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National Healthcare Quality Report, 2013

Chapter 1. Introduction and Methods

In 1999, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce an annual report on "national trends in the quality of health care provided to the American people."i With support from the Department of Health and Human Services (HHS) and private-sector partners, AHRQ has designed and produced the National Healthcare Quality Report (NHQR) to respond to this legislative mandate. The NHQR provides a comprehensive overview of the quality of health care received by the general U.S. population and is designed to summarize data across a wide range of patient needs—staying healthy, getting better, living with chronic illness and disability, and coping with the end of life.

AHRQ was further tasked with producing an annual report that tracks "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations."ii Titled the National Healthcare Disparities Report (NHDR), this report examines disparities in health care received by designated priority populations. These populations consist of groups with unique health care needs or issues that require special focus, such as racial and ethnic minorities, low-income populations, and people with special health care needs. AHRQ's charge includes a directive to examine disparities in health care access, utilization, costs, outcomes, satisfaction, and perceptions of care.

The first NHQR and NHDR were significantly shaped by several Institute of Medicine (IOM) reports. Two of these reports, Crossing the Quality Chasm (IOM, 2001) and To Err Is Human (Kohn, et al., 2000), raised awareness about gaps in the quality of health care and patient safety. The extensive literature review included in a third report, Unequal Treatment (IOM, 2003), drew attention to disparities in the care rendered to racial and ethnic populations, low-income populations, and other vulnerable groups. Since 2003, AHRQ has designed and produced the NHQR and NHDR with support from an HHS Interagency Work Group and AHRQ's National Advisory Council. This is the 11th in the series of reports.

Evolution of the Reports

Over the past decade AHRQ has enhanced and refined the NHQR and NHDR measure set and methodology:

  • 2003: Reports were introduced.
  • 2004: Reports were expanded to include tracking of the Nation's progress in quality improvement and disparities reduction.
  • 2005: Reports introduced a set of core measures and several new composite measures.
  • 2006: Methods for quantifying and tracking changes in health care were refined.
  • 2007: Chapter on health care efficiency was introduced.
  • 2008: Chapter on patient safety was expanded. AHRQ commissioned IOM to review past reports and offer recommendations for enhancing future reports and associated products.
  • 2009: Theme focused on effects of lack of health insurance on quality and disparities. New sections were included on lifestyle modification, healthcare-associated infections, patient safety culture, and care coordination.
  • 2010: As recommended by IOM, a single Highlights chapter was produced integrating findings from both reports and concentrating on national priorities that IOM identified. Theme focused on care across the urban-rural continuum. New chapters on care coordination and health system infrastructure were added. Measure-specific benchmarks were introduced that reflect the high level achieved in the best performing States.
  • 2011: As mandated by the Patient Protection and Affordable Care Act of 2010,iii HHS produced a report to Congress on a National Strategy for Quality Improvement in Health Care (National Quality Strategy; HHS, 2011).iv This report set priorities for the Nation to advance three quality improvement aims: better care, healthy people, and affordable care. The Highlights of the NQHR and NHDR began concentrating on these priorities as well as those of the Action Plan to Reduce Racial and Ethnic Health Disparities. Theme focused on care received by older Americans. Lesbian, gay, bisexual, and transgender people were added as a new priority population experiencing health care disparities.
  • 2012: Reports began incorporating national tracking measures identified in the National Quality Strategy 2013 Annual Progress Report to Congress. Theme focused on health care disparities for granular ethnicity categories as defined by the 2011 HHS data collection standards for race and ethnicity.

The 2013 NHQR and NHDR continue to align measures with the National Quality Strategy in an effort to inform policymakers, the public, and other stakeholders of the Nation's progress in achieving National Quality Strategy aims. The theme of the 2013 reports highlights one of AHRQ's priority populations, individuals with disabilities, including children with special health care needs.

Expanded analyses of quality of care and access to care are presented for people with disabilities, who currently represent 20% of the adult population. Disability prevalence is expected to increase due to aging of the "Baby Boom" generation and increased life expectancy for those born with disability or who acquire disability (Froehlich, et al., 2013). This report also adds adults with multiple chronic conditions as a new priority population experiencing health care disparities.

Organization of the NHQR and NHDR

The NHQR and NHDR are designed as chartbooks that contain data on more than 250 health care quality measures from more than 45 databases. Measures in these reports are selected with guidance from the AHRQ Interagency Work Group, an advisory body of representatives from across many HHS agencies. Measures represented in these reports are among the most important and scientifically supported measures. Together, these measures provide an annual snapshot of how our Nation's health care system is performing and the extent to which health care quality and disparities have improved or worsened over time.

