PBRNs and ACTION:PBRNs and ACTION:Accelerating the ImplementationAccelerating the Implementationof Evidence-Based Healthcareof Evidence-Based Healthcare

David Lanier, MDDavid Lanier, MDCP3CP3

Cynthia Palmer, MScCynthia Palmer, MScCDOMCDOM

AHRQ MissionAHRQ Mission

To improve the quality, safety, efficiencyTo improve the quality, safety, efficiency

and effectiveness of healthcareand effectiveness of healthcare

for all Americansfor all Americans

Translation

Facilitate Informed Health Care Decisions by: Patients Providers Policymakers

Increased emphasis on implementing Increased emphasis on implementing evidence-based healthcareevidence-based healthcare

ScientificEvidence

Understandableand UsableInformation

ChallengesChallenges

Passive diffusion/implementation of evidence Passive diffusion/implementation of evidence takes too longtakes too long

Lengthy time requirements of funding through Lengthy time requirements of funding through traditional grant mechanismstraditional grant mechanisms

Historical delays in passage of annual Historical delays in passage of annual Congressional appropriationsCongressional appropriations

Traditional (AHC) research settings not ideally Traditional (AHC) research settings not ideally suited for implementation/translational worksuited for implementation/translational work

1000 Population at risk (including children)Population at risk (including children)

Ecology of Medical Care UpdatedEcology of Medical Care Updated Green, Yawn, Lanier. N Engl J Med 2001;344:2021-25Green, Yawn, Lanier. N Engl J Med 2001;344:2021-25

Report one or more health-related Report one or more health-related symptomssymptoms800

Consider seeking health careConsider seeking health care327

217 Visit a physician’s officeVisit a physician’s office

Visit a CAM providerVisit a CAM provider

65Visit a hospital outpatient clinic Visit a hospital outpatient clinic (21)(21)

Receive home health care Receive home health care (17)(17)

Visit an E.D. Visit an E.D. (13)(13)

Are in a hospital Are in a hospital (8)(8)

Are in an academic health center (<1) Are in an academic health center (<1)

New Funding Mechanism RequiredNew Funding Mechanism Required

Easy access to healthcare sites where most Easy access to healthcare sites where most Americans receive careAmericans receive care

Targeted activities related to implementation of Targeted activities related to implementation of research evidence into practiceresearch evidence into practice

Shorten the cycle of soliciting and funding projectsShorten the cycle of soliciting and funding projects Include funding for dissemination and spread of Include funding for dissemination and spread of

project findingsproject findings

Master Task Order ContractsMaster Task Order Contracts

Identify/define groups eligible to carry out Identify/define groups eligible to carry out rapid turn-around task ordersrapid turn-around task orders

Award master contracts through open Award master contracts through open competitioncompetition

Awardees are pre-qualified to compete for Awardees are pre-qualified to compete for specific task order workspecific task order work

Each master contractor assured of being Each master contractor assured of being awarded at least one task order over life of awarded at least one task order over life of contractcontract

Task OrdersTask Orders

Master contractor reports interests/strengths of Master contractor reports interests/strengths of networknetwork

AHRQ defines the work to be done and the AHRQ defines the work to be done and the timeframe for completion (RFTO)timeframe for completion (RFTO)

Funding (ranging from $150,000 to >$2 million) from Funding (ranging from $150,000 to >$2 million) from AHRQ and/or our Federal (e.g., CDC) or private AHRQ and/or our Federal (e.g., CDC) or private (e.g. RWJF) partners(e.g. RWJF) partners

Master contractors usually have <6 wks to respond Master contractors usually have <6 wks to respond to RFTOto RFTO

Responses peer-reviewed and award(s) made within Responses peer-reviewed and award(s) made within 3-6 wks3-6 wks

Typical task order completed within 6-30 mosTypical task order completed within 6-30 mos

Two Master Contractor Programs Two Master Contractor Programs EstablishedEstablished

Practice-Based Research Networks (PBRNs): Practice-Based Research Networks (PBRNs): networks composed of smaller (1-20 clinician) networks composed of smaller (1-20 clinician) community-based primary care practicescommunity-based primary care practices

Accelerating Change and Transformation in Accelerating Change and Transformation in Organizations and Networks (ACTION): Organizations and Networks (ACTION): composed of hospital systems, health plans, composed of hospital systems, health plans, long-term care, other care-delivery systemslong-term care, other care-delivery systems

PBRNsPBRNs

Groups of ambulatory practices devotedGroups of ambulatory practices devoted

principally to the primary care of patients,principally to the primary care of patients,

affiliated with each other and academicaffiliated with each other and academic

researchers in order to investigateresearchers in order to investigate

questions related to community-basedquestions related to community-based

practice and to improve the quality ofpractice and to improve the quality of

primary care.primary care.

