committee and our external scientific
advisors, who donated their time to develop what I think is really an outstanding agenda.
We'd also like to thank the Donaghue Foundation for the poster session reception this afternoon,
and I hope that all of you will attend that gathering. And last, but no means least, I'd
like to thank the Hill Group for their superior logistical support.
I have just a few announcements before we get started. First, I'd just like to point
your attention to your badge, which lists the sessions for which you preregistered.
Note that this year we're really going to enforce the capacity for the think tanks.
I know they're pretty popular, but if you didn't preregister for one and you want to
attend one, please check with the registration desk to see if there's room. Otherwise, just
go to a session where there's spaces.
Also, because of the weather, the hotel is going to accommodate us and offer a buffet
lunch or also, I think, box lunches will be available. So if you don't want to go out,
you'll be able to get some food for lunch at the hotel. If you do want to go out, there
are places in walking distance, and you can get a list of restaurants at the registration
desk.
You'll also note that there's several display tables with information about implementation
research training opportunities. And thanks to the VA, we've compiled a directory of implementation
science training programs, which you can see at the conference website, or there are also
handouts at the registration desk.
And I'd also like to draw your attention to a new training opportunity being offered by
NIH. This August, in North Carolina, it's a training institute on dissemination and
implementation research in health. And more information about that can also be found at
the registration desk or at the -- this website. Or if you check the OBSSR website, it'll give
you more information about the goals of the institute, and how to apply. The applications
are due April 15th.
Now, I'd like to turn it over to Dr. Robert Kaplan, who's OBSSR's new director. He joins
us from UCLA, where he was professor in the Department of Health Services at the School
of Public Health, and the Department of Medicine. He's had a long and distinguished career as
a behavioral scientist and I think many of you know him from his leadership at the American
Psychological Association, and also the Society of Behavioral Medicine. NIH is extremely fortunate
to have recruited such a leader. So please join me in welcoming Dr. Bob Kaplan.
>> MS: Well, thank you very much. What a pleasure to be here and to see so many of my old friends
all in the same place. It's like going to the best scientific meeting. So it's a pleasure
to be here. I think many of you know that I'm a very seasoned NIH employee, I've been
here almost a month. Or a little bit over a month. So it's great. I'm learning all the
acronyms and it's going to -- I'd say check back with me in a year or so, I'll be about
halfway down the list.
But I would like to take the opportunity to thank Helen Meissner. Helen organized the
conference in collaboration with the organizing committee, and what a lot of you don't realize
is that she's very well recognized at the NIH. Last Friday, when I was cleaning up my
office to go home, I got this little envelope that was a citation from Director Collins,
and it says in recognition of outstanding leadership in NIH programs in the science
of dissemination and implementation, and in health disparities. And you can see Helen
there, holding her award, with Dr. Collins, on -- let's see, it would be her right side.
Dr. Taybach and Deb Olster, the deputy director of the Office of Behavioral and Social Sciences
Research. So we appreciate her and it turns out that everybody appreciates her. So, thank
you, Helen.
I just want to make a few introductory comments. I think, to this group, this is very old stuff.
But when I go out and talk to people, the world out there doesn't really recognize how
important dissemination and implementation sciences are. We spend billions of dollars
developing new cures, and we work very hard to build better pills. And, in fact, discovery
drives this enormous pharmaceutical industry and device industry in this country.
Yet, something's missing. Steve Wolfe, whose papers I read in preparation for this, points
out that for every one dollar that we spend developing new pharmaceutical products, and
new interventions in medicine, we spend about a penny on developing, or studying, new ways
to implement these new products. There are enormous numbers of new randomized clinical
trials. So we have lots of new information. [unint.] the new risk factor treatment trials
that were published between 2004 and 2009. 2004 is very important because that's the
last year that we revised the major guidelines for prevention of cardiovascular disease,
the ATP3 guidelines and the JNC7 guidelines. And since then there have been 41 new randomized
clinical trials. Also, it's worth saying that epidemiologists continue to produce new information,
but, in fact, in areas like cardiovascular disease we pretty much knew what the risk
factors were for coronary disease when the first publication of the Framingham Study
was published in 1961. That's about 50 years ago.
Now, I think this is going to be a little bit hard to read. But we know from a lot of
different evidence that we aren't reaching significant portions of the population that
we want to reach. Now we're getting better. And it's worthwhile to say that we're doing
better each year. Each time there's a new edition of the National Health and Nutrition
Examination Survey, the numbers look a little bit better. But still, among people who have
hypertension, as identified in the [unint.] study, only about 80% of them actually know
that they have hypertension. And among those, only about 70% are treated. And among those,
only about 50% have their hypertension controlled. Now this is actually much better than it was
20 years ago. But there's still significant numbers of people who could do better.
