How to Describe Five Health Topics in the Context of Comparative Performance Reports

How to describe the health and community context for comparative

performance reports: sample language for five health topics

AIR provides technical assistance for Aligning Forces for Quality, a national initiative of the Robert Wood Johnson Foundation i

How to Describe Five Health Topics in the Context of Comparative Performance Reports

ContentsIntroduction.......................................................................................1

What you will find in this guide...........................................................2

How to use this guide.........................................................................3Considerations for implementation........................................................................................3

Sample text for Alliance Web sites......................................................4Asthma...................................................................................................................................4

Breast Cancer Screening........................................................................................................6

Cervical Cancer Screening.....................................................................................................7

Diabetes.................................................................................................................................9

Heart Disease.......................................................................................................................10

Congestive Heart Failure.....................................................................................................12

Heart Attack.........................................................................................................................14

Tips and resources...........................................................................17Tips......................................................................................................................................17

Online resources..................................................................................................................18

Key reference articles..........................................................................................................19

Endnotes.............................................................................................................21

AIR provides technical assistance for Aligning Forces for Quality, a national initiative of the Robert Wood Johnson Foundation ii

Introduction

This document provides a framework, tips and sample text for five health topics: asthma, breast cancer screening, cervical cancer screening, diabetes and heart disease. Alliances can use this text to help consumers understand the importance of condition-specific performance measures. As consumers are primarily interested in learning about their particular health condition, Alliances can provide this kind of information to draw consumers to the site and engage them in using quality information about those conditions.

Further, Alliances can incorporate this language into their current Web sites and reports in fulfillment of the 2010 Dashboard Public Measurement and Public Reporting 11 (PM/PR-11) requirement.

The sample text in this guide aims to encourage consumers to use your Alliance’s Web site and performance reports and help them understand how population data and comparative quality information are relevant to their health.

Use this sample text to:

• Provide engaging information about asthma, breast cancer screening, cervical cancer screening, diabetes, and heart disease

• Describe the impact of these conditions on both individuals and communities

• Help consumers learn what good care looks like

• Link health information to quality standards and comparative quality reports

The Consumer Audience

The Alliances are charged with engaging consumers who are often unaware of quality information and evidence-based medicine. Consumers may have limited understanding and even misconceptions about these topics.1 Often, they are not familiar with or do not understand recommended care guidelines and performance measures. Further, consumers may not be familiar with the mechanisms and effects of various conditions on the body and may not understand medical terminology. Finally, they may not make the connection between personal health and population health. Thus, this document is intended to provide consumer-friendly information to encourage consumers to share responsibility for their health and well-being.

AIR provides technical assistance for Aligning Forces for Quality, a national initiative of the Robert Wood Johnson Foundation 1

PM/PR 11 Requirement“Including contextual information and population-based data in performance reports can be useful for consumers to help them understand the scope of health problems in their community. This information should include: 1) description and prevalence of

disease condition (quantified where possible);

2) health risk of disease condition (quantified where possible);

3) distribution of disease in the population (quantified where possible);

4) financial burden of disease condition (quantified where possible); and

5) clinical protocols reflecting evidenced-based care for disease condition.

PM/PR 11 assesses whether Alliances have included in their performance report contextual information and population-based data about the disease conditions reflected in the performance measures.”

How to Describe Five Health Topics in the Context of Comparative Performance Reports

Helping consumers to see their role in their community’s health and involving them in their personal health decisions can result in significant benefits to the overall health care system and the community.

The National Program Office of the Robert Wood Johnson Foundation’s (RWJF’s) Aligning Forces for Quality (AF4Q) sponsored this work. This guide was prepared by the American Institutes for Research on behalf of RWJF’s AF4Q initiative. Formally launched in 2008, AF4Q is the RWJF’s signature effort to improve the quality of health care in targeted communities. AF4Q operates in 17 regions nationwide, with the goal of bringing together everyone who gets, gives, and pays for health care to lift the quality of care provided locally and to provide models for national reform.

The language in this document supplements the descriptions of hospital and physician performance measures for the treatment of these conditions provided in other AF4Q documents available at www.forces4quality.org.

Related materials

This guide is the part of a series of technical assistance products developed by AIR to support the efforts of Alliances to engage consumers in using quality information. This initial series will include the following materials available in fall 2010:

• How To Display Comparative Information That People Can Understand and Use

• How To Report Results of the CAHPS Clinician and Group Survey

• How to Get Consumer Feedback and Input Into Web Sites.

What you will find in this guide

This guide provides a brief overview of issues to consider in presenting contextual information about specific health topics, population-based data, and reports of comparative performance on an Alliance-sponsored Web site. To assist Alliances in providing contextual information to consumers about key health topics, this guide also presents sample text and tips for your Web site.

• The sample text provides information regarding the scope of selected health problems in the community, describes recommended care for the each health topic, and suggests links to performance reports. Because data sources will vary across Alliances, the sample text for each condition includes several illustrations of how you can describe the impact of the health condition on the community.

• Tips and resources cover how to incorporate contextual information and population-based data into your Web site, resources for Alliances, links for consumers and key references.

AIR provides technical assistance for Aligning Forces for Quality, a national initiative of the Robert Wood Johnson Foundation 2

How to Describe Five Health Topics in the Context of Comparative Performance Reports

Five health topics are addressed:

• Asthma

• Breast cancer screening (mammograms)

• Cervical cancer screening (Pap tests)

• Diabetes

• Heart disease, including monitoring of cholesterol and blood pressure and treatments for congestive heart failure and heart attack

For each topic, we provide sample text in the following common structure:

1) What is x [health topic]? a) Basic descriptionb) Symptoms and effect on body

2) Who is at risk for x [health topic]?a) Causes, if known b) Risk factors for the condition

3) How does x [health topic] affect our community?a) How common is x [health topic] in our community? (Prevalence)b) How does x [health topic] affect people in our community? (Disease burden)

i) Financial burden of disease condition, quantified where possibleii) Other information about the toll of the condition on the community (e.g., school

absenteeism, productivity losses, health care utilization) c) How does x [health topic] affect groups within our community? (Distribution of

condition in the community)

4) What is the recommended care (clinical protocols) for x condition?

