Measuring Health Care Quality

1. Figure 1 Measuring Health Care Quality Carolyn M. Clancy, MD Director U.S. Agency for Healthcare Research and Quality for KaiserEDU.org May 2008

2. Health Care Quality Figure 5 • Varies A LOT; NOT clearly related to $$ spent • Matters – can be measured and improved • Measurement science is evolving: • Structure, process and outcomes • Broad recognition that patient experience is essential component • Strong focus on public reporting • Motivates providers to improve • Not yet ‘consumer friendly’

3. 70 Million Americans Benefit from Quality Measurement Figure 6 • 96% of heart attack victims were prescribed beta-blocker treatment in 2005, up from 62% in 1996* • 77.7% of children enrolled in private health plans received all recommended immunizations, up 5% from 72.5% in 2004* • Evidence-based guidelines from the American College of Cardiology and the American Heart Association have reduced mortality among patients who have had a heart attack * National Committee for Quality Assurance

4. AHRQ’s National Reportson Quality and Disparities Figure 7 • New editions available • New efficiency chapter • Disability data added • More on health literacy

5. 2007 National Reports: Some Good News, Need for Improvement Figure 8 • The rate of improvement in quality between 1994 and 2005 was 2.3%, down from 3.1% from 1994-2004 • More than 60% of the disparities in quality of care have stayed the same or worsened for Blacks, Asians and the poor, and approximately 56% of disparities have not improved for Hispanics • For Blacks, Asians, Hispanics and poor populations, about half of the core measures of quality used to track access to care are improving

6. Uninsurance is a Major Barrier to Reducing Disparities Figure 9 Better Same Worse • Uninsured individuals do worse than privately insured individuals on almost 90% of quality measures • Uninsured individuals do worse than privately insured individuals on all access measures 100% 1 75% 50% 25% 0 Access (6CRM) Quality (9CRM) 2007 National Healthcare Disparities Report, AHRQ

7. Overall Scope Figure 10 • Patients receive the proper diagnosis and treatment only about 55% of the time* • Overall, disparities in health care quality and access are not getting smaller ** • Total health care expenditures in 2006 totaled $2.1 trillion (16% of GDP) and are projected to reach $4.1 trillion (19.6% of GDP) by 2016*** * McGlynn E, Asch S, et al. The Quality of Health Care Delivered to Adults in the United States N Engl J Med 2003;348:2635-45. ** AHRQ 2007 National Healthcare Disparities Report *** National Health Expenditure Accounts

8. What? Figure 11

9. Why? Figure 12 • The “why” is a systems challenge: • The U.S. has extremely talented and qualified health care professionals who have not been trained to work in teams • The delivery system is fragmented, so information doesn’t follow patients as they move from hospitals to other sites of care • Payment is quality neutral Light Figure Fragment Craig A. Kraft Washington, DC

10. There Are Major Opportunities for Improvement: Examples Figure 13 • Uptake of health information technology, while still relatively slow, is gaining traction • Growing focus on comparative effectiveness research • HHS Secretary Michael Leavitt’s Value-Driven Health Care Initiative • Chartered Value Exchanges • National Learning Network Downtown USA Alejandra Vernon

11. Emerging Methods in Comparative Effectiveness & Safety Figure 14 • A series of 23 articles by AHRQ researchers on new approaches in comparative effectiveness methods are compiled in a special October edition of Medical Care • A valuable new resource for scientists committed to advancing the comparative effectiveness and safety research • The Resource Center in Oregon led the development process, helped draft the document and manage work groups, and handled public comment Source:http://effectivehealthcare.ahrq.gov/reports/med-care-report.cfm

12. Figure 16 Role Of IT In Reducing Medical Errors Percent who say… Have you or a family member ever created your own set of medical records to ensure that you and all of your health care providers have all of your medical information? The coordination among the different health professionals that they see is a problem Yes They have seen a health care professional and noticed that they did not have all of their medical information 32% They had to wait or come back for another appointment because the provider did not have all their medical information 1% Don’t know No 67% Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).

13. Figure 17 Personal Experience Did the error have serious health consequences, minor health consequences, or no health consequences at all? Have you been personally involved in a situation where a preventable medical error was made in your own medical care or that of a family member? Serious health consequences Yes 21% 34% No Minor health consequences 10% 65% 3% No health consequences 1% Don’t Know Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).