And the left side of the slide shows that this varies, actually rather dramatically,
by socio-economic status and race. So if you work through these numbers, if you say that
among all people who have hypertension, just as the example that we're considering, only
80% of them even know they have the condition. Among those, about 70% are treated, and among
those about 50% are controlled. That means that only about 28% of people who could benefit
from treatment are actually getting the full benefit. And actually, we know from very systematic
studies, that most people can have their blood pressure controlled in very carefully controlled
situations. It might take them two or three drugs to get there, but it can be achieved
in most cases. So we have a lot of ground that we could cover through better dissemination
and implementation.
And it's also worth saying that we're doing relatively well in relation to other countries
in the world. So, for example, there was an IOM report that was published relatively recently
that suggests that diseases like coronary heart disease now account for about 30% of
deaths in middle and low income countries. And these tend to be overlooked by governments,
by global health institutions, and by developmental agencies. But if you look at some countries
-- and one of the most shocking examples was that in China only about 6% of people who
are aware they have hypertension, in China, have their blood pressure controlled.
So, we also note that some relatively simple interventions might have substantial potential
to fill this gap. So Steve Wolfe, and Johnson reported just a few years ago, through, you
know, sort of back of the envelope simulation, that simple -- simple reminders, so office
reminders, for example, might -- they estimated that they would prevent seven times more death
than replacing older cholesterol lowering medications with newer ones that are considered
to be more potent. So the investment in dissemination actually might produce significantly more
health benefit than finding that better pill.
I'll just give you a quick example. I recently looked at a whole bunch of the randomized
clinical trials. So, again, there we identified 41 of them that have been -- that were published
between 2009 -- 2004 and 2009 -- and it turns out that when you look across the hypertension
studies, they vary -- they vary a lot. If you look at the ALLHAT Study, it turns out
that a lot of the newer studies produced results that are somewhat inconsistent. But it's worth
saying that a 10% change in mortality rate associated with a new medication would be
extremely rare across these studies. So let's just say, we'll let's consume -- let's assume
that it would be a big benefit and there would be a 10% reduction in hypertension related
deaths in comparison to current therapies. And if you assume that you had a population
of 100,000 that you would be working with, that might save 10,000 lives, by getting to
this -- this better pill. But if only 50% of the people use the medication in a manner
that provided full benefit, the lives lost due to poor dissemination are about five times
greater than what you would get by going to that -- that next best pill.
So, I think this is an extremely important science. By the way, when we get beyond the
medical side of it to community dissemination, the problems become even more challenging
and perhaps even more important. So, I'm very enthused to be here, and here are some of
the take home messages.
First of all, we have a very large investment in building better treatments. Which I'm in
favor of, by the way, I don't want to leave you with the impression that I don't think
we should -- we need to continue this -- this big investment in better treatments. But there's
substantial evidence that dissemination and implementation is not optimal. And there's
potentially a huge payoff by improving the science of dissemination and implementation.
So I'm really thrilled to be here and I'm thrilled to be part of this, and I'm thrilled
to be working people like Helen, and Russ Lasko and the others who have been teaching
about -- teaching me about this.
But with that, I have the privilege and opportunity to introduce today's keynote speaker, who's
Dr. Carolyn Clancy. And I think many of you know Dr. Clancy, so I won't make the introduction
long. But just to say that I think that she's one of the most important leaders that we
have in our science, but also in the government in general. Dr. Clancy is a general internist.
She is the Director of the Agency for Healthcare Research and Quality, a job that she's had
since 2003. Before that she was the Director of AHRQ Center on Outcomes and Effectiveness
Research. Dr. Clancy was trained at Boston College and the University of Massachusetts
Medical School. She was Henry J. Kaiser Family Foundation fellow at the University of Pennsylvania.
And she had a career in academia at the Medical College of Virginia, before joining the government.
Dr. Clancy is a member of the Institute of Medicine. She also is a master of the American
College of Physicians, and in 2009 she was awarded the William B. Graham Prize for health
services research. She has a broad range of interests and she's, I think, done more than
anybody that I can imagine, in trying to bring together the mission of the AHRQ with the
NIH and a whole bunch of other agencies within the Department of Health and Human Services,
and all across government. So, Carolyn, it's a great pleasure to have you here. I think
that I -- I think that Carolyn actually was once my project officer and we worked together
on the national [unint.] treatment trials. So it's great to see you and have you here.
>> FS: Thanks so much, and it's really nice to [inaud.]. Well, good morning everyone.
I really want to congratulate the conference organizers for starting with hail. Now, I
mean, is that a way to wake you up to how important this is? If there's one message
I leave you with today, it's that not only is this work important, all research is, and
science is, by definition, important -- but it's really show time for this country for
this kind of work. And we need it to sustain the opportunity provided by this affordable
care act. Where we can get to a place where if AHRQ were no longer funding so many studies,
documenting yet again that people without insurance get crummy care. Just as one example.
