Chapter 8
Condition-Specific Action Plans

The 15 communities that participated in the summit were actively involved in developing action plans to redesign care in one of the five priority areas of: asthma, depression, diabetes, heart failure, and pain control in advanced cancer. Prior to the summit, they completed preparatory work so that the working groups addressing each area could be as productive as possible (see Chapter 1 for a description this preparatory work).

At the summit, participants were assigned to condition-specific breakout groups. Care was taken to ensure a proper balance among local and national-level stakeholder groups and to include individuals with proficiency in the cross-cutting areas discussed in Chapters 27, as well as nationally recognized experts in each condition. Subgroups were assigned specially tailored discussion questions (see Appendix J), and a facilitation process was used to generate broad ideas that were later narrowed and refined into more detailed strategies. The working groups were instructed that ideally, they should identify a couple of pragmatic strategies—the “art of the possible”—and one “transformational” strategy that could be considered more radical and groundbreaking than the others.

It is important to note that the working groups acknowledged that in many of the priority areas featured at the summit, health care disparities persist for minority/underserved populations within a community. Although this specific issue was not the focus of the summit, its importance was stressed. The IOM has issued several reports on this topic, including Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care and a six-volume compendium on the uninsured (IOM, 2001b, 2002a,b,c, 2003a,b, 2004).



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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Chapter 8 Condition-Specific Action Plans The 15 communities that participated in the summit were actively involved in developing action plans to redesign care in one of the five priority areas of: asthma, depression, diabetes, heart failure, and pain control in advanced cancer. Prior to the summit, they completed preparatory work so that the working groups addressing each area could be as productive as possible (see Chapter 1 for a description this preparatory work). At the summit, participants were assigned to condition-specific breakout groups. Care was taken to ensure a proper balance among local and national-level stakeholder groups and to include individuals with proficiency in the cross-cutting areas discussed in Chapters 2–7, as well as nationally recognized experts in each condition. Subgroups were assigned specially tailored discussion questions (see Appendix J), and a facilitation process was used to generate broad ideas that were later narrowed and refined into more detailed strategies. The working groups were instructed that ideally, they should identify a couple of pragmatic strategies—the “art of the possible”—and one “transformational” strategy that could be considered more radical and groundbreaking than the others. It is important to note that the working groups acknowledged that in many of the priority areas featured at the summit, health care disparities persist for minority/underserved populations within a community. Although this specific issue was not the focus of the summit, its importance was stressed. The IOM has issued several reports on this topic, including Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care and a six-volume compendium on the uninsured (IOM, 2001b, 2002a,b,c, 2003a,b, 2004).

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Following are brief synopsizes of the strategies identified by the working groups as most salient to their respective conditions (see Table 8-1). Audience feedback on the working groups’ proposals is summarized at the end of each section. ASTHMA Impact Asthma affects more than 20 million Americans, including 6.3 million children and adolescents. It is the sixth most common chronic condition in the United States, resulting each year in more than 4,400 deaths. Economic costs of the disease total $14 billion, $4.6 billion of which is due to lost productivity. Asthma is also the leading cause of school absenteeism due to a chronic illness. The strain on the health care system is immense. Yearly, asthma leads to 9.3 million physician visits, more than 400,000 hospitalizations, and more than 1.8 million emergency room visits (ALA, 2002). The nation’s pediatric and minority populations bear the brunt of this disease; a disproportionate number of acute asthma attacks, deaths, hospitalizations, and emergency department visits are seen among children and racial minorities (ALA, 2002). In 2001, the highest prevalence rates of asthma were among those aged 5–17, with a rate of 98.1 cases per 1,000 children. Among African American patients, the prevalence of asthma was 22.7 percent higher than that among whites. Key Strategies for High-Quality Asthma Care The asthma working group identified the following strategies for overcoming current barriers to high-quality care for this disease: Measurement and transparency Information and communications technology Finance and community collaboration Patient/family control Table 8-1. Key Strategies Identified by Condition-Specific Working Groups   CONDITION Strategy Asthma Depression Diabetes Heart Failure Pain Control Finance   Information and Communications Technology     Patient/Family Control     Community Collaboration       Measurement         Training and Education         Clinical Engagement         Public Awareness         Restructuring of Clinical Service Provision         Coordinated Leadership        

