Evidence-based healthcare is being embraced by public and private healthcare stakeholders as a solution to rising healthcare costs, poor quality, and safety concerns. These recent developments are shaping how value and quality are defined in healthcare. The programs and initiatives driving evidence-based healthcare can be categorized into four major categories:
- Measuring Value in Healthcare
- Payer Adoption of EBM Principles
- Generation of Medical Information and Evidence
- Defining Clinical Research Priorities
1) Measuring Value in Healthcare
Ambulatory Care Quality Alliance (AQA)
AQA was created in 2004 to improve how physician performance is measured. AQA includes representatives of physicians, hospitals, employers, business coalitions, and consumers. Federal agencies, such as the Centers for Medicare & Medicaid Services (CMS) are also part of the AQA. In 2005, AQA adopted a set of 26 quality measures that target prevention, coronary artery disease, heart failure, diabetes, asthma, depression, and prenatal care. This group of measures is intended to provide clinicians, consumers, employers and health plans with a way of evaluating physician performance.
Hospital Quality Alliance (HQA)
HQA seeks to improve the care provided by the nation’s hospitals and provide quality information to consumers and others. The HQA is led by the various organizations representing hospitals and collaborates with other medical and business associations. HQA's Hospital Compare web site provides consumers with information so that they can compare the quality of their local hospitals. This information is specific to treatment of medical conditions such as heart attacks, heart failure, pneumonia and also the rate of surgical infections. The 20 hospital quality measures currently listed on Hospital Compare have gone through several years of extensive testing.
Medicare Health Support (MHS)
MHS is a program administered by the Centers for Medicare & Medicaid Services was initiated by the 2003 Medicare Modernization act. The program aims to improve health outcomes, increase patient satisfaction, and reduce Medicare spending by coordinating patient care. MHS helps patients get the care they need and adhere to their physicians orders.The program is voluntary andMedicare beneficiaries, with diabetes or congestive heart failure, and multiple chronic conditions are invited to participate. Beneficiaries enrolled in Medicare Advantage (Medicare's managed care program) are not eligible. Beneficiaries who accept the program will receive regular health information mailings, phone calls from registered nurses, and other services. The three-year trial phase of the program began in 2005-2006 in Central Florida; Chicago; Mississippi; Northwest Georgia: Oklahoma; Tennessee; Washington, DC-Maryland; and Western Pennsylvania. MHS is currently being evaluated before it is launched nationwide.
National Quality Forum (NQF)
NQF is a private, not-for profit membership organization that endorses voluntary national standards for measurement and public reporting of healthcare performance information. The NQF has adopted a consensus-based process for examining the types of performance measures that should be used in healthcare. NQF has over 300 member organizations including leaders in the public and private sectors, such as the Centers for Medicare & Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), AARP, CIGNA, and General Motors. NQF projects include endorsing standards for hospital care and ambulatory care quality measurement and reporting, and a project that aims to create a framework and identify measures for reporting on drug management quality.
Pharmacy Quality Alliance (PQA)
Created in 2006, PQA is leading in the design of ways to measure pharmacy quality. The PQA is lead by a steering group is comprised of associations, such as National Association of Chain Drug Stores (NACDS), the Long Term Care Pharmacy Association (LTCPA), the American Pharmacists Association (APhA), the Pharmaceutical Care Management Association (PCMA). PQA hopes to improve health care quality and patient safety in pharmacy care by measuring pharmacy performance, figuring out how pharmacy services can improve health outcomes and reduce costs, and reporting information to consumers, physicians, and health plans.
2) Payer Adoption of EBM Principles
Blue Cross and Blue Shield Association (BCBSA) Technology Evaluation Center (TEC)
Founded in 1985 by BCBSA, the TEC develops scientific criteria for assessing medical technologies through comprehensive reviews of clinical evidence. The TEC produces technology assessments of the clinical effectiveness and appropriateness of a given medical procedure, device, or drug for use by private and public clients, including the BCBSA, Kaiser Permanente, and CMS. The TEC conducts an average of 20 to 25 assessments a year. Although TEC assessments may be the basis for private and public payers' coverage decisions, the TEC does not advocate, require, encourage, or discourage any particular treatment, procedure, or service or recommend any reimbursement decisions. The TEC is also an Evidence-based Practice Center (EPC) for the Agency for Healthcare Research and Quality (AHRQ).
Drug Effectiveness Review Project (DERP)
The DERP is run by Oregon Health & Science University's (OHSU) Center for Evidence-Based Policy and is a joint effort by 15 state Medicaid programs and two organizations, the California Health Care Foundation and Canadian Agency for Drugs and Technologies in Health. The project is completing a set of reports that compares the effectiveness of 25 different drugs. Many states use DERP reports to decide which drugs state Medicaid programs will cover. The Consumers Union and AARP websites also use the information from DERP reports to help consumers compare the effectiveness and costs of similar drugs.
The Medicaid Evidence-Based Decisions Project (MED)
Announced in June 2006, MED is a collaboration project from Oregon Health Sciences University's Center for Evidence-Based Policy, the creator of the Drug Effectiveness Review Project (DERP). The MED is meant to provide state Medicaid programs high quality clinical evidence to support benefit design and coverage decisions. The project includes access to systematic reviews of existing evidence; technology assessments of existing and emerging health technologies; and support in designing evaluations of products where little evidence exists. Participating states will identify developments of interest that have relevance for other states and the Center for Evidence-Based Policy will gather, organize, summarize, and post information related to these developments.