But we've got a huge amount of work to do, so I'm going to jump right in and actually
build on Bob's comments. You'll think we rehearsed. But actually, that's not the case. Great.
So I'm starting off with a picture of Peter Pronovost, from Johns Hopkins. Now, we had
the privilege of supporting his work, the Keystone Project. Now, I have to tell you,
this project has changed my social life. Because when I go out with my husband and some of
his colleagues and friends ask what do you do, he always gives me this murderous look
that pretty much says keep it short, no details. Do not geek them out. Now, I can simply say
do you read the New Yorker. And we have a very pleasant conversation. But the reason
I emphasize this study, that achieved dramatic and sustained reductions in serious central
in infections. Which, by the way, have a very high case fatality rate. Is it's one of the
few homeruns I can point to in healthcare.
The intervention they developed and tested worked at vary large medical centers like
the University of Michigan and in small Michigan hospitals as well. We're now working with
him and the American Hospital Association to expand this literally across the country.
Now, I don't want to pretend that every hospital has jumped onboard and said we're there, we're
with you. It's more like about 25% have enthusiastically stepped forward. But, you know what, those
that have, they're seeing exactly the same sorts of dramatic improvements. And his point
in this slide, and this quote, is just that we have failed to appreciate just how big
a challenge this is.
And, indeed, everything about the Affordable Care Act, in not exactly the most elegant
language, but if you look at all the provisions in there around improving safety and quality,
they all point to us building a healthcare system that is focused on the needs of patients
and families. Now, for those of you who provide clinical care and think that that's what I
do, I totally agree with you. The system isn't so helpful though.
This past fall my father passed away and my entire large extended family got to be with
him at the end, and that was all lovely. But I watch my siblings, none of whom are in heath
or medicine. I'm the oldest of seven, so if you're one of seven, you can't be shy. It's
just not consistent with survival and thrival. So I watched them ask questions, and they
asked, really, what are good, logical questions, from their standpoint. But they were always
kind of off point. And it made me realize just how difficult this system is to navigate
for people who are well educated, much less people who come to this with more challenges.
So we've got a lot of work to do. So what I want to talk to you about is what we're
up to at AHRQ. I know some of our NIH colleagues are working so hard they don't always know
all about AHRQ, so I just thought I'd give you the very, very brief overview. And I want
to share some high level findings from our annual reports to the Congress on how we're
doing in quality and disparities, and then I want to get into the issues of dissemination
and implementation, and draw the line from the science that you're doing every day to
health system transformation and patient centered care.
So, just at a very high level, big priorities for AHRQ are improving the safety and quality
of care. Notice I'm not saying conduct and support research that will one day, hopefully,
get us to -- that someone will use and then they will improve care. Although that's really
what it's about. We -- but we take the urgency facing healthcare very, very seriously. And
we also take seriously the dedication of healthcare professionals across this country, in all
disciplines. Every one of them gets up every single day to do the best job they can, and
they work in systems that make that painful and difficult, and it's almost never really
the default, easy, thing to do. So we've got a lot of good work ahead of us.
We also support work in the effectiveness and comparative effectiveness -- what we're
now calling patient centered outcomes research. We've had very explicit authority since the
Medicare Drug Bill passed in 2003. Now, very interestingly for all your work, that authority
has three parts. The middle part we know all about. Support and conduct and so forth. The
first part says researchers don't set the priorities by themselves. The priorities are
actually set in close transparent collaboration with multiple stakeholders, public and private
sectors. And the third portion says -- and this is where many of you work -- the information
has to be accessible and available to multiple audiences, and understood.
Now, if you think about the fact that Bob talked about all the discoveries we've made,
in 2011 it's a great time to be alive. We have no excuse for not doing a better job
with hypertension, because unlike the early days, when the tradeoff was between, you know,
living longer, or not being clear if the drugs we were giving you were making it feel like
it wasn't worth it, right. Now, for many decisions -- diagnostic, therapeutic, and so forth -- we've
got two or more good options. What we don't have is an easy way for people, clinicians
and patients, to work together to figure out what's the right option for them.
Now, every researcher who breathes gets up every day to make a difference in peoples'
lives. Without question, it's a given, this is what drives them to work around the clock,
late into the night, again and again and again. To resubmit that grant after all that constructive
input from peer review, and so forth. And yet that passion and the skill set of communicating
effectively about benefits and harms of alternative interventions, particularly to people of health
literacy, don't often co-reside in the same individuals. So that means the research team
has to be bigger and we do a lot of work trying to make data available for researchers, and
for hypothesis generation.