How to use this guide

This document provides sample text, tips for implementing the text and resources that Alliances can use for their Web sites and reports. The Alliances can select pieces of the language that are most useful for their sites and customize the language based on local data and resources. The text is adapted from publicly available, trustworthy resources, which are cited. The sample text is followed by tips, resources and references that can provide more background information about consumer information and engagement. Alliances should seek clinical review before posting any health information on their Web sites.

Considerations for implementationAlliances will need to make the linkages between familiar and valued types of information about diseases, treatments and intervention strategies to less familiar information regarding

AIR provides technical assistance for Aligning Forces for Quality, a national initiative of the Robert Wood Johnson Foundation 3

How to Describe Five Health Topics in the Context of Comparative Performance Reports

performance reports. Providing community-specific information about the disease burden associated with various conditions may help link these messages.

Tailor messages to your Alliance’s Web site

The strategies your Alliance uses will depend in large part on the organization and navigation of your Web site. In general, good contextual information should:

• Capture the user’s attention

• Facilitate the user’s understanding of the scope of the health issue and the impact on both individuals and the community

• Build knowledge about quality measures and performance reports

Bring it home

Making health information personal is key. Helping consumers to understand the scope of health issues in their communities requires connecting population data to relevant personal experiences. Similarly, engaging consumers in performance measurement and quality reporting requires connecting personal health with quality health care. Use statistics about conditions and their effects in your community. You can highlight how your community is doing by comparing local data to state or national data. In the case of performance reports, first describe what is known about standards for good care, then relate those standards of care to the actions health providers and patients should take to improve people’s health and well-being.

Sample text for Alliance Web sites

AsthmaWhat is asthma?

Asthma is a disease that affects the airways that carry air in and out of the lungs. Asthma can make it hard to breathe. If you have asthma, your airways are inflamed. The airways get swollen and very sensitive. Your airways tend to react strongly to certain substances in the air.

When asthma becomes worse than usual, it's called an asthma attack. Many things can set off, or trigger, an asthma attack. Allergies, exercise, air pollution or a cold can trigger asthma. Asthma triggers are different for each person. In a severe asthma attack, the airways can close so much that vital organs do not get enough oxygen. Sometimes, asthma attacks are so serious that you need to go to the emergency room or stay overnight in the hospital.2

Who is at risk for asthma?

You are more likely to get asthma if:

2 National Heart, Lung and Blood Institute. What causes asthma? Retrieved Aug. 11, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_Causes.html.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

• your parents have asthma

• you have allergies

• you have a skin allergy called eczema

You can get asthma at any age, but it often starts in childhood. Once you have asthma, it doesn’t go away, although you could get much better.3

How does asthma affect our community?

Good examples of community-specific information

• How common is asthma in our community?

o 1 out of every 10 children in [our state] has asthma.4 This is 3 times higher than the national average.5

o Asthma is also more common for adults in [our state] than the national average.6

• How does asthma affect people in our community?

o 2 out of every 3 children in [our state] with asthma have asthma that is not controlled by medication.Error: Reference source not found This means that these children have constant coughs or other breathing problems. The children may also be more likely to have asthma attacks and to need to go to the hospital emergency room.

o In [our community], asthma is the most common reason children and teenagers miss school. Asthma is also the most common reason children have to go to the hospital.7

o 1 out of 3 people in [our state] with ongoing asthma did not fill even one prescription for a controller medicine in a year.8 This medicine is an inhaler that helps people control their asthma and prevent attacks.

o The average cost for a hospital visit due to asthma is $12,000 in [our state].Error:Reference source not found

• How does asthma affect groups within our community?

o More African Americans and American Indians have asthma than other racial or ethnic groups in [our state].Error: Reference source not found

What is the recommended care for asthma?

People with asthma should work with their doctors to make an asthma action plan. Recommended care includes taking two kinds of medicines to help you breathe better.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

• Medicines for long term control: "controllers" or "preventers" are inhalers that work over time to decrease swelling in airways. If you use these “controller” or “preventer” medicines every day, you will be less likely to have an asthma attack.

• Medicine to get better faster: "quick relievers" are fast-acting inhalers that open narrowed airways within minutes. Quick relievers are for asthma attacks

These medicines help you breathe better, feel better, and sleep better. The medicines also help protect you from serious long-term damage to your airways. It’s important to work with your doctor to get the best combination of medications for you.9

About [X%] of patients with asthma in [our community] get recommended care for asthma. Use the quality reports on this site to compare how often doctors in our community give prescriptions for recommended medicines to their patients with asthma: [link to Public Report URL]. Higher scores are better.

Breast Cancer ScreeningWhat is breast cancer screening?

Screening is looking for cancer before a person has any symptoms. Screening can help find cancer at an early stage, when it is easier to treat. The most common way to screen for breast cancer is to get a mammogram. A mammogram is an x-ray picture of the inside of the breast.10 Mammograms can find about 80% (80 out of 100) of all breast cancers.11

Breast cancer occurs when there are tumors, or groups of cells clumped together, in breast tissue.12 Early breast cancer can be hard to notice or feel. A mammogram can find signs of cancer before you may be able to feel something like a hard lump in your breast.Error: Reference source not found

When breast cancer is found early, it has a higher chance of being treated successfully. Mammograms are important because they can find changes before you can.

Who is at risk for breast cancer?

Breast cancer mainly affects women who are 55 years old or older. People with a family history of certain kinds of breast cancer or cancer of the ovaries may also be more likely to get breast cancer.Error: Reference source not found Women with higher risks of breast cancer should get mammograms at an earlier age.13

Breast cancer is the second most common cancer for women. Breast cancer is more common for white women than women of other races or backgrounds.14

Some women are more likely to die because of breast cancer than other women Breast cancer is the most common cause of death due to cancer for Hispanic women.15 African American women with breast cancer are more likely to die because of breast cancer than women of any other racial or ethnic group.Error: Reference source not found Some research has found that African American women get breast cancer at an earlier age than most women.

Talk with your doctor to learn more about your risks for breast cancer.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

How does breast cancer affect our community?

