Welcome to the Center on Health Care Effectiveness

Journal Articles

• "Primum Non Nocere: Reconciling Patient-Centered Outcomes with Evidence-Based Care." Eugene C. Rich. Journal of Comparative Effectiveness Research, March 2013. This “Methods to Policy” piece discusses opportunities and challenges in reconciling increased demands for evidence to be “patient-centered” with the realities of highly diverse patient circumstances, preferences, and clinical situations.
• "Matching Study Designs to Disability-Related Comparative Effectiveness Research Questions." Jeffrey Ballou, Eugene Rich, and Matthew Kehn. Journal of Comparative Effectiveness Research, January 2013.This article presents methodological and design issues for researchers to consider when addressing disability-related comparative effectiveness research questions.
• "Commentary: Teaching Health Centers and the Path to Graduate Medical Education Reform." Eugene C. Rich. Academic Medicine, December 2012. This commentary discusses the lessons and opportunities presented through the Teaching Health Center Graduate Medical Education program and suggests that advocates of this should be cautious in applying lessons learned to broader graduate medical education policy reform.
• "Past as Prologue: How Comparative Effectiveness Research Became Patient-Centered Outcomes Research." Eugene C. Rich. Journal of Comparative Effectiveness Research, November 2012. This "methods to policy" piece outlines the evolution of comparative effectiveness research to patient-centered outcomes research in U.S. policy circles. It also addresses the real-world implications of this work for health care researchers, patients, providers, and other stakeholders.
• "The Implications of Comparative Effectiveness Research for Academic Medicine." Eugene C. Rich, Ann C. Bonham, and Darrell G. Kirch, Academic Medicine, June 2011. This article examines the central role academic medicine can play in the growth of comparative effectiveness research, the implications of this research for comprehensive health care reform, and opportunities to use evidence-based medicine to address high costs and suboptimal outcomes in the U.S. health care system.
• "Where Americans Get Acute Care: Increasingly, It's Not at Their Doctor's Office." Stephen R. Pitts, Emily R. Carrier, Eugene C. Rich, and Arthur L. Kellermann, Health Affairs, September 2010. This article examines the changing nature of first-contact care in the United States and its shift from primary care practitioners to emergency physicians, specialists, and outpatient departments. This pattern is far different from urgent access to primary care in other industrialized countries; and a dramatic departure from the image of the family doctor making home visits, so prevalent in the popular culture of a bygone era. Health reform provisions that advance patient-centered medical homes and accountable care organizations may need to take special measures to address this serious problem of acute care access. Only 42 percent of the 354 million annual visits for acute care—treatment for newly arising health problems—are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Almost all “after hours” acute care visits in the United States are to emergency department or other urgent care facilities; very few are currently with primary care physicians.
• "Commentary: Putting Evidence to Work: An Expanded Research Agenda for Academic Medicine in the Era of Health Care Reform." Ann C. Bonham, Eugene C. Rich, David A. Davis, David E. Longnecker, Stephen J. Heinig, Academic Medicine, August 2010. The historic Patient Protection and Affordable Care Act (HR 3590) has brought into sharp focus the need and opportunity for an expanded continuum of biomedical research. An updated research agenda must build on basic science and classical clinical investigation to place a more deliberate emphasis on patient- and population-outcome-oriented science and to apply science to help transform our current inefficient and expensive health care system into a more evidence-based system of effective, coordinated, safe, and patient-centered health care. If academic medicine is to play a leading role in this 21st-century transformation of health care through research, as it did in the 20th century, those in the community must think strategically about what needs to be done to be part of the solution for transforming the nation's health care delivery systems and prevention strategies, and the changes in institutional, organizational, and individual behaviors and values required to get there. Not all institutions will engage in the science called for in health care reform, but for those institutions with the interest, capacity, and resources to move forward, what is needed?
• Patient-Centered Medical Homes
  A national symposium on the patient-centered medical home brought together experts in primary care, health services and implementation research, health systems and insurance, as well as policymakers to develop a research agenda. The commissioned papers, reflecting discussions at the conference, are in the June issue (subscription required) of the Journal of General Internal Medicine:
  
  "Using Evidence to Inform Policy: Developing a Policy-Relevant Research Agenda for the Patient-Centered Medical Home." Bruce Landon, James Gill, Richard Antonelli, and Eugene Rich. This paper summarizes the symposium.
  
  "U.S. Approaches to Physician Payment: The Deconstruction of Primary Care." Robert Berenson and Eugene Rich. This paper addresses why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home and the relevance of payment reforms, such as pay-for-performance and episodes/bundling.
  