Primary Care PBRNsPrimary Care PBRNs

Real-world primary care practicesReal-world primary care practices

Clinicians include all primary care specialties (family medicine, Clinicians include all primary care specialties (family medicine, general internal medicine, pediatrics, family nurse practitioners) general internal medicine, pediatrics, family nurse practitioners)

Work with academic researchers to answer questions related to Work with academic researchers to answer questions related to primary care practice or the delivery of primary care servicesprimary care practice or the delivery of primary care services

Laboratories for Laboratories for effectivenesseffectiveness studies in office settings with studies in office settings with competing demands for high quality care and greater competing demands for high quality care and greater efficiency/productivityefficiency/productivity

Depend upon outside funding (grants, contracts) to support their Depend upon outside funding (grants, contracts) to support their workwork

CapacityCapacity 28 PBRNs identified in 199428 PBRNs identified in 1994

177 PBRNs identified in 2005177 PBRNs identified in 2005

Headquartered in urban, suburban and rural areasHeadquartered in urban, suburban and rural areas

2,724 practices are affiliated with PBRNs located in all 50 2,724 practices are affiliated with PBRNs located in all 50 states and Puerto Rico states and Puerto Rico

16 million patients are affiliated with PBRNs 16 million patients are affiliated with PBRNs – Average of 198,112 patients per PBRN (range 1200 to Average of 198,112 patients per PBRN (range 1200 to

2.7 million)2.7 million)

Why Is Primary Why Is Primary Care Important to AHRQ?Care Important to AHRQ?

Majority of daily patient/clinician interactions occur in Majority of daily patient/clinician interactions occur in ambulatory settingsambulatory settings

Majority of prescriptions for medications written in Majority of prescriptions for medications written in ambulatory settingsambulatory settings

While growth of HMOs and large integrated healthcare While growth of HMOs and large integrated healthcare systems has been dramatic, >50% of Americans still systems has been dramatic, >50% of Americans still receive primary care services in smaller (3-10 clinician) receive primary care services in smaller (3-10 clinician) practicespractices

Significant amount of care in these settings flies under Significant amount of care in these settings flies under radar of most national quality monitoring effortsradar of most national quality monitoring efforts

Consortia of NetworksConsortia of Networks

North Carolina Network Consortium (NCNC): North Carolina Network Consortium (NCNC): UNC, Duke, Adolescent Research, Mecklenburg, Robeson UNC, Duke, Adolescent Research, Mecklenburg, Robeson CountyCounty

PRIME Net: PRIME Net: RIOSNet, CaReNet, SERCN, SPUR-Net, RIOSNet, CaReNet, SERCN, SPUR-Net, CRNCRN

SNOCAP: SNOCAP: High Plains, CaReNet, BIGHORN, AAFP-High Plains, CaReNet, BIGHORN, AAFP-NRNNRN

ePCRN Consortium: ePCRN Consortium: MAFPRN, AAFP-NRN, MAFPRN, AAFP-NRN, Alabama, LA Net, Alabama, LA Net, OKPRN, Penn State, STARNet, South OKPRN, Penn State, STARNet, South Florida, BuffaloFlorida, Buffalo

Individual NetworksIndividual Networks

ACORN (Virginia Commonwealth)ACORN (Virginia Commonwealth) Irene (Iowa)Irene (Iowa) OKPRN (Oklahoma)OKPRN (Oklahoma) ORPRN (Oregon)ORPRN (Oregon) PeRC (Children’s, Philadelphia)PeRC (Children’s, Philadelphia) PPRNet (Univ South Carolina)PPRNet (Univ South Carolina)

PBRN Task Order Contractors: PracticesPBRN Task Order Contractors: Practices

PBRN Task Order Contractors: PBRN Task Order Contractors: Age-Range of PatientsAge-Range of Patients

PBRN Task Order Contractors: PBRN Task Order Contractors: Patient Race/EthnicityPatient Race/Ethnicity

PBRN Task Order Contractors: PBRN Task Order Contractors: Physician Provider DisciplinePhysician Provider Discipline

