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AHRQ’s Effective Health Care Program: Integrating Comparative Effectiveness Research into Everyday Practice

Slide Presentation in Text Format

Tuesday, October 12, 2010
2 - 3:30 pm ET

Slide 1

• On the top of the slide are the logos for the Department of Health and Human Services and the Agency for Healthcare Research and Quality (AHRQ).

 

Slide 2

Questions

To submit a question:

• Press the “Ask a Question” button located at the bottom of the screen. 
• When you click on the button, a box will appear at the bottom of your screen requesting that you to enter your e-mail address and your question. 
• Once completed, press the “Send” button.

Slide 3

Agenda

• Introduction- Stephanie Chang, M.D. (Facilitator)
• Integrating Comparative Effectiveness Research into Practice- Carolyn M. Clancy, M.D.
• Q&A from Audience
• Patient-Centered Outcomes Research and the Effective Health Care Program- Jean Slutsky, P.A., M.S.P.H.
• Q&A from Audience
• Physician Implementation- Amir Qaseem, M.D., Ph.D., M.H.A., FACP- American College of Physicians
• Nurse Practitioner Implementation- Mary Jo Goolsby, Ed.D., M.S.N., ANP-C- American Association of Nurse Practitioners
• Patient Implementation- Nilay Shah, M.S., Ph.D. - Mayo Clinic
• Q&A from Audience

Slide 4

Questions

To submit a question:

• Press the “Ask a Question” button located at the bottom of the screen. 
• When you click on the button, a box will appear at the bottom of your screen requesting that you to enter your e-mail address and your question. 
• Once completed, press the “Send” button.

 

Slide 5

Integrating Comparative Effectiveness Research into Practice

Carolyn M. Clancy, M.D.
AHRQ Director

An image of Dr. Carolyn Clancy is on the left hand side of the slide.

Slide 6

AHRQ’s Mission

An image of many people and a map of the United States of America are shown in the middle of the slide with the words “Improve the quality, safety, efficiency and effectiveness of health care for allAmericans” on the top of the image.

Slide 7

AHRQ Portfolios

The slide has an image of a pie chart that is divided into five equal portions each with a title: Comparative Effectiveness Research, Value, Health IT, Patient Safety, and Innovations/Emerging Issues.

Slide 8

An image of a 60-year-old woman with osteoarthritis seeking guidance from a physician.

Slide 9

The slide contains an image of a man in his early 50s discussing his newly diagnosed prostate cancer with his physician.

Slide 10

Keeping the Patient at the Center

• Patients are more involved in their care.
• Each patient is different.
• Patients need reliable, relevant, and understandable information.

 

On the left side of the slide there is an image of a young woman with her physician.

Slide 11

Comparative Effectiveness Research

• Focuses on patient-centered outcomes

 

• Unbiased and practical, evidence-based information

• Compares drugs, devices, tests and surgeries, and approaches to health care
  • benefits and harms
  • what is known and what isn’t

 

• Descriptive, not prescriptive

On the bottom right side there are scales that contain the words “benefits” and “harms” on either side.

Slide 12

What can comparative effectiveness research do for you?

• Help make decisions more consistent, transparent and rational
• Clarify nature of disputes over practice and policy
• Help inform quality improvement efforts
• Help patients make decisions about their own care

 

Slide 13

An Unprecedented Investment in Comparative Effectiveness Research

• 2005-2009 - AHRQ received $129 million from Congress for comparative effectiveness research

 

• 2009 - The American Recovery and Reinvestment Act contained  $1.1 billion for comparative effectiveness research, including $300 million to AHRQ
  • Stakeholder Input and Involvement
  • Horizon Scanning
  • Evidence Synthesis
  • Evidence Gap Identification
  • Evidence Generation
  • Research Training and Career Development

The American Recovery and Reinvestment Act seal is on the right bottom corner of the slide.

