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Measuring Health Care QualityMeasuring Health Care QualityCarolyn M. Clancy, MDCarolyn M. Clancy, MD
DirectorDirectorU.S. Agency for Healthcare Research and QualityU.S. Agency for Healthcare Research and Quality
forfor
KaiserEDU.orgKaiserEDU.orgMay 2008May 2008
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Health Care QualityHealth Care Quality
Varies Varies A LOTA LOT; ; NOTNOT clearly related to $$ spent clearly related to $$ spent Matters – can be measured and improvedMatters – can be measured and improved Measurement science is evolving:Measurement science is evolving:
– Structure, process and outcomesStructure, process and outcomes– Broad recognition that patient experience is essential Broad recognition that patient experience is essential
componentcomponent
Strong focus on public reportingStrong focus on public reporting– Motivates providers to improveMotivates providers to improve– Not yet ‘consumer friendly’Not yet ‘consumer friendly’
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70 Million Americans Benefit 70 Million Americans Benefit from Quality Measurement from Quality Measurement
96% of heart attack victims were 96% of heart attack victims were prescribed beta-blocker treatment in prescribed beta-blocker treatment in 2005, up from 62% in 19962005, up from 62% in 1996**
77.7% of children enrolled in private 77.7% of children enrolled in private health plans received all health plans received all recommended immunizations, up recommended immunizations, up 5% from 72.5% in 20045% from 72.5% in 2004**
Evidence-based guidelines from Evidence-based guidelines from the American College of Cardiology the American College of Cardiology and the American Heart Association and the American Heart Association have reduced mortality among have reduced mortality among patients who have had a heart patients who have had a heart attackattack
* * National Committee for Quality AssuranceNational Committee for Quality Assurance
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AHRQ’s National ReportsAHRQ’s National Reportson Quality and Disparitieson Quality and Disparities
New editions availableNew editions available
– New efficiency chapterNew efficiency chapter
– Disability data addedDisability data added
– More on health literacyMore on health literacy
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2007 National Reports: Some Good 2007 National Reports: Some Good News, Need for ImprovementNews, Need for Improvement
The rate of improvement in quality The rate of improvement in quality between 1994 and 2005 was 2.3%, between 1994 and 2005 was 2.3%, down from 3.1% from 1994-2004down from 3.1% from 1994-2004
More than 60% of the disparities in More than 60% of the disparities in quality of care have stayed the same or quality of care have stayed the same or worsened for Blacks, Asians and the worsened for Blacks, Asians and the poor, and approximately 56% of poor, and approximately 56% of disparities have not improved for disparities have not improved for HispanicsHispanics
For Blacks, Asians, Hispanics and poor For Blacks, Asians, Hispanics and poor populations, about half of the core populations, about half of the core measures of quality used to track measures of quality used to track access to care are improving access to care are improving
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Uninsurance is a Major Barrier to Uninsurance is a Major Barrier to Reducing DisparitiesReducing Disparities
Uninsured individuals do Uninsured individuals do worse than privately worse than privately insured individuals on insured individuals on almost 90% of quality almost 90% of quality measuresmeasures
Uninsured individuals do Uninsured individuals do worse than privately worse than privately insured individuals on all insured individuals on all access measuresaccess measures
0
25%
50%
75%
100%
QualityQuality
(9CRM)(9CRM) Access
Access
(6CRM)
(6CRM)
1
BetterBetterSameSameWorseWorse
2007 National Healthcare Disparities Report, AHRQ2007 National Healthcare Disparities Report, AHRQ
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Overall ScopeOverall Scope
Patients receive the proper diagnosis and Patients receive the proper diagnosis and treatment only about 55% of the timetreatment only about 55% of the time**
Overall, disparities in health care quality and Overall, disparities in health care quality and access are not getting smaller access are not getting smaller ****
Total health care expenditures in 2006 totaled Total health care expenditures in 2006 totaled $2.1 trillion (16% of GDP) and are projected to $2.1 trillion (16% of GDP) and are projected to reach $4.1 trillion (19.6% of GDP) by 2016reach $4.1 trillion (19.6% of GDP) by 2016*** ***
* * McGlynn E, Asch S, et al. The Quality of Health Care Delivered to Adults in the United States McGlynn E, Asch S, et al. The Quality of Health Care Delivered to Adults in the United States N Engl J Med 2003;348:2635-45. N Engl J Med 2003;348:2635-45.
