Future Directions for the National Healthcare Quality and Disparities Reports (2010)

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Summary As the United States continues to devote extensive resources toward achieving a high-value, high-quality health care system, the capacity to evaluate the state of care is increasingly important. Since 2003, the annual publication of the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) by ­the Agency for Healthcare Research and Quality (AHRQ) has played an important role in documenting trend data on the state of health care quality and disparities. The general message from the most recent reports is that while some areas have improved, the overall quality of health care in the United States is suboptimal. Across all of the process of care measures tracked in the NHQR, persons received the recommended care less than 60 percent of the time. Furthermore, even when quality has improved on a measure tracked in the NHQR, disparities in care often persist across socioeconomic groups, racial and ethnic groups, and geographic areas (AHRQ, 2009a,b). AHRQ asked the Institute of Medicine (IOM) to review past NHQRs and NHDRs and provide a vision so that the reports can contribute to advancing the quality of health care for all persons in the United States. The IOM formed the Committee on Future Directions for the National Healthcare Quality and Disparities Reports to address this task. Through its research and deliberations, the Future Directions committee concluded that while the reports alone will not improve the quality of health care, they can make a compelling case for closing the gap between current performance levels and recommended standards of care. The committee recommends that AHRQ: • Align the content of the reports with nationally recognized priority areas for quality improvement to help drive national action. • Select measures that reflect health care attributes or processes that are deemed to have the greatest impact on population health. • Affirm through the contents of the reports that achieving equity is an essential part of quality improvement. • Increase the reach and usefulness of AHRQ’s family of report-related products. • Revamp the presentation of the reports to tell a more complete quality improvement story. • Analyze and present data in ways that inform policy and promote best-in-class achievement for all actors. • Identify measure and data needs to set a research and data collection agenda.  Personal communication, Ernest Moy, Agency for Healthcare Research and Quality, August 10, 2009.  

 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS The Future Directions committee makes these recommendations with the aim of helping AHRQ to focus its national reporting endeavor on the central aspirations of quality improvement—improving health, value, and equity—by directing attention to the closure of performance gaps in health care areas likely to have the greatest population health impact, be most cost effective, and have a meaningful effect on eliminating disparities. ESTABLISHING NATIONAL PRIORITY AREAS As part of its charge, the Future Directions committee was to establish priority areas in health care quality and disparities. The committee evaluated priorities previously put forth by numerous organizations, such as those included in an earlier IOM report Priority Areas for National Action: Transforming Health Care Quality (IOM, 2003). Box S-1 contains the list of priority areas recommended by the Future Directions committee; the list includes six priority areas identified by the National Priorities Partnership (NPP) (NPP, 2008)  plus two additional areas that the committee believes are essential: access to health care and health systems infrastructure. These eight priority areas should help guide the selection of measures to be featured in the national healthcare reports. Recommendation 1: AHRQ should ensure that both the NHQR and NHDR report on the prog- ress made on the priority areas for health care quality improvement and disparities elimination, and should align selection of measures with priority areas. Until a national set of priority areas is established, AHRQ should be guided by the Future Directions committee’s recommended priority areas. A variety of stakeholders and legislative initiatives have called for a national strategy for quality improvement and disparities reduction. Common priority areas and goals can help drive concerted national and local action toward the same ends. National priority areas, and goals within those priority areas, have implications for resource allocation across the U.S. Department of Health and Human Services (HHS) and externally, and therefore cannot be set by AHRQ alone. The IOM report Leadership by Example: Coordinating Government Roles in Improving Health Care Quality stressed that if the federal government could take collective action across programs for which it has account- ability, it would lead the way to action elsewhere (IOM, 2002a). The HHS Secretary is positioned to direct HHS programs to focus on the achievement of national priorities and goals through policies that support a stronger quality improvement infrastructure (e.g., measure development, the collection and analysis of evidence-based performance information), health policy interventions (e.g., changes in insurance coverage, support of prevention and care coordina­tion services), public reporting, incentive payments, demonstration projects, benefit design, health professions education, or other avenues, such as refining performance measures through research and funding data sources. The Future Directions committee wants to underscore the importance of such a broader commitment to national priority areas and the need for this direction to come from the Secretary of HHS. The committee, how- ever, refrains from offering a specific recommendation to the Secretary about national priority areas because its charge was limited to advising AHRQ. Health care reform legislation passed in March 2010 has a requirement and process for establishing national quality improvement priorities.  AHRQ can use the priority areas offered in this report to guide the selection of measures and the content of the NHQR and NHDR until a national strategy is formulated that replaces them.  The National Priorities Partnership (NPP) includes 32 public and private organizations including AHRQ, the Centers for Medicare and Medicaid Services (CMS), the IOM, the Robert Wood Johnson Foundation’s Aligning Forces for Quality, The Leapfrog Group, and The Joint Commission.  Patient Protection and Affordable Care Act, Public Law 111-148 § 3011, 111th Cong., 2d sess. (March 23, 2010). 

