1. 2007 National Healthcare Quality Report: Overview of Findings AcademyHealth Annual Research Meeting June 10, 2008 Jeff Brady, M.D., M.P.H. Acting Director, US National Healthcare Reports

2. Presentation Outline The National Healthcare Reports: Background and Purpose The National Healthcare Reports: Background and Purpose What’s New and Findings What’s New and Findings – 2007 NHQR – 2007 NHDR 2007 State Snapshots 2007 State Snapshots

3. The National Healthcare Reports: Background and Purpose

4. Origin of the NHQR / NHDR Beginning in fiscal year 2003, the HHS Secretary, acting through the Director, shall submit to Congress: NHQR an annual report on national trends in the quality of health care provided to the American people. NHQR an annual report on national trends in the quality of health care provided to the American people. NHDR to track prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations. NHDR to track prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations. Mandated by Congress in Healthcare Research and Quality Act (PL. 106-129)

5. NHQR and NHDR Goals Provide a snapshot of health care delivery Provide a snapshot of health care delivery – 41 core measures of quality – 211 total measures Indicate the biggest gaps in care Indicate the biggest gaps in care Show national and State trends Show national and State trends Suggest how we can reach our goals Suggest how we can reach our goals Promote alignment of measures across public and private quality initiatives Promote alignment of measures across public and private quality initiatives

6. NHQR and NHDR Framework Consumer Perspectives on Health Care Needs Components of Health Care Quality SafetyEffectiveness Patient Centeredness Timeliness Staying healthy Getting better Living with illness or disability Coping with the end-of-life Source: Institute of Medicine Committee. “Envisioning the National Health Care Quality Report,” 2001

7. Relationship Between NHQR and NHDR 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, efficiency Safety, effectiveness, timeliness, patient centeredness, + equity Variation across States Variation across populations

8. Content and Organization 2007 NHQR/NHDR Effectiveness Effectiveness – Cancer – Diabetes – End Stage Renal Disease (ESRD) – Heart Disease – HIV and AIDS – Maternal and Child Health – Mental Health and Substance Abuse – Nursing Home, Home Health, and Hospice Care Patient Safety Patient Safety Timeliness Timeliness Patient Centeredness Patient Centeredness Efficiency* Efficiency* Access to Health Care Access to Health Care Priority Populations Priority Populations NHQR NHDR *NHQR only

9. NHQR/DR Data Sources Provider/facility sample surveys CDC,NCHS – NAMCS CDC,NCHS – NHAMCS CDC,NCHS – NHDS CMS – ESRD CPMP CSHSC – Community Tracking Study Physician Survey Population sample surveys AHRQ – MEPS AHRQ – CAHPS CDC – BRFSS CDC,NCHS – National Asthma Survey CDC,NCHS – NHANES CDC,NCHS – NHIS CDC,NCHS – National Immunization Survey CMS – MCBS HRSA – Healthy Schools Healthy Communities User Visit Survey NHPCO – Family Evaluation of Hospice Care SAMHSA – NSDUH U.S. Census Bureau – U.S. Census Surveillance and vital statistics CDC – NPCR CDC – HIV/AIDS Surveillance System CDC – TB Surveillance System CDC,NCHS – NVSS NIH – SEER Organizational data systems AHRQ – HCUP CMS – Hospital Compare CMS – Medicare Patient Safety Monitoring System CMS – OASIS CMS – Nursing Home Minimum Data Set CMS – QIO HIVRN – 2001-2003 IHS – NPIRS NCQA – HEDIS NIH – USRDS SAMHSA – TEDS

10. 2007 National Healthcare Quality and Disparities Reports Released March 3rd

11. 2007 NHQR What’s New and Findings

12. New in the 2007 NHQR Chapter 2, Effectiveness Chapter 2, Effectiveness – Cancer: Cancer treatment measures – HIV and AIDS: HIV testing measures – Nursing Home and Home Health: Pain management for nursing home residents Chapter 6, Efficiency Chapter 6, Efficiency

