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The First National Reports on U.S. Healthcare Quality and Disparities

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By Anna Poker, M.S., R.N.; Heddy Hubbard, M.P.H., R.N.; Beth A. Collins Sharp, Ph.D., R.N.

This article was originally published in the Journal of Nursing Care Quality 2004;19(4):316-21. Copyright 2004 by Lippincott Williams & Wilkins.


Purpose of the Reports
Conceptual Framework of the NHQR/NHDR
Design of Reports


In the Healthcare Research and Quality Act of 1999 (Public Law 106-129), Congress mandated that the Agency for Healthcare Research and Quality (AHRQ) produce annual reports on healthcare quality and disparities in the United States. The National Healthcare Quality Report and the National Healthcare Disparities Report were first released in 2003 by AHRQ. These reports include broad sets of performance measures to portray the Nation's progress toward improving the quality of care provided to all Americans. This article provides an overview of the framework, development, and future uses of the reports by consumers, practitioners, researchers, and policymakers.

The Agency for Healthcare Research and Quality (AHRQ), a part of the U.S. Department of Health and Human Services (HHS), is the lead agency charged with supporting research designed to improve the quality of healthcare, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use, and access. The information assists healthcare decisionmakers, patients, clinicians, health system leaders, and policymakers to make more informed decisions and improve the quality of healthcare services.

The Healthcare Research and Quality Act of 1999 was signed into law for the purpose of assigning to AHRQ the task of "closing the numerous data gaps throughout the healthcare delivery system...and to serve as a bridge between the best science in the world with the best health care in the world."1 Another task of AHRQ was to support the improvement of quality of healthcare by developing annual reports to the Nation on quality and disparities, promoting evidence-based medicine, detecting and preventing errors in healthcare, supporting primary care research, and applying the power of the computer in healthcare.

The above legislation directed AHRQ to produce two annual reports for Congress, the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR). AHRQ commissioned the Institute of Medicine (IOM) to help develop two separate visions for each of these reports to examine the quality of care provided to the general population and major subgroups. In 2001, the IOM report Envisioning the National Healthcare Quality Report provided suggestions for a framework of healthcare quality, types of measures to include in the report and selection criteria, and target audience selection for the NHQR.2 The IOM report Guidance for the National Healthcare Disparities Report provided recommendations for measuring socioeconomic status, access to quality healthcare for various racial and ethnic minorities and non-minorities, and strategies for developing adequate data sources for the NHDR.3

AHRQ adopted the IOM recommendation for both reports, and the wheels were set in motion to start conception of the reports. These companion reports were released in December 2003. This article addresses the purpose, conceptual framework, design, and challenges of developing annual reports to the Nation on trends in healthcare quality and trends in healthcare disparities.

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Purpose of the Reports

The goal of the two reports, NHQR and NHDR, is to capture the status of the quality of care provided to all Americans while emphasizing major subgroup populations. The IOM advocated that the NHQR "focus on performance of the healthcare delivery system with regard to personal healthcare, rather than public health functions."2 The goal of the NHQR is to identify gaps in delivery of quality healthcare, areas on which we need to focus our attention, and areas we can benchmark. The NHQR provides comprehensive information about quality of care in the Nation to policymakers, providers, and consumers.

The NHDR tracks racial, ethnic, and socioeconomic disparities in care over time across rural, urban, and inner-city areas and among priority populations (e.g., low income, women, children, and others) across the Nation.4 The NHDR identifies where differences exist and data gaps that need to be addressed with new data source development. The report can be the trigger to the development of new and improved interventions to enhance equity of healthcare delivery to subgroups of the population.

Although the two companion reports may provide some overlapping data, Congress, policymakers, providers, and consumers need both reports to get a clear understanding of the status of quality of care in the Nation, particularly in regard to effectiveness and patient safety. They need the information presented in the reports to make better decisions about policies, legislation, and future healthcare endeavors that will support the continuous improvement of care provided to the Nation.

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Conceptual Framework of the NHQR/NHDR

The IOM formed special committees composed of leading experts in quality and quality measurement to develop the conceptual frameworks for the two separate reports. Figure 1 depicts the two dimensions of the matrix developed by the committee as a conceptual framework for the NHQR:

  • The components of healthcare quality (i.e., effectiveness, safety, patient centeredness, and timeliness).
  • Consumer perspectives on healthcare needs (i.e., staying healthy, getting better, living with illness or disability, and coping with the end of life).

This matrix provides a guideline as to what areas should be measured while realizing that individual measures may change in future reports. A third dimension, equity, extends across both the components (healthcare quality and consumer perspectives on healthcare needs) and is explored in detail in the NHDR.

The NHDR is built upon the NHQR's conceptual framework of these two components. The NHDR conceptual framework (Figure 2) expands that of the NHQR by adding equity to the components of healthcare quality (to include effectiveness, safety, patient centeredness, timeliness, and equity), as well as access to care, use of services, and costs of services. The matrix relates these concepts to patient needs (i.e., staying healthy, getting better, living with illness or disability, and coping with the end of life).

