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

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3 Updating the Framework for the NHQR and NHDR The Future Directions committee’s updated framework for health care quality builds on previous IOM recommendations for measuring the state of health care in the NHQR and NHDR. The revised framework encompasses both well-established and emerging components of high-quality health care. The framework is a tool for examining AHRQ’s portfolio of measures for comprehensiveness and for categorizing mea- sures presented in the NHQR and NHDR. The framework’s quality of care components are effectiveness, safety, timeliness, patient-centeredness, access, efficiency, care coordination, and health systems infra- structure capabilities. The committee includes in the framework the crosscutting dimensions of value and equity, which are to be reported for each of the quality of care components and to be considered when ranking measures for inclusion in the NHQR and NHDR. Before beginning to publish the annual NHQR and NHDR in 2003, AHRQ sought the IOM’s guidance regarding the overall content and organization for the reports (Appendix A). The IOM reports Envisioning the National Healthcare Quality Report (IOM, 2001b) and Guidance for the National Healthcare Disparities Report (IOM, 2002) provided the original conceptual framework for quality measurement in the NHQR and NHDR (Appendix C), upon which the Future Directions committee has built. This chapter provides the rationale for an expanded framework and, in a complementary Appendix D, explores measurement possibilities for the new framework components. The framework is intended to define “dimensions and categories of measurement that will outlast any spe- cific measures used at particular times. In essence, it lays down an enduring way of specifying what should be measured while allowing for variation in how it is measured over time” (IOM, 2001b, p. 42). In this sense, the framework presents a performance measure classification matrix that is of use not only for the NHQR and NHDR but also for all national healthcare report-related products. Because the framework components accommodate a broad spectrum of measures, and the universe of potential measures is voluminous and ever expanding, the prior- ity areas discussed in the previous chapter are one element in helping define a narrower set of measures within the framework components. (Chapter 4 includes the Future Directions committee’s recommendations on further defining the set of measures according to their potential health care quality impact.) 39 

40 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS THE ORIGINAL FRAMEWORK FOR THE NHQR AND NHDR The original conceptual framework put forth in the 2001 Envisioning the National Healthcare Quality Report highlighted four components of health care quality: (1) safety, (2) effectiveness, (3) patient-centeredness, and (4) timeliness. These components corresponded to four of the six aims of quality health care set forth in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Century (see Box 3-1). At the time, measurement of efficiency was considered underdeveloped and thus omitted from the framework. The component of equitable care was deemed a crosscutting dimension (see Appendix C for the framework originally adopted by AHRQ for the NHQR and NHDR). Envisioning the National Healthcare Quality Report recommended that the performance measures presented in the NHQR be framed in consumer categories (i.e., in terms of “staying healthy, getting better, living with illness or disability, and coping with end-of-life care”) (IOM, 2001b, p. 6). Subsequently, AHRQ found it more useful to frame the presentation of data by clinical stages of care (i.e., prevention, acute treatment, management) because that is the context in which most measures are currently developed. Although AHRQ’s clinical stages of care are less patient-focused than the consumer categories, the committee agrees that the clinical stages of care are easily understood by patients as well as the policy makers, health care professionals, and researchers to whom the infor- mation in the NHQR and NHDR is primarily directed. Moreover, although data in the reports are not presented by the consumer categories, AHRQ indicated that these categories are implicitly considered when identifying potential measures for inclusion in its full measure set.  Envisioning the National Healthcare Quality Report acknowledges that the conceptual framework should be dynamic in nature in order to adjust to “changes in conceptualization of quality or significant changes in the nature of the U.S. health care system” (IOM, 2001b, p. 42). Indeed, since the development of the original conceptual framework, new areas for health care performance measurement have emerged, as have attributes of what consti- tutes high-quality care, thus leading the Future Directions committee to update the framework. AN UPDATED FRAMEWORK FOR THE NHQR AND NHDR The six quality aims expressed in the 2001 IOM Crossing the Quality Chasm report (see Box 3-1) have become the basic vernacular for discussing health care quality improvement and disparities elimination. Many other orga- nizations, ranging from providers to health plans to quality improvement organizations, have used the six aims to organize their own measurement or reporting efforts. For example, Aetna’s High Performance Provider Initia- tives and Hudson River Health Care (a safety net clinical setting) track performance measurement based on these aims (Aetna, 2008; Hudson River Healthcare, 2009). Because continuity is important to preserve and because the original conceptual framework for the national healthcare reports stems from the IOM’s six aims, the committee decided to build on the pre-existing framework rather than propose an entirely new one. The framework remains applicable to both the NHQR and NHDR. The Future Directions committee looked to prominent organizations and collaboratives engaged in health care quality improvement and disparities elimination for their informed perspectives on the latest advancements in and concerns about the current state of health care. Sources included the Healthy People 2020 Consortium, the National Quality Forum (NQF), the Institute for Healthcare Improvement, the Centers for Medicare and Medicaid Services (CMS), the HHS Office of Minority Health, the Kaiser Family Foundation, the World Health Organization (WHO), the Robert Wood Johnson Foundation, the Health Care Quality Indicators Project of the Organisation for Economic Co-operation and Development (OECD), The Commonwealth Fund’s Commission on a High Perfor- mance Health System, the Quality Alliance Steering Committee, the National Committee for Quality Assurance, the Out of Many One Health Data Task Force, and the AQA alliance.  Personal communication, Future Directions committee chair’s site visit to AHRQ, April 30, 2009. 

UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 41 BOX 3-1 The Six Aims of Quality Care from the IOM’s Crossing the Quality Chasm Report The IOM’s 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century found that the U.S. health care delivery system does not provide consistent, high-quality care to all people. The report says that between the health care that Americans have now and the care that they could have “lies not just a gap, but a chasm” (p. 1). The Quality Chasm report strongly recommends that all health care constituencies—health professionals, federal and state policy makers, public and private purchasers of care, regulators, organization managers and governing boards, and consumers—commit to adopting a shared vision for improvement based on six specific aims for health care: • S afe—avoiding injuries to patients from the care that is intended to help them • Effective—providing services based on scientific knowledge to all who could benefit and refraining from provid- ing services to those not likely to benefit (avoiding underuse and overuse, respectively) • Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions • Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care • Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy • Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status SOURCE: IOM, 2001a, pp. 5-6. Framework Additions Figure 3-1 shows the expanded conceptual framework for health care quality and disparities reporting. First, the committee explicitly includes access and efficiency as quality care components. These components are currently presented in one report or the other (access measures are reported in the NHDR but not the NHQR, and efficiency measures are beginning to be reported in the NHQR but not the NHDR). The inclusion of these two components in the framework reflects their relevance for reporting in both the NHQR and NHDR. The Future Directions committee identified care coordination and capabilities of health systems infrastruc- ture as necessary health care components to include in the national healthcare reports. These components are not necessarily health care aims/attributes in themselves, but are a means to those aims since they are elements of the health care system that better enable the provision of quality care. Care coordination and health systems infrastructure are of interest to the extent that they improve effectiveness, safety, timeliness, patient-centeredness, access, or efficiency. For this reason, these components are depicted as foundational, supporting the performance measurement of the other quality components and spanning across the different types of care. Measures and data sources for care coordination and systems infrastructure tend to be at a developmental stage,  and evidence of the impact on quality improvement for many measures in these areas has yet to be strongly established. Therefore, for these foundational components, the committee suggests that only measures that have demonstrated improvement in at least one of the other six components of care be reported in the national healthcare reports. For example, the Care Transitions Measure (often referred to as the CTM-3 measure) is a validated care coordination measure that quantifies hospital performance based on patient or caregiver experience with hospital transitions (Coleman, 2006; Parry et al., 2008). The care process captured by this measure has demonstrated positive health outcomes including reduced readmissions of patients discharged from hospitals and improved self-management and recov- ery of symptoms (Care Transitions Program, 2009). Reporting of this measure is not yet national in scope, but it holds promise as a care coordination measure that could be reported in the national healthcare reports at some point in the future.  In the context of this report, the term developmental refers to measures that are currently partially developed but not yet well tested or vali- dated, or measures that have been validated but still lack sufficient national data on which to report. Aspirational refers to performance areas for which no measures yet exist—at best, there is a proposed way to measure performance. 

42 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 3-1  An updated conceptual framework for categorizing health care quality and disparities measurement. Figure 3-1 duplicate of Figure S-1 Another enhancement to the conceptual framework R01677 is the presence of equity and value, which are displayed editable in a manner that conveys their applicability to each vectors quality component, including the foundational elements of care coordination and health systems infrastructure. The committee views the dimensions of equity and value as ideals that can and should be achieved by improvement in each of the other framework components. Although the committee has added components to the framework on which AHRQ should report, AHRQ should have flexibility to provide a more in-depth focus on some, but not necessarily all, of the identified priorities and their component parts from one year to the next, as long as there is comparability between the NHQR and NHDR for the measures selected for that year’s report. Application of the Care Components As noted in Envisioning the National Healthcare Quality Report, “The framework is a tool for organizing the way one thinks about health care quality. It provides a foundation for quality measurement, data collection, and subsequent reporting” (IOM, 2001b, p. 42). The Future Directions committee’s expanded matrix of care compo- nents and types of care provides a way for AHRQ to continue categorizing potential and existing measures, ensure a balance in measure selection across the framework components, and identify gaps in its portfolio of measures selected for tracking—including those featured in the NHQR, NHDR, and the online resources, such as the State Snapshots and NHQRDRnet. For example, if the NPP priority area to “eliminate overuse while ensuring the delivery of appropriate care” were adopted for the national healthcare reports, then overuse measures would fall within the efficiency component of the framework. Likewise, measures for the priority of palliative care would help fill the current gap in the reports related to patient-centered performance measures for the management of chronic conditions. The committee’s recommended framework is not intended to specify the priority areas for quality measure- ment discussed in Chapter 2. There is currently some overlap between priority areas and framework components. Priorities might, at times, place more emphasis on one area of the framework than another, and measures applicable to one priority might apply to a single or multiple framework component(s) (see Chapter 4, Figure 4-3). AHRQ has strived for breadth by covering much of the framework’s matrix in the annual healthcare reports and maintaining a more comprehensive measure set in derivative products. AHRQ acknowledges that maintaining 

UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 43 and reporting on such a vast collection of measures has limited its ability to provide more in-depth treatment of the topics covered (Moy, 2009). Therefore, the committee presents priorities that can be used as a first step in whittling the measurement possibilities, and then followed by more quantitative steps described in Chapter 4. Application of Equity and Value Equity and value apply to each of the care components, including the foundational elements, and the results of equity and value assessments should be reported for each measure in the NHQR and NHDR. Findings can be included in graphics or text describing whether equity has been achieved and the value (based on the costs and benefits) that would accrue if quality gaps between current and desired levels of performance were closed (for example, if all persons, rather than 55 percent, received preventive services) and if equity gaps were closed. AHRQ currently applies the concept of equity by presenting quantitative differences in performance levels by geographic areas (NHQR) and different populations (NHDR). The Future Directions committee observes this has been useful for dividing the content between the two reports, but that at times the separation can lead to misleading conclusions about the progress of the country in achieving quality. As noted in Chapter 2, the committee believes that the NHQR should include population equity findings and the NHDR should include additional information on the potential impact of closing the quality gap. Presenting value for each component is a complex endeavor because value can mean various things to dif- ferent people. (For the broad definition of value used in this report, see Box 3-2.) AHRQ has begun to incorpo- rate total and indirect costs for medical conditions, and estimates of the cost effectiveness of interventions (e.g., quality adjusted life years [QALYs]). The Future Directions committee lauds this movement, but also encourages AHRQ to report for each measure the potential quantifiable value of closing the gap between current and desired performance levels. Depending on the data available to describe the impact of closing the gap, findings might be presented in terms such as net health benefit, the size of the population affected, or estimated expenditure and possible cost savings. The committee believes that using its updated framework provides AHRQ with a matrix to classify its current and future portfolio of measures to examine where measurement gaps might exist, while accommodating shift- ing priorities for the nation’s health care system. Additionally, since equity and value are criteria in the proposed measure selection process (see Chapter 4), quantification of these concepts should be included in the data presented in the national healthcare reports. As a result, the committee recommends: 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. Additional justification for including equity and value, as well as each of the added quality of care compo- nents, is discussed in the following sections. To complement the justifications, Appendix D explores measurement possibilities for access, efficiency, care coordination, and health systems infrastructure. RATIONALE FOR THE DIMENSIONS OF EQUITY AND VALUE Equity and value represent dimensions of quality integral to all aspects of health care; each represents a larger goal of quality improvement that should be reflected in assessing individual quality measurement data.  In an examination of the quality of care delivered to a random sample of patients nationwide, McGlynn and colleagues estimated that only 55 percent of the population was receiving the recommended level of care (McGlynn et al., 2003). 

