Post on 10-Aug-2020
Meeting Many Needs...Especially Those of the Patient
The Tenth National Quality ColloquiumCambridge, MAAugust 18, 2011
Paul Wallace MDSVP and Director, Center for Comparative Effectiveness
Research
The Lewin GroupFalls Church, VA
Paul.Wallace@lewin.com1
2
Dealing with innovation…• Focusing on change that matters
• Documenting innovations to support effective learning and spread
• Balancing flexibility and speed with rigor in developing evidence to support policy change
3
Dealing with innovation…• Focusing on change that matters
• Documenting innovations to support effective learning and spread
• Balancing flexibility and speed with rigor in developing evidence to support policy change
• Designing with the end in mind: the impact of the perspective of the targeted user on the
content and conduct of evaluation4
Effective learning and spread…
Policy; National
States; Systems;Health Plans
Hospitals; Practices
Patients, Providers
What works?
How can we make it work here?
How does this impact me,
here and now?
The average patient,
seen by the average
doctor, in the average
health system, with
average coverage
Opportunities to accelerate spread• “Macro”‐
What works?
– Analysis of successes and failures– Effectiveness studies
• “Meso”
‐
How can we make it work here?
– Logic models
– Technical assistance • “Micro”
‐
How does this impact
me, here and now?– Activation and adherence insights– Heterogeneity of treatment effects
– Shared Decision making
Common Perform
ance Measures and Targets
9
Logic Models
• What the Health Care System does to patients (e.g. cancer
screening)
• What the Health Care System does with patients and their
families (e.g. care management)
• What patients best do by themselves, with support of the
health care system (e.g. behavior change)
10
Balancing rigor with flexibility and speed…
Policy; National
States; Systems;Health Plans
Hospitals; Practices
Patients, Providers
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P < 0.05
“Gray Areas”...
12
Insufficient evidence because the evidence is:
A. Of insufficient quantity and/or quality
B. Conflicting or inconsistent
C. There is no evidence
Medically appropriate
Generally not
medically
appropriate
66
3
738
1
The last 115 new technologies examined:
?
“Gray Areas”...
13
Insufficient evidence because the evidence is:
A. Of insufficient quantity and/or quality
B. Conflicting or inconsistent
C. There is no evidence
Medically appropriate
Generally not
medically
appropriate
66
3
738
1
The last 115 new technologies examined:
“Gray Areas”...
14
Insufficient evidence because the evidence is:A. Of insufficient quantity
and/or qualityB. B. Conflicting or inconsistentC. There is no evidence
Medically appropriate
Generally not
medically
appropriate
Heterogeneity (“THE”)CER/Trial Design
HIT: EMR&Registries
Provider Issues
Payer issues
Patient Issues
Pharma/Life Sciences Issues
Policy Issues
“Gray Areas”...
15
Insufficient evidence because the evidence is:A. Of insufficient quantity
and/or qualityB. B. Conflicting or inconsistentC. There is no evidence
Medically appropriate
Generally not
medically
appropriate
Opportunities:HTE
CER/Trial DesignHIT: EMR&Registries
Provider Response Options
Payer Response
Options
Patient Response Options
Pharma/Life Sciences
Response Options
Policy Options
e.g. EMR(structured
data
collection),
Archimedes
…
value based
benefit
designs,
coverage with
evidence
development
shared decision making, Social media
(patientslikeme.com) “Pay 4Response”CED, 0therCER,
infrastructure
investment…
Comparative Population
Effectiveness: The Kaiser Permanente National Joint Replacement Registry
[Evaluation]feedback
changed practicewith respect to:implant selection,
minimallyinvasive
procedures,uncementedknees, andsurgical
indications andpreoperative care.
Paxton,EW et al; The
Permanente Journal
15:12‐16, 2008
Opportunities to balance rigor and reality• Macro
‐
What works?
– Find boundaries of appropriate variation– Effectiveness studies
• Meso
‐
How can we make it work here?– Promote and link “parallel processing”
– Serial observation (e.g. rapid cycle)• Micro
‐
How does this impact me, here
and now?– Registries– Patient generated data– “Patients like me”(see patientslikeme.com)
17
Balance use of experimental and observational approaches
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The line it is drawn The curse it is cast
The slow one now Will later be fast
As the present now Will later be past
The order is Rapidly fadin'
And the first one now Will later be last
For the times they are a‐changin'.