Post on 23-Jan-2015
description
transcript
Thinking Beyond Our Borders: What We Can Learn about Improving
Care from Other Countries
Dr. Lisa Simpson
President and CEO
April 24, 2012
Outline
Introduction
What do international studies tell us about
health and health care in the U.S.?
Leading Approaches in Other Countries
Burgeoning Field of Implementation Science
Concluding Thoughts
AcademyHealth: Improving
Health & Health Care AcademyHealth is a leading national organization serving the fields of health
services and policy research and the professionals who produce and use this
important work.
Together with our members, we offer programs and services that support the
development and use of rigorous, relevant and timely evidence to:
1. Increase the quality, accessibility and value
of health care,
2. Reduce disparities, and
3. Improve health.
A trusted broker of information, AcademyHealth
brings stakeholders together to address the current
and future needs of an evolving health system,
inform health policy, and translate evidence into action.
3
Leveraging >4,500 Diverse,
Expert Members & Organizations
3
Behavioral Health Services Research
Child Health Services Research
Disability Research
Disparities
Gender and Health
Health Economics
Health Information Technology
Health Workforce
Interdisciplinary Research Group on Nursing Issues
Long-Term Care
Public Health Systems Research
Quality & Value
Translation & Communications
State Health Research and Policy
AcademyHealth Interest Groups
4
Mission and Programs Methods and professional skill-building
seminars, methods council
Electronic Data Methods (EDM) Forum
Changes in Health Care Financing and
Organization (HCFO)
Multi-payer Claims Database (MPCD)
Annual Research Meeting
Address the current and future needs of an evolving health system
Translate evidence into action
AHRQ Knowledge Transfer Initiative
Beacon Evaluation and Innovation Network
National Library of Medicine’s HSRProj
National Health Policy Conference
Public Health Services Research
AHRQ Healthcare Innovations Exchange
State Coverage Initiatives
AHRQ Medicaid Medical Director’s
Learning Network
Advocacy and Public Policy
Inform health policy
5
Conferences
Annual Research Meeting (ARM)
– June 24-26, 2012 in Orlando, FL
– Over 2,000 attendees
Health Policy Orientation
– October 22-25, 2012 in Washington DC
– Limited to 50 participants
National Health Policy Conference
(NHPC)
– February 4 – 5, 2013 in DC
– Over 800 attendees
AcademyHealth Focus
2012-2014
Fundamental program areas
– Generate new knowledge
– Move knowledge into action
Strategic priority areas
– Health care costs and value
– Delivery system transformation
– Public and population health
Push audiences
– Delivery system leaders
– States
ARM Opportunities for
Students
Registration and hotel discounts
Scholarships
Meet-the-expert breakfast
Networking events
Career Coaches
Awards for best dissertation & poster
Declaring My Biases!
1. The US is far too insular
in its approach to the
world!
2. There is much to be
learned from other
countries as we struggle
to improve health and
health care.
3. Others in the audience
know far more than I do!
Agenda
Introduction
What do international studies tell us about
health and health care in the U.S.?
Dimensions of Comparison
Health and outcomes
Health care costs
Health care utilization
Adults Who Report Being Daily Smokers, 2009
28.0 26.2
24.9
21.9 21.5 21.5 21.0 20.4 19.0 18.1
16.6 16.2 16.1 14.3
0
10
20
30
40
NETH FR* JPN GER UK OECDMedian
NOR SWIZ** DEN NZ** AUS** CAN US SWE
Percent
* 2008.
** 2007.
Source: OECD Health Data 2011 (June 2011).
THE
COMMONWEALTH
FUND
33.8
26.5 24.6 24.2
23.0
14.7
11.8 11.2 11.2 10.0
8.1
3.9
0
5
10
15
20
25
30
35
40
US* NZ** AUS** CAN* UK GER NETH FR* SWE NOR* SWIZ** JPN
Obesity (BMI>30) Prevalence Among Adult Population, 2009
Note: Body-mass index (BMI) estimates based on national health interview surveys (self-reported data)
are usually significantly lower than estimates based on actual measurements.
Percent
Measured Self-reported
THE
COMMONWEALTH
FUND
* 2008.
** 2007.
Source: OECD Health Data 2011 (June 2011).
Breast Cancer Five-Year Relative Survival Rate,
2002–2007 (or nearest period)
90.5 87.1 86.1 85.2
82.4 82.1 81.9 78.5
0
20
40
60
80
100
US CAN SWE NETH DEN NZ NOR UK
Source: OECD Health Care Quality Indicators Data 2009.
Percent
THE
COMMONWEALTH
FUND
* 2006.
