Tracking the Nation

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Tracking the Nations Health Care The National
Healthcare Quality and Disparities Reports

• Edward Kelley
• Ernest Moy
• Center for Quality Improvement and Patient Safety

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Reports Mandates

• Mandated by Congress in the Healthcare
• Research and Quality Act (PL. 106-129)
• Beginning in fiscal year 2003, the Secretary,
  acting through the Director, shall submit to
  Congress an annual report on national trends in
  the quality of health care provided to the
  American people.
• To track prevailing disparities in health care
  delivery as it relates to racial factors and
  socioeconomic factors in priority populations

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Why are the reports important?

• New tools for monitoring health care delivery
• Summarize information
• Makes clear where improvement is most needed
• Provide consensus on what is important to measure
• Facilitates measurement alignment

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How the NHDR and NHQR are Related
NHQR NHDR
Snapshot of quality of health care in America Snapshot of disparities in health care in America
Quality Quality Access
Safety, effectiveness, timeliness, patient centeredness Equity
Variation across states Variation across populations
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How the Reports Fit into AHRQs Focus on
Implementation

• Purpose of the Reports
• To promote awareness of the status of health care
  quality and disparities in America and

• To lead to action and support AHRQs overall
  mission to improve the quality of health care
  for all Americans.

Quality?
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Who Helped Design the NHQR?

• Public and private call for measures
• Measure set culled with HHS agencies
• Released for public comment, provider
  associations, industry gave feedback Final
  proposed measure set approved by HHS partners

ASPE, CDC, HRSA, CMS, NCHS, SAMHSA, NIH, Data
Council, HIS, FDA
AMA, AHA, JCAHO, Midwest Business Group on
Health, NAHDO, NASHP, IOM, general public
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Conceptual Framework
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Priority Areas What Conditions are Included?

• Defined by national experts brought together by
  IOM (Bill Roper, co-chair)
• Aligned with HHS existing prioritiesHP2010,
  Secretarys prevention agenda, IOM priority areas
• Includes cancer, chronic kidney disease,
  diabetes, heart disease, HIV/AIDS, maternal and
  child health, mental illness-depression,
  respiratory illness (e.g., asthma, flu), nursing
  home and home health, patient safety, timeliness,
  patient centeredness, resource consumption

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Who Has Helped Design the
NHDR?

• AHRQ-led effort starting in 2001
• IOM Committee on Guidance for Designing a NHDR
• DHHS
• Interagency Workgroup for the NHDR ACF, AoA,
  ASH, ASL, ASPA, ASPE, CDC, CMS, FDA, HRSA, IHS,
  NCHS, NIH, OCR, OMH, SAMHSA
• Data Council
• Extensive input from other organizations
  stakeholders
• Congressional staff, Asian and Pacific Islander
  American Health Forum, American Association of
  Health Plans, Association of State and
  Territorial Health Officials, National Rural
  Health Association, NMA, AAFP, AMA, ANA, AAHP

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NHDR Conceptual Framework
Quality of Care Quality of Care Quality of Care Quality of Care
Effective-ness Safety Timeli-ness Patient Centered-ness
Staying Healthy Staying Healthy Staying Healthy Staying Healthy
Getting Better Getting Better Getting Better Getting Better
Living with Illness or Disability Living with Illness or Disability Living with Illness or Disability Living with Illness or Disability
Coping with the End of Life Coping with the End of Life Coping with the End of Life Coping with the End of Life
Access to Care Access to Care Access to Care Access to Care Access to Care
Entry Barriers Structural Barriers Cultural Barriers Use Costs
Staying Healthy Staying Healthy Staying Healthy Staying Healthy Staying Healthy
Getting Better Getting Better Getting Better Getting Better Getting Better
Living with Illness or Disability Living with Illness or Disability Living with Illness or Disability Living with Illness or Disability Living with Illness or Disability
Coping with the End of Life Coping with the End of Life Coping with the End of Life Coping with the End of Life Coping with the End of Life
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What is in the NHDR?

• For the first time, the NHDR
• Tracks disparities at the national level
• Reports on disparities in terms understandable by
  patients and providers
• Gives policymakers, researchers and providers
  information to reduce disparities
• Report chapters
• Quality of Health Care
• Access and Receipt of Health Care
• Priority Populations

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Measure Selection Process

• Identify pool of candidate measures
• Map candidate measures into conceptual framework
• Evaluate and vet candidate measures
• Identify draft measure set
• Analysis of draft measure set
• Finalize final 2003 measure set
• Review and vet 2003 measure set
• Finalize 2004 measure set

Call for measures 600-700 NHQR/NHDR measures
2003 reports 150 NHQR measures 240 NHDR
measures
2004 reports 178 NHQR measures 238 NHDR measures
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Measure Topics

• Quality of Health Care
• Effectiveness
• Cancer, Diabetes, ESRD, Heart Disease, HIV/AIDS,
  Maternal and Child Health, Mental Disease,
  Respiratory Disease, Nursing Home and Home Health
  Care
• Safety
• Timeliness
• Patient centeredness

• Access to Health Care
• Getting into the system
• Insurance, Usual Source of Care, Perceptions of
  Need
• Getting care within the system
• Perceptions of care
• Patient-provider communication, relationship
• Health care use

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AHRQ Priority Populations

• Women
• Children
• Elderly
• Racial and ethnic minorities
• Low-income
• Residents of rural areas
• Persons with special health care needs
• Disabled
• Chronic care
• End of life

