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Measuring Health Care QualityMeasuring Health Care QualityCarolyn M. Clancy, MDCarolyn M. Clancy, MD

DirectorDirectorU.S. Agency for Healthcare Research and QualityU.S. Agency for Healthcare Research and Quality

forfor

KaiserEDU.orgKaiserEDU.orgMay 2008May 2008

Figure 1

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Health Care QualityHealth Care Quality

Varies Varies A LOTA LOT; ; NOTNOT clearly related to $$ spent clearly related to $$ spent Matters – can be measured and improvedMatters – can be measured and improved Measurement science is evolving:Measurement science is evolving:

– Structure, process and outcomesStructure, process and outcomes– Broad recognition that patient experience is essential Broad recognition that patient experience is essential

componentcomponent

Strong focus on public reportingStrong focus on public reporting– Motivates providers to improveMotivates providers to improve– Not yet ‘consumer friendly’Not yet ‘consumer friendly’

Figure 5

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70 Million Americans Benefit 70 Million Americans Benefit from Quality Measurement from Quality Measurement

96% of heart attack victims were 96% of heart attack victims were prescribed beta-blocker treatment in prescribed beta-blocker treatment in 2005, up from 62% in 19962005, up from 62% in 1996**

77.7% of children enrolled in private 77.7% of children enrolled in private health plans received all health plans received all recommended immunizations, up recommended immunizations, up 5% from 72.5% in 20045% from 72.5% in 2004**

Evidence-based guidelines from Evidence-based guidelines from the American College of Cardiology the American College of Cardiology and the American Heart Association and the American Heart Association have reduced mortality among have reduced mortality among patients who have had a heart patients who have had a heart attackattack

* * National Committee for Quality AssuranceNational Committee for Quality Assurance

Figure 6

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AHRQ’s National ReportsAHRQ’s National Reportson Quality and Disparitieson Quality and Disparities

New editions availableNew editions available

– New efficiency chapterNew efficiency chapter

– Disability data addedDisability data added

– More on health literacyMore on health literacy

Figure 7

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2007 National Reports: Some Good 2007 National Reports: Some Good News, Need for ImprovementNews, Need for Improvement

The rate of improvement in quality The rate of improvement in quality between 1994 and 2005 was 2.3%, between 1994 and 2005 was 2.3%, down from 3.1% from 1994-2004down from 3.1% from 1994-2004

More than 60% of the disparities in More than 60% of the disparities in quality of care have stayed the same or quality of care have stayed the same or worsened for Blacks, Asians and the worsened for Blacks, Asians and the poor, and approximately 56% of poor, and approximately 56% of disparities have not improved for disparities have not improved for HispanicsHispanics

For Blacks, Asians, Hispanics and poor For Blacks, Asians, Hispanics and poor populations, about half of the core populations, about half of the core measures of quality used to track measures of quality used to track access to care are improving access to care are improving

Figure 8

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Uninsurance is a Major Barrier to Uninsurance is a Major Barrier to Reducing DisparitiesReducing Disparities

Uninsured individuals do Uninsured individuals do worse than privately worse than privately insured individuals on insured individuals on almost 90% of quality almost 90% of quality measuresmeasures

Uninsured individuals do Uninsured individuals do worse than privately worse than privately insured individuals on all insured individuals on all access measuresaccess measures

0

25%

50%

75%

100%

QualityQuality

(9CRM)(9CRM) Access

Access

(6CRM)

(6CRM)

1

BetterBetterSameSameWorseWorse

2007 National Healthcare Disparities Report, AHRQ2007 National Healthcare Disparities Report, AHRQ

Figure 9

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Overall ScopeOverall Scope

Patients receive the proper diagnosis and Patients receive the proper diagnosis and treatment only about 55% of the timetreatment only about 55% of the time**

Overall, disparities in health care quality and Overall, disparities in health care quality and access are not getting smaller access are not getting smaller ****

Total health care expenditures in 2006 totaled Total health care expenditures in 2006 totaled $2.1 trillion (16% of GDP) and are projected to $2.1 trillion (16% of GDP) and are projected to reach $4.1 trillion (19.6% of GDP) by 2016reach $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 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. N Engl J Med 2003;348:2635-45.