**** AHRQ 2007 National Healthcare Disparities Report AHRQ 2007 National Healthcare Disparities Report
*** *** National Health Expenditure AccountsNational Health Expenditure Accounts
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What?What?
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Why?Why?
The “why” is a systems challenge:The “why” is a systems challenge:– The U.S. has extremely talented and The U.S. has extremely talented and
qualified health care professionals who qualified health care professionals who have not been trained to work in teamshave not been trained to work in teams
– The delivery system is fragmented, so The delivery system is fragmented, so information doesn’t follow patients as information doesn’t follow patients as they move from hospitals to other sites they move from hospitals to other sites of careof care
– Payment is quality neutralPayment is quality neutral
Light Figure Fragment Light Figure Fragment Craig A. Kraft Craig A. Kraft
Washington, DCWashington, DC
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There Are Major Opportunities There Are Major Opportunities for Improvement: Examplesfor Improvement: Examples
Uptake of health information Uptake of health information technology, while still relatively technology, while still relatively slow, is gaining tractionslow, is gaining traction
Growing focus on comparative Growing focus on comparative effectiveness researcheffectiveness research
HHS Secretary Michael HHS Secretary Michael Leavitt’s Value-Driven Health Leavitt’s Value-Driven Health Care InitiativeCare Initiative– Chartered Value ExchangesChartered Value Exchanges– National Learning NetworkNational Learning Network
Downtown USA Alejandra Vernon
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Emerging Methods in Emerging Methods in Comparative Effectiveness & SafetyComparative Effectiveness & Safety
A series of 23 articles by AHRQ A series of 23 articles by AHRQ researchers on new approaches researchers on new approaches in comparative effectiveness in comparative effectiveness methods are compiled in a special methods are compiled in a special October edition of October edition of Medical CareMedical Care
A valuable new resource for A valuable new resource for scientists committed to advancing scientists committed to advancing the comparative effectiveness and the comparative effectiveness and safety researchsafety research
The Resource Center in Oregon The Resource Center in Oregon led the development process, led the development process, helped draft the document and helped draft the document and manage work groups, and manage work groups, and handled public commenthandled public comment
Source: http://effectivehealthcare.ahrq.gov/reports/med-care-report.cfm
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Percent who say…Percent who say…
Role Of IT In Reducing Medical Errors
The coordination among the The coordination among the different health professionals different health professionals
that they see is a problem that they see is a problem
32%
69%
48%
They had to wait or come back They had to wait or come back for another appointment for another appointment
because the provider did not because the provider did not have all their medical have all their medical
informationinformation
They have seen a health care They have seen a health care professional and noticed that professional and noticed that
they did not have all of their they did not have all of their medical informationmedical information
Have you or a family member ever Have you or a family member ever created your own set of medical created your own set of medical records to ensure that you and all records to ensure that you and all of your health care providers have of your health care providers have all of your medical information?all of your medical information?
Don’t know
No
Yes
Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey National Survey on Consumers’ Experiences with Patient Safety and Quality Information, on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).November 2004 (Conducted July 7 – September 5, 2005).
32%
67%
1%
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Personal Experience
Have you been personally involved in a situation where a preventable medical error was made in your own medical care or that of a family member?
Yes
Don’t Know
No
Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).
Did the error have serious health consequences, minor health consequences, or no health consequences at all?