Medicare's National and Local Coverage Determination Processes
Medicare makes coverage policies on items (drugs and devices) and services at both the national and local levels. However, most technologies are never the subject of specific coverage policies and get paid for through existing reimbursement systems. Medicare covers items and services that are deemed “reasonable and necessary.” In national coverage determinations (NCDs), CMS provides opportunities for public participation and reviews the evidence-base of an item or service by adhering to the general principles of EBM. In certain cases, CMS may convene the Medicare Coverage Advisory Committee (MCAC) or commission a technology assessment to supplement the Agency’s internal review. Items or services may also be covered through local coverage determinations (LCDs), which are developed by local Medicare contractor medical directors independently of CMS.
Washington State Health Technology Assessment Program (SHTAP)
SHTAP is a key part of Washington State's strategy for improving health care and is run by the Health Care Authority (HCA), the agency that runs many of the state's health plans. SHTAP will focus on comparative effectiveness reviews to medical and surgical devices and procedures, medical equipment, and durable goods. Launched in the summer of 2006, the program has started some of its initial tasks, including hiring a program director, determining which centers will conduct the evidence-based technology assessment, and holding a stakeholder meeting.
3) Generation of Medical Information and Evidence
Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program
The AHRQ Effective Health Care Program conducts research that focuses on the outcomes and effectiveness of healthcare services and treatments. AHRQ works with academic centers across the country to bring together existing data, conduct original research, and help the public learn about current available research. AHRQ's Evidence-based Practice Centers (EPCs) synthesize current evidence by reviewing published research studies. The Centers for Education and Research on Therapeutics (CERTs) research the best use of drugs, medical devices, and biological products. The 13 DEcIDE centers will generate new evidence by conducting research using de-identified data sources. AHRQ is also working with the John M. Eisenberg Center at Oregon Health and Science University to put its research into short, consumer-friendly handouts that can be used by health plans, patients, and doctors.
Chronic Conditions Data Warehouse (CCW)
CMS has contracted with the Iowa Foundation for Medical Care (IFMC) to establish CCW. CCW is a research database designed to: 1) identify areas for improving the quality of care provided to chronically ill Medicare beneficiaries; 2) identify ways to reduce program spending; and 3) make current Medicare data more readily available to researchers studying chronic illness in the Medicare population. In the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Congress required the Medicare program to make data readily available to researchers studying chronic conditions in the Medicare population. The CCW provides researchers with Medicare beneficiary claims, survey, and assessment data linked by beneficiary across the continuum of care. http://www.ccwdata.org
Institute of Medicine (IOM) Roundtable on Evidence-Based Medicine
The Roundtable objectives include both finding ways to generate better evidence for clinical decision-making and prompting stronger public and provider commitment to putting evidence into practice. Areas of focus include assessment priorities and approaches, data and policy issues, translation strategies, and cooperative arrangements in EBM. Michael McGinnis of the IOM leads the Roundtable and it includes leadership from government, health plan, provider, consumer, employer, academic, and health technology manufacturer sectors. Over the next three years, the Roundtable will explore issues and options for improving the ways evidence is generated and used for clinical decision-making.
The National Institute for Health and Clinical Excellence (NICE)
Established as a part of the British National Health Service in 1999, NICE conducts technology appraisals, including clinical and cost effectiveness, and provides guidance to the NHS on the use of new and existing technologies. NICE develops its guidance by using NHS staff and other healthcare stakeholders including healthcare professionals, patients, caregivers, industry, and academics. NICE's Citizens Council helps to integrate broad social values judgments of the general public into the guidance NICE prepares.
4) Defining Clinical Research Priorities
Consumers United for Evidence-Based Healthcare (CUE)
Led by the U.S. Cochrane Center at Johns Hopkins University, the CUE is a group of consumer health advocates who want to help consumers to use scientific evidence in their healthcare decisions. Through training, meetings, and outreach, CUE members learn how to incorporate evidence-based healthcare into their advocacy activities and teach their constituents about existing research. CUE members will also strengthen consumer's influence on healthcare research by providing the Cochrane Collaboration with consumer input. In the future, the CUE hopes to develop an internet course and a list of resource materials on evidence-based healthcare, as well as publish a newsletter that describes the latest research findings and opportunities for consumer involvement.
Food and Drug Administration (FDA) Patient Representative Program
The FDA's Patient Representative Program provides the FDA with the views of patients and their family members on illnesses. The representatives must be experienced patient advocates who are the knowledgeable about the disease and officially associated with a patient advocacy organization. Patient representatives sit as both voting and non-voting participants in the FDA advisory committees that help the FDA make decisions about approving new drugs and medical devices for marketing. Anyone can nominate to a candidate to serve as a Patient Representative and self-nominations are also accepted.
James Lind Alliance (JLA)
Established by the United Kingdom’s Medical Research Council, JLA identifies questions about the effects of medical treatments that are important to both patients and clinicians. JLA is developing two Working Partnerships to identify patients and clinicians shared concerns about medical research. The JLA also supports the Database on Uncertainties about the Effects of Treatments (DUETs), which contains patients and clinicians questions of about medical treatments. The JLA intends to use this work to inform organizations which fund research about what matters most to patients and doctors in order to influence future research.