Now, the Recovery Act was a huge boon, both to AHRQ and to NIH, and others, with a total
of 1.1 billion dollars coming out of that. I'll bet some of you are still tired from
writing some of those grant applications. So let me say thank you. What's very clear
is that the point of this was to be -- beginning to -- was a down payment on what I'll call
the scientific infrastructure to make health reform sustainable. We know now that simply
knowledge and awareness is not going to be enough to get us to systematically high quality
care. I know that when we see results that are less than what we'd all like for ourselves,
that if you tested the doctors, nurses, pharmacists and so forth, they'd all do exceedingly well.
It's all about implementation and execution. That is the big part.
So trying to figure out how we could make investments in robust systems and infrastructure
to make the right thing, the easy thing to do, that is a key part of this work as well.
As well as a strong focus on the needs of what we refer to at AHRQ, taking language
from our authorizing statute, as priority populations. Populations that are often not
well represented traditionally in research.
So, with apologies to Archie Cochrane, I thought I would reframe some of the questions we ask
about clinical interventions. For the work that we're engaged in together, for any intervention
to improve care, the first question, of course, is can it work? But a very important sub-question
is do we understand how and why it worked? A second is, will it work here? In this particular
context and in this particular environment, community, market, and so forth. And, of course,
the real show time aspect is can we replicate it and scale it? I will mention a little bit
later that, you know, CMS now has up to 10 billion dollars over the next decade to develop,
test, and implement new models of care delivery, helping us to get to a place where we -- our
payment system is more aligned with the goals and outcomes we want from healthcare. That's
fantastic. They are going to struggle with these issues as well. Lots and lots of good
ideas in this country. We tend to be a little bit shorter on the execution side.
So we've had the privilege in comparative effectiveness research over the past six years
or so to work very closely with colleagues in the private sector, and also to try to
increase the knowledge base so that we get closer to this value proposition in healthcare.
Now, before the Recovery Act, we got a total of 129 million dollars over five years. So
those of you who know anything about rough price tags for clinical trials will know that's
not the business we're in. Our business, and this is what has made our collaboration with
NIH in this area just so fruitful and wonderful, certainly for us, is to actually build the
infrastructure and test and develop methods to learn from all of the data generated as
a byproduct of providing care, and to figure out how can we aggregate that. And also know
that we can be confident in the results. Sometimes we can't. Sometimes we're going to make mistakes
doing that. But there are so many questions in clinical care and healthcare policy where
-- that are simply not ever going to be tested in a clinical trial. It just won't happen.
People will consider it unethical or against their beliefs and so forth.
So just turning to the annual reports we make to the Congress, three weeks ago today we
released our eighth annual report. So the really good news is that every single year
since we started doing this, across all settings and populations, we've seen statistically
significant improvements in care. Slightly less good news is if you look at that number,
this is actually a little higher, the 2.3% number, than some other years. And if you
think about the numbers you see associated with annual increases in what we're spending
on healthcare, even when the economy has slowed down for the past couple of years, you can
see there's an important disconnect that policymakers understand in a very clear way. And urgent
attention is clearly needed to improve quality and reduce disparities in a number of key
areas that I've highlighted here.
Cancer screening, diabetes management, just to pause on diabetes management for a moment.
You know, health plans have been reporting on quality for about 20 years now. And now
they report not only whether the right tests were ordered, but also what are the short
term outcomes, including management of diabetes, management of cardiac risk factors, and so
forth. Now, I want to set aside for a moment -- I'm highly aware of the controversy about
what's the right level of hemoglobin A1c. But we're looking at a level of about 9 here,
okay, this is not as precise as we're worried about in clinical trials. The top 10% of plans
get it right 71% of the time. Now, that's up from where they were a few years ago. So
it's been steady improvement. But we're tolerating a failure rate in -- in care for an important
chronic illness of almost 30%, and that's in the best. So we've got a huge amount of
work to do.
Just to highlight a couple of areas. Two areas that we saw improving were palliative care
and end of life care, and patient and family engagement in their care. Three that are lagging
were population health, safety, and access to care. And three require more data for us
to be able to say anything about -- care coordination, we supported a systematic review on this topic
a few years ago and the opening sentence of the final report says, we don't have a single
definition of care coordination. Well, we don't have very much good information. What
are opportunities of wasting resources in healthcare, something of a sensitive topic.
And all eight areas showed disparities related to race, ethnicity and socioeconomic status.
So a lot of work to do.
Now some things are getting better and that's really, really good news. Anyone here from
NHLBI should feel very, very proud of the work that the cardiac and heart disease community
has done in terms of door to balloon time. This is not easy stuff. It requires team work
and execution in a highly orchestrated kind of way, almost like music or dancing, I guess.
