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Making Quality Count
Millions of Americans receive high-quality health care services. The United States has many of the world's finest health care professionals, academic health care centers, and other institutions. Yet, too often, patients receive substandard care. Sometimes they receive too many services or unnecessary services that undermine the quality of care and needlessly increase costs. At other times they do not receive needed services that have been proven to be effective.
The research that provided much of the basis for the 2001 report by the Institute of Medicine (IOM), Crossing the Quality Chasm, goes back several decades to early studies on quality of care, most of which were supported by AHRQ and its predecessor agencies. In its report, the IOM pointed out that quality problems occur across all types of cancer care and in all aspects of the process of care. For example, the IOM report described "underuse of mammography for early cancer detection, lack of adherence to standards for diagnosis, inadequate patient counseling regarding treatment options, and underuse of radiation therapy and adjuvant chemotherapy following surgery."
Poor quality care leads to patients who are sicker, have more disabilities, incur higher costs, and have lower confidence in the Nation's health care system. There is great potential to improve the quality of health care provided to Americans, and AHRQ is committed to this goal. We are working to develop and test measures of quality, identify the best ways to collect, compare, and communicate data on quality, and widely disseminate information about effective strategies to improve the quality of care.
Following are examples of AHRQ-supported research now in progress that focuses on improving health care quality:
- Harvard University researchers are assessing the quality of care provided to HIV patients by clinics receiving Title III Ryan White funds, changes in care subsequent to quality training, and the organizational characteristics and policies that facilitate or hinder such changes, such as providers' attitudes and beliefs, formal training, knowledge, and experience. They will assess the effects of an intensive quality improvement project involving multiple HIV care sites and identify clinician and clinic characteristics that predict the most improvement and sustained change.
- Diabetes affects 10 million patients, costs $100 billion annually, and causes significant complications, including vision problems, kidney problems, problems with the nervous system, and cardiovascular disease. In this 3-year project underway at the University of Chicago, researchers are testing two models of quality improvement applied to diabetes care in community health centers (CHCs): one, a collaborative approach including intensive, extended training in total quality management and a chronic disease model; and two, a control model consisting of basic brief training in total quality management and a chronic disease model. The long-term goal is to improve the quality of care and outcomes of poor, vulnerable patients with diabetes who receive their care at rural and urban CHCs, which are critical sites of primary care for 10 million Americans who reside in medically underserved areas.
- A quality improvement study on identifying and treating dangerous levels of jaundice in newborns has contributed to the issuance of a guideline by the American Academy of Pediatrics, which has been advising the research effort. In addition, the Joint Commission on Accreditation of Healthcare Organizations has issued a "sentinel event alert," suggesting that many gaps in quality of care can be seen as patient safety issues. Jaundice is a very frequent condition in newborns that, rarely, can become a devastating illness called kernicterus, producing levels of developmental disability that may not be apparent for months or years. Jaundice occurs when the developing liver produces levels of bilirubin beyond the ability of the infant's body to process, damaging the brain. The condition is also related to dehydration, gastroenteritis, and inadequate nutrition. Shorter hospital stays are thought to create discontinuities in care that occur just when bilirubin levels may be peaking. The researchers are attempting to find feasible and effective interventions that will ensure reliable identification and treatment of dangerous bilirubin levels. The study, which will use this condition to explore quality improvement in complex health care organizations, is being carried out in cooperation with Blue-Cross-Blue Shield of Texas and the Henry Ford
Examples of recent findings from AHRQ-supported research on improving health care quality include:
- Researchers at the University of Alabama have developed and tested a straightforward statistical method for creating quality benchmarks that respond to both level and volume of performance. The method, called Achievable Benchmarks of Care (ABCs), reduces the influence of apparent high performers, such as physicians, whose ratings apply to very small numbers. If a physician were to have only one diabetic patient, for example, performing a foot exam on that single patient might not be a good indication of routinely high quality. The artificially high indicator, if it became the benchmark, was thought to reduce the motivation of other physicians to attain the benchmark level. ABCs have been tested in feedback to physicians on care for diabetes and several other conditions. In most cases, ABCs have been shown to result in improved quality.
- A catalogue has been developed of over 300 quality indicators for mental health and substance abuse services, providing information on the evidence base and the current users of these methods. The Harvard-based researchers have designed a system for Web access for service providers looking to improve the quality of care they deliver.
- When county emergency medical service (EMS) administrators in Southern California decided to include airway intubation for children among the procedures used by paramedics on ambulances, as it is for adults, they sought out a pediatric emergency physician from the Harbor-UCLA Medical Center in Torrance and asked her to develop a training program for the paramedics. As she examined the task, she became aware that there was no evidence that intubation was an effective replacement for bag-valve-mask resuscitation for children in respiratory distress. Working with all the ambulance providers in Los Angeles and Orange Counties, the researcher developed a plan for a randomized, controlled trial, which was carried out with support from the Health Resources and Services Administration and the Agency for Healthcare Research and Quality. The study found that in comparison with the bag-valve-mask method, intubation did not improve outcomes, had a high risk of error, and seemed of questionable value for children in ambulances. The county has revised its plans, and EMS providers nationally have taken these findings into account in administering their systems.