PBRN Task Orders To DatePBRN Task Orders To Date

First award made in July, 2007First award made in July, 2007 Twelve RFTOs released/funded to dateTwelve RFTOs released/funded to date Funding $4.7 millionFunding $4.7 million One project completed (12 month task One project completed (12 month task

order)order)

PBRN Task Order ProjectsPBRN Task Order Projects

Integrating evidence-based clinical and Integrating evidence-based clinical and community servicescommunity services

Preparing primary care to respond to a pan-flu Preparing primary care to respond to a pan-flu public health threatpublic health threat

Assessing the costs to primary care of Assessing the costs to primary care of collecting and reporting quality-related datacollecting and reporting quality-related data

Assessing barriers to quality measurement Assessing barriers to quality measurement and reporting in primary careand reporting in primary care

Clinical impact of nurse-based care Clinical impact of nurse-based care managementmanagement

Development of a health literacy universal Development of a health literacy universal precautions toolkitprecautions toolkit

PBRN Task Order ProjectsPBRN Task Order Projects

Primary care management of sleep apneaPrimary care management of sleep apnea Pediatric asthma hospitalizations and the Pediatric asthma hospitalizations and the

quality of primary carequality of primary care Implementation and evaluation of electronic Implementation and evaluation of electronic

standing ordersstanding orders Primary care participation in health Primary care participation in health

information exchangesinformation exchanges Establishing benchmarks for the medical Establishing benchmarks for the medical

office survey on patient safetyoffice survey on patient safety Management in primary care of patients Management in primary care of patients

suspected of having CA-MRSA infectionssuspected of having CA-MRSA infections

ACTION = ACTION = Accelerating Change and Accelerating Change and Transformation in Organizations and NetworksTransformation in Organizations and Networks

5-year model of field-based research 5-year model of field-based research 15 large partnerships15 large partnerships Partnerships include over 150 Partnerships include over 150

collaborating organizations collaborating organizations Partners located in all StatesPartners located in all States

DECISION-MAKERS

RESEARCHERS

PUBLICATIONS

Info + Info + ToolsTools

InfoInfo + + ToolsTools

Through ACTION, Partnering to Promote Through ACTION, Partnering to Promote Knowledge Transfer and ExchangeKnowledge Transfer and Exchange

ACTION GoalsACTION Goals

Be responsive to user, stakeholder and Be responsive to user, stakeholder and operational needs for innovation in health care operational needs for innovation in health care delivery delivery

Accelerate the development, implementation, Accelerate the development, implementation, dissemination and uptake of evidence-based dissemination and uptake of evidence-based products, strategies and findings into practiceproducts, strategies and findings into practice

Prioritize generalizable approaches to enable Prioritize generalizable approaches to enable spread to other settingsspread to other settings

Current ACTION Partners?Current ACTION Partners?Health Services Research Organizations:

Abt Associates, Inc., Cambridge, MA American Institutes for Research, Silver Spring, MDRAND Corporation, Santa Monica, CARTI International, Research Triangle Park, NCThe CNA Corporation, Alexandria, VA

Academic Institutions:Boston University School of Public Health, Boston, MAIndiana University, Indianapolis, INUCSF School of Medicine, San Francisco, CAUniversity of Iowa Center for Health Policy and Research, Iowa City, IAWeill 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, DCAurora Health Care, Milwaukee, WIDenver Health, Denver, CO Health Research and Educational Trust, Chicago, IL

Future ACTION Partners?Future ACTION Partners?

Anticipate an Anticipate an open open recompetion of recompetion of ACTION by ACTION by 20102010

ACTION Partnerships Include…ACTION Partnerships Include…

Hospital systemsHospital systems Ambulatory care practicesAmbulatory care practices Long-term care systems (nursing homes, home health, assisted Long-term care systems (nursing homes, home health, assisted

living)living) Safety net systemsSafety net systems Health plansHealth plans University schools of medicine, nursing, public health, health policy, University schools of medicine, nursing, public health, health policy,

and managementand management Health services and outcomes research organizationsHealth services and outcomes research organizations Veterans Integrated Delivery System NetworksVeterans Integrated Delivery System Networks QIOsQIOs JCAHO, NCQA and other national organizations for healthcare JCAHO, NCQA and other national organizations for healthcare

quality assurancequality assurance Associations of healthcare providersAssociations of healthcare providers Consumer advocacy organizations Consumer advocacy organizations

Why ACTION? Why ACTION?

Because We Need To…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?How Does Contract Process Work?