SUMMARY  BOX S-1 The Committee’s Eight Recommended National Priority Areas for Health Care Quality Improvement The IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports recommends a set of eight national priority areas for health care quality improvement for use in the NHQR and NHDR; it believes these priorities can guide the national healthcare reports. The recommended areas include six priority areas identified by the National Priorities Partnership (NPP, 2008), as well as two additional priorities that the committee believes are important to highlight. The six NPP priority areas included in the committee’s set of national priority areas are: 1. P atient and family engagement: Engage patients and their families in managing their health and making deci- sions about their care. 2. Population health: Improve the health of the population. 3. Safety: Improve the safety and reliability of the U.S. health care system. 4. Care coordination: Ensure patients receive well-coordinated care within and across all health care organiza- tions, settings, and levels of care. 5. Palliative care: Guarantee appropriate and compassionate care for patients with life-limiting illnesses. 6. Overuse: Eliminate overuse while ensuring the delivery of appropriate care. The two additional priority areas in the committee’s set are: 7. Access: Ensure that care is accessible and affordable for all segments of the U.S. population. 8. Health systems infrastructure capabilities: Improve the foundation of health care systems (including infra- structure for data and quality improvement; communication across settings for coordination of care; and workforce capacity and distribution among other elements) to support high-quality care. UPDATING THE CONCEPTUAL FRAMEWORK FOR THE REPORTS AHRQ has designed the NHQR and NHDR around a conceptual framework of quality recommended in ear- lier IOM reports (IOM, 2001, 2002b). The Future Directions committee presents an updated framework as shown in Figure S-1. The components of quality care now explicitly include access and efficiency as areas to present in both reports. Care coordination and capabilities of health care systems infrastructure were also added and are displayed as foundational components; progress on these elements can contribute to each of the other components across all types of care. The components of quality care in the revised framework can continue to be used as a way to categorize measures by topic and to organize the chapters of the NHQR and NHDR. Furthermore, the framework incorpo- rates the crosscutting dimensions of value and equity, and reporting on each measure should include, whenever data permit, the potential contribution to both value and equity of closing the gap between current and desired performance levels. Recommendation 2: AHRQ should adopt the committee’s updated framework for quality reporting to reflect key measurement areas for health care performance and use it to ensure balance among the eight components of quality care in AHRQ’s overall measure portfolio. AHRQ should further use its crosscutting dimensions of equity and value to rank measures for inclusion in the reports. Priority areas (Box S-1) are not expected to change annually; they should be in place for a number of years so that actions can be directed toward them and progress monitored. Over time, however, priorities may change, while the classification framework (Figure S-1) is expected to be more enduring. 