And the proportion of people across this country who get their intervention in less than 90
minutes, that's the goal, has doubled in the past few years from something about 40% to
over 80%. That is fantastic. We don't see improvements at that scale. And, indeed, we
see other areas of treating acute illnesses and injuries that are improving much, much
more than that 2.3%. When you look at chronic illness management, preventive services, and
immunizations, improvements where they are, are much, much more modest.
So in terms of -- we take enormous pride -- and work for organizations and institutions that
celebrate the notion of evidence based healthcare, and evidence based treatment decisions. And
indeed, the Affordable Care Act, in some ways, is a terrific model of evidence based policy.
You all may not have known that, but preventive services, for example, are exempt from co-payments
for those services rated A or B by the preventive services task force. That's just one example.
But ultimately, the kinds of complex decisions that people have to make involve tradeoffs
for individuals. Very similar to Barbara McNeil's famous study of people with head and neck
cancer, right. Now she used healthy volunteers to ask this question, but the essential question
she posed to them was if you have surgery, you'll live longer. But if you have radiation,
you'll get to keep your voice, which you don't have with surgery. What would you like? Now,
at that time, by and large, patients weren't terribly involved in this conversation. They
were pretty much told, this is what we're going to do, you're going to have surgery
because it will increase your life expectancy. And 20% of people enrolled in this study said
no, I actually would prefer to have a higher quality of life, which touches on work that
Bob Kaplan has done throughout his career.
So we know that in order to give people some of the tools from the science that we're supporting,
we've got to try a variety of techniques. Including audio announcements in supermarkets.
Indeed, I went to Safeway about ten days ago. Not only is AHRQ there, but now we've been
followed by CDC and FDA. I don't know who else is coming. We might have used up this
space. But we also have a specific center that we support, named for John Eisenberg,
former director, focused on communication and clinical decision sciences, that develops
prototype guides for clinicians, for policy makers and for consumers. Same scientific
base but developed in a very, very different way.
Now we were really, really excited and there's an amazing amount of good work going on, in
addition to the 300 million dollars directly allocated to us by the Congress, 173 of the
400 million dollars allocated to the Secretary's office is also being mobilized by AHRQ and
I have to say it was really a fantastic opportunity for us to partner with NIH. Not just on a
project or an initiative, but for an entire portfolio. So just to give you a sense of
some of the investments that we're trying in dissemination. We are supporting a publicity
center and regional offices. Looking for every opportunity to get this information to people.
Bob started off with a slide that said only 80% of people with high blood pressure know
they have it. Well, lord knows, if they show up anywhere in healthcare, we're going to
tell them. But what people who don't have a need to show up; right? How do we reach
them? That's what this is about. We're investing in online continuing education. I don't see
this of the Everest of our ambitions, by the way, but knowledge is necessary, if not entirely
sufficient for leading to the improvements that we have. We're testing different models
of academic detailing, and also evaluating those efforts to try to learn which strategies
worked for what circumstances and so forth.
Interestingly, when we started this work in comparative effectiveness, the focus was mostly
on clinical interventions. Which of these many options is the right one for an individual.
As a result of the Recovery Act and the congressionally required Institute of Medicine study -- some
of you may remember those top 100 questions -- as well as the Federal Coordinating Council
For Comparative Effectiveness Research, and lots and lots of stakeholder input. Independently,
both groups concluded that -- that work needed to focus not just on clinical things, but
on how we deliver them, or care improvement strategies. Now, on one level that's great.
On another level, I hope you all are ready for this challenge and all your colleagues
back at home. We all know what 20 milligrams of Lipitor is. We often don't know if we're
reaching the right people with it or if people are taking it. But we -- it has a standard
meaning. If you fill in the blank for many of the strategies we're talking about, whether
that's knowledge transfer, research utilization, care management, care coordination, disease
management, and the list goes on -- you've seen one, you've seen one. We simply don't
have a standard taxonomy and definition of terms. Instead, we usually yell at the Congressional
Budget Office for not scoring these as being worthwhile investments. And yet most of the
time they're right, because we haven't built that science space. So if you were having
any nagging doubts about how important your work is, I hope that you will put those to
rest.
Now, just to give you an example of customizing an explicit intervention. Two years ago a
study funded by AHRQ at Boston Medical Center, Project RED, the re-engineered discharge.
All right? Actually used a nurse and a pharmacist to reduce readmissions by 30% in the next
30 days, and also reduce return visits to the emergency room by that same amount. Now,
in this world, that is fantastic, and right now, at a policy level, all hospitals are
going to have to address this challenge. How do we prevent avoidable readmissions? And
having been my dad's navigator from here to Boston for the past couple of years, I'm just
here to tell you there's a lot of low hanging fruit. People go home without a clear sense
of what they're up to and so forth. But the really interesting part is that two weeks
before this study was published in the Annals of Internal Medicine, Boston Medical Center
laid off a couple of hundred staff.