Good examples of community-specific information

How common is breast cancer in our community? How many people get the mammograms they need?

o Every year, over 207,000 people in the U.S. get breast cancer.16 In [our state], 2,500 patients get breast cancer every year.17

o Some of the women in our community might not get mammograms when they need them. About half the women with breast cancer [in our state] are diagnosed during the early stages of breast cancer.18 That means that the other half is diagnosed with more serious breast cancer. If more women were screened, more women would get diagnosed at an early stage, when it is easier to cure and less likely to need surgery to remove the breast.

o In the U.S., about 64% of women get mammograms at the recommended time. In [our community], 72% of women do.19

• How does breast cancer affect people in our community?

o Health care use for women with breast cancer cost $279 million in [our state] in 2001. Costs were lower for women whose cancer was found in earlier stages than for women whose cancer was in advanced stages.20

• How does breast cancer affect groups within our community?

o In [x county], the number of people with breast cancer is similar to the rest of state and U.S. But more people die from breast cancer here than in other places.Error: Reference source not found This difference may mean that women in [x county] are less likely to get mammograms or the care they need once they have breast cancer.

o Just like in the U.S. overall, African American women with breast cancer in [our state] are much more likely to die from this disease than white women with breast cancer.Error: Reference source not found

What is the recommended care for breast cancer screening?

All women between the ages of 50 and 74 need a mammogram every other year.Error: Reference source not found Some women at higher risk for breast cancer may need to start getting mammograms at an earlier age (40 or even earlier). Some women at higher risk also need mammograms or other tests more often.21

About [X%] of women in [our community] get mammograms when they should. Use the reports on this site to compare how often doctors’ offices in our community follow recommendations for breast cancer screening. You can see how many women who needed breast cancer screening got a mammogram: [link to Public Report URL]. The higher the score, the better.22

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

Cervical Cancer Screening What is cervical cancer screening?

Screening is looking for cancer before a person has any symptoms. This can help find cancer at an early stage, when it is easier to treat.23 To screen for cervical cancer, a doctor performs a Pap test, sometimes called a Pap smear. This test looks for changes in the cells of the cervix. The cervix is the lower part of the womb, which opens into the vagina. The Pap test can find cancer cells or cells that could turn into cancer.24

Cervical cancer is a slow-growing cancer and is usually caused by HPV (human papillomavirus). HPV is a group of viruses that are spread by having sex with an infected person.Error: Reference source not found,25

Because cervical cancer takes a long time to develop, regular Pap tests may find changes in cells before they become cancer.26 This means that getting regular Pap tests can find cancer early, when treatment has the best chance of success.

Who is at risk for cervical cancer?

Any woman can get cervical cancer. You are more likely to be at risk for cervical cancer if you:

• Have the virus called HPV (human papillomavirus)

• SmokeError: Reference source not found

How does cervical cancer affect our community?

Good examples of community-specific information

• How common is cervical cancer? How many women get screened regularly?

o About 12,000 women every year get cervical cancer in the U.S.Error: Reference source not found

o In [our state], about 320 women got cervical cancer in 2009.

o In 2005, about 86% of women in the U.S. got a Pap test in the last 3 years.27 Slightly fewer women in [our state]—about 83%—got a Pap test in the last 3 years.28

• How does cervical cancer affect people in our community?

o [Our state] has slightly fewer deaths due to cervical cancer than the U.S. overall. But we have more deaths for African American women than the U.S.29

o Every year, cervical cancer treatment costs over $2 billion in the U.S.30 In [our community], cervical cancer treatment costs $X.

• How does cervical cancer affect groups within our community?

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

o In [our state], women who had not gotten a Pap test in the past 3 years were more likely to have low income and less than a high school education.Error: Referencesource not found

o Women between the ages of 18 and 29 in [our state] were also less likely to get their needed Pap tests.Error: Reference source not found

What is the recommended care for cervical cancer screening?

All women between the ages of 21 and 64 should get a Pap test at least once every 3 years. Women younger than 30 have a higher risk of cervical cancer and may need to get a Pap test every year. Women who have had an abnormal Pap test also may need to a get Pap test every year.31

About [X%] of women who need cervical cancer screening in [our community] get the Pap test when they should. You can use quality reports to find out how well doctors’ offices in our community follow recommended care for cervical cancer screening: [link to Public Report URL]. The report shows how well physicians screened women who are 21 to 64 years old with a Pap test at least once in the last 3 years.

DiabetesWhat is diabetes?

Diabetes is a disease that keeps your body from making or using insulin. Insulin is a hormone made by your pancreas. Insulin helps turn the food you eat into energy your body needs.32

1 Carman, K. L., Maurer, M., Yegian, J. M., Dardess, P., McGee, J., Evers, M., & Marlo, K.O. (2010). Evidence that consumers are skeptical about evidence-based health care. Health Affairs, 7, 1400–1406.

3 National Heart, Lung and Blood Institute. Living with asthma. Retrieved Aug. 11, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_LivingWith.html.

4 Patrick, D. L., Murray, T. P., Bigby, J., Auerbach, J., & Mullen, J. (2009). Burden of asthma in Massachusetts. Retrieved Aug. 11, 2010 from http://asthmaregionalcouncil.org/uploads/StateAsthma%20Programs/burden_in_mass.pdf.

5 National Center for Chronic Disease Prevention and Health Promotion. (2010). Healthy youth! Health topics: Asthma. Retrieved Aug. 17, 2010 from http://www.cdc.gov/HealthyYouth/asthma/.

6 Garland, R. The burden of asthma in Oregon 2008. (2009). Retrieved Aug. 11, 2010 from http://www.oregon.gov/DHS/ph/asthma/burden/2008/burden.pdf.

9 Partner for Quality Care. (2010). Learn more about ‘daily control’ asthma medication. Oregon Health Care Quality Corporation. Retrieved Aug. 11, 2010 from http://www.partnerforqualitycare.org/pdf/learnmore_asthma_meds.pdf.

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When you have diabetes, your body doesn’t change food into energy as well as it should. Sugar builds up in your blood. If blood sugar stays too high, it can slowly cause damage to your heart, eyes, kidneys and feet.Error: Reference source not found When diabetes is not controlled for long periods of time, it can lead to heart disease, blindness, kidney failure, and loss of fingers, toes, hands or feet.33,34

There are two types of diabetes. Type 1 diabetes is when the body does not produce enough insulin. Type 1 diabetes usually is first diagnosed during childhood. Type 2 diabetes is when the body does not respond as it should to insulin. Both adults and children can get type 2 diabetes.Error: Reference source not found

Who is at risk for diabetes?

Almost everyone knows someone who has diabetes. Risk factors for type 2 diabetes include:

• Older age

• Being overweight or obese

• Family history of diabetes

• Having diabetes during a pregnancy. This is called gestational diabetes.

