Key Themes and Highlights From the National Healthcare Quality Report
National Healthcare Quality Report, 2008
Health care helps people stay healthy, recover from illness, live with chronic disease or disability, and cope with dying. Quality health care delivers these services in a way that is safe, timely, patient centered, efficient, and equitable. Unfortunately,Americans too often do not receive care that they need or they receive care that causes harm. Care can be delivered too late or without full consideration of a patient's preferences and values. Many times, our system of health care distributes services inefficiently and unevenly across populations.
Each year since 2003, the Agency for Healthcare Research and Quality (AHRQ), together with its partners in the Department of Health and Human Services (HHS), has reported on progress and opportunities for improving health care quality, as mandated by the U.S. Congress. The information amassed for the National Healthcare Quality Report (NHQR) since its inception is a growing knowledge base that addresses two critically important questions:
- What is the status of health care quality in the United States?
- How is the quality of the health care delivered to Americans changing over time?
The significance of tracking this sector's performance is evident from many vantage points. More than $2 trillion is spent each year on health care in the United States, and costs are escalating relentlessly, threatening the financial security of families and businesses. Quality and value are increasingly considered in decisions made by patients and payers. To help patients choose doctors and hospitals prudently, tools have been produced that gather information about and rate providers. To motivate providers to deliver high quality care, purchasers are starting to reward superior performance and refusing to pay for additional care needed to correct medical errors. This is a dynamic area that will likely continue to develop and affect ways in which care is selected, delivered, and paid for. Monitoring the success of these efforts is crucial as stakeholders refine their quality improvement activities and reassure Americans that they are receiving the optimal health care they deserve.
The NHQR is built on 220 measures categorized across four dimensions of quality: effectiveness, patient safety, timeliness, and patient centeredness. Guided by a subcommittee of AHRQ's National Advisory Council and an HHS Interagency Work Group,i this year's report focuses on the state of health care quality for a group of 45 core report measures that represent the most important and scientifically credible measures of quality for the Nation. By focusing on 45 core measures, the 2008 report provides a more readily understandable summary and explanation of the key results derived from the data.ii While the measures selected for inclusion in the NHQR are derived from the most current scientific knowledge, this knowledge base is not evenly distributed across the dimensions of health care quality. For example, there are many measures on the effectiveness of care for heart attacks, but few measures of medication safety or end-of-life care. The analysis in the following pages centers on measures for which data are available and fit within a framework provided by the Institute of Medicine.
Three themes from the 2008 NHQR emphasize the need to accelerate progress if the Nation is to achieve high-quality health care. These themes also reflect the challenges that still remain:
- Health care quality is suboptimal and continues to improve at a slow pace.
- Reporting of hospital quality is leading improvement, but patient safety is lagging.
- Health care quality measurement is evolving, but much work remains.
i The HHS Interagency Work Group, which represents 18 HHS agencies and offices, was formed to provide advice and support to AHRQ and the National Reports team.
ii Data on all NHQR measures are available in the Data Tables appendix.
Health Care Quality Is Suboptimal and Continues To Improve at a Slow Pace
For the past 6 years, the NHQR has summarized the state of health care quality. This undertaking is difficult, as no single national health care quality survey collects a standard set of data elements from the same defined population for the same period each year. Rather, data are available from a wide range of sources that focus on different populations and data years.
Despite these limitations, we find that health care quality in America is suboptimal. Receipt of needed health care varies widely. While patients hospitalized with a heart attack receive 95% of recommended services, only 15% of patients on dialysis are registered on a kidney transplant waiting list. Across the core report measures tracked in the NHQR, the median level of receipt of needed care was 59%. We can and should do better.
To track the progress of health care quality in this country, the NHQR presents an annual rate of change in quality, which represents how quickly the quality of services delivered by the health care system is improving or declining based on the report's core measures. Another way to describe this is the speed of improvement or decline in the quality of the U.S. health care system. Based on these core report measures, quality of care continues to improve at a slow pace.
Figure H.1 Median annual rate of change overall and by measure category from baseline to most recent data year
Note: Go to Chapter 1, Introduction and Methods, for discussion of year intervals used for analysis. Ns indicate number of measures included in each group.
- The median annual rate of change for the 39 core measures was 1.8% over the measurement period (Figure H.1). Although this rate of change is modest, 87% of the core measures (39 out of 45) showed at least some improvement.
