Transcript Where Comparative Effectiveness Research is Headed

Variation: How It Manifests,
What to Do About It
Carolyn M. Clancy, MD
Director
Agency for Healthcare Research and Quality
AHA Task Force on Variation in Health Care Spending Meeting
Washington, DC – November 10, 2009
Variation: How It Manifests,
What to Do About It
 A Major Public Policy Issue
 Variation in Care Delivery
and Spending
 Comparative Effectiveness
Research: Can It Help?
The Status Quo Is Not Acceptable
Not Just for Policy Wonks
 Up to 30 percent of health care
spending goes toward useless
treatments that we don’t need
 Overtreatment costs the U.S.
system $700 billion a year
 “Unnecessary treatment and
tests aren’t just expensive; they
also can harm patients.”
The Public Is Paying Attention!
 June 1 article became
required reading in the
White House
 McAllen, TX, is the
second most expensive
health care market in
the USA: why?
 Medicare spending half
of that of El Paso, TX,
despite similar
community profiles
Health Care Spending Per Capita
Source: Congressional
Research Service.
Washington, DC. Pub No.
RL34175
Based on 2003 data from
the Organisation for
Economic Co-operation
and Development (OECD)
Pharmaceutical Spending Per Capita
Source: Congressional
Research Service.
Washington, DC. Pub No.
RL34175
Based on OECD data 2006
Global Trends in
Health Expenditures
18
Australia
Health Exp as % of Total GDP
16
Canada
France
14
Germany
12
Italy
Japan
10
Korea
8
Mexico
Poland
6
Spain
4
Sweden
Turkey
2
United Kingdom
United States
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2006
From: http://www.oecd.org/document/16/0,3343,en_2649_34631_2085200_1_1_1_1,00.html
Per Capita Medicare Spending:
Regional Variations
From:
Congressional
Budget Office.
Research on
Comparative
Effectiveness of
Medical
Treatments. 2008
How Do They Do That?
Multi-stakeholder effort examining high-performing regions
Lowest region in state (actual-expected)
 La Crosse, WI
 Portland, ME (one of only two HRRs in Maine)
 Asheville, NC
Actual cost < expected
 Temple, TX (second lowest after Lubbock)
 Everett, WA (second lowest after Spokane)
Four are problematic
 Richmond, VA (highest actual-expected in state)
 Sacramento, CA (actual > expected)
 Cedar Rapids, IA (actual > expected, but in a low-cost state)
 Tallahassee, FL (actual > expected)
Source: Calculations from HCUP data using Dartmouth Atlas regions
http://www.ihi.org/IHI/Programs/StrategicInitiatives/HowDoTheyDoThat.htm?TabId=0
Variation in Employer-Sponsored
Health Insurance
 Among the 116.1 million private
sector employees in the USA,
87.7 percent worked where
employer-sponsored health
insurance was offered in 2008
 For the 10 largest metro areas,
premiums for single coverage
ranged from $3,857 to $4,874 in
2008
 For the 10 largest metro areas,
premiums for family coverage
ranged from $11,454 to $13,835
in 2008
Crimmel BL. Offer Rates,
Take-Up Rates, Premiums,
and Employee
Contributions for
Employer- Sponsored
Health Insurance in the
Private Sector for the 10
Largest Metropolitan
Areas, 2008. MEPS
Statistical Brief #261,
September 2009
Variation in Family Premiums
Health Care Spending Per Capita
and Life Expectancy
Source: Congressional
Research Service.
Washington, DC. Pub
No. RL34175.
Based on OECD data
2006
Higher Prices
Don’t Always Mean Better Care
Medicare Spending Per Beneficiary, 2006 (according to the Dartmouth Atlas of Health Care)
$10,000
$9,000
$8,000
$7,000
$6,000
$5,000
25
30
35
40
45
50
55
60
65
70
75
Overall Quality of Health Care, 2008 (measures compiled by the federal Agency for Healthcare Research and Quality
Lower
Average
Higher
New York Times, September 8, 2009
AHRQ’s National Reports on
Quality and Disparities
 The median annual rate of
change for all quality
measures was 1.4%
– Of 190 measures, 132 (69%)
showed some improvement
 Some reductions in
disparities of care
according to race, ethnicity,
and income
– Inequities persist in health
care quality and access
The Outcomes Movement
 Geographic variation in practice patterns
– Poor relationship between costs and outcomes
– Need to establish best practices
 Cost containment
– Recognition of limited resources
 System management
– Improved management, accountability
A. Epstein, NEJM 1990
Comparative Effectiveness
and the Recovery Act
 The American Recovery and
Reinvestment Act of 2009 includes
$1.1 billion for comparative
effectiveness research:
– AHRQ: $300 million
– NIH: $400 million (appropriated to
AHRQ and transferred to NIH)
– Office of the Secretary: $400 million
(allocated at the Secretary’s discretion)
Federal Coordinating Council appointed to coordinate comparative
effectiveness research across the federal government
AHRQ’s Priority Conditions for
the Effective Health Care Program
 Arthritis and non