• Higher than normal levels of blood sugar. This is called impaired glucose tolerance or pre-diabetes.

• Not exercising enoughError: Reference source not found

10 National Cancer Institute. Breast cancer screening. (2010). Retrieved Aug. 11, 2010 from http://www.cancer.gov/cancertopics/pdq/screening/breast/Patient/page3#Keypoint6.

11 National Cancer Institute. (2009). Mammograms. Retrieved September 13, 2010 from: http://www.cancer.gov/cancertopics/factsheet/Detection/mammograms.

16 National Cancer Institute. (2010). Breast cancer. Retrieved Aug. 11, 2010 from http://www.cancer.gov/cancertopics/types/breast.

17 Partner for Quality Care. (2010). Testing for breast cancer. Oregon Health Care Quality Corporation. Retrieved Aug. 11, 2010 from http://www.partnerforqualitycare.org/pdf/whatis_breast_cancer.pdf.

18 Healthy Memphis Common Table. Quality care ratings: Women’s health by medical offices: Breast cancer screening. Retrieved Aug. 11, 2010 from http://www.healthymemphis.org/find_quality_care.php?f=doctors&report_sub_category=womhealth#report_table.

19 Quality Health Together. (2010). Find quality care: Women’s health. Retrieved Aug. 17, 2010 from http://www.qualityhealthtogether.org/find_quality_care.php?p=find_quality_care&sub_page=1&current_measure=Women_s+Health.

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Risk factors for type 1 diabetes are less clear than they are for type 2 diabetes. Family history, genetics, and problems with the body’s system for fighting infection give a higher risk for type 1 diabetes.35

How does diabetes affect our community?

Good examples of community-specific information

• How common is diabetes in our community?

o About 1 in every 10 people in [our state] had diabetes in 2007. The number of people in [our state] with diabetes has risen significantly in the last 10 years.36

• How does diabetes affect people in our community?

o In the United States diabetes costs about $174 billion in health care use and time away from work.37

o In [our state], diabetes costs $6.5 billion in health care and time away from work in 2007.38

• How does diabetes affect groups within our community?

o Diabetes is more common for African Americans than any other racial or ethnic group in [our state].Error: Reference source not found

20 Max, W. (2006). The cost of breast cancer in California. Retrieved Aug. 11, 2010 from http://www.cbcrp.org/research/PageGrant.asp?grant_id=2591.

23 National Cancer Institute. (2010). Cervical cancer. Retrieved Aug 20, 2010 from http://www.cancer.gov/cancertopics/pdq/screening/cervical/patient.

24 Medline Plus. Information about pap tests. Retrieved Aug. 11, 2010 from http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&query=pap+test&x=17&y=16.

26 National Cancer Institute. What you need to know about cervical cancers. Retrieved Aug. 17, 2010 from http://www.cancer.gov/cancertopics/wyntk/cervix/page4.

7 Asthma Initiative of Michigan for Healthy Lungs. Detroit Alliance for Asthma Awareness. (2010). Retrieved Jul. 14, 2010 from http://www.getasthmahelp.org/UserCoalitionViewHomePage.asp?coaID=4.

8 Kohn, M., Moore, J., Girard, K., Ritacco, B., Moseley, K., et al. (2008).Guide to improving asthma care in Oregon: 2008 indicators for quality care in health systems. Retrieved Jul. 29, 2010 from http://www.oregon.gov/DHS/ph/asthma/guideor.shtml#The_Guide.

14 Centers for Disease Control and Prevention. (2010). Breast cancer rates by race and ethnicity. Retrieved Aug. 11, 2010 from http://www.cdc.gov/cancer/breast/statistics/race.htm.

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o Diabetes is more common for people with lower incomes or education in [our state].Error: Reference source not found

What is the recommended care for diabetes?

If you have diabetes, make sure you get regular check-ups that include the following tests:

• Blood pressure check

• Blood test for A1c. This test shows the average blood sugar level for 2 to 3 months.

• Blood test for cholesterol level. This test shows the level of cholesterol, a fat, waxy-like substance, in your blood.

• Eye exam

• Blood and urine tests to check how the kidneys are working

22 Community Health Alliance of Humboldt – Del Norte, Inc. (2010). Breast cancer screening. 2010. Retrieved from Aug. 11, 2010 from http://www.communityhealthalliance.org/?p=find_quality_care&report=physician&physician_section=performance&v=prevention&s=&selected_measure=Breast+Cancer+Screening&submit=View.

27 Soni, A. (2007). Use of the Pap test as a cancer screening tool among women age 18–64, U.S. noninstitutionalized population (Statistical Brief No. 173). Agency for Healthcare Research and Quality. Retrieved from Aug. 11, 2010 from http://www.meps.ahrq.gov/mepsweb/data_files/publications/st173/stat173.pdf .

28 Michigan Department of Community Health. (2009). Facts about cervical cancer. Retrieved Aug. 11, 2010 from www. michigan .gov/documents/ Cervical Facts_6648_7.pdf .

29 Michigan Public Health Institute Cancer Epidemiology and Evaluation Cancer Staff. (2009). The Cancer Burden in Michigan: Selected Statistics: 1991–2009. Retrieved Aug. 11, 2010 from http://www.michigancancer.org/PDFs/MCCReports/CancerBurden-Sept2009/AllSections.pdf.

30 Centers for Disease Control and Prevention. Cervical cancer statistics. (2010). Retrieved Jul. 29, 2010 from: http://www.cdc.gov/cancer/cervical/statistics/.

31 Centers for Disease Control and Prevention. (2010). Cervical cancer screening. Retrieved Jul. 29, 2010 from http://www.cdc.gov/cancer/cervical/basic_info/screening.htm.

32 GYMR. (2010). Successfully Reporting & Communicating Performance Measures: Lessons from Consumers. Princeton, NJ: Robert Wood Johnson Foundation.

33 National Diabetes Information Clearinghouse. (2008). Diabetes overview (NIH Publication No. 09–3873). U.S. Department of Health and Human Services, National Institutes of Health, National Institute for Diabetes and Digestive and Kidney Diseases. Retrieved Aug.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

To help control your diabetes and prevent damage to your organs, you need to keep your blood sugar level as close to normal as possible.Error: Reference source not found Talking with your doctor to understand diabetes can help you stay healthy and lower your chances of having heart disease, stroke or other problems.39

About [X%] of people with diabetes in [our community] get recommended care for diabetes. You can use quality reports to compare how well doctors’ offices give recommended care for diabetes. The report shows how often patients got each of the recommended tests [Link to Public Report URL]. Higher scores are better.

