Summary

The Institute of Medicine (IOM) Committee on Quality Measures for the Healthy People Leading Health Indicators was charged by the Office of the Assistant Secretary for Health to identify measures of quality for the 12 Leading Health Indicator (LHI) topics and 26 LHIs in Healthy People 2020, the current version of the Department of Health and Human Services (HHS) 10-year agenda for improving the nation’s health (see Box S-1 for the complete charge).

HHS referred the committee to two guiding documents: the Consensus Statement of Quality in Public Health (Public Health Quality Forum, 2008) and Priority Areas for Improvement of Quality in Public Health (Honoré and Scott, 2010). To respond to its charge, the committee reviewed these documents along with Healthy People 2020 materials, earlier IOM reports, and reports of other organizations. The two documents provide a definition of quality in public health (see Box S-2); a list of nine quality aims, or “characteristics of quality in public health,” and six priority areas, or drivers of quality improvement in the public health system, which are also part of the committee’s charge. These quality characteristics and drivers for quality improvement are discussed in detail in Chapter 1.

The committee saw its task as helping to identify measures of quality to be used by partners in the health system broadly defined (beginning with public health and health care, plus contributions of other sectors) rather than identifying specific quality measures for specific public health programs. The former involves focusing primarily on intermediate and ultimate outcome measures, while identifying measures for specific programs requires a greater focus on process and intermediate outcomes.



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Summary The Institute of Medicine (IOM) Committee on Quality Measures for the Healthy People Leading Health Indicators was charged by the Office of the Assistant Secretary for Health to identify measures of quality for the 12 Leading Health Indicator (LHI) topics and 26 LHIs in Healthy People 2020, the current version of the Department of Health and Human Services (HHS) 10-year agenda for improving the nation’s health (see Box S-1 for the complete charge). HHS referred the committee to two guiding documents: the Consen- sus Statement of Quality in Public Health (Public Health Quality Forum, 2008) and Priority Areas for Improvement of Quality in Public Health (Honoré and Scott, 2010). To respond to its charge, the committee re- viewed these documents along with Healthy People 2020 materials, ear- lier IOM reports, and reports of other organizations. The two documents provide a definition of quality in public health (see Box S-2); a list of nine quality aims, or “characteristics of quality in public health,” and six priority areas, or drivers of quality improvement in the public health sys- tem, which are also part of the committee’s charge. These quality charac- teristics and drivers for quality improvement are discussed in detail in Chapter 1. The committee saw its task as helping to identify measures of quality to be used by partners in the health system broadly defined (beginning with public health and health care, plus contributions of other sectors) rather than identifying specific quality measures for specific public health programs. The former involves focusing primarily on intermediate and ultimate outcome measures, while identifying measures for specific programs requires a greater focus on process and intermediate outcomes. 1

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2 TOWARD QUALITY MEASURES FOR POPULATION HEALTH BOX S-1 Statement of Task A. Scope The scope of work for this project is to use the nine aims for improve- ment of quality in public health (population-centered, equitable, proactive, health promoting, risk reducing, vigilant, transparent, effective, and efficient) as a framework to identify quality measures for the Healthy People Leading Health Indicators (LHIs). B. Services to Be Performed Task 1: A committee will review existing literature on the 12 LHI topics and the 26 Leading Health Indicators. Quality measures for the LHIs that are aligned with the nine aims for improvement of quality in public health will be identified. When appropriate, alignments with the six Priority Areasa for Im- provement of Quality in Public Health will be noted in the Committee’s report. The report should also address data reporting and analytical capacities that must be available to capture the measures and for demonstrating the value of the measures to improving population health. Task 2: The committee will provide recommendations for how the measures can be used across sectors of the public health and health care systems. a The six priority areas (also known as drivers) are population health metrics and infor- mation technology; evidence-based practices, research, and evaluation; systems think- ing; sustainability and stewardship; policy; and workforce and education. The purpose of measurement is threefold1: assessment, improvement, and accountability. A health department, for example, assesses health in its geographic area to inform community members and other stakehold- ers and to inform resource allocation. Health departments, hospitals, and other organizations use measures for improvement processes at dif- ferent levels (e.g., ranging from program-specific efforts to system- or community-wide). Measures can also be used to demonstrate accounta- bility to funders, partners, legislators, and communities. 1 Some sources collapse two of the three.

