The Agency for Healthcare Research and Quality (AHRQ) hosted its fifth annual conference, which some attendees refer to as "AHRQ-A-Palooza," September 19-21 in Bethesda, MD. Nearly 1,800 individuals attended the event in person or via the Webcasted plenary sessions to explore the conference theme of "Leading Through Innovation and Collaboration." Choosing that theme, said Carolyn Clancy, M.D., AHRQ director, brings "attention to the urgent need for addressing the challenges that we face" and "points to the need for collaboration with others, both in and outside of the industry, to achieve the kind of improvements that will truly be transformational."
Panelists for the first plenary, "Addressing Health Care Disparities, Access, and Quality of Care," discussed approaches and considerations for reducing disparities in health care. "This is one of those issues for which there is almost universal agreement. We all want to eliminate disparities in care," Dr. Clancy said. "Mention it in a talk, and applause often breaks out spontaneously. Yet, in practice, the gap between that applause and taking that first step sometimes feels really, really big." Panelist Gary R. Gunderson, D.Min., M. Div., senior vice president for the Faith & Health Division at Methodist Le Bonheur Healthcare in Memphis, TN, provided an overview of his hospital's "audacious" first step that involved building a "web of trust" among 400 congregations to reduce health care disparities in Memphis. With the help of a local chaplain, he began tackling the misperception that hospitals see the community's needs first. "Actually, we don't. [Communities] are the ones who know before we do, in greater detail and further intricacy, what it is like to live on the ground in Memphis," he said.
The congregational partners have taught Gunderson's hospital that the critical issue the community faces is not communication but navigation. To address that problem, his team mapped the health care assets available in the community and found that a lot of what they thought they needed was already there. Now "navigators" are in place in hospitals so hospital and primary care partners can help people access the "extraordinary abundance of assets," Dr. Gunderson said. Susan Vega, manager of senior programs at Alvio Medical Center in Chicago, IL, is also a fan of this asset-based community planning approach. When patients visiting her center are eligible for public assistance programs, she helps them complete the paperwork instead of referring them to another office. And she does not wait for people to come through her door; she finds them through school-based clinics, health fairs, and community events, and ensures that everyone who hears her speak has a name and a phone number to call if they need her help navigating the system. Policy, unfortunately, can often worsen disparities, said Herb C. Smitherman, Jr., M.D., M.P.H., assistant dean, Community and Urban Health at Wayne State University in Detroit, MI.
For example, if individuals are on Medicaid, they lose that health insurance once they get a job. Then, because they can no longer afford to see their doctor, they can't get their medications, they get sick, and they lose their job. "This is social policy and it's really driving our health policy," Dr. Smitherman said. Innovative programs, though, can make inroads in reducing disparities and cost while improving care. Dr. Smitherman cited a 5-year program that helped Detroit's private hospitals reduce their uncompensated care costs, which were totaling $400-$500 million each year. By putting community health workers in every hospital emergency room, they were able to identify uninsured patients who were relying on emergency room care for common colds or answers to medication questions and connect 33,000 of these uninsured patients to primary care providers. As a result, today these patients get better care that costs less.
Ms. Vega also stressed the pressing need for more bilingual clinicians to reduce disparities. Her group tracks the number of bilingual individuals enrolled in nursing programs and has found that if every slot were taken by a bilingual individual, the need for bilingual nurses would still outpace the demand. Bridging language barriers is one part of reducing disparities. But the problem is larger than that, said Rhonda M. Johnson, M.D., M.P.H., medical director of Health Equity and Quality Services at Highmark, Inc., in Pittsburgh, PA. "We have to have a disparity lens on everything we do. I think sometimes it feels overwhelming, because the problems are so large and they are so ingrained. There's social, there's health care, there's access, there's language and communication, and the list goes on and on. But the lesson I have learned is that you have to start somewhere. You must build a collective consciousness so the efforts to address disparities have uptake and spread."