- The median annual rate of change for all measures was 1.4%. Of these 190 measures, 132 showed at least some improvement (69%).
- The three measure categories, prevention, acute treatment, and chronic management, reflect different types of care that patients often need. The highest rate of improvement was in measures related to treatment. In this area, 66% of the measures showed some improvement.
- The median annual rates of change for the management and prevention areas were similar to the overall rate of change. Although these categories had lower rates than the treatment category, 62% of management measures (34/55) and 82% of prevention measures (37/45) showed improvement.
Overall, despite promising improvement in select areas, the health care system is not achieving the more substantial strides needed to close the gap or "quality chasm" that persists. Despite efforts to transform the U.S. health care system to focus on effective preventive and chronic illness care, it continues to perform better when delivering diagnostic, therapeutic, or rehabilitative care in response to acute medical problems. This system achieves higher performance on measures related to acute treatment, such as that for heart attacks, as opposed to prevention and anticipatory management of chronic illnesses, such as cancer screening and diabetes management.
Lessons from quality improvement initiatives in other sectors, such as manufacturing and transportation, are reminders that there is no quick fix or easy overall remedy. Instead, it seems clear that quality improvement in health care, as in other sectors, requires a coordinated, deliberate, consistent, and sustained approach. It is important to recognize that health care quality is improving and this improvement is happening slowly. It is occurring simultaneously with dedicated efforts to improve.
In a general sense, the changes offer some confirmation that work and attention to quality improvement have a positive influence and can translate into results. The country should plan for continuous vigilance focused on the important task of improving health care quality, not only to accelerate progress, but also to sustain the gains in quality that have been achieved and to enhance the return on investment for what we spend on health care.
Making Patient's and Families' Lives Better
The NHQR concentrates on health care quality at the national level. Measures of health care quality averaged over the U.S. population are not a substitute for the daily reality faced by every health care provider and patient in clinics and hospitals. At the same time, however, the statistics reported in the NHQR and NHDR reflect the aggregated everyday experiences of patients and their doctors and nurses across the Nation. It makes a difference in people's lives when breast cancer is diagnosed early with timely mammography; when a patient suffering from a heart attack is given the correct lifesaving treatment in a timely fashion; when medications are correctly administered; and when doctors listen to their patients and their families, show them respect, and answer their questions.
This 2008 report summarizes the areas where progress in health care quality has excelled and where it has lagged. But reports do not improve quality by themselves. Findings need to be disseminated and awareness raised. Providers need to be trained. Community partnerships that bring together all the stakeholders that can make or break a quality improvement initiative need to be created and maintained. Building on information contained in the NHQR and NHDR, HHS organizations are implementing an exciting range of programs that address health care quality nationwide.
Disseminate Quality Information
Health care differs from one place to another. Delivering data that can be used for local benchmarking and improvement is a key step in raising awareness and driving quality improvement. AHRQ's "State Snapshots" Web tool was launched in 2005. This tool helps State health leaders, researchers, consumers, and others understand the status of health care quality in individual States. The 51 State Snapshots are based on more than 100 NHQR measures, each of which evaluates a different segment of health care performance and shows each State's strengths and weaknesses. Although the measures are the products of complex statistical formulas, they are expressed on the Web site as simple, five-color graphic "performance meters." The State Snapshots also allow users to compare a State's performance with that of other States in the same region and to see how a State compares with best performing States.
This year's State Snapshots is complemented by an update of NHQRDRnet and NHQRDRnet, a pair of interactive Web-based tools for searching AHRQ's storehouse of national health care data. For 2008, NHQRDRnet and NHQRDRnet are combined into a single QRDRnet tool to facilitate topic-based table searches across the two reports. This online search engine allows users to create spreadsheets and customize searches of information in the NHQR and NHDR.
The Health Care Innovations Exchange is an AHRQ program designed to support health care professionals in sharing and adopting innovations that improve the delivery of care to patients. Providers and policymakers can explore this site to find innovative strategies and quality-related tools, learn how to improve an organization's ability to innovate and adopt new ideas, and interact with innovators and adopters.
Training is also critical. The Patient Safety Improvement Corps, a partnership program between AHRQ and the Department of Veterans Affairs, provides knowledge and skills to provider teams needed to improve patient safety. The curriculum includes investigation of reports of medical error and the development, implementation, and evaluation of safety interventions. A DVD for self-paced instruction is also available.