 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS Types of Care Components of ing Quality Care Preventive Acute Chronic Condition utt r o ssc sions Care Treatment Management C en Dim Effectiveness Safety Timeliness V E A Patient/family-centeredness Q L U U Access I E T Efficiency Y Care Coordination Health Systems Infrastructure Capabilities FIGURE S-1  An updated conceptual framework for categorizing health care quality and disparities measurement. Figure S-1 ADOPTING A TRANSPARENT AND QUANTITATIVE R01677 MEASURE SELECTION PROCESS editableAHRQ The question has arisen as to whether the measures vectors currently monitors in the national healthcare reports reflect attributes and processes with the greatest potential to improve the health of the country. AHRQ has indicated that it has reached capacity for the number of measures it can monitor given the agency’s current resources for data collection, analysis, and presentation. Adding or removing measures from the established set is challenging for AHRQ because there are advocates for each of the current NHQR and NHDR measures. The Future Directions committee recommends a new measure selection approach. Determining relevance to priority areas, categorization into framework components, and ranking are sequential steps in ascertaining which measures should be selected for reporting. Candidate measures within each component of quality in the framework are assessed for their relative contribution to improving value (i.e., population health) and equity, and ranked accord- ing to that potential. Measures with higher potential would be chosen for tracking in the NHQR and NHDR. AHRQ’s measure selection process should have external input based on objective and quantitative methods and should be transparent. The Future Directions committee recommends establishing a Technical Advisory Sub­ committee for Measure Selection to the AHRQ National Advisory Council for Healthcare Research and Quality (NAC). This body would apply quantitative techniques to establish the value of closing the quality gap (such as clinically preventable burden, cost-effectiveness analysis, and net health benefit) and to discern the degree of disparities. The committee’s proposed measure selection process is intended to guide AHRQ in selecting, ranking for inclusion in reports or other products, and retiring measures. The process also accounts for systematic identifica- tion of areas requiring further measurement research or data development. Recommendation 3: AHRQ should appoint a Technical Advisory Subcommittee for Measure Selec- tion to the National Advisory Council for Healthcare Research and Quality (NAC). The technical advisory subcommittee should conduct its evaluation of measure selection, prioritization, inclusion, and retirement through a transparent process that incorporates stakeholder input and provides public documentation of decision-making. This subcommittee should: • Identify health care quality measures for the NHQR and NHDR that reflect and will help measure progress in the national priority areas for improving the quality of health care and 

SUMMARY  eliminating disparities while providing balance across the IOM Future Directions committee’s revised health care quality framework. • Prioritize existing and future health care quality measures based on their potential to improve value and equity. • Recommend the retirement of health care quality measures from the NHQR and NHDR for reasons including but not limited to the evolution of national priorities, new evidence on the quality of the measure, or the attainment of national goals. • Recommend a health care quality measure and data source development strategy for national reporting based on potential high-impact areas for inclusion in AHRQ’s national quality research agenda. Box S-2 summarizes the roles of the Technical Advisory Subcommittee and the NAC. ENHANCING HEALTH CARE DATA RESOURCES As the nation enhances health information technology (HIT) and its health care data infrastructure, AHRQ should leverage its position as producer of the NHQR and NHDR to identify measurement and data needs and promote promising measures for which national data may not yet be available. Data emerging from electronic health records, health information exchanges, national registries, and provider- and community-based initiatives have the potential to complement or replace some of the data sources currently used in the NHQR and NHDR, and AHRQ will need financial support to take advantage of these data opportunities. Subnational data (e.g., state-level or voluntary disease registry data) can complement AHRQ’s current sources when national data do not provide information about important performance measurement questions. For instance, subnational data that meet specified criteria for appropriateness could be featured as illustrative textboxes or sidebars; they would be denoted as not being nationally representative, but rather, as helping inform national dialogue. BOX S-2 Proposed Roles in Selecting Measures and Developing a Research Agenda AHRQ’s National Advisory Council for Healthcare Research and Quality (NAC) [existing entity] • provides guidance to AHRQ on priorities for a national health services research agenda across all of AHRQ’s portfo- lio of activities [current role]; • provides, through existing informal subcommittee, general guidance on the NHQR and NHDR and associated products [current role and could continue as a separate subcommittee or be subsumed by the Technical Advisory Subcommittee]; and • comments on the recommendations of the Technical Advisory Subcommittee for Measure Selection and considers measurement and data needs agenda for inclusion in AHRQ’s research portfolio [new role]. NAC Technical Advisory Subcommittee for Measure Selection [new entity] Provides guidance to AHRQ and the NAC by: • soliciting suggestions for measure selection and exclusion from external stakeholders; • reviewing measures for use as core measures in the NHQR and NHDR and for supplementary measures for State Snapshots and other online data resources; • recommending a prioritized measurement list by considering national priority areas, impact on value and equity, and utilization of techniques to quantify the impact of closing the quality gap; • identifying aspirational measurement areas and data needs and a strategy for development (including a research agenda); and • identifying measures for retirement based on continued contribution to quality advancement and needs of stake- holder groups. 