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Measurement and Transparency. The working group suggested that national organizations and appropriate subspecialty providers promote mandatory reporting of a defined set of valid performance measures for asthma care—including measures of self-management—within 3 years. The group emphasized that validated measures now exist; the challenge is routine incorporation of the data required to generate such measures into the information systems of care. The group also emphasized the importance of enhancing population-based surveillance of asthma to complement clinical measures. Information and Communications Technology. A coalition of health plans, the Centers for Medicare and Medicaid Services (CMS), consumer groups, and other health providers should facilitate the adoption of an easily accessible personal record summary, such as the Continuity of Care Record described in Box 3-2 in Chapter 3. The format of the record would allow clinical data to be transferred to any computer system, as well as allow for a printed report in a readable format for paper transfer. Additionally, the group proposed that patients have full access to their health records and that decision support be incorporated into those records for both clinicians and patients. Finance and Community Collaboration. This dual strategy calls for defining an appropriate mix of finance solutions—focused not only on health insurance, but also on such alternatives as schools, community health foundations, and state health departments—to effectively deliver a package of evidence-based chronic disease management and community services for asthma. These resources would be linked to communitywide aims established through a process of community activation, such as a multistakeholder coalition. Additionally, progress and outcomes would be monitored through a transparent system of continuous measurement and evaluation based on communitywide surveillance and stakeholder feedback. Patient/Family Control. This strategy requires a total transformation of the culture of health care, characterized by a universal emphasis on and acknowledgment of the importance of self-management. The group proposed both a national approach—mainly through standards and measures—and a local approach based on engaging consumers and consumer organizations, as well as working with clinicians and others to create programs and tools that will allow patients and families to take control. Access to on-line records and tools is extremely important to achieving this goal. Audience Feedback The audience requested further clarification concerning the relationship between coalition structures and financing. The intent of the asthma working group was that coalitions be responsible for establishing aims that would then ultimately drive dollars; at the same time, the group acknowledged that community coalitions often do not have the authority or expertise to formally allocate resources and monitor their use. The group emphasized that community-based asthma efforts should draw on all available resources, such as housing authorities, schools, and employers—not just health insurance—looking at different streams of funding that would be appropriate to each. A separate concern was raised about whether self-management could foster a culture of self (patient or family)-blame. The asthma group acknowledged the importance of safeguarding against this eventuality, and shared the perspective from the literature that effective self-care (see Chapter 5) creates partnerships based on respect and collaborative goal setting, rather than transfer of sole authority and blame to the patient. Finally, the audience stressed the importance of environmental determinants of health, particularly for asthma. It was suggested that these factors must be an integral component of any asthma action plan.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities DEPRESSION Impact Major depression is a disorder characterized by depressed mood, loss of interest or pleasure, and other symptoms that may include changes in sleep and appetite and thoughts of suicide. The disorder differs both quantitatively and qualitatively from normal sadness and bereavement (APA, 1994). Approximately one in seven men and one in four women will have an episode of major depression at some point during their lives (Blazer et al., 1994). In a given year, 18.8 million American adults—9.5 percent of the adult population—suffer from a depressive disorder or depression (NCQA, 2003). Major depression is associated with enormous clinical and societal burdens in the United States. Depressed patients suffer from levels of disability similar to or greater than those associated with a host of other chronic medical conditions (Wells et al., 1989). The 2000 Global Burden of Disease Study estimates that major depression contributes more than any other single medical condition to disability in the United States (WHO, 2000). The economic costs of depression to the nation are $43.7 billion annually: $23.8 billion in indirect costs, such as mortality and work loss, and $19.9 billion in direct costs. In 1995, the annual economic cost of depression was $600 per depressed worker; one-third of this cost was for treatment, and 72 percent was related to absenteeism and lost productivity (NCQA, 2003). Despite these substantial costs, national health expenditures for depression are low relative to the disorder’s associated disability (Druss et al., 2002). Key Strategies for High-Quality Depression Care The depression working group identified the following strategies for overcoming current barriers to high-quality care for this condition: Finance Information and communications technology Training and education Finance. The working group called for transforming the way depression care is currently financed—both privately and publicly—to support payment for performance of evidence-based screening and treatment. Mental health is particularly fragmented in this regard, with private-sector funding being primarily employer based and public-sector funding spanning multiple agencies, such as Medicare, Medicaid, and state and local programs. Coupled with the need to redesign reimbursement are issues of access and the availability of “no wrong door”; that is, those who suffer from depression should have high-quality access, referral, and treatment regardless of where they present for care within the spectrum of health services. Specific strategies at the national level proposed by the working group for year one included the following: Congress fixing the inequities in mental health care copayments under Medicare. The National Quality Forum and national coalitions establishing metrics for effective and efficient care. CMS implementing the recommendations for depression care management from the report of the President’s New Freedom Commission on Mental Health (New Freedom Commission on Mental Health, 2003). CMS incorporating evidence-based depression care into disease management demonstrations.