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Transcript of Web Conference

Buy-Right for Health Care Quality: Evidence and Indicators

Using AHRQ Indicators for Hospital-Level Reporting and Payment

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This Web Conference was offered on October 27, 2004. It was designed to help health care purchasers understand the evidence base for quality-based purchasing and public reporting, and to increase their understanding of an important tool set available to assist with evaluations of health care quality.

Penny Daniels: Good afternoon and welcome to our Web conference, Using AHRQ Quality Indicator for Hospital Level Reporting and Payment. This is the second event in a two-part series entitled "Buy Right for Healthcare Quality: Evidence and Indicators." This Web session will explore how the AHRQ Quality Indicators which are commonly called the QIs and we'll use that designation throughout the session, how they can be used to report on hospital performance and motivate improvements in healthcare quality. This series is sponsored by the Department of Health and Human Services Agency for Healthcare Research and Quality, often referred to by the acronym AHRQ, or AHRQ. My name is Penny Daniels and I will be your moderator for this session. Here's an overview of our Web conference today. We'll begin with a pre-recorded introduction by Dr. Carolyn Clancy, Director of AHRQ. As a physician and healthcare services researcher, Dr. Clancy is deeply interested in ways to assess and incentivise healthcare improvements. Although she can't be with us in person today, Dr. Clancy wanted to share her perception of how the AHRQ QIs can drive patient focused, efficient and high quality care. Next we'll hear from our panelist, Denise Remus, Lewis Foxhall, Andy Webber and Debra Ness. Dr. Remus is a senior research scientist at AHRQ and is responsible for the QI program. She is also the lead author on the AHRQ QI Guidance Document. Dr. Foxhall who joins our panel by telephone is Associate Vice President for Health Policy at the University of Texas, MD Anderson Medical Center. Dr. Foxhall helped lead the effort to use the AHRQ QIs to report on the quality of Texas hospitals. Andrew Webber is president and CEO of the National Business Coalition on Health, an organization that advises members on quality based purchasing in healthcare. And the final member of our panel is Deborah Ness, President of the National Partnership for Women and Families. This organization supports a wide range of initiatives to make healthcare more patient-centered and user-friendly. After our brief presentations we will invite our listeners to send us their questions and/or comments by phone or E-mail.

In the meantime if you experience any Web related technical difficulties during this event, please click the 'help' function in your window to troubleshoot your Web connection. If it seems that your slides are not advancing you may need to re-start your browser and log on again. If you are on the phone, dial *0, *1 or *0. Let's just double-check that? Is it *1 or *0. It is *1. *1 to be connected to technical-no *0 to be connected to technical assistance. Also if you have difficulty with the audio stream or if you experience an uncomfortable lag time between the streamed audio and the slide presentation, we encourage you to access the audio by phone. The number is 1-877-407-3039. That's also on your screen. This is also the number to call to ask questions during the Q & A part of our program. Now let's begin with some opening comments from Dr. Carolyn Clancy.

Dr. Clancy: On behalf of the Agency for Healthcare Research and Quality, or AHRQ, I want to welcome all of you to this Web conference. Accurate and accessible information about the quality of care provided in our nation's hospitals is obviously of great importance to all of us. We're very pleased that there are participants in this Web conference who represent purchasers, providers and other organizations who are actively involved in the reporting and use of hospital quality data.

I'd like to start by giving a quick overview of the current emphasis on public reporting and pay-for-performance in the hospital setting. I think we're all familiar with the evidence that American healthcare quality has a number of gaps. There are gaps between the quality of care that we know is possible, and the quality of care that most persons actually receive when they enter a hospital. There are other gaps between the care that persons may receive in some hospitals and what they would get in another facility with less resources, leadership and/or commitment to quality improvement. National reports on the quality of healthcare and on disparities in healthcare linked to patient race, ethnicity and socioeconomic status paint a fairly clear picture of a healthcare system that can be much better than it currently is.

At the same time quality in healthcare is being critiqued, we're also attempting to cope with rapidly increasing costs for care. While these cost increases have many causes, it's very clear that poor quality care is one of these causes. As a result, purchasers of healthcare, including many of the groups that you represent, are looking for ways to provide incentives for quality that's high and hopefully more efficient. And of course American healthcare is also placing greater emphasis on patient-centered or patient-focused care, in which patients play a more active role in healthcare decisions. So as consumers talk with their doctor and browse the Web looking for health information, they want help in assessing the quality of care available in hospitals and other settings.

