Twenty Quality Priority AreasTwenty Quality Priority Areas

Internet 2Internet 2

J. Michael Fitzmaurice, Ph.D.J. Michael Fitzmaurice, Ph.D.

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

AgendaAgenda

AHRQ/LandscapeAHRQ/Landscape Setting PrioritiesSetting Priorities Priority AreasPriority Areas FutureFuture

FY 1995 - FY 2003 FY 1995 - FY 2003 Appropriation HistoryAppropriation History

Dollar in MillionsDollar in Millions

$159

$125$144 $147

$171

$204

$271

$300 $308

$50

$100

$150

$200

$250

$300

$350

1995 1996 1997 1998 1999 2000 2001 2002 2003

Fiscal Years

September 3, 2002J:/fms/FY90-03apphist.ppt

AHRQ MissionAHRQ Mission

To support, conduct, and disseminate research that To support, conduct, and disseminate research that improves the outcomes, quality, access to, and cost and improves the outcomes, quality, access to, and cost and utilization of health care servicesutilization of health care services– AHRQ is the lead Federal agency in research for improving AHRQ is the lead Federal agency in research for improving

the quality of carethe quality of care– Research to improve clinical, health care system, and public Research to improve clinical, health care system, and public

policy decisionspolicy decisions

Secretary Tommy ThompsonSecretary Tommy ThompsonMarch 21, 2003March 21, 2003

In the modern era, every century has had its major In the modern era, every century has had its major

advance that has brought medical science another advance that has brought medical science another

giant step forward. In the 18th century, vaccination giant step forward. In the 18th century, vaccination

offered precious immunity from age-old plagues. offered precious immunity from age-old plagues.

The 19th century introduced knowledge of bacteria The 19th century introduced knowledge of bacteria

and disease transmission. The 20th century brought and disease transmission. The 20th century brought

us the miracle of antibiotics. What will the major us the miracle of antibiotics. What will the major

advance of the 21st century be? advance of the 21st century be? II am convinced that am convinced that

the medical revolution of our children’s lifetimes will be the application of information technology to the medical revolution of our children’s lifetimes will be the application of information technology to health care.health care.

AHRQ Quality Indicator (QI) AHRQ Quality Indicator (QI) SetsSets

Prevention Quality Prevention Quality

IndicatorsIndicators

Inpatient Quality Indicators Inpatient Quality Indicators

Patient Safety Indicators Patient Safety Indicators ((released March 2003released March 2003))

Ambulatory care sensitive Ambulatory care sensitive

conditionsconditions

Mortality following procedures Mortality following procedures Mortality for medical conditionsMortality for medical conditions Utilization of proceduresUtilization of procedures Volume of proceduresVolume of procedures

Post-operative complicationsPost-operative complications Iatrogenic conditionsIatrogenic conditions

Current QI ActivitiesCurrent QI Activities

User-friendly package for Prevention QI moduleUser-friendly package for Prevention QI module User-friendly package for Inpatient QI moduleUser-friendly package for Inpatient QI module Stanford completes Patient Safety IndicatorsStanford completes Patient Safety Indicators User-friendly package for Patient Safety QI moduleUser-friendly package for Patient Safety QI module Continued developmentContinued development CMS collaborationCMS collaboration Analysis for National Quality ReportAnalysis for National Quality Report

AvailableAvailable AvailableAvailable CompleteComplete AvailableAvailable

On-goingOn-going On-goingOn-going 2002-32002-3

LandscapeLandscape

IOM, To Err is Human, Building a Safer Health System IOM, To Err is Human, Building a Safer Health System (2002)(2002)– Patient safety is a major problem in the USPatient safety is a major problem in the US– Between 44,000 and 98,000 lives are lost annually as a Between 44,000 and 98,000 lives are lost annually as a

result of medical errors in hospitalsresult of medical errors in hospitals– Health systems do not adequately support health Health systems do not adequately support health

professionals and patientsprofessionals and patients

LandscapeLandscape

IOM, Crossing the Quality Chasm:IOM, Crossing the Quality Chasm:– Large gaps in health care quality existLarge gaps in health care quality exist– Inadequate health care delivery system to implement effective Inadequate health care delivery system to implement effective

treatmentstreatments

A New Health System for the 21st Century (2001)A New Health System for the 21st Century (2001)– More responsive to patients’ needsMore responsive to patients’ needs– More capable of delivering science-based careMore capable of delivering science-based care