Slide 14

Patient Protection and Affordable Care Act

• Section 6301:  Patient-Centered Outcomes Research
• Name change:  Comparative Effectiveness Research = Patient-Centered Outcomes Research
• Patient-Centered Outcomes Research Institute
  • Independent, nonprofit Institute with public- and private-sector funding
  • Sets priorities and coordinates with existing agencies that support patient-centered outcomes research
• Prohibits findings to be construed as mandates on practice guidelines or coverage decisions and contains patient safeguards

 

An image of a hospital is on the right side of the slide.

Slide 15

Improving Health Care is a Team Sport

An image of a baseball team in a huddle is shown in the middle of the slide.

Slide 16

Questions

To submit a question:

• Press the “Ask a Question” button located at the bottom of the screen. 
• When you click on the button, a box will appear at the bottom of your screen requesting that you to enter your e-mail address and your question. 
• Once completed, press the “Send” button.

Slide 17

Patient Centered Outcomes Research and the Effective Health Care Program

Jean Slutsky, P.A., M.S.P.H
Director, AHRQ’s Center for
Outcomes and Evidence

An image of Jean Slutksy is on the left side of the slide.

 

Slide 18

AHRQ’s Effective Health Care Program

• Created in 2005, authorized by Section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003

 

• To improve the quality, effectiveness, and efficiency of health care delivered through Medicare, Medicaid, and children’s programs by focusing on
  • What is known now
  • What research gaps are critical to fill
  • Clinical effectiveness

Slide 19

A Framework for Patient-Centered Outcomes Research

This framework outlines the step-by-step process for how the development and implementation of patient-centered outcomes research leads to improvement in health care. Once a topic is nominated, a horizon scan and synthesis of the evidence is completed, followed by evidence generation. Then the research is translated, disseminated and implemented.

Slide 20

Research Focus 14 Priority Conditions

• Arthritis and non-traumatic joint disorders
• Cancer
• Cardiovascular disease, including stroke and hypertension
• Dementia, including Alzheimer’s Disease
• Depression and other mental health disorders
• Developmental delays, ADHD and autism
• Diabetes mellitus
• Functional limitations and disability
• Infectious diseases, including HIV/AIDS
• Obesity
•  Peptic ulcer disease and dyspepsia
•  Pregnancy including preterm birth
•  Pulmonary disease/asthma
•  Substance abuse

 

Slide 21

Research Focus:
Priority Populations

• Low-income groups
• Minority groups
• Women
• Children
• The elderly
• Individuals with special health-care needs, such as those with disabilities, those who need chronic care or end-of-life care, or those who live in inner-city and rural areas

Slide 22

Effective Health Care Program Research

Since 2005…

• 25 Research Reviews
• 16 Research Reports
• 36 Methods Research Reports and Guidance documents
• 36 Consumer, Clinician Guides

and counting…

On the left side of the slide there are images research reports.

Slide 23

Effective Health Care Program Translation Products

The slide has multiple images of the different products that the Effective Health Care Program creates from the systematic review report.  These products include: CE Modules, Interactive Case Study, faculty slides, patient decision aid, policy maker summary, consumer guide, clinician guide, Web site, and executive summary.

Slide 24

Consumer Guides

• Paired with clinician guides to promote shared decision making
• Guides available in
  • Print
  • Online
  • Audio podcasts
  • Spanish translations

 

http://effectivehealthcare.ahrq.gov/

Images of various consumer guides and the Radio Podcast are present on the bottom and right side of the slide.

Slide 25

Get involved!

• Nominate topics online
• Comment via the Web on draft key questions and reports
• Share with colleagues and patients

 

www.effectivehealthcare.ahrq.gov

Slide 26

Spreading the Word

Get updates about the Effective Health Care Program and alerts when new reports or guides are available.
(An e-mail icon is present right next to the above bullet point.)

Share the reports, guides, or other tools with your colleagues and patients.
(An image of the many social networks to share the reports is next to the above bullet point.)

