Slide Presentation from the AHRQ 2008 Annual Conference
On September 10, 2008, David Lanier and Cynthia Palmer, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (3.3 MB; Plugin Software Help).
Practice Based Research Networks (PBRNs) and ACTION: Accelerating the Implementation of Evidence-Based Healthcare
- David Lanier, MD
Center for Primary Care, Prevention, and Clinical Partnerships (CP3)
Cynthia Palmer, MSc
Center for Delivery, Organization and Markets (CDOM)
Agency for Healthcare Research and Quality (AHRQ) Mission
- To improve the quality, safety, efficiency and effectiveness of healthcare for all Americans.
Increased emphasis on implementing evidence-based healthcare
- Flow chart illustrates this sequence:
- Scientific Evidence.
- Understandable and Usable Information.
- Facilitate Informed Health Care Decisions by:
- And back to Scientific Evidence.
- Passive diffusion/implementation of evidence takes too long.
- Lengthy time requirements of funding through traditional grant mechanisms.
- Historical delays in passage of annual Congressional appropriations.
- Traditional (AHC) research settings not ideally suited for implementation/translational work.
Ecology of Medical Care Updated
- Image depicts a series of boxes representing data. Each box represents a subgroup of the largest box, which comprises 1,000 persons of all ages. It is based on findings in The Ecology of Medical Care by Green, Yawn, and Lanier, published in issue 344 of the New England Journal of Medicine in 2001, which analyzes the place of care from a community perspective.
- Total population at risk (including children): 1,000.
- Persons reporting one or more health-related symptoms: 800.
- Persons who consider seeking health care: 327.
- Persons who visit a physician's office: 217.
- Persons who visit a complementary and alternative medicine (CAM) provider: 65.
- Persons who visit a hospital outpatient clinic: 21.
- Persons who receive home health care: 17.
- Persons who visit an emergency department: 13.
- Persons who are in a hospital: 8.
- Persons who are in an academic health center: fewer than 1.
New Funding Mechanism Required
- Easy access to healthcare sites where most Americans receive care.
- Targeted activities related to implementation of research evidence into practice.
- Shorten the cycle of soliciting and funding projects.
- Include funding for dissemination and spread of project findings.
Master Task Order Contracts
- Identify/define groups eligible to carry out rapid turn-around task orders.
- Award master contracts through open competition.
- Awardees are pre-qualified to compete for specific task order work.
- Each master contractor assured of being awarded at least one task order over life of contract.
- Master contractor reports interests/strengths of network.
- AHRQ defines the work to be done and the timeframe for completion (Request For Task Order [RFTO]).
- Funding (ranging from $150,000 to >$2 million) from AHRQ and/or our Federal (e.g., Centers for Disease Control and Prevention [CDC]) or private (e.g. Robert Wood Johnson Foundation [RWJF]) partners.
- Master contractors usually have <6 weeks to respond to RFTO.
- Responses peer-reviewed and award(s) made within 3-6 weeks.
- Typical task order completed within 6-30 months.
Two Master Contractor Programs Established
- Practice-Based Research Networks (PBRNs): networks composed of smaller (1-20 clinician) community-based primary care practices.
- Accelerating Change and Transformation in Organizations and Networks (ACTION): composed of hospital systems, health plans, long-term care, other care-delivery systems.
- Groups of ambulatory practices devoted principally to the primary care of patients, affiliated with each other and academic researchers in order to investigate questions related to community-based practice and to improve the quality of primary care.
Primary Care PBRNs
- Real-world primary care practices.
- Clinicians include all primary care specialties (family medicine, general internal medicine, pediatrics, family nurse practitioners).
- Work with academic researchers to answer questions related to primary care practice or the delivery of primary care services.
- Laboratories for effectiveness studies in office settings with competing demands for high quality care and greater efficiency/productivity.
- Depend upon outside funding (grants, contracts) to support their work.
- 28 PBRNs identified in 1994.
- 177 PBRNs identified in 2005.
- Headquartered in urban, suburban and rural areas.
- 2,724 practices are affiliated with PBRNs located in all 50 states and Puerto Rico.
- 16 million patients are affiliated with PBRNs.
- Average of 198,112 patients per PBRN (range 1200 to 2.7 million).