Unveiling a New Campaign
Attendees at the first plenary also got a sneak peek of AHRQ's updated "Questions are the Answer" initiative. The initiative includes an original series of new videos on the AHRQ Web site, , that features real patients and clinicians discussing the importance of asking questions and sharing information to get high-quality care and better health outcomes. Unfortunately, the reality is that decreased reimbursements are forcing doctors to see more patients, which reduces the amount of time doctors have to talk with patients, noted Dr. Smitherman, a practicing physician for 25 years. He spoke of a woman he treated who had had at least $30,000 worth of diagnostic tests in three different emergency rooms and was facing a cardiac catheterization. His diagnosis, after spending 20 minutes getting her health history, was that she had heartburn. "It took time, which we have less and less and less of," he said. "Communication, communication: I can't overemphasize it."
Panelists for the second plenary, titled "Addressing Health System Change, Patient Safety, and Quality of Care," focused on innovation and implementation. "With quality, the good news is that the latest AHRQ National Healthcare Quality Report shows statistically significant improvement every year, across all populations and settings, since 2003. The slightly less good news is that the magnitude of those improvements is very modest, usually in the 1 to 2 percent ballpark. We're moving in the right direction—I don't want to discount that—but it's slow," Dr. Clancy said. The panelists all agreed that implementing innovations quickly is challenging. Arnie Milstein, M.D., M.P.H., professor of medicine at Stanford and Director of the Stanford Clinical Excellence Research Center, said that cost-lowering, health-improving innovations might have quicker uptake if they move large numbers of patients and their revenue to providers who are willing to be accountable, for example, by participating in outcome registries that can be used to measure care quality.
Market forces do influence how quickly innovations are adopted. "There's no question that until purchasers and payers really crack the whip, this is not going to go as fast as we want it to go," said Molly Joel Coye, M.D., M.P.H., chief innovation officer for the University of California Los Angeles Health System. "We know there is a lot of money that can be saved everywhere in the country if the systems get really serious about how to do that." Appreciating that system change is crucial for innovation adoption is also essential if hospitals are to be successful adopters. "If they don't have clear systems in place to actually be able to do it, and if they don't have the driving force and the clear steps that are needed, it's very easy to go off track," Dr. Coye said.
She cited the Veterans Administration's (VA's) success in monitoring chronic disease in the community, noting that if other health systems tried to duplicate the VA's work they might be misguided by buying in-home monitoring technology, not realizing that the VA's program is based on a system, not a technology. One innovation that has achieved noteworthy spread is a Comprehensive Unit-based Safety Program (CUSP) that virtually eliminated blood stream infections in Michigan, saving 1,500 lives and $100 million annually. The protocol is now being implemented across the United States and has reduced blood stream infections by 60 percent. The father of CUSP is Peter Pronovost, M.D., Ph.D., a practicing anesthesiologist and critical care physician and senior vice president for patient safety and quality at Johns Hopkins University in Baltimore, MD. He attributes the success of the project to the fact that the protocol uses a measure that clinicians believe is valid, is guided by implementation science, and involves a community of clinicians.
"Clinicians saw this as a social problem that they were capable of solving," he said. Dr. Pronovost added that the biggest barrier was overcoming the belief that you actually couldn't take a solution to a problem and bring it to scale across the country. He used the example of Roger Bannister breaking the 4-minute mile in 1954, even after physicians said the human body wasn't capable of this feat. Once Bannister broke that record, many, many others—including 10 male high school runners in a track meet in Falmouth, MA in August—accomplished that feat as well. "I think the only thing that changed was their belief," he said. "Roger Bannister freed up what was possible and in doing so it empowered all these other people to say, 'Hey, we can do that too.' That's what you and the people at AHRQ are trying to do."
Editor's Note: The plenary session Webcasts and session speaker presentations will be posted on the AHRQ Web site later this fall. The 2012 AHRQ Annual Conference will be held September 9-12 at the Bethesda North Marriott Convention Center in Maryland.