Add buttons or widgets to your Web site.
(An image of potential widgets that could be used on a Web site is placed next to the above bullet point).

Slide 27

Focus on the Findings

• Comparative Effectiveness of ACEIs or ARBs Added to Standard Medical Therapy for Treating Stable Ischemic Heart Disease
• Comparative Effectiveness and Safety of Oral Diabetes Medications for Adults with Type 2 Diabetes

 

Slide 28

Key Questions for Evidence Synthesis: ACEI and ARBs for Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function

• The comparative effectiveness of different combination treatments:
  • ACEI or ARB + Standard Therapy vs Standard Therapy Alone
  • ACEI + ARB + Standard Therapy vs ACEI + Standard Therapy
  • ACEI or ARB + Standard Therapy vs Standard Therapy Alone Close to a Revascularization Procedure

• The benefits and harms associated with each treatment modality.
• The differences in the benefits or harms between various subpopulations of patients.

 

Coleman CI, et al. AHRQ Comparative Effectiveness Review No. 18.  October 2009.

Slide 29

Results of Evidence Synthesis: ACEI and ARBs for Stable Ischemic Heart Disease and Preserved Left Ventricular Systolic Function.

• Adding an ACEI or an ARB can provide additional clinical benefits for some patients.
• Adding an ACEI may increase the risk of cough, syncope, or hyperkalemia.
• Adding an ARB may increase the risk of hyperkalemia.
• Adding an ACEI does not impact cardiovascular mortality in patients with end-stage renal disease and left ventricular hypertrophy.

Coleman CI, et al. AHRQ Comparative Effectiveness Review No. 18.  October 2009

Images of consumer guides and a clinician guide are shown on the right side of the slide.

Slide 30

Comparative Effectiveness Review: Oral Diabetes Medications for Adults With Type 2 Diabetes

• Major Finding:  Metformin, a blood glucose drug prescribed for type 2 diabetes, is less likely to cause weight gain and may be more likely than other treatments to decrease bad cholesterol
• First analysis to summarize evidence on the effectiveness and adverse events for all approved oral medications commonly used in the U.S. for type 2 diabetes

AHRQ Comparative Effectiveness Review No. 8, Comparative Effectiveness and Safety of Oral Diabetes Medications for Adults with Type 2 Diabetes, July 2007, Available at www.effectivehealthcare.ahrq.gov

On the right side of the slide there are images of the consumer and clinician guides on Comparing Oral Medications for Adults with Type 2 Diabetes.

Slide 31

In the Pipeline

• More than 100 topics
  • Evidence Synthesis
  • Future Research Needs
  • Original Research
  • Methods Research

 

An image of an industrial pipe is present on the right hand side.

Slide 32

How to Access Products

AHRQ Web site: www.effectivehealthcare.ahrq.gov        

• Full reports and summary guides for patients and clinicians
• Opportunities to nominate research topics or comment on research questions and draft reports
• Audio files
• Spanish translations for consumer guides
• CE Activities
• Faculty slides

 

AHRQ Publications Clearinghouse:  (800) 358-9295

Request FREE, printed summary guides.

Slide 33

How to Stay Informed

• EHC Program Web site:

                        www.effectivehealthcare.ahrq.gov

•  E-mail notices: http://www.effectivehealthcare.ahrq.gov/index.cfm/join-the-e-mail-list1/

 

• EHC Program newsletter, Comparative Effectiveness News

Slide 34

Questions

To submit a question:

• Press the “Ask a Question” button located at the bottom of the screen. 
• When you click on the button, a box will appear at the bottom of your screen requesting that you to enter your e-mail address and your question. 
• Once completed, press the “Send” button.

