1. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Tracking the Nation’s Health Care: The National Healthcare Quality and Disparities Reports Edward Kelley Ernest Moy Center for Quality Improvement and Patient Safety

2. Advancing Excellence in Health Care Reports Mandates Mandated by Congress in the Healthcare Research and Quality Act (PL. 106-129) “Beginning in fiscal year 2003, the Secretary, acting through the Director, shall submit to Congress an annual report on national trends in the quality of health care provided to the American people.” “Beginning in fiscal year 2003, the Secretary, acting through the Director, shall submit to Congress an annual report on national trends in the quality of health care provided to the American people.” To track “prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations” To track “prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations”

3. Advancing Excellence in Health Care Why are the reports important? New tools for monitoring health care delivery New tools for monitoring health care delivery Summarize information Summarize information Makes clear where improvement is most needed Makes clear where improvement is most needed Provide consensus on what is important to measure Provide consensus on what is important to measure Facilitates measurement alignment Facilitates measurement alignment

4. Advancing Excellence in Health Care How the NHDR and NHQR are Related NHQRNHDR Snapshot of quality of health care in America Snapshot of disparities in health care in America Quality Quality + Access Safety, effectiveness, timeliness, patient centeredness Equity Variation across states Variation across populations

5. Advancing Excellence in Health Care How the Reports Fit into AHRQ’s Focus on Implementation Purpose of the Reports: To promote awareness of the status of health care quality and disparities in America; and To promote awareness of the status of health care quality and disparities in America; and To lead to action and support AHRQ’s overall mission “to improve the quality… of health care for all Americans.” To lead to action and support AHRQ’s overall mission “to improve the quality… of health care for all Americans.” Quality?

6. Advancing Excellence in Health Care Who Helped Design the NHQR? Public and private call for measures Public and private call for measures Measure set culled with HHS agencies Measure set culled with HHS agencies Released for public comment, provider associations, industry gave feedback Final proposed measure set approved by HHS partners Released for public comment, provider associations, industry gave feedback Final proposed measure set approved by HHS partners ASPE, CDC, HRSA, CMS, NCHS, SAMHSA, NIH, Data Council, HIS, FDA AMA, AHA, JCAHO, Midwest Business Group on Health, NAHDO, NASHP, IOM, general public

7. Advancing Excellence in Health Care Conceptual Framework

8. Advancing Excellence in Health Care Priority Areas: What Conditions are Included? Defined by national experts brought together by IOM (Bill Roper, co-chair) Defined by national experts brought together by IOM (Bill Roper, co-chair) Aligned with HHS existing priorities—HP2010, Secretary’s prevention agenda, IOM priority areas Aligned with HHS existing priorities—HP2010, Secretary’s prevention agenda, IOM priority areas Includes: cancer*, chronic kidney disease, diabetes*, heart disease, HIV/AIDS, maternal and child health, mental illness-depression, respiratory illness (e.g., asthma, flu), nursing home and home health, patient safety, timeliness, patient centeredness, resource consumption Includes: cancer*, chronic kidney disease, diabetes*, heart disease, HIV/AIDS, maternal and child health, mental illness-depression, respiratory illness (e.g., asthma, flu), nursing home and home health, patient safety, timeliness, patient centeredness, resource consumption

9. Advancing Excellence in Health Care Who Has Helped Design the NHDR? AHRQ-led effort starting in 2001 AHRQ-led effort starting in 2001 IOM Committee on Guidance for Designing a NHDR IOM Committee on Guidance for Designing a NHDR DHHS DHHS – Interagency Workgroup for the NHDR: ACF, AoA, ASH, ASL, ASPA, ASPE, CDC, CMS, FDA, HRSA, IHS, NCHS, NIH, OCR, OMH, SAMHSA – Data Council Extensive input from other organizations & stakeholders Extensive input from other organizations & stakeholders – Congressional staff, Asian and Pacific Islander American Health Forum, American Association of Health Plans, Association of State and Territorial Health Officials, National Rural Health Association, NMA, AAFP, AMA, ANA, AAHP

