Arlene S. Bierman, M.D., M.S. Director, Center for Evidence and - - PowerPoint PPT Presentation

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:

www.ahrq.gov zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA

To produce evidence to make health care safer, higher quality, more accessible, equitable and affordable To work with HHS and

• ther partners to make

sure that the evidence is understood and used

Evidence Generation and Implementation: SRs as the Keystone

Chuck Friedman, U. of Michigan, 2017

Hallmarks of a Learning Health Care System zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA

• 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 Resources Values

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AHRQ’s Evidence Reviews

• Identifies evidence need
• Provides ongoing input

Stakeholder- Driven

• EPC Methods Guide
• Peer review

Scientifically Rigorous

• Conflicts of interest evaluation
• Transparency and public comment

Independent and Unbiased

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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

• r 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

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Caution: Not all Systematic Reviews are Equal

Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-analyses (Ioannidis 2016) Figure summarizes bio-med meta- analyses produced in 2016

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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

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zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA Knowing when trials are needed (or not)

Cumulative Meta- Analyses of 60 Trials

• f 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

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Clinical Decision Support (2016-)

http://cds.ahrq.gov

Advancing evidence into practice through CDS and making CDS more shareable, standards-based, and publicly-available zyxwvutsrqponmlkjihgfedcbaWUTSRQPONMLJIHGFEDCBA

Four components:

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1. 2. 3. 4. Engaging a stakeholder community Creating prototype infrastructure for sharing CDS and developing CDS Advancing CDS through demonstration and dissemination research Evaluating the overall initiative

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,

• pen source code

► Piloted in Epic but based on standards (e.g., HL7

FHIR) that can be used by other EHRs

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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

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Pain Management Summary – Content

Pertinent Medical History

► Conditions associated with chronic pain ► Risk factors for opioid-related harms

Pain Assessments

► Wong-Baker FACES Rating Scale ► PEG & STarT Back Screening Tools**

Historical treatments

► Opioid medications ► Non-opioid medications ► Non-pharmacologic treatments ► Stool softeners and laxatives

Risk Considerations

► MME amount** ► Urine drug screen results ► Benzodiazepine medications ► Naloxone medications ► Risk screenings relevant to pain

management**

Objectives:

• Display relevant data to inform pain

management decisions

• Include concepts outlined in the CDC

guideline

• Provide contextual notifications via flags
• Facilitate shared decision making
• Ease clinician cognitive burden by

unifying in one view data that are normally scattered on multiple screens Be aware:

• The Summary does not display or provide

notifications for all of the CDC recommendations

• The summary does not make treatment

recommendations

• Clinicians are encouraged to use their

medical knowledge and awareness of evidence-based guidelines to make the 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

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Your Questions