Figure 1

Measuring Health Care Quality

Carolyn M. Clancy, MD
Director U.S. Agency for Healthcare Research and Quality
for

KaiserEDU.org May 2008

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Figure 5

Health Care Quality

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

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Figure 6

70 Million Americans Benefit from Quality Measurement

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

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Figure 7

AHRQs National Reports on Quality and Disparities

New editions available
New efficiency chapter
Disability data added

More on health literacy

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Figure 8

2007 National Reports: Some Good News, Need for Improvement

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

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Figure 9

Uninsurance is a Major Barrier to Reducing Disparities

Uninsured individuals

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

Uninsured individuals

100%

1
75%

Better Same Worse

do worse than privately insured individuals on all access measures

50%

25%

0 2007 National Healthcare Disparities Report, AHRQ

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Figure 10

Overall Scope
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
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Figure 11

What?

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Figure 12

Why?
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 doesnt follow patients as they move from hospitals to other sites of care
Payment is quality neutral
Light Figure Fragment Craig A. Kraft Washington, DC

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Figure 13

There Are Major Opportunities for Improvement: Examples

Uptake of health information

technology, while still relatively slow, is gaining traction Growing focus on comparative effectiveness research HHS Secretary Michael Leavitts Value-Driven Health Care Initiative

Chartered Value Exchanges National Learning Network

Downtown USA
Alejandra Vernon

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Figure 14

Emerging Methods in Comparative Effectiveness & Safety

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

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Figure 16

Role Of IT In Reducing Medical Errors

Percent who say
The coordination among the different health professionals that they see is a problem

69%

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?

They have seen a health care professional and noticed that they did not have all of their medical information They had to wait or come back for another appointment because the provider did not have all their medical information

Yes

32%
48%

32%

1%
Dont 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).

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Figure 17

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

Yes

34%
No

21% 10% 3%

Serious health consequences Minor health consequences No health consequences

65%

1% Dont
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).

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Figure 18

Guidelines & Measures

More emphasis needs to be placed on whats most important

We measure what we can

Rather Than

Identifying what counts and determining how it can be measured

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Figure 19

Guidelines Measures Incentives

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
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Figure 20

Reconciling Guidelines and Quality Measures

Developing guidelines that address a wide range of needs

Low-Risk Patients

Higher Risk Patients

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Figure 21

Challenges in Addressing Multiple Conditions

Interactions between illnesses Interactions between treatments

Multiple medications

Multiple providers

Tension between therapeutic goals

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Figure 22

Setting Priorities for Patients with Multiple Conditions

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

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Figure 23

Patient-Centered Guidelines
If care is to be patient

centered, guidelines need to reflect this goal

Quality measures

must accommodate differences in:

Patient values Patient preferences

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Figure 24

What Level of Collaboration Is Practical?

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
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Figure 25

The Goal
Historically, the focus

has been on structure In recent years, there has been more interest in process the right care Tomorrows goal? Outcomes and end results

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Figure 26

The Information Exists

Information on topics including guidelines,

measures, incentives and outcomes are available for a wide range of uses. Included is information about:
Hospitals: Hospital Compare Nursing Homes: Nursing Home Compare Health Plans: National Committee for Quality Assurance

Various Health Care Organizations: Quality Check

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Figure 27

CBO Report on Comparative Effectiveness

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
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Figure 28

Reasons for Optimism

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

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Figure 29

Future Opportunities
The primary opportunity

involves patients
We will not improve chronic illness care without active, informed patients Patients as shoppers Women are key

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Figure 30

This is not a Political Issue, Its a Practical Issue

Quality and access

are linked
Quality will be a major

theme of multiple reform proposals

Quality is central to

getting better value for what were spending on health care

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Figure 31

21st Century Health Care

Improving quality by promoting a culture of safety through Value-Driven Health Care
Information-rich, patientfocused enterprises

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

21st Century Health Care

Information and evidence transform interactions from reactive to proactive (benefits and harms)

Actionable information available to clinicians AND patients in real time

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Figure 32

Measuring Health Care Quality

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
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Figure 33

Resources
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

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