• identification of important measurement and data gaps to set a research and data collection agenda;2 and

  • best-in-class benchmarks that show the gap between current average performance and the best attained performance.

Overall, the presentation in the reports needs to tell a more complete quality improvement story.

In previous chapters, the Future Directions committee has recommended a number of steps to address these issues. Specifically, the committee suggests a set of national priority areas for quality improvement and disparities, and recommends that AHRQ ensure the NHQR and NHDR report on progress made toward these national priorities (Chapter 2). AHRQ should more closely align future iterations of the NHQR and NHDR to ensure a focus on equity in the NHQR; the relationship between quality and equity is underscored in the updated quality framework, which includes equity and value as crosscutting components (Chapter 3). Moreover, the committee recommends the use of a more quantitative and transparent process for ranking performance measures for use in the NHQR and NHDR and for documenting measurement and data gaps (Chapter 4). New data sources, including subnational ones, may be appropriate for inclusion in future national reports. Furthermore, to ensure the ability to measure and compare quality across all population groups, standardized data on race, ethnicity, and language need, as well as other sociodemographic descriptors, must be collected and analyzed (Chapter 5). Finally, the committee recommends that the current emphasis in the NHQR on comparing quality data to average national performance be modified so that greater emphasis is placed on outcomes that have been previously attained by health care providers, health care organizations, or states (i.e., best-in-class benchmark) (Chapter 6).

Performance gaps have been repeatedly documented by the national healthcare reports and other quality reporting entities. The Future Directions committee supports the broader dissemination of re-designed reports and associated products to spur the engagement of actors across the U.S. health care system in affecting substantial and accelerated progress on national priority areas. Change, however, will require a broad national commitment and engagement. Impetus for action, complementary to the reports, should come from a combination of federal and state leadership with broad stakeholder consensus on national priorities, from leadership and direction by public and private sector entities (particularly insurers and employers), and from the commitment of resources that aim to remove barriers to improving the quality of U.S. health care.


The statement of task for the Future Directions committee (see Chapter 1) specifically asked that the committee “take note of recommendations that are estimated to be a reach for the current resources of AHRQ” (IOM, 2008). The committee acknowledges that implementing most elements of the recommendations presented in this report will require additional funding.

Investing in National Quality Measurement Efforts

When considering the need for AHRQ to receive additional funding to implement the committee’s recommendations, the committee used existing and expected health care spending and recent recommendations for funding quality measurement enterprises as a context for understanding the necessary degree of investment. With $2.3 trillion spent on U.S. health care in 2008, health care expenditures constitute more than 16 percent of the U.S. gross domestic product (GDP) (CMS, 2010; Cutler, 2009). Moreover, health care spending is projected to comprise 20 percent of the country’s GDP by 2017 (Keehan et al., 2008) and up to 40 percent of the GDP by 2050 (CBO, 2007).

A number of proposals—elements of which are similar to activities proposed by the Future Directions committee—have estimated funding needed to enhance the nation’s quality improvement infrastructure. For example,


The 2008 NHDR lists the population groups (e.g., Asian or Pacific Islander, American Indian/Alaska Native, and poor) for which data are not available for its core measures (p. 287).

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