Heart DiseaseWhat is heart disease?

Heart disease includes coronary artery disease, congestive heart failure, and heart attack. Coronary artery disease is the most common type of heart disease among adults. It happens when cholesterol builds up in your blood. Cholesterol is a waxy, fat-like substance that your body needs. But when you have too much in your blood, it can build up on the walls of your arteries. The build-up of cholesterol in arteries is called plaque. This build-up can block the flow of blood to your heart, so your heart has to work harder. Sometimes, this block is bad enough to cause a heart attack or stroke. 40

Heart disease can make you have chest pain or be short of breath because not enough blood is getting to your heart.41 Over time, coronary artery disease can weaken the heart muscle. This may lead to heart failure, a serious condition in which the heart can't pump blood the way that it should. An irregular heartbeat, called an arrhythmia, can also develop. Error: Reference source not found

Who is at risk for heart disease?

Both men and women are at risk for heart disease. It is the leading cause of death for men and women in the United States.42

Risk factors for heart disease include:

• High cholesterol

• Being overweight or obese

11, 2010 from http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#what.

34 Centers for Disease Control and Prevention. (2010). Diabetes public health resource: Basics about diabetes. Retrieved Jul. 29, 2010 from http://www.cdc.gov/Diabetes/consumer/learn.htm.

35 Centers for Disease Control and Prevention. (2010). 2003 National Diabetes Fact Sheet. Retrieved Aug. 17, 2010 from http://www.cdc.gov/diabetes/pubs/general.htm.

39 Healthy Memphis Common Table. (2010). Diabetes care by medical office. Retrieved Aug. 11, 2010 from http://www.healthymemphis.org/find_quality_care.php?f=doctors&report_sub_category=diabetes#pre_reports.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

• Diabetes

• High blood pressure

• Sleep apnea. This condition causes people to stop sleeping normally one or more times during the night and sometimes even stop breathing.

• Not exercising

• Stress

• Drinking too much alcohol

• Family history of heart disease43,44,45

How does heart disease affect our community?

Good examples of community-specific information

• How common is heart disease in our community?

o Over 17 million people in the United States have coronary artery disease.46 Over 1 million people in [our state] have had a heart attack, stroke or chest pain.47

• How does heart disease affect people in our community?

o Heart disease is the second leading cause of death in [our state], but it is the number 1 cause of death in the United States overall.Error: Reference source not found,48

o 1 out of 4 deaths in [our state] were caused by heart disease in 2009.49

o Heart disease will cost the United States more than $316 billion due to health care use and time away from work in 2010.Error: Reference source not found Heart disease and stroke cost more than $4 billion in [our state] every year.50

• How does heart disease affect groups within our community?

o In 2005, almost 1 in 9 people in [our state] had an unhealthy behavior they could try to change.51 For example, if people stop smoking, they lower their chance of getting heart disease.

o African American men were more likely to have to stay overnight in the hospital because of heart disease than any other group in [our state].Error: Reference source not found

50 Heart Disease and Stroke Prevention Program. (2010). Preventing and managing heart disease and stroke in Washington. Retrieved Aug. 11, 2010 from http://www.doh.wa.gov/cfh/heart_stroke/default.htm.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

o Between 1997 and 2004, most patients [in our state] who had to stay overnight in the hospital due to heart disease also had diabetes or high blood pressure.Error: Reference source not found

What is recommended care for heart disease?

If you have heart disease, be sure to get regular check-ups. Talk with your doctor about medicines, heart-healthy habits and the tests that are right for you. All people with heart disease should get the following tests:

• Blood pressure check

• Blood test for cholesterol level

About [X%] of people with heart disease in [our community] get recommended care for heart disease. You can use quality reports to compare how well doctors’ offices give recommended care for heart disease. The report shows how often patients got each of the recommended tests: [link to Public Report URL]. Higher scores are better.

Congestive Heart FailureWhat is congestive heart failure?

Congestive heart failure is a serious condition in which the heart is weak and not able to work as well as it should. 52 When you have heart failure, your heart is not able to fill with enough blood or it can’t push the blood through the rest of your body.

People with heart failure may feel tired and notice swelling in their arms, legs, ankles and veins. They may have trouble sleeping or breathing and have frequent urination. They can have a cough, particularly at night when they rest on their backs.53

Heart failure cannot be cured. But medication and healthy habits, like eating healthy, exercising and not drinking alcohol, can help prevent problems.54

Who is at risk for heart failure?

Risk factors for heart failure include:55,56

• Age 65 or older

• Heart disease, also called coronary artery disease

• Diabetes

• High blood pressure

• Being overweight or obese

More men than women have heart failure. African Americans are more likely than any other racial or ethnic group to have heart failure and may develop symptoms earlier than age 65.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

How does heart failure affect our community?

Good examples of community-specific information

• How common is heart failure in our community?

o About 2% of adults in [our state] have heart failure, and most of them are over 60.57

• How does heart failure affect people in our community?

o In 2005 in [our state], more than 11,000 overnight stays in the hospital for heart failure could have been prevented if the doctors and patients had followed clinical guidelines for the best care.Error: Reference source not found

• How does heart failure affect groups within our community?

o Similar to the national percentage, about 63% of adults with heart failure in [our state] were overweight or obese.Error: Reference source not found

What is recommended care for heart failure?

Recommended care at the doctor’s office

If you have heart failure, be sure to get regular check-ups.

Talk with your doctor about medicines, heart healthy habits and the tests that are right for you. All people with heart failure should get the following tests:

• Blood pressure check

• Blood test for cholesterol level

About [X%] of people with heart failure in [our community] get recommended care for heart failure in the doctor’s office. You can use quality reports to compare how well doctors’ offices give recommended care for heart disease. The report shows how often patients got each of the recommended tests [Link to Public Report URL]. Higher scores are better.

Recommended care at the hospital58

If you have to go to the hospital, you and your family should make sure the hospital does the following things, which are proven to reduce the chance of problems and lead to good results.