Out of this broad context there has emerged a strong national consensus that healthcare quality and efficiency can and should be improved, and that improvement requires trustworthy measures of quality in every setting of care. I'm sure most of you know that the Centers for Medicare and Medicaid Services, or CMS, has begun to report on quality data for many hospitals. A number of states have public reporting initiatives along with other organizations who report quality information to the public or to their members. A recent analysis that our co-sponsor identified 47 distinct public reporting initiatives currently underway. While all of these efforts are motivated by our desire to advance the goals of efficiency, access and quality in healthcare, information that's being reported is quite hard for purchasers, providers or consumers to use. As we at AHRQ have listened to stakeholders, there's a strong consensus that public reporting and quality based purchasing need reliable and valid measures of quality that would support objective assessments of quality and fair comparisons between hospitals. Our stakeholders have also told us that there also should be guidelines for how these measures should and should not be used.

Over the past several years AHRQ has funded a number of research projects to develop objective measures of quality in hospitals. We've also sponsored conferences and forums to discuss these measures and how they can be used. In the very early 1990s, AHRQ and its partners released a set of hospital Quality Indicators. We wanted hospitals to use those indicators to monitor and improve the quality of their care. As we've continued to improve and add to this measure set, we've also been compiling information and expert opinion about whether these measures could be used for other purposes such as public reporting. On September 30th of this year, we publicly released a Guidance Document that summarizes these conclusions. Through this Web conference we want to jumpstart efforts to use this document to extend the applications of our Quality Indicator set to the things we know you care about. I want to emphasize that our intent is not to endorse a national approach or provide a one-size-fits-all assessment of which measures to use. That's not the kind of role we've taken any measurement effort because that's not the role our authorizing legislation sets out for us. Rather our Guidance Document was developed in response to our observation and knowledge that some states and purchasers have opted to use the Quality Indicators for public reporting and payment, and have asked us for the best scientific guidance on how to do so. This Guidance Document responds to those requests. As a next step, we expect to be taking these measures through the National Quality Forum consensus process.

So today's presenters offer us several important perspectives on how AHRQ's Quality Indicators can be used to encourage quality improvement, potentially support consumer choice, and to financially reward providers of high quality care. I want to thank each presenter for the leadership roles they're playing, and for the insights they're sharing with us today.

Penny Daniels: Our thanks to Dr. Clancy for that overview. Let's turn now to Dr. Denise Remus. Denise we just heard Dr. Clancy talk about AHRQ's development of a set of hospital Quality Indicators. Why did AHRQ decide to make this such a priority?

Dr. Remus: Well, as Dr. Clancy noted, there's a growing emphasis on being able to measure and reward high quality care. AHRQ recognized that this goal required evidence based measures to assess quality in hospitals. And if you want to use quality measurements to support consumer choice, or to support performance based purchasing, you do need standardized measures. AHRQ felt that supporting the development of these measures was central to its mission.

Penny Daniels: So tell us how AHRQ developed the QIs and what exactly they measure.

Dr. Remus: Well, Penny, through the Healthcare Cost and Utilization Project, commonly referred to as HCUP, which is a State/Federal partnership, AHRQ has access to a uniform database representing approximately 90% of all discharges in the United States. As you can see on the map on the screen, most states collect inpatient data, and almost all states partner with HCUP. In the early 1990s our HCUP partners asked us to assist them in maximizing the use of their hospital discharge data. This early work resulted in the development of the HCUP QIs. While these were useful for initial efforts, the agency identified the need for enhanced measures to populate our national quality, healthcare quality reports. Through a contract with Stanford University's Evidence Based Practice Center, the HCUP QIs were evaluated and new indicators, the AHRQ Quality Indicators were developed. The AHRQ QIs now replace the original HCUP indicators which we no longer support. The objective of the QIs is multiple. It's to provide a tool to highlight potential quality concerns, to identify areas that need further study, and to enable tracking of changes over time. It's also to facilitate transparency through access to comparative quality information, to facilitate decisionmaking by a variety of stakeholders, including federal, state and local policymakers, healthcare leaders, clinicians and purchasers. We also want to maximize existing resources by complimenting current and future measurement efforts.

Penny Daniels: Denise, it's my understanding that you've developed measures of different aspects of quality.

Dr. Remus: That's right. The QIs have three distinct measurement sets. The Prevention Quality Indicators, or PQIs, identify hospital admissions that evidence suggests could have been avoided, at least in part, through timely access to high-quality outpatient care. These are reflective of community services and are not intended for use at the hospital level. The Inpatient Quality Indicators, or the IQIs, reflect quality of care inside hospitals, including inpatient mortality for medical conditions and surgical procedures, the utilization of procedures for which there are questions of overuse or underuse, and volume of procedures. Finally, the third set, the Patient Safety Indicators, or PSIs, reflect quality of care inside hospitals, but focus on potentially avoidable complications.