** 2005.
*** Among countries shown.
36
21
16
13 12 12 12
11 11 11 9
0
10
20
30
40
US* DEN SWIZ* FR NZ Median*** SWE CAN NETH** NOR UK
Diabetes Lower Extremity Amputation Rates
per 100,000 Population Age 15 and Older, 2007
Source: OECD Health Care Quality Indicators Data 2009.
THE
COMMONWEALTH
FUND
* In-hospital case-fatality rates within 30 days of admission.
** 2006.
*** 2005.
Mortality After Admission for Acute Myocardial Infarction*
per 100 Patients, 2007
6.6 6.3
5.1
4.2
3.3 3.2 2.9 2.9
0
2
4
6
8
NETH** UK US* CAN NZ NOR DEN SWE
Source: OECD Health Care Quality Indicators Data 2009.
THE
COMMONWEALTH
FUND
$2,983 $3,445 $3,487
$3,722 $3,978
$4,218 $4,363
$4,914 $5,144
$5,352
$7,960
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
NZ(10.3%)
AUS(8.7%)*
UK(9.8%)
SWE(10.0%)
FR(11.8%)
GER(11.6%)
CAN(11.4%)
NETH(12.0%)
SWIZ(11.4%)
NOR(9.6%)
US(17.4%)
Health Spending per Capita, 2009 Adjusted for Differences in Cost of Living
* 2008.
Source: OECD Health Data 2011 (June 2011).
% GDP
Dollars
THE
COMMONWEALTH
FUND
18 Health Care Spending per Capita by Source of Funding, 2009 Adjusted for Differences in Cost of Living
3,795 4,501
3,072 3,081 3,242 3,100 3,033 2,935 2,342 2,400 2,325
3,189
43
504 646 424 587 69 188
476 184 99
976
808
1,568 636 552 291
620 364 627
399 454
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
US NOR SWIZ CAN GER FR SWE UK AUS* NZ JPN*
Out-of-pocket spending
Private spending
Public spending
* 2008.
Dollars
7,960
4,363 4,218 3,978
3,722 3,487 3,445
2,878 2,983
5,352 5,144
Source: OECD Health Data 2011 (June 2011).
THE
COMMONWEALTH
FUND
0
1000
2000
3000
4000
5000
6000
7000
8000
1980 1984 1988 1992 1996 2000 2004 2008
US
NOR
SWIZ
NETH
CAN
DEN
GER
FR
SWE
UK
AUS
NZ
JPN
Source: OECD Health Data 2011 (June 2011).
Average Health Care Spending per Capita, 1980–2009 Adjusted for differences in cost of living
19
Dollars
THE
COMMONWEALTH
FUND
Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year
Percent
1 5 6
11 12 13 16
24
35 36 39
0
10
20
30
40
50
60
More than US$1,000 in
out-of-pocket costs
1 4 5 6 7 8 8 8
11 14
27
Serious problems paying or
unable to pay medical bills
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
THE
COMMONWEALTH
FUND
21 Average Annual Number of Physician Visits per Capita, 2009
13.2
8.2
6.9 6.5 6.3
5.7 5.5 5.0
4.6 4.3 4.0 3.9
2.9
0
2
4
6
8
10
12
14
JPN* GER FR AUS OECDMedian
NETH CAN* UK DEN NZ** SWIZ** US* SWE
* 2008.
** 2007.
Source: OECD Health Data 2011 (June 2011).
THE
COMMONWEALTH
FUND
Patients with a Regular Doctor versus a Medical Home
99 99 99 91
99 99 97 96 97 100 95
74 70
65
56 53 52 51 49 48 48
33
0
20
40
60
80
100
UK SWIZ NZ US NOR FR AUS CAN GER NETH SWE
Has a regular doctor or place of care
Has a medical homePercent
Patients with a medical home have a regular practice who is
accessible, knows them, and helps coordinate their care
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
THE
COMMONWEALTH
FUND
Rated Quality of Care in Past Year as “Excellent” or “Very Good,”
by Medical Home
79
72
49
35
44
83
65 62
72
88
77
56
46
38
27 26
59
34
44
57 60
43
0
20
40
60
80
100
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Medical home No medical home
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
THE
COMMONWEALTH
FUND
Waited Less Than a Month to See Specialist
92 88
81 80 79
68 67 63
59 52
47
0
20
40
60
80
100
SWIZ US NETH UK GER NZ FR SWE AUS CAN NOR
Percent
Base: Saw or needed to see a specialist in the past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
THE
COMMONWEALTH
FUND
Shared Decision-Making with Specialists
80 79 72
67 67 64 61
50 48
40 37
0
20
40
60
80
100
SWIZ UK NZ NETH US AUS CAN GER SWE NOR FR
Percent reporting positive shared decision-making experiences with specialists*
* Reported specialist always/often: 1) Gives opportunities to ask questions about recommended treatment;
2) Tells you about treatment choices; and 3) Involves you as much as you want in decisions about your care.