By expanding the equity section of the NHQR, the NHDR framework adds a third dimension to include racial, ethnic, and socioeconomic differences. Also, since access to care is essential to high-quality care, the NHDR framework shows that all measures of access and quality of care should be examined in relation to race, ethnicity, and socioeconomic differences. Finally, because differences in healthcare are interpreted in the context of underlying variations in health, this conceptual framework rests on a representation of differences in health status and healthcare need.

Edward Kelley, Ph.D., director of the NHQR, indicates that the NHQR measure set is the foundation for both reports. The NHDR examines the specialty areas of race, ethnicity, and socioeconomic status. The NHQR analyzes quality across components of quality and priority conditions, whereas the NHDR focuses on quality and access for priority populations, the equity dimension, and barriers to access to quality care. National quality improvement and disparities reduction endeavors need to be coordinated to enhance care delivery to all consumers.

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Design of Reports

Measures and Data Sources

The process for measure selection started with the adoption of the IOM's recommendations for measure selection criteria based on importance, scientific soundness, feasibility, and availability of nationally representative data. AHRQ developed a call for measures to Federal and private sectors. Recommendations and comments for measures for the NHQR and NHDR came from key constituencies and colleagues, including:

  • AHRQ staff with special expertise.
  • HHS Data Council.
  • Quality Interagency Coordination Task Force (QuIC).
  • National Committee on Vital and Health Statistics.
  • U.S. Senate Committee on Health, Education, Labor, and Pensions.
  • American Medical Association, American Hospital Association, Joint Committee on Accreditation of Healthcare Organizations, Midwest Business Group on Health.
  • State policymakers through organizations such as the National Association of Health Data Organizations and National Academy for State Health Policy.
  • IOM committee members for Crossing the Quality Chasm: A New Health System for the 21st Century, Envisioning the National Healthcare Quality Report, and Envisioning the National Healthcare Disparities Report.

Final measures were selected by the two Interagency Work Groups, one Interagency group for the NHQR and one for the NHDR, with some members serving on both groups. The Interagency groups were widely representative and included staff from:

  • Assistant Secretary for Planning and Evaluation/HHS.
  • Centers for Disease Control and Prevention (CDC).
  • Centers for Medicare & Medicaid Services.
  • Food and Drug Administration.
  • Health Resources and Services Administration.
  • Indian Health Service.
  • National Center for Health Statistics/CDC.
  • National Institutes of Health.
  • Substance Abuse and Mental Health Services Administration.

The final measure set for the NHQR was narrowed down to 147 measures from approximately 600 nominated measures by the Interagency work group with emphasis on proposed public comments. The final measure set for both reports addresses the following priority conditions in the effectiveness domain: cancer, diabetes, heart disease, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), maternal and child health, mental health, respiratory diseases, end-stage renal disease, long term care, and home health.

Once the measures were selected, existing data sets to support the reports were identified. The current reports rely heavily on Federal data sets. Some areas such as mental health and HIV/AIDS were limited because of an absence of nationally representative data.

Organization of Reports

National Healthcare Quality Report

The format of the reports is similar, in as much as both reports are presented in chapters. The NHQR consists of four sections:

  • Report on the findings in the quality of care framework.
  • Tables Appendix—detailed tables for each measure in the measure set.
  • Measure Specifications Appendix—with specifications for all the measures and data sources contained in the measure set.
  • Measure Background Appendix—specific information and rationale for inclusion of measures in the measure set.

The individual chapters are divided into sections that highlight key findings across the measures for each area of the report. The NHQR chapters have five main sections:

  • Background and impact (e.g., effectiveness of cancer care).
  • How we measure quality of care for the chapter topic.
  • How the Nation is doing on the chapter topic.
  • What we do not know about quality measurement on the chapter topic.
  • What can be done focusing on best practices and research goals.

National Healthcare Disparities Report

The NHDR report is divided into the following chapters:

  • Quality of Healthcare—presents racial, ethnic, and socioeconomic differences within the general population in the provision of healthcare in relation to quality.
  • Access to Healthcare— presents racial, ethnic, and socioeconomic differences within the general population in the provision of healthcare in relation to access to care.
  • Priority Population—discusses differences in healthcare for the designated priority groups of women, children, elderly, racial and ethnic subpopulations, rural populations, and individuals with special needs.

Both the NHQR and the NHDR can be accessed on the Web at

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AHRQ was mandated by Congress to develop NHQR and NHDR to assess the status of quality care and existing disparities in care provided to the American people. The NHQR and NHDR are to track quality care and are to be used as tools to improve the status quo in the future.

