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lacks face validity for summarizing performance because three to five specific measures will never satisfactorily represent care at a high level of aggregation (for example, care for chronic conditions). By contrast, a comprehensive system can represent the quality of care delivery on different dimensions by including a large number of measures applied to a population of interest and aggregated to produce index scores. A comprehensive system works well when there is evidence of variability within and between the diagnosis and management of different conditions and when the question being asked is framed at a high level (for example, how well the health system is helping the population to stay healthy; how much of a problem underuse is). Because the leading indicators approach is familiar, this appendix focuses on how a comprehensive approach to quality assessment for the National Health Care Quality Report might be implemented.


How good is the quality of care in America? That is the question many people would like to have answered if only the measures, the data, and the appropriate analytic framework were available. We begin by describing a new method for evaluating effectiveness that is under development at RAND because it offers a useful approach to assessing quality nationally.

Description of the QA Tools System

Under funding from public and private sponsors,1 RAND has developed a comprehensive system for assessing the quality of care for children, adults, and the vulnerable elderly. We call this system QA Tools. We briefly discuss how the clinical areas were selected, how the indicators were chosen, what is included in the system, and how the system is being implemented.

Selecting Clinical Areas

We reviewed national data sources to identify the leading causes of morbidity and mortality and the most common reasons for physician visits in the United States for different age and gender groups in the population.2Table B.1 shows the list of 58 clinical areas included in the QA Tools system by population group: 20 include indicators for children, 36 for adults, and 23 for the vulnerable elderly. The clinical areas, broadly defined, represent about 55 percent

1 Health Care Financing Administration, Agency for Healthcare Research and Quality, California HealthCare Foundation, Pfizer, and the Robert Wood Johnson Foundation.

2 Age or gender groups: 0–1, 1–5, 6–11, 12–17, 18–50 (men separate from women), 50–64, 65–75, over 75.

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