LandscapeLandscape

How to improve quality--Chasm guidanceHow to improve quality--Chasm guidance– Promote a focus on improving care in a limited set of priority Promote a focus on improving care in a limited set of priority

areasareas– Chronic conditions Chronic conditions

Should have emphasisShould have emphasis They account for much of the health care burden and use of resourcesThey account for much of the health care burden and use of resources

– Invoke collaborative efforts Invoke collaborative efforts

Bridging the Quality ChasmBridging the Quality Chasm

Where Where WeWhere Where WeWe Are Want To BeWe Are Want To Be

TRIPTRIP

ImplementationImplementation

DiffusionDiffusionAdoptionAdoption

EducationEducationInnovationInnovation

Ten Highest Cost ConditionsTen Highest Cost Conditions

Heart Disease ($58B)Heart Disease ($58B) Cancer ($46B)Cancer ($46B) Trauma ($44B)Trauma ($44B) Mental Disorders ($30B)Mental Disorders ($30B) Pulmonary Conditions ($29B)Pulmonary Conditions ($29B)

Diabetes ($20B)Diabetes ($20B) Hypertension ($18B)Hypertension ($18B) Cerebrovascular Disease ($16B)Cerebrovascular Disease ($16B) Osteoarthritis ($16B)Osteoarthritis ($16B) Pneumonia ($16B)Pneumonia ($16B)

Source: J. Cohen and N. Krauss, “Spending and Service Use Among Source: J. Cohen and N. Krauss, “Spending and Service Use Among People with the Fifteen Most Costly Medical Conditions, 1997,” People with the Fifteen Most Costly Medical Conditions, 1997,” Health Health Affairs, Affairs, March/April 2003.March/April 2003.

Which priority areas?Which priority areas?

HHS contracted with IOMHHS contracted with IOM– To select criteria for screening potential To select criteria for screening potential

priority areaspriority areas– To develop a process for applying those To develop a process for applying those

criteriacriteria– To generate a list of 12-20 candidate areasTo generate a list of 12-20 candidate areas

Priority Areas for National Action: Priority Areas for National Action: Transforming Health Care QualityTransforming Health Care Quality

IOM (2003) GoalIOM (2003) Goal– To identify priority areas that presented the greatest To identify priority areas that presented the greatest

opportunity to narrow the gap between what the opportunity to narrow the gap between what the health care system is routinely doing now and what health care system is routinely doing now and what we know to be the best medical practicewe know to be the best medical practice Improve the delivery of existing best practice treatments.Improve the delivery of existing best practice treatments.

FrameworkFramework

Based onBased on– Foundation for Accountability (1997)Foundation for Accountability (1997)– IOM, National Health Care Quality Report (2001)IOM, National Health Care Quality Report (2001)

Five domainsFive domains– Staying healthy (preventive care)Staying healthy (preventive care)– Getting better (acute care)Getting better (acute care)– Living with illness/disability (chronic care)Living with illness/disability (chronic care)– Coping with end of life (palliative care)Coping with end of life (palliative care)– Cross-cutting systems interventions (coordination of care)Cross-cutting systems interventions (coordination of care)

Priority Area Selection CriteriaPriority Area Selection Criteria ImpactImpact

– Burden: disability, mortality, economic costsBurden: disability, mortality, economic costs

ImprovabilityImprovability– Gap between current and evidence-based best practice --size and probability of Gap between current and evidence-based best practice --size and probability of

improvementimprovement

InclusivenessInclusiveness– Range--(equity) of individuals (socioeconomic, r/e, gender)Range--(equity) of individuals (socioeconomic, r/e, gender)– Generalizability--(representativeness) to many conditionsGeneralizability--(representativeness) to many conditions– Breadth--(reach) across settings and providersBreadth--(reach) across settings and providers

What’s the process?What’s the process?

Determine a framework for the priority areasDetermine a framework for the priority areas Identify candidate areasIdentify candidate areas Establish criteria for selecting final priority areasEstablish criteria for selecting final priority areas Apply impact and inclusiveness to the candidatesApply impact and inclusiveness to the candidates Apply criteria of improvability and inclusiveness to the Apply criteria of improvability and inclusiveness to the

preliminary set of areas obtained in the step abovepreliminary set of areas obtained in the step above

What’s the process? (2)What’s the process? (2)

Identify priority areas, reassess, and approveIdentify priority areas, reassess, and approve FinallyFinally

– Implement strategies for improving care in he priority Implement strategies for improving care in he priority areas, areas,

– Measure the impact of implementationMeasure the impact of implementation– Review/update the list of areas\Review/update the list of areas\

What are the priority areas?What are the priority areas?