The task to develop reports that had no precedent presented numerous challenges to the original NHQR/NHDR team. Since evaluation of healthcare quality of care was never done at a national level in the United States, this endeavor involved the AHRQ team working in unchartered waters and searching for data that are not fully captured. The team needed to not only track quality trends but also to identify measures that could support quality improvement. The team and Interagency group, acting with guidance from the IOM, decided to use only national data since the reports had to address national quality and disparities. They also decided to use only existing data that had been well received by the statistical community. By relying only on existing national data, the reports could not adequately track data in all areas; in other words, there were no data for parts of the framework.

Another challenge existed in finding a way to present the data so that all users could benefit from the reports. The findings in the reports need to be disseminated to users in ways they can optimally benefit from them. However, the users are varied and need the data formatted and customized for their specific needs.

Researchers, practitioners, policymakers, vendors, and consumers require data to be presented and organized in ways they can interpret and use for further dissemination and for improvement endeavors. Researchers need to know gaps in data that need to be investigated. Practitioners need to have analyses of the findings seamlessly embedded in their decision support systems to access at point of patient care. Policymakers need a customized data breakdown that may affect their unique State and/or locality. Vendors need to identify ways to introduce innovative products seamlessly into existing integrated systems. Consumers need to access specific information related to their own condition and socioeconomic, ethnic and/or racial background (e.g., diabetes information for Native Americans).

The current NHQR/NHDR team is actively pursuing the development of various other products to gear the data more specifically to user needs. For example, a Diabetes Workbook is in its final stages of development to provide State-specific diabetes information.

In the first set of reports, AHRQ Director Dr. Carolyn Clancy comments that "we are only partway there." Although the data inform others about problems with our healthcare delivery in regard to disparities and the quality of care provided, the data do not provide us with information as to why these problems exist and how best to fix them. The NHQR and NHDR future versions need to not only track data but also capture effective processes to enhance our healthcare delivery system.

Optimizing the significance of the NHQR and NHDR to all users will involve continual review of the reports by them. AHRQ has developed the QualityTools Web site ( to provide information for users and to receive comments and/or advice about the reports. Users are urged to provide feedback about measure sets and the accessibility and usability of the reports.

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Both reports revealed that we have more to learn and that greater improvement is possible. They also identify that opportunities for preventive care are frequently missed, and management of chronic diseases presents unique challenges. The NHQR depicts that high-quality healthcare is not universal. The NHDR portrays that disparities in quality of healthcare are pervasive and disparities in access to healthcare contribute to disparities in quality of care.

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The NHQR and NHDR can provide relevant data for the nursing community. Nurse researchers can address existing gaps in measure sets. Practitioners and policymakers, especially in public health, home health, and long-term care, can use the reports for benchmarking and for local quality improvement monitoring.

The need to improve the delivery of healthcare to all Americans has been evident in many literature sources.5 Furthermore, financial resources are diminishing as spending is rapidly increasing. In 1998, national spending was more than $1.1 trillion or 13.5 percent of the gross domestic product.6

To start building solutions, we have to identify what the problems are and where they exist. The purpose of these reports is to begin the process of improving quality of healthcare to all Americans. Initially, the reports capture data to identify and locate problems. Future reports will endeavor to identify causes and potential solutions to existing healthcare problems. The impact of NHQR and NHDR will be shaped by not only AHRQ but also the multiple users of the data as we continue the process of improving out healthcare delivery system.

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1. Healthcare Research and Quality Act of 1999. Public L No. 106-129. 42 U.S.C. 299 §902(g) and §913(b)(2).

2. Hurtado MP, Swift EK, Jorrigan JM, eds. Envisioning the National Healthcare Quality Report. Washington, DC: National Academies Press; 2001.

3. Swift EK, ed. Guidance for the National Healthcare Disparities Report. Washington, DC: National Academies Press; 2002.

4. Siegel S, Moy E, Burstin H. Assessing the nation's progress toward elimination of disparities in healthcare. J Gen Intern Med 2004;19:195-200.

5. Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. Quality First: Better Healthcare for All Americans. Washington, DC: U.S. Government Printing Office; 1998.

6. Levit, K, Cowan C, Lazenby H, et al. Health spending in 1998: signals of change. Health Aff 2000;19(1):124-32.

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Anna Poker is with the Center for Quality Improvement and Patient Safety, AHRQ, Rockville, MD.
Heddy Hubbard and Beth Collins Sharp are with the Center for Outcomes and Evidence, AHRQ.

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Address correspondence to Anna Poker, M.S., R.N.: Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Director, Bioterrorism Preparedness Program, 540 Gaither Rd., Rockville, MD 20850. E-mail:

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The authors acknowledge the hard work, support, and assistance provided for the article from the original NHQR/NHDR team, including Daniel Stryer, M.D., Ernest Moy, M.D., M.P.H., Chunliu Zhan, M.D., Ph.D., Beth Koziak, Ph.D., Judy Sangl, Sc.D., and Sari Siegel, M.A. Special thanks to Edward Kelley, Ph.D., for his leadership with the team and contributions to the writers of the article.

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