Arlene S. Bierman, M.D., M.S. Director, Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality PCORI Annual Meeting November 1, 2018 Washington, DC
Agency for Health Care Research and Quality (AHRQ) Mission: To produce evidence to make health care safer, higher quality, more accessible, equitable and affordable zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA To work with HHS and other partners to make sure that the evidence is understood and used www.ahrq.gov
Evidence Generation and Implementation: SRs as the Keystone Chuck Friedman, U. of Michigan, 2017
zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Hallmarks of a Learning Health Care System Leaders committed to a culture of quality • improvement Evidence systematically gathered and applied • Clinicians receive new evidence via information • technology Clinicians cite evidence in shared • decisionmaking with patients Data on care analyzed, used to improve care • Outcomes consistently assessed, protocols • reevaluated in continuous feedback cycle for quality improvement
In Press : Montori et al JGIM 2018
AHRQ EPC Program Est. in 1997 • Support 12 academic/research organizations • Provide independent and unbiased synthesis of • evidence Partner with external organizations to promote • evidence-based decisions Evidence Values Resources 6
AHRQ’s Evidence Reviews Stakeholder- • Identifies evidence need Driven • Provides ongoing input Scientifically • EPC Methods Guide Rigorous • Peer review Independent Conflicts of interest evaluation • and Unbiased • Transparency and public comment 7
U.S. Preventive Services Task Force Is an independent panel of non-Federal experts in • prevention & evidence-based medicine Makes evidence-based recommendations about • clinical preventive services, including screening, counseling, and preventive medications ► Recommendations address only services offered in the primary care setting or services referred by a primary care clinician ► Recommendations apply to adults & children with no signs or symptoms (or unrecognized signs and symptoms)
USPSTF Recommendation Development Process Rigorous 4-stage recommendation development process: • ► Topic nomination ► Draft and final research plans ► Draft evidence review and recommendation statement ► Final evidence review and recommendation statement 4-week public comment period on all draft materials • The • Task Force works with AHRQ Evidence-based Practice Centers (EPCs) to develop research plans and review evidence Subject matter experts are consulted throughout the • recommendation development process Procedure Manual available under Methods and Processes at: • www.uspreventiveservicestaskforce.org
Federal Partnerships 10
Caution: Not all Systematic Reviews are Equal Mass Production of zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Redundant, Misleading, and Conflicted Systematic Reviews and Meta-analyses (Ioannidis 2016) Figure summarizes bio-med meta- analyses produced in 2016 11
zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Why Does Quality of Systematic Reviews Matter? Low quality Systematic Reviews can result in: • ► Biased interpretation due to conflicts of interest ► Incomplete picture due to non-systematic and skewed search (e.g. cherry picking studies to include in review) ► Inadequate assessment of data quality , evidence strength, or confidence in conclusions ► Inaccurate or misleading conclusions 12
zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Knowing when trials are needed (or not) Cumulative Meta- Analyses of 60 Trials of Intravenous Thrombolytic Agents for Myocardial Infarction by the MantelHaenszel Fixed-Effects Method and DerSimonian and Laird Random- Effects Method. Lau J et al. N Engl J Med 1992;327:248-254.
AHRQ PCOR Dissemination and Implementation Initiative: Overview
NEW FOA: Screening and Management of Unhealthy Alcohol Use in Primary Care Screening and Management of Unhealthy Alcohol Use in Primary Care: Dissemination and Implementation of PCOR Evidence (R18) Through this announcement, AHRQ seeks applications to disseminate patient-centered outcomes research (PCOR) findings directly to primary care practices and support practices in implementing PCOR clinical and organizational findings. Applicants must propose a comprehensive plan that uses evidence-based strategies designed to improve the delivery of patient-centered approaches to identifying and managing unhealthy alcohol use among adults (across the lifespan), including screening and brief intervention (SBI) and medication assisted therapy (MAT). https://www.ahrq.gov/news/grants-alcohol-use.html
zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Non-pharmacologic Treatment of Chronic Pain Purpose: To assess which noninvasive, nonpharmacological treatments for common chronic pain conditions improve function and pain for at least one month after treatment. Sponsoring partners: ASPE and CDC https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/nonpharma-chronic-pain-cer-209.pdf 16
zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Clinical Decision Support (2016-) http://cds.ahrq.gov Advancing evidence into practice through CDS and making CDS more shareable, standards-based, and publicly-available Four components: 1. Engaging a stakeholder community 2. Creating prototype infrastructure for sharing CDS and developing CDS 3. Advancing CDS through demonstration and dissemination research 4. Evaluating the overall initiative 19
Newly-released Opioid CDS New, interoperable clinical decision support • (CDS) to help clinicians help their patients with chronic pain ► Pain Management Summary or “dashboard” accessed as an app within the EHR ► Consolidates into a single view data normally scattered across multiple screens ► Includes technical files, implementation guidance, open source code ► Piloted in Epic but based on standards (e.g., HL7 FHIR) that can be used by other EHRs 20
zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Pain Management Summary - Highlights • Informed by 2016 CDC guideline • Consolidates patient-specific information normally found on different tabs and screens into a single view • Launched by clicking a link from the home screen within a patient record in the EHR • Uses SMART on FHIR health IT standard for interoperability • Piloted in a community health center 21
Pain Management Summary – zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Content Objectives : Pertinent Medical History • Display relevant data to inform pain ► Conditions associated with chronic pain management decisions ► Risk factors for opioid-related harms • Include concepts outlined in the CDC Pain Assessments guideline ► Wong-Baker FACES Rating Scale • Provide contextual notifications via flags ► PEG & STarT Back Screening Tools ** • Facilitate shared decision making Historical treatments • Ease clinician cognitive burden by ► Opioid medications unifying in one view data that are normally vtsronliedcaONLIC ► Non-opioid medications scattered on multiple screens ► Non-pharmacologic treatments Be aware: ► Stool softeners and laxatives • The Summary does not display or provide Risk Considerations notifications for all of the CDC ► MME amount** recommendations ► Urine drug screen results • The summary does not make treatment recommendations ► Benzodiazepine medications • Clinicians are encouraged to use their ► Naloxone medications medical knowledge and awareness of ► Risk screenings relevant to pain evidence-based guidelines to make the management** best decision for each patient ** involve LOINC code constraints 22
Achieving the Quadruple Aim
AHRQ EPC Program Find evidence reports: • ► https://www.effectivehealthcare.ahrq.gov Sign up for listserv: • ► https://effectivehealthcare.ahrq.gov/email-updates/ Get involved with ongoing topics: • ► Contact us – EPC@ahrq.hhs.gov 24
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