**** AHRQ 2007 National Healthcare Disparities Report AHRQ 2007 National Healthcare Disparities Report

*** *** National Health Expenditure AccountsNational Health Expenditure Accounts

Figure 10

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What?What?

Figure 11

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Why?Why?

The “why” is a systems challenge:The “why” is a systems challenge:– The U.S. has extremely talented and The U.S. has extremely talented and

qualified health care professionals who qualified health care professionals who have not been trained to work in teamshave not been trained to work in teams

– The delivery system is fragmented, so The delivery system is fragmented, so information doesn’t follow patients as information doesn’t follow patients as they move from hospitals to other sites they move from hospitals to other sites of careof care

– Payment is quality neutralPayment is quality neutral

Light Figure Fragment Light Figure Fragment Craig A. Kraft Craig A. Kraft

Washington, DCWashington, DC

Figure 12

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There Are Major Opportunities There Are Major Opportunities for Improvement: Examplesfor Improvement: Examples

Uptake of health information Uptake of health information technology, while still relatively technology, while still relatively slow, is gaining tractionslow, is gaining traction

Growing focus on comparative Growing focus on comparative effectiveness researcheffectiveness research

HHS Secretary Michael HHS Secretary Michael Leavitt’s Value-Driven Health Leavitt’s Value-Driven Health Care InitiativeCare Initiative– Chartered Value ExchangesChartered Value Exchanges– National Learning NetworkNational Learning Network

Downtown USA Alejandra Vernon

Figure 13

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Emerging Methods in Emerging Methods in Comparative Effectiveness & SafetyComparative Effectiveness & Safety

A series of 23 articles by AHRQ A series of 23 articles by AHRQ researchers on new approaches researchers on new approaches in comparative effectiveness in comparative effectiveness methods are compiled in a special methods are compiled in a special October edition of October edition of Medical CareMedical Care

A valuable new resource for A valuable new resource for scientists committed to advancing scientists committed to advancing the comparative effectiveness and the comparative effectiveness and safety researchsafety research

The Resource Center in Oregon The Resource Center in Oregon led the development process, led the development process, helped draft the document and helped draft the document and manage work groups, and manage work groups, and handled public commenthandled public comment

Source: http://effectivehealthcare.ahrq.gov/reports/med-care-report.cfm

Figure 14

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Percent who say…Percent who say…

Role Of IT In Reducing Medical Errors

The coordination among the The coordination among the different health professionals different health professionals

that they see is a problem that they see is a problem

32%

69%

48%

They had to wait or come back They had to wait or come back for another appointment for another appointment

because the provider did not because the provider did not have all their medical have all their medical

informationinformation

They have seen a health care They have seen a health care professional and noticed that professional and noticed that

they did not have all of their they did not have all of their medical informationmedical information

Have you or a family member ever Have you or a family member ever created your own set of medical created your own set of medical records to ensure that you and all records to ensure that you and all of your health care providers have of your health care providers have all of your medical information?all of your medical information?

Don’t know

No

Yes

Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey National Survey on Consumers’ Experiences with Patient Safety and Quality Information, on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).November 2004 (Conducted July 7 – September 5, 2005).

32%

67%

1%

Figure 16

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Personal Experience

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?

Yes

Don’t Know

No

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).

Did the error have serious health consequences, minor health consequences, or no health consequences at all?

Minor health consequences

No health consequences

Serious health consequences

65%

1%

21%

10%3%

34%

Figure 17

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Guidelines & MeasuresGuidelines & Measures

More emphasis needs to be placed More emphasis needs to be placed on what’s most importanton what’s most important

We measure what we can

Identifying what counts and

determining how it can be measured

Rather Than

Figure 18

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Guidelines Measures Guidelines Measures IncentivesIncentives

““You can get 60% of the improvement from 15% of the You can get 60% of the improvement from 15% of the change”change”

Don BerwickDon Berwick

Where should the busy primary care practice begin?Where should the busy primary care practice begin? Where should policy makers target their incentives?Where should policy makers target their incentives?