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Within 3 years, lessons learned from implementation of the above strategies should inform a national policy and practice model, as well as be used to update evidence-based practice and metrics to build a business case for quality. At the local level in year one, the working group proposed (1) conducting experiments to test a pay-for-performance model of evidence-based care, for example, paying for a bundled set of visits or team collaboration; and (2) encouraging health insurers/payers to have explicit policies and educational efforts regarding which providers get paid for depression care and how. By year three at the local level, data from these pilots should be used to develop a national payment model, and there should be a move toward national guidelines for screening and follow-up. Information and Communications Technology. The group identified information and communications technology as a cross-cutting requirement for all of its proposed strategies. One of the fundamental challenges is that the way behavioral health information is treated must be the same as for all other health information, and consistent with the Health Insurance Portability and Accountability Act (U.S. DHHS, 2004). The initial 1-year goal proposed by the group is for the Substance Abuse and Mental Health Services Administration, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, CMS, and others to convene the 15 communities participating in the summit so as to include all the key stakeholders and define a shared dataset for behavioral and primary care services. This first year would see pilot collection of these data and conclude with recommendations for a national data policy. Over the course of 3 years, the initiative would be expanded to include a broader base of community agencies and stakeholders. The process for the 3-year effort would mirror that for the 1-year pilot, but with an expanded group of participants. Training and Education. A central goal defined by the working group was broadening the scope of training, expertise, and knowledge with regard to the screening, referral, and treatment of the disease. A dual strategy was proposed, beginning in year one with existing providers, as well as those in the training phase. This workforce initiative would be linked to ongoing licensing and certification programs. A set of core competencies would be developed; it was speculated that these competencies could be relevant across each of the five priority areas addressed at the summit. After the first year, the 3-year goal would be to expand the initiative to the national level. Audience Feedback The importance of primary care practitioners and specialists screening for depression in patients with chronic conditions such as diabetes and heart failure was emphasized. Additionally, given the prevalence of depression, it was suggested that screening be expanded into the community, using community-based agencies or other entities for initial detection and follow-up. The working group had focused on interventions at the provider level—health care practitioners and behavioral health specialists—but agreed that moving toward a more encompassing public health model would be a desirable though challenging option. Privacy issues were also debated, with two opposing viewpoints being presented. On one side was the belief that behavioral health information should have the same protection as other health care data—the philosophy of the depression working group. This approach would foster integration of such information into electronic health records and other health information systems. Others, however, were adamant about the need for special protection for behavioral health data, such as double passwords. Regardless, it was agreed that patients ultimately should have control over which of their behavioral health information is shared or withheld.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Closing comments from the audience served to heighten awareness of significant gaps in the evidence base for appropriate screening and treatment of children and adolescents with depression. These shortfalls were acknowledged by the working group, and the need for further research directed at this age group was underscored. DIABETES Impact Diabetes ranks as the sixth leading cause of death in the United States, affecting 18 million people and contributing to more than 213,000 deaths in 2000 (ADA, 2004). Diabetes is associated with many long-term, serious medical complications, including heart disease, stroke, hypertension, blindness, kidney disease, neurological disease, and increased risk of lower-limb amputation. In 2002, the economic costs attributed to diabetes-related illness totaled $132 billion. Of this total, $92 billion was direct costs, such as personal health care spending and hospital care, and $40 billion was indirect costs, including disability, premature mortality, and work-loss days. Controlling for differences in age, sex, and race/ethnicity, medical expenditures for diabetics were approximately 2.4 times higher than those that would have been incurred by the same group in the absence of diabetes (Hogan et al., 2003). Unfortunately, diabetes is a growing problem. In the 1990s, its prevalence increased by 33 percent. This increase occurred across all groups—gender, racial, educational, economic, and age—though racial/ethnic disparities exist. Compared with Caucasians and Asian/Pacific Islanders, diabetic-related deaths are three times more frequent in African Americans, 2.5 times in American Indians/Alaska Natives, and 1.5 times in Hispanics (CDC, 2000). Key Strategies for High-Quality Diabetes Care The diabetes working group identified the following strategies for