 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS Recommendation 4: AHRQ should use subnational data for domains that do not yet have national data in order to illustrate the types of national data that need to be developed to satisfy measurement and data gaps. Subnational data should meet the following minimum requirements for reporting: • The data source allows the calculation of a measure of interest, ideally one identified as a national priority. • The data source uses reliable and well-validated data collection mechanisms and tested measures. • The sample used in the data source is representative of the population intended to be reported on (e.g., a region, state, population group) or is drawn from the entire population group even if it is not necessarily generalizable to the nation. Fundamental to addressing disparities in care is the need to expand the availability of descriptive data for populations at risk for poor quality care. An independent consensus study conducted by a subcommittee to the Future Directions committee culminated in the report Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement, which was released in August 2009 (IOM, 2009). That report highlighted the need to increase the standardized collection and use of race, ethnicity (including granular ethnicity), and language need data across all sources of quality improvement data, and the Future Directions committee concurs with that report’s recommendations (see Appendix G). The NHQR and NHDR would benefit from further analyses and presentation of quality data as a function of race, ethnicity, and language need, as well as of socioeconomic and insurance status. Socioeconomic status (SES), for instance, may be an intervening variable between race, ethnicity, and disparities. Therefore, examining the relationships between race/ethnicity and quality, both with and without SES included, would provide important information. The 2008 IOM report State of the USA Health Indicators recommended that data be first presented by race, ethnicity, and SES, and then by race and ethnicity stratified by SES (IOM, 2008). This committee agrees with that recommendation and finds it important for AHRQ to stratify race and ethnicity by SES and, when able, control for SES via multivariate regression. Presenting this detail in graphic form for each measure could become unwieldy in the context of the print reports, so the committee suggests that AHRQ present data when they reveal disparities or note that the analyses were performed and did not reveal a disparity, particularly after taking SES into account. Recommendation 5: AHRQ should: • Continue to stratify all quality measures in the NHDR by at least the OMB race and Hispanic ethnicity categories, by socioeconomic status variables (e.g., income, education), and by insur- ance status. • Strive toward stratifying measures by language need (i.e., English language proficiency and preferred spoken language for health care-related encounters), and extend its analyses in the NHDR and derivative products to include quality measures stratified by more granular ethnicity groups within the OMB categories whenever the data are available. • Document shortcomings in the availability of OMB-level race and Hispanic ethnicity data, granular ethnicity data, language need, and socioeconomic and insurance status data to sup- port these analyses; work to enhance the collection of these data in future iterations of the source datasets; and whenever necessary, should utilize alternative valid and reliable data sources to provide needed information even if it is not available nationally. IMPROVING PRESENTATION AND DISSEMINATION Clearly conveying information about the gaps that exist in the quality of U.S. health care and the benefits of closing those gaps would provide audiences for the NHQR and NHDR with a stronger rationale for improving  The full text of this report is available online: http://www.nap.edu/catalog.php?record_id=12696. 

