Methods for Quality Improvement Research: AHRQ Introduction Denise Dougherty, Ph.D. Office of Extramural Research, Education, and Priority Populations June 2004

AHRQ’s Mission Statement To improve the quality and safety, efficiency and effectiveness, of health care for all Americans To improve the quality and safety, efficiency and effectiveness, of health care for all Americans

Selected Quality Challenges in U.S. Health Care Cancer – rate of women diagnosed at advanced stages has not declined over last several years, while other cancer rates have Cancer – rate of women diagnosed at advanced stages has not declined over last several years, while other cancer rates have Diabetes – Diabetes – – 1/5 of patients got all 5 recommended tests in 2000 – No eye or foot exam for 1/3 of patients Heart disease – Heart disease – – Only 25% of people with high blood pressure have it under control – < 50% of acute heart attack patients are advised to quit smoking in the hospital – 69% of heart attack patients get beta blockers on admission

Quality Challenges (2) HIV-AIDS – AIDS incidence increased in ’02 HIV-AIDS – AIDS incidence increased in ’02 Mental health – 80% of adult patients diagnosed with depression do not have optimal levels of contact with a health care provider Mental health – 80% of adult patients diagnosed with depression do not have optimal levels of contact with a health care provider Respiratory disease – black children are nearly twice as likely to be admitted to a hospital for asthma as white children Respiratory disease – black children are nearly twice as likely to be admitted to a hospital for asthma as white children Children are nearly twice as likely as adults to get an antibiotic for a common cold Children are nearly twice as likely as adults to get an antibiotic for a common cold Patient safety – HP2010 targets for hospital-acquired infections are not being met Patient safety – HP2010 targets for hospital-acquired infections are not being met Source: National Healthcare Quality Report, 2003.

4 Interacting Levels for Changing the System Public Policy Public Policy Health systems and plans Health systems and plans Clinical microsystems Clinical microsystems Patient Patient Sources: Berwick; Shortell

AHRQ funding announcements Improvement/Implementation research REACHES (forthcoming) REACHES (forthcoming) THQIT RFAs (2004) THQIT RFAs (2004) PBRNS and TRIP PA (2004) PBRNS and TRIP PA (2004) TRIP 2 RFAs and 2 PAs TRIP 2 RFAs and 2 PAs Innovations in Organization and Financing to Improve Cost, Quality, Access PA Innovations in Organization and Financing to Improve Cost, Quality, Access PA Partnerships for Quality RFA (2002) Partnerships for Quality RFA (2002) Health Disparities Collaboratives Evaluation (RFA—Chin and Guadagnoli) Health Disparities Collaboratives Evaluation (RFA—Chin and Guadagnoli) Quality Improvement RFA (1998) Quality Improvement RFA (1998) Translational research in diabetes PA (jointly with NIH and CDC) Translational research in diabetes PA (jointly with NIH and CDC)

Other Agencies’ Improvement/Implementation Announcements (Selected) NIMH NIMH – STATE IMPLEMENTATION OF EVIDENCE-BASED PRACTICES (RFA 2002—NIMH AND SAMHSA) (RFA 2002—NIMH AND SAMHSA) – DISSEMINATION AND IMPLEMENTATION RESEARCH IN MENTAL HEALTH (PA 2001-NIMH) (PA 2001-NIMH) – EFFECTIVENESS, PRACTICE, AND IMPLEMENTATION IN CMHS’ CHILDREN’S SERVICE SITES (PA 2003 – NIMH) (PA 2003 – NIMH) – IMPLEMENTATION OF INTERVENTION STRATEGIES FOR CHILDREN WITH DISRUPTIVE BEHAVIORS (RFA 2000-NIMH) (RFA 2000-NIMH)