The Centers for Disease Control and Prevention's National Methicillin-Resistant Staphylococcus Aureus (MRSA) Education Initiative disseminates knowledge about MRSA in community settings. It promotes recognition of signs and symptoms, diagnosis and treatment, and prevention and control measures appropriate for MRSA. Information is available for clinical audiences and the general public, particularly high-risk groups.
The AHRQ-sponsored Keystone ICU Project helped 108 intensive care units reduce rates of blood stream infections associated with central venous catheters. AHRQ is currently working to develop tools to teach additional hospitals how to reduce these types of complications. AHRQ is also supporting training of multidisciplinary hospital teams to address hospital-acquired MRSA and other health care-associated infections.
Improving quality is a "team sport." TeamSTEPPS is an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and teamwork skills among health professionals. It includes a comprehensive set of ready-to-use materials and a training curriculum to integrate teamwork principles into any health care system. The Department of Defense, in collaboration with AHRQ, developed TeamSTEPPS and has built a national training and support network called the National Implementation of TeamSTEPPS Project. This network is currently conducting training sessions throughout the country.
Partnerships do the actual work of making improvements. In 2008, HHS designated 25 communities as Chartered Value Exchanges (CVEs). These local collaborations of health care providers, employers, insurers, and consumers work jointly to improve care and make quality and price information widely available. CVEs have access to Medicare data on physician quality of care, which they can combine with private-sector data to produce comprehensive community guides to quality. They are also part of a nationwide Learning Network that provides peer-to-peer learning experiences and technical assistance.
In 2008, the Centers for Medicare & Medicaid Services (CMS) awarded contracts to Quality Improvement Organizations (QIOs) for the 9th Scope of Work, which will run through 2011. This collaboration focuses on improving the quality and safety of health care services to Medicare beneficiaries. The work of QIOs contributed substantially to the rapid improvement in the HQA measures they track. New activities include work on projects that span the entire spectrum of the health community, intensive support of providers most in need of QIO assistance, and development of a more robust monitoring framework that will track the impact QIOs are having on the quality of care provided to Medicare beneficiaries.
The Health Resources and Services Administration (HRSA) over the last decade has operated quality improvement collaboratives know as the Health Disparities Collaboratives, as well as other collaboratives such as the Organ Transplant Collaborative and the Patient Safety Clinical Pharmacy Collaborative. These adult-learner national learning networks have connected Federal and national partners, State, County, and local partners, and many private organizations such as foundations, professional organizations, and subject matter experts. These collaboratives have shown significant outcomes in improving health care.
Reporting of Hospital Quality Is Leading Improvement, but Patient Safety Is Lagging
In the analysis of trends for this year's NHQR, it is also clear that quality improvements continue to be unevenly spread across the settings of care examined in the NHQR. Some areas have shown increasing rates of improvement while improvements in other areas have slowed. For example, care delivered in hospitals improved at an annual rate of change of almost 3%, which continues to be the highest rate of quality improvement among the major health care delivery settings. Hospital improvement was led by Hospital Quality Alliance (HQA) measures that are submitted to the Centers for Medicare & Medicaid Services (CMS) for pay-for-reporting and public reporting on the Hospital Compare Web site. The top four core measures that improved the fastest were all composites of HQA measures. In contrast, care in ambulatory settings improved at a rate that only slightly exceeded 1%.
Figure H.2. Median annual rate of change overall and by health care setting from baseline to most recent data year
Note: Not all measures were included in the "all measures" category. For example, the 13 composite measures were not included because their component measures were included. Also, measures for which there is only one year of data were not included. Go to Chapter 1, Introduction and Methods, for discussion of year intervals used for analysis. Ns indicate number of measures included in each group.
- The median annual rate of change for hospital measures is twice the rate for all measures (Figure H.2). In this category, 65% of the measures showed some improvement (39 out of 60).
- Rates for home health and long-term care measures also improved at a rate greater than the overall rate.
- Although ambulatory care measures, covering care typically delivered in doctors' offices and other outpatient settings, had the lowest rate, 75% of these measures showed at least some improvement.