Penny Daniels: So, Denise, the QIs were originally developed for hospitals working to improve quality. Some groups now are using them for public reporting and pay-for-performance. Is this a concern?

Dr. Remus: Well, a measure that works for one purpose, like quality improvement, doesn't necessarily work as well for other purposes. So current and potential users asked AHRQ for recommendations concerning how to use the indicators appropriately. The Guidance Document was designed to address this need, or as some have noted, to lift the warning labels.

Penny Daniels: So what kinds of organizations are using the QIs for public reporting?

Dr. Remus: Well, as a few examples, the State of Texas reports these indicators on a public Web site that allows consumers and other stakeholders to compare rates of the Inpatient Quality Indicators across Texas hospitals. Dr. Foxhall played a major role in developing this reporting system and he's going to tell us more about it. As another example, the Niagara Health Quality Coalition uses the Inpatient Quality Indicators to report on performance of hospitals across the State of New York. Their data is also available on a public Web site. The slide you're now looking at provides the Web site addresses for both of these reports, and also summarizes, reports a Web site for an article or report that summarizes hospital public reporting initiatives that are ongoing. And when you look at these and see the range of indicators being used, it's easy to understand the priority that AHRQ has given to developing standardized measures.

Penny Daniels: What about organizations that are using the QIs for pay for performance?

Dr. Remus: The CMS Hospital Quality Initiative expanded in 2003 to include the Premier Demonstration Project. This is a 3-year project to recognize and provide financial rewards to hospitals. Two of the indicators they are using are the AHRQ Patient Safety Indicators. Another example of a private pay-for-performance initiative is the Anthem Blue Cross and Blue Shield of Virginia, Quality Insights Hospital Incentive Program, which began in late 2003. This program is designed to align financial incentives with achievement of specific performance objectives. The patient safety component in the program includes the selection of two AHRQ PSIs for monitoring and risk cost analysis when appropriate.

Penny Daniels: Denise, it sounds like there are many AHRQ Quality Indicators, but that no one organization is using all of them, why is that?

Dr. Remus: Well, Penny, this is a key point. We developed the Guidance Document to help potential users select the indicators that were most appropriate for them. We would never tell anyone to use all of the indicators or even tell them that there is one indicator that they absolutely ought to use. Instead, the Guidance Document is designed to help organizations who want to monitor or report on quality, to use the best science in making and implementing their selection decisions. To enable that, the Guidance Document illustrates some typical uses of the QIs and identifies the factors that organizations should consider in their selection decisions. Individual organizations are likely to have different uses. Some may be interested in public reporting, others in paying for quality. They may have different priorities, a greater or lesser emphasis on cardiac care, for example, or different market needs. They also may have differing data situations, variations in data completeness and coding quality. The guide also includes recommendations on how to use the QIs most productively. For example, we offer suggestions including involving hospitals early in the measurement effort, to use the QIs as part of a broader [dashboard], presenting outcomes with process measures, paring mortality and volume indicators, using multiple years of data, and evaluating the use of composite measures.

Penny Daniels: So now Denise, it seems like in the AHRQ QI program you're kind of shifting from developing the measures, to helping organizations figure out how to use them.

Dr. Remus: Well, actually we're doing both. There are continuing efforts to refine the existing measures. We're also developing pediatric QIs that will focus specifically on quality of care for children. We're also working with 3MO who produces all patient refined, or APR-DRG Grouper, which is used to risk adjust in our mortality inpatient quality indicators, to increase the access to their grouper. We're also focusing on helping users. We're undertaking several important initiatives. By next spring we will have more comparative data available so that hospitals could compare their rates with peer groups. By summer of 2005, we'll be releasing new QI software that will allow organizations to calculate their QI rates without having to have access to statistical software packages such as SAS or SPSS. The software is being developed by Batel International (ph) our support contractor. And we'll include built in data quality text to screen out bad information and a broader range to report and output the data. This should make it much easier for hospitals and other organizations to use the QIs. We're also expanding our support efforts to include enhancements to our Web site, and we're sponsoring our first annual QI user conference which will be held in the DC area sometime between May and September next year.

Penny Daniels: That's very exciting Denise, thank you so much for that great overview of the program. And I'm sure our audience will have some questions for you a little later, but for now, let's turn to Dr. Lewis Foxhall to get the perspective of someone who is both a physician and a leader in the effort to evaluate the quality of care in Texas hospitals. Dr. Foxhall, do you think that publicly reporting on hospital quality is a fad, or something that's here to stay?

