You asked for information on evidence-based practice centers, particularly one at the Oregon Health and Science University.

SUMMARY

The federal Agency for Healthcare Research and Quality (AHRQ) contracts with 13 evidence-based practice centers (EPC) in the U. S. and Canada, including one at the Oregon Health and Science University, as an approach to improving the quality, effectiveness, and appropriateness of health care. The centers review research literature on various medical care and health systems topics and produce reports and technology assessments that synthesize the evidence. Their findings are communicated to federal and state agencies, professional societies, health delivery systems, providers, payers, and others in the field.

The Oregon EPC began operating in 1997. It is currently involved in three major projects: drug effectiveness, preventive services, and food-related health claims. The drug effectiveness project is a joint effort by several states and the Oregon EPC to obtain evidence on the effectiveness and safety of drug classes and apply it to public policy, especially the development of Medicaid preferred drug lists. The preventive service project assesses the merits of preventive measures, including screening

tests, counseling, immunizations, and preventive medications. The food-related health claims project supports a federal Food and Drug Administration’s initiative to give consumers scientifically based information about the likely health benefits of food.

Oregon has taken several steps to integrate evidence-based practice into state agency operations. A 2001 law required the state to establish a Medicaid preferred drug list based first on clinical effectiveness as demonstrated in peer-reviewed research and secondly on cost. In 2003, the legislature required the Office of Mental Health and Addiction Services to show during the budgeting process that an increasing percentage of its program funding is being spent on cost-effective, evidence-based practices.

NATIONAL FOCUS

The AHRQ contracts with 13 EPCs in the U. S. and Canada, including one at the Oregon Health and Science University. Two other U. S. EPCs are at public universities (North Carolina and Minnesota), while the others are private universities (Johns Hopkins, Stanford, Duke, Tufts) and private institutions (Rand, ECRI).

The EPCs review scientific and other studies to develop evidence reports and technology assessments on topics relevant to clinical, social and behavioral science, economic, and other health care organization and delivery issues—specifically those that are common, expensive, or significant for the Medicare and Medicaid populations. The intent is to improve the quality, effectiveness, and appropriateness of health care by synthesizing the evidence and communicating the findings to federal and state agencies, professional societies, health delivery systems, providers, payers, and others in the field.

The EPCs have conducted more than 100 reviews and analyses. Topics are chosen by professional societies, health plans, insurers, employers, and patient groups. They cover practices in a wide range of conditions and services such as cancer, pediatrics, endocrinology, cardiac, mental health, and quality improvement and patient safety. The EPCs conduct rigorous, comprehensive syntheses and analyses of the scientific literature. Their reports may include cost analyses. All EPCs collaborate with other medical and research organizations so that a broad range of experts is included in the development process.

Agencies and organizations use the reports as a foundation for developing and implementing their own clinical practice guidelines, review criteria, performance measures, and other clinical quality improvement tools, as well as for formulating policies related to specific health care technologies.

More information on the AHRQ program is available at http: //www. ahrq. gov/clinic/epc/.

OREGON EPC

The Oregon EPC began operating in 1997 under the auspices of the Oregon Health and Science University. John Kitzhaber, a former Oregon governor and physician, directs it. The center is currently involved in three major projects: drug effectiveness, preventive services, and food-related health claims. Further information on the EPC and each of these projects is available at http: //www. ohsu. edu/epc/.

Drug Effectiveness Review Project

This project is a joint effort by states and the Oregon EPC to obtain the best available evidence on the effectiveness and safety of a class of drugs and apply it to public policy, especially the development of Medicaid preferred drug lists. States pay a fee to participate, and they determine which drugs the center studies. The Oregon EPC conducts some reviews and contracts with EPCs at UCLA and the University of North Carolina to review other drugs.

To date, the project has released reviews of 20 drug classes including proton pump inhibitors, calcium channel blockers, and statins; it updates them every six months.

Preventive Services

The AHRQ contracts with the Oregon EPC to conduct reviews for the U. S Preventive Service Task Force, which is an independent panel of experts convened by the U. S. Public Health Service to evaluate clinical research assessing the merits of preventive measures, including screening tests, counseling, immunizations, and preventive medications. The center has examined topics such as the efficacy of screening for cholesterol, gonorrhea, and hip dysplasia and speech and language intervention strategies for children.

Food-Related Health Claims

The federal Food and Drug Administration (FDA) contracts with the Oregon EPC (through AHRQ) to review food-related health claims as part of its Consumer Health Information for Better Nutrition Initiative, which aims to provide consumers with scientifically based information about the likely health benefits of food. The FDA selects the claims to be reviewed. The EPC reports on the scientific basis for the claim and rates the strength of the evidence. FDA uses the reports in deciding whether to allow the claims in product labeling and advertising.

OREGON EVIDENCE-BASED PRACTICE LAW

Prescriptions

In 2001, at the urging of then-governor Kitzhaber, the Oregon legislature enacted a law requiring a preferred drug list for its Medicaid fee-for-service program (S. 819). This Practitioner-Managed Prescription Drug Plan must ensure that:

1. decisions concerning the clinical effectiveness of prescription drugs are made by licensed health practitioners, are based on the latest peer-reviewed research, and consider the health condition of a patient or characteristics of a patient, including the patient's gender, race or ethnicity; and

2. the cost of prescription drugs in the Oregon Health Plan (Medicaid) is managed through market competition among pharmaceutical manufacturers by publicly considering, first, the effectiveness of a given drug and, second, its relative cost.

In practice, for each drug class included on the drug list, the state first forms a subcommittee of physicians, pharmacists, and other healthcare or beneficiary specialists, who work with independent researchers from the Oregon EPC to conduct detailed literature reviews. Only after the clinical review process is complete and recommendations regarding products’ comparative effectiveness are prepared does the state Medicaid agency consider the prices of drugs deemed to be clinically effective or for which there is a lack of evidence to indicate one drug’s effectiveness over another. Interested parties may contribute testimony throughout most of the process, and the state posts all clinical reports supporting its selections on a state-run website (OregonRx).

Mental Health

Legislation in 2003 (SB 267, ch. 699) requires the Office of Mental Health and Addiction Services (and four other state agencies) to show that at least 25% of their program funding during the FY 06-07 budget biennium supports evidence-based programs. That percentage rises to 50% during the FY 08-09 biennium and 75% in subsequent bienniums. The law defines an evidence-based program as one that “incorporates significant and relevant practices based on scientifically based research” and is cost-effective. It requires each agency to assess existing programs and set goals to enable it to reach the targets. The agencies must report annually to the legislature on their spending, and the legislature may consider any agency’s failure to meet the targets in making subsequent budget decisions.

The law allowed the agencies to adopt implementing rules. The mental health office created work groups to further refine the definition of “evidence-based practice” and “cost-effective. ” For the former, it established a three-tier system based on the strength of the science and the efficacy of the practice in treatment settings. A copy of the legislation and further information on how the office implemented it are available at http: //www. oregon. gov/DHS/mentalhealth/ebp/main. shtml.

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