Multilevel Interventions in Health Care Conference: Discussant comments by Thomas Vogt, MD, MPH
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Multilevel Interventions in Health Care Conference: Discussant comments by Thomas Vogt, MD, MPH

discussion for this session is Tom Vogt. I can tell, he’s got
his hands full with this group. But he’s a former
senior investigator at Kaiser Permanente Center for
Health Services Research. His work is investigating
improving prevention services in medical care settings, the
quality and cost of preventive care, primary
care organization, and satisfaction with care
across several states and multiple managed care systems.
And it looks like he’s more than prepared to deal
with this group. So, without further ado
I’ll let Tom go ahead.>>>[APPLAUSE]>>>TOM VOGT: Thank you. I’m
not sure anyone is prepared to deal with this group,
but I’ll start out. I’m not going to
show you slides. I made some, and I looked
at them and didn’t like them because as I thought
about these papers, I sort of – synthesis of them
came together and so I am going to do this verbally. I do have
slides and they’ll be in the little thumb drive you’ve
got, if you must see them. But they’re not my preferred
approach at this point. I want to start out by
talking about what a practical multi-level
intervention should have. What are the characteristics
that we’re shooting for here? Well, I thought about
categorizing in light of the three presentations
that you’ve just heard. And when I started that I
had notes all over the place. And as I looked at those notes
they sort of distilled down into the following points.
One, a practical multi-level intervention should be
broadly applicable. It should apply to a lot of
folks because otherwise you’re wasting a lot of time and
money on the few that it does apply to. It should be
effective across multiple levels, which is both a design
issue and a synergy issue. And we’ve been talking
about both of those things. It should be adopted
across multiple levels, which of course is
synergistic approach. It should be implemented
faithfully, meaning that the design of what you put in
place should reflect the knowledge base at the time you
do the design of the study. It should learn from the past.
And then finally, it should be maintained over a
long period of time. The time issue that Dr.
Alexander was discussing. And it should be maintained,
not just in one level but presumably in multiple levels,
although that’s a question in itself. Now, if you think
about the points that I just made and you list them like I
did and you redefine them, they look a lot like
reach, efficaciousness, adoption, implementation and
maintenance. Which using those terms you may have heard
because Dr. Glasgow is the father and grandparent
of the REAIM model, and is sitting out there. And
it seemed to me the REAIM model applies not just to single
interventions but it applies to how you would approach the
design and the evaluation of multiple level interventions
considering all those elements. But it isn’t sufficient;
it’s a place to start. There are some badly needed
things that we rarely discuss and that I’m going to take the
opportunity of standing up here to mention, because I think
that in some ways our approach to behavioral interventions
in general is sort of like the story of the emperor’s new
clothes. And I should warn you, I’m going to use two
clichés in this talk and this is the first one. The
emperor’s new clothes. I think clichés are clichés
because there’s almost always some truth to them. In the
story of the emperor’s new clothes you will recall the
emperor was convinced to walk around naked and he told
everybody how wonderful and beautiful his new
clothes were so everybody believed him until some
naive little child said, he doesn’t have any clothes
on. And suddenly everybody realized that the child was
right. Well, I think in our interventions there are
some examples like that. I think the most effective
prevention intervention I have encountered in my entire career
was the implementation of HITA standards for integrated
health care systems in the early 1990’s. In those days
integrated health care systems were being dogged by various
contractors to give data, and they all wanted something
different, so they finally got together and agreed that
NCQA would do these HITA standards and everybody would
be providing the same data. In a single year immunization
and screening rates increased by 50 to 100% in nearly all
the participating health care systems. I challenge you to
find any better intervention in all of our studies,
50 to 100% in one year. Why did that happen? It happened
because the health care systems involved made a
budget for doing it. And it happened because
they made the people who were supposed to do it accountable
for doing it and doing it right. And in one year
everything changed. Budget and accountability
is something I never see in behavioral studies. It’s not
measured, it’s not a variable, but it is crucial. If you
don’t have it in the budget, even if it’s implemented it
will fade away. And I think we’ve all experienced
that. Besides budget and accountability, the impact
must be sustained over time. I think that there are some
opportunities right now that are new for all of us as
researchers, that have not been available before that
will help us do multi-level interventions at least
in health care systems, which is the one we’re
talking the most about. For those of you who haven’t,
some of you in this room have been participating in
these. But those who haven’t, I think you may not realize
the degree to which progress has been made in standardizing
and collapsing across health care systems longitudinal
electronic medical records data to ask questions at reasonable
cost that we’ve never been able to ask before. Some of my
colleagues and I have been doing this for more than ten
years in the Kaiser Permanente system, which is just one
member of the National HMO Research Network, which now
has a virtual data warehouse that covers more than 15 million
people across 18 health care systems. And it isn’t easy,
but it is now possible to collect data on total
populations of health care systems over long periods
of time, a decade or more. And that offers extraordinary
opportunities to create historical prospectus studies
in ways that we’ve never been able to do before. Those
don’t prove necessarily that they’re correct, but they
give us a new avenue for developing hypotheses and
looking at questions that we simply can’t look at in
randomized trials because they’re too expensive
and too long term. So having said that, I would
advise those of you who are interested to get in touch with
some people who have worked with those kinds of data.
Jane Zapka sitting down here has done that, and so have
several others in this room. Diana Buest, I saw her
somewhere. And I would like to finish by going back to
my second cliché which is the old story about the
drunk who is crawling around on the ground and the
policeman walks up and says what are you looking for? And
he said, my keys, I lost my keys. And the policeman says,
well where did you lose them? And he said, well over in
the alley over there. And the policeman says, why
are you looking for your keys here under the streetlight,
and he said because it’s dark in the alley. And the point I am
going to bring up with that, and I think this is crucial
crucial if we want to do effective multi-level
interventions, if we want to address the problem that Dr.
Quisney raised this morning that we ranked 36th in the
world in life expectancy, but that was in the year 2000,
and in 2009 we ranked 52nd. So that’s the direction that
we’re going. And that is, we have to acknowledge as
researchers even if our benefactors at the National
Cancer Institute or other NIH institutes are
not allowed to acknowledge, that the problem when we want
to look at cost effectiveness and cost containment that is
responsible for poor and overly expensive U.S. health
care, is largely not scientific but social and political. And
it was the original proposals from the Obama Administration
to reform health care included clear attempts
to reduce costs. For example, the outrageous
notion that Medicare might be able to negotiate drug prices.
Congress refused to allow them to do that. All of the
cost cutting elements of the original proposals
were stripped. Which is pretty much
what killed the 1994, 1993 attempt at reform in
the Clinton Administration. Don’t researchers have an
obligation to start talking about the social and
political contributions to ineffective and overly
expensive care? Thank you.>>>[APPLAUSE]

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