Dr. Foxhall: I think it's here to stay, and there are several good reasons for that. When we started planning to publicly report hospital data here in Texas a lot of physicians and hospitals pushed back and opposed the idea. There wasn't much agreement on what to measure, how to do risk- adjustment, or even whether anyone would pinch into this stuff once we had it reported. Now everyone knows that information about hospital quality is being reported by states, and magazines and insurance companies and even the federal government. So the discussion has really changed from, should it be reported, to, what's the best information and how do we format it in the best way to make sense of it all. As more data becomes available I think insurance companies, major care organizations and CMS are looking at it and starting to think about how to link payments to measures of quality, and it's also getting easier for consumers to go to the Web and find out information about hospitals. So I think measuring quality is going to be more and more common.

Penny Daniels: So, Dr. Foxhall, you were involved in the development of a Texas hospital quality report that was based on some of the AHRQ QIs. Could you tell us how that project got started and why you chose to use the AHRQ QIs?

Dr. Foxhall: Our group is the Texas Healthcare Information Council, it was created by the Texas legislature back in 1995, and it works in collaboration with the Health and Human Services Commission here in the state, and it's primary aim is to provide data that will enable Texas consumers and healthcare purchasers to make informed decisions. I was a member and was fortunate to chair the council for a while and we'd looked at a number of measures as we were trying to sort this out. There were several that were available at the time that we looked at it, and we also considered developing some of our own. Texas hospitals initially had some significant concerns about the raw ability of using data derived from administrative data, but the cost of clinical data from chart extraction was really prohibitive. So we selected AHRQ's QIs because all of them were supported by good background research and extensive evaluation. So we found also that the APR-DRG risk-adjustment methodology was very helpful in getting facility buy-in-the methodology was transparent so the hospital could see what was being done, and could even reproduce the information of they wanted to. So despite those initial concerns, public release really was well accepted.

Penny Daniels: What quality information do you report on?

Dr. Foxhall: The report provides three general types of information. We look at volume indicators for certain complex medical and surgical procedures, risk-adjusted mortality for surgical procedures, risk-adjusted mortality for some medical procedures and also we got some utilization indicators for procedures about which questions have been raised about overuse or underuse.

Penny Daniels: What does a consumer or managed care company actually see when they look at your reports on the Web?

Dr. Foxhall: All the reports are laid out using the same basic format. At the top of the report there's a short explanation of what the procedure is and how to interpret the slide, and then below that is a data table, a bar graph that basically shows information in an easy to understand way about volume or mortality rates for each hospital, and then that's easily compared with the state average.

Penny Daniels: How much effort is required by the hospitals to produce these reports?

Dr. Foxhall: The effort is not insignificant, but we try to make it as reasonable as possible, and using administrative data, this helps cut down the amount of effort that the hospitals have to put into the process. Once the data is initially set up and formatted, it's abstracted directly from those billing forms so that keeps the work effort to a minimum.

Penny Daniels: So is anyone looking at or using the quality reports you produce at this point?

Dr. Foxhall: Well, we know the Web site is looked at by a lot of consumers, we also know that health facilities and consumer groups are buying public use datasets for their own use, and there's anecdotal evidence that hospitals and professional groups are using the information in their quality improvement activities.

Penny Daniels: As I understand it, public reporting of quality information is, of course, designed to motivate hospitals to improve. Is there any evidence that this is working in Texas?

Dr. Foxhall: Obviously there are many changes happening in healthcare in Texas that could impact hospital quality indicator rights. So, there's no real way we can say for sure that public reporting caused these changes to occur. But we do know that things are happening. We know that many of the indicator rights that you can see here on the slide have changed for the better since we started the project, and data reporting we think may have been a catalyst for some of these changes that you can see.

Penny Daniels: Okay. We're looking at statewide mortality rate trends at this point, can you tell us a little bit more about that?

Dr. Foxhall: Well, these trends are, as you can see here, for example, looking at the mortality data for several high volume medical conditions, you see the declines of statewide mortality data for acute myocardial infarction, congestive heart failure or acute stroke and pneumonia, and I could argue that these trends started before the reporting process began, but the bottom line is that their mortality rates have gone down in the state. And we think that public reporting certainly was one of the factors involved here.

Penny Daniels: Okay, one final question for you Dr. Foxhall, before we turn to our next panelist, having gone through this experience now, is there anything you would do differently or advise others to do differently?

Dr. Foxhall: Well, I think we were pretty much perfect! But maybe not totally perfect, perhaps-it was challenging, trying to work through this, and at that time, just because of the state of quality reporting and the process involved were just starting to be used across the nation. But actually standardized measures are much more available now than when we started, and there are more tools available now, to help develop and use appropriate sets of quality indicators. You're still going to face challenges from hospitals concerned about the fairness of the measures, and it's still challenging to present data in a way that's helpful for consumers and still fair for the facilities being reported on. But I think it is easier to get started now than it was back five years ago.

