Strengthen Quality Measurement and Improvement

AHRQ's second research goal includes developing and testing measures of quality, as well as studies of the best ways to collect, compare, and communicate these data, and identifying and widely disseminating effective strategies to improve quality of care. To facilitate the use of this information in the health care system, the Agency focuses on research that determines the most effective ways to improve health care quality, including promoting the use of information on quality through a variety of strategies, such as information dissemination and assessing the impact on health care organization and financing.

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Measuring and Improving the Quality of Health Care

In Fiscal Year 1999, AHRQ funded a significant expansion of quality agenda using various strategies, including:

• Funding new research to better understand the determinants of quality, supporting the development of new tools to enhance our ability to accurately measure the quality of care, particularly for sub-groups of the population who may be at-risk for poor quality, and working with public and private sector partners to foster the translation of new findings into practice.
• Serving as a convener of public and private stakeholders (e.g. the directors of the Nation's leading multi-specialty groups) to both identify key quality challenges where an evidence base is lacking to improve quality and to disseminate new findings.
• Acting as the government's lead Agency for the Quality Interagency Coordination (QuIC) Task Force and shepherding numerous initiatives, including addressing, in partnership with the Department of Labor, how health care workers' environment can affect the quality of patient care delivered.
• Actively disseminating results and evidence based tools to the general public, health care system leaders, and State policymakers.

In Fiscal Year 1999, AHRQ funded 24 grants, totaling over $8.8 million, to measure and improve the quality of health care. These grants included responses to three Requests for Applications (RFAs):

1. Translating Research into Practice (TRIP)—To generate new knowledge about approaches, both innovative and established, that are effective and cost-effective in promoting the use of rigorously derived evidence in clinical settings and lead to improved health care practice and sustained practitioner behavior change.
2. Quality Measurement for Vulnerable Populations—To develop and test new quality measures which can be used in the purchase or improvement of health care services for vulnerable populations.
3. Assessment of Quality Improvement Strategies in Health Care—To rigorously evaluate strategies for improving health care quality that are currently in widespread use by organized quality improvement systems.

Translating Research Into Practice (TRIP)

AHRQ has a growing agenda to accelerate the translation of research into clinical practice. The Agency is committed to informing practitioners, patients, consumers and other decisionmakers about needed health care changes as revealed by research. As we obtain the knowledge of what can be improved, the Agency must be able to promote the adoption and use of these research findings. By doing so, we will be better able to demonstrate that the benefits observed in research are achievable in daily practice and yield measurable and sustainable improvements in health care. AHRQ's commitment to translating research into practice, particularly to overcome racial and ethnic disparities of care, was strengthened significantly in Fiscal Year 1999.

TRIP I. In Fiscal Year 1999, AHRQ published the Translating Research into Practice (TRIP I) RFA. The following six projects were funded and address a variety of health care problems, primarily through randomized controlled trials:

• Improving Diabetes Care Collaboratively in the Community. The objective of this grant is to improve quality of care and health outcomes of indigent, vulnerable patients with diabetes who receive their care at community health centers (CHC), critical sites of primary care for 10 million Americans who reside in medically underserved areas. (University of Chicago)
• Do Urine Tests Increase Chlamydia Screening in Teens? The objective of this study is to improve screening for chlamydia among sexually active young women. Chlamydia is the most common sexually transmitted disease and is associated with pelvic inflammatory disease and sterility. The purpose of the study is to have doctors implement existing guidelines for chlamydia screening in a network-model managed-care system. This is the first time such a study has been done in a network-model system. (University of California at San Francisco)
• Evidence Based Practice: From Book to Bedside. Despite ample evidence of the clinical benefits of improved pain management and the existence of an AHRQ pain-management guideline, practice has been very slow to change, and pain is still greatly undertreated. The objective of this study is to promote the use of a multidimensional approach to treating acute pain in hospitalized elderly. This study would also determine the cost-effectiveness of the intervention. (University of Iowa)
• Evidence-based 'Reminders' in Home Health Care. In 1996, 3.6 million Medicare beneficiaries received 3 million home health visits at a cost of more than $18 billion. Although home health is a major provider of health care, a 1999 study by the IOM noted that little is known about processes or outcomes of care associated with home health services. This study will examine providers' use of evidence-based guidelines in the treatment of two highly prevalent chronic diseases—congestive heart failure and cancer—and the impact that use of guidelines has on the quality and cost of care. (Visiting Nurse Service of New York)
• Evidence-based Surfactant Therapy for Preterm Infants. Surfactant is the natural substance that prevents the collapse of lung tissue and is lacking in premature infants. This puts them at risk of lung collapse and respiratory distress syndrome (RDS). These problems require mechanical ventilation, increase the cost of care, and put infants at increased risk of death. However, these problems could be reduced if existing guidelines were followed, which recommend that all premature infants be given surfactant, typically within 15 minutes of delivery. This practice is not yet common, and surfactant is typically given only to premature infants in obvious respiratory distress. The purpose of this study is to encourage the appropriate and timely use of surfactant. (University of Vermont)
• Practice Profiling to Increase Tobacco Cessation. Smoking is the leading cause of preventable death and disability. In 1996 AHRQ published its "Clinical Guideline for Smoking Cessation." This guideline endorsed the four key performance components of tobacco cessation activities for practices: ask, advise, assist and arrange. A substantial body of literature suggests that there are significant barriers for physicians who try to implement these activities. One barrier is the lack of performance data that helps physicians assess their effectiveness when supplying smoking cessation services to their patients. The aim of this proposal is to answer the question: Does personalized data feedback (profiling) of tobacco cessation performance to physicians improve their provision of these services? (Maine Medical Assessment Foundation)