To changes that:To changes that:

Produce the greatest benefitProduce the greatest benefit Address the biggest quality gapAddress the biggest quality gap Can be implemented most easily, cheaply and safelyCan be implemented most easily, cheaply and safely

Figure 19

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Reconciling Guidelines Reconciling Guidelines and Quality Measuresand Quality Measures

Developing guidelines that address a wide range of needs… Developing guidelines that address a wide range of needs…

Low-Risk Patients

Higher Risk Patients

Figure 20

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Challenges in Addressing Challenges in Addressing Multiple ConditionsMultiple Conditions

Interactions between illnesses

Interactions between treatments

Tension between therapeutic goals

Multiple providers

Multiple medications

Figure 21

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Setting Priorities for Patients Setting Priorities for Patients with Multiple Conditionswith Multiple Conditions

Address the need for clinicians to set Address the need for clinicians to set priorities, weighing the benefits and burdens priorities, weighing the benefits and burdens of increasingly complex medical regimentsof increasingly complex medical regiments

Make sure guidelines keep up with unique Make sure guidelines keep up with unique issue of treating older and more frail patientsissue of treating older and more frail patients

Figure 22

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““Patient-Centered” GuidelinesPatient-Centered” Guidelines

If care is to be patient If care is to be patient centered, guidelines centered, guidelines need to reflect this goalneed to reflect this goal– Quality measures Quality measures

must accommodate must accommodate differences in:differences in: Patient valuesPatient values Patient preferencesPatient preferences

Figure 23

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What Level of Collaboration What Level of Collaboration Is Practical?Is Practical?

Guidelines may need to reflect local values, disease Guidelines may need to reflect local values, disease burdens, priorities and resourcesburdens, priorities and resources

BUT WE NEED TO SHARE… BUT WE NEED TO SHARE…

Information on how to develop clear and practical Information on how to develop clear and practical guidelines guidelines

Evidence on barriers and facilitators to implementing Evidence on barriers and facilitators to implementing guidelinesguidelines

Evidence about integration of guidelines in electronic Evidence about integration of guidelines in electronic health recordshealth records

Globalize the evidence, localize the decision-makingGlobalize the evidence, localize the decision-making

Figure 24

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The GoalThe Goal

Historically, the focus Historically, the focus has been on structurehas been on structure

In recent years, there In recent years, there has been more interest has been more interest in process – the right in process – the right carecare

Tomorrow’s goal? Tomorrow’s goal? Outcomes and end Outcomes and end resultsresults

Figure 25

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The Information ExistsThe Information Exists

Figure 26

Information on topics including guidelines, Information on topics including guidelines, measures, incentives and outcomes are available measures, incentives and outcomes are available for a wide range of uses. Included is information for a wide range of uses. Included is information about:about:– Hospitals:Hospitals:– Nursing Homes: Nursing Homes: – Health Plans:Health Plans:– Various Health Care Organizations: Various Health Care Organizations:

Hospital CompareHospital Compare

Nursing Home CompareNursing Home Compare

National Committee for Quality AssuranceNational Committee for Quality Assurance

Quality Check Quality Check ®®

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CBO Report on CBO Report on Comparative EffectivenessComparative Effectiveness

Discusses several Discusses several mechanisms for organizing mechanisms for organizing and funding additional and funding additional comparative effectiveness comparative effectiveness research effortsresearch efforts

Reviews the different types of Reviews the different types of research that could be research that could be pursued and the likely pursued and the likely benefits and costsbenefits and costs

Considers the potential Considers the potential effects that such research effects that such research could have on health care could have on health care spendingspending

Congressional Budget Office Congressional Budget Office Report:Report:

Figure 27

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Reasons for OptimismReasons for Optimism