Using Research Findings to Improve Quality of Care
Thousands of Medicare patients with atrial fibrillation (AF) can benefit from a new quality improvement tool developed with support from AHRQ. Findings from a second study can be used to improve end-of-life care by encouraging more discussions between terminally ill HIV patients and their doctors.
Atrial fibrillation. Researchers found that their new CHADS2 method for predicting risk of stroke in patients with AF is more accurate than existing methods. CHADS2 may be especially helpful for identifying low-risk patients who, by taking aspirin, can avoid the office visits, expense, and risks associated with warfarin, which carries a risk of bleeding.
End-of-life discussions. Half of all HIV-infected people in the United States—especially blacks, Hispanics, injection drug users, and people with low education—never talk about end-of-life care with their doctors. Such discussions could improve physicians' understanding of the types of care their patients want when they are very ill and close to death, and they may lead to designation of a surrogate to make decisions when the patient is too ill to
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Patient Safety and Reducing Errors in Medicine
The November 1999 report of the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System, focused a great deal of attention on the issues of medical errors and patient safety and showed that a wide gap exists in the quality of care people receive and the quality of care that we as a Nation are capable of providing. The report indicated that as many as 44,000 to 98,000 people die in hospitals each year as at the result of medical errors. Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country.
More people die from medical errors than from automobile accidents (43,458), breast cancer (42,297), or AIDS (16,516). It is estimated that about 7,000 people each year die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries.
Although the increased public attention on this issue is a recent phenomenon, AHRQ has recognized for some time that reducing medical errors is critically important for improving the quality of health care. In 1993, the Agency published one of the first reports focused on medical errors. This landmark report noted that 78 percent of adverse drug reactions were due to system failures, such as the misreading of handwritten prescriptions. Subsequent studies sponsored by AHRQ have focused on the detection of medical errors, investigation of diagnostic inaccuracies, the relationship between nurse staffing and adverse events, computerized adverse drug event monitoring, and computer-assisted decisionmaking tools to reduce the potential for errors and improve safety.
Americans are very concerned about medical errors. According to a national poll conducted by the National Patient Safety Foundation:
- 42 percent of respondents had been affected by a medical error, either personally or through a friend or relative.
- 32 percent of the respondents indicated that the error had a permanent negative effect on the patient's health.
The results of an AHRQ/Kaiser Family Foundation survey found that more than 60 percent of the respondents believe there is a role for government in promoting, monitoring, and providing information about the quality of care provided by doctors, hospitals, and health plans.
In FY 2001, AHRQ invested $50 million in 94 new research grants, contracts, and other projects to reduce medical errors and improve patient safety. This effort represents the Federal government's largest single investment in research on medical errors. These projects will address key unanswered questions about when and how errors occur and provide science-based information on what patients, clinicians, hospital leaders, policymakers, and others can do to make the health care system safer. The results of this research will identify improvement strategies that work in hospitals, doctors' offices, nursing homes, and other health care settings across the Nation. AHRQ's $50 million investment is the first phase of a multiyear effort.
Examples of funded projects in the six major categories of AHRQ's FY 2001 patient safety initiative follow.
- Collecting and reporting medical errors data. For example, State health officials in New York and Massachusetts will examine how to improve State-mandated reporting of errors. A project at Harvard Pilgrim Healthcare will evaluate data collected from more than 16,000 primary care physicians participating in 10 of the Nation's leading HMOs to identify medication errors and test ways to prevent them.
- Using computers and information technology to prevent medical errors. Researchers at the University of Alabama at Birmingham and Creighton University in Omaha will test whether the use of hand-held computers with decision support systems can reduce medical errors in primary care clinics. At Montefiore Medical Center in New York City, researchers will use computer simulation tools to train surgery residents and to identify, quantify, and analyze errors and "near misses."
- Working conditions and patient safety. Researchers will examine how staffing, fatigue, stress, sleep deprivation, organizational culture, shift work, and other factors can lead to errors. For example, researchers at the University of California, San Francisco, will assess the relationship between daily changes in the working conditions in hospitals—including nurse staffing ratios, workload, and skill mix—and medical errors.
- Innovative approaches to improving patient safety. One project involves creation of a Center of Excellence in patient Safety Research at the University of Texas in Houston that will apply lessons learned from crew resource management in aviation to build stronger team work in health care. Another project at the University of Chicago will examine how to improve communication and other aspects of team work.