Translating Research Into Practice II (TRIP II). In Fiscal Year 2000, AHRQ published a second Request for Applications (RFA) for TRIP. Seven million dollars has been set aside for this RFA. TRIP II is aimed at applying some of the techniques and methods developed in idealized practice settings or based on theoretical constructs to community-based settings.

TRIP II focuses on partnerships between researchers and health care systems and organizations (e.g., purchaser groups, integrated health service delivery systems, academic health systems, and managed care programs) to evaluate different strategies for improving the quality of care. Priority in funding is being placed on one or more of seven specified areas—the six in the President's Race and Disparities Initiative (infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV infection/AIDS, and immunizations) and pediatric asthma. Of particular interest are health systems and organizations that utilize the strengths of information systems for implementing strategies for quality improvement.

Half of the $7 million will be used for projects that translate research findings to improve quality of care for minorities, and up to $1.2 million for the translation of research on pediatric asthma into practice. Another $1.05 million will be targeted to applicants previously funded by AHRQ who have developed strategies for translating evidence into practice through partnerships with organizations, but have not had the funds to evaluate these strategies (e.g., PORTs and PORT-IIs). For these projects, the topic may be outside of the seven specified areas.

Quality Measurement for Vulnerable Populations

In Fiscal Year 1999, AHRQ funded 13 grants, for a total of $3.6 million, related to developing and testing quality measures for vulnerable populations. Quality measures provide a tool to evaluate whether a health care provider has taken an appropriate action at the right time, given a patient's condition and preferences. Simple examples of quality measures include the percentage of diabetics receiving yearly eye or foot examinations, or the percentage of patients with pneumonia who receive a correct antibiotic within an appropriate time frame. A summary of selected grants from this specific effort is provided below:

• Quality of Hypertension Care for Asian Refugees. This project will study the Hmong in Fresno California, who are Southeast Asian refugees who have poorer health than the general population. The researchers will conduct focus groups with both the Hmong and their health care providers in order to develop quality-of-care instruments that are culturally sensitive to the Hmong. The goal of the project is to improve hypertension care for this population. (University of California at San Francisco)
• Measuring Patient Satisfaction: Low Literacy Populations. The purpose of this project is to adapt the Consumer Assessment of Health Plans (CAHPS®) survey to serve adults with low levels of literacy. The investigators will develop an illustrated version and an interactive voice-response version of the self-administered CAHPS®, which has been widely adopted by managed care organizations to measure patient satisfaction with the quality of care. Both of the new instruments will be tested in a Medicaid population in Philadelphia. (University of Pennsylvania)
• Measuring the Quality of Care for Diabetes. This study will use Medicaid data from six States to develop a quality measure for ambulatory diabetes care. The States, selected because of a low prevalence of Medicaid managed care, are Kentucky, Pennsylvania, Alabama, Georgia, California and Indiana. (Harvard University)

Quality Improvement Strategies in Health Care

In Fiscal Year 1999, AHRQ awarded $2.6 million to support five grants to assess quality improvement strategies, including education, the use of information systems, continuous quality improvement, behavioral interventions, and the use of regulations. These projects will bolster our understanding of which quality improvement efforts work for which conditions, which types of patients, and under what circumstances. The findings from these studies will strengthen the underlying evidence base for efforts to bring better care to all Americans. A summary of selected grants is provided below:

• Organizational Determinants of HIV Care Improvement. HRSA requires new Title-III recipients of Ryan White funds to participate in a continuous quality-improvement (CQI) program. This project is taking advantage of this requirement by testing prospectively the value of this process-oriented approach to quality improvement. It is assessing the quality of HIV care provided by participating clinics, changes in such care subsequent to quality training, and the organizational characteristics and policies related to such changes. (Harvard Medical School)
• Strategies for CQI: A National Randomized Trial. This project is assessing the impact of a national cardiac surgery database in providing the infrastructure needed to conduct a national program of quality improvement for patients undergoing coronary artery bypass grafting procedures. The aims of the research are to:
  1. Demonstrate that a national voluntary database mechanism can collect and process outcomes measures that can be used for large-scale quality-improvement initiatives.
  2. Demonstrate that national bypass surgery risk-adjusted benchmarks can be developed from these data and applied in individualized reports to improve quality.
  3. Perform a national randomized trial to determine whether specific surgical care patterns can be influenced by a performance feedback.
  4. Determine the incremental value of regional continuous quality-improvement efforts.
  (Society of Thoracic Surgeons, Chicago)
• Evaluating Quality Improvement Strategies. This project is testing the effectiveness of an office-based quality-improvement strategy for the treatment of childhood asthma. This study has a community-based setting in 70 primary care practices. The quality interventions focus on increasing the degree to which the individual practices use known "best clinical practices" for pediatric asthma care. Each practice will target those areas found to be most in need of improvement at that particular practice. A sample of areas being targeted include appropriate use of anti-inflammatory medicine, use of a written plan of action for at-home use, and control of environmental factors in the home that trigger asthma attacks, such as dust and smoking. Because of the high degree of participation by all of the primary care practices within this integrated health care delivery system, improved treatment will also be a reality by the end of the project period. (Children's Hospital, Boston)

New Efforts to Measure and Improve the Quality of Health Care

In Fiscal Year 2000, AHRQ continues to focus on quality improvement and quality-measures development through a new RFA, "Making Quality Count" ($1 million). This is a joint effort between AHRQ and the National Cancer Institute (NCI), inviting applications for demonstrations that facilitate consumer and patient use of information about quality. (NCI is providing an additional $500,000 toward this effort.)

This RFA is based on several initiatives that have identified gaps in the research. In particular, the Quality Commission recommended further research to "enhance understanding of how information on quality is and can be used by consumers in their purchasing decisions; how consumers value and use different types of quality information; differences in values among populations (e.g., with different educational, cultural, socioeconomic and health status); and effective dissemination strategies for consumer information" (Quality First, 1998). The Quality Commission was particularly interested in research that evaluates consumer information and assistance programs for vulnerable individuals (those with low literacy, complex chronic conditions, or language and cultural barriers). In addition to these gaps, it is also important to know more that will improve our understanding of the ways in which consumers use quality information to make decisions about their use of health care services, from disease detection through treatment.

The demonstrations will develop and test methods and models for developing information on quality for consumer and patient use in health care decisions, as well as evaluate the impact of strategies to provide information about quality to consumers and patients.

Healthcare Cost and Utilization Project Quality Indicators (HCUP QI)

Many organizations lack the resources to build a quality and access assessment program from the ground up. HCUP Quality Indicators provide a low-cost approach to meeting short-term information needs that support and stimulate continuous quality improvement efforts. Developed as a quick and easy-to-use screening tool, HCUP QIs are starting points in identifying clinical areas appropriate for further, more in-depth study and analysis.

HCUP Quality Indicators were designed for use with hospital data and are available as a computer software tool for self-assessments of inpatient care as well as for the evaluation of community access to primary care. These assessments can be conducted by hospitals, hospital associations, and States. The uniform data in HCUP make possible comparative studies of health care services on the use and cost of hospital care, the quality of health care services, and use of services by special populations, including racial minorities, women, children and persons with rare medical conditions.

HCUP QIs span three dimensions of care:

• The first dimension—potentially avoidable adverse hospital outcomes—examines nine inpatient mortality rates among low-risk patients receiving common elective procedures, such as hip replacements, and seven complication rates during hospitalizations, such as urinary tract infection following major surgery.
• The second dimension—potentially inappropriate utilization of hospital procedures— addresses nine utilization rates for which there are concerns of overuse or underuse, such as cesarean section deliveries.
• The third dimension—potentially avoidable hospital admissions—indirectly assesses access to and appropriateness of primary care by identifying eight conditions prompting hospitalizations, such as immunization-preventable pneumonia and influenza among the elderly, that are thought to be avoidable with adequate primary care.

The Utah Department of Health uses HCUP QIs from AHRQ and applies them to Utah discharge data to create annual reports on hospital performance. Comparative data, derived from AHRQ's HCUP nationwide inpatient sample, is also provided to hospitals.