Slide 35

Agenda

• Introduction- Stephanie Chang, M.D. (Facilitator)
• Integrating Comparative Effectiveness Research into Practice- Carolyn M. Clancy, M.D.
• Q&A from Audience
• Patient-Centered Outcomes Research and the Effective Health Care Program- Jean Slutsky, P.A., M.S.P.H.
• Q&A from Audience
• Physician Implementation- Amir Qaseem, M.D., Ph.D., M.H.A., FACP- American College of Physicians
• Nurse Practitioner Implementation- Mary Jo Goolsby, Ed.D., M.S.N., ANP-C- American Association of Nurse Practitioners
• Patient Implementation- Nilay Shah, M.S., Ph.D. - Mayo Clinic
• Q&A from Audience

 

Slide 36

Physician Implementation: Clinical Practice Guidelines

Amir Qaseem, M.D., Ph.D., M.H.A., FACP
Director, Clinical Policy
American College of Physicians

Slide 37

Who We Are

• Largest medical specialty organization in the U.S.
• 130,000 members
  • Internists
  • Internal medicine sub-specialists
  • Residents/fellows training in internal
    medicine or its subspecialties
  • Medical students
• Headquarters in Philadelphia and an office in Washington, D.C.

 

ACP logo is shown at the right bottom corner of all of Dr. Qaseem’s slides.

Slide 38

History of ACP Clinical Guidelines

• Program was established in 1981
• Early ACP guidelines addressed diagnostic tests and technologies
• Screening, Dx, and Rx

Slide 39

ACP Clinical Policies

• Clinical Policies
  • Clinical Guidelines
  • Guidance Statements
  • High-Value Cost Conscious Care Advice
• Evidence Reviews
  • ACP sponsored
  • AHRQ’s Evidence-based Practice Centers (EPC)- Nation’s top medical schools, universities, or medical centers that conduct AHRQ’s research reviews.
  • Collaboration with other societies

 

Slide 40

ACP & AHRQ

• Working together since1999
• AHRQ Evidence-based Practice Centers (EPC) & Effective Health Care Program
• 66% of our guidelines based on EPC evidence reports

 

Slide 41

ACP’s Guidelines Coverage

• Top three most valued products
• Most common reason to visit ACP’s Web site
• 25 of the top 100 most read articles ever in the Annals of Internal Medicine
• Top most read article in Internal Medicine on Medscape
• All ACP Guidelines are regularly covered by print, TV, radio, and online stories

 

Slide 42

ACP Guidelines Coverage

This table describes ACP’s media coverage of their clinician guides by clinical topic.

Slide 43

AHRQ Reports

• Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis
• Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression
• Diagnosis and Treatment of Erectile Dysfunction
• Pharmacological Treatment of Dementia
• Use of Spirometry for Case Finding, Diagnosis, and Management of COPD

 

Slide 44

ACP Membership Feedback

• High quality guidelines
• Based on scientific evidence
• Helpful source of advice
• Not rigid or difficult to apply
• Not difficult to understand or use

 

Slide 45

Upcoming Guidelines based on EHC Program Research Reports

• Management of Patients with Chronic Kidney Disease
• Diagnosis and Management of Obstructive Sleep Apnea
• Diagnosis and Management of Urinary Incontinence
• CE & Safety of Oral Diabetes Medications
• Off-label use of Atypical Antipsychotics
• Treatments to Prevent Fractures in Patients with Osteoporosis

 

Slide 46

Nurse Practitioner Implementation: Continuing Education Programming

Mary Jo Goolsby, Ed.D., M.S.N., NP-C, FAANP
Director of Research and Education
American Academy of Nurse Practitioners

Slide 47

Background

• 2009 AANP promoted awareness of the Effective Health Care (EHC) Program resources
  • Goal to inform nurse practitioners  (NPs) of resources to integrate comparative effectiveness research findings into clinical practice
• Accredited CE identified as vehicle to enhance uptake of CER resources
• Introduced select Clinician Guides as CE modules
  • Summaries of research review findings comparing benefits/harms associated with treatment options
  • Relevant, practice-oriented

 

A seal of the American Academy of Nurse Practitioners is on the right upper corner of the slide and is present on all of Dr. Goolsby’s slides.