- Disseminating research results. Several large health care provider organizations—including the American Hospital Association's Hospital Research and Educational Trust, the American College of Physicians-American Society of Internal Medicine, the American College of Surgeons, and the National Patient Safety Foundation—will partner with AHRQ to disseminate results from patient safety research and test the effectiveness of innovative educational strategies for clinicians. The goal is to better equip health care providers to deliver safe patient care. Another project will study ways of sharing information modeled on hospital and medical school "morbidity and mortality" conferences.
- Other patient safety initiatives. These include activities to expand the evidence base on what works and doesn't work in improving safety; meetings of State and local officials to advance local and regional patient safety efforts; funding for small businesses to explore new products to help improve safety; and other initiatives.
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Working Conditions and Quality of Care
Increasing our understanding of how working conditions affect health care workers, the risks for errors, and the quality of services provided to patients is of major importance to the health care industry. Recent efforts to reduce costs and streamline the delivery of care have led to significant changes in the health care workplace. The experiences of other industries demonstrate that differences in the equipment and physical characteristics of the workspace, changes in work responsibility and process, and differences in staffing levels can affect the quality of the products or services provided. For example, research on working conditions in the aviation industry has provided evidence of the relationship between aviation safety and work hours, including the effect of factors such as fatigue, lack of sleep, and shift work.
Despite the importance of these factors, there has been scant research focused on the importance of the quality of the workplace environment—not only for worker satisfaction, worker health, and the avoidance of disability, but also for the quality and productivity of the work performed. Workplace factors, including the way work is organized and staffed, may pose a threat, not only to the health and well-being of workers, but also to the quality of care they provide to patients and the safety of the patients.
In FY 2001, AHRQ funded 30 projects that will examine the effects of working conditions on health care workers' ability to provide safe, high-quality care in ambulatory, inpatient (both hospital and long-term care institutions), and home care settings. Examples of the critical issues to be addressed include:
- Effects of extended work hours, sleep deprivation and fatigue, and stress on residents and nurses working in hospital-based settings.
- Relationship between working conditions—such as nurse to patient ratios, workload, and skill mix—and the occurrence or near occurrence of medical errors or adverse events.
- Impact of workplace characteristics, organizational culture, and teamwork on the safety, quality, and outcomes of care in inpatient settings, specifically intensive care units and surgical settings.
- Relationship between nursing home working conditions—such as staffing levels, job design, and job satisfaction—and worker outcomes, patient outcomes, and quality of care.
- Impact of financial incentives and the work environment on the quality of care in both ambulatory and inpatient settings.
- Effects of employee training, satisfaction, and understanding of patient safety on patient outcomes and quality of care.
Working conditions—The characteristics of the health care workplace and workforce, including the physical environment, workflow design, staffing, and organizational culture.
Health care workers—Workers, including physicians, nurses, pharmacists, physician assistants, nursing assistants, and emergency medical technicians who provide direct care to patients in health care settings such as hospitals, ambulatory care settings, and nursing homes.
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Helping Patients and Consumers Use Quality Information
Americans are demanding greater value and quality in their health care. In today's rapidly changing health care environment, consumers need solid, reliable information to help them choose among health care plans, practitioners, and facilities. They also need information to help them participate more actively and effectively in their personal health care decisions. AHRQ is playing a unique role in providing the information consumers want and need to help them get the best possible health care.
Consumer Assessment of Health Plans
The Consumer Assessment of Health Plans Study (CAHPS®) is an easy-to-use kit of survey and reporting tools that provide reliable information to help consumers and purchasers assess and choose among health plans. Some recent CAHPS® accomplishments include:
- AHRQ and the Centers for Medicare & Medicaid Services (CMS) collaborated with the CAHPS® consortium to develop a Medicare CAHPS® Disenrollee Survey of beneficiaries enrolled in managed care plans that was fielded by CMS. Answers to the survey allow researchers to distinguish disenrollment decisions related to quality (e.g., limited access to specialists) from those that are unrelated to quality (e.g., enrollee moving out of the plan service area).
- Working in collaboration with the California Health Care Foundation and the Pacific Group on Health, the CAHPS® team has developed a version of CAHPS® to assess care given at the group practice level. This activity is in response to strong consumer interest in the ability of physicians in group practices to provide high-quality care.
- AHRQ and CMS are collaborating in the development of a CAHPS® survey to obtain consumers' assessments of health care and services received in nursing homes. Survey development and sampling and data collection procedures were completed in FY 2001. Additional testing will be carried out in FY 2002.
Making Quality Count for Patients and Consumers
AHRQ has funded three demonstration projects to enhance the health care systems' ability to provide patients with information on health care quality. Total projected funding for these three projects is $3.4 million. The researchers will develop and test methods and models for developing information on quality for consumer and patient use in health care decisions, as well as evaluate the impact of strategies to provide information about quality to consumers and patients. The newly funded projects are:
- Information about quality in a randomized evaluation. This project underway at the University of California, Davis, will identify factors associated with consumers' use of employer-disseminated information on health plan and medical group performance and determine if and how consumers use or do not use such information during open enrollment.