13. Annual Median Rate of Change The annual median rate of change from 1994 to 2005 was 2.3% The annual median rate of change from 1994 to 2005 was 2.3% From 2000 to 2005, the annual median rate of change was 1.5% From 2000 to 2005, the annual median rate of change was 1.5% n=number of measures

14. Improvement in Core Measures Most measures show some improvement Most measures show some improvement Of the 41 core measures reported: Of the 41 core measures reported: – 27 improved – 6 declined – 6 showed no change

15. Variation in Health Care Quality Variation in quality of health care across the Nation is decreasing, but not for all measures Variation in quality of health care across the Nation is decreasing, but not for all measures More measures have seen progress in terms of decreases in variation between the best performing State and the worst performing State between 2000 and 2005: More measures have seen progress in terms of decreases in variation between the best performing State and the worst performing State between 2000 and 2005: – Variability decreased for 28 measures – Variability increased for 13 measures – There was no change for 18 measures

16. Example of Decreased Variation Heart attack patients given smoking cessation counseling while hospitalized Source: CMS, Medicare Quality Improvement Organization Program

17. Patient Safety The safety of health care has improved since 2000, but more needs to be done The safety of health care has improved since 2000, but more needs to be done n=number of measures

18. Patient Safety Improvements Areas where significant attention has been concentrated, such as appropriate timing of antibiotics for surgery and reducing medication errors, have shown progress: Areas where significant attention has been concentrated, such as appropriate timing of antibiotics for surgery and reducing medication errors, have shown progress: – Over 30% more patients received appropriate timing for antibiotics before and after surgery in 2005 than in 2004 – From 2004 to 2005, adverse drug events from warfarin and low-molecular-weight heparin declined 21% and 28%, respectively – Deaths following complications of care declined 2.4% from 1994 to 2004

19. Disparities Report Findings Disparities in health care quality are staying the same or increasing Disparities in health care quality are staying the same or increasing n=number of core measures

20. 2007 State Snapshots http://statesnapshots.ahrq.gov

21. State Snapshots -- Overview Summary performance meters Summary performance meters Individual measures Individual measures Focus on clinical issues Focus on clinical issues State context State context Methods & Interpretation Guides Methods & Interpretation Guides Web tool for State policymakers to view NHQR/NHDR health care quality, State-by-State:

22. State Snapshots: Summary Performance Meters Summary meters – a State’s performance compared to its region and the nation for: Summary meters – a State’s performance compared to its region and the nation for: – All Available Measures – Care by Clinical Area Cancer Cancer Diabetes Diabetes Heart Disease Heart Disease Maternal and Child Health Maternal and Child Health Respiratory Disease Respiratory Disease Clinical preventive services Clinical preventive services – Types of Care Preventive Preventive Acute Acute Chronic Chronic – Settings of Care Hospital Hospital Ambulatory Ambulatory Nursing Home Nursing Home Home Health Home Health

23. Summary Performance Meters: State Compared to Region or Nation Click meter to view data

24. State Snapshots: What’s New for 2007 State Dashboards State Dashboards – All of a State’s summary meters Focus on Healthy People 2010 Table Focus on Healthy People 2010 Table – State’s performance on goals Focus on Clinical Preventive Services Meter Focus on Clinical Preventive Services Meter – State’s performance on recommended services Contextual Dials of State’s environment: Contextual Dials of State’s environment: – Demographics (age, income, race, education) – Population health status (obesity, mental health) – Health care resources (specialist physicians, admission rate, HMOs)

25. State Dashboard: Performance Meters all in one Place Click meter to view metrics compared to all states

26. State Performance on Healthy People 2010 Goals

27. State Performance in Clinical Preventive Services

28. State Contextual Factors Click dial to view data

29. NHQR/NHDR Resources & Contacts http://www.ahrq.gov/qual/qrdr07.htm http://www.ahrq.gov/qual/qrdr07.htm http://www.ahrq.gov/qual/qrdr07.htm Request Reports: 1-800-358-9295 Request Reports: 1-800-358-9295 ahrqpubs@ahrq.gov ahrqpubs@ahrq.govahrqpubs@ahrq.gov Jeff Brady, Jeff.Brady@ahrq.hhs.gov Jeff Brady, Jeff.Brady@ahrq.hhs.gov Jeff.Brady@ahrq.hhs.gov Acting Director, National Healthcare Reports Lead Staff, NHQR Karen Ho, Karen.Ho@ahrq.hhs.gov Karen Ho, Karen.Ho@ahrq.hhs.gov Karen.Ho@ahrq.hhs.gov Lead Staff, NHDR Lead Staff, NHDR Ernest Moy, Ernest.Moy@ahrq.hhs.gov Ernest Moy, Ernest.Moy@ahrq.hhs.gov Ernest.Moy@ahrq.hhs.gov NHQR/NHDR Team