- Map of the United States of America shows the geographic distribution of PBRN and Practice locations among the states. Each blue dot represents one PBRN and each red dot represents one practice affiliated with a PBRN. There are 2,209 total practices. A full list of the PBRNs can be found at http://pbrn.ahrq.gov.
Why Is Primary Care Important to AHRQ?
- Majority of daily patient/clinician interactions occur in ambulatory settings.
- Majority of prescriptions for medications written in ambulatory settings.
- While growth of HMOs and large integrated healthcare systems has been dramatic, >50% of Americans still receive primary care services in smaller (3 10 clinician) practices.
- Significant amount of care in these settings flies under radar of most national quality monitoring efforts.
Consortia of Networks
- North Carolina Network Consortium (NCNC): University of North Carolina (UNC), Duke, Adolescent Research, Mecklenburg, Robeson County.
- PRIME Net: RIOSNet, CaReNet, SERCN, SPUR—Net, CRN.
- SNOCAP: High Plains, CaReNet, BIGHORN, American Academy of Family Physicians National Research Network (AAFP-NRN).
- ePCRN Consortium: MAFPRN, AAFP-NRN, Alabama, LA Net, OKPRN, Penn State, STARNet, South Florida, Buffalo.
- ACORN (Virginia Commonwealth).
- Irene (Iowa).
- OKPRN (Oklahoma).
- ORPRN (Oregon).
- PeRC (Children's, Philadelphia).
- PPRNet (Univ South Carolina).
PBRN Task Order Contractors: Practices
- Pie chart depicts the settings of the 2,209 practices participating in networks:
- 34.6% of the practices are in urban settings.
- 34.4% of the practices are in rural settings.
- 31% of the practices are in suburban settings.
PBRN Task Order Contractors: Age Range of Patients
- Slide depicts a box comparing two pie charts:
- The first pie chart breaks down the 11,877,396 patients that are cared for by the PBRN, by age group.
- 30% are young adults.
- 28% are older adults.
- 22% are children.
- 20% are elderly.
- The second pie chart breaks down the 281,421,906 people living in the United States as determined by the 2000 census, by age group.
- 36.9% are young adults.
- 28.6% are children.
- 22% are older adults.
- 12.4% are elderly.
PBRN Task Order Contractors: Patient Race/Ethnicity
- Slide depicts a box comparing two pie charts:
- The first pie chart breaks down the 11,877,396 patients that are cared for by the PBRN, by race/ethnicity.
- 65% are Caucasian.
- 16% are Hispanic.
- 15% are African American.
- 4% are Native American.
- 1% are categorized as other.
- The second pie chart breaks down the 281,421,906 people living in the United States as determined by the 2000 census, by race/ethnicity.
- 72% are Caucasian.
- 12.5% are Hispanic.
- 12.3% are African American.
- .0.9% are Native American.
- 3.6% are categorized as other.
PBRN Task Order Contractors: Physician Provider Discipline
- Slide compares two pie charts:
- Disciplines of physicians enrolled in primary care PBRNs.
- 80% family practice.
- 9% general internal medicine.
- 7% pediatricians.
- 3% other.
- Disciplines of primary care physicians included in the AMA Masterfile.
- 43% family practice.
- 36.7% general internal medicine.
- 20.1% pediatricians.
- Family physicians make up a much larger percentage of PBRN physicians versus all primary care physicians (80% versus 43%). A lower percentage of general internal medicine physicians (9% versus 36.7%) and pediatricians (7% versus 20.1%) are represented in PBRNs compared to all primary care physicians in the U.S.
PBRN Task Orders To Date
- First award made in July, 2007.
- Twelve RFTOs released/funded to date.
- Funding $4.7 million.
- One project completed (12 month task order).
PBRN Task Order Projects
- Integrating evidence-based clinical and community services.
- Preparing primary care to respond to a pan-flu public health threat.
- Assessing the costs to primary care of collecting and reporting quality-related data.
- Assessing barriers to quality measurement and reporting in primary care.
- Clinical impact of nurse-based care management.
- Development of a health literacy universal precautions toolkit.
PBRN Task Order Projects
- Primary care management of sleep apnea.
- Pediatric asthma hospitalizations and the quality of primary care.
- Implementation and evaluation of electronic standing orders.
- Primary care participation in health information exchanges.
