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Where Comparative Effectiveness Research is Headed

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					     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




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      Crimmel BL. Offer Rates,
  ranged from $3,857 to $4,874 in   Take-Up Rates, Premiums,
  2008                              and Employee
                                    Contributions for
 For the 10 largest metro areas,   Employer- Sponsored
  premiums for family coverage      Health Insurance in the
  ranged from $11,454 to $13,835    Private Sector for the 10
  in 2008                           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-             Diabetes Mellitus
    traumatic joint disorders    Functional limitations
   Cancer                          and disability
   Cardiovascular disease,        Infectious diseases
    including stroke and            including HIV/AIDS
    hypertension                   Obesity
   Dementia, including            Peptic ulcer disease
    Alzheimer Disease               and dyspepsia
   Depression and other           Pregnancy including
    mental health disorders         pre-term birth
   Developmental delays,          Pulmonary
    attention-deficit               disease/Asthma
    hyperactivity disorder         Substance abuse
    and autism
               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 non-
   government investment for
   future research
     Thank You
    www.ahrq.gov

www.hhs.gov/recovery