The New Health Dialogue

Photo from AHRQ

I’ve heard Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality, speak several times, but until this week, I never had a chance to just sit down in her office and ask what’s on her mind. The agency is probably best known for its outcomes and effectiveness research (the AHRQ division she led before becoming director in 2003). For instance it just did a study on rotator cuff treatment, and AHRQ is doing a series of consumer guides to diseases like breast or prostate cancer, which present patients with complex treatment choices. But I was less interested in specifics of this treatment or that treatment, than in how the agency’s work -- Research and QUALITY -- fits into health care in an era of reform.

Clancy is particularly interested in how to make medicine serve the patient -- patient-centered research. Here are some of the thoughts she shared.

We’ve known for years about variation in practice -- health spending is higher in some areas than others, and people in high-spending areas are not necessarily healthier or better off.  There are numerous reasons for that -- but part of it can be traced back to “clinical uncertainty” that arises from the lack of a good evidence base for both clinicians and patients, she said. 

In some clinical areas, the evidence is clear cut. A hysterectomy, for instance, is appropriate for uterine cancer. But it’s not so clear when a hysterectomy is the best choice for a noncancerous condition. And getting doctors to incorporate evidence into their practices -- to change “the tide of professional consensus” -- remains a challenge.

The 2003 Medicare drug law included an explicit mandate for comparative effectiveness research, and a call for the findings to be made available and accessible. (The AHRQ website has patient/consumer friendly sections). More resources for both research and health IT were included in last year’s stimulus package. “I love the turn of phrase patient-centered outcome research,” she told me. But if patients are going to make difficult choices, “it’s good to know what the science is behind those choices.”

One long-standing challenge has been how to get evidence into the clinic -- how to change physician habits and practices when change is warranted. There have been some successes. Giving beta blockers to patients who had a heart attack -- in the hospital and afterward -- is now so common that one of the main quality-monitoring groups doesn’t even measure it anymore, it’s done without outside prodding. But Clancy said it took about 25 years to get to that point. And many, many other challenges remain unsolved. Sometimes the science isn’t clear cut. But sometimes even clear science doesn’t bring about changes in the behavior or perceptions of clinicians or patients.

Health care reform has the potential to change the patient experience, to improve quality. But “it’s going to be a heavy lift” for the health care system. What makes Clancy excited about this particular moment in time, though, is that she sees around the country people and health systems that are already figuring it out. She cited Denver Health (a health system that, coincidentally, New America has also done some work with) as an example of a system that is doing higher quality care, more economically. And if they can save money where it isn’t needed, that frees up money for where it is needed.

People trying to improve health care quality used to focus on the doctor. Now they know it’s the system, Clancy said. “The clinicians would all do very well on an exam. They would ace it,” she said. “It’s not about knowledge. It’s about practical implementation. And we’re not going to get there one campaign at a time.” It’s going to take redesign and reinvention. Having good models of systems that are changing for the better -- whether it’s the sustained improvement that some Michigan hospitals have shown in reducing central line infections or an innovative small group medical practice in Wisconsin that has figured out how to provide high quality care while eliminating most of the irritating time patients spend waiting to see doctors or get tests -- will make it easier to move forward.

We asked what about health reform would give her the most excitement or joy, she said, simply having so many more people covered. People can’t have quality care, if they don’t have care in the first place.

“Our biggest joy will be when we examine how many people are uninsured, and its impact on health and health care. That will be the biggest joy, seeing that [uninsured] number go down… When we send Congress our annual report, we won’t have to have that section about what uninsurance does for the quality of care that you get.”

“And what excites me -- beyond the opportunity to make dramatic improvements in quality -- is the chance to give patients and families more of a voice in health care. There is growing interest in the opportunities that the Affordable Care Act provides to make this more about patients in families. That is what everyone in health care wants to do. It has been too provider focused -- not by design… Clinical care is going to look a whole lot different over the next few years. And we’ll know it is patient-focused when a patient can say [to a clinician or hospital] your services are organized around my life. Not the other way around.”