Project concepts welcomed from all sources, any Project concepts welcomed from all sources, any timetime

Topics must be critical to AHRQ, health systems, Topics must be critical to AHRQ, health systems, sponsorssponsors

Solicit proposals from closed pool of ACTION Solicit proposals from closed pool of ACTION partnerships throughout the year partnerships throughout the year

ACTION partnerships submit proposals within 4-6 ACTION partnerships submit proposals within 4-6 weeksweeks

Proposal review by small Proposal review by small ad hocad hoc committee of committee of expertsexperts

~2-4 months from solicitation to award~2-4 months from solicitation to award

How Does Funding Work?How Does Funding Work?

2006 - 2008 2006 - 2008 58 awards 58 awards totaling $30.2 milliontotaling $30.2 million• 78% competitive awards78% competitive awards• 22% sole source (most 22% sole source (most

externally funded)externally funded)

Average award = $520 K Average award = $520 K (range: $120K to $3 million)(range: $120K to $3 million)

Average duration = 23 months Average duration = 23 months (range: 9 to 36 months)(range: 9 to 36 months)

Amounts Awarded by TopicAmounts Awarded by Topic

Topic MillionsPatient Safety $12.2

Organization/Value $5.2

Public Health Preparedness $4.5

Healthcare Information Technology $3.8

Prevention $3.3

Long-term Care $1.2

Total $30.2

External Sponsorship, 2006-2008External Sponsorship, 2006-2008

13 fully sponsored projects: 13 fully sponsored projects: • RWJF (1)RWJF (1)• CDC (6)CDC (6)• HRSA (2)HRSA (2)• ASPR (4)ASPR (4)

3 co-sponsored projects: 3 co-sponsored projects: • DoDDoD• ONCONC• CMSCMS

Main Strategic AdvantagesMain Strategic Advantages

Extensive Extensive depth and breadthdepth and breadth of care settings, data and of care settings, data and implementation capacityimplementation capacity

Huge Huge diversity diversity (geographic, (geographic, demographic, payer) among demographic, payer) among >100 million recipients of care >100 million recipients of care

Speed Speed average project average project duration of 23 monthsduration of 23 months

Focus on Focus on knowledge transfer knowledge transfer and exchangeand exchange

How Do We Encourage KHow Do We Encourage Knowledge nowledge Transfer and Exchange?Transfer and Exchange?

Examples of project deliverables:Examples of project deliverables:– Workshops, webcasts, training programs, technical Workshops, webcasts, training programs, technical

assistance in care delivery settings assistance in care delivery settings – DVDs, “how to” guides, workbooksDVDs, “how to” guides, workbooks– Presentations to healthcare operational leadershipPresentations to healthcare operational leadership– Live/web-assisted conferencesLive/web-assisted conferences– Tested scalable, scenario-appropriate models Tested scalable, scenario-appropriate models – Publications in peer-reviewed and trade journalsPublications in peer-reviewed and trade journals

Ready access to Steering Committee members’ Ready access to Steering Committee members’ organizations (e.g., AHA, MGMA, NBGH, RWJF) for rapid organizations (e.g., AHA, MGMA, NBGH, RWJF) for rapid dissemination (member webcasts, listserves, annual dissemination (member webcasts, listserves, annual meetings, journals)meetings, journals)

PBRN Task Order Example #1:PBRN Task Order Example #1:Pandemic Flu Management in Primary CarePandemic Flu Management in Primary Care

How to manageHow to managepatient surgespatient surgesduring during pandemic flu?pandemic flu?HIT-assistedHIT-assistedsystems tosystems tofaciliate patient faciliate patient

self-management.self-management.

Development of Development of enhanced interactive enhanced interactive phone systemsphone systems

Interactive website with Interactive website with patient education patient education materialsmaterials

University of Oklahoma University of Oklahoma (OKPRN)(OKPRN)

12 month project12 month project

PBRN Example #2:PBRN Example #2:Measuring costs to primary care practices of Measuring costs to primary care practices of

collecting/reporting quality datacollecting/reporting quality data

Policy issuePolicy issue: : What is the cost to a primary care practice of What is the cost to a primary care practice of collecting/reporting quality-related data? Who should bear the collecting/reporting quality-related data? Who should bear the financial burden?financial burden?