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SUMMARY 3 BOX S-2 HHS Definition of Quality in Public Health The HHS Public Health Quality Forum defined quality in public health as “the degree to which policies, programs, services and research for the popu- lation increase desired health outcomes and conditions in which the popula- tion can be healthy” (Public Health Quality Forum, 2008, p. 3). The committee’s charge called for using the nine aims or characteris- tics as a “framework to identify quality measures.” The committee found that the nine quality characteristics in general do not directly lend them- selves to being used as the framework for measures. The committee used as a conceptual framework the Health Outcome Logic Model (see Figure S-1), which is based on the structure–process–outcome framing of Donabedian (2005), but modified to reflect the definition of quality in public health provided in Box S-2. As high-level operating principles outlining the attributes of health systems (broadly defined) that seek to continuously improve quality, the nine characteristics relate primarily to the Resources and Characteristics component of the logic model. The two smaller boxes on the left (Resources and Capacity and Interventions) align with the first two parts—structure and process, respectively—of the Donabedian framework, while the boxes in the mid- dle and on the right (Healthy Conditions and Healthy Outcomes, respec- tively) refer to the third part of the Donabedian framework—outcomes, both intermediate and ultimate or long-term. Different types of metrics— referring to structure, process, and outcome—may be used as measures FIGURE S-1 Health outcome logic model.

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4 TOWARD QUALITY MEASURES FOR POPULATION HEALTH of quality.2 The committee focused on intermediate and ultimate out- comes because the measurements of Resources and Capacity do not di- rectly link to the LHIs, while the specific process measures are numerous and reflect the Interventions actually implemented. The committee used the logic model to help them classify the LHIs and to help select measures of quality related to the LHIs. For example, some of the LHIs, such as Air Quality Index (AQI), fit in the category of Healthy Conditions. The ultimate outcome related to AQI is lower cardi- ovascular and respiratory mortality and morbidity. Other LHIs, such as infant mortality, fit in the category Healthy Outcomes. Measures for Healthy Conditions related to infant mortality include prenatal care, childhood vaccines, and tobacco use. The report outlines an approach to assist HHS in its efforts toward a national framework for quality that goes well beyond health care and clinical primary prevention. The approach, with three findings and six recommendations (see Box S-3, page 6), includes 1. The adoption of a logic model or conceptual framework to help identify loci for measures 2. The adoption of a set of recommended criteria to select measures of quality 3. A system to manage measures (to bring greater coherence and encourage parsimony and efficiency) 4. An entity to endorse measures of quality for the multisectoral health system 5. Consideration of potential uses for measures of quality by differ- ent partners and other contributors to the multisectoral health system The committee does not offer a set of measures for each of the Lead- ing Health Indicators for several reasons, including  The length of time and extent of effort that would have been necessary to develop in-depth literature reviews for each topic and for all 26 indicators (including identifying the best available 2 Two caveats: (1) Only outcome measures that are modifiable through some type of action or intervention can be used as measures of quality. Autism is one such example of a condition that does not yet have evidence-based preventive interventions. (2) It may be easier to describe quality measures for specific defined health care services (e.g., cancer screening), but harder to do so for the broad concept of population health.

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SUMMARY 5 evidence-based interventions for each), to develop a logic model for each LHI that would help identify measures related to each intervention, and to evaluate each measure according to standard, outlined criteria.  The lasting value of developing a framework and process for a continually updated set of measures rather than identifying a static set of measures. Furthermore, many measures of quality relate to the specific interven- tions implemented and are context specific. For this reason, too, describ- ing a process seemed more useful than providing specific examples that would result from applying that process. Because it focused on the 26 LHIs, the committee did not include other issues of great importance to the nation’s health, such as disaster preparedness, the quality of the governmental public health system itself, and poverty as a health determinant. Pertinent to the last example, the Healthy People 2020 chapter on social determinants was under develop- ment at the time the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives conducted its deliberations on the selection of the LHIs. Because of this, the social determinants of health are minimally reflected among the LHIs, but may warrant addi- tional attention at this point in the process of implementing Healthy Peo- ple 2020 (e.g., consideration for adding to the LHIs). The committee also recognizes that the top health indicators at the local level may differ— suicide (a Healthy People LHI) may be a challenge in one community, while hepatitis C infection rates (not a Healthy People LHI) may be a priority concern in another. This is one of the reasons that the committee outlined criteria to be used by different communities to find measures that meet their needs. Given the fast track nature of the committee’s work, the committee conducted a literature review sufficient to enable it to provide a general discussion of potential quality measures for each of the 26 LHIs, with some examples provided in Table 3-1. Furthermore, the committee used LHIs under four topics (tobacco use; maternal, infant, and child health; environmental quality; and nutrition, physical activity, and obesity) to develop case studies building on the Health Outcome Logic Model to show the locus for potential measures at each step along the pathway to the relevant outcome. The committee thus offers a starter set toward a portfolio of measures of quality for the health system. The discussion preceding the four case studies also included an examination of the six priorities or drivers, and where appropriate, the ways in which planners

