1. Twenty Quality Priority Areas Internet 2 J. Michael Fitzmaurice, Ph.D. Agency for Healthcare Research and Quality

2. Agenda AHRQ/Landscape AHRQ/Landscape Setting Priorities Setting Priorities Priority Areas Priority Areas Future Future

3. FY 1995 - FY 2003 Appropriation History Dollar in Millions September 3, 2002 J:/fms/FY90-03apphist.ppt

4. AHRQ Mission To support, conduct, and disseminate research that improves the outcomes, quality, access to, and cost and utilization of health care services To support, conduct, and disseminate research that improves the outcomes, quality, access to, and cost and utilization of health care services – AHRQ is the lead Federal agency in research for improving the quality of care – Research to improve clinical, health care system, and public policy decisions

5. Secretary Tommy Thompson March 21, 2003 In the modern era, every century has had its major advance that has brought medical science another giant step forward. In the 18th century, vaccination offered precious immunity from age-old plagues. The 19th century introduced knowledge of bacteria and disease transmission. The 20th century brought us the miracle of antibiotics. What will the major advance of the 21st century be? I am convinced that the medical revolution of our children’s lifetimes will be the application of information technology to health care.

6. AHRQ Quality Indicator (QI) Sets Prevention Quality Prevention QualityIndicators Inpatient Quality Indicators Inpatient Quality Indicators Patient Safety Indicators Patient Safety Indicators (released March 2003) Ambulatory care sensitive Ambulatory care sensitiveconditions Mortality following procedures Mortality following procedures Mortality for medical conditions Mortality for medical conditions Utilization of procedures Utilization of procedures Volume of procedures Volume of procedures Post-operative complications Post-operative complications Iatrogenic conditions Iatrogenic conditions

7. Current QI Activities User-friendly package for Prevention QI module User-friendly package for Prevention QI module User-friendly package for Inpatient QI module User-friendly package for Inpatient QI module Stanford completes Patient Safety Indicators Stanford completes Patient Safety Indicators User-friendly package for Patient Safety QI module User-friendly package for Patient Safety QI module Continued development Continued development CMS collaboration CMS collaboration Analysis for National Quality Report Analysis for National Quality Report  Available  Complete  Available  On-going  2002-3

8. Landscape IOM, To Err is Human, Building a Safer Health System (2002) IOM, To Err is Human, Building a Safer Health System (2002) – Patient safety is a major problem in the US – Between 44,000 and 98,000 lives are lost annually as a result of medical errors in hospitals – Health systems do not adequately support health professionals and patients

9. Landscape IOM, Crossing the Quality Chasm: IOM, Crossing the Quality Chasm: – Large gaps in health care quality exist – Inadequate health care delivery system to implement effective treatments A New Health System for the 21st Century (2001) A New Health System for the 21st Century (2001) – More responsive to patients’ needs – More capable of delivering science-based care

10. Landscape How to improve quality--Chasm guidance How to improve quality--Chasm guidance – Promote a focus on improving care in a limited set of priority areas – Chronic conditions Should have emphasis Should have emphasis They account for much of the health care burden and use of resources They account for much of the health care burden and use of resources – Invoke collaborative efforts

11. Bridging the Quality Chasm Where Where We We Are Want To Be TRIP Implementation Diffusion Adoption Education Innovation

12. Ten 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 People with the Fifteen Most Costly Medical Conditions, 1997,” Health Affairs, March/April 2003.

13. Which priority areas? HHS contracted with IOM HHS contracted with IOM – To select criteria for screening potential priority areas – To develop a process for applying those criteria – To generate a list of 12-20 candidate areas

14. Priority Areas for National Action: Transforming Health Care Quality IOM (2003) Goal IOM (2003) Goal – To identify priority areas that presented the greatest opportunity to narrow the gap between what the health care system is routinely doing now and what we know to be the best medical practice Improve the delivery of existing best practice treatments. Improve the delivery of existing best practice treatments.

