Monday, February 3, 2014

Evidence to Improve the Quality of Care

This post originally appeared on the Robert Wood Johnson Foundation (RWJF) Human Capital Blog.

Richard Kronick, Ph.D., was named director of the Agency for Healthcare Research and Quality (AHRQ) in August 2013. Dr. Kronick is a health policy researcher with a background in academia as well as in Federal and State government.  He received an RWJF Investigator Award in Health Policy Research in 1998.

Human Capital Blog (HCB): Congratulations on your new position at AHRQ. This is an exciting time for health care. What do you see as AHRQ’s place in the U.S. health care universe?

Richard Kronick: Thank you! You’re right—this is an exciting time.

We have an almost $3 trillion health care system. We pour tremendous resources into the delivery of medical care—but comparatively little effort into trying to understand how health care can be delivered more safely, with higher quality, and be more accessible and affordable. AHRQ’s role is to produce evidence that can be used to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services (HHS) and other partners to make sure that the evidence is understood and used.

HCB: What is your agenda and what are your priorities for AHRQ?

Kronick: We have four priorities. The first is dissemination and implementation of patient-centered outcomes research. One way we’ll be doing this is to support small- and medium-sized primary care practices to help build their ability to use PCOR findings. In particular, we want to support practices in improving their patients’ outcomes on cardiovascular risk factors, the so-called ABCS (aspirin, blood pressure, cholesterol, and smoking), and more broadly to help practices adopt PCOR findings as they emerge. In addition, we are interested in knowing if and how this type of support can help practices achieve those goals so future Agency PCOR dissemination initiatives might draw on the lessons learned.

The second priority is to produce evidence that will make health care safer. AHRQ’s work has already had a substantial impact here. For instance, in one project, our work has contributed to an approximately 40 percent reduction in central line-associated bloodstream infections in a broad set of hospitals. The same intervention has led to an approximately 20 percent reduction in catheter-associated urinary tract infections so far in the project, although these are preliminary numbers. We will be extending this work to surgical site infections and ventilator acquired pneumonia, as well as working on reducing harm from other adverse events—particularly reducing falls, pressure ulcers, and harms from obstetric care.

Our third priority is to produce evidence to make health care more accessible. Chiefly we will do this by evaluating the effects of the Medicaid and marketplace coverage expansions under the Affordable Care Act, with a focus on producing the evidence that decision makers will need to increase access in the future. 

Our fourth priority is to produce evidence that will increase the affordability of health care. One way we will do this is by working with states to increase the transparency of health care prices—to improve data, measures, and public reporting strategies so consumers can understand the price of services as well as their quality.  We will also work on producing information to compare the resources and quality of care produced by health care systems within the United States.   

HCB: How would you characterize the quality of care in the United States today?

Kronick: I would characterize it as uneven. In some areas we do very well, but in some we do not. Only about 50 percent of patients with high blood pressure have it controlled, and many people with high cholesterol are not working with members of their health care team on making progress. There’s too much variation, across regions and across providers, without adequate effort to understand the effects of different methods of delivering care on health outcomes. 

HCB: What are some of the barriers to improving quality? How can AHRQ help us overcome these barriers?

Kronick: The first barrier is access. There are millions of people who currently don’t have health insurance—and the evidence is clear that they receive lower quality care than those who do have insurance.

And, of course, there are tremendous disparities in health care quality by race, ethnicity, and socioeconomic status, as AHRQ documents each year in our National Healthcare Quality Report and National Healthcare Disparities Report.

A third barrier is that our incentives for providing high-quality care aren’t very mature yet. Although we’ve learned a lot recently, it’s still very difficult to measure what it is we want providers to do. We struggle to develop accountability mechanisms that will reward quality.

I should point out that many of these quality problems are endemic throughout the world. They’re not unique to the United States—but some of them are magnified in the United States. This is particularly true with fragmentation. In many places in the United States, providers don’t talk much with each other, care is not well coordinated, and patients can fall through the cracks.

The key to overcoming these barriers is to understand how access to the system can be improved. That’s one thing that AHRQ can do: we can produce evidence to help providers, patients, and policy makers understand how to improve access to care.

HCB: You won a Robert Wood Johnson Foundation Investigator Award in Health Policy Research in 1998, and were a professor at the University of California at San Diego. In academia, you focused on whether and how markets can be made to work well in health care, particularly for vulnerable populations. Will you tackle this issue at AHRQ?

Kronick: Yes. And, as an aside, the RWJF award was among very important opportunities for me to expand my thinking on these issues.  But, our health care system remains a market-based system, and that’s not changing. So the challenge we face is to make the market work as well as it can for as many Americans as possible, including the ones who have limited access.

That’s where our third and fourth priorities—concerning access and affordability—will be important. Understanding the effects of coverage expansion means paying attention to the effects of competition between insurers and between providers at the local level. At AHRQ we will be very focused on producing evidence needed by the Secretary of HHS and by members of Congress going forward.

For instance, with the coverage expansion, how much will utilization increase? I’m pretty confident utilization will increase, but less confident by how much. When the State of Oregon embarked on its coverage expansion, the thinking was that use of outpatient services might increase by 80 percent or even double, but the reality was closer to 35 percent. These are the things we need to understand on a national scale as we increase coverage, because the Affordable Care Act won’t be static. We’ve already seen some changes in it, and I anticipate we may see more changes as we understand its effects more fully. This is the kind of information that the Secretary and the Congress will demand.

HCB: Is there upcoming AHRQ research that you expect will have a significant impact?

Kronick: We do have some research that should get some well-deserved attention. For instance, we will have a study coming out early in 2014 about the effect of patient safety improvements in reducing adverse events in treatment of certain conditions.

We’ll also release some work on CUSP for catheter-associated urinary tract infections. CUSP has been a very important program, and we are looking at ways to extend it beyond healthcare-associated infections to other patient safety problems.

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