Future Directions for the National Healthcare Quality and Disparities Reports (2010) / Chapter Skim
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4 Adopting a More Quantitative and Transparent Measure Selection Process
4 Adopting a More Quantitative and Transparent Measure Selection Process
Pages 59-88
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From page 59... ...
. Since 2003, AHRQ has refined its measure set for the national healthcare reports and related products, and the measure set now includes approximately 260 individual measures, including a set of 46 core measures that are more prominently featured in the body of the 2008 NHQR and NHDR.
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From page 60... ...
AHRQ'S APPROACH TO SELECTING MEASURES The measure selection process for the national healthcare reports has been undertaken primarily by AHRQ staff in consultation with an HHS Interagency Workgroup consisting of program and data experts, as well as with some limited external feedback from AHRQ's NAC. AHRQ's Initial Measure Selection Process and Criteria AHRQ's initial selection approach for measures in the NHQR and NHDR began with a call for measures involving all HHS agencies, as well as substantial input from private-sector entities that were solicited by the IOM during the research for its 2001 Envisioning the National Healthcare Quality Report (IOM, 2001)
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From page 61... ...
To select the 46 core measures for the NHQR and NHDR, AHRQ staff and the HHS Interagency Workgroup prioritized measures by the three original IOM criteria and several additional ones. Usability was added as a new primary criterion -- one that is also articulated Additional measures were added to the initial full measure set.
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From page 62... ...
, then AHRQ has tried to present paired process and outcome measures. The Future Directions committee recognizes the limitations of process measures, as does AHRQ, and encourages AHRQ to continue to report paired measures whenever possible.
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From page 63... ...
The Future Directions committee recommends broadening the range of input that AHRQ currently receives, making the process transparent, and incorporating a more systematic and quantitative process for ranking measures. The proposed selection process more closely looks at the gap between current and desired performance levels and the relative value of bridging that gap while also taking equity into account.
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From page 64... ...
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 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.
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From page 65... ...
The status quo did not appear tenable because AHRQ and HHS Interagency Workgroup members have already acknowledged the difficulty of being able to prioritize and eliminate health care quality measures through the current process (other than plans to semi-retire from the 2009 reports process measures that have a greater than 95 percent achievement rate [AHRQ, 2008a]
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From page 66... ...
A precedent for this more formal relationship is the NAC Subcommittee on Quality Measures for Children's Healthcare in Medicaid and Children's Health Insurance Programs that was formed for a specific task -- namely, the identification of an initial core measure set for children under the Child Health Insurance Program Reauthorization Act. This NAC subcommittee includes two members from the NAC but meets separately from the NAC for detailed working sessions. The relationship of the NAC Subcommittee on Quality Measures for Children's Healthcare in Medicaid and Children's Health Insurance Programs is shown in Figure 4-1, and the Future Directions committee envisions the same relationship for the NAC Technical Advisory Subcommittee for Measure Selection for the NHQR and NHDR.
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From page 67... ...
The NAC and its subcommittees -- which would include the proposed NAC Technical Advisory Subcommittee for Measure Selection -- conduct their business in public under the Federal Advisory Committee Act. The fact that these bodies operate in public under this law is an attractive facet of their operation. Federal Advisory Committee Act, Public Law 92-463, 92nd Cong., 2nd sess.
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From page 68... ...
The Future Directions committee is particularly interested in this level of documentation because of its potential value in stimulating creation of an agenda for measure and data source development (including testing additional questions on existing data collection surveys or inclusion of elements in electronic health records) when desirable measures or data are not yet available (Battista and Hodge, 1995; Gibson et al., 2004; Whitlock et al., 2010)
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From page 69... ...
. Steps in the Process and Criteria Figure 4-2 provides a schematic outline of the steps in the Future Directions committee's proposed process for reviewing performance measurement areas -- both for currently reported measures and new measures -- for inclusion in the NHQR and NHDR.
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From page 70... ...
FIGURE 4-2 The Future Directions committee's proposed decision-making process for selecting performance measures for the NHQR and NHDR and identifying measure and data needs. NOTE: The steps noted with an asterisk (*
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From page 71... ...