15. Framework Based on Based on – Foundation for Accountability (1997) – IOM, National Health Care Quality Report (2001) Five domains Five domains – Staying healthy (preventive care) – Getting better (acute care) – Living with illness/disability (chronic care) – Coping with end of life (palliative care) – Cross-cutting systems interventions (coordination of care)

16. Priority Area Selection Criteria Impact Impact – Burden: disability, mortality, economic costs Improvability Improvability – Gap between current and evidence-based best practice -- size and probability of improvement Inclusiveness Inclusiveness – Range--(equity) of individuals (socioeconomic, r/e, gender) – Generalizability--(representativeness) to many conditions – Breadth--(reach) across settings and providers

17. What’s the process? Determine a framework for the priority areas Determine a framework for the priority areas Identify candidate areas Identify candidate areas Establish criteria for selecting final priority areas Establish criteria for selecting final priority areas Apply impact and inclusiveness to the candidates Apply impact and inclusiveness to the candidates Apply criteria of improvability and inclusiveness to the preliminary set of areas obtained in the step above Apply criteria of improvability and inclusiveness to the preliminary set of areas obtained in the step above

18. What’s the process? (2) Identify priority areas, reassess, and approve Identify priority areas, reassess, and approve Finally Finally – Implement strategies for improving care in he priority areas, – Measure the impact of implementation – Review/update the list of areas\

19. 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 mile/moderate asthma Asthma--appropriate treatment for persons with mile/moderate asthma Cancer screening that is evidence-based-- focus on colorectal and cervical cancer Cancer screening that is evidence-based-- focus on colorectal and cervical cancer

20. Priority Areas (2) Children with special health care needs Children with special health care needs Diabetes--focus on appropriate management of early disease Diabetes--focus on appropriate management of early disease End of life with advanced organ system failure--focus on congestive heart failure and chronic obstructive pulmonary disease End of life with advanced organ system failure--focus on congestive heart failure and chronic obstructive pulmonary disease Frailty associated with old age--preventing falls and pressure ulcers, maximizing function, and developing advanced care plans Frailty associated with old age--preventing falls and pressure ulcers, maximizing function, and developing advanced care plans

21. Priority Areas (3) Hypertension--focus on appropriate management of early disease Hypertension--focus on appropriate management of early disease immunization--children and adults immunization--children and adults Ischemic heart disease--prevention, reduction of recurring events, and optimization of functional capacity Ischemic heart disease--prevention, reduction of recurring events, and optimization of functional capacity Major depression--screening and treatment Major depression--screening and treatment

22. Priority Areas (4) Medication management--preventing medication errors and overuse of antibiotics Medication management--preventing medication errors and overuse of antibiotics Nosocomial infections--prevention and surveillance Nosocomial infections--prevention and surveillance Pain control in advanced cancer Pain control in advanced cancer Pregnancy and childbirth--appropriate prenatal and intrapartum care Pregnancy and childbirth--appropriate prenatal and intrapartum care

23. Priority Areas (5) Severe and persistent mental illness--focus on treatment in the public sector Severe and persistent mental illness--focus on treatment in the public sector Stroke--early intervention and rehabilitation Stroke--early intervention and rehabilitation Tobacco dependence treatment in adults Tobacco dependence treatment in adults Obesity (an emerging area) Obesity (an emerging area)

24. What for the future? Data collection and measurement systems for... quality improvement efforts Data collection and measurement systems for... quality improvement efforts Support development of … standardized measures of quality Support development of … standardized measures of quality Report measures of key attributes and outcomes to the public Report measures of key attributes and outcomes to the public Revise selection criteria and priority area list Revise selection criteria and priority area list

25. What for the future? Review evidence based and update priorities every 3-5 years Review evidence based and update priorities every 3-5 years Assess changes in society’s attributes that could affect health and alter priorities Assess changes in society’s attributes that could affect health and alter priorities Disseminate the results of strategies for QI in the priority areas Disseminate the results of strategies for QI in the priority areas

26. Strategy This is the development of a strategy for addressing the high priority areas of health care This is the development of a strategy for addressing the high priority areas of health care Determining the priorities is a collaborative process Determining the priorities is a collaborative process These priorities are for everyone These priorities are for everyone

27. Twenty Quality Priority Areas Internet 2 J. Michael Fitzmaurice, Ph.D. Agency for Healthcare Research and Quality

28. Practice-Based Research Networks AHRQ supports research in groups of physician practices on such topics as: automated electronic reminders to AHRQ supports research in groups of physician practices on such topics as: automated electronic reminders to – Improve compliance with guidelines for managing patients with diabetes – Improve screening and detection of patients at higher risk for tuberculosis using CDC guidelines – Improve lipid management (improving cholesterol and calculating the risk of cardiovascular disease for a patient)

29. Practice-Based Research Networks (PBRNs) 36 new PBRN grants awarded in 2002 19 PBRN grants awarded in 2000