Penny Daniels: Thank you very much Dr. Foxhall. Participants in this Web conference who are interested in public reporting may have some additional questions for you later in the Webcast, but first, we now turn to our next presenter, Andrew Webber who leads the National Business Coalition on Health. Andy, tell us about the Coalition first of all.

Andrew Webber: Well, thank you Penny. And let me first say it's a great pleasure to be here and I certainly want to, at the outset, applaud the leadership of AHRQ, Dr. Clancy and Denise Remus for removing the warning label from the AHRQ Quality Indicators, and really getting behind the public accountability agenda that we're talking about here today. And secondly, their commitment to not only removing the warning label, but giving users in the field some real guidance through the Guidance Document, about how to move from measurement into active implementation of the program. So again, let me say at the very beginning, it's a pleasure to be here and I applaud these steps today. Penny, the National Business Coalition on Health is a national non-profit organization of 80 employer-based healthcare coalitions. We've been around for a dozen years as an organization, and our coalitions represent about 7,000 individual employers who have come together in local communities because they are really committed to reforming the healthcare delivery system through value-based purchasing. That's who we are.

Penny Daniels: Why is value-based purchasing such a priority for you?

Andrew Webber: Well, I think very simply, purchasers, employers, make a significant investment in the healthcare field. We purchase health insurance benefits on behalf of our employees and their loved ones, and as we all know in this environment, those healthcare costs are going up. So we want to know that our investment in healthcare is leading to better value. And when we look at some of the research, actually we need to stop and say, 'Are we getting the value for our dollar?' And research actually that's represented here, a report by the Duran Institute and the Midwest Business Group on Health, a member of ours, it demonstrates that 30% of total healthcare costs reflect poor quality, based on underuse, overuse, misuse and waste in the healthcare system. I think, Penny, we can do a lot better than that. But finally, while we're good in the employer community at sort of pointing fingers at all the problems in healthcare, I think we also recognize and acknowledge that we're part of the problem and have to be part of the solution. And that's why we're very much, as an organization, and our members are really behind what we call the value based purchasing movement. And the core dimensions of value based purchasing include what we're talking about here today. The need for good comparable performance measurement at all levels of the healthcare system, whether at the plan level, hospital level, physician level-we need to get to that level over time. We need good reliable performance information. But secondly, we need to make that information transparent, and we need to educate and inform, particularly consumers, about performance information so they can make better decisions and better selections in healthcare. And finally, I think employers have a big role to play in again, coaching our consumers to use the information to make better selections and moving, sort of migrating as we say here, market share to the better performers-but finally as Denise talked about, we're also committed to this pay-for-performance agenda as well. We need to align economic incentives so the better performers in healthcare truly are rewarded with greater reimbursement over time.

Penny Daniels: Andy, this seems very consistent with changes that the Institute of Medicine has been recommending.

Andrew Webber: It is, and I tell all our members that if there's one required reading in healthcare it is Crossing the Quality Chasm of the Institute of Medicine, and the Institute of Medicine did lay out a blueprint for the reform of the healthcare delivery system, and I'd like to point out here that it starts-the driver for the reinvention and the reengineering of care delivery that needs to go on, starts with the development of, as they call it, a supportive payment environment. It's again, that value based purchasing agenda, that's paying-for-performance. That's identifying better performance that we as a driver can then accelerate the pace by which the delivery system moves into quality improvement activity. And related to that, I'd like to identify, if I could Penny, a few of the activities within our membership that relate to this value based purchasing agenda. Denise talked about how performance measurement in its first generation is really a [light] for quality improvement-perhaps it's not ready for public reporting. We have not worked through all the scientific and technical issues, and when you make information public you have reputations of the provider community at stake. And this very much reflects sort of the movement of our community-they started using performance measurement in developing community based collaboratives with the provider community, working with hospitals, working with healthcare plans, working with individual physicians in a safe, supportive environment, where information is used not to broadcast it and send it to the media, but really to support and engage the provider community in quality improvement collaboratives.

But now we are committed to moving the agenda to the next step, and as you can see here, more of our members are moving into public reporting, and producing public report cards in local communities. Focused first at the healthcare plan level, our major customer, secondly with hospitals, and we have a long way to go, and not the discussion for today's agenda, but one that's certainly ripe and being talked about, how do we even produce public report cards for individual physicians and then ultimately moving into financial incentives.

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