overcoming current barriers to high-quality care for diabetes: Team approach to comprehensive care Greater application of information and communications technology Research on patient-centered wants and needs Finance Team Approach to Comprehensive Care. Multidisciplinary teams are critical to achieving high-quality, comprehensive diabetes care. The working group encouraged the development of systems and alignment of incentives to support this approach to care, while moving away from an exclusive focus on the one-on-one office visit. Greater Application of Information and Communications Technology. The working group proposed that patients should own a portable electronic health record, made possible by either “smart card” technology or web-based information repositories. To move closer to this goal, the group suggested that a national summit be convened by the IOM and the National Health Information Infrastructure (NHII) to address electronic health record standardization. Topics to be considered include (1) data elements for diabetes and other conditions; and (2) means to facilitate registries, as well as communication among clinicians and between health care providers and patients. Research on Patient-Centered Wants and Needs. Additional research is needed to illuminate the patients’ perspectives on the care they wish to receive and on the tools they need to manage their diabetes effectively. Finance. Payment systems should focus primarily on process improvement and outcome performance. The working group suggested paying for currently uncovered services such as

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities group visits, nutritional support, and care coordination, and creating incentives to support patients in the self-management of their care. Innovative financial mechanisms could generate a resource pool from savings over time for reinvestment in diabetes care, such as information and communications technology infrastructure. Audience Feedback Of all diseases, diabetes is probably the one for which the best consensus exists on a core set of performance measures. The audience stressed the need for more widespread implementation of programs that pay for performance on the basis of these measures—programs that hinge on demonstrating a return on investment, particularly to purchasers and employers. Reformatting the compensation system to reward team-based care and addressing multiple comorbidities among diabetics, such as high blood pressure and depression, are lingering challenges. HEART FAILURE Impact Heart failure has become an epidemic: It currently affects 4.9 million Americans, with an additional 550,000 cases being diagnosed annually. Fully 80 percent of men and 70 percent of women under age 65 diagnosed with heart failure are expected to die within 8 years. From 1979 to 2000, heart failure–related deaths increased by 148 percent. Heart failure is particularly pervasive among the elderly. After age 65, its incidence approaches 1 percent of the entire population, and this figure rises precipitously in those aged 75 and older. Several events portend further increases in the prevalence of heart failure. Recent improvements in the treatment and survival of acute myocardial infarction have resulted in a larger number of patients with impaired cardiac function. Simultaneously, the aging of the population will result in greater numbers of patients with heart failure. In 2003, the National Heart, Lung, and Blood Institute estimated the total costs of heart failure at $24.3 billion. Heart failure is the most frequently occurring Medicare diagnosis-related group (DRG), accounting for $3.6 billion ($5,471 per hospital discharge) in payments to hospitals for Medicare beneficiaries in 1998 (AHA, 2003). These sobering figures underscore the importance of revolutionizing heart failure care to realize its potential level of quality. Key Strategies for High-Quality Heart Failure Care The heart failure working group identified strategies at three levels for overcoming current barriers to high-quality care: At the community level, community awareness and activation—creating demand for high-quality heart failure care at the local level. At the patient level, creating a patient-centered health environment that includes patient-carried health information. At the provider-level, clinical engagement, including aligning financial incentives and creating a business case for quality, and creating methods to make it easier for clinicians to provide good care. The working group suggested that transforming heart failure care necessitates a certain tension—simultaneously creating anxiety over the status quo while committing to measurable improvement in the quality of care. This tension would provide the impetus for change. Additionally, the group envisioned patients playing a pivotal role in managing their care, as well as in assessing and reporting their health status. Finally, the group underscored the importance of overall prevention, although full

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities development of this component was beyond the scope of the summit discussions. Community Activation. Multiple strategies at the local level were proposed to immediately begin raising awareness and creating a community-level sense of urgency for better heart failure care. These strategies included (1) holding dialogues to educate communities and, most important, learn from them what they need in order to take a more dominant role in improving care; (2) implementing the feedback gathered from communities quickly through local demonstration projects; (3) influencing local leadership to elevate the problem and sustain focus through a local infrastructure; (4) instigating and supporting local media campaigns; (5) engaging business coalitions to advocate for better care so afflicted individuals can be more financially productive; (6) mobilizing caregivers to be more creative and opportunistic in meeting the demands of those for whom they care; and (7) highlighting the experiences of patients who have heart failure to generate community commitment to the urgency and value of improving heart failure care. In