Now this actually raised some very important questions; right. Because the nurse and pharmacist
involved in this study actually were brought in and superimposed on the people who worked
there. I don't mean they were sitting on them literally, but I mean they were additional
staff; right. And the question was, how do you weave that into core business and who's
going to have the resources when the economy is actually forcing us to lay people off?
So the result was actually a virtual discharge nurse, and in this particular slide I'm highlighting
that they're specifically focusing on a virtual nurse with a strong focus on African American
women. Now we got to show this to Secretary Sebelius last year. I have to confess, when
I first heard about this I was a little nervous. I pictured my father plopped in front of a
video, nodding off. Well, if you've read the Tipping Point, it does all the things you're
supposed to do for this kind of technology. You have to keep touching the screen. It's
programmed for your specifics, and, in fact, if you don't touch it within a certain amount
of time, the bell goes off and a real nurse comes in. I don't know that this is end of
the story, but, I mean, it is one very innovative approach.
Jack Nadelman, who I know is here, recently sent me the study he just -- and his team
-- just published in the New England Journal, showing that below target nurse staffing and
high patient turnover are independently associated with the risk of deaths among patients. Wow.
High stakes work here.
And we have made a variety of materials available for clinicians. I'm just listing some of the
ones that are most recently available. Comparing oral medications for people with type 2 diabetes;
antidepressants for adults; and the list goes on. All available for free on our website.
And we're very, very excited about the expanded, continuing medical education. Part of the
reason I'm excited is that thoughtful leaders in this area know that continuing medical
education, if it's going to continue to have an important role has got to be linked more
directly with the delivery of care. And they also know that the days of -- I'm thinking
of an old flyer I got -- taking a little trip to Sea World for the weekend to learn about
flexible sigmoidoscopy -- are pretty much over; right. I mean we're all about making
this online and visual. So we're putting resources out there for educators to use. And my favorite
part of what we're doing in patient centered outcomes research is actually the patient
guides. Because it demystifies what it is that we're talking about. A number of them
provide questions for patients to bring in with them, so that ultimately they can be
more active partners in their own care.
Now, the Affordable Care Act also made resources available for something called the Patient-Centered
Outcomes Research Institute, or PCORI. I know Brian Mittman is here some where and was on
the planning committee. Brian is actually a member of what we've been referring to as
the rock star methodology committee that was also required by the statute itself. This
is a very, very interesting mode. It's a private sector entity funded by a mix of public, that
is to say trust fund, Medicare trust fund, dollars and in a couple of years that will
-- what will be added to that is a tax or an investment -- you can choose your word
-- paid by insurers and self-insured employers on a per capita basis. So ultimately a total
stream of funding somewhere between five and six hundred million dollars a year. What's
very, very unique though, and I think this is relevant to all of our work here, is the
board governing this is not only scientists. There are some fantastic researchers on that
board, but by law there are three representatives from industry, who happen to be superb scientists
themselves, there are three patients, there are people representing insurers, employers,
healthcare delivery and so forth. As well as the directors of AHRQ and NIH. A very,
very different kind of conversation.
Now, to say that this board is completely enthusiastic about patient centered care would
be a profound understatement. Two weeks ago the board met for the third time, because
they were just appointed in late September. And they actually, we had a listening session
out in St. Louis. Anyone here from St. Louis? Great. I don't know if you were able to join
it -- oh, great, thank you. I was quite struck, as I'm sure you were, by the fact that we
split into little tables. Now, understand, there's a whole variety of folks there. So
on one side of me there's a guy who does health benefits for employees who work for a chain
of regional grocery stores. On the other side of me is a guy who's funded by SAMSHA and
works with some of the most vulnerably, seriously mentally ill patients. And so, very, very
broad range of input. Almost every single table, at the top of their list for priorities
for this institute was implementing what we know. Slightly different language from the
different groups. But way, way at the top of the list. There's already so much focus
out there.
So this institute has not started its funding yet. The URL is pcori.org, watch that space.
I would expect that there will be some announcements in the relatively near future. I don't mean
tomorrow. Okay. So we don't need to distract yourself from the conference.
I mentioned the Center for Medicare and Medicaid Innovation. A billion dollars a year here,
to test different models of care, and yet, ultimately, they are going to be accountable
for asking exactly the same kinds of questions. Can it work? Can it work here? Do we know
how and why it worked? And, if anything, the stakes are going to be higher for that center
because for the first time, you know, Medicare and Medicaid have funded demonstrations forever.
Some of them are extremely well done, with evaluations. But when it's over, that's it.