Base: Seen specialist in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
THE
COMMONWEALTH
FUND
Cross-Cutting Themes and Implications
Outcomes and quality have improved but there is room for
improvement in all countries
There is a clear need to contain public spending
Per capita spending has risen by 70% since the early
90’s
U.S. is an outlier on access and affordability
Cost-sharing and benefit design matters
Strong primary care “medical homes” make a difference in
all countries
Health care systems: getting more
value for money (OECD Report, 2010)
There is no health care system that performs systematically
better in delivering cost-effective health care.
On average, life expectancy at birth could be raised by more
than two years, while holding health care spending steady, if all
countries were to become as efficient as the best performers.
Health outcomes are highly disparate across individuals and
such inequalities can be reduced without sacrificing efficiency
There is no “one-size-fits-all” approach to reforming health care
systems.
By improving the efficiency of the health care system, public
spending savings would be large, approaching 2% of GDP on
average in the OECD.
Outline
Overview of AcademyHealth
How the U.S. Compares: Quality and
Outcomes
Leading Approaches in Other Countries
Strategies in Use
OECD:
– Reliance on market mechanisms and
regulations to steer demand and
supply
– Coverage principles to promote equity
– Budget and management approaches
to control public spending
Market Mechanisms
Users
– Price signals
– Gate keeping & limited choice among providers
Providers
– Mitigating volume incentives
– Regulating prices
– Enhancing patient choice
– User information on quality and price
Common International Trends
Standardizing and integrating health
information technology and other electronic
data innovations
Bolstering the research enterprise and
integrating CER into decision-making
Engaging patients meaningfully in their care
and shifting the perspective of research to be
patient-centered
Kalipso Chalkidou, NICE International
Engaging Patients
American patients who feel engaged by their
providers are more likely to rate their care as high
quality than engaged patients in other countries
Low income patients were less likely to feel engaged
than higher income patients
American patients are likely to report positive care
experience, even if clinical needs were not met
American patients exhibited the greatest disparities in
care and engagement
R. Osborn and D. Squires, "International Perspectives on Patient Engagement:
Results from the 2011 Commonwealth Fund Survey," Journal of Ambulatory Care
Management, April/June 2012 35(2):118–28.
Divergent Actions, Similar Trends Compared: OECD Health Care Quality Indicators
Project and the US National Healthcare Quality
Report
Found:
– Choice of breadth or priorities
– Methods must be developed to both edit indicators
and preserve core set for longitudinal study
– Communication, translation, dissemination are key
– Momentum matters
Edward T. kelley 1 , 2 , Irma Arispe 3 and Julia Holmes 3
Beyond the initial indicators: lessons from the OECD Health Care Quality Indicators
Project and the US National Healthcare Quality Report
Int J Qual Health Care (September 2006) 18 (suppl 1): 45-51. doi: 10.1093/intqhc/mzl027
http://intqhc.oxfordjournals.org/content/18/suppl_1/45.long
US Activity vs. International Generate the right data and
evidence
– Inform patient choice as well as
traditional decision makers
– HIT, electronic data, systematic
reviews, real-world
demonstrations, measure
standardization/harmonization
Identify the right populations
and partners
– Patient- centered research
Engage both to make more
informed and creative ideas
– PCORI, patient-centered
medical homes
Generate the right data and
evidence
– Convergence of payer and
regulator use of CER
– HIT, electronic data, systematic
reviews, cost-focused analysis,
international pilots, measure
standardization/ harmonization
Identify the right populations
and partners
– Patient- centered research,
product developers, health
system professionals
Engage both to make more
informed and creative ideas
– Value-based pricing
Population Health, Patient Experience, Per
Capita Cost
HHS implementation in the US
IHI Triple Aim Partners 2011 – UK (NHS)
– Australia
– Sweden
– Singapore
– New Zealand
– Canada
http://www.ihi.org/offerings/Initiatives/TripleAi
m/Pages/Participants.aspx
Population Health is…
…the health outcomes of a group of
individuals, including the distribution
of such outcomes within the group.
Group can be defined by geography or
include other types such as employees,
ethnic groups, disabled persons, etc…
36
Source: Kindig and Stoddart. “What is Population Health?” Am J Public Health.