addition, efforts should be initiated to audit local communities with regard to their current state of and commitment to high-quality heart failure care. The working group also discussed possibilities for linking the Oregon Heart Failure Project (see Box 5-2 in Chapter 5) and the Greater Flint Health Coalition’s Guidelines Applied to Practice program (see Box 7-4 in Chapter 7), addressing outpatient and inpatient care, respectively. Patient-Carried Health Information. The ability to exchange patient health information electronically across multiple systems is essential. The working group suggested that the federal government should take a leadership role in accelerating the adoption of national data standards. The group supported the concept that patients should have full control over their health records and the ability to “hand carry” this information among providers. Critical elements of this hand-carried record include the patient’s previous diagnostic evaluations; current doses of evidence-based therapies and records of previous experiences with poorly tolerated treatments; current self-management practices—for example, records of ideal and serial weights, along with strategies for responding to deviations in weight; and serial health status assessments. By providing patients with such records, many of the substantial barriers to coordination of care could readily be overcome. The group suggested that this effort should begin now and be further expanded by 2007. Aligning Financial Incentives. At the hospital and system levels, an immediate effort to pay for performance is essential as a means to hasten the implementation of well-established best practices. The working group acknowledged that unique patient and community features require a flexible approach to rendering care. If current reimbursement approaches were redesigned to pay for performance—including adhering to established processes of care, minimizing hospitalizations, and optimizing patients’ health status—providers could have greater flexibility in providing care without the risk of incurring a financial penalty. Enabling Clinicians. The current frenetic pace of clinical practice demands consideration of new models that make it easier to increase the efficiency and effectiveness of heart failure care. Potential strategies and resources to this end at the national level include: The American College of Cardiology supporting registry efforts that adhere to its Guidelines Applied to Practice program (American College of Cardiology, 2004). The American Heart Association continuing its work in guideline development and dissemination (AHA, 2004). Linking community information to the American Heart Association’s heart profiler, a web-based resource providing treatment options and links to evidence-

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities based heart failure care in a user-friendly format (AHA, 2004). Monitoring and tracking performance standards promulgated by the Physician Consortium for Performance Improvement, convened by the American Medical Association (AMA, 2004). Expanding recognition programs of the National Committee for Quality Assurance that feature clinicians who provide high-quality care relative to certain benchmarks (NCQA, 2004). The working group also proposed mobilizing state public health systems with experience in developing registries and tracking cases over time. Additionally, efforts to link heart failure care to care for other conditions, such as depression and diabetes, ought to be initiated so the totality of patients’ comorbidities can be addressed as efficiently as possible. Finally, the working group suggested that to support the community activation approaches noted above, guidelines and performance measures for communities should be developed by 2007. Audience Feedback Audience feedback on heart failure care focused mainly on the use of disease registries. The drawbacks of having separate registries for each chronic disease were noted, which feasibly could multiply to hundreds of conditions and become unmanageable. Instead, a registry-like application or database could be conveniently populated by whatever mechanism was currently being used to document care. For example, if an electronic health record were being used, the ability to export some registry-like function would be built into its design, so as to avoid duplicate data entry and decrease administrative overhead. Thus, there was an explicit call for data standards that would include as a criterion the ability for the data to be useful and serviceable for disease registries. PAIN CONTROL IN ADVANCED CANCER Impact Virtually all patients approaching the end of life with cancer can live reasonably comfortably without disabling side effects. Achievement of this goal, however, requires employing current clinical guidelines. The American Pain Society, the Agency for Healthcare Research and Quality, the World Health Organization, and the National Comprehensive Cancer Network all provide guidelines to assist with decision making in pain management (IOM, 2001a). Identification of the cause and type of pain, repeated use of standardized assessment tools to assess pain severity and response to treatment, evaluation of the effect of pain interventions on mental alertness, and flexibility in revising treatment regimens are the mainstays of effective care. Unfortunately, continuing misconceptions about dependence and addiction, the risks of oversedation, and regulatory problems with opiates have contributed to inadequate implementation of these clinical guidelines. Educating providers about the use of opiates and other medications restricted by policies of the Drug Enforcement Agency is essential to resolve problems of inadequate dosing and reluctance to prescribe (IOM, 2001a). The results of a 1999 study on the effectiveness of physician adherence to pain management guidelines highlight the importance of this point. After oncologists employed a multilevel treatment algorithm based on the Agency for Healthcare Policy and Research Guidelines for Cancer Pain Management, significant reductions in patients’ usual pain intensity occurred (Du Pen et al., 1999).

