National reports show it takes 17 years[1] before medical research is put into practice by health care providers. Why does it take so long? Are there levers or tools, such as payment incentives or provider education, that state health policymakers can use to bridge that gap?
The National Academy for State Health Policy (NASHP) recently convened a workgroup of state policymakers to monitor emerging patient-centered outcomes research and explore potential policy implications. The group will also provide guidance on effective dissemination and implementation strategies that could lead to putting research into practice sooner. The workgroup includes officials from 10 states, including Medicaid, insurance, patient, mental health, labor, and public health representatives and state legislators.
NASHP, in partnership with the Center for Evidence-based Policy and with support from the Patient-Centered Outcomes Research Institute (PCORI), kicked off the workgroup in January 2018 by exploring two recently-published studies. The first examined interventions to address childhood obesity and the second assessed the impact of a shared decision-making tool for patients presenting in the emergency room (ER) with chest pain — the second most common reason for ER visits in the United States, which represents 8 million annual visits. Both studies were funded by PCORI, which supports comparative effectiveness research and engages patients at every step of the research process so their perspectives inform research topics, design, and outcomes, which benefit them as the ultimate health care user.
The workgroup considered the research and raised two key questions about when and how they should engage with research to improve health care in their states:
- Does this evidence merit action?
- If yes, how is this evidence actionable? What policy levers, strategies, or tools can state health policymakers use to put this evidence into practice?
When Does Evidence Merit Action?
Policymakers are generally hesitant to make decisions based on a single study, and instead seek to understand evidence based on a wider body of literature. To help with that process, the Center for Evidence-based Policy presented relevant systematic reviews to the workgroup on childhood obesity interventions[2] and shared decision making.[3] These reviews helped the workgroup members establish that the studies and their findings were consistent with the published literature.
PCORI is also helping to put research into context for policymakers by piloting economic impact models for a number of PCORI-supported studies. For example, one study examined self-monitoring of blood sugar levels among patients with type 2 diabetes who are not using insulin. At the end of the one-year study, there were no differences in blood sugar levels and quality of life between patients who checked their blood sugar levels with finger pricks daily and those who did not.[4] These findings illustrate the potential for cost savings on unnecessary testing supplies, savings that would be magnified if the research is adopted more widely into practice.
How Is Evidence Actionable?
When research merits action because of its health and/or economic impact, what policy levers do state health policymakers have? The answer to this question is not always obvious, especially when the research focuses more on a clinical level rather than at a health program administrative or delivery systems level. State officials, however, are eager to consider what actions they may be able to take when the evidence supports a change or new direction.
- Could a state Medicaid agency seek to use payment as a lever to encourage providers or consumers to utilize certain services?
- For example, the US Centers for Disease Control and Prevention’s 6/18 Initiative is working with Medicaid programs to use payments as a lever to advance evidence-based prevention, such as eliminating copays for smoking cessation programs in South Carolina.
- Are there opportunities for states to use their managed care health plans to put evidence into practice? When appropriate, could a managed care organization implement a change through quality improvement efforts?
- For example, Tennessee, as part of its Medicaid quality improvement efforts, is increasing the use of pediatric preventive services by creating incentives for managed care organizations through a pay-for-performance program.
- Are there educational outreach strategies such as practice facilitation or academic detailing that a state could use to implement evidence in practice?
- For example, through the Agency for Healthcare Research and Quality’s (AHRQ) EvidenceNOW initiative, state cooperatives are using practice facilitation and academic detailing to improve primary care providers’ performance on cardiovascular disease prevention.[5]
Looking forward, the workgroup expressed interest in exploring emerging evidence related to improving health care systems such as care coordination efforts through behavioral health homes or emerging workforce roles such as peer health navigators. They also expressed interest in studies related to reducing disparities through tele-health. Future blogs will explore discussions of policy implications of new research on these topics and others.
Notes
[1] Institute of Medicine (IOM). 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press.
[2] Emma Mead, et al. “Diet, physical activity and behavioral interventions for the treatment of overweight or obese children from the age of 6 to 11 years,” Cochrane Database of Systematic Reviews 2017. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012651/abstract
[3] Dawn Stacey, et al. “Decision aids for people facing health treatment or screening decisions,” Cochrane Database of Systematic Reviews 2017. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001431.pub5/abstract
[4] https://www.pcori.org/research-results/2013/does-daily-self-monitoring-blood-sugar-levels-improve-blood-sugar-control-and
[5] For more information, see NASHP’s recent brief: Lessons in Advancing Evidence-Based Primary Care from the Heart of Virginia Healthcare EvidenceNOW Cooperative