  "How to Buy a Medical Home? Policy Options and Practical Questions." Robert Berenson and Eugene Rich. This paper describes payment options to support the patient-centered medical home and identifies conceptual strengths and weaknesses.
• "Prospects for Rebuilding Primary Care Using the Patient-Centered Medical Home." Bruce Landon, James Gill, Richard Antonelli, and Eugene Rich, Health Affairs (subscription required), May 2010. This article analyzes potential barriers in the U.S. to the patient-centered medical home model, which is considered policy shorthand for the reinvention of primary care. Barriers include developing new payment models, personnel and infrastructure funding, and methods to facilitate transforming existing practices to functioning medical homes.

Issue Briefs

• "Orthogonal Design: A Powerful Method for Comparative Effectiveness Research with Multiple Interventions." Issue Brief. Jelena Zurovac and Randy Brown, April 2012. Orthogonal design affords an opportunity to design interventions in real-world settings and to study intervention components that can be implemented in various ways. This issue brief introduces orthogonal design, describes key design and implementation considerations, and illustrates how it can be applied in comparative effectiveness research studies.
• "Consumer and Provider Perspectives on Shared Decision Making: A Systematic Review of the Peer-Reviewed Literature." Nyna Williams and Chris Fleming, September 2011. This brief reports on findings from a systematic review of the peer-reviewed literature on consumer and provider perspectives on shared decision making, the process by which consumers join providers in the clinical decision-making process. The use of comparative effectiveness research rests on greater engagement in shared decision making by providers and consumers.
• "Choosing Wisely: Selecting Outcomes for Comparative Effectiveness Research on Services for Adults with Disabilities." Debra Lipson, Matthew Kehn, and Eugene Rich, July 2011. This issue brief lays out criteria to help researchers select and report on the outcomes that matter most to adults with disabilities and to the providers and others responsible for their care.
• “Matching Study Designs to Research Questions in Disability-Related Comparative Effectiveness Research." Jeffrey Ballou, Eugene Rich, and Matthew Kehn, July 2011. Individuals with disabilities have complex characteristics and health service needs, which can make strong study design and implementation a challenge. Because of this complexity, randomized controlled trials, the “gold standard” of study design to evaluate evidence, may not always be necessary or even ethical. This research brief offers strategies and guidance help researchers enlarge the set of study designs to help use comparative effectiveness to answer disability-relevant health care questions.
• "Comparative Effectiveness of Care Coordination for Adults with Disabilities." Melanie Au, Samuel Simon, Arnold Chen, Debra Lipson, Gilbert Gimm, and Eugene Rich, July 2011. Care coordination for adults with disabilities is typically marked by costly services delivered by a variety of providers, but comparative effectiveness research can help address these challenges. This research brief presents a framework for describing the range of personal characteristics, services, outcomes, and financing issues to consider in a systematic review of care coordination. It also presents key findings from a systematic review of the recent care coordination literature, summarizes what additional information is needed, and discusses implications for future research on which care coordination strategies work best for various disabled populations.
• "Identifying, Monitoring, and Assessing Promising Innovations: Using Evaluation to Support Rapid-Cycle Change." Marsha Gold, David Helms, and Stuart Guterman, June 2011. This issue brief examines the mission of the Center for Medicare and Medicaid Innovation, as well as challenges in balancing relevance and rigor to learn how to improve payment and delivery.
• "Using Comparative Effectiveness Research: Information Alone Won’t Lead to Successful Health Care Reform." Topics in Health Care Effectiveness #2. Dominick Esposito, Arnold Chen, Margaret Gerteis, and Timothy Lake, December 2010. To provide better value and improve patient care in the U.S. health care system, comparative effectiveness research (CER) needs to be disseminated, implemented, and interpreted. This brief examines how to put CER into use at the point of care, focusing on knowledge translation, provider incentive reform, delivery system transformation, and consumer engagement.

Other

• "Paying Wisely: Reforming Incentives to Promote Evidence-Based Decisions at the Point of Care." White paper. Eugene C. Rich, Tim Lake, and Christal Stone Valenzano, October 2012. This white paper describes how current financial incentives in the fee-for-service (FFS) system can lead to the over- and underuse of services at the point of care by physicians and other clinicians. It explores prominent payment reform models and concludes that no single approach consistently rewards evidence-based care. The paper also suggests that more targeted use of these models—grounded in recalibrated FFS—might be the most effective way to neutralize incentives and facilitate evidence-based decision making at the point of care.