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6 TOWARD QUALITY MEASURES FOR POPULATION HEALTH and evaluators can reflect on the nine quality aims or characteristics in the process of selecting measures for use. Finally, the committee discussed the relevance of quality measures to a variety of potential users, and the need and opportunities for a level of integration of services, research, data collection, and planning, as appro- priate, between public health agencies and health care delivery organiza- tions, with the goal of improving health outcomes. The committee viewed HHS’s adoption of the Three-Part Aim (better care, lower cost,3 and a healthier population) as creating a bridge between the health care and public health sectors or a platform for beginning to speak the same language and use some of the same metrics. Logic models similar to the one used in this report and the detailed models prepared for the four case studies can be used to explore resources, capacities, and interventions, especially at the local level, and to identify loci for measures, using the selection criteria to meet local needs. In closing, the committee offers suggestions for how measures of quality related to LHIs and, more broadly, for population health, could be used by decision makers, includ- ing government agencies, funders, hospitals and other health care organi- zations, and communities. BOX S-3 Findings and Recommendations Recommendation 1-1: The committee recommends that all partners in the multisectoral health system (public health, health care, community organiza- tions, and others, as appropriate) should adopt as their explicit purpose to continually improve health outcomes of the entire population and the condi- tions in which people can be healthy. The extent to which this purpose is achieved reflects the overall quality of the health system. Finding 2-1: The committee finds that partners in the multisectoral health system currently use a vast and complex array of measures of quality in a manner that seems uncoordinated. Recommendation 2-1: The committee recommends that HHS and its partners in population health improvement (e.g., public health agencies, health care organizations, community organizations) adopt a portfolio of measures of the quality of the multisectoral health system. The portfolio of measures should 3 The committee recognizes that the underlying goal with respect to cost is to control the increase in cost, and not necessarily reduce cost, as that is likely to be unfeasible.

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SUMMARY 7 a. include summary scores reflecting population-level healthy out- comes and healthy conditions; b. balance parsimony with sufficient breadth; and c. inform assessment, improvement, and accountability of the multi- sectoral health system. Recommendation 2-2: The committee recommends that HHS and other relevant organizations adopt the following set of criteria for selecting and pri- oritizing measures of quality for use in population health improvement, includ- ing the Leading Health Indicators: Criteria for conditions or outcomes to be measured a. Reflective of a high preventable burdena b. Actionable at the appropriate level for intervention Criteria for the measures c. Timely d. Usable for assessing various populations e. Understandable f. Methodologically rigorous g. Accepted and harmonized Recommendation 2-3: The committee recommends HHS should ensure the implementation of a systematic approach to develop and manage a portfolio of measures of quality for the multisectoral health system. HHS also should establish or designate a nongovernmental and appropriately equipped entity to endorse measures of quality. Recommendation 2-4: The committee recommends HHS should develop, implement, and support data collection, analysis, and dissemination mecha- nisms and infrastructure for the portfolio of quality measures so they are usa- ble for health assessment and improvement at the national, state, and local levels. Finding 3-1: The committee finds that a. Many of the LHIs are measures of health outcomes or of conditions that can directly affect health outcomes and are, therefore, measures b of the quality of the multisectoral health system. b. The LHIs that meet the definition above of a quality measure can be used for assessment, improvement, and accountability. To be used thus, they must be relevant and measurable at the national, state, and local levels. c. The LHIs reflect conditions or outcomes that directly contribute to the Healthy People 2020 foundation measures (e.g., general health sta- tus, health-related quality of life) and the ecologic modelc that under- lies it, even if these are not explicitly represented among the LHIs. continued

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8 TOWARD QUALITY MEASURES FOR POPULATION HEALTH BOX S-3 Continued Finding 4-1: The committee finds that the concept of a Three-Part Aim de- scribed in the National Quality Strategy could play a growing and important role in the process of establishing population health as an essential area of focus in transforming health care and health in the United States. The com- mittee also finds that additional development is needed by users of the Three-Part Aim to incorporate evidence-based measures representing social and environmental determinants of health, equity, and the concept of total population health. Recommendation 4-1: The committee recommends that HHS convene stakeholders to facilitate the use of measures of quality for the multisectoral health system and their integration into all activities under the Three-Part Aim with a special focus on the social and environmental determinants, equity, and the concept of total population health. a The concept of high preventable burden has two components: high burden and exist- ence of effective interventions. This concept (burden × effectiveness), refers to burden as the absolute burden, not relative burden. In other words, a condition like phenylke- tonuria (PKU) has a high preventable burden if one thinks of the denominator as all people with PKU, but it is a low absolute preventable burden if one uses the entire population. b To illustrate, the rate of adult tobacco use is an LHI, but it can be used as a measure of quality because it gives an indication of the system’s success in implementing evidence-based interventions to reduce use of tobacco. A rate of tobacco use that stagnates could provide an indication of a system that requires attention (an influx of resources, technical assistance in the area of policy analysis and development, collab- oration, etc.) to improve its performance on reducing tobacco use. c The ecological model is a diagram adapted from Whitehead and Dahlgren (1991) by an IOM committee and in Healthy People 2020 planning by HHS to show the array of determinants of health, or the ecology of health as several concentric circles, beginning with individual level factors at the center (biologic and genetic factors); followed by behavior, family, social networks, and communities; followed by broad policies pertain- ing to the determinants of health (education, income, etc.) at the state and national level (see HHS, 2008; IOM, 2003a).