The Agency for Healthcare Research and Quality and the Development of a Learning Health Care System.

Opinion VIEWPOINT Andrew B. Bindman, MD Department of Medicine and Philip R. Lee Institute for Health Policy Studies, University of California– San Francisco, San Francisco. Corresponding Author: Andrew B. Bindman, MD, Philip R. Lee Institute for Health Policy Studies, University of California– San Francisco, 3333 California St, Ste 265, San Francisco, CA 94118 (andrew .bindman@ucsf.edu). jamainternalmedicine.com The Agency for Healthcare Research and Quality and the Development of a Learning Health Care System The Agency for Healthcare Research and Quality (AHRQ), of which I was the director from May 2016 un- til January 2017, has played a leading federal role in pro- moting evidence-based medicine through its support of health services research, the synthesis of clinical re- search findings into evidence, and strategies to move evi- dence into practice. Although evidence-based medi- cine remains an aspirational goal, studies consistently show gaps between optimal care as determined by re- search evidence and actual practice. 1 In this Viewpoint, I describe a strategy begun during my time at AHRQ that has the potential to be more effective than prior ap- proaches for moving evidence into practice. AHRQ has regarded the synthesis of research find- ings on a topic, with rigorous statistical and other scien- tific techniques to be the highest form of evidence. Thus, the agency has supported the methods and the actual work of doing this by partnering with evidence-based practice centers located at 13, primarily academic, insti- tutions in the United States and Canada, which pub- lished 56 evidence reviews on prevention, treatment, and delivery system topics in 2016. 2 The predecessor of AHRQ, known as the Agency for Health Care Policy and Research (AHCPR), would take the additional step of translating the findings from evi- dence reviews into practice guidelines. However in some cases, most notably a guideline related to treatment of back pain, a group of clinicians, who perceived that their clinical decision making and autonomy were being threatened by federal practice guidelines, sought to un- dermine the agency’s role in this work. These clinicians organized a lobbying effort in Congress, which resulted in the renaming of AHCPR as AHRQ, a reduction in the agency’s budget, and the elimination of guideline de- velopment as a part of the agency’s functions. 3 As an alternative to producing clinical guidelines, AHRQ began working with clinical specialty societies to support the implementation of evidence into practice, a role that specialty societies have embraced. These or- ganizations are invited to nominate topics for AHRQ to conduct an evidence review. Once the reviews are com- pleted, the hope is that the specialty societies will use the findings to issue guidance to clinicians. Although AHRQ is not responsible for the development of the guidelines, it maintains the National Guidelines Clearinghouse. 4 For many clinicians, specialty societies are trusted and influential sources of information on practice. How- ever, there are limitations in relying on them to broker information between investigators and clinicians. Spe- cialty societies are not in a position to understand the wide range of workflow challenges clinicians face in implementing their guidance. Furthermore, specialty so- cieties also lobby on behalf of the financial interests of their members, which can introduce a conflict for inter- preting evidence and issuing practice guidance. The con- tradictions in guidance among specialty societies may contribute to variation in practice even within the same health care system, and thereby undermine patients’ ability to have consistent information with which they can participate in shared decision making. Given the large gaps in time between the produc- tion of new knowledge and its application in practice, the current approach to disseminating evidence to clini- cians seems inadequate. Patients can be deprived of information about potentially beneficial treatment ap- proaches, and the lack of a system to counteract differ- ential rates of dissemination among clinicians who care for patients with different social characteristics may con- tribute to health care disparities. The rapid consolidation of physicians into health care organizations provides another means for disseminating evidence that could improve the inconsistent results achieved by relying on specialty societies. Motivated in large part by alternative payment models that hold clini- cians accountable for cost and quality, these organizations have a need to be consistent in their practices and to de- velop their capacity to become learning health care sys- tems, which can continually improve care over time. Learning health care systems adopt evidence on a systematic basis and ensure that it is incorporated into decision making throughout the organization in a con- sistent way. 5 This can be evidence developed outside or within the organization, such as through the analysis of electronic health data. The goal is not to have all pa- tients with a similar clinical need receive the same treat- ment, but rather to ensure that patients receive consis- tent information regardless of their clinician or the specific location of care. Patients require consistent in- formation to engage in shared decision making. The path to becoming a learning health care sys- tem is unchartered territory for most health care orga- nizations. If they are to succeed, they will need help in developing processes for adopting, generating, and ap- plying evidence. Because AHRQ is neither a payer nor a regulator, it is the federal agency best positioned to serve as a facilitator that can help health care organizations to make this transition. AHRQ has relevant experience in establishing the scientific methods health care organi- zations can use to judge the quality of evidence they gen- erate from their own data or that they wish to adopt from external research. AHRQ has also had success in build- (Reprinted) JAMA Internal Medicine Published online May 25, 2017 © 2017 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/intemed/0/ by a UCSF LIBRARY User on 06/14/2017 E1