You know, we have a report, that's nice, and we keep on going. Now there's going to be
a direct link with subsequent iterations of policy. This is a brand new path and brand
new opportunity. But, again, implementation science is what it's all about.
A couple of other comments. We make available an opportunity for people who are innovators
in healthcare but have no interest whatsoever in publishing. That they want to solve problems
and that's what they're passionate about. To share their lessons learned so we can learn
from them on our healthcare innovations exchange. For some of you, looking for ideas, or looking
for what people are doing out there, it's a great place to visit, innovations.ahrq.gov.
The Affordable Care Act has a number of provisions around quality. Now I'm highlighting here,
some here, where AHRQ is specifically mentioned. All of these, by the way, are authorized but
not funded. But the larger point is if you were to read the Affordable Care Act -- I
wouldn't recommend this for everyone -- but I would guess at least 20% of the number of
pages is focused on improving care delivery. That's a lot of pages. I've read a whole lot
of them, several different times. You could not write a movie script out of these pages;
okay. Well, but -- because they don't actually all connect in a logical sequence. So the
front end of the bill, there's a lot of directives to CMS to keep doing what they're doing now,
but do more of it, faster. And then, of course, there's the innovations center and PCORI.
Later today, the Secretary will announce a national strategy for quality, which is a
brand new idea. So that should be out later this morning. But none of -- they don't add
up to a coherent script. But what I think it says is that policy makers get it in a
really, really big way. They can come up with all kinds of schemes for financing and subsidies
and all of that, but if we don't fix the core business of healthcare delivery, if we don't
use all of our scientific tools to make sure that people get the best possible care, wherever
they are, this entire opportunity will have been wasted.
So I wanted to leave you with some important questions. And I'm coming at this more from
a policy perspective, but also from someone who funds research. So, first, when does dissemination
and implementation start? Historically, we've thought of that as a post publication opportunity;
right. Wait until it's out and I've been on NPR, and then we'll talk about developing
initiatives. I think there's another -- at least one other major competing hypothesis,
which is about priming the pump. And priming the pump, in other words, when you've got
a lot of stakeholders along with you, is really important. First, when the actual big study
and the homerun is published, this isn't news to them. They've already been thinking about
how they would do that. Secondly, in terms of really improving care, oftentimes the information
that researchers have is astonishingly important to people running programs.
So just to give you an example. When the Children's Health Insurance Program was first funded,
we co-funded with a foundation a project to evaluate various aspects of its implementation
in nine states. So the interesting thing here was this bill gave states an enormous amount
of flexibility, does that sound familiar -- and states could learn from each other. But along
the way, and very, very early on, there was a stakeholder panel guiding this -- and the
researchers were able to give to these folks very important, what I would call non-publishable
but utterly vital information. Like what other programs are children we're trying to reach
enrolled in? All right. If most of them are in WIC or in the school lunch program, well,
bingo, I know where to deploy my people. You're not going to publish that. This isn't stuff
we should be embargoing.
A second big question that we struggle with a lot is can we assess efficacy and effectiveness
in improvement interventions concurrently? In other words, can we celebrate a worthy
approach of rapid cycle research and learning, where we learn as we go? What does that look
like? What are the problems with it, and so forth. How do we assess what's scalable? How
are the people at the innovation center, who are not researchers, going to know this one
looks good and we should fund it and this one looks really cool and innovative, but
I can't imagine how you'd scale it. This is N of one and I just don't see it.
What are the explicit rules for partners and stakeholders? I'm sure many of my colleagues
at AHRQ and NIH would agree that it is astonishingly easy for us to write into a funding announcement,
you must show credible commitment, blah, blah, blah. This is an IQ test for researchers;
right. They develop the boilerplate letters, everybody signs on saying, you know, we're
definitely onboard, you're giving this institution more money. But there isn't really a partnership
there. How would we know that such a credible partnership exists?
Should we be training bi-lingual champions? Whether those are health professionals, health
coaches, or some other group of people who understand enough about research that they
know what research can do or not, but also understand the needs of the people who are
providing care and running systems in which care is provided.
And my personal favorite is, can research infrastructure also serve clinical operations?
You know, at 10,000 feet it feels like a great idea; right. First of all, we're on our way
to perfect electronic health records; right. Pretty soon researchers will be able to pull
right up to the server with a vacuum and put their there and get a database. Obviously,
there's a lot of hard work over the next few years to get there. But why should research
be so separate? And we are seeing that in healthcare now; right. A lot of hospitals
and other organizations collecting data for quality. For the most part that's separate
from, say, professional organization registries. In some kind of efficiency way that doesn't
feel like it makes a lot of sense. Some of the investments we've been fortunate enough
to make with the Recovery Act funds are actually pushing the envelope on can we do both. In
other words, can we support rigorous research, and that infrastructure also goes on to serve
the needs of the clinical enterprise?