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Key Strategies for High-Quality Pain Control in Advanced Cancer Care The pain control working group identified the following strategies for overcoming current barriers to high-quality care in this area: Raising public awareness Restructuring clinical service provision Creating strong, coordinated leadership The working group emphasized the importance of articulating the following vision of what could be achieved within a few years if society really wanted “no unacceptable pain” to be the norm: Every person living with cancer pain can count on, and every clinician can promise, that the patient can live to the end of life without having to endure unacceptable cancer pain. The working group’s definition of success was that within 3 years, 100 percent of cancer patients would report that their pain was being regularly measured and that they were being routinely asked whether that pain was acceptable. Additionally, greater than 95 percent of cancer patients would report that their pain was less than 5 on a scale of 0–10, or in deference to differences in patient choices, greater than 95 percent of cancer patients would report that their pain was within a level acceptable to them. These three criteria were meant to be examples; a set of such measures would need to be developed and rapidly implemented. Public Awareness. There is a fundamental problem with inaccurate and inadequate information concerning pain control that contributes to misunderstanding among both patients and clinicians. Pain control cuts across many conditions, and although it is “owned by many” has the dilemma of being “owned by none” with regard to a lack of clarity around leadership—both clinical and organizational. To address this pressing issue, the American Pain Association committed at the summit to coordinating the development of a public awareness campaign. The availability of publicly reported, standardized, valid performance measures would be an essential support for this initiative. Restructuring of Clinical Service Provision. The working group suggested the following strategies for redesigning the way pain control is provided to cancer patients, focused on enhanced continuity, rapid response, and availability of expertise: Round-the-clock accessibility of technical support and health record information for patients, their families/caregivers, and clinicians Correct prescribing practices—including for opioids—without retribution Incorporation of evidence-based prescribing practices into maintenance of certification and accreditation for clinicians Strong, Coordinated Leadership. The working group stressed that a lack of coordination and shared mission creates a more substantial barrier to success in this area than does any lack of research insights or proven model programs. Despite the many passionate advocates dedicated to the effective assessment and management of pain, this endeavor is without the clear, coordinated leadership needed to realize the vision put forth by the working group. To address this issue, therefore, the Agency for Healthcare Research and Quality offered to serve as the convening body to bring together key players such as the American Pain Foundation, the National Cancer Institute, CMS, the National Business Group on Health, and the Department of Veterans Affairs. Together these groups would forge a consensus on a timetable and responsibilities for carrying the effort forward.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Audience Feedback An audience member suggested developing a detailed charge for the above group that would be spearheading national efforts around pain control. It was suggested that the tasks to be accomplished by the group—whether developing a stronger evidence base or dealing with clinicians’ fears of having their licenses revoked as a result of prescribing opioids—be prioritized. REFERENCES ADA (American Diabetes Association). 2004. ADA: Basic Diabetes Information. [Online]. Available: http://www.diabetes.org/diabetes-statistics/national-diabetes-fact-sheet.jsp [accessed April 30, 2004]. AHA (American Heart Association). 2003. Heart Disease and Stroke Statistics: 2003 Update. [Online]. Available: http://www.americanheart.org/presenter.jhtml?identifier=1200026 [accessed May 1, 2003]. AHA. 2004. American Heart Association. [Online]. Available: http://www.americanheart.org [accessed April 28, 2004]. ALA (American Lung Association). 