Task Order AwardsTask Order Awards: One Task Order to North Carolina (NCNC) to measure costs of collecting/reporting global quality measures; Second Task Order to Univ Colorado (SNOCAP) to measure costs of collecting/reporting diabetes-specific measures

Results anticipated: November, 2008 (14 month projects)

PBRN Example #3:PBRN Example #3:Management of Suspected CA-MRSAManagement of Suspected CA-MRSA

Congressional appropriation to Congressional appropriation to AHRQ in December, 2007AHRQ in December, 2007

CDC has established evidence-CDC has established evidence-informed principles for informed principles for ambulatory management; but ambulatory management; but feasibility/actual outcomes feasibility/actual outcomes unknownunknown

Three task orders awarded Three task orders awarded August, 2008August, 2008

ACTION Is 2 ½ Years Old…ACTION Is 2 ½ Years Old…

Some early task orders are completed and Some early task orders are completed and others have interim results. others have interim results.

How are we doing?How are we doing?

Example 1: 60% MRSA Infection Reduction in Indianapolis Hospitals

Problem– >126,000 MRSA infections per yr in hospitals>126,000 MRSA infections per yr in hospitals– >5,000 patients die as a result >5,000 patients die as a result – Over $2.5 billion excess healthcare costsOver $2.5 billion excess healthcare costs

Products and Results– Indiana University developed and implemented

a novel approach to reduce MRSA in ICUs in hospital systems in Indianapolis

– improved surveillance, hand hygiene, contact isolation

– Avg 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

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30

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50

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1960 1966 1972 1978 1984 1990 1996 2002

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USA (ICUs) Denmark (BSIs)

Example 2: National Spread of Example 2: National Spread of TeamSTEPPSTeamSTEPPS

ProblemProblem – Poor communication and lack of teamwork among health care

professionals contribute to errors in patient safety Products and ResultsProducts and Results

– AHRQ, DoD and AHRQ, DoD and American Institutes for Research built national built national training and support network for TeamSTEPPS, an evidence-based training and support network for TeamSTEPPS, an evidence-based teamwork system teamwork system

– TeamSTEPPS National Implementation program fully operational TeamSTEPPS National Implementation program fully operational nationwidenationwide

– 1200 Master Trainers/Change Agents being trained (including in 1200 Master Trainers/Change Agents being trained (including in ACTION partnerships) ACTION partnerships)

– Other spread: e.g., all Maine hospitals using TeamSTEPPSOther spread: e.g., all Maine hospitals using TeamSTEPPS

Example 3: Example 3: $10 Million in Reduced Waste at Denver Health Hospital

Problem- 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 US

Products and Results– Denver Health trained all hospital middle managers in waste

reduction using Lean– Examples:

Better organized respiratory therapy equipment 40% reduction in time spent searching (estimated $9,220/year saved)

Disposal of 75 dumpsters of old files, equipment, supplies, hazardous materials ~ $300,000 in capital improvement and improved safety

Switch from paper to electronic forms cost savings of $7,500/yr

Example 4: Improved Example 4: Improved Health Health Care Planning in DisastersCare Planning in Disasters

ProblemProblem– Lack of planning for emergencies Lack of planning for emergencies – Example: Hurricane KatrinaExample: Hurricane Katrina

Products and Results (3 of many examples)Products and Results (3 of many examples)– Alternate Site LocatorAlternate Site Locator toto help State and local officials help State and local officials

quickly locate appropriate alternate health care sites if quickly locate appropriate alternate health care sites if existing ones are overwhelmedexisting ones are overwhelmed

– Emergency Preparedness Resource InventoryEmergency Preparedness Resource Inventory to to help local/regional planners inventory equipment, help local/regional planners inventory equipment, personnel, and supplies in advancepersonnel, and supplies in advance

– Staffing for Disaster Preparedness Response ModelStaffing for Disaster Preparedness Response Model to improve antibiotic dispensing and vaccination to improve antibiotic dispensing and vaccination campaigns for disease outbreakscampaigns for disease outbreaks

Questions? Comments?Questions? Comments?

ACTION Program Officer: ACTION Program Officer: CCynthia.Palmer@ahrq.hhs.govynthia.Palmer@ahrq.hhs.govACTION Fact Sheet at: ACTION Fact Sheet at: www.ahrq.gov/research/action.pdfwww.ahrq.gov/research/action.pdf

PBRN Program Officer: PBRN Program Officer: David.Lanier@ahrq.hhs.govDavid.Lanier@ahrq.hhs.govPBRN website: PBRN website: www.ahrq.gov/research/primarix.htmwww.ahrq.gov/research/primarix.htm

ContactsContacts