When examining change across multiple diseases and care settings, it is often difficult to determine from the available data why changes in performance occur. Public reporting and strong advocacy from multiple stakeholders in support of quality, as in the case of HQA measures, may influence broad system change and subsequent quality improvements in certain areas. Institutional health care settings, such as hospitals and nursing homes, typically have structured quality improvement programs that help raise performance in these organizations. Usually, ambulatory care settings do not have such programs. The availability of health information technology (HIT) as part of institutional infrastructure may also contribute to improvements in quality.
Improvement is important across all dimensions of health care quality. It is critically important in the area of patient safety. Patients have an expectation that they will not be harmed by the health care they receive. For 6 years, the National Healthcare Quality Report and the National Healthcare Disparities Report (NHDR) have presented a snapshot of the safety of health care provided to the American people. This analysis has been based on a set of databases that were created to respond to the need for information documented in such publications as the Institute of Medicine's landmark 2000 report To Err Is Human. Some of our findings are disturbing. For example, approximately one out of seven adult hospitalized Medicare patients experiences one or more adverse events.
Tracking trends in patient safety is complicated by difficulties assessing and ensuring the systematic reporting of medical errors and patient safety events. However, with improvements in data quality, a clearer picture of trends in health care safety is emerging. Distressingly, measures of patient safety in the NHQR indicate not only a lack of improvement but also, in fact, a decline of almost 1 percent in this area.
Figure H.3. Median annual rate of change by clinical condition and for patient safety from baseline to most recent data year
Note: Go to Chapter 1, Introduction and Methods, for discussion of year intervals used for analysis. Ns indicate number of measures included in each group.
- Respiratory disease measures showed the highest median annual rate of change across all measurement areas (Figure H.3).
- The rate of improvement for heart disease measures is nearly twice that for all measures.
- Cancer measures, as well as those for maternal and child health, showed modest improvement similar to the overall rate.
- Diabetes measures showed no improvement.
- Safety measures were the only area to show an overall decline, with only 45% of the measures showing at least some improvement (17 out of 38).
It is evident that more attention devoted to patient safety is needed to reverse this apparent trend and to help ensure that health care does not result in avoidable patient harm. Systems for identifying and learning from patient safety events need to be improved. Patient safety reporting systems are often laborious and cumbersome, and health care providers express fear that findings may be used against them in court or harm their professional reputations. Many factors, such as concerns about sharing data confidentially across facilities or State lines, limit the ability to aggregate data in sufficient numbers to rapidly identify important risks and hazards in the delivery of patient care. More work is also needed to develop measures that capture the underlying processes and conditions that lead to adverse events and the practices that are most effective in mitigating them.
Fortunately, recent progress has been made in raising awareness, improving event reporting systems, and establishing national standards for data collection. The Patient Safety and Quality Improvement Act of 2005 provides for the voluntary formation of Patient Safety Organizations (PSOs). These entities can receive and analyze patient safety data and work with providers to improve care without fear of legal discovery. PSOs can also report deidentified data to a Network of Patient Safety Databases, and findings from this resource will be published in future NHQRs and NHDRs.
Health Care Quality Measurement Is Evolving, but Much Work Remains
Just as the Nation works to understand and better define quality in health care consistent with current science, AHRQ and its report partners grapple with the challenge of applying uniform definitions of health care quality and measuring it in ways that provide the most meaningful information possible for policymakers and other users of the reports.
Improve Quality Measures
Although health care quality measurement is clearly evolving, much work remains. The complex nature of health care makes measuring the quality of health care services particularly difficult. As scientific evidence evolves, we must not only ensure revision and coordination of extant quality measures, but also develop new quality measures to address emerging issues. For example, it is increasingly recognized that some aspects of quality can best be assessed through a patient's eyes. Patients see problems from a personal perspective and may observe deficiencies that busy providers do not notice. They may be uniquely situated to detect flaws during transitions of care and experience the effects of inadequate care coordination.
Patient centeredness, the aspect of quality related to patient self-management and engagement in medical decisionmaking, can only be defined from a patient's perspective. Measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys capture some aspects of patient experience, but more work is urgently needed to expand patient-focused measures of health care quality.
Coordinate Measure Development
Another challenge is the often opportunistic, incremental, and fragmented development of quality measures without detailed consideration of data sources, analysis and maintenance requirements, and user needs. Uncoordinated and isolated measure development can lead different groups to create and advocate competing and sometimes conflicting measures of the same process or outcome. At best, this is duplicative; at worst, it can create confusion and unnecessary labor for providers trying to supply quality information to multiple stakeholders. Calls for new measures may also be hampered by resource constraints.