2002. Trends in Asthma Morbidity and Mortality, 2002. Online. Available: http://www.lungusa.org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/ASTHMA1.PDF [accessed Jan. 6, 2004]. AMA (American Medical Association). 2004. AMA (CQI) Physician Consortium for Performance Improvement. [Online]. Available: http://www.ama-assn.org/ama/pub/category/2946.html [accessed April 28, 2004]. American College of Cardiology. 2004. Guidelines Applied in Practice (GAP) Program. [Online]. Available: http://www.acc.org/gap/gap.htm [accessed April 28, 2004]. APA (American Psychiatric Association). 1994. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition. Washington, DC: American Psychiatric Association Blazer DG, Kessler RC, McGonagle KA, Swartz MS. 1994. The prevalence and distribution of major depression in a national community sample: The National Comorbidity Survey. The American Journal of Psychiatry 151(7):979–986. CDC (Centers for Disease Control and Prevention). 2000. Unrealized Prevention Opportunities: Reducing the Health and Economic Burden of Chronic Disease. Atlanta, GA: CDC. Druss BG, Marcus SC, Olfson M, Pincus HA. 2002. The most expensive medical conditions in America: This nationwide study fund that the most disabling conditions are not necessarily the ones we spend the most to treat. Health Affairs (Millwood, VA) 21(4):105–111. Du Pen SL, Du Pen AR, Polissar N, Hansberry J, Kraybill BM, Stillman M, Panke J, Everly R, Syrjala K. 1999. Implementing guidelines for cancer pain management: Results of a randomized controlled clinical trial. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology 17 (1):361–370. Hogan P, Dall T, Nikolov P. 2003. Economic costs of diabetes in the U.S. in 2002. Diabetes Care 26(3):917–932. IOM (Institute of Medicine). 2001a. Improving Palliative Care for Cancer. Washington, DC: National Academy Press. IOM. 2001b. Insuring Health—Coverage Matters: Insurance and Health Care. Committee on the Consequences of Uninsurance, eds. Washington, DC: National Academy Press. IOM. 2002a. Insuring Health—Care without Coverage: Too Little, Too Late. Committee on the Consequences of Uninsurance, eds. Washington, DC: National Academy Press. IOM. 2002b. Insuring Health—Health Insurance is a Family Matter. Committee on the Consequences of Uninsurance, eds. Washington, DC: National Academy Press. IOM. 2002c. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BS, Stith AY, Nelson BD, eds. Washington, DC: National Academy Press.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities IOM. 2003a. Insuring Health—A Shared Destiny: Community Effects of Ununsurance. Committee on the Consequences of Uninsurance, eds. Washington, DC: National Academy Press. IOM. 2003b. Insuring Health—Hidden Costs,Value Lost: Uninsurance in America. Committee on the Consequences of Uninsurance, eds. Washington, DC: National Academy Press. IOM. 2004. Insuring Health—Insuring America's Health: Principles and Recommendation. Committee on the Consequences of Uninsurance, eds. Washington, DC: National Academy Press. NCQA (National Committee for Quality Assurance). 2003. Antidepressant Medication Management: State of Health Care Quality 2002. [Online]. Available: http://www.ncqa.org/sohc2002/SOHC_2002_AMM.html [accessed April 10, 2003]. NCQA. 2004. Heart/Stroke Recognition Program. [Online]. Available: http://www.ncqa.org/hsrp/ [accessed April 28, 2004]. New Freedom Commission on Mental Health. 2003. Final Report—Achieving the Promise: Transforming Mental Health Care in America. Pub. No. SMA-03-3832. Rockville, MD: U.S. DHHS. U.S. DHHS (United States Department of Health and Human Services). 2004. HHS—Office for Civil Rights—HIPAA. [Online]. Available: http://www.os.dhhs.gov/ocr/hipaa/ [accessed March 24, 2004]. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, Berry S, Greenfield S, Ware J. 1989. The functioning and well-being of depressed patients: Results from the Medical Outcomes Study. The Journal of the American Medical Association 262(7):914–919. WHO (World Health Organization). 2000. Global Burden of Disease 2000 Version 1 Estimates. [Online]. Available: http://www3.who.int/whosis/menu [accessed May 29, 2002].