44 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS BOX 3-2 Definitions of Equity and Value as Used in This Report Because the committee proposes a new approach for assessing equity and value in future iterations of the NHQR and NHDR, and because there are many interpretations of the term value, the committee thought it important to define the terms equity and value as they are used in this report. The Future Directions committee bases its definition of equity on the previous IOM definition of what is equitable: providing health care to all individuals in a manner “that does not vary in quality because of personal charac- teristics such as gender, ethnicity, geographic location, and socioeconomic status.” (IOM, 2001a, p. 6) The committee defines value as: a measure of stakeholder utility (subjective preference by a group or individual) for a particular combination of quality and cost of care or performance output. Equity Envisioning the National Healthcare Quality Report and Guidance for the National Healthcare Disparities Report recommended the inclusion of equity in the framework (IOM, 2001b, p. 62, 2002, p. 11), and the Future Directions committee’s framework retains it as a crosscutting element. Although the illustrated framework in the IOM’s Envisioning the National Healthcare Quality Report did not explicitly include equity, the report specifically recommended that “equity be examined as an essential crosscutting issue” and that variations in the quality of care by race, ethnicity, gender, age, income, geographic location, insurance status, or socioeconomic status “have to be considered within each cell of the classification matrix in order to examine equity” (IOM, 2001b, p. 62). Guidance for the National Healthcare Disparities Report reiterated that AHRQ should use the framework recom- mended in Envisioning the National Healthcare Quality Report as the basis for the NHDR and that the NHDR was to “highlight health care issues related to equity and the extent to which health care disparities undermine its achievement” (IOM, 2002). AHRQ focuses the NHQR on geographic differences by state and the NHDR on differences by gender, ethnic- ity, and socioeconomic status, as well as rural and metropolitan differences. Usually, the terms equity and disparities are more closely aligned in the literature with the quality of care, or lack thereof, being delivered to the populations featured in the NHDR. AHRQ has indicated that it defines disparities for the NHDR as “simple differences” and that its use of the term “disparities” does not have any more detailed implications. Others researchers and quality stakeholders distinguish the meaning of differences and disparities (see Figure 3-2 for one such example). The IOM report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003b) describes a disparity as a difference in health or clinical outcomes that is not attributable to clinical appropriateness or patient preferences. A body of literature identifies inequities in health care for different populations, primarily for low-income or certain racial and ethnic groups (Asch et al., 2006; Baicker et al., 2004; Blendon et al., 2007; Doescher et al., 2001; Fiscella et al., 2000). The Census Bureau projects that by 2045, half of the people living in the United States will be members of racial minority population groups (U.S. Census Bureau, 2008). Given these demographic changes, disparities may affect an even greater number of individuals in the future. Studies have assessed the implications of such demographic trends, coupled with known disparities, on costs to the health care system (LaVeist et al., 2009; Waidmann, 2009). Equity has often been viewed separately from quality when in fact, the two concepts are interconnected. Equity for minority, low-income, and other populations should be on the nation’s quality improvement agenda to ensure “equal access to available care for equal need, equal utilization for equal need, equal quality of care for all” (Whitehead, 1990, p. 8). Achieving equity should not be the sole purview of those working to address the core needs of low-income populations or communities of color. The interconnectedness of equity and qual- 

UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 45 Clinical Need and Appropriateness, Patient Preferences Quality of Care Difference Non-Minority Healthcare Systems and Non-Minority Legal/Regulatory Systems Minority Disparity Minority Minority Non- Discrimination: Bias, Stereotyping, and Uncertainty FIGURE 3-2  Differences, disparities, and discrimination: Populations with equal access to health care. SOURCE: IOM, 2003b. Reprinted with permission from Mark G. McGuire 2010. ity has been recognized by numerous entities and Figure 3-2within the quality enterprise (Chin and Chien, individuals 2006; Disparities Solution Center, 2009; Frist, 2005;R01677 RWJF, 2010), indicating that equity is an “integral part of quality improvement scholarship” (Chin and Chien, 2006, vectors editable p. 79). This connection should be made more visible by quality improvement programs (Chin et al., 2007; Watson, 2005), and the NHQR can play a role in doing so. As Chin and Chien stated: “We know a considerable amount about the mechanisms causing these [racial] disparities. There is therefore a crying need for solutions to reduce disparities, and QI [quality improvement] interventions must play a key role,” (Chin and Chien, 2006, p. 79). Integrating equity information into the NHQR and spotlighting promising interventions can assist in linking disparities elimination to quality improvement. The causes of both quality problems and disparities are often context-specific. Bias might be a significant problem in one area whereas access or costs might predominate in another. Arguably, access-related issues (e.g., insurance, costs, geography, health literacy, language) are among the most important drivers of health care dispari- ties. The Future Directions committee agrees that AHRQ can primarily report differences among population groups without determining the cause, but that AHRQ should examine, whenever data allow, the effect of possible drivers so that analyses will better inform policy. Fully understanding the degree of disparities is often made difficult by data limitations, a topic further addressed in Chapter 5. Value The term value is used in varied ways in contemporary health care parlance. Some definitions are deceptively simple (e.g., “quality for cost”). Correspondingly, some observers take the term high value to be synonymous with a good cost-effectiveness ratio—the best achievable health outcomes per dollar spent (Porter, 2009). The committee recognizes that in the quality improvement literature, value-based care often refers to developing quality health care that is cost effective (CMS, 2008a; HHS, 2009; Patrick, 2009; Wong et al., 2009), or optimizing the “the ratio of benefits to cost” (IOM, 2010, p. 29). Other definitions of value are more complex and encompassing, and attempt to incorporate subjective attributes of value in the health care system, such as positive patient experiences with desired health outcomes (Wharam and Sulmasy, 2009). The Future Directions committee presents value as a crosscutting dimension of health care quality such that a high-value health care system is one that maximizes all the components of quality care outlined in the proposed 