30. EXTRA SLIDES FOLLOW

31. Postoperative Complications From 2003 to 2005, the percentage of surgical patients… With postoperative pneumonia or a venous thromboembolic event did NOT change significantly With postoperative pneumonia or a venous thromboembolic event did NOT change significantly Who developed a urinary tract infection increased slightly; however, it should be noted that this measure changed in 2005 to include only patients with catheter- associated urinary tract infection. Who developed a urinary tract infection increased slightly; however, it should be noted that this measure changed in 2005 to include only patients with catheter- associated urinary tract infection. 2007 National Healthcare Quality Report, Source: CMS, Medicare Patient Safety Monitoring System

32. Adverse Drug Events In 2005, adverse drug events in the hospital related to some frequently used medications … Ranged from 6.89% of Medicare patients who received warfarin to 13.0% of Medicare patients who received intravenous heparin. Ranged from 6.89% of Medicare patients who received warfarin to 13.0% of Medicare patients who received intravenous heparin. The rates of adverse events associated with low-molecular- weight heparin and warfarin decreased significantly between 2004 and 2005. The rates of adverse events associated with low-molecular- weight heparin and warfarin decreased significantly between 2004 and 2005. 2007 National Healthcare Quality Report, Source: CMS, Medicare Patient Safety Monitoring System

33. State Snapshots: What’s behind each meter? A State’s relative performance compared to a group – region / all states A State’s relative performance compared to a group – region / all states – A subset of NHQR measures (e.g., hospital measures) – Classify each state’s performance for each measure: First, calculate all-state and regional averages First, calculate all-state and regional averages Then, determine if state is statistically better than average, average, or worse than average Then, determine if state is statistically better than average, average, or worse than average – Score state for results across all NHQR measures in subset Each better than average measure = 1 point Each better than average measure = 1 point Each average measure = 0.5 point Each average measure = 0.5 point Each worse than average = 0 points Each worse than average = 0 points – Sum points and divide by the number of measures

34. State Snapshots: Individual Measures Strongest and Weakest Measures for a State compared to all States reporting Strongest and Weakest Measures for a State compared to all States reporting – Strongest demonstrate where a State may be leading the way in quality – Weakest highlight some of the opportunities for improvement State Rankings for 15 Measures State Rankings for 15 Measures – Ordinal rank on individual measures of each State’s performance out of 50 States + DC Downloadable table of all measures for a State and for all States Downloadable table of all measures for a State and for all States

35. 2007 NHDR Findings

36. Access to Health Care Disparities in access to care are staying the same or increasing Disparities in access to care are staying the same or increasing n=number of core measures

37. NHDR Findings Over 60% of disparities in quality of care have stayed the same or worsened for Blacks, Asians, and poor populations Over 60% of disparities in quality of care have stayed the same or worsened for Blacks, Asians, and poor populations Nearly 60% of disparities have stayed the same or worsened for Hispanics Nearly 60% of disparities have stayed the same or worsened for Hispanics For Blacks, Asians, Hispanics, and poor populations, disparities in at least half the core measures of access to care are not improving. For Blacks, Asians, Hispanics, and poor populations, disparities in at least half the core measures of access to care are not improving.

38. Recent Uses by Statewide Data Organizations Utah Health Data Committee Utah Health Data Committee – Challenges in Utah’s Health Care (released June 2007) Maine Quality Forum Maine Quality Forum – Developing “Maine Snapshots” to report at the hospital-level Arkansas Center for Health Improvement Arkansas Center for Health Improvement – Establish baseline for tracking improvement