Recommended care during the hospital stayError: Reference source not found

• Make sure the hospital

o Gives you a test to check how well your heart is able to pump blood. The LV function test checks how well the left side of the heart is working. The left ventricle (LV) of the heart is the chamber that pumps blood to the rest of the body.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

o Advises you to stop smoking

Recommended care just before leaving the hospitalError: Reference source not found

• Make sure the hospital

o Gives you instructions for follow-up care

o Gives you a prescription for medicine to make the heart work better. This medicine comes in two kinds: ACEIs (angiotensin converting enzyme inhibitors) and ARBs (angiotensin receptor blockers). Your doctor needs to decide which kind of medicine is best for you.

About [X%] of patients with heart failure get recommended care during or after a hospital stay in [our community]. You can use quality reports to compare how well hospitals give recommended care for heart failure. These report shows how often patients got each of the recommended tests: [link to Public Report].

Heart AttackWhat is a heart attack?

A heart attack happens when blood can’t flow to a part of the heart. A heart attack is also called acute myocardial infarction, or AMI. If your blood flow does not start again right away after a heart attack, there could be damage to a part of your heart or body.59

A heart attack may cause you to feel pressure, often in the center of your chest. The feeling lasts a few minutes, stops, then starts again.60 Women may have signs that are different from those of men.61 Women may not feel pressure in the chest. Instead, women may feel pain or pressure in their necks, shoulders, upper backs or stomachs. They may also have nausea, feel dizzy, sweat, or feel extremely tired.

Who is at risk for heart attacks?

Risk factors for a heart attack include:Error: Reference source not found,Error: Reference source not found,Error:

Reference source not found

• High cholesterol

• High blood pressure

• Diabetes

• Being overweight or obese

• Smoking

• Not exercising

• High-fat diet

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

• Drinking too much alcohol

• Family history of heart attacks or heart disease

How do heart attacks affect our community?

Good examples of community-specific information

• How common are heart attacks in our community?

o Every year in the United States, about 1.26 million people have a heart attack.Error: Reference source not found In 2006, about 4% of people in [our state] had a heart attack.62

• How do heart attacks affect people in our community?

o There were 25 hospitalizations due to heart attack for every 100,000 hospitalizations in [our state] in 2007.

12 National Cancer Institute. (2009). What you need to know about breast cancer. Retrieved Aug. 11, 2010 from http://www.cancer.gov/cancertopics/wyntk/breast/page1.

13 Agency for Healthcare Research and Quality. (2009). Screening for breast cancer: Recommendation statement. Retrieved Aug. 11, 2010 from http://www.ahrq.gov/clinic/uspstf09/breastcancer/brcanrs.htm.

15 Centers for Disease Control and Prevention. (2010). Breast cancer: Fast facts. Retrieved Aug. 11, 2010 from http://www.cdc.gov/cancer/breast/basic_info/fast_facts.htm.

21 Susan G. Komen for the Cure. (2010). Early detection and screening. Retrieved Aug. 11, 2010 from http://ww5.komen.org/BreastCancer/RecommendationsforWomenwithHigherRisk.html.

36 California Department of Health: California Diabetes Program. (2009). 2008 fact sheet. Retrieved Aug. 11, 2010 from http://www.caldiabetes.org/get_file.cfm?contentID=1029&ContentFilesID=1101.

37 Centers for Disease Control and Prevention. (2008). National diabetes fact sheet: General information and national estimates on diabetes in the United States, 2007. Retrieved Aug. 11, 2010 from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf.

38 The Michigan Diabetes Prevention and Control Program. (2008). Diabetes in Michigan—2008. Retrieved Aug. 11, 2010 from http://www.michigan.gov/documents/mdch/Diabetes_Fact_Page-2008_274978_7.pdf.

40 Centers for Disease Control and Prevention. (2009). Heart disease. Retrieved Aug. 11, 2010 from http://www.cdc.gov/heartdisease/coronary_ad.htm.

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o About 1 in 6 deaths in the United States are due to heart attacks or angina.63 About 1 in X deaths in our state are from heart attack.

• How do heart attacks affect groups within our community?

o 1 in 4 people with heart disease in [our state] are obese, and this makes them more likely to have a heart attack.64

o Heart attacks in [our state] are more common for people 65 or older and for people with lower incomes.

What is the recommended care for heart attacks?

When you have a heart attack, it is important to get to the hospital right away. To reduce damage to the heart, blood needs to begin flowing to the heart as quickly as possible after a heart attack. Without that blood, the heart doesn’t get the oxygen and nutrients it needs.

41 National Heart, Lung and Blood Institute. (2009). What is coronary artery disease? Retrieved Aug. 11, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_WhatIs.html.

42 Centers for Disease Control and Prevention. (2010). Heart disease facts. Retrieved Aug. 11, 2010 from http://www.cdc.gov/heartdisease/facts.htm.

43 Centers for Disease Control and Prevention. (2010). Heart disease conditions. Retrieved Aug. 11, 2010 from http://www.cdc.gov/heartdisease/conditions.htm.

44 Centers for Disease Control and Prevention. (2009). Heart disease behavior. Retrieved Aug. 11, 2010 from http://www.cdc.gov/heartdisease/behavior.htm.

45 Centers for Disease Control and Prevention. (2009). Heart disease heredity. Retrieved Aug. 11, 2010 from http://www.cdc.gov/heartdisease/heredity.htm.

46 American Heart Association. Cardiovascular disease statistics. Retrieved Aug. 17, 2010 from http://www.americanheart.org/presenter.jhtml?identifier=4478.

47 Bureau of Health Risk Reduction. The burden of cardiovascular disease in New York: Mortality, prevalence, risk factors, costs, and selected populations. Retrieved Aug. 11, 2010 from http://www.health.state.ny.us/diseases/cardiovascular/heart_disease/docs/burden_of_cvd_in_nys.pdf.

49 Division for Heart Disease and Stroke Prevention. (2010). State program: Tennessee capacity Building. 2010. Retrieved Aug. 17, 2010 from http://www.cdc.gov/dhdsp/state_program/tn.htm.

51 Tennessee Department of Health Office of Policy, Planning and Assessment Surveillance, Epidemiology and Evaluation. (2007). The burden of heart disease and stroke in Tennessee: An update. Retrieved Aug. 18, 2010 from http://hit.state.tn.us/Reports/OtherHealthReports/Heart%20Disease%20Burden%20Update

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Most heart attack patients should take medicine to prevent another heart attack. People who have had a heart attack are more likely to have another heart attack or a stroke. Aspirin and medicines called “beta blockers” can help prevent another heart attack. These drugs make it easier for the heart to pump blood.

