Transcript Health Care Quality

Figure 1
Measuring Health Care Quality
Carolyn M. Clancy, MD
Director
U.S. Agency for Healthcare Research and Quality
for
KaiserEDU.org
May 2008
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Figure 5
Health Care Quality
 Varies A LOT; NOT clearly related to $$ spent
 Matters – can be measured and improved
 Measurement science is evolving:
– Structure, process and outcomes
– Broad recognition that patient experience is
essential component
 Strong focus on public reporting
– Motivates providers to improve
– Not yet ‘consumer friendly’
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Figure 6
70 Million Americans Benefit
from Quality Measurement



96% of heart attack victims were
prescribed beta-blocker treatment in
2005, up from 62% in 1996*
77.7% of children enrolled in private
health plans received all
recommended immunizations, up
5% from 72.5% in 2004*
Evidence-based guidelines from
the American College of Cardiology
and the American Heart Association
have reduced mortality among
patients who have had a heart
attack
* National Committee for Quality Assurance
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Figure 7
AHRQ’s National Reports
on Quality and Disparities
 New editions available
– New efficiency chapter
– Disability data added
– More on health literacy
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Figure 8
2007 National Reports: Some Good
News, Need for Improvement
 The rate of improvement in quality
between 1994 and 2005 was 2.3%,
down from 3.1% from 1994-2004
 More than 60% of the disparities in
quality of care have stayed the same or
worsened for Blacks, Asians and the
poor, and approximately 56% of
disparities have not improved for
Hispanics
 For Blacks, Asians, Hispanics and poor
populations, about half of the core
measures of quality used to track access
to care are improving
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Figure 9
Uninsurance is a Major Barrier to
Reducing Disparities
 Uninsured individuals
do worse than privately
insured individuals on
almost 90% of quality
measures
100%
1
Better
Same
Worse
75%
 Uninsured individuals
do worse than privately
insured individuals on
all access measures
50%
25%
0
2007 National Healthcare Disparities Report, AHRQ
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Figure 10
Overall Scope
 Patients receive the proper diagnosis and
treatment only about 55% of the time*
 Overall, disparities in health care quality and
access are not getting smaller **
 Total health care expenditures in 2006 totaled
$2.1 trillion (16% of GDP) and are projected to
reach $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
N Engl J Med 2003;348:2635-45.
** AHRQ 2007 National Healthcare Disparities Report
*** National Health Expenditure Accounts
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Figure 11
What?
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Figure 12
Why?
 The “why” is a systems challenge:
– The U.S. has extremely talented and
qualified health care professionals who
have not been trained to work in teams
– The delivery system is fragmented, so
information doesn’t follow patients as
they move from hospitals to other sites
of care
– Payment is quality neutral
Light Figure Fragment
Craig A. Kraft
Washington, DC
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Figure 13
There Are Major Opportunities
for Improvement: Examples
 Uptake of health information
technology, while still relatively
slow, is gaining traction
 Growing focus on comparative
effectiveness research
 HHS Secretary Michael
Leavitt’s Value-Driven Health
Care Initiative
–
–
Chartered Value Exchanges
National Learning Network
Downtown USA
Alejandra Vernon
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Figure 14
Emerging Methods in
Comparative Effectiveness & Safety
Source:

A series of 23 articles by AHRQ
researchers on new approaches
in comparative effectiveness
methods are compiled in a special
October edition of Medical Care

A valuable new resource for
scientists committed to advancing
the comparative effectiveness and
safety research