New this year, measures of the effectiveness of health care have been divided into two chapters. A chapter on effectiveness of care for common clinical conditions is followed by a chapter on effectiveness of care across the lifespan.

The NHQR and NHDR are complementary reports and, with few exceptions, are similarly organized. Where applicable, key findings from the NHDR are included in the NHQR, and NHQR findings are reported in the text of the NHDR. Readers should refer to the report from which results have been drawn to gather additional details on the data presented. Report chapters include the following:

A critical caveat should be noted regarding potentially avoidable hospitalizations. Comparatively high rates of potentially avoidable hospitalizations may reflect inefficiency in the health care system. Therefore, groups of patients should not be "blamed" for receiving less efficient care. Instead, examining disparities in efficiency may help make the business case for addressing disparities in care. Investments that reduce disparities in access to high-quality outpatient care may help reduce rates of avoidable hospitalizations among groups that have high rates.

Highlights, which immediately precede the current chapter, combines broad sets of measures to offer a high-level overview of the progress that has been made in advancing health care quality and reducing disparities in the United States. The Highlights chapter incorporates findings from both the NHQR and NHDR, and the same Highlights chapter is used in both reports.

Chapter 1: Introduction and Methods provides background on the NHQR and NHDR and modifications to the reports that have occurred over time. This chapter includes measures that have been added or retired from the measure list, along with an overview of the methods used to generate estimates, measure trends, and examine disparities.

Chapter 2: Effectiveness of Care for Common Clinical Conditions is organized around several clinical areas: cancer, cardiovascular disease, chronic kidney disease, diabetes, HIV and AIDS, mental health and substance abuse, musculoskeletal diseases, and respiratory diseases. New to the 2013 report are data from the Ryan White HIV/AIDS program that examine primary care and support services for people living with and affected by HIV disease.

Chapter 3: Effectiveness of Care Across the Lifespan examines four types of health care services that typically cut across clinical conditions: maternal and child health, lifestyle modification, functional status preservation and rehabilitation, and supportive and palliative care. New to the 2013 reports are measures of adolescent receipt of counseling about birth control and of patient perceptions of home health care.

Chapter 4: Patient Safety tracks safety within a variety of health care settings. In prior years, this chapter focused on hospitals, with an examination of healthcare-associated infections, postoperative and other hospital complications, and preventable hospital deaths. In the 2013 reports, this chapter has been expanded to include measures of patient safety in nursing homes, home health settings, and ambulatory care settings. Many new measures have been added from an assortment of new data sources.

Chapter 5: Timeliness examines the delivery of time-sensitive clinical care and patient perceptions of how quickly they receive care. Among the measures reported in this chapter are the ability to get care when the patient needs it and emergency department wait times.

Chapter 6: Patient Centeredness examines individual experiences with care in an office or clinic setting, as well as during a hospital stay. The 2013 reports include a new discussion of provider-patient communication for adults receiving home health care. Measures reported in this chapter focus on perceptions of communication with providers and satisfaction with the provider-patient relationship.

Chapter 7: Care Coordination presents data to assess the performance of the U.S. health care system in coordinating care across providers or services. Care coordination is measured, in part, using readmission measures as well as measures of success in transitioning across health care settings. The 2013 reports contain a new section on information gathering by home health care providers.

Chapter 8: Efficiency discusses how well the health care system promotes quality, affordable care, and appropriate use of services. The emphasis in this chapter is on overuse of health services, as measures representing misuse or underuse overlap with other sections of the report and are included in various chapters.

Chapter 9: Health System Infrastructure explores the capacity of the U.S. health care system to support high-quality care. Infrastructure measures, which are primarily structural measures of quality, include adoption of computerized data systems and the supply of selected health care professionals. The 2013 reports contain a new discussion of nurse practitioners and physician assistants and a new discussion on e-prescribing.

Chapter 10: Access presents measures that cut across several priority areas and includes measures that focus on barriers to care, such as lack of insurance, financial barriers to care experienced by the population with health insurance, and usual source of care.

Chapter 11: Priority Populations continues to be unique to the NHDR. This chapter summarizes quality and disparities in care for populations at elevated risk for receiving poor health care, including racial and ethnic minorities, low-income populations, older adults, residents of rural areas, and individuals with disabilities or special health care needs. New to the 2013 report is a display of the prevalence of multiple chronic conditions among Medicare beneficiaries and additional data from California on lesbian, gay, bisexual, and transgender populations.