- Establishing benchmarks for the medical office survey on patient safety.
- Management in primary care of patients suspected of having CA-MRSA infections.
ACTION = Accelerating Change and Transformation in Organizations and Networks
- 5-year model of field-based research.
- 15 large partnerships.
- Partnerships include over 150 collaborating organizations.
- Partners located in all States.
Through ACTION, Partnering to Promote Knowledge Transfer and Exchange
- Slide depicts two overlapping circles, one representing researchers, the other decisionmakers, indicating how information, tools and publications are actively generated at the interface of these two groups.
- Be responsive to user, stakeholder and operational needs for innovation in health care delivery.
- Accelerate the development, implementation, dissemination and uptake of evidence-based products, strategies and findings into practice.
- Prioritize generalizable approaches to enable spread to other settings.
Current ACTION Partners?
- Health Services Research Organizations:
- Abt Associates, Inc., Cambridge, MA.
- American Institutes for Research, Silver Spring, MD.
- RAND Corporation, Santa Monica, CA.
- RTI International, Research Triangle Park, NC.
- The CNA Corporation, Alexandria, VA.
- Academic Institutions:
- Boston University School of Public Health, Boston, MA.
- Indiana University, Indianapolis, IN.
- University of California San Francisco (UCSF) School of Medicine, San Francisco, CA.
- University of Iowa Center for Health Policy and Research, Iowa City, IA.
- Weill Medical College of Cornell University, New York, NY.
- Yale New Haven Health Services Corporation, New Haven, CT.
- Other Health Care Organizations:
- American Association of Homes and Services for the Aging, Washington, DC.
- Aurora Health Care, Milwaukee, WI.
- Denver Health, Denver, CO.
- Health Research and Educational Trust, Chicago, IL.
Future ACTION Partners?
- Anticipate an open recompetion of ACTION by 2010.
ACTION Partnerships Include...
- Hospital systems.
- Ambulatory care practices.
- Long-term care systems (nursing homes, home health, assisted living).
- Safety net systems.
- Health plans.
- University schools of medicine, nursing, public health, health policy, and management.
- Health services and outcomes research organizations.
- Veterans Integrated Delivery System Networks.
- Quality Improvement Organizations (QIOs)
- Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), National Committee for Quality Assurance (NCQA), and other national organizations for healthcare quality assurance.
- Associations of healthcare providers.
- Consumer advocacy organizations.
- Because We Need To...
- Quit describing problems, start solving them.
- Partner to promote knowledge transfer and exchange.
- Speed up getting project results.
- Encourage uptake of innovation to improve health care delivery.
How Does Contract Process Work?
- Project concepts welcomed from all sources, any time.
- Topics must be critical to AHRQ, health systems, sponsors.
- Solicit proposals from closed pool of ACTION partnerships throughout the year.
- ACTION partnerships submit proposals within 4 6 weeks.
- Proposal review by small ad hoc committee of experts.
- ˜2-4 months from solicitation to award.
How Does Funding Work?
- 2006 2008: 58 awards totaling $30.2 million.
- 78% competitive awards.
- 22% sole source (most externally funded).
- Average award = $520 K (range: $120K to $3 million).
- Average duration = 23 months (range: 9 to 36 months).
Amounts Awarded by Topic
- Patient Safety—$12.2.
- Public Health Preparedness—$4.5.
- Healthcare Information Technology—$3.8.
- Long-term Care—$1.2.
External Sponsorship, 2006-2008
- 13 fully sponsored projects:
- RWJF (1)
- CDC (6)
- Health Resources and Services Administration (HRSA) (2)
- Assistant Secretary for Preparedness and Response (ASPR) (4)
- 3 co-sponsored projects:
- Department of Defense (DoD)
of the National Coordinator for Health Information Technology (ONC)
- Centers for Medicare and Medicaid Services (CMS)
Main Strategic Advantages
- Extensive depth and breadth of care settings, data and implementation capacity.
- Huge diversity (geographic, demographic, payer) among >100 million recipients of care.
- Speed—average project duration of 23 months.
- Focus on knowledge transfer and exchange.
How Do We Encourage Knowledge Transfer and Exchange?
- Examples of project deliverables:
- Workshops, Webcasts, training programs, technical assistance in care delivery settings.