14. Guidelines & Measures Figure 18 More emphasis needs to be placed on what’s most important We measure what we can Identifying what counts and determining how it can be measured Rather Than

15. Guidelines Measures Incentives Figure 19 “You can get 60% of the improvement from 15% of the change” Don Berwick • Where should the busy primary care practice begin? • Where should policy makers target their incentives? To changes that: • Produce the greatest benefit • Address the biggest quality gap • Can be implemented most easily, cheaply and safely

16. Reconciling Guidelines and Quality Measures Figure 20 Developing guidelines that address a wide range of needs… Low-Risk Patients Higher Risk Patients

17. Challenges in Addressing Multiple Conditions Figure 21 Interactions between illnesses Interactions between treatments Multiple medications Multiple providers Tension between therapeutic goals

18. Setting Priorities for Patients with Multiple Conditions Figure 22 • Address the need for clinicians to set priorities, weighing the benefits and burdens of increasingly complex medical regiments • Make sure guidelines keep up with unique issue of treating older and more frail patients

19. “Patient-Centered” Guidelines Figure 23 • If care is to be patient centered, guidelines need to reflect this goal • Quality measures must accommodate differences in: • Patient values • Patient preferences

20. What Level of Collaboration Is Practical? Figure 24 Globalize the evidence, localize the decision-making • Guidelines may need to reflect local values, disease burdens, priorities and resources BUT WE NEED TO SHARE… • Information on how to develop clear and practical guidelines • Evidence on barriers and facilitators to implementing guidelines • Evidence about integration of guidelines in electronic health records

21. The Goal Figure 25 • Historically, the focus has been on structure • In recent years, there has been more interest in process – the right care • Tomorrow’s goal? Outcomes and end results

22. The Information Exists Figure 26 • Information on topics including guidelines, measures, incentives and outcomes are available for a wide range of uses. Included is information about: • Hospitals: • Nursing Homes: • Health Plans: • Various Health Care Organizations: Hospital Compare Nursing Home Compare National Committee for Quality Assurance Quality Check ®

23. CBO Report on Comparative Effectiveness Figure 27 Congressional Budget Office Report: • Discusses several mechanisms for organizing and funding additional comparative effectiveness research efforts • Reviews the different types of research that could be pursued and the likely benefits and costs • Considers the potential effects that such research could have on health care spending

24. Reasons for Optimism Figure 28 • Multiple stakeholders are working together • AQA & HQA established the Quality Alliance Steering Committee to promote quality measurement, transparency and improvement in care • There is clear recognition that there should be one set of measures • A move is underfoot toward real standardization across agencies and organizations • A shared sense of urgency exists on improving patient outcomes, workforce productivity and costs • The National Quality Forum is bringing stakeholders together to establish priorities for moving forward

25. Future Opportunities Figure 29 • The primary opportunity involves patients • We will not improve chronic illness care without active, informed patients • Patients as shoppers • Women are key

26. This is not a Political Issue, It’s a Practical Issue Figure 30 • Quality and access are linked • Quality will be a major theme of multiple reform proposals • Quality is central to getting better value for what we’re spending on health care

27. 21st Century Health Care Figure 31 Improving quality by promoting a culture of safety through Value-Driven Health Care Information-rich, patient-focused enterprises Information and evidence transform interactions from reactive to proactive (benefits and harms) Evidence is continually refined as a by-product of care delivery 21st Century Health Care Actionable information available – to clinicians AND patients – “in real time”

28. Measuring Health Care Quality Figure 32 AHRQ Mission To improve the quality, safety, efficiency, and effectiveness of health care for all Americans AHRQ Vision As a result of AHRQ's efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest cost http://www.ahrq.gov

29. Resources Figure 33 To learn more about health care quality, visit these websites: • Agency for Heathcare Research and Quality, http://www.ahrq.gov/ • Quality of Care, Reference Library, KaiserEDU.org http://www.kaiseredu.org/topics_reflib.asp?id=139&parentid=70&rID=1 • The Commonwealth Fund, http://www.commonwealthfund.org/topics/topics_list.htm?attrib_id=15312 • Institute for Healthcare Improvement, http://www.ihi.org/ihi • National Committee on Quality Assurance,http://www.ncqa.org/ • Robert Wood Johnson Foundation, http://www.rwjf.org/pr/topic.jsp?topicid=1053