Multiple stakeholders are working together Multiple stakeholders are working together – AQA & HQA established the Quality Alliance Steering AQA & HQA established the Quality Alliance Steering

Committee to promote quality measurement, Committee to promote quality measurement, transparency and improvement in caretransparency and improvement in care

There is clear recognition that there should There is clear recognition that there should be one set of measuresbe one set of measures– A move is underfoot toward real standardization A move is underfoot toward real standardization

across agencies and organizationsacross agencies and organizations A shared sense of urgency exists on A shared sense of urgency exists on

improving patient outcomes, workforce improving patient outcomes, workforce productivity and costs productivity and costs – The National Quality Forum is bringing stakeholders The National Quality Forum is bringing stakeholders

together to establish priorities for moving forwardtogether to establish priorities for moving forward

Figure 28

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Future OpportunitiesFuture Opportunities

The primary opportunity The primary opportunity involves patients involves patients – We will not improve We will not improve

chronic illness care chronic illness care without active, informed without active, informed patientspatients

– Patients as shoppers Patients as shoppers – Women are keyWomen are key

Figure 29

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This is not a Political Issue, This is not a Political Issue, It’s a Practical IssueIt’s a Practical Issue

Quality and access Quality and access are linkedare linked

Quality will be a major Quality will be a major theme of multiple theme of multiple reform proposalsreform proposals

Quality is central to Quality is central to getting better value for getting better value for what we’re spending what we’re spending on health careon health care

Figure 30

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2121stst Century Health Care Century Health Care

Improving quality by promoting a culture of safety Improving quality by promoting a culture of safety through Value-Driven Health Care through Value-Driven Health Care

21st Century Health Care

Information-rich, patient-Information-rich, patient-focused enterprisesfocused enterprises

Information and Information and evidence transform evidence transform

interactions from interactions from reactive to reactive to

proactive (benefits proactive (benefits and harms)and harms)

Evidence is Evidence is continually refined continually refined as a by-product of as a by-product of

care deliverycare delivery

Actionable information available – to Actionable information available – to clinicians AND patients – “in real time”clinicians AND patients – “in real time”

Figure 31

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Measuring Health Care QualityMeasuring Health Care Quality

http://www.ahrq.govhttp://www.ahrq.gov

AHRQ Mission AHRQ Mission

To improve the quality, safety, To improve the quality, safety, efficiency, and effectiveness of efficiency, and effectiveness of health care for all Americanshealth care for all Americans

AHRQ VisionAHRQ Vision

As a result of AHRQ's efforts, As a result of AHRQ's efforts, American health care will provide American health care will provide services of the highest quality, with services of the highest quality, with the best possible outcomes, at the the best possible outcomes, at the lowest costlowest cost

Figure 32

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ResourcesResources

To learn more about health care quality, visit these websites:To learn more about health care quality, visit these websites:

Agency for Heathcare Research and Quality, Agency for Heathcare Research and Quality, http://www.ahrq.gov/http://www.ahrq.gov/

Quality of Care, Reference Library, KaiserEDU.orgQuality of Care, Reference Library, KaiserEDU.org

http://www.kaiseredu.org/topics_reflib.asp?id=139&parentid=70&rID=1http://www.kaiseredu.org/topics_reflib.asp?id=139&parentid=70&rID=1

The Commonwealth Fund, The Commonwealth Fund, http://www.commonwealthfund.org/topics/topics_list.htm?attrib_id=15312 http://www.commonwealthfund.org/topics/topics_list.htm?attrib_id=15312

Institute for Healthcare Improvement, Institute for Healthcare Improvement, http://www.ihi.org/ihihttp://www.ihi.org/ihi

National Committee on Quality Assurance,National Committee on Quality Assurance,http://www.ncqa.org/http://www.ncqa.org/

Robert Wood Johnson Foundation, Robert Wood Johnson Foundation, http://www.rwjf.org/pr/topic.jsp?topicid=1053 http://www.rwjf.org/pr/topic.jsp?topicid=1053

Figure 33