Appendixes are available online for both the NHQR and NHDR at http://nhqrnet.ahrq.gov/inhqrdr/reports/nhqr. These consist of:

  • Data Sources, which provides information about each database analyzed for the reports, including data type, sample design, and primary content.
  • Measure Specifications, which provides information about how measures are generated and analyzed for the reports. Measures highlighted in the report are described, as well as other measures that were examined but not included in the text of the report.
  • Detailed Methods, which provides detailed methodological and statistical information about selected databases analyzed for the reports.

Alignment with National Quality Strategy priorities and tracking measures continues. Table 1.1 provides a crosswalk between the National Quality Strategy priorities and the report chapters. Chapter 11, Priority Populations, addresses all six priorities.

Table 1.1. Alignment of NHQR and NHDR chapters with National Quality Strategy priorities

Priority NHQR and NHDR Chapters Addressing Priority
Making sure care is safer by reducing harm in the delivery of care Chapter 4: Patient Safety
Ensuring that each person and family is engaged as partners in their care Chapter 6: Patient Centeredness
Promoting effective communication and coordination of care Chapter 7: Care Coordination
Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease Chapter 2: Effectiveness, Cardiovascular Disease Chapter 3: Effectiveness, Lifestyle Modification
Working with communities to promote wide use of best practices to enable healthy living Chapter 2: Effectiveness, Mental Health and Substance Abuse Chapter 3: Effectiveness, Lifestyle Modification
Making quality care more affordable for individuals, families, employers, and governments, by developing and spreading new health care delivery models Chapter 8: Efficiency Chapter 10 Access

Measure Set for the 2013 NHQR and NHDR

The 2013 reports continue to focus on a consistent subset of measures, the "core" measures, which includes the most important and scientifically supported measures in the full measure set. "Supporting measures" are included in summary statistics and may be presented to complement core measures in key areas. Often, data are unavailable to track these measures on an annual basis. In other cases, supporting measures do not meet methodological or other criteria for inclusion as core measures, but they are still useful in characterizing the performance of the health care system.

Core Measures

In 2005, the Interagency Work Group selected core measures from the full measure set. Consistency in core measures enables AHRQ to monitor trends over time to identify areas for which health care is improving or getting worse. Core measures are presented each year in which new data are available to report. A subset of the core measure group is presented on an alternating basis, typically rotating across odd or even years of the report. All alternating core measures are included in trend analyses. Examples of alternating measures include the set of measures focusing on breast cancer and colorectal cancer. While measures are tracked annually, breast cancer measures are presented in odd calendar years; these measures are contained in the 2013 reports. Colorectal cancer measures are also tracked annually, but results are presented in even calendar years, such as in the 2012 Quality and Disparities reports.

New Measures

With the assistance of the Interagency Work Group, each year AHRQ reviews the NHQR and NHDR measure list to identify areas where additional information on the performance of the health care system is needed. Suitability of a measure for reporting may be based on the adequacy of data used to generate the measure, extent to which the measure has been scientifically tested, and acceptance of the measure by relevant stakeholders. New measures, which are listed in Table 1.2, were presented to and approved by the members of the Interagency Work Group for inclusion in the 2013 reports.

Table 1.2. New measures in NHQR and NHDR, 2013

Chapter Measure Data Source
Effectiveness: Cardiovascular Disease Costs of disparities in hospitalizations for congestive heart failure Agency for Healthcare Research and Quality
Effectiveness: Maternal and Child Health Teens ages 15-19 years who received counseling or information about birth control from a health care provider during the last 12 months National Center for Health Statistics
Patient Safety Home health patients with improvement in their surgical site wounds Outcome and Assessment Information Set
Patient Centeredness Provider-patient communication among adults receiving home health care Home Health Care CAHPS
Care Coordination Information gathering by home health care providers among adults receiving home health care Home Health Care CAHPS

Retired Measures

Since the first NHQR and NHDR, significant improvements in a number of measures of quality of care have occurred, with U.S. health care providers achieving overall performance levels exceeding 95%. The success of these measures limits their utility for tracking improvement over time. Because these measures cannot improve to a significant degree, including them in the measure set creates a ceiling effect that may dampen quantification of rates of change over time.