- DVDs, "how to" guides, workbooks.
- Presentations to healthcare operational leadership.
- Live/Web-assisted conferences.
- Tested scalable, scenario-appropriate models.
- Publications in peer-reviewed and trade journals.
- Ready access to Steering Committee members' organizations (e.g., American Hospital Association [AHA], Medical Group Management Association [MGMA], National
Business Group on Health [NBGH], RWJF) for rapid dissemination (member Webcasts, listserves, annual meetings, journals).
PBRN Task Order Example #1: Pandemic Flu Management in Primary Care
- How to manage patient surges during pandemic flu?
- Health Information Technology (Health IT)-assisted systems to facilitate patient self-management.
- Development of enhanced interactive phone systems.
- Interactive Web site with patient education materials.
- University of Oklahoma (OKPRN).
- 12 month project.
PBRN Example #2: Measuring costs to primary care practices of collecting/reporting quality data
- Policy issue: What is the cost to a primary care practice of collecting/reporting quality-related data? Who should bear the financial burden?
- Task Order Awards: One Task Order to North Carolina (NCNC) to measure costs of collecting/reporting global quality measures; Second Task Order to University of Colorado (SNOCAP) to measure costs of collecting/reporting diabetes-specific measures.
- Results anticipated: November, 2008 (14 month projects).
PBRN Example #3: Management of Suspected CA MRSA
- Congressional appropriation to AHRQ in December, 2007.
- CDC has established evidence-informed principles for ambulatory management; but feasibility/actual outcomes unknown.
- Three task orders awarded August, 2008.
ACTION Is 2 ½ Years Old...
- Some early task orders are completed and others have interim results.
- How are we doing?
Example 1: 60% Methicillin-resistant Staphylococcus Aureus (MRSA) Infection Reduction in Indianapolis Hospitals
- >126,000 MRSA infections per year in hospitals.
- >5,000 patients die as a result.
- Over $2.5 billion excess healthcare costs.
- Products and Results:
- Indiana University developed and implemented a novel approach to reduce MRSA in Intensive Care Units (ICUs) in hospital systems in Indianapolis.
- Improved surveillance, hand hygiene, contact isolation.
- Average 60% reduction in MRSA infections in intervention units; 20% reduction in control units.
- Other hospitals in the Indianapolis area and elsewhere eager to adopt this approach.
- Congress funding AHRQ to further enhance and spread successful approaches to reduce MRSA and other healthcare associated infections.
Example 2: National Spread of TeamSTEPPS™
- Poor communication and lack of teamwork among health care professionals contribute to errors in patient safety.
- Products and Results:
- AHRQ, DoD and American Institutes for Research built national training and support network for TeamSTEPPS™, an evidence-based teamwork system.
- TeamSTEPPS™ National Implementation program fully operational nationwide.
- 1200 Master Trainers/Change Agents being trained (including in ACTION partnerships).
- Other spread: e.g., all Maine hospitals using TeamSTEPPS™.
Example 3: $10 Million in Reduced Waste at Denver Health Hospital
- Estimates of overuse, underuse, and misuse of resources range from 30% (Midwest Business Group on Health) to 50% (Intermountain Health Care) of all healthcare expenses in the U.S.
- Products and Results:
- Denver Health trained all hospital middle managers in waste reduction using Lean.
- Better organized respiratory therapy equipment led to 40% reduction in time spent searching (estimated $9,220/year saved).
- Disposal of 75 dumpsters of old files, equipment, supplies, hazardous materials led to ˜ $300,000 in capital improvement and improved safety.
- Switch from paper to electronic forms led to cost savings of $7,500/year.
Example 4: Improved Health Care Planning in Disasters
- Lack of planning for emergencies.
- Example: Hurricane Katrina.
- Products and Results (3 of many examples):
- Alternate Site Locator to help State and local officials quickly locate appropriate alternate health care sites if existing ones are overwhelmed.
- Emergency Preparedness Resource Inventory to help local/regional planners inventory equipment, personnel, and supplies in advance.
- Staffing for Disaster Preparedness Response Model to improve antibiotic dispensing and vaccination campaigns for disease outbreaks.
Current as of January 2009
PBRNs and ACTION: Accelerating the Implementation of Evidence-Based Healthcare. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/091008slides/LanierPalmer.htm