10. Advancing Excellence in Health Care NHDR Conceptual Framework Quality of Care Effective- ness Safety Timeli- ness Patient Centered- ness Staying Healthy Getting Better Living with Illness or Disability Coping with the End of Life Access to Care Entry Barriers Structural Barriers Cultural Barriers UseCosts Staying Healthy Getting Better Living with Illness or Disability Coping with the End of Life Disparities Health Status / Health Care Need

11. Advancing Excellence in Health Care What is in the NHDR? For the first time, the NHDR: For the first time, the NHDR: – Tracks disparities at the national level – Reports on disparities in terms understandable by patients and providers – Gives policymakers, researchers and providers information to reduce disparities Report chapters Report chapters – Quality of Health Care – Access and Receipt of Health Care – Priority Populations

12. Advancing Excellence in Health Care Measure Selection Process Identify pool of candidate measures Identify pool of candidate measures Map candidate measures into conceptual framework Map candidate measures into conceptual framework Evaluate and vet candidate measures Evaluate and vet candidate measures Identify draft measure set Identify draft measure set Analysis of draft measure set Analysis of draft measure set Finalize final 2003 measure set Finalize final 2003 measure set Review and vet 2003 measure set Review and vet 2003 measure set Finalize 2004 measure set Finalize 2004 measure set Call for measures 600-700 NHQR/NHDR measures 2003 reports ~150 NHQR measures ~ 240 NHDR measures 2004 reports 178 NHQR measures 238 NHDR measures

13. Advancing Excellence in Health Care Measure Topics Quality of Health Care Effectiveness Effectiveness – Cancer, Diabetes, ESRD, Heart Disease, HIV/AIDS, Maternal and Child Health, Mental Disease, Respiratory Disease, Nursing Home and Home Health Care Safety Safety Timeliness Timeliness Patient centeredness Patient centeredness Access to Health Care Getting into the system Getting into the system – Insurance, Usual Source of Care, Perceptions of Need Getting care within the system Getting care within the system Perceptions of care Perceptions of care – Patient-provider communication, relationship Health care use Health care use

14. Advancing Excellence in Health Care AHRQ Priority Populations Women Women Children Children Elderly Elderly Racial and ethnic minorities Racial and ethnic minorities Low-income Low-income Residents of rural areas Residents of rural areas Persons with special health care needs Persons with special health care needs – Disabled – Chronic care – End of life