Slide 48

The NP Role

• NPs are licensed independent practitioners
• NP Scope of Practice includes:
  • Diagnosis and management of both acute and chronic conditions
  • Emphasis on health promotion and disease prevention
  • Services include, but not limited to:
    • ordering, conducting, supervising, and interpreting diagnostic studies
    • prescription of pharmacologic and non-pharmacologic therapies
      • Prescriptive authority in all 50 States/DC

 

Slide 49

NPs Growing Resource for Health Care Delivery

• Over 679 million annual visits to NPs in 2008

 

•  In 2004¹:
  •  10.8% of adults had seen an
• NP within the past year
  •  18.5% of seniors had seen an
• NP within the past year

¹ Ferrer (2007) Pursuing Equity: Contact with Primary Care and Specialist Clinicians by Demographics, Insurance, and Health Status.  Annals of Family Medicine.

² AANP (2010) National NP Database.

A graph is shown on the right side of the slide that shows NP Growth².  The chart shows that NPs have grown nationally from 1999 to 2010.

Slide 50

AANP CE Center History

• The mission of the American Academy of Nurse Practitioners includes promotion of excellence in NP practice, education, and research
• CE is consistently rated by members as most valuable AANP service
• AANP CE Center launched mid-2007
  • Approximately 16,000 registered users
  • Approximately 65 programs available
  • 6,500 program “accesses” in August 2010

 
Slide 51

Current Effective Health Program Care Clinician Guide CE Modules

• ACEIs or ARBs for Adults with Hypertension
• Premixed Insulin Analogues: A Comparison with Other Treatments for Type 2 Diabetes
• Fracture Prevention Treatment for Postmenopausal Women with Osteoporosis

 

Slide 52

Participation Rates

• ACEIs or ARBS
  • >1,700 accesses through August 2010
• Premixed Insulin Analogues
  • >600 accesses through August 2010
• Fracture Prevention Treatment
  • Newly launched

 

Slide 53

Evaluations & Comments

• Activities highly rated based on standard evaluations
  • Objectives achieved
  • Content relevant to practice
  • Related resources useful

 

Slide 54

Survey of Participants

• Recent brief online survey of 1,185 NPs who had completed at least one of the EHC Program post-tests
• 103 responses within one week:
  • Mainly family (57%) or adult (33%) NPs
  • 98% found discussions helpful in their clinical practice
  • 57% had reviewed related material (Full Report, Patient Guide)
  • 29% had used other material from the site

Slide 55

Comment Excerpts

• Great way to learn about issues. . . Enjoy all extra material I can access
• Specifically recalled the comparison of side effects cited in the ACEI vs ARB article. . . helpful to be reminded that the ACEI vs ARBs are similar in their RAAS/renal protective  mechanism
• Most simple and complete information is what I use day-to-day
• Good resource for evidence-based practice

Slide 56

Comment Excerpts

• Working in surgical practice. . . look for these types of resources for patient followup which most of time is directed towards primary care
• Satisfied with Effective Health Care Program resources as CE offering, plus the opportunity to use the Web site
• I was able to use this information in: lectures I prepared for the community, discussion with patients and colleagues, obtaining personal knowledge and resources

 

Slide 57

Summary Slide

• NPs are seeking evidence-based, practical resources
• Online CE successful approach to enhancing awareness of and clinical integration of Effective Health Care Program resources

 

Slide 58

Patient Implementation:
Decision Aids

Nilay Shah, M.S., Ph.D.
Division of Health Care Policy and Research and
Knowledge and Encounter Research (KER) Unit
Mayo Clinic

Slide 59

Disclosure

Relevant Financial Relationships
Funded by the American Diabetes Association & the Agency for Healthcare Research and Quality (AHRQ) (R18HS018339)

Off-Label Usage
None

Research Team: Victor Montori, Maggie Breslin, Barbara Yawn, Steven Smith, Jeanette Ziegenfuss, and numerous primary care clinicians

In upper right-hand corner there is a Mayo Clinic graphic of a physician and patient.