Each year, measures for which performance has reached 95% are retired. Data on retired measures will continue to be collected and these measures will be added back to the reports if their performance falls below 95%. Note that this process differs from the removal of measures tracked by the Centers for Medicare & Medicaid Services (CMS). CMS uses different criteria to remove measures and ceases data collection of removed measures. The following measures were retired in 2013 because performance had reached the 95% threshold:

  • Hospital patients with heart failure and left ventricular systolic dysfunction prescribed angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge.
  • Hospital patients with pneumonia who had blood cultures collected before antibiotics were administered.
  • Hospital patients with pneumonia who received the initial antibiotic dose within 6 hours of hospital arrival.
  • Hospital patients age 65 and over with pneumonia who received a pneumococcal status assessment with vaccination if needed.

Priority Populations

In the NHQR and NHDR, measures are tracked for the overall population and for specific priority populations. Comparisons are made across groups defined by age, sex, race, ethnicity, income, education, health insurance, activity limitations, and geographic location. In general, the largest subgroup is used as the reference group. When supported by data, charts in the reports are standardized to show contrasts by:

  • Age: 0-17, 18-44, 45-64, and 65 and over.
  • Sex: Male and female.
  • Race: White, Black, Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and more than one race.v
  • Ethnicity: Hispanic and non-Hispanic.vi
  • Income: Poor, low income, middle income, and high income.vii
  • Education: People with less than a high school education,viii high school graduates, and people with any college.
  • Health insurance, ages 0-65: Any private insurance, public insuranceix only, and no insurance.
  • Health insurance, age 65 and over: Medicare and any private insurance, Medicare and other public insurance, and Medicare only.
  • Disabilities: Basic activity limitations include problems with mobility, self-care (activities of daily living), domestic life (instrumental activities of daily living), and activities that depend on sensory functioning (limited to people who are blind or deaf); complex activity limitations include limitations experienced in work and in community, social, and civic life. For the purpose of the NHDR, adults with disabilities are those with physical, sensory, and/or mental health conditions that can be associated with a decrease in functioning in such day-to-day activities as bathing, walking, doing everyday chores, and engaging in work or social activities. The paired measure is intended to be consistent with statutory definitions of disability, such as the first criterion of the 1990 Americans With Disabilities Act (ADA) (i.e., having a physical or mental impairment that substantially limits one or more major life activities [HHS, 2005; LaPlante, 1991]) and other Federal program definitions of disability.
  • Children with special health care needs (CSHCN): Children ages 0-17 with activity limitations or with the need or use of more health care or other services than is usual for most children of the same age. Question sequencesx are asked about the following five health consequences: the need or use of medicines prescribed by a doctor; the need or use of more medical care, mental health care, or education services than is usual for most children; limitations in or inability to do things most children can do; the need or use of special therapy such as physical, occupational, or speech therapy; and the need or use of treatment or counseling for emotional, developmental, or behavioral problems. Children with responses to at least one of the five health consequences along with all of the followup questions were identified as having a special health care need.
  • Geographic location: Large central metropolitan, large fringe metropolitan, medium metropolitan, small metropolitan, micropolitan, and noncore areas based on the National Center for Health Statistics Urban-Rural Classification Scheme (Ingram & Franco, 2006).

Other important groups have been more difficult to identify in health care data. Beginning in the 2011 reports, information on lesbian, gay, bisexual, and transgender people has been included, but few databases support these analyses. Beginning in the 2012 reports, contrasts by granular racial subgroups have been included. Information on populations identified as Mexican, Puerto Rican, Cuban, other Hispanic/Latino/Spanish origin, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, other Asian, Native Hawaiian, Guamanian or Chamorro, Samoan, and other Pacific Islander have been sought but no health care database that identifies all of these subgroups has been found. Beginning in these 2013 reports, analyses by number of multiple chronic conditions have been included, but databases differ in the chronic conditions that can be identified. Improving measurement and data for these groups is critical to understand the reasons they cannot access high-quality health care and to develop effective interventions to help them overcome these barriers.

While the reports do not address social determinants directly, analyses of disparities in health care related to family income and education are at the core of the Disparities Report and demonstrate the importance of socioeconomic status on quality of and access to health care. The CDC Health Disparities and Inequalities Report (CDC, 2013) includes further discussion on social determinants of health.

Analyses

Size of Disparities Across Groups

Two criteria are applied to determine whether the difference between two groups is meaningful:

  • First, the difference between the two groups must be statistically significant with p <0.05 on a two-tailed test.
  • Second, the relative difference between the comparison group and the reference group must have an absolute value of at least 10%.