Minor health consequences
No health consequences
Serious health consequences
65%
1%
21%
10%3%
34%
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Guidelines & MeasuresGuidelines & Measures
More emphasis needs to be placed More emphasis needs to be placed on what’s most importanton what’s most important
We measure what we can
Identifying what counts and
determining how it can be measured
Rather Than
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Guidelines Measures Guidelines Measures IncentivesIncentives
““You can get 60% of the improvement from 15% of the You can get 60% of the improvement from 15% of the change”change”
Don BerwickDon Berwick
Where should the busy primary care practice begin?Where should the busy primary care practice begin? Where should policy makers target their incentives?Where should policy makers target their incentives?
To changes that:To changes that:
Produce the greatest benefitProduce the greatest benefit Address the biggest quality gapAddress the biggest quality gap Can be implemented most easily, cheaply and safelyCan be implemented most easily, cheaply and safely
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Reconciling Guidelines Reconciling Guidelines and Quality Measuresand Quality Measures
Developing guidelines that address a wide range of needs… Developing guidelines that address a wide range of needs…
Low-Risk Patients
Higher Risk Patients
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Challenges in Addressing Challenges in Addressing Multiple ConditionsMultiple Conditions
Interactions between illnesses
Interactions between treatments
Tension between therapeutic goals
Multiple providers
Multiple medications
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Setting Priorities for Patients Setting Priorities for Patients with Multiple Conditionswith Multiple Conditions
Address the need for clinicians to set Address the need for clinicians to set priorities, weighing the benefits and burdens priorities, weighing the benefits and burdens of increasingly complex medical regimentsof increasingly complex medical regiments
Make sure guidelines keep up with unique Make sure guidelines keep up with unique issue of treating older and more frail patientsissue of treating older and more frail patients
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““Patient-Centered” GuidelinesPatient-Centered” Guidelines
If care is to be patient If care is to be patient centered, guidelines centered, guidelines need to reflect this goalneed to reflect this goal– Quality measures Quality measures
must accommodate must accommodate differences in:differences in: Patient valuesPatient values Patient preferencesPatient preferences
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What Level of Collaboration What Level of Collaboration Is Practical?Is Practical?
Guidelines may need to reflect local values, disease Guidelines may need to reflect local values, disease burdens, priorities and resourcesburdens, priorities and resources
BUT WE NEED TO SHARE… BUT WE NEED TO SHARE…
Information on how to develop clear and practical Information on how to develop clear and practical guidelines guidelines
Evidence on barriers and facilitators to implementing Evidence on barriers and facilitators to implementing guidelinesguidelines
Evidence about integration of guidelines in electronic Evidence about integration of guidelines in electronic health recordshealth records
Globalize the evidence, localize the decision-makingGlobalize the evidence, localize the decision-making
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The GoalThe Goal
Historically, the focus Historically, the focus has been on structurehas been on structure
In recent years, there In recent years, there has been more interest has been more interest in process – the right in process – the right carecare
Tomorrow’s goal? Tomorrow’s goal? Outcomes and end Outcomes and end resultsresults
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The Information ExistsThe Information Exists
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Information on topics including guidelines, Information on topics including guidelines, measures, incentives and outcomes are available measures, incentives and outcomes are available for a wide range of uses. Included is information for a wide range of uses. Included is information about:about:– Hospitals:Hospitals:– Nursing Homes: Nursing Homes: – Health Plans:Health Plans:– Various Health Care Organizations: Various Health Care Organizations:
Hospital CompareHospital Compare
Nursing Home CompareNursing Home Compare
National Committee for Quality AssuranceNational Committee for Quality Assurance
Quality Check Quality Check ®®
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CBO Report on CBO Report on Comparative EffectivenessComparative Effectiveness
Discusses several Discusses several mechanisms for organizing mechanisms for organizing and funding additional and funding additional comparative effectiveness comparative effectiveness research effortsresearch efforts
