AHRQ director outlines priorities, supportive programs

“Quality performance and payment policy are not passing fads,” Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), told participants at the inaugural Orthopaedic Quality Institute (OQI). Dr. Clancy is widely respected in both the medical and political worlds and has frequently testified before Congress on how to make healthcare more efficient. She outlined her agency’s priorities, specifically in terms of improving quality in the delivery of musculoskeletal health care.

“There is too much guesswork in our current healthcare system,” said Dr. Clancy. “ARRA made unprecedented national investments in healthcare research, access, and delivery, so that we identify, support, and disseminate evidence on best practices to care providers.”

Comparing effectiveness
ARRA, for example, provided more than $1 billion to facilitate comparative effectiveness research, help fill the evidence gaps, and assist providers in making treatment recommendations for their patients. ARRA also earmarked more than $40 billion to increase the use of electronic health records by physicians and hospitals.

According to Dr. Clancy, ARRA laid the groundwork for the scientific infrastructure needed to meet the promises of PPACA. “PPACA established a national quality strategy with the goal of providing better, more reliable, more accessible, and less costly care to patients,” she noted. Part of that strategy involves constructing payment systems that reward quality rather than quantity and that encourage educating and involving patients in care decisions.

The Patient-Centered Outcomes Research Institute (PCORI), for example, is an independent organization, created by PPACA, to commission research that is guided by patients, caregivers, and the broader healthcare community rather than by industry. The goal of such research is to produce evidence-based information that can be used by all providers. AAOS fellow Kevin J. Bozic, MD, MBA, co-chair of the OQI and chair of the AAOS Health Care Systems Committee, sits on a PCORI advisory panel.

Within AHRQ, explained Dr. Clancy, is a similar program—the Effective Health Care (EHC) Program—that also seeks to use evidence-based medicine to help clinicians identify the best treatment strategies for patients. Among the studies conducted by the EHC program are the following:

• identifying the best pain management interventions for elderly patients with hip fractures
• examining the effectiveness of certain treatments for osteoarthritis (OA) of the knee
• assessing fracture prevention treatment for postmenopausal women with osteoporosis

Dr. Clancy reviewed the results of the knee OA study, which examined the use of supplements (glucosamine, chondroitin, or both combined), viscosupplementation (hyaluronic injections), and arthroscopic lavage and débridement of the knee. The study concluded that, based on available research, none of these treatments is effective for the general knee OA patient population and advised clinicians to consider other treatments.

With better evidence and more coordinated care, Dr. Clancy expressed her hope that by the end of 2013, preventable hospital-acquired conditions will decrease by 40 percent. A second goal of the project is to reduce the number of preventable hospital readmissions due to complications during a transition from one care setting to another by 20 percent.

The need for registries
Registries and other quality reporting mechanisms are also important for increased data aggregation. Registries across the globe have been used to identify evidence gaps, assess comorbidities, assist in postmarket device surveillance, define preoperative patient risks, and even define procedure prices within payment reform models.

The AHRQ has an orthopaedic hip and knee registry project, the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR). FORCE-TJR is currently collecting data from 30,000 patients in areas such as longitudinal pain and function and postprocedure complications and revisions.

AHRQ is also participating in efforts to create and enhance other orthopaedic registries such as the American Joint Replacement Registry (AJRR) and the International Consortium of Orthopedic Registries, an initiative funded by the U.S. Food and Drug Administration and organized by the Center for Musculoskeletal Outcomes and Patient-Oriented Research at the Hospital for Special Surgery in New York.

According to Dr. Clancy, orthopaedic registries can assist in defining “functional failure” of a total joint replacement. They can also be used to construct, validate, and refine prediction algorithms to identify patients who may be at risk. This information can then be translated into clinical practice guidelines that can lead to quality measures.

“This is a ‘we’ game…”
When audience members asked about including risk adjustment in the development of quality measures, Dr. Clancy acknowledged physicians’ anxiety about being unfairly penalized for performing operations on higher risk patients. Nonetheless, she maintained, “This is a ‘we’ game, not an ‘I’ game. Interest in assessing clinician performance will continue, and this evidence cannot be aggregated without the help and guidance from physicians.

“As long as the glaring variations in the quantity of never events, preventable hospital-acquired conditions, and preventable readmissions continue to occur and drive up healthcare costs in the United States, the demand for performance measures will continue.”

For more on the Orthopaedic Quality Institute, see “Who defines quality in orthopaedics?”

Madeleine Lovette is the communications specialist in the AAOS office of government relations. She can be reached at lovette@aaos.org

Additional Resources

Patient-Centered Outcomes Research Institute (PCORI)

Effective Health Care Program (EHC)

Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR)

American Joint Replacement Registry (AJRR)

International Consortium of Orthopedic Registries (ICOR)