Adjusted percentages, which quantify the magnitude of disparities after controlling for a number of confounding factors, were generated for several measures in the Effectiveness and Access chapters of the NHDR. In examining the relationship between race and ethnicity, for example, multivariate regression analyses were performed to control for differences in the distribution of income, education, insurance, age, gender, and geographic location.

Trend Analyses

Prior to the 2011 report a log-linear regression analysis was conducted to estimate average annual rate of change.xi Historically, progress on individual measures was reported based solely on the magnitude of the annual rate of change. Progress on a measure was deemed to be improving if the annual rate of change was greater than 1% in the desirable direction. Progress on a measure was deemed to be getting worse when the annual rate of change was greater than 1% in the undesirable direction.

  • Model:            ln(M) = β0 + β1Y, where ln(M) is the natural logarithm of the measure value, β0 is the intercept or constant, and β1 is the coefficient corresponding to year Y
  • Weight:           w = (M2/v), where M2 is the square of the measure value and v is the variance

Progress on individual measures was determined as follows:

  • Progress on a measure is deemed to be improving if the average annual rate of change is greater than 1% in the desirable direction, and p < 0.10.xii
  • Progress on a measure is deemed to be getting worse when the average annual rate of change is greater than 1% in the undesirable direction, and p < 0.10.
  • Progress is determined to have remained the same if the average annual rate of change is less than or equal to 1% in either the desirable or undesirable direction or p ≥ 0.10.

Trends in Disparities in Population Subgroups

Across subpopulation groups, absolute annual changes were estimated to ascertain the extent to which disparities in quality and access measures were increasing, decreasing, or remaining the same over time. As shown below, calculation of change in subgroup disparities was conducted in a manner similar to that described above, except that a linear regression model was used in the analyses.

  • Model:            M = β0 + β1Y, where M is the value of the measure, β0 is the intercept or constant, and β1 is the coefficient corresponding to year Y
  • Weight:           w = (1/v), where v is the variance

New this year, the difference in annual change between a group and its reference group relative to the reference group baseline estimate was calculated. Determinations of whether subgroup differences have grown, narrowed, or remained the same were based on estimated differences in annual change as specified below:

  • Subgroup differences are deemed to be narrowing if the change in disparities is less than −1% per year and p < 0.10.
  • Subgroup differences are deemed to be growing if the change in disparities is greater than 1% per year and p < 0.10.
  • Subgroup differences are deemed to have remained the same if the change in disparities is  −1% to 1% per year or p ≥ 0.10.

Only those measures with 4 or more years of data were included in this trending analysis. Due to methodological changes in trending analysis, it is not appropriate to compare the annual changes for measure subgroups estimated with this method to those estimated prior to the 2011 report.

Benchmarking Strategy

Measure-specific benchmarks were first incorporated into the NHQR and NHDR in 2010. Benchmarks reflect the highest level of performance documented for individual measures, with performance assessed at the State level. Benchmarks enable readers to assess national performance on a measure relative to that of the highest performing States. They also aid in establishing reasonable performance improvement goals.

From an equity perspective, standards of performance should not differ across population groups. As such, benchmarks corresponding to measures included in both the NHQR and NHDR were identical. Benchmarks were estimated for the subset of measures for which State data were available.

With few exceptions, values of benchmarks estimated in 2010 (which were based on 2008 data) have been carried over to the 2013 reports. These exceptions include measures for which the benchmark has been reached. For this small number of measures, which are identified in the relevant chapters of the reports, newer data are used to construct new benchmarks.

For measures for which State-level data were available, benchmarks were estimated as the average value for the 10% of States that had the best performance on the measure of interest. The benchmarks are based on 50 States and the District of Columbia. Benchmarks were estimated only if data were available for a minimum of 30 States. The States that contributed to the benchmark for the measure of interest are noted in alphabetical order in the footnotes.

State-level estimates used in constructing benchmarks were primarily calculated from the same data source as the measure. In some cases, such as when the number of individuals sampled from a specific State was too small, data did not support estimation at a subnational level and benchmarks were not identified. We made exceptions for three measures derived from the Medical Expenditure Panel Survey (MEPS) and the National Health Interview Survey (NHIS).