If you have to go to the hospital for a heart attack, your family member or close friend should make sure you get these things, which are proven to reduce the chance of problems and lead to good results.Error: Reference source not found

Recommended care when you get to the hospitalError: Reference source not found

• Make sure the hospital

%202007.pdf

52 National Heart, Lung and Blood Institute. (2010). What is heart failure? Retrieved Aug. 17, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_WhatIs.html.

53 National Heart, Lung and Blood Institute. (2010). What are the signs and symptoms of heart failure? Retrieved Aug. 17, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_SignsAndSymptoms.html.

54 National Heart, Lung and Blood Institute. (2010). How is heart failure treated? Retrieved Aug. 11, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_Treatments.html.

55 National Heart, Lung and Blood Institute. (2010). Who is at risk? Retrieved Aug. 11, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_WhoIsAtRisk.html

56 Division for Heart Disease and Stroke Prevention. (2010). Facts-at-a-glance reports: Heart failure fact sheet. Retrieved Aug. 11, 2010 from http://www.cdc.gov/dhdsp/library/fs_heart_failure.htm.

58 Robert Wood Johnson Foundation. (2010). Language to use in public reporting about hospital care. Princeton, NJ.

59 National Heart, Lung and Blood Institute. (2008). What is a heart attack? Retrieved Aug. 13, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/HeartAttack/HeartAttack_WhatIs.html.

60 National Heart, Lung and Blood Institute. (2008). What are the signs and symptoms of a heart attack? Retrieved Aug. 13, 2010 from http://www.nhlbi.nih.gov/health/dci/Diseases/HeartAttack/HeartAttack_Signs.html.

61 Oregon Department of Health Services. The Burden of Heart Disease and Stroke in Oregon: 2007. 2007. Retrieved from: http://www.oregon.gov/DHS/ph/hdsp/docs/2007BurdenReport.pdf.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

o Gives you aspirin when you get to the hospital. Aspirin is a blood thinner and can improve blood flow in your body.

o Gives you medicine to help break up blood clots and improve blood flow to the heart. You may hear your doctor or hospital staff call this medicine fibrinolytic drugs or anti-thrombolyics.

o Does a procedure to open blood vessels to help blood flow to the heart. This procedure is called PCI or percutaneous coronary intervention.

Recommended care during the hospital stayError: Reference source not found

• Make sure the hospital

o Advises you to stop smoking

Recommended care just before leaving the hospitalError: Reference source not found

• Make sure the hospital

o Gives you a prescription for aspirin

o Gives you a prescription for medicine to lower blood pressure. This medicine, called a beta blocker, works by slowing the heart rate and keeping the blood vessels open in the heart, brain, and rest of the body.

o Gives you a prescription for medicine to make the heart work better. This medicine comes in two kinds: ACEIs (angiotensin converting enzyme inhibitors) and ARBs (angiotensin receptor blockers). Your doctor needs to decide which kind of medicine is best for you.

About [X%] of heart attack patients in [our community] get recommended care during or after a hospital stay. You can use quality reports to compare how well hospitals give recommended care for heart attack. The report shows how often patients got each of the recommended tests and medicines: [link to Public Report URL]. Higher scores are better.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

Tips and resources

TipsThe tips below can help you develop text about your particular health topics and reports.

• Use plain language that is action oriented.

• Make the information relevant to consumers in your community.

• Explain the importance of the health information. For example, explain how health care utilization, such as hospitalizations or emergency room visits, can be avoided and explain how modifiable health risks (e.g., unmanaged asthma, diabetes) can affect health care utilization and expenditure.

• Align the health information on your Web site with your community’s health initiatives.

• Connect the community’s experience to the national experience (e.g., is the burden in your community higher than in the U.S.? Do the health care providers in your area meet the clinical protocols as often as their counterparts in other parts of the U.S.?)

• Include information about the direct (medical) and indirect (productivity) costs associated with the condition in your community. Where available, connect the community’s costs to the costs borne by individuals.

• Include information about the distribution of the condition in the community. This information could include differences due to socioeconomic status, educational attainment, insurance coverage, urban/rural communities, race/ethnicity, gender and age.

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Checklist for Evaluating Contextual Language

Use these criteria to assess your approach to presenting information to consumers.Criterion YesDo you talk directly to the consumer in plain, consumer-friendly language?

Do you include a simple description of the condition, including the body system affected, risk factors, and symptoms of the condition?

Do you include information about the prevalence of the condition in your community (not just the nation)?

Do you include information about the distribution of the condition in your community?

Do you include information about the financial costs associated with the condition in your community?

Do you make the link between the condition, recommended care, and comparative quality information?

How to Describe Five Health Topics in the Context of Comparative Performance Reports

• When reporting statistics, use natural frequencies, such as 1 out of 10. When comparing rates, use a common denominator such as 10 or 100.

• Coach consumers to find out more and include links to other places on your Alliance Web site as well external community resources.

Online resources Alliances can use the following online resources to find information about health topics important to your community.

Resources for descriptions of conditions

• Centers for Disease Control and Prevention: http://www.cdc.gov

• National Cancer Institute: http://www.cancer.gov

• National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov

• National Institute of Diabetes and Digestive and Kidney Diseases: http://www2.niddk.nih.gov/

Resources for population data

• Current Population Survey (U.S. Census): http://www.census.gov/cps/

• Behavioral Risk Factor Surveillance Survey (Centers for Disease Control): http://www.cdc.gov/BRFSS/

• National Health Interview Survey (Centers for Disease Control): http://www.cdc.gov/nchs/nhis.htm

• Medical Expenditure Panel Survey (MEPS) and MEPSnet: http://www.meps.ahrq.gov/mepsweb/data_stats/meps_query.jsp

• Environmental Protection Agency resources: http://www.epa.gov

• Mobilizing Action toward Community Health (MATCH), County Health Rankings: http://www.countyhealthrankings.org

• State or county health departments

Resources for consumers on health and treatments

• Healthfinder: http:// www.healthfinder.gov/

• Medline Plus: www.nlm.nih.gov/medlineplus

• Diseases and Conditions Index at National Heart, Lung and Blood Institute: http://www.nhlbi.nih.gov/health/dci/index.html

• Agency for Healthcare Research and Quality: http://www.ahrq.gov/clinic/ppipix.htm

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

• Questions are the answer: http://www.ahrq.gov/questionsaretheanswer/

Resources for language to use in communicating with consumers

Resources for communicating about evidence-based health care and getting high quality care including using the internet and getting the most out of visits to health care providers. Communication Toolkit: http://www.businessgrouphealth.org/usinginformation/Default.aspx

Language for communicating with consumers about hospital quality measures. Language to Use in Public Reporting About Hospital Care: http://www.forces4quality.org/resource/language-use-public-reporting-about-hospital-care

Key reference articles The articles below can provide further background on engaging consumers to use evidence and comparative quality reports.