traumatic joint disorders
Cancer
Cardiovascular disease,
including stroke and
hypertension
Dementia, including
Alzheimer Disease
Depression and other
mental health disorders
Developmental delays,
attention-deficit
hyperactivity disorder
and autism
 Diabetes Mellitus
 Functional limitations






and disability
Infectious diseases
including HIV/AIDS
Obesity
Peptic ulcer disease
and dyspepsia
Pregnancy including
pre-term birth
Pulmonary
disease/Asthma
Substance abuse
IOM’s 100 Priority Topics
 Topics in 4 quartiles; groups of 25.
 First quartile is highest priority. Included in first
quartile:
– Compare the effectiveness of screening,
prophylaxis and treatment interventions for
eradicating MRSA
– Compare the effectiveness of strategies for
reducing HAIs
– Compare the effectiveness of genetic and
biomarker testing and usual care in preventing
and treating clinical conditions for which
biomarkers exist
Initial National Priorities for Comparative Effectiveness
Research http://www.iom.edu
Office of the Secretary’s Spend Plan
for Recovery Act CER Funding
 Designed to complement AHRQ and NIH activities
– Data Infrastructure: Identify unique high-level
opportunities to build the foundation for sustainable
CER infrastructure to fundamentally change the
landscape
– Dissemination, Translation and Implementation:
Innovative strategies that go beyond evidence
generation and lead to improved health outcomes
– Priority Populations and Interventions:
Coordination of efforts across multiple activities to
include subgroups that traditionally have been
under-represented in research activity
Specific Investments (Examples)
 Data Infrastructure
– Enhance Availability and Use of Medicare Data to Support
Comparative Effectiveness Research
– Distributed Data Research Networks, Including Linking Data
 Dissemination and Translation
– Dissemination of CER to Physicians, Providers, Patients and
Consumers Through Multiple Vehicles
– Accelerating Dissemination and Adoption of CER by Delivery
Systems
 Research
– Optimizing the Impact of Comparative Effectiveness Research
Findings through Behavioral Economic RCT Experiments
– Comparative Effectiveness Research on Delivery Systems
AHRQ Spend Plan for Recovery
Act’s CER Funding
 Stakeholder Input and Involvement: To occur




throughout the program
Horizon Scanning: Identifying promising
interventions
Evidence Synthesis: Review of current research
Evidence Generation: New research with a
focus on under-represented populations
Research Training and Career Development:
Support for training, research and careers
The Right Treatment for the Right Patient at the Right Time
Translating the Science into
Real-World Applications
 Examples of Recovery Act Evidence Generation
projects:
– Clinical and Health Outcomes Initiative in Comparative
Effectiveness (CHOICE): First coordinated national effort
to establish a series of pragmatic clinical comparative
effectiveness studies ($100M)
– Request for Registries: Up to five awards for the creation
or enhancement of national patient registries, with a
primary focus on the 14 priority conditions ($48M)
– DEcIDE Consortium Support: Expansion of multi-center
research system and funding for distributed data network
models that use clinically rich data from electronic health
records ($24M)
Additional Proposed Investments
 Supporting AHRQ’s long-term commitment to
bridging the gap between research and practice:
– Dissemination and Translation
 Between 20 and 25 two-three-year grants ($29.5M)
 Eisenberg Center modifications (3 years, $5M)
– Citizen Forum on Effective Health Care
 Formally engages stakeholders in the entire Effective
Health Care enterprise
 A Workgroup on Comparative Effectiveness will be
convened to provide formal advice and guidance ($10M)
Opportunities for Hospitals
CER can:
 Provide evidence to inform
choices of drugs, devices
 Enhance potential for
understanding how research
can benefit diverse populations
and engage communities
 Help develop infrastructure,
training, registries, and nongovernment investment for
future research
Thank You
www.ahrq.gov
www.hhs.gov/recovery