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Databases

• Surveys collected from samples of civilian,
  noninstitutionalized populations
• AHRQ, Medical Expenditure Panel Survey (MEPS),
  1998-2000
• California Health Interview Survey (CHIS), 2001
• CDC-NCHS, National Health and Nutrition
  Examination Survey (NHANES), 1999-2000
• CDC-NCHS, National Health Interview Survey
  (NHIS), 1998 and 2000
• CDC-NCHS/National Immunization Program, National
  Immunization Survey (NIS), 2001
• CMS, Medicare Current Beneficiary Survey (MCBS),
  1999
• The Commonwealth Fund, Health Care Quality
  Survey, 2001
• NCHS, National Health and Nutrition Examination
  Survey (NHANES), 1999-2000
• NCHS, National Health Interview Survey (NHIS),
  1998 and 2000
• NCHS, National Immunization Survey (NIS), 2001
• SAMHSA, National Household Survey of Drug Abuse
  (NHSDA), 2000.
• Data collected from samples of health care
  facilities
• CDC-NCHS, National Ambulatory Medical Care Survey
  (NAMCS), 1999-2000
• CDC-NCHS, National Home and Hospice Care Survey
  (NHHCS), 2000
• CDC-NCHS, National Hospital Ambulatory Medical
  Care Survey-Outpatient Department (NHAMCS-OPD),
  1999-2000
• CDC-NCHS, National Hospital Ambulatory Medical
  Care Survey-Emergency Department (NHAMCS-ED),
  1999-2000
• CDC-NCHS, National Hospital Discharge Survey
  (NHDS), 1998-2000
• CDC-NCHS National Nursing Home Survey (NNHS),
  1999

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NHQR/NHDR Key Findings and Next Steps

• Ernest Moy
• Edward Kelley
• Center for Quality Improvement and Patient Safety

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Key Findings

• High quality health care is not universal.
• Preventive care
• Chronic disease management
• There is more to learn.
• Greater improvement is possible.

• Disparities in health care are pervasive.
• Preventive care
• Chronic disease management
• Access to care
• There is more to learn.
• Greater improvement is possible.

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Key Report Findings
High quality health care is not universal.
Disparities in health care are pervasive.
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There is more to learn.

• NHQR Gaps
• Limited measures
• HIV/AIDS
• Mental Health
• Timeliness
• Patient Centeredness
• End of life care

• NHDR Gaps
• Limited data
• Native Hawaiians
• American Indians
• Asians
• Children
• Rural residents
• Special care needs

• Limited understanding
• Trends
• Best practices
• How to integrate quality and disparities
  activities

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Greater improvement is possible.

• Of quality measures with trend data, a third show
  improvement, two-thirds show no change or
  deterioration.
• Blacks and Hispanics do worse than whites on half
  of quality measures.
• Hispanics and Asians do worse than whites on
  two-thirds of access measures.
• Poor people do worse on two-thirds of quality and
  access measures.

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Next Steps

• Begin to fill gaps
• Measurement
• Data
• Information
• Begin to refine report products
• Reports
• Spin-off products

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Filling Measurement Gaps

• Child Health MEPS adds child preventive services
  module in 2001
• Patient Safety
• Add analyses of Medicare Patient Safety
  Monitoring System this year
• HCUP develops special disparities analytic file
  that allows national estimates by race/ethnicity
• Timeliness Add measures of clinical timeliness
• Cultural Competency/Language MEPS adds questions
  to Access to Care module in 2002

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Filling Data Gaps

• Asians MEPS oversamples Asians in 2002
• AI/ANs IHS supplements national analyses with
  IHS data
• Low income HRSA supplements national analyses
  with CHC data
• Elderly More MCBS analyses
• Rural Adopt new metro, micro, non-core
  categories
• Special health care needs Add analyses of Survey
  of Children with Special Health Care Needs

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Filling Information Gaps

• New analyses
• Trends
• Regional analyses
• More stratified/multivariate analyses
• More summary measures
• Review of best practices

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National Reports Products

NHQR/DR-net
QI Clearinghouse
Workbooks Knowledge Packs Patient Guides
qualitytools.gov
Information packs
Webcasts
Working papers Articles Supplements
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Report Diffusion Strategies, Tactics, and Actions
Knowledge
Improvement
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Refining the Report Products

• Chartbook
• Shorter
• Less text, more graphics
• Focus on a smaller number of highlight measures
• Push more detail to Appendices
• Spin-off Products
• Actionable
• Targeted audiences
• Specific strategies, tactics, and actions

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Diabetes Resource Guide for State Leaders
Compare State data with national benchmarks,
identify gaps in State data, and develop a
complete inventory of the data systems available
at the State and local levels.
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ULP Web Conferences

Making Quality Count Tools, Strategies, and
Resources
A Series of Two Free Web-assisted Audio Conferences for State, Local, and Health System Policymakers.
Tuesday, February 10 and Wednesday, February 18, 2004 200330 p.m., EST
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Peer-reviewed Literature
NHQR-DR Medical Care Supplement Fall 2004
Prevention Health Care Quality in America
Findings from the first National Healthcare
Quality and Disparities Reports
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http//www.innovations.ahrq.gov/qualitytools/
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Web-based data tools
NHQR/DR-net
Quality Improvement Clearinghouse
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How you can help

• Review first Reports
• Review http//www.innovations.ahrq.gov/qualitytool
  s/
• Provide advice about
• Adding and refining measures
• Accessibility and usability of reports and tools
• Tell us about your experiences
• Measuring quality and disparities
• Improving quality
• Reducing disparities

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For Further Information

• AHRQs web site for the NHQR and NHDR
• http//www.innovations.ahrq.gov/qualitytools/
• Contact information
• Dr. Ed Kelley, Director
• National Healthcare Quality Report
• (ekelley_at_ahrq.gov)
• Dr. Ernie Moy, Senior Service Fellow
• National Healthcare Disparities Report
• (emoy_at_ahrq.gov)
• Dr. Dan Stryer, Director
• Center for Quality Improvement and Patient Safety
• (dstryer_at_ahrq.gov)