2003 March; 93(3): 380–383.
Population Health
Churchill had it right! – Americans will make the right choice, after…
Costs have put it on the table – Private sector focus
– ACA
Provisions in ACA for Population Health
Addresses need for systematic
approach to definition, funding, evidence
base, communication, and need for
cooperation.
The introduction of a reliable, steady
stream of funding for public health
research.
Encourages development and use of
common metrics to measure
effectiveness.
Promotes prevention in the health care
system
Source: Bovberg, et al. “What directions for Public Health under the
Affordable Care Act?” The Urban Institute Health Policy Center, November
2011.
Population Health
• “Because improvement in population health requires the attention and actions of multiple actors (legislators, managers, providers, and individuals), the field of population health needs to pay careful attention to the knowledge transfer and academic-practice partnerships that are required for positive change to occur.”
• Moves beyond current distinction between public health programs & health care delivery
• Integrated approach supported by multiple aspects of the ACA
39
Source: Kindig and Stoddart. “What is Population Health?” Am
J Public Health. 2003 March; 93(3): 380–383.
“Health in All Policies” Approach
– Increasing awareness that factors outside
of the health system affect health status
– Incorporates Social Determinant
perspective
– Policy Relevance
• Improved productivity
• Reduced health care costs (‘economic
security’)
40
Evidence-Generating Orgs
How to Act on what we Learn?
Though we are
generating new
evidence, aligning
interests and
partnering with
stakeholders… how do
we translate,
disseminate, and
implement what we
know to improve care?
Agenda
Overview of AcademyHealth
How the U.S. Compares: Quality and
Outcomes
Leading Approaches in Other Countries
Burgeoning Field of Implementation Science
What is implementation science?
Research relevant to the scientific
study of methods to promote the
uptake of research findings into
routine healthcare in both clinical
and policy contexts.
http://www.implementationscience.com/
What is in a name?
Implementation science
Improvement science
Delivery system research
Dissemination and implementation research
Quality improvement research
Pipeline from research to practice to policy
The Translational Pathway
Innovation
Pilot testing
Rigorous assessment
Replication and spread
Scale-up
Focus on Adoption, the “Triple S”
Scale up, Sustainability, Spread
US
– AHRQ
– PCORI
– CMMI
– Million Hearts
– VA
– NIH – Dissemination and implementation
activities; NCATS/CTSA
International
Focus on Adoption, the “Triple S”
Scale up, Sustainability, Spread
Cochrane Effective Practice and Organisation
of Care (EPOC) Group
– Reviews of interventions designed to improve
professional practice and the delivery of effective
health services.
Health evidence Canada
– Facilitate the adoption and implementation of
effective policies/programs/interventions at the
local and regional public health decision making
levels across Canada.
A New International Society on
Research on How to Improve Care
An inclusive approach: mental health healthcare,
treatment for substance abuse, the work of allied
health professions, and preventive healthcare.
Open to researchers from all traditions: rigorous
methods, focused on improving healthcare,
knowledge that can be transferred across settings.
Improvement science, behavioral medicine,
knowledge translation
Start international debate, shared vision, seek
funding opportunities and engage stakeholders.
Now seeking comment online.
Outline
Overview of AcademyHealth
How the U.S. Compares: Quality and
Outcomes
Leading Approaches in Other Countries
Burgeoning Field of Implementation Science
Concluding Thoughts
Future Challenges
Ensuring rigorous methods match policy and practice
needs.
Key requirements for creating comparable indicators
that address the needs of policy-makers are:
– appropriate methods of summarizing complex information;
– a narrative that picks out the key issues and uncertainties;
– a diagnosis of why the reported variations are arising; and
– an assessment of implications for policy action.
http://www.euro.who.int/en/what-we-do/data-and-evidence/health-
evidence-network-hen/publications/2012/health-system-
performance-comparison-an-agenda-for-policy,-information-and-
research-2012
Future Challenges (cont)
Harmonize and coordinate federal efforts to
fund research
Build a high performing comparative
effectiveness research system to achieve
rapid-learning potential of electronic health
records, databases, data sharing, networks
Support a rapid-learning culture for the US
health care system
Etheredge, Lynn. “Creating a High-Performance System
for Comparative Effectiveness Research.” Health
Affairs. 29; No. 10 (2010): 1761-1767
Wither AcademyHealth?
Continued focus on
– Evidence generation
– Evidence translation
Engage & learn from international colleagues
– Update to 2009 report on CER efforts
– Delegation to Beijing to attend 2nd Global
Symposium on Health Systems Research
– Your thoughts?
Questions?
Lisa Simpson, MB, BCh, MPH, FAAP President and CEO