- Helping elders include quality in health plan choice. This project, which is underway at Research Triangle Institute, will develop and evaluate an integrated information and decision support strategy for use by employee benefits staff in counseling employees aged 60 to 64 about their Medicare plan options.
- Quality factors in nursing home choice. Researchers at the University of Colorado Health Center will develop and evaluate information strategies to help consumers use quality factors in making nursing home choices.
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National Healthcare Quality Report
AHRQ is developing the first-ever annual report on the quality of health care in the United States, as called for in the Agency's reauthorization legislation, which became law in 1999. The goal of the report, now in its early design phase and due out in 2003, is to provide a clear, easily understood picture of the quality of health care in America. The development of a national report on health care quality is an important step in improving the quality of the Nation's health care system and addressing the health care needs of priority populations. Go to "Research on the Health Care of Priority Populations" in this report to learn about AHRQ's program priorities and activities focused on women, children, and minorities.
The project is being led by AHRQ in collaboration with the Centers for Disease Control and Prevention's (CDC's) National Center for Health Statistics. An interagency work group will develop the final content and design of the report. Other members of the work group include the Department's Office of the Assistant Secretary for Planning and Evaluation, CDC, the Centers for Medicare & Medicaid Services, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration.
As of FY 2001, work on the National Healthcare Quality Report (NHQR) is proceeding as follows:
- A 14-member Institute of Medicine (IOM) committee of leading experts in quality and quality measurement was formed and recommended that the NHQR quality monitoring system be based on a conceptual framework that addresses both dimensions of patient care (e.g., safety, effectiveness, patient centeredness, timeliness, equity) and patient needs (e.g., staying healthy, getting better, living with illness, coping with end-of-life issues).
- AHRQ initiated a call to relevant Federal agencies to identify candidate measures to fill in the conceptual framework. The IOM issued a complementary call for measures to the private sector. Over 400 measures were submitted. An interagency workgroup is evaluating the candidate measures for inclusion in the first report, using criteria suggested by the IOM (e.g., importance, scientific soundness, feasibility).
- AHRQ is identifying and modifying existing data sources to support the NHQR. For example, AHRQ is enhancing its Medical Expenditure Panel Survey (MEPS) by increasing the size and geographic dispersion of the sample and adding quality-related content. AHRQ also has begun a project to look at private-sector data sources, which likely will take on added importance in the future.
- AHRQ is conducting market research to identify the needs of potential audiences for the report and to develop a report design that will meet those needs. We also have begun a project to review existing report systems to help in the development of the NHQR. Future plans include the creation of a Web-based product that will allow users to narrow the focus from national data to get detail on quality performance measures for population subgroups and geographic areas (e.g., regions, States).
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National Healthcare Disparities Report
AHRQ is also developing the first-ever report on prevailing disparities in health care delivery in the United States. A large and consistent body of research, much of it funded by AHRQ, has demonstrated persistent disparities in health care quality and access associated with race, ethnicity, socioeconomic position, sex, age, and place of residence. For example, a recent study of Medicare patients revealed that black patients with congestive heart failure or pneumonia received poorer quality care than whites. Further, these differences are associated with greater mortality among black patients.
The Agency's reauthorization legislation, which became law in late 1999, directed AHRQ to develop a report, beginning with fiscal year 2003, on prevailing disparities in health care delivery as they relate to racial factors and socioeconomic factors in priority populations. AHRQ's priority populations include rural, inner-city, low-income groups, minority groups, women, children, the elderly, and individuals with special health care needs. The National Healthcare Disparities Report (NHDR) will serve as a companion document to the National Healthcare Quality Report, providing greater depth and insights into differences in health care quality for priority populations.
This report will be an unprecedented effort to present a comprehensive picture of prevailing disparities in health care in the United States, and it will identify opportunities for improving care for priority populations. The report also will provide a benchmark for evaluating the success of programs to reduce disparities in health care.
The project is being led by AHRQ and will involve collaboration with multiple components of the Department of Health and Human Services. As of FY 2001, work on the NHDR is proceeding as follows:
- A 14-member Institute of Medicine (IOM) committee of leading experts in quality measurement, access to care, and disparities in care was formed to inform the framework and content of the NHDR. Building on prior IOM work done for the NHQR, the committee will make recommendations regarding the linkage of the two reports. The IOM also will provide a forum for public input and comment into the design of the NHDR.
- Modifications to the Medical Expenditure Panel Survey (MEPS) have been made to allow assessment of quality for priority populations.
- In conjunction with work conducted for the NHQR, AHRQ is conducting market research to identify the needs of potential audiences for the disparities report and to inform the design and format of the report itself.
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