; the Future Directions committee believes other types of trustworthy study designs can be utilized to establish the evidence base. Scientifically Sound Measure Availability Application of Criterion B, scientific soundness, follows identification of importance and improvability because if the area is not one that is meaningful and important, it will not matter how scientifically sound a measure is.
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From page 72... ...
. See Box 2-3 in Chapter 2 for the Future Directions committee's recommended priority areas; other priorities may emerge in establishing a national health reform quality improvement strategy.
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From page 73... ...
can be separately ranked by applying quantitative techniques such as net health benefit and cost effectiveness analysis; however, data are often not available to stratify every measure by sociodemographic variables, payers, and small area geography. Furthermore, ranking each measure by 15 sociodemographic categories and by multiple geographic variables, for example, may not lead to a consistent ranking pattern.
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From page 74... ...
Given that, the Future Directions committee still encourages some representation of each component. However, over time better data may allow more even application of the quantitative methods across the components and it could turn out that some components will have a greater quality improvement impact than others and thus should become areas of greater focus within the national healthcare reports.
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From page 75... ...
NHQR/NHDR Yes, documents geographic variation (Criterion F) FRAMEWORK COMPONENTS Ranks higher than other PRIORITY AREA: Population Health Yes, has the potential to increase value (Criterion D)
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From page 76... ...
QUANTITATIVE TOOLS FOR PRIORITIZING MEASURES Techniques for assessing and describing relative degree of value and equity/inequity among performance measures and their utilization in prioritizing performance measures for inclusion in the NHQR and NHDR are considered in the discussion that follows. Similarly, the Phase 1 report for Healthy People 2020 indicated that as communities seek to prioritize their own local objectives for improvement, they should try to use more quantitative techniques in the process (Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, 2008a)
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From page 77... ...
Net health benefit. A program's net health benefit is the difference between the health benefit achieved by a program, and the amount of health gain that would be needed to justify the program's costs.
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From page 78... ...
CPB is relevant to prioritizing quality measures based on its ability to quantify the health impact of a measure's associated clinical intervention. Therefore, CPB provides a means for comparisons across different clinical interventions (e.g., mammography versus maintenance-phase medications for depression)
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From page 79... ...
. Prioritizing Measures with High Health Impact and Effective Resource Use To identify measures with the greatest potential value, particularly related to clinical effectiveness measures, the committee examined two strategies that employ health impact analysis and cost-effectiveness analysis.
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From page 80... ...
. This approach is used to quantify the potential value of quality improvement for a given measure by estimating the incremental health benefit gained by a clinical standard of care net of its incremental costs: "the difference between the health benefit achieved by a program, and the amount of health gain that would be needed to justify the program's cost" (Hauck et al., 2004, p.
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From page 81... ...
Meltzer and Chung's paper explores the net health benefit methods and their theoretical applicability to 14 NHQR measures that span different framework components. The strategy can be used to estimate the potential value of improving performance on existing quality measures, which can then be used to prioritize measures for reporting.
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From page 82... ...
The framework components of care coordination and health systems infrastructure capabilities were not assessed using these strategies because measures for these components were not presented in the latest edition of the national healthcare reports. Chapter 3 referenced some studies that indicated potential cost-effectiveness using care coordination and implementing HIT.
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From page 83... ...
In absolute terms, the gap has shrunk from 4 points to 3 points. In relative terms, the African American rate is still double the White rate.
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From page 84... ...
. The Reference Population As Nerenz and Fiscella have noted, the quality measures that matter to the overall population also matter to minority populations (Fiscella, 2007; Nerenz et al., 2006)
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From page 85... ...
2003b. Preliminary measure set for home health in the National Healthcare Quality Report -- request for comments.
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From page 86... ...
2004. Evaluation of the development process of the National Healthcare Quality Report.
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From page 87... ...
Center for Healthcare Policy and Research, University of California, Davis. Presentation to the IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports, March 11, 2009.
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From page 88... ...
1998. Net health benefits: A new framework for the analysis of uncertainty in cost-effectiveness analysis.
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