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Quality Improvement for Diabetes and Asthma Care: AHRQ's Guides and Workbooks for State Action

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On December 6, 2007, Hosanna Coffey gave an overview of the Asthma and Diabetes workbooks at the State Healthcare Quality Improvement Workshop. This is the text version of the event's slide presentation. Please select the following link to access the slides: (PowerPoint® File, 1.3 MB).

Slides: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18


Slide 1: Quality Improvement for Diabetes and Asthma Care: AHRQ's Guides and Workbooks for State Action

Rosanna M. Coffey, PhD
Thomson Healthcare (Medstat)

State Healthcare Quality Improvement Workshop:
Tools You Can Use to Make a Difference
December 6-7, 2007

On the top of the slide are the logos for the Department of Health & Human Services and the AHRQ logo. The Department of Health & Human Services logo is an artistic image of an eagle with the outlined profile of faces. The AHRQ logo reads, "AHRQ — Agency for Healthcare Research and Quality: Advancing Excellence in Health Care, www.ahrq.gov."

This presentation uses a template with a blue background and a header with the AHRQ and Department of Health & Human Services logos on the left.

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Slide 2: Colleagues

  • AHRQ
    • Dwight McNeill, PhD
    • Ed Kelley, ScD
    • Ernest Moy, MD, MPH
    • Roxanne Andrews, PHD
  • TH
    • Kelly McDermott, MA
    • Karen Ho, MS
    • David Adamson, PhD
  • CSG
    • Trudi Matthews, MA
    • Jenny Sewell

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Slide 3: AHRQ's Goals

  • Motivate leaders of quality improvement.
    • State policymakers
    • Employers
  • Create products that help leaders take action.

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Slide 4: Guides & Workbooks (G&Ws)

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Slide 5: Why? Variation in quality (asthma)

This slide is three scatterplots. The first scatterplot shows hospital admission for pediatric asthma under age 18 (PQI 4). The plot shows a large distribution of points, ranging from the best-in-class average of approximately 60 hospital admissions per 100,000 population to over 300 hospital admissions, which is far above the national average of 175 admissions.

The second plot shows hospital admission for adult asthma age 18-64 (PQI 15). Data are not as varied as for pediatric asthma. Still, the data vary from the best-in-class average of 55 hospital admissions to 150 admissions. The national average is 110 hospital admissions per 100,000 population.

The third scatterplot shows hospital admission for adult asthma age 65 and older (PQI 15 modified). The data range from the best-in-class average of 120 hospital admissions to 225 admissions, with the national average at 175 admissions per 100,000 population.

The source of the data is the Asthma Guide.

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Slide 6: Why? Difficult to synthesize research on quality and costs (asthma)

The slide is a bar graph. Along the x-axis is utilization, broken into ED visits, hospitals stays, and outpatient visits; missed work/school days; and medication cost. The categories are broken into randomized controlled, all controlled, and without a control group. Along the y-axis is percent change from quality improvement.

— Utilization

ED Visits
Randomized controlled: -7%
All controlled: -8%
Without a control group: -34%

Hospital Stays
Randomized controlled: -32%
All controlled: -39%
Without a control group: -73%

Outpatient Visits
Randomized controlled: -24%
All controlled: -25%
Without a control group: -52%

— Missed work/school days
Randomized controlled: -57%
All controlled: -57%
Without a control group: -51%

— Medication Cost
Randomized controlled: 5%
All controlled: 5%
Without a control group: 39%

Source: Asthma Calculator

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Slide 7: What's in Guides/Workbooks?

  • Guides: Provide information on:
    1. Motivation — Making the case.
    2. Framework — Strategy for state-led QI.
    3. Scan — State QI activities.
    4. Data — Measuring quality of care.
    5. Implications — Moving ahead to action.
  • Workbooks help you make your case.
    • Work through the module exercises.
    • Assemble data on prevalence, cost, and potential savings.
    • Provide critical information to a State work group.

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Slide 8: AHRQ Partners for G&Ws

The slide is a table with three columns and seven rows. The columns are titled, "Advisors," "Diabetes," and "Asthma."

Advisors Diabetes Asthma
Federal CDC CDC, NHLBI
State (Public health) AR, WA OR, NY, WA
State (Data orgs) GA, MA, MI, WA GA, NY, PA
State (Lawmakers) KS, OH, NY, MN, WA  
Advocates ADA AAA, ALA, ATS
QI groups   JCAHO
Clinician researchers   (several)
  • The federal advisor for diabetes is the CDC. The federal advisors for asthma are the CDC and the NHLBI.
  • The state (public health) advisors for diabetes are AR, WA. The state (public health) advisors for asthma are OR, NY, WA.
  • The state (data orgs) advisors for diabetes are GA, MA, MI, WA. The state (data orgs) advisors for asthma are GA, NY, and PA.
  • The state (lawmakers) advisors for diabetes are KS, OH, NY, MN, WA. There are no state (lawmakers) advisors for asthma.
  • The advocate group advising on diabetes is the ADA. The advocate groups advising on asthma are AAA, ALA, ATS.
  • There is no QI group advising on diabetes. The QI group advising on asthma is JCAHO.
  • No clinician researchers advised on diabetes. Several clinician researchers advised on asthma.