Aspden, P., Wolcott, J., & Bootman, J. L. (2007). Preventing medical errors 2007. Washington, DC: National Academy Press.

Baker, D. P., Gustafon S., Beaubien, et al. (2005). Medical teamwork and patient safety: The evidence-based relation [Literature review]. (AHRQ Publication No. 05-0053) Rockville, MD: Agency for Healthcare Research and Quality.

Bennett, G. G., Wolin, K. Y., Puleo, E. M., Masse, L. C., & Atienza, A. A. (2009). Awareness of national physical activity recommendations for health promotion among US Adults. Medical & Science in Sports & Exercise, 41(10), 1849–1855.

Brookfield, S. (1986). Understanding and facilitating adult learning. San Francisco: Jossey-Bass.

Center for Advancing Health. (2010). Snapshot of people’s engagement in their health care. Accessed 28 Jul 2010: http://www.cfah.org/pdfs/CFAH_Snapshot_2010_Full.pdf.

Carman, K. L., Maurer, M., Yegian, J. M., Dardess, P., McGee, J., Evers, M., & Marlo, K. O. (2010). Evidence that consumers are skeptical about evidence-based health care. Health Affairs, 29(7),1400–1406.

Fox, S., & Jones, S. (2009). The social life of health information: Americans’ pursuit of health takes place within a widening network of both online and offline sources. Washington,

57 Minnesota Department of Health. (2007). Heart failure in Minnesota. Retrieved Aug. 11, 2010 from http://www.health.state.mn.us/divs/hpsc/hep/transform/081607documents/heartfailureinminnesota.pdf.

62 Oregon Department of Health Services. (2007). The burden of heart disease and stroke in Oregon: 2007. Retrieved from http://www.oregon.gov/DHS/ph/hdsp/docs/2007BurdenReport.pdf.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

DC: Pew Internet & American Life Project. Retrieved on July 15, 2009, from http://www.pewinternet.org/~/media//Files/Reports/2009/PIP_Health_2009.pdf.

Freire, P., & Macedo, D. (1987). Literacy: Reading the word and the world. Westport, CT: Bergin & Garvey.

Greenfield, S., Kaplan, S., & Ware, J. (1985). Expanding patient involvement in care. Annals of Internal Medicine, 102(4), 520–528.

Hammons, T., Piland, N., Small, S., Hatlie, M., & Burstin, H. (2003). Ambulatory patient safety. Journal of Ambulatory Care Management, 26(1), 63–82.

Hibbard, J., & Cunningham, P. (2008). How engaged are consumers in their health and health care, and why does it matter? Washington, DC: Center for Studying Health System Change. Retrieved on July 21, 2009, from http://www.hschange.com/CONTENT/1019/.

Holman, H., & Lorig, K. (2000). Patients as partners in managing chronic disease. British Medical Journal, 320, 526–527.

Hurley, R. E, et al. (2009). Early experiences with consumer engagement initiatives to improve chronic care. Health Affairs, 28(1), 277–283.

Knowles, M., Holton, E., & Swanson, R. (2005). The adult learner: The definitive classic in adult education and human resource development. Houston, TX: Butterworth-Heinemann.

Lake Research Partners. (2009). Re-forming health care: Americans speak out about chronic conditions and the pursuit of healthier lives. Summary of key findings from a survey of Americans with chronic conditions. Washington, DC: National Council on Aging. Retrieved Jan. 26, 2010, from http://www.ncoa.org/improving—health/chronic—disease/healthier—lives.html.

Lorig, K., & Holman, H. (2001). Patient self-management: A key to effectiveness and efficiency in care of chronic disease. Public Health Reports, 119, 239–243.

National Cancer Institute. (2008). Confusion about cancer prevention: Association with behavior (HINTS Brief No. 9). Washington, DC: Author. Retrieved on Oct. 14, 2009, from http://hints.cancer.gov/docs/HINTSBrief_9_010708.pdf.

Stewart, M., Brown, J. B., Donner, A., McWhinney, I. R., Oates, J., Weston, W.W., et al. (2000). The impact of patient-centered care on outcomes. Journal of Family Practice, 49(9), 796–804.

Werner, R., Konetzka, T., & Kruse, G. (2009). Impact of public reporting on unreported quality of care. Health Services Research, 44(2), 379–398.

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How to Describe Five Health Topics in the Context of Comparative Performance Reports

Williams, S., & Heller, A. (2007). Patient activation among Medicare beneficiaries: Segmentation to promote informed health care decision making. International Journal of Pharmaceutical and Healthcare Marketing, 1(3), 199–213.

Endnotes

25 Centers for Disease Control and Prevention. Cervical cancer: Inside knowledge: Get the facts about gynecological cancers. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Publication #99-9123. 2010. Retrieved Aug. 17, 2010 from http://www.cdc.gov/cancer/cervical/pdf/Cervical_FS_0510.pdf.

48 Puget Sound Health Alliance Community Checkup. (2010). Why is heart disease important? Retrieved Aug. 11, 2010 from http://www.wacommunitycheckup.org/index.php?p=viewreports&reporttype=3&orgname=all&category=7&county=All+Counties&search.x=42&search.y=15#.

63 American Heart Association. Heart attack and angina statistics. Retrieved Aug. 13, 2010 from http://www.americanheart.org/presenter.jhtml?identifier=4591.

64 Missouri Department of Health and Senior Services. Heart Disease Profile – for Missouri Residents. Retrieved Aug. 13, 2010 from http://cntysvr1.lphamo.org/pubdocs/HeartDProfile/header.php?cnty=929.

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