46 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS conceptual framework (Figure 3-1). For the purposes of this report, the committee defines value as “a measure of stakeholder utility (subjective preference by a group or individual) for a particular combination of quality and cost of care or performance output” (see Box 3-2). This is a broad concept, not limited to enhancing economic value but also enhancing health impact and patient experience. Assessing value is not to be confused with measuring the efficiency of health care services, which refers to maximizing objective performance (health care outcomes) by producing the best possible outputs from a given set of resources or inputs (McGlynn, 2008). While more difficult to measure and more subjective, the broad concept of value is ultimately the key overarching utility placed on health care, and thus the committee believes that it is important to include in its framework this concept explicitly and distinctly from efficiency. A high-value health care system involves providing care whose benefits “are worth” or exceed their costs by being appropriate and affordable to society, and where treatment has large aggregate health benefits, measured, for example, using the concept of clinically preventable burden. (Cost-effectiveness and clinically preventable burden are discussed further in Chapter 4.) For some health care services and some dimensions of care, it will be difficult to quantify cost-effectiveness or clinically preventable burden. Examples include making care more patient-centered and improving care coordination, which can be fundamental to a patient’s perception of experiences with care (Wharam and Sulmasy, 2009). The fact that quantifying cost-effectiveness and clinically preventable burden may be difficult for these dimensions of health care does not mean that improving these dimensions does not enhance value. So while the committee wants increased consideration in the NHQR and NHDR of the quantitative benefits that would accrue from closing the gap based on available value metrics (e.g., cost-effectiveness analysis), the committee acknowledges that such quantitative data are just one facet of assessing value. RATIONALE FOR THE FOUR NEW QUALITY OF CARE COMPONENTS The committee concludes that high-quality, equitable health care is facilitated by enhanced access to care, efficiency, care coordination, and a supportive health systems infrastructure. For that reason, the committee has included all four of these quality components in the updated framework. This chapter does not present the rationale for including the pre-existing framework components of effectiveness, safety, timeliness, and patient centeredness as the rationale for each was presented in Envisioning the National Healthcare Quality Report, and AHRQ has responded by reporting on these topics. Access The IOM defines access as “the timely use of personal health services to achieve the best possible health outcomes” (IOM, 1993, p. 4). Access to care remains a central challenge for the U.S. health care system (Ginsburg et al., 2008; IOM, 1993, 1998, 2009), and this topic has been highlighted in the NHDR as a component of health care quality that exhibits disparities. The committee finds that improving access is a fundamental aspect of quality for the entire population. Therefore, access should be addressed in both reports. With more than 46 million uninsured Americans as of 2008 (U.S. Census Bureau, 2009a) and large numbers of Americans reporting they have gone without needed care (Cunningham and Felland, 2008; IOM, 2009), access is a critical issue for the nation. Uninsurance affects all population groups, not only low-income or minority groups. For example, as of 2008, people with household incomes greater than $50,000 per year (middle and higher income families) constituted 22.2 percent of the uninsured population (U.S. Census Bureau, 2009b), and non-Hispanic Whites made up nearly half of the uninsured individuals in the United States (U.S. Census Bureau, 2009c). Although the availability of health insurance is significant when measuring access and utilization—insurance is an entryway into the health care system and is often linked with health status (DeVoe et al., 2003; Hadley, 2002; Ross et al., 2006)—other aspects are also barriers to receiving appropriate medical care. For example, even if more people obtain insurance coverage, problems will likely persist in access to care, including affordability (Cummingham et al., 2008; IOM, 2009), access to a usual or ongoing primary care provider (Goldman and McGlynn, 2005; Sack, 2008), and the ability to see those physicians (Ahmed et al., 2001; Hall et al., 2008). Affordability of health care is a major concern for Americans (Blendon et al., 2004; Gallup Consulting, 

UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 47 2009)—medical causes and related costs (in the form of medical bills, or lost wages due to days unable to work) were behind 62 percent of all personal bankruptcies in the United States in 2007 (Himmelstein et al., 2009). Addi- tionally, 35 percent of adults with health insurance still experience access problems due to cost (Collins et al., 2008; Cummingham et al., 2008; Gabel et al., 2009; Wang et al., 2009). Deemed the underinsured, the number of individuals who fall into this category rose from 16 to 25 million from 2003 to 2007 (Schoen et al., 2008). High deductibles and copayments, exclusion by condition or by service, the Medicare Part D donut hole, and caps on coverage all contribute to lack of affordability (Briesacher et al., 2009; IOM, 2009). Primary care represents the entry point and foundation for successful health care systems (Grumbach and Mold, 2009; Starfield and Shi, 2002, 2007). Individuals who report having usual and continuous sources of care (particularly primary care) are associated with overall better health regardless of other factors (including general health status, insurance status, greater utilization of health care services, fewer delays in getting care, and better preventive care) (Doescher et al., 2001; RWJF, 2002; Starfield and Shi, 2007; Starfield et al., 2003). Ensuring access to care for other specialties, such as mental and oral health care, is also important for overall health and availability to needed care (Chapin, 2009; Edelstein and Chinn, 2009; Pomerantz et al., 2008). Regular access to health care services has been shown to correlate with reduced hospital use while preserving quality because ongoing clinical preventive services allow for the prevention of disease or detection of asymptomatic disease or risk factors at early, treatable stages (Bodenheimer, 2005). If someone is not seeking ongoing care for his or her conditions, it is possible that the illness will not be managed effectively (Collins et al., 2008), increasing one’s risk of a worsened condition that ultimately may be costlier to treat. The combination of insurance coverage, affordability, and access to ongoing sources of care illustrates that access is a broad topic with multiple dimensions, and that it can be assessed by a variety of measures (AHRQ, 2009b; Cantor et al., 2007; The Commonwealth Fund Commission on a High Performance Health System, 2008; NCQA, 2009). The printed version of the 2008 NHDR reported on 10 access measures (AHRQ, 2009b). AHRQ breaks down the access section in the NHDR into two categories: “facilitators and barriers to care” and “health care utilization” (which includes measures of dental, emergency, and mental health care). By organizing the access section in this way, AHRQ attempts to capture the discrete variables that affect access. The committee suggests that AHRQ begin, at a minimum, to include those same or related measures in the NHQR as indicators of how well the structure of the nation’s health care system responds to the various needs of patients.  Exploratory methods for measuring some other aspects of access to care are presented in Appendix D. Efficiency Efficient care is defined in the IOM’s Quality Chasm report as “avoiding waste, including waste of equipment, supplies, ideas, and energy” (IOM, 2001a, p. 6). While this definition captures the concept of efficiency, to better convey the technical aspects involved with measuring efficiency, the committee also uses a definition put forth by Safavi (2006) and McGlynn (2008): maximizing performance (health care outcomes) by producing the best possible outputs from a given set of resources or inputs. Efficiency measurement includes optimal management of resources (such as administrative, operational, and clinical policies and practices) in order to maximize health care value (Bentley et al., 2008). Efficiency is only one aspect of value-based care. Assessing efficiency is a distinct process that focuses solely on the objective use of resources (e.g., human labor, supplies, devices, money) relative to producing health care outcomes (e.g., hospital discharge, clinical examinations). For instance, measuring efficient performance could mean assessing the number of health care professionals required to properly execute a surgical procedure. Unlike value, it does not include aspects of patient-centeredness or valued patient experiences (for which there are limited metrics) nor is it always equated with comparative-effective analysis, which is another way to assess value. Efficiency was previously omitted from the original framework recommended in Envisioning the National Healthcare Quality Report on the grounds that it was “outside the scope of the Quality Report and will be better addressed by specific efforts designed to face the considerable methodological and measurement challenges  This committee has been informed by AHRQ staff that the 2009 NHQR will include data on insurance and underinsurance status. 

48 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS involved” (IOM, 2001b, p. 66). Nine years later, growing costs and purchaser concern with value have created an increased level of interest in measures of efficiency for the health system. As of 2008, the United States spent 16.2 percent of its gross domestic product (GDP) ($2.3 trillion) on health care (CMS, 2010), a total that is projected to reach nearly 20 percent of the GDP (an estimated $4.3 trillion) by 2017 (Keehan et al., 2008). The committee, therefore, agrees that the contribution of efficiency to health care value and quality cannot be ignored and that this component must be more comprehensively addressed in the NHQR and NHDR. AHRQ first attempted to address the component of efficiency in the 2007 NHQR, yet efficiency remains an underdeveloped aspect of the report for which AHRQ has specifically requested guidance. In assessing efficiency, it is important to note that much of the research on health care efficiency suggests that cost and quality are not necessarily correlated (Fisher et al., 2003; Roski et al., 2008; Scholle et al., 2005; Solberg et al., 2002): the amount of money or resources spent on health care is not always indicative (or predic- tive) of the quality of services received or outcomes achieved (Weinstein and Skinner, 2010). Examples show that some of the most cost-efficient delivery of health care services is occurring in settings with the highest quality care, providing models for others of how to attain efficient and high-quality care that offers high value (Cantor et al., 2007; The Commonwealth Fund Commission on a High Performance Health System, 2008). Yet there are examples that demonstrate the contrary, where higher total per capita state spending on health care is correlated with better quality care (Cooper, 2009a). The complexity implied in these results illustrates the challenges in providing national measures of efficiency. To better understand how efficiency can be measured, it is useful to refer to Bentley and colleagues’ description of the different types of waste in the U.S. health care system. Equating waste with inefficiency, they break down the different aspects of efficiency in the system into three main components: administrative, operational, and clinical: Administrative waste is the excess administrative overhead that stems primarily from the complexity of the U.S. insurance and provider payment systems (e.g., billing/claims processing, sales/marketing practices, compliance pro- cedures, benefits design), operational waste refers to other aspects of inefficient production process (e.g., unnecessary or duplicative procedures, use of defective devices that cause errors, or wasted time transporting people or materials), and clinical waste is created by the production of low-value outputs (e.g., overuse of certain procedures). (Bentley et al., 2008, p. 632) Because outputs are always considered when evaluating efficiency measures, there is a distinction to be made between efficiency measures and measures of cost. Cost measures consider resource consumption (the inputs used) relative to costs without consideration, or in isolation, of the results produced (i.e., resources used by unit price) (AQA, 2009; Krumholz et al., 2008). Efforts to incorporate quality outcomes (whether a patient’s health outcomes or a provider’s performance outcomes) in the construction of efficiency measures are underdeveloped, and significant questions have been raised regarding the use of these measures for public reporting, tiered network design, or pay-for-performance (McGlynn, 2008). Nonetheless, some cost and efficiency measures being used may help suggest opportunities for development of this area in the NHQR and NHDR (see Appendix D). This committee encourages the development of efficiency measures that determine health outcomes as an output. McGlynn’s systematic review identifies two different types of outputs, or products, of the health care system: health services (e.g., visits, drugs, admissions) and health outcomes (e.g., preventable deaths, functional status, blood pressure control) (McGlynn, 2008). The review notes that the vast majority of efficiency measures from the examined literature focused on health services as the output, and that only 4 (out of 250) used health outcomes as the desired end. The committee agrees that ideal assessments of efficiency would use health outcomes as the outputs of interest, as the goal of high-value care is not merely to provide inexpensive care. The dearth of such efficiency measures deserves attention, and their development in the future could be an area that AHRQ plays a role in supporting. Involvement in this task will be important because a number of unresolved methodological issues persist regarding the creation of credible and reliable efficiency measures (e.g., how to incorporate quality outcomes, ensuring reliability of measurement, attribution of providers, and validating risk-adjustment methods) (Hussey and McGlynn, 2009). 

UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 49 Considerations for Reporting Efficiency Measures The committee acknowledges the inevitable trade-off in reporting measures that capture information at a national level rather than at a more local or organizational level; the more national level a measure is, the more useful it might be to policy makers and the less useful it might be to health care providers or community-level decision-makers. Likewise, the more local or organizationally specific measures are, the more the reverse is true. However, the committee agrees that as national reports, the NHQR and NHDR should continue to primarily focus on reporting system-level (state and national) efficiency measures that reflect a broader perspective. Additional data relevant to other stakeholders (e.g., providers, payers), or reported at a more local level, could be presented via online mechanisms, derivative publications (e.g., fact sheets), or links to other source data (e.g., CMS). AHRQ should begin presenting cost and efficiency measures in both the NHDR and the NHQR and stratify these measures in ways that illustrate the variation in care for different populations. Such stratification will be useful because significant differences have been found regarding the use of health care services among different populations. For example, non-Hispanic Whites have high rates of overuse for many procedures including coronary revascularization (Epstein et al., 2003), typanostomy tubes (Kogan et al., 2000), and use of antibiotics (Gonzalez et al., 1997). In comparison, African Americans, and in some cases Latinos, have higher rates for theoretically avoidable procedures (e.g., treatment of late stage cancer, limb amputations) and inappropriate use of emergency department visits and hospitalizations for avoidable conditions (potentially due to neglected prevention screen- ings and disease management) (Fiscella, 2007; Shavers et al., 2009). Reporting such findings is informative for promoting more targeted quality and disparities interventions. Care Coordination The IOM has previously identified care coordination as 1 of its 20 national priorities for improving quality and as a primary area for performance measurement (IOM, 2003a, 2006). Other organizations, including CMS, WHO, The Commonwealth Fund, NQF, and the NPP, have also identified care coordination as a valuable component for enhancing health care delivery and patient experiences (CMS, 2008b; The Commonwealth Fund Commission on a High Performance Health System, 2006; NPP, 2008; NQF, 2009; WHO, 2008). Increasing evidence shows that fragmented or uncoordinated care often hinders optimal patient care. Suboptimal care coordination can refer to poor transitions at hospital discharge (Coleman et al., 2007), inadequate reconciliation of medications (NPP, 2008), and inadequate communication between primary care physicians, specialists, and other health care providers that can lead to contradictory messages or instructions for patient care. These gaps contribute to errors, adverse events, and avoidable costs including avoidable hospitalizations and unnecessary duplication of tests and procedures (Bodenheimer, 2008; Epstein, 2009; Wolff et al., 2002). Consequently, the committee feels that care coordination is sufficiently important for providing quality care, and highlights it as a separate framework component. In a well-coordinated system, information for decision-making and care provision is shared across providers and settings so that integrated and well-communicated care occurs seamlessly throughout a patient’s care experi- ence (AHRQ, 2007). Efforts to coordinate care occur within a variety of health care environments (including across public and private sectors) and aim to improve patient outcomes and reduce health care spending (AHRQ, 2007). Care coordination programs have been found to reduce readmissions in hospitals, increase length of time between discharge and readmission, improve patient and caregiver communication (AHRQ, 2007; Naylor et al., 2004), improve patient satisfaction with care received (Neumeyer-Gromen et al., 2004), and improve health outcomes (Foy et al., 2010; Peikes et al., 2009; Wadhwa and Lavizzo-Mourey, 1999). Most of these programs address complex chronic diseases and aim to reduce the costs associated with these conditions (CMS, 2009a). That said, there is reason to believe that care coordination can benefit all populations and individuals (Starfield and Shi, 2004). Involving the patient in information exchanges and decision-making is another aspect: Care coordination is a function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time. Coordination maximizes the value of ser- vices delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes. (NQF, 2006) 

50 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS Care coordination’s importance as an emerging area for measurement is further supported by its potential to reduce costs to the health care system. While evidence of cost reduction is mixed, in some instances, increasing the integration of services or coordination of care among multiple settings has been demonstrated to be cost-effective (AHRQ, 2007; Choudhry et al., 2007; Neumeyer-Gromen et al., 2004; Peikes et al., 2009; Smith et al., 2007). Such findings are particularly significant given that 10 percent of individuals in the U.S. account for 70 percent of total health care expenditures (Monheit, 2003). In other instances, however, care coordination programs have not been shown to provide any cost savings (Peikes et al., 2009; Wadhwa and Lavizzo-Mourey, 1999). In spite of the mixed empirical findings, the committee believes that care coordination, because of the poten- tial to improve health outcomes and patient experiences and lower costs, is an important foundational element of quality across the spectrum of care and contributes to each of the other care components (e.g., effectiveness, safety, patient-centeredness). Thus, care coordination should be monitored through reporting in the NHQR and NHDR. Although AHRQ is expected to report on a number of care coordination measures in the 2009 NHQR and NHDR, some measures are intended to appear only once due to limitations in AHRQ’s data sources. Among those measures being planned for reporting include: integration of information (receipt of test results, doctor with infor- mation about care from specialists, and other providers in practice with enough information about an individual to provide care), transitions of care (complete written discharge instructions, inadequate discharge information), and perception of care coordination. Reporting of these measures is an improvement, and the committee believes that AHRQ should continue to report care coordination measures in future reports, giving the topic appropriate attention in a separate chapter. Additional suggestions for reporting care coordination measures can be found in Appendix D. Capabilities of Health Systems Infrastructure Ensuring well-coordinated, high-quality health care requires supportive systems infrastructure. Such an infra- structure means having information systems in place for data collection, quality improvement analysis, and clinical communication support. Additionally, systems infrastructure includes having an adequate and well-distributed workforce in place, and the organizational capacity to support emerging models of care, cultural competence services, and ongoing improvement efforts. Adequate systems infrastructure for various care models helps pro- mote and sustain performance improvement and has the potential to increase system efficiency by streamlining administrative, operational, and clinical processes, and reducing duplication of work (Bodenheimer and Grumbach, 2003; Bodenheimer et al., 2002, 2009; Grumbach, 2003; Grumbach and Bodenheimer, 2004). Conversely, a lack of system capabilities can disadvantage specific populations (e.g., rural populations with fewer available health care professionals, minority populations served by providers without health information technology [HIT] support). Because many of the performance measures for infrastructure capabilities are still developing, the committee encourages further investigation and evaluation of measures in this area. Among the infrastructure capabilities that could be further evaluated for reporting in the national health care reports are care management processes, the adoption and use of HIT, workforce distribution, and the relevance of these capabilities to disparity populations. Integrated Delivery Systems Growing evidence highlights the benefits of integrated delivery systems on system efficiency and patient outcomes (Bradley et al, 2005; Coleman et al., 2009; Enthoven, 2009), including integrated systems that promote cultures of safety and team-based practices (Shortell et al., 2004; Singer et al., 2009). Examples of effective integrative models of care include the patient centered medical home (PCMH) and Wagner’s chronic care model (CCM). Each promotes the collaboration of various health care professionals, within and across settings, to provide continuous, patient-centered care. A PCMH is defined as “a team-based model of care led by a personal [primary care] physician who provides continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes” (American College of Physicians, 2010). Medical homes enhance access to care through “open schedul-  Personal communication, Ernest Moy, Agency for Healthcare Research and Quality, October 13, 2009. 

UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 51 ing, expanded hours, and new options for communication between patients, their personal physician, and practice staff” (The Patient-Centered Primary Care Collaborative, 2007). One study has shown that disparities in health care quality can be diminished or eliminated through clinical practices (e.g., ready telephone access, availability of medical care or advice on weekends/evenings, organized and timely office visits, provider continuity) (Beal et al., 2007). Similarly, the CCM promotes health systems whose structure enables community-based services, support for self-management of care, information support systems, and delivery system design (Improving Chronic Care Illness, 2010). The element of information support systems is particularly important for these models of care, as it provides continuity in patient records and clinician communication. HIT Infrastructure As the future of health care becomes more electronically driven, adequate HIT systems will increasingly pro- vide a foundation for tracking quality improvement in care delivery and patient outcomes. Although the adoption of an HIT system is no guarantee of better health care quality outcomes, and more work is needed to determine its impact on quality improvement, the increased and more efficient use of HIT can make available additional sources of valuable data on clinical outcomes (Arrow et al., 2009). Appropriate HIT represents a supportive foun- dation for new health care models (e.g., the CCM and PCMH) and payment reforms (e.g., pay-for-performance and value-based purchasing) (Bodenheimer et al., 2002; The Patient-Centered Primary Care Collaborative, 2007). The adoption and use of HIT as a tool to manage costs and improve the quality of care delivered (Balfour et al., 2009) has been shown to help reduce medical errors and adverse events, enable better documentation and file organization, provide patients with information that assists their adherence to medication regimens and scheduled appointments, and assist doctors in tracking their treatment protocol (Balfour et al., 2009; Herzer and Seshamani, 2009; Keenan et al., 2006; Keyhani et al., 2008; O’Connell et al., 2004). The committee recognizes, though, that not all aspects of HIT adoption have resulted in positive effects. Systems that integrate poorly with other informa- tion systems may be more time-consuming to use or may unnecessarily duplicate efforts (Campbell et al., 2006). Many electronic health record (EHR) systems that providers currently use have little, if any, interoperability with one another, creating an inability to share information between providers (Improving Chronic Care Illness, 2010). Furthermore, heavy reliance on these systems may affect general provider communication skills and the occurrence of face-to-face interactions among clinicians or with their patients (Ash et al., 2007). The proposed requirements for receiving incentive payments under the HITECH Act include the collection and reporting of race, ethnicity, and language data for at least 80 percent of Medicare or Medicaid patients seen by that hospital or provider (CMS, 2009b, pp. 50, 55, 69, 77-78). Each hospital or provider seeking a HITECH incentive payment will have to provide patient quality data stratified by race, ethnicity, and language (CMS, 2009b, pp. 52, 56, 83). As these hospitals and providers implement HIT systems, and as states build health information exchanges to share these data, the nation’s overall capacity for quality data collection and reporting by race, ethnicity and language will dramatically increase. These additional data will provide a stronger basis for identifying cultural competence needs and other disparity gaps. Such endeavors highlight the advantage of having solid infrastructure capabilities from which the national healthcare reports will likely benefit. The adoption of HIT in the United States is relatively low. Evidence suggests that only 17 percent of physicians in ambulatory care environments have EHR access (RWJF et al., 2008), and a study of acute care hospitals shows that only 1.5 percent of those surveyed have a comprehensive EHR system (i.e., present in all clinical units) (Jha et al., 2009). Nevertheless, the need to establish such systems has gathered momentum from the HITECH portion of the American Recovery and Reinvestment Act of 2009 (ARRA). In 2009, the federal government invested $49 billion for HIT, most specifically for EHRs, but also for e-prescribing, quality reporting, and health information exchange (Chang, 2009). HITECH, which focuses on quality, promotes HIT as a means to improve health outcomes and efficiency of health care systems (Blumenthal, 2009).  American Recovery and Reinvestment Act of 2009, Public Law 111-5 § 4101, 111th Cong., 1st sess. (February 17, 2009). 