Other Selected (2) OTHER NIH: OTHER NIH: – COMMUNITY IMPLEMENTATION OF HIV PREVENTION INTERVENTIONS (RFA NIMH, NIDA, NINR) (RFA NIMH, NIDA, NINR) – INTERVENTIONS TO IMPROVE HYPERTENSION CONTROL RATES IN AFRICAN AMERICANS (RFA 2004—NHLBI) (RFA 2004—NHLBI)

NIH Implementation/Improvement Awards – NHLBI Guideline Implementation RCTs (Diette, Cloutier, Cabana, Crabtree) (Diette, Cloutier, Cabana, Crabtree) – Improving Use of ADHD guidelines (Bickman, NIMH grant) (Bickman, NIMH grant) – Quality Improvement School Mental Health Services (Kataoka-Endo, NIMH K award) (Kataoka-Endo, NIMH K award) – Quality improvement for Depression (Rubinstein, NIMH award) (Rubinstein, NIMH award)

NIH Awards (2) Pathways to overcoming disparities in depression Pathways to overcoming disparities in depression – (Wells, NIMH award) Improving Diabetes by Primary Care Translation (IMPACT) Improving Diabetes by Primary Care Translation (IMPACT) – (Peterson, DK project) Improving Palliative Care for Patients with Cancer Improving Palliative Care for Patients with Cancer – (Ahles, CA project)

Selected publications from AHRQ- supported QI/TRIP research Glasgow, R.E., Bull, S.S. (2001). "Making a difference with interactive technology: considerations in using and evaluating computerized aids for diabetes self-management education." Diabetes Spectrum, Vol. 14, pp Glasgow, R.E., Bull, S.S. (2001). "Making a difference with interactive technology: considerations in using and evaluating computerized aids for diabetes self-management education." Diabetes Spectrum, Vol. 14, pp Scribano, P.V., Lerer, T., Kennedy, D., Cloutier, M.M. (2001). "Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department." Academic Emergency Medicine, Vol. 8, pp Scribano, P.V., Lerer, T., Kennedy, D., Cloutier, M.M. (2001). "Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department." Academic Emergency Medicine, Vol. 8, pp Margolis P, et al., Practice based education to improve delivery systems for prevention in primary care: randomised trial. BMJ Feb 14;328(7436):388. Epub 2004 Feb 06. Margolis P, et al., Practice based education to improve delivery systems for prevention in primary care: randomised trial. BMJ Feb 14;328(7436):388. Epub 2004 Feb 06.

Selected publications (continued) Shafer MA, et al., Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls. JAMA Dec 11;288(22): Shafer MA, et al., Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls. JAMA Dec 11;288(22): Casebeer, et al., Designing tailored Web-based instruction to improve practicing physicians' preventive practices. J Med Internet Res Jul-Sep;5(3):e20. Casebeer, et al., Designing tailored Web-based instruction to improve practicing physicians' preventive practices. J Med Internet Res Jul-Sep;5(3):e20.

Upcoming PAs—What Will AHRQ Be Looking for? Interventions Interventions Reach and generalizability Reach and generalizability Beyond direct attempts in single settings to “change provider behavior” Beyond direct attempts in single settings to “change provider behavior” Sample questions: Sample questions: – Interventions that demonstrate the forces and processes that will support adoption of promising innovations and system changes and development of routines that sustain improvements? – Which interventions work best when they are bundled with other practices to create systemic change? Solid research designs Solid research designs – Difficult to do; we are working on it

Suggestions/Caveats Suggestion: work with colleagues who understand organizational behavior and systems Suggestion: work with colleagues who understand organizational behavior and systems Caveat: Appropriate single-setting research on limited innovative interventions may still be necessary and appropriate. Make the case! Caveat: Appropriate single-setting research on limited innovative interventions may still be necessary and appropriate. Make the case!

For more information about AHRQ funding Debbie Rothstein, Ph.D. Debbie Rothstein, Ph.D. – Senior Advisor, Extramural Research – Office of Extramural Research, Education, and Priority Populations (OEREP) – Francis Chesley, MD Francis Chesley, MD – Director, OEREP –