15. Advancing Excellence in Health Care Databases Surveys collected from samples of civilian, noninstitutionalized populations: Surveys collected from samples of civilian, noninstitutionalized populations: – AHRQ, Medical Expenditure Panel Survey (MEPS), 1998-2000 – California Health Interview Survey (CHIS), 2001 – CDC-NCHS, National Health and Nutrition Examination Survey (NHANES), 1999-2000 – CDC-NCHS, National Health Interview Survey (NHIS), 1998 and 2000 – CDC-NCHS/National Immunization Program, National Immunization Survey (NIS), 2001 – CMS, Medicare Current Beneficiary Survey (MCBS), 1999 – The Commonwealth Fund, Health Care Quality Survey, 2001 – NCHS, National Health and Nutrition Examination Survey (NHANES), 1999-2000 – NCHS, National Health Interview Survey (NHIS), 1998 and 2000 – NCHS, National Immunization Survey (NIS), 2001 – SAMHSA, National Household Survey of Drug Abuse (NHSDA), 2000. Data collected from samples of health care facilities: Data collected from samples of health care facilities: – CDC-NCHS, National Ambulatory Medical Care Survey (NAMCS), 1999-2000 – CDC-NCHS, National Home and Hospice Care Survey (NHHCS), 2000 – CDC-NCHS, National Hospital Ambulatory Medical Care Survey-Outpatient Department (NHAMCS-OPD), 1999-2000 – CDC-NCHS, National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED), 1999-2000 – CDC-NCHS, National Hospital Discharge Survey (NHDS), 1998-2000 – CDC-NCHS National Nursing Home Survey (NNHS), 1999 – CMS, End-Stage Renal Disease Clinical Performance Measurement Program, 2001 – CMS, Nursing Home Resident Profile Table, 2001 – NCHS, National Ambulatory Medical Care Survey (NAMCS), 1999-2000 – NCHS, National Home and Hospice Care Survey (NHHCS), 2000 – NCHS, National Hospital Ambulatory Medical Care Survey-Outpatient Department (NHAMCS-OPD), 1999-2000 – NCHS, National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED), 1999-2000 – NCHS, National Hospital Discharge Survey (NHDS), 1998-2000 – NCHS’s National Nursing Home Survey (NNHS), 1999 – NIH, United States Renal Data System (USRDS), 2000 – SAMHSA, Client/Patient Survey Sample (CPSS), 1997. – CMS, Quality Indicators program, 1998-1999. Data extracted from administrative data systems of health care organizations: Data extracted from administrative data systems of health care organizations: – AHRQ, Healthcare Cost and Utilization Project State Inpatient Databases 16- State database (HCUP SID), 2000 – Medicare claim data from CMS – HIV Research Network data (HIVRN), 2000. Data from surveillance and vital statistics systems: Data from surveillance and vital statistics systems: – CDC-National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 2000 – CDC-National Center for HIV, STD, and TB Prevention, TB Surveillance System, 1998-1999 – CDC-NCHS, National Vital Statistics System (NVSS), 2000 – NIH, Surveillance, Epidemiology, and End Results (SEER) program.

16. Advancing Excellence in Health Care

17. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov NHQR/NHDR: Key Findings and Next Steps Ernest Moy Edward Kelley Center for Quality Improvement and Patient Safety

18. Advancing Excellence in Health Care Key Findings High quality health care is not universal. High quality health care is not universal. – Preventive care – Chronic disease management There is more to learn. There is more to learn. Greater improvement is possible. Greater improvement is possible. Disparities in health care are pervasive. Disparities in health care are pervasive. – Preventive care – Chronic disease management – Access to care There is more to learn. There is more to learn. Greater improvement is possible. Greater improvement is possible.

19. Advancing Excellence in Health Care Key Report Findings High quality health care is not universal. Disparities in health care are pervasive.

20. Advancing Excellence in Health Care There is more to learn. NHQR Gaps Limited measures Limited measures – HIV/AIDS – Mental Health – Timeliness – Patient Centeredness – End of life care NHDR Gaps Limited data Limited data – Native Hawaiians – American Indians – Asians – Children – Rural residents – Special care needs Limited understanding Limited understandingTrends Best practices How to integrate quality and disparities activities

21. Advancing Excellence in Health Care Greater improvement is possible. Of quality measures with trend data, a third show improvement, two-thirds show no change or deterioration. Of quality measures with trend data, a third show improvement, two-thirds show no change or deterioration. Blacks and Hispanics do worse than whites on half of quality measures. Blacks and Hispanics do worse than whites on half of quality measures. Hispanics and Asians do worse than whites on two-thirds of access measures. Hispanics and Asians do worse than whites on two-thirds of access measures. Poor people do worse on two-thirds of quality and access measures. Poor people do worse on two-thirds of quality and access measures.