52 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS Health Care Workforce The health care workforce is another aspect of systems infrastructure on which the NHQR and NHDR should report. Considered the backbone of the health care system, the workforce is comprised of all health care providers, from physicians, dentists, and nurses, to laboratory and pharmacy technicians, to nursing home staff. Ensuring a sufficient number of providers is important for the health care delivery system and can be an indicator of the quality of care delivered. For example, Cooper examined the supply of physicians in various states relative to reported state rankings of quality care and found that the total supply of physicians (both specialists and primary care) was associated with the quality of care delivered (Cooper, 2009b). Other studies demonstrate that the ratio between nurses and patients in a given organization can also impact the quality of care delivered (Gordon et al., 2008; Kane et al., 2007; Needleman et al., 2002). Currently, staffing shortages are a concern for several physician specialties (AMA, 2009; IOM, 2008), nurses (Gerson et al., 2005), and other health care professionals (HRSA, 2009). Ensuring a large enough and appropriately distributed workforce to respond to expected increases in patient demand (IOM, 2008) will be an important task. The implications of shortages are illustrated by recent data that indicate access to primary care has been declin- ing, in part due to an emerging primary care workforce shortage (Bodenheimer et al., 2007). A significant number of primary care physicians cannot and will not accept new patients (CDC, 2007). Combined with the aging of the baby boomer population, shortages of primary care and other health care professionals are expected to remain in many areas of the country (IOM, 2008). The ratio of providers per 100,000 has been widely used to estimate provider shortages in geographic areas (HRSA, 2009). For example, there are numerous parts of the United States that are designated as medically under- served areas or populations (MUA/Ps) as well as areas designated as health professional shortage areas (HPSAs) (HRSA, 2009), where the distribution of health care professionals or sites available to serve populations are lower than what is recommended. Southern and mid-western states tend to have the highest number of HPSAs compared to other regions of the country (HRSA, 2010). Reporting some data on these designated underserved areas, per- haps at the state level, may help inform where additional action could be taken to improve delivery of or access to care. Furthermore, analyzing these data in conjunction with information on receipt of health care services and patient outcomes would be the type of informative analyses that the Future Directions committee would like to see provided in the NHQR and NHDR. AHRQ could provide other assessments of availability for various types of health care professionals to better inform this issue, including but not limited to information on primary care and specialist physicians, nurses, mental health, and dental care professionals. Infrastructure to Support Access and Utilization The significance of health infrastructure capabilities can be of particular importance for underserved areas and priority populations. Appropriate information systems and a well-trained workforce are key elements for providing access to needed care in the form of enabling services, such as patient outreach, patient navigation services, and training in cultural competence (Fiscella, 2007; HRSA, 2007; Ro et al., 2003). Knowledge of a patient or group’s language and cultural needs better equips providers to deliver high-­quality care and communicate effectively with patients. Currently, there are limited national data regarding linguistic competency (among providers or patients) or the use of various interpreter services (e.g., in-person translation, telephonic and video health care interpretation, translation of documents). Yet, the presence of these services in health care settings will be increasingly important as the population of the United States increases in diversity and potentially includes more individuals with limited English proficiency (Betancourt et al., 2005; Moreno et al., 2009). For example, with the U.S. Hispanic population projected to comprise 30 percent of the population by 2050 (U.S. Census Bureau, 2008), reporting on measures that capture the persistence of linguistic barriers will be important. AHRQ currently reports data on a measure of workforce diversity that reflects the racial and ethnic make-up of reported registered nurses, licensed practical nurses, and licensed vocational nurses in the United States, and another measure on the availability of language assistance at the usual source of care for limited English-proficient 

UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 53 adults (AHRQ, 2009a). Striving to report these data at the state level would be even more informative. AHRQ might also further analyze the data reported for the workforce diversity and language assistance measures to determine whether the individuals who receive culturally or linguistically competent care have better outcomes. Since the purpose of performance reporting is to inform how to improve quality care and patient outcomes, analysis that can illuminate these findings will be beneficial. SUMMARY The framework proposed by this committee can be viewed as a building block for AHRQ’s national healthcare reports, as it provides a foundation on which to base the reporting of national health care performance. The addi- tional quality components of access, efficiency, care coordination, and health systems infrastructure capabilities should be viewed as areas in which evidence has shown potential for improving quality care, and progress should be made in how to measure the impact of these components on the delivery system. The committee recognizes that some measures for these additional framework components are still in the developmental stage, but encour- ages AHRQ to foster measure development by highlighting gaps and promoting the research necessary to advance measurement and reporting endeavors. By choosing to identify new framework components for which there are often only developmental measure choices, the Future Directions committee has set a course for looking beyond data availability and encouraging the development of measures and data that may demonstrate greater effective- ness for improving the standard of care. While the committee recognizes that the national healthcare reports are an inappropriate testbed for the cre- ation of actual measures, it believes that AHRQ can play a role in identifying possible areas for future measure development. The committee encourages AHRQ and other entities to identify or develop impactful measures for each of the eight framework components. Areas of research could include establishing more targeted measures for efficiency, or evaluating the evidence of the quality impact of workforce trained in emerging models of care, such as the integrated systems promoted by the PCMH model. Such exploration could help the national healthcare reports be as responsive as possible to desired or developing areas of performance measurement and reporting. The expanded portfolio of measures that may result from applying this proposed framework to the national healthcare reports should reflect the needs of a variety of stakeholders but should not be so large as to unduly tax AHRQ’s resources. To streamline measure selection for the increased number of framework components, reporting on a measure should occur only after it has been subject to the measure selection process proposed by the com- mittee in Chapter 4. The work required to transition the NHQR and NHDR to report on a potentially different set of measures, as dictated by a national set of priorities and the proposed strategies for measure selection, could be significant. To alleviate some of this burden, the committee recommends additional resources (see Chapter 7). REFERENCES Aetna. 2008. Aetna’s high performance provider initiatives. Driving Improvement Opportunities: 2009 Update, November 13, 2009, New York. PowerPoint Presentation. Ahmed, S. M., J. P. Lemkau, N. Nealeigh, and B. Mann. 2001. Barriers to healthcare access in a non-elderly urban poor American population. Health & Social Care in the Community 9(6):445-453. AHRQ (Agency for Healthcare Research and Quality). 2007. Closing the quality gap: A critical analysis of quality improvement strategies, volume 7—care coordination. Rockville, MD: Agency for Healthcare Research and Quality, DHHS. ———. 2009a. Appendix C: Measure specifications. In National Healthcare Quality and Disparities Reports, 2008. http://www.ahrq.gov/qual/ qrdr08/measurespec/ (accessed December 8, 2009). ———. 2009b. National Healthcare Disparities Report, 2008. Rockville, MD: Agency for Healthcare Research and Quality. AMA (American Medical Association). 2009. Physician workforce planning. http://www.ama-assn.org/ama/pub/about-ama/our-people/ member-groups-sections/international-medical-graduates/ama-working-imgs/physician-workforce-planning.shtml (accessed December 8, 2009). American College of Physicians. 2010. What is the patient-centered medical home? http://www.acponline.org/running_practice/pcmh/ understanding/what.htm (accessed February 22, 2010). AQA (Ambulatory Care Quality Alliance). 2009. AQA principles of “efficiency” measures. http://www.aqaalliance.org/files/PrinciplesofEfficiency Measurement.pdf (accessed September 21, 2009). 

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