Care coordination (cc) Care coordination (cc) Self-management/health literacy (cc)Self-management/health literacy (cc) Asthma--appropriate treatment for persons with Asthma--appropriate treatment for persons with

mile/moderate asthmamile/moderate asthma Cancer screening that is evidence-based--focus on Cancer screening that is evidence-based--focus on

colorectal and cervical cancercolorectal and cervical cancer

Priority Areas (2)Priority Areas (2)

Children with special health care needsChildren with special health care needs Diabetes--focus on appropriate management of early diseaseDiabetes--focus on appropriate management of early disease End of life with advanced organ system failure--focus on congestive End of life with advanced organ system failure--focus on congestive

heart failure and chronic obstructive pulmonary diseaseheart failure and chronic obstructive pulmonary disease Frailty associated with old age--preventing falls and pressure ulcers, Frailty associated with old age--preventing falls and pressure ulcers,

maximizing function, and developing advanced care plansmaximizing function, and developing advanced care plans

Priority Areas (3)Priority Areas (3)

Hypertension--focus on appropriate management of Hypertension--focus on appropriate management of early diseaseearly disease

immunization--children and adultsimmunization--children and adults Ischemic heart disease--prevention, reduction of Ischemic heart disease--prevention, reduction of

recurring events, and optimization of functional capacityrecurring events, and optimization of functional capacity Major depression--screening and treatmentMajor depression--screening and treatment

Priority Areas (4)Priority Areas (4)

Medication management--preventing medication Medication management--preventing medication errors and overuse of antibioticserrors and overuse of antibiotics

Nosocomial infections--prevention and surveillanceNosocomial infections--prevention and surveillance Pain control in advanced cancerPain control in advanced cancer Pregnancy and childbirth--appropriate prenatal and Pregnancy and childbirth--appropriate prenatal and

intrapartum careintrapartum care

Priority Areas (5)Priority Areas (5)

Severe and persistent mental illness--focus on Severe and persistent mental illness--focus on treatment in the public sectortreatment in the public sector

Stroke--early intervention and rehabilitationStroke--early intervention and rehabilitation Tobacco dependence treatment in adultsTobacco dependence treatment in adults Obesity (an emerging area)Obesity (an emerging area)

What for the future?What for the future?

Data collection and measurement systems for ... quality Data collection and measurement systems for ... quality improvement effortsimprovement efforts

Support development of … standardized measures of Support development of … standardized measures of qualityquality

Report measures of key attributes and outcomes to the Report measures of key attributes and outcomes to the publicpublic

Revise selection criteria and priority area listRevise selection criteria and priority area list

What for the future?What for the future?

Review evidence based and update priorities Review evidence based and update priorities every 3-5 yearsevery 3-5 years

Assess changes in society’s attributes that could Assess changes in society’s attributes that could affect health and alter prioritiesaffect health and alter priorities

Disseminate the results of strategies for QI in the Disseminate the results of strategies for QI in the priority areaspriority areas

StrategyStrategy

This is the development of a strategy for This is the development of a strategy for addressing the high priority areas of health careaddressing the high priority areas of health care

Determining the priorities is a collaborative Determining the priorities is a collaborative processprocess

These priorities are for everyoneThese priorities are for everyone

Twenty Quality Priority AreasTwenty Quality Priority Areas

Internet 2Internet 2

J. Michael Fitzmaurice, Ph.D.J. Michael Fitzmaurice, Ph.D.

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

Practice-Based Practice-Based Research NetworksResearch Networks

AHRQ supports research in groups of physician practices on AHRQ supports research in groups of physician practices on such topics as: automated electronic reminders tosuch topics as: automated electronic reminders to – Improve compliance with guidelines for managing patients with Improve compliance with guidelines for managing patients with

diabetesdiabetes– Improve screening and detection of patients at higher risk for Improve screening and detection of patients at higher risk for

tuberculosis using CDC guidelines tuberculosis using CDC guidelines – Improve lipid management (improving cholesterol and calculating Improve lipid management (improving cholesterol and calculating

the risk of cardiovascular disease for a patient)the risk of cardiovascular disease for a patient)

Practice-Based Research NetworksPractice-Based Research Networks (PBRNs) (PBRNs) 36 new PBRN grants awarded in 200236 new PBRN grants awarded in 2002

19 PBRN grants awarded in 200019 PBRN grants awarded in 2000