For these measures of colorectal cancer screening, diabetes care, and pneumococcal vaccination, almost identical data were available from Behavioral Risk Factor Surveillance System (BRFSS) State data. However, BRFSS sampling and mode of administration differ from MEPS and NHIS. Hence, to calculate a benchmark for these measures, we first calculated the ratio of the benchmark based on the top 10% achievable benchmark to the overall national estimate from BRFSS. We then applied this ratio to the overall national estimate from MEPS or NHIS. For example, if the BRFSS benchmark to national estimate ratio for a measure was 1.5, we would multiply the national estimate for that measure from MEPS by 1.5 to obtain a corresponding benchmark.

Time To Achieve Benchmark

The reports again include projections of the time expected for population subgroups to achieve the designated benchmark based on past performance. Using standard linear regression of the actual values over time and extrapolating to future years, we calculated the time required for the population, or population subgroup, to perform at the level of the best performing States. Since projections of future performance were based on past performance data, we needed to ensure reliability by limiting estimates to those cases in which at least 4 data points were available.

An important caveat to consider in using information on time to achieve benchmarks is that the linear estimation approach used to derive these estimates assumes that characteristics of the population, technology, and health care infrastructure remain constant. Changes in the characteristics of the population or health care system may be expected to alter achievement of benchmarks. Advances in medical science, changes in the organization of health services, or reductions in the uninsured population following implementation of the Patient Protection and Affordable Care Act would be expected to alter the performance trajectory. In some cases, the time to achieve the benchmark will drop, while in other cases it may increase.

Time to achieve a benchmark is not presented for measures that met one or more of the following conditions:

  • Average annual rate of change is less than 1%.
  • Time to benchmark of all groups is estimated at 25 or more years.
  • Trends over time show movement away from the benchmark (these occurrences are mentioned in the reports).
  • Direction of trend changes over time; operationally, these were identified as cases in which there were at least 4 years of data showing "upward" movement and at least 4 years of data showing "downward" movement.

Methods Used in Highlights

Data presented in the Highlights differ from those in other chapters of the report in that measures are grouped along several dimensions that offer insight into the performance of specific elements of the health care system. Groupings include:

  • Type of quality measure: Processes and outcomes of care.
  • Type of care: Prevention, acute care, and chronic disease management.
  • Settings of care: Hospital, nursing home, home health and hospice, and ambulatory settings.
  • Geographic regions: New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, West South Central, Mountain, and Pacific census divisions.

The Highlights also summarize disparities by race and ethnicity. For each racial or ethnic subgroup, the percentages of measures for which that group received worse care, similar care, or better care than the reference group (White or non-Hispanic White) were estimated. Group rates were divided by reference group rate to calculate the relative rate for core measures, with each core measure framed negatively (e.g., for immunization, the likelihood of not receiving the vaccine).

The process involved in compiling data for the Highlights is complicated by the fact that data on all measures are not collected or reported each year. In the summary trend analyses, we obtain all available data points between the year 2000 and the current data year for each measure. For most measures, trends include data points from 2000-2002 to 2010-2011.

In addition, we examine trends for subsets of the measure set for which estimates are available each year. Table 1.3 lists the quality measures for which estimates are available every year from 2005 to 2010 and constitute the panel of quality of care process measures shown in the Highlights, as well as the access measures for which estimates are available every year from 2002 to 2011 and constitute the panel of access measures shown in the Highlights.

To avoid duplication of estimates within categories, composite measures are not included in other categories where estimates from their component measures are used. For example, the diabetes composite measure (which includes hemoglobin A1c measurement, eye exam, flu vaccination, and foot exam) contributes to the overall rate for the core measures group but not to the diabetes group rate, which uses the estimates from the four supporting component measures.

Using the analytic approach previously described, we calculated the sum of measures that were identified as better, worse, or the same (when considering subgroup differences) or that were improving, worsening, or remaining the same over time (when considering trend data). The distribution of measures by subpopulation, type of service, and type of measure (i.e., quality or access) is presented as a way to summarize the status of health care quality and disparities in the United States.