SUMMARY  specific elements of care. The Future Directions committee underscores the importance of integrating disparities elimination into quality improvement activities by enhancing the structural relationship between the two national healthcare reports (i.e., a shared Highlights section for both reports, health care access and equity information in the NHQR, and health care quality benchmarks in the NHDR). Therefore, the committee recommends: Recommendation 6: AHRQ should ensure that the content and presentation of its national health- care reports and related products (print and online) become more actionable, advance recognition of equity as a quality of care issue, and more closely match the needs of users by: • incorporating priority areas, goals, benchmarks, and links to promising practices; • redesigning print and online versions of the NHQR and NHDR to be more integrated by recognizing disparities in the NHQR and quality benchmarks in the NHDR; • taking advantage of online capability to build customized fact sheets and mini-reports; and • enhancing access to the data sources for the reports. The audiences for the NHQR and NHDR include a range of stakeholders with specific areas of interest (e.g., heart disease, rural health, racial disparities, delivery settings), as well as varying degrees of sophistication in data analysis. To better meet the needs of these diverse audiences, the committee suggests that AHRQ refine and expand its product line (Table S-1) and focus the NHQR and NHDR on a national quality improvement strategy. Additionally, the committee encourages enhanced Web-based data capabilities so that users can customize reports to their own topical needs and access primary data for analyses. The story AHRQ relays in the national healthcare reports should engage readers and encourage, guide, or sup- port action by them. For that reason, the committee believes that AHRQ should modify the reports from their cur- rent chartbook format to make them less a catalog of data and instead a more forward-looking and action-oriented document that tells a quality improvement story. Such a document would include: (1) takeaway messages that address the performance gap (i.e., time to close gap at current rate of change, the net benefit for health of closing the gap), (2) benchmarks to demonstrate high levels of attained performance and to inform realistic targets for goals, (3) data analyzed and presented in ways that can inform specific actors or policies (e.g., data by payer type, by insurance status, by program type), (4) illustrative examples of promising practices and islands of excellence, and (5) identified data and measurement needs required to strengthen the quality improvement infrastructure. The committee believes that the NHQR and NHDR should both remain annual publications to maintain vis- ibility of the issues they cover. However, the reports could emphasize different priority areas or components of quality from year to year to allow for more in-depth coverage. By incorporating demonstrably attained but challenging benchmarks based on best-in-class performance, the NHQR, the NHDR, and the State Snapshots can help serve as catalysts for improvement. Defining a benchmark, though, can depend on the data source and unit of analysis in the research question being asked. Some measures may be suited to analyzing data only by one type of unit such as states, health plans, or hospitals, while others may be by more than one type of unit (such as by both state and hospital). Because providing multiple benchmarks may add too much visual clutter in graphic displays, some achievement levels could be presented in sidebars. Present- ing benchmarks set by best state performance may particularly satisfy the needs of Congressional and state policy makers, principal audiences to which the reports are geared. For comparative purposes, the committee suggests presenting a uniform quality benchmark across the NHQR and NHDR. For each measure, the performance benchmark in the NHQR should also be available in the NHDR to inform how each population group relates to the benchmark as well as continuing to show the differences among population groups. Recommendation 7: To the extent that the data are available, the reporting of each measure in the NHQR and NHDR measure set should include routinely updated benchmarks that represent the best known level of performance that has been attained. 

 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS TABLE S-1  Tailoring Products to Meet the Needs of Multiple Audiences Product Potential Audiences Recommended Content Shared “Highlights” Section Policy makers, media, Features progress on the national priorities areas and measurement areas with the [redefined product to be used public, foundations greatest potential for quality improvement impact on population health, value, in both the NHQR and NHDR and other funders of and equity; evidence-based policies/best practices that will enhance or hinder and that can be disseminated research, national progress; actions that stakeholder groups can take; and what is needed to make as a stand-alone product] quality organizations progress toward national goals. Includes a summary of progress by states. Includes summary on state of disparities. NHQR Quality, advocacy, Information on a set of measures organized by the expanded quality framework to [refinement of existing and standards setting address: effectiveness, safety, timeliness, patient-centeredness, access, efficiency, product] organizations; health care coordination, and capabilities of health systems infrastructure. care providers, Includes access, a topic previously addressed only in the NHDR. plans, payers, and purchasers at the Details that disparities exist (beyond the current displays on geographic variation national and state or age) by including a separate chapter or summary on socioeconomic, racial, and level; research ethnic disparities; and acknowledges in messages when socioeconomic and racial community disparities exist for individual measures. NHDR Quality, advocacy, Maintains parallelism with the NHQR by applying the expanded quality [refinement of existing and standards setting framework to its organization and presentation of measures. product] organizations; health Includes benchmarks, not just comparisons among populations. care providers, plans, payers, and Provides more in-depth coverage of priority populations. purchasers at the national and state level; research community Fact Sheets and Advocacy groups, Includes short story of key facts and potential actions related to certain disease- Mini-Reports strategic partners for specific or priority population topics in the NHQR and NHDR. [expanded products] dissemination, media, public State Snapshots State government; Provides expanded measure set sortable by core measures, Healthcare [refinement of existing health care providers, Effectiveness Data and Information Set (HEDIS) measures, state rankings, and product] plans, payers, and comparisons between states with similar population characteristics, not simply in purchasers at the state neighboring geographic regions. and local level Adds to context by including best performance attained (for all states and for peers), variation within state (e.g., by geography, providers, payers, race/ethnicity/ language, and the availability and type of insurance). Includes access measures. Online Data Access Advocacy groups; Has capability to collect text and data by topic to yield a customized report. [expansion of existing stakeholders in Links to other helpful data sources and intervention information. approaches] quality improvement, media, and public Provides access to full datasets for user manipulation, and links to other sites that • Customizing reports via provide expanded metrics on health care data (e.g., CMS), and more local and the NHQRDRnet Researchers (for organizational-level data. access to primary • Data repository of data for additional Has tools to show users how to mirror AHRQ’s analytic approaches. primary datasets national-, state-, and local-level analyses) Guide to Using the NHQR All potential Explains how to access and utilize available data. and NHDR user audiences, Gives examples of how different stakeholder groups can apply the knowledge to [new product] but particularly action. researchers 

SUMMARY  Because the success of the national healthcare reports relies so heavily on presentation and dissemination, the committee recommends engaging external experts to further assist in conceptualizing the reports’ presentation techniques and raising their profile among current and potential user audiences. Recommendation 8: AHRQ should engage experts in communications and in presentation of statisti- cal and graphical information to ensure that more actionable messages are clearly communicated to intended audiences, summarization methods and the use of graphics are meaningful and easily understood, and statistical methods are available for researchers using data. IMPLEMENTING RECOMMENDED CHANGES Implementing many of the Future Directions committee’s recommendations will require additional federal funding, although it is expected that numerous upgrades can be made to the NHQR, NHDR, and State Snapshots with existing funds. While the committee is fully cognizant of federal budgetary constraints, it is also aware of growing stakeholder demand for value and equity in the face of substantial expenditures for health care (an esti- mated $2.3 trillion in 2009) (CMS, 2010; Cutler, 2009). The redesigned NHQR and NHDR would specifically focus on the factors of value and equity, and the closure of gaps in quality in high impact areas. Additional funds would be required to: (1) support the measure prioritization process, (2) strengthen performance metrics, (3) obtain the necessary data for new measurement areas from sources both within and external to HHS, (4) produce the re- envisioned national healthcare reports and related products and disseminate them effectively to engage national and state policy makers and other actors, and (5) sponsor a rigorous evaluation. Recommendation 9: To the extent that existing resources cannot be reallocated, or AHRQ cannot leverage its resources by partnering with other stakeholders and HHS agencies, AHRQ should work to obtain additional funds to support the work of the Technical Advisory Subcommittee for Measure Selection, the upgrades and additions to AHRQ’s national healthcare report-related products, and the development of new measures and supporting data sources. In Chapter 7, the committee presents a suggested timeline of steps for implementation of activities related to the committee’s recommendations, and in Appendix I, the committee presents one possible funding scenario. The ultimate purpose of the NHQR and NHDR is to produce relevant information for policy makers, the public, and individuals and entities responsible for implementing quality interventions. AHRQ will therefore need to evaluate the NHQR and NHDR and related products, their use, and their impact as a basis for understanding how they might most efficiently and effectively contribute to improving national health care quality and eliminat- ing disparities. Recommendation 10: AHRQ should regularly conduct an evaluation of its products to determine if they are meeting the needs of its target audiences and to assess the degree to which the information in the AHRQ products is leveraged to spur action on quality improvement and the elimination of disparities. Underlying all of the committee’s recommendations is a consensus that the NHQR and NHDR should promote action to improve the quality of U.S. health care, not just create awareness of historical trends in the quality of care. The NHQR and NHDR can and should be tools to catalyze and leverage public and private efforts to improve health care quality and promote equity. The reports are natural vehicles for transmitting a strategic vision for health care quality improvement and tracking the effect of health reform legislation. No report alone will make change, but a common effort to close quality and disparities gaps will help us accomplish the vision of better health care and health for the country. 

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