A related issue is whether and when to retire measures that indicate high performance levels. The benefits of continuing to monitor measures with high performance may be outweighed by the costs of data collection. On the other hand, continued but less frequent reporting of some measures may be needed to maintain vigilance, reduce disparities, and ensure continued high performance, as we have seen in areas of improved hospital treatment for heart attack and heart failure. The efficiency of measure development and retirement could be enhanced by more explicit coordination and support of this activity.
The work of the National Quality Forum (NQF) helps to enhance measure harmonization and reduce measure clutter. Its mission is to coordinate and promote the consensus development process for health care quality measurement among its organizational members. NQF has endorsed more than 500 measures, and this library represents the best means currently available to track quality of care. What is needed now is consensus on a single set of core measures that will be used by all payers and stakeholders to monitor quality improvement. Such a set would facilitate benchmarking and reduce the measurement burden on providers. Along with achieving consensus on a core measure set, systems for maintaining and revising this set are required. HHS recently released an inventory of quality measures used by the Department for reporting, payment, and quality improvement. This inventory is designed to help synchronize measurement and advance collaboration within the quality improvement community towards a uniform set of performance measures.
Also critical to development of health care quality measures is evidence-based medicine. Measures can only be developed where there is a firm understanding of the natural course of disease and the comparative effectiveness of diagnostic and therapeutic strategies. Rigorous, comprehensive syntheses of research studies need to be conducted using objective criteria and transparent processes. Research syntheses need to be translated into products usable by measure developers. Coordination of the measure development enterprise will require close and ongoing collaboration between the generators and synthesizers of scientific evidence.
Enable Health Information Technology to Support Quality Improvement
The unavailability of data is another obstacle. Realistically, HIT infrastructure is needed to ensure that relevant data are collected regularly, systematically, and unobtrusively. However, the high implementation costs of HIT to health care organizations often delay the quality measurement contributions that HIT would otherwise offer. In addition, information systems are necessary but insufficient for ensuring high-quality health care. Systems need to generate performance information that can be understood by end users and that are interoperable across different institutions' data platforms, policies, and procedures.
Quality improvement typically requires examining patterns of care across panels of patients rather than one patient at a time. Unfortunately, information systems often are not designed to collect data to support quality improvement as the primary purpose. Retrofitting legacy health information systems to capture data on quality measures is often labor intensive. Also, many benefits of improved information technologies require systems that go beyond simple automated record keeping. Ideally, performance measures should be calculated automatically from health records in a format that can be easily shared across all providers involved with a patient's care.
Promote Data Standardization
Another issue that has plagued data collection, especially related to patient safety, is the lack of standardized vocabularies that ensure a common definition of specific terms. Implementation of the Patient Safety and Quality Improvement Act of 2005 should help. AHRQ coordinated the development of common definitions and reporting formats for patient safety events. These Common Formats were released in 2008 and support data aggregation, analysis, and learning throughout the quality improvement cycle. AHRQ has contracted with NQF to assist in gathering and analyzing feedback on the Common Formats, and plans to issue updates and revisions based on user input.
Finally, pertinent to this report is the manner in which a large amount of complex information is condensed to create a meaningful summary for decisionmaking. In this 2008 NHQR, AHRQ has refined the criteria for selecting the data used to analyze trends and calculate summary estimates of changes in quality. This analysis is described in more detail in Chapter 1, Introduction and Methods.
With the publication of this sixth NHQR, AHRQ stands ready to contribute to efforts that encourage and support the development of national, State, tribal, and "neighborhood" solutions using national data and benchmarks in quality. This report documents some areas where important progress has been achieved in improving patients' quality of life as well as many areas where much more should be done. We need to accelerate the pace of quality improvement, especially related to patient safety. The success of CMS reporting initiative may serve as a guide, but more work is needed to improve, standardize, and coordinate quality measurement. Information of quality then needs to be shared with partners with the skills and commitment to change health care. Building on data in the NHQR and NHDR and the State Snapshots, we believe that policymakers can design and target strategies and clinical interventions to ensure that patients receive the high-quality care that makes their lives better.
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