22. Advancing Excellence in Health Care Next Steps Begin to fill gaps Begin to fill gaps – Measurement – Data – Information Begin to refine report products Begin to refine report products – Reports – Spin-off products

23. Advancing Excellence in Health Care Filling Measurement Gaps Child Health: MEPS adds child preventive services module in 2001 Child Health: MEPS adds child preventive services module in 2001 Patient Safety Patient Safety – Add analyses of Medicare Patient Safety Monitoring System this year – HCUP develops special disparities analytic file that allows national estimates by race/ethnicity Timeliness: Add measures of clinical timeliness Timeliness: Add measures of clinical timeliness Cultural Competency/Language: MEPS adds questions to Access to Care module in 2002 Cultural Competency/Language: MEPS adds questions to Access to Care module in 2002

24. Advancing Excellence in Health Care Filling Data Gaps Asians: MEPS oversamples Asians in 2002 Asians: MEPS oversamples Asians in 2002 AI/ANs: IHS supplements national analyses with IHS data AI/ANs: IHS supplements national analyses with IHS data Low income: HRSA supplements national analyses with CHC data Low income: HRSA supplements national analyses with CHC data Elderly: More MCBS analyses Elderly: More MCBS analyses Rural: Adopt new metro, micro, non-core categories Rural: Adopt new metro, micro, non-core categories Special health care needs: Add analyses of Survey of Children with Special Health Care Needs Special health care needs: Add analyses of Survey of Children with Special Health Care Needs

25. Advancing Excellence in Health Care Filling Information Gaps New analyses New analyses – Trends – Regional analyses – More stratified/multivariate analyses – More summary measures Review of best practices Review of best practices

26. Advancing Excellence in Health Care NHQRNHDRDocument Data Products Focus Areas Research Reports General Awareness qualitytools.gov NHQR/DR-net Workbooks Knowledge Packs Patient Guides QI Clearinghouse Working papers Articles Supplements Information packs Webcasts National Reports Products

27. Advancing Excellence in Health Care Knowledge Report Diffusion Strategies, Tactics, and Actions Improvement

28. Advancing Excellence in Health Care Refining the Report Products Chartbook Chartbook – Shorter – Less text, more graphics – Focus on a smaller number of “highlight” measures – Push more detail to Appendices Spin-off Products Spin-off Products – Actionable – Targeted audiences – Specific strategies, tactics, and actions

29. Advancing Excellence in Health Care Compare State data with national benchmarks, identify gaps in State data, and develop a complete inventory of the data systems available at the State and local levels. Diabetes Resource Guide for State Leaders

30. Advancing Excellence in Health Care Making Quality Count: Tools, Strategies, and Resources A Series of Two Free Web-assisted Audio Conferences for State, Local, and Health System Policymakers. Tuesday, February 10 and Wednesday, February 18, 2004 2:00–3:30 p.m., EST 2:00–3:30 p.m., EST ULP Web Conferences

31. Advancing Excellence in Health Care NHQR-DR Medical Care Supplement Fall 2004 Prevention Health Care Quality in America: Findings from the first National Healthcare Quality and Disparities Reports Peer-reviewed Literature

32. Advancing Excellence in Health Care http://www.innovations.ahrq.gov/qu alitytools/

33. Advancing Excellence in Health Care NHQR/DR-net Quality Improvement Clearinghouse Web-based data tools

34. Advancing Excellence in Health Care How you can help Review first Reports Review first Reports Review http://www.innovations.ahrq.gov/qualitytools/ Review http://www.innovations.ahrq.gov/qualitytools/ http://www.innovations.ahrq.gov/qualitytools/ Provide advice about Provide advice about – Adding and refining measures – Accessibility and usability of reports and tools Tell us about your experiences Tell us about your experiences – Measuring quality and disparities – Improving quality – Reducing disparities

35. Advancing Excellence in Health Care For Further Information AHRQ’s web site for the NHQR and NHDR: http://www.innovations.ahrq.gov/qualitytools/ Contact information: Dr. Ed Kelley, Director National Healthcare Quality Report (ekelley@ahrq.gov) ekelley@ahrq.gov Dr. Ernie Moy, Senior Service Fellow National Healthcare Disparities Report (emoy@ahrq.gov) emoy@ahrq.gov Dr. Dan Stryer, Director Center for Quality Improvement and Patient Safety (dstryer@ahrq.gov) dstryer@ahrq.gov