Table 1.3. Panels of measures used in the Highlights 

Quality of care measures
  • Women with clinical Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at the time of surgery (lumpectomy or mastectomy).
  • Women under age 70 treated for breast cancer with breast-conserving surgery who received radiation therapy to the breast within 1 year of diagnosis.
  • Patients with colon cancer who received recommended treatment: resected colon specimen had at least 12 regional lymph nodes pathologically examined.
  • Hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge
  • Adults age 40 and over with diagnosed diabetes who received 2 or more hemoglobin A1c measurements in the calendar year
  • Adults age 40 and over with diagnosed diabetes who received a dilated eye examination in the calendar year
  • Adults age 40 and over with diagnosed diabetes who had their feet checked for sores or irritation in the calendar year
  • Adult patients with HIV and at least two CD4 cell counts of 200 or less who received Pneumocystis pneumonia prophylaxis during the past year
  • Adult patients with HIV and at least two CD4 cell counts of 50 or less who received Mycobacterium avium complex prophylaxis during the past year
  • Children ages 19-35 months who received 4 or more doses of diphtheria-tetanus-pertussis vaccine
  • Children ages 19-35 months who received 3 or more doses of polio vaccine
  • Children ages 19-35 months who received 1 or more doses of measles-mumps-rubella vaccine
  • Children ages 19-35 months who received 3 or more doses of Haemophilus influenzae type B vaccine
  • Children ages 19-35 months who received 3 or more doses of hepatitis B vaccine
  • Children ages 19-35 months who received 1 or more doses of varicella vaccine
  • Children who had their height and weight measured by a health provider within the past 2 years
  • Children ages 2-17 who had a dental visit in the calendar year
  • Children ages 3-6 who ever had their vision checked by a health provider
  • Children for whom a health provider gave advice within the past 2 years about how smoking in the house can be bad for a child
  • Children 0-40 lb for whom a health provider gave advice within the past 2 years about using a child safety seat while riding in the car
  • Children 41-80 lb for whom a health provider gave advice within the past 2 years about using a booster seat when riding in the car
  • Children over 80 lb for whom a health provider gave advice within the past 2 years about using lap or shoulder belts when driving or riding in a car
  • Children ages 2-17 for whom a health provider gave advice within the past 2 years about using a helmet when riding a bicycle or motorcycle
  • People age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months
  • People age 12 and over who needed treatment for an alcohol problem and who received such treatment at a specialty facility in the last 12 months
  • Adults ages 18-64 at high risk (e.g., COPD) who received an influenza vaccination in the last 12 months
  • Adults age 65 and over who received an influenza vaccination in the last 12 months
  • Adults ages 18-64 at high risk (e.g., COPD) who ever received pneumococcal vaccination
  • Adults age 65 and over who ever received pneumococcal vaccination
  • Hospital patients with pneumonia who had blood cultures collected before antibiotics were administered
  • Hospital patients with pneumonia who received the initial antibiotic dose consistent with current recommendations
  • Hospital patients age 50 and over with pneumonia discharged during October-February who received an influenza screening or vaccination
  • Hospital patients age 65 and over with pneumonia who received a pneumococcal screening or vaccination
  • People with current asthma who are now taking preventive medicine daily or almost daily (either oral or inhaler)
  • Adult current smokers with a checkup in the past year who received advice in last 12 months to quit smoking
  • Adults with obesity who ever received advice from a health professional to exercise more
  • Children ages 2-17 for whom a health provider gave advice within the past 2 years about the amount and kind of exercise, sports, or physically active hobbies they should have
  • Adults with obesity who ever received advice from a health professional about eating fewer high-fat or high-cholesterol foods
  • Children ages 2-17 for whom a health provider gave advice within the past 2 years about healthy eating
  • Long-stay nursing home residents who spend most of their time in bed or in a chair
  • Long-stay nursing home residents who have moderate to severe pain
  • Low-risk long-stay nursing home residents with a catheter inserted and left in their bladder
  • Home health care patients who have less shortness of breath
  • Home health care patients who have less urinary incontinence
  • Home health care patients who needed urgent, unplanned medical care
  • Short-stay nursing home residents who had moderate to severe pain
  • Short-stay nursing home residents with pressure sores
  • Short-stay nursing home residents with delirium

Access to care measures

  • People under age 65 with health insurance
  • People under age 65 with any private health insurance
  • Adults age 65 and over with any private health insurance
  • People under age 65 who were uninsured all year
  • People under age 65 with any period of uninsurance during the year
  • People without a usual source of care who indicate a financial or insurance reason for not having a source of care
  • People with a usual primary care provider
  • People unable to get or delayed in getting needed medical care, dental care, or prescription medicines due to financial or insurance reasons
  • People unable to get or delayed in getting needed medical care
  • People unable to get or delayed in getting needed dental care
  • People unable to get or delayed in getting needed prescription medicines
  • People with a usual source of care, excluding hospital emergency rooms, who has office hours nights or weekends
  • People with difficulty contacting their usual source of care during regular business hours over the telephone about a health problem

Key: COPD = chronic obstructive pulmonary disease.