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Slide 9: 1. Making the Case

  • Why should states make asthma or diabetes a priority for QI initiatives?
    • Increasing prevalence.
    • Significant disparities.
    • State variation.
    • Potential cost savings.
    • Quality improvement opportunity.
  • In the workbook:
    • How to estimate prevalence by sub-groups.
    • Resources for state data.
    • How to estimate costs of asthma/diabetes care.

On the right slide of the graph is an image entitled, "Age-Standardized Prevalence of Diagnosed Diabetes per 100 Adult Population by State, 1994 and 2002." The image is of a map of the United States in 1994 and a map of the United States in 2002. The maps show that in 1994, prevalence in most states was 4 to 5.9%. In 2002, prevalence increased dramatically, with most states showing rates above 6%.

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Slide 10: 2: Strategy for State-led Quality Improvement

This slide has an image of three concentric circles, which are divided into thirds. The image shows that the strategy for quality improvement rests on planning (e.g., strategize, design), doing (e.g., test, measure), and assessing (e.g., analyze, evaluate).

The process is as follows:

  • Provide leadership to create a vision.
  • Work in partnership with key stakeholders.
  • Implement improvement by leading partners to create interventions and assess impact.

In the Workbook, worksheets for planning a state QI program are included.

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Slide 11: 3. Scan State Activities

  • Review module on national and specific state activities
  • Investigate your own state's activities
  • Learn from what other states have done

In Workbook:

  • A checklist for summarizing your state's activities

The slide has an image of pages from the workbook.

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Slide 12: 4. Data & Measures: The Keys to Improvement

  • Motto: "You can't change what you can't measure."
  • Measures: Learn the standard measures for the disease.
  • State data: Do an inventory of relevant data.
  • National data: Assemble benchmarks (Tip: don't be satisfied with "average".)

In the Workbook:

  • List of state data sources (hands-on session)
  • How to compare to the best-in-class (hands-on session)
  • And much more.

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Slide 13: 4. Data & Measures: Types and Examples

  • Process: Performance indicators based on clinical care guidelines.
    • Doctor visit every 6 months.
    • Written asthma management plan.
  • Outcome: Health status, the ultimate objective.
    • Mortality rates.
    • Hospitalization rates.
  • Contextual Factors: Difficult to change.
    • Access — percent uninsured.
    • Prevalence — percent with diabetes or asthma.

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Slide 14: 4. Data & Measures

Process Improvement Should Relate to Outcomes

The slide shows an image of an arrow. The text inside the arrow reads, "Daily medications for patients with persistent asthma."

The arrow is pointing to an octagon that reads, "Reduced asthma hospitalizations in the total population."

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Slide 15: 4. Data & Measures: Benchmarks for Asthma Quality Improvement

This slide is identical to slide five of this presentation. The slide contains three scatterplots. The first scatterplot shows hospital admission for pediatric asthma under age 18 (PQI 4). The plot shows a large distribution of points, ranging from the best-in-class average of approximately 60 hospital admissions per 100,000 population to over 300 hospital admissions, which is far above the national average of 175 admissions.

The second plot shows hospital admission for adult asthma age 18-64 (PQI 15). Data are not as varied as for pediatric asthma. Still, the data vary from the best-in-class average of 55 hospital admissions to 150 admissions. The national average is 110 hospital admissions per 100,000 population.

The third scatterplot shows hospital admission for adult asthma age 65 and older (PQI 15 modified). The data range from the best-in-class average of 120 hospital admissions to 225 admissions, with the national average at 175 admissions per 100,000 population.

The source of the data is the Asthma Guide.

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Slide 16: 5. Take the Opportunity: Have an Impact on Quality of Care

THE QI CYCLE:

  • Plan: Identify issue, stakeholders, goals (topics)
  • Do:
    • Select change agents
    • Providers — Societies, IHI, etc.
    • Health plans — NCQA
    • Employers — Firms/coalitions
    • States — Who in state?
    • Guide & support with resources
  • Assess: Evaluate, modify, test, & reassess

Implement successes broadly.

Use the QI Cycle to assess and modify implementations.

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Slide 17: The Workbook Steps for States

  • Make your case: Assess avoidable hospitalizations, prevalence, costs, and potential saving related to the disease.
  • Understand state-led quality improvement:
    1. Apply the 3 steps - leadership, partnership, and improvement.
    2. Identify national resources to help.
  • Review relevant programs of QI in your state.
  • Understand measurement and data:
    1. Learn about measures for the disease.
    2. Assess available data for state and local estimates; identify gaps.
    3. Find national benchmarks to compare your state against.
  • Summarize your state's case for disease quality improvement and identify next steps to take action (e.g., set preliminary goals).

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Slide 18:

Rosanna Coffey, PhD
Rosanna.Coffey@thomson.com
301-309-3829

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The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care