Slide 60

Comparative Effectiveness and Safety of Oral Diabetes Medications

• Glycemic control
• Blood pressure / Lipids
• All cause mortality
• Cardiovascular morbidity and mortality
• Microvascular outcomes
• Functional status and quality of life

 

Source:  Bolen et. al. July 2007.  Comparative effectiveness and safety of oral diabetes medications for adults with type 2 diabetes.  Available at: http://effectivehealthcare.ahrq.gov   

On the right side of the slide is an image of a systematic review.

Slide 61

This image points to how comparative effective research applies to coverage decisions and clinical encounters.

Slide 62

This slide points to how patients make decisions about their medications after a discussion with the clinician. It also points to how the decision aid can be used during the discussion, which should be based on research and patient values. 

Slide 63

The decision aid incorporates research evidence, practice review, advisory group, and live clinical setting.

Image of “baseball card” decision aids.

Slide 64

The decision aid incorporates research evidence, practice review, advisory group, and live clinical setting.

Image of the “narrative cards” decision aid.

Slide 65

The decision aid incorporates research evidence, practice review, advisory group, and live clinical setting.

Image of the all the decision aids.

Slide 66

Image of the “issue cards” decision aid.

Slide 67

Image of the decision aid.

Slide 68

Summary

• The use of decision aids in primary care practice was acceptable and efficient.

 

• Was the decision aid effective?
  • Patients found the tool helpful
  • Improved knowledge
  • Increased involvement
  • Not on decisional conflict
  • Not on the nature of choices made
  • Videos of the encounters tells a different story:
    • Greater patient participation
    • Different conversation -  patient-centered concerns
  • Not on adherence

Slide 69

Next steps

Diverse populations
Longitudinal followup (repeated use)

Another key consideration:  IMPLEMENTATION – Normalization Process Theory (NPT)

iADAPT RFA – Designing and testing a decision aid for Depression Medications (HS019214)

Slide 70

Challenges for Translation

• Patient-important outcomes
• Practice challenges
• “Costs”

 

Slide 71

RESULTS OF THE PILOT TRIAL ARE AVAILABLE IN: 
Mullan RJ, Montori VM, Shah ND, Christianson TJH, Bryant SC, Guyatt GH, Perestelo-Perez LI, Stroebel RJ, Yawn BP, Yapuncich V, Breslin MA, Pencille L, Smith SA.  The diabetes medication choice decision aid: a randomized trial.  Arch Int Med 2009 Sep;169:1560-1568.

A VERSION OF THE DIABETES CARDS IS AVAILABLE AT:
http://kercards.e-bm.info

Slide 72

Questions

• To submit a question:
  • Press the “Ask a Question” button located at the bottom of the screen. 
  • When you click on the button, a box will appear at the bottom of your screen requesting that you enter your e-mail address and your question. 
  • Once completed, press the “Send” button.

 

Slide 73

For more information about …

AHRQ’s Effective Health Care Program:
www.effectivehealthcare.ahrq.gov

 

Access FREE resources 
AHRQ’s Publications Clearinghouse:      
(800) 358-9295

Slide 74

Also…

• Sign up for e-mail notices: http://www.effectivehealthcare.ahrq.gov/index.cfm/join-the-e-mail-list1/

 

• More questions? E-mail us: EHC_Clinicians@ahrq.hhs.gov

 

Slide 75

Thank you

• Thank you for joining us today.
• Please take a moment to provide feedback at the end of this event.
• A recording and transcript for today’s event will be available at a later date at www.effectivehealthcare.ahrq.gov