Reporting Conventions

In presenting data and results, the NHQR and NHDR adhere to the following conventions, which are presented below to facilitate understanding of report findings.

  • Unless otherwise stated, results discussed in the reports are statistically significant at the p < 5% level for subgroup differences and at the p < 10% level for trend analyses.
  • For most measures presented in the reports, a higher score indicates better performance. However, in some cases, lower scores are better. Measures for which lower scores represent better performance are identified in chart notes.
  • Trend analyses were performed only for measures for which a minimum of 4 years of data were available.
  • Information on the construction of each measure is not always contained in the text, and readers should refer to the Measure Specifications appendix for measure details.
  • When racial subgroups used by data sources for routine reporting are inconsistent with NHQR and NHDR standards, the source classification is used in the reports.
  • Some measures may omit certain racial or ethnic groups because data for these groups were unavailable or did not meet criteria for statistical reliability, quality, or confidentiality. 

References

Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report – United States, 2013. MMWR 2013;62(Suppl 3). Available at: www.cdc.gov/mmwr/pdf/other/su6203.pdf (PDF File, 2.8 MB). Accessed January 16, 2014.

Froehlich-Grobe K, Lee J, Washburn RA. Disparities in obesity and related conditions among Americans with disabilities. Am J Prev Med 2013;45(1): 83-90.

Ingram D, Franco S. 2006 Urban-Rural Classification Scheme for Counties. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Health Statistics; 2006. Available at: http://www.cdc.gov/nchs/data_access/urban_rural.htm. Accessed November 3, 2013.

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.

Institute of Medicine, Committee on Future Directions for the National Healthcare Quality and Disparities Reports. Future directions for the National Healthcare Quality and Disparities Reports. Washington, DC: National Academies Press; 2010.

Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; 2003.

Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer health system, Washington, DC: Institute of Medicine, Committee on Quality of Health Care in America; 2000.

LaPlante MP. The demographics of disability. Milbank Q 1991;69 (Suppl 1-2):55-77.

Report to Congress: national strategy for quality improvement in health care. Washington, DC: U.S. Department of Health and Human Services; March 2011.

The Surgeon General's call to action to improve the health and wellness of people with disabilities. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General; 2005.


i 42 U.S.C. 299b-2(b)(2).
ii I42 U.S.C. 299a-1(a)(6).
iii Public Law 111-148.
iv The National Quality Strategy identified six priority areas as a means to achieve the quality improvement aims. These include: (1) making sure care is safer by reducing harm in the delivery of care; (2) ensuring that each person and family is engaged as partners in their care; (3) promoting effective communication and coordination of care; (4) promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease; (5) working with communities to promote wide use of best practices to enable healthy living; and (6) making quality care more affordable for individuals, families, employers, and governments, by developing and spreading new health care delivery models.
v Asian includes the former category of Asian or Pacific Islander prior to Office of Management and Budget guidelines, when information was not collected separately by group.
vi Not all data sources collect information by race and ethnicity separately. In such cases, comparisons are made by combining racial/ethnic group categories (e.g., comparing non-Hispanic Blacks and Hispanics with non-Hispanic Whites.)
vii Unless otherwise indicated, throughout this report, poor is defined as having family income less than 100% of the Federal poverty level (FPL); low income refers to income of 100% to 199% of the FPL; middle income refers to income of 200% to 399% of the FPL; and high income refers to income of 400% of the FPL and above. These are based on U.S. census poverty thresholds for each data year, which are used for statistical purposes.
viii Less than a high school education refers to people who did not complete high school.
ix Public insurance includes Medicaid, Children's Health Insurance Program (CHIP), State-sponsored or other government-sponsored health plans, Medicare, and military plans.
x A CSHCN Screener instrument was developed through a national collaborative process as part of the Child and Adolescent Health Measurement Initiative coordinated by the Foundation for Accountability. For more information, see: Bethel CD, Read D, Stein REK, et al. Identifying children with special health care needs: development and evaluation of a short screening instrument. Ambul Pediatr 2002 Feb;2(1):38-48.
xi Regression models were specified as follows: ln(M) = β0 + β1(Y), where ln(M) = natural logarithm of the measure value (M); β0 = intercept or constant; β1(Y) = coefficient corresponding to year (Y). The average annual rate of change was calculated as 100 x (exp(β1) − 1).
xii A probability of 0.10 was selected as the significance level because the magnitude of the standard errors varied considerably by type of data.


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 1. Introduction and Methods. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhqr13/chap1.html

 

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