The Resource Center in Oregon
led the development process,
helped draft the document and
manage work groups, and
handled public comment
http://effectivehealthcare.ahrq.gov/reports/med-care-report.cfm
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Figure 16
Role Of IT In Reducing
Medical Errors
Percent who say…
The coordination among the
different health professionals
that they see is a problem
69%
Yes
They have seen a health care
professional and noticed that
they did not have all of their
medical information
They had to wait or come back
for another appointment
because the provider did not
have all their medical
information
Have you or a family member ever
created your own set of medical
records to ensure that you and all
of your health care providers have
all of your medical information?
32%
48%
32%
1%
Don’t
know
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).
No
67%
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Figure 17
Personal Experience
Did the error have serious health
consequences, minor health
consequences, or no health
consequences at all?
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
34%
21%
No
10%
3%
65%
Serious health
consequences
Minor health
consequences
No health
consequences
1% Don’t
Know
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).
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Figure 18
Guidelines & Measures
More emphasis needs to be placed
on what’s most important
We measure
what we can
Rather Than
Identifying what
counts and
determining how
it can be measured
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Figure 19
Guidelines Measures
Incentives
“You can get 60% of the improvement from 15% of the
change”
Don Berwick
 Where should the busy primary care practice begin?
 Where should policy makers target their incentives?
To changes that:
 Produce the greatest benefit
 Address the biggest quality gap
 Can be implemented most easily, cheaply and safely
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Figure 20
Reconciling Guidelines
and Quality Measures
Developing guidelines that address a wide range of needs…
Low-Risk Patients
Higher Risk Patients
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Figure 21
Challenges in Addressing
Multiple Conditions
Interactions
between illnesses
Multiple
medications
Multiple providers
Interactions between
treatments
Tension between
therapeutic goals
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Figure 22
Setting Priorities for Patients
with Multiple Conditions
 Address the need for clinicians to set
priorities, weighing the benefits and burdens
of increasingly complex medical regiments
 Make sure guidelines keep up with unique
issue of treating older and more frail patients
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Figure 23
“Patient-Centered” Guidelines
 If care is to be patient
centered, guidelines
need to reflect this goal
– Quality measures
must accommodate
differences in:
 Patient values
 Patient preferences
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Figure 24
What Level of Collaboration
Is Practical?
Globalize the evidence, localize the decision-making
 Guidelines may need to reflect local values, disease
burdens, priorities and resources
BUT WE NEED TO SHARE…
 Information on how to develop clear and practical
guidelines
 Evidence on barriers and facilitators to implementing
guidelines
 Evidence about integration of guidelines in electronic
health records
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Figure 25
The Goal
 Historically, the focus
has been on structure
 In recent years, there
has been more interest
in process – the right
care
 Tomorrow’s goal?
Outcomes and end
results
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Figure 26
The Information Exists
 Information on topics including guidelines,
measures, incentives and outcomes are available
for a wide range of uses. Included is information
about:
– Hospitals: Hospital Compare
– Nursing Homes: Nursing Home Compare
– Health Plans: National Committee for Quality Assurance
– Various Health Care Organizations: Quality Check ®
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Figure 27
CBO Report on
Comparative Effectiveness
Congressional Budget Office
Report:
 Discusses several
mechanisms for organizing
and funding additional
comparative effectiveness
research efforts
 Reviews the different types of
research that could be
pursued and the likely
benefits and costs
 Considers the potential
effects that such research
could have on health care
spending
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Figure 28
Reasons for Optimism
 Multiple stakeholders are working together
–
AQA & HQA established the Quality Alliance Steering
Committee to promote quality measurement,
transparency and improvement in care
 There is clear recognition that there should
be one set of measures
–
A move is underfoot toward real standardization
across agencies and organizations
 A shared sense of urgency exists on
improving patient outcomes, workforce
productivity and costs
–
The National Quality Forum is bringing stakeholders
together to establish priorities for moving forward
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Figure 29
Future Opportunities
 The primary opportunity
involves patients
– We will not improve
chronic illness care
without active, informed
patients
– Patients as shoppers
– Women are key
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Figure 30
This is not a Political Issue,
It’s a Practical Issue
 Quality and access
are linked
 Quality will be a major
theme of multiple
reform proposals
 Quality is central to
getting better value for
what we’re spending
on health care
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Figure 31
21st Century Health Care
Improving quality by promoting a culture of safety
through Value-Driven Health Care
Information-rich, patientfocused enterprises
Evidence is
continually refined
as a by-product of
care delivery
21st Century
Health Care
Information and
evidence transform
interactions from
reactive to
proactive (benefits
and harms)
Actionable information available – to
clinicians AND patients – “in real time”
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Figure 32
Measuring Health Care Quality
AHRQ Mission
To improve the quality, safety,
efficiency, and effectiveness of
health care for all Americans
AHRQ Vision
As a result of AHRQ's efforts,
American health care will provide
services of the highest quality, with
the best possible outcomes, at the
lowest cost
http://www.ahrq.gov
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Figure 33
Resources
To learn more about health care quality, visit these websites:

Agency for Heathcare Research and Quality,
http://www.ahrq.gov/

Quality of Care, Reference Library, KaiserEDU.org
http://www.kaiseredu.org/topics_reflib.asp?id=139&parentid=70&rID=1

The Commonwealth Fund,
http://www.commonwealthfund.org/topics/topics_list.htm?attrib_id=15312

Institute for Healthcare Improvement,
http://www.ihi.org/ihi

National Committee on Quality Assurance,
http://www.ncqa.org/

Robert Wood Johnson Foundation,
http://www.rwjf.org/pr/topic.jsp?topicid=1053
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