Reviews the different types of Reviews the different types of research that could be research that could be pursued and the likely pursued and the likely benefits and costsbenefits and costs
Considers the potential Considers the potential effects that such research effects that such research could have on health care could have on health care spendingspending
Congressional Budget Office Congressional Budget Office Report:Report:
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Reasons for OptimismReasons for Optimism
Multiple stakeholders are working together Multiple stakeholders are working together – AQA & HQA established the Quality Alliance Steering AQA & HQA established the Quality Alliance Steering
Committee to promote quality measurement, Committee to promote quality measurement, transparency and improvement in caretransparency and improvement in care
There is clear recognition that there should There is clear recognition that there should be one set of measuresbe one set of measures– A move is underfoot toward real standardization A move is underfoot toward real standardization
across agencies and organizationsacross agencies and organizations A shared sense of urgency exists on A shared sense of urgency exists on
improving patient outcomes, workforce improving patient outcomes, workforce productivity and costs productivity and costs – The National Quality Forum is bringing stakeholders The National Quality Forum is bringing stakeholders
together to establish priorities for moving forwardtogether to establish priorities for moving forward
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Future OpportunitiesFuture Opportunities
The primary opportunity The primary opportunity involves patients involves patients – We will not improve We will not improve
chronic illness care chronic illness care without active, informed without active, informed patientspatients
– Patients as shoppers Patients as shoppers – Women are keyWomen are key
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This is not a Political Issue, This is not a Political Issue, It’s a Practical IssueIt’s a Practical Issue
Quality and access Quality and access are linkedare linked
Quality will be a major Quality will be a major theme of multiple theme of multiple reform proposalsreform proposals
Quality is central to Quality is central to getting better value for getting better value for what we’re spending what we’re spending on health careon health care
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2121stst Century Health Care Century Health Care
Improving quality by promoting a culture of safety Improving quality by promoting a culture of safety through Value-Driven Health Care through Value-Driven Health Care
21st Century Health Care
Information-rich, patient-Information-rich, patient-focused enterprisesfocused enterprises
Information and Information and evidence transform evidence transform
interactions from interactions from reactive to reactive to
proactive (benefits proactive (benefits and harms)and harms)
Evidence is Evidence is continually refined continually refined as a by-product of as a by-product of
care deliverycare delivery
Actionable information available – to Actionable information available – to clinicians AND patients – “in real time”clinicians AND patients – “in real time”
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Measuring Health Care QualityMeasuring Health Care Quality
http://www.ahrq.govhttp://www.ahrq.gov
AHRQ Mission AHRQ Mission
To improve the quality, safety, To improve the quality, safety, efficiency, and effectiveness of efficiency, and effectiveness of health care for all Americanshealth care for all Americans
AHRQ VisionAHRQ Vision
As a result of AHRQ's efforts, As a result of AHRQ's efforts, American health care will provide American health care will provide services of the highest quality, with services of the highest quality, with the best possible outcomes, at the the best possible outcomes, at the lowest costlowest cost
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ResourcesResources
To learn more about health care quality, visit these websites:To learn more about health care quality, visit these websites:
Agency for Heathcare Research and Quality, Agency for Heathcare Research and Quality, http://www.ahrq.gov/http://www.ahrq.gov/
Quality of Care, Reference Library, KaiserEDU.orgQuality of Care, Reference Library, KaiserEDU.org
http://www.kaiseredu.org/topics_reflib.asp?id=139&parentid=70&rID=1http://www.kaiseredu.org/topics_reflib.asp?id=139&parentid=70&rID=1
The Commonwealth Fund, The Commonwealth Fund, http://www.commonwealthfund.org/topics/topics_list.htm?attrib_id=15312 http://www.commonwealthfund.org/topics/topics_list.htm?attrib_id=15312
Institute for Healthcare Improvement, Institute for Healthcare Improvement, http://www.ihi.org/ihihttp://www.ihi.org/ihi
National Committee on Quality Assurance,National Committee on Quality Assurance,http://www.ncqa.org/http://www.ncqa.org/
Robert Wood Johnson Foundation, Robert Wood Johnson Foundation, http://www.rwjf.org/pr/topic.jsp?topicid=1053 http://www.rwjf.org/pr/topic.jsp?topicid=1053
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