So at the end of the day, we want more about bringing healthcare and information, and science,
to people's lives, rather than making them navigate the maze that we've made healthcare
delivery. And just to leave you with a bumper sticker, because these days it's all about
tweeting and so forth. Thank you very much for your attention and I'm thrilled by the
>> Q: [inaud.] questions?
>> MS: Yes, sure.
>> Q: [inaud.]
>> FS: I have time for a few questions, and there are mics here in the aisle.
>> FS: All the aisles, I guess. This is always the awkward moment, when someone getting up
to run to the facilities is mistaken for a questioner. Hi, Jack.
>> MS: Good morning, Carolyn. In your slide on the three things we needed to worry about,
you talked about displacing -- what gets displaced. In your conversation, you talked about weaving
into practice. And I think weaving is a better metaphor for what we're trying to do. The
question is how do new things get integrated into what we're doing? We have a clear need
to slough off a lot of things that aren't producing value in care. But that doesn't
mean we'll get new things in. So where do you see the research enterprise going to deal
with the very practical organizational issues of integration of new ideas into current practice?
>> FS: So I see a couple of key points for the research enterprise. One is we need more
studies like the one done by Beth McLin, who's here today, where she tested her quality measures
in the VA healthcare system. And actually had the opportunity to examine how they did
when using these metrics, as well as how they did using different measures that are sort
of spiritually aligned, but a little bit different. And she was actually able to show that, you
know, there wasn't -- there didn't appear to be -- I'm grossly oversimplifying, so find
her at the break -- there didn't appear to be a whole lot of this teaching to the test
going on. In other words, we did well here because that's what we're being tested on.
I think the challenge actually in question needs to be framed to this field; right. How
is it that we prepare people and provide and sufficient resources and encouragement for
multidisciplinary teams? We all know this is a team sport. That aren't about multiple
disciplines of scientists only, but also have organizational leaders there. Because right
now we've got a lot of healthcare systems where truth be told, the people actually at
the very top level don't understand data at all. This is not how they were brought up
or raised and have made their careers. And suddenly they've got to demonstrate that they
thrive and do well in a world where we're asking for -- I mean, we, the policy enterprise
-- asking for it all the time. So to the extent that -- this is where I was trying to get
to with bilingual champions -- how do you bring people onboard who can help carry the
water and understand that it's actually important to test what we're doing, rather than just
saying I've got a great idea, go do it.
>> Q: Okay. One more.
>> FS: Oh, great.
>> Q: Is this mic on?
>> FS: Yes.
>> Q: Okay. Hi, Lawton Cooper, NHLBI. That was very encouraging, thank you very much
for [unint.] those of us at NIH, including NHLBI, who are trying to -- you know, despite
the tough budgetary times, to -- to move more -- you know, to encourage more researchers
out there to submit grants in implementation science to NIH. But I think what we need help
with, perhaps from AHRQ, is defining -- so that we're not accused, as I was recently,
of -- well, I don't want to say -- accuse is the wrong word -- but warned about mission
creep. How to define what is -- what is uniquely NIH about -- what kind of research would be
specifically NIH type research in this area?
>> FS: Well, I would expect, off the top of my head, because I think that this would be
the basis for some very fruitful ongoing discussions and collaborations, and, frankly, I would
love to hear from people at this conference about that as well. Because if there's one
thing the current environment makes us very attentive to, is that we don't want -- we
want to be investing resources as wisely as possible because there's likely to be fewer
of them. In general, I would think it very important that NHLBI, for example, is focusing
on disseminating their work. I would probably expect that there would be -- and making sure
that it's used in practice and so forth -- I would expect that they'd probably be less
attentive to, say, problems in diabetes care, unless there was a very clear line between,
you know, diabetes as a risk factor for heart disease and so forth. The opportunity, I think,
that we have not fully taken advantage of, which is why we're so pleased to be here,
is before you launch a new initiative, shouldn't we be thinking together. And the same goes
for AHRQ, about how our efforts -- you know, how there can be synergy between standing
investments and so forth.
So I'll just leave it at that. I think what's almost sinking this healthcare system is,
you know, well intentions. Initiative overload. Like the announcements in the supermarket
and so on and so forth, we've got a passion, bingo, it's out there. We want to prevent
diabetes, that's out there. We want to do this, and after a while it's sort of like,
whoa, I'm totally, totally lost. What does this have to do with my day job? And I think
that question is where we could really come together and collaborate very effectively.
Thank you.
>> FS: Okay. Time for the first set of concurrent sessions. I think most of the rooms are downstairs,
but if you need help finding -- there are some people at the registration desk. And
we'll meet back here after the break.