munity level), and the potential for these data to provide insight into multiple care systems (orthopedics and oncology) and care settings (rehabilitation, ambulatory care, and acute hospital).

Episodic efficiency Measurement of the efficiency of episodic care refers to a unit of analysis that reflects the level of resources used in the care of a specific, relatively brief episode (e.g., acute back pain) as part of the total care received by patients. Examples of such measures are methods for calculating adjusted average payments for all patient refined-diagnosis related groups and episode treatment groups. Many researchers have identified the need for measuring episodic efficiency to address issues ranging from cost containment and attribution to reduction in waste. Issues such as nonstandardized use of these measures, validity of and availability of data sources, and risk adjustment hinder progress in this area, however. (For further discussion, refer to Appendix H.)


Multiple studies have demonstrated marked variations in access to health care (Cassil and Sorian, 2002; IOM, 2002, 2003, 2005; Isaacs and Schroeder, 2004; Sheikh and Bullock, 2001). As equity is a cross-cutting quality aim, it is important that it be measured not only to achieve comprehensive measurement, but also to test how well the health care system is functioning on all other quality aims. The committee was thus concerned by the relatively few measures available for evaluating equity, particularly with regard to issues of access and disparities in care. Greater attention should be focused on these issues, with consideration of the following measures and methods.

Access An important area of disparity in care is health insurance coverage. Ambulatory care measures, which reflect the quality of care for individuals in any ambulatory care setting, are one useful kind of equity measure. Yet they are obtained most easily by sampling only insured populations. Thus greater use should be made of hospital-based measures, which include all patients at a given institution regardless of their payer or insurance status. Other important issues of access include those related to transportation, service hours, and manpower. Rural communities are a particularly critical population to assess, as they often have limited access to high-quality care (IOM, 2005). The committee believes that in the short term, it will be necessary to identify representative samples of patients from all sites where the uninsured may receive care—whether uncompensated care from physicians’ office-based practices or emergency rooms, or care provided by established safety net providers.

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