The goal for the reports is quality improvement and, eventually, consumer information. At present the reports are only sent to Utah's hospitals and legislators.

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Progress Toward a National Report on Quality

Recent policy debates have underscored our inability to answer a fundamental question: Is the overall quality of health care in America improving, declining, or the same as it was last year? While we currently track changes in health care spending and health status (through the annual Health USA reports) and the Nation's progress in meeting our public health goals (through the Healthy People reports), we have no system in place to track and report to the Nation objective information on the overall performance of our health care delivery system.

This report will highlight the trajectory of the American health care sector, monitor progress towards improved health care quality, and complement existing measurements of health care expenditures (such as the percentage of GDP spent on health care), access (such as the number of uninsured), and the work of the CDC on developing Leading Health Indicators. The purpose of the Report to the Nation on the Quality of Health Care in America is to provide policymakers with a national perspective on health care services, organization and delivery that most affect the quality and safety of patient care.

In Fiscal Year 1999, AHRQ began to lay the groundwork for the eventual production of a national report on healthcare quality. First, and foremost was the continuing need for additional quality measures for the report. The emphasis on vulnerable populations above will be an important contribution to this. In addition, the Agency is expanding the number of quality indicators that can be used with HCUP to understand the quality of inpatient care. Second, the Agency has been working with its Federal partners and external advisors to conceptualize the scope, purpose, and audience for this report, which is now required by the Agency's reauthorization (P.L. 106-129). The Institute of Medicine is providing assistance in this effort, as are the National Center for Health Statistics in the Centers for Disease Control and Prevention, the Health Care Financing Administration (HCFA), the National Cancer Institute, and the Office of the Assistant Secretary for Planning and Evaluation (ASPE). In Fiscal Year 2000, the Agency is evaluating existing data collection efforts such as the MEPS to determine and develop the methods and instruments needed to collect detailed information on quality from respondents, both households and providers.

President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

The President's Commission called for the development of an ability to "track and report the Nation's progress in (1) achieving the national aims for improvement; (2) undertaking related quality measurement and reporting; and (3) implementing the Consumer Bill of Rights and Responsibilities."

—Quality First, April 1998

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Help for Patients and Consumers of Health Care

Americans are demanding greater value and quality in their health care. To achieve these goals in today's rapidly changing health care environment, consumers need solid, reliable information to help them choose among health care plans, practitioners and facilities, and to participate more actively in their personal health care decisions. AHRQ plays a unique role in helping to provide the information consumers need and want. The following are two examples of AHRQ-sponsored research that promote informed consumer decisionmaking.

Consumer Assessment of Health Plans (CAHPS®)

The Consumer Assessment of Health Plans (CAHPS®) is an easy-to-use kit of survey and report tools that provides reliable information to help consumers and purchasers assess and choose among health plans.

Information from CAHPS® surveys is available to help more than 90 million Americans with their 2000 health care benefits decisions. In 1999, 26 million Medicare beneficiaries were among the first to benefit from this survey. These beneficiaries received the assessment of beneficiaries enrolled in managed care plans. Beneficiaries in more than 200 markets throughout the country received CAHPS® data on managed care plans in their area. Data were provided in the handbook sent to each beneficiary and were placed on the Medicare.gov Web site.

In 1999, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits Program, provided Federal employees with the results of CAHPS® during the open-enrollment period. Nine million Federal workers were able to make plan decisions based on consumers' reports of the quality of care they received.

Building on previous CAHPS® accomplishments, a number of new efforts are under way:

• AHRQ and HCFA collaborated with the CAHPS® consortium to develop a Medicare CAHPS® Disenrollee Survey of beneficiaries enrolled in managed care plans that will be fielded by HCFA in Fiscal Year 2000. The survey asked the reasons why beneficiaries disenrolled from their managed care plan. The project also includes development of reports to Medicare beneficiaries on the results of the disenrollee survey. These reports will show the disenrollment rates for each managed care plan as well as the reasons for disenrollment. By obtaining the reason for disenrollment, it is possible to distinguish between those that are unrelated to quality (e.g., moving out of the area that the plan serves) and those that are related to quality (e.g., limited access to specialists).
• Development has started on a CAHPS® survey that would collect data at the Group Practice Level. As implied by its name, CAHPS® was originally developed to assess the performance of health plans. Research has shown that consumers are also very interested in assessments of doctors. Therefore, a CAHPS® survey is being developed that will provide data on the performance of group practices. Similar survey questions will be asked, but under the new CAHPS® the unit of analysis will be the group practice, rather than the health plan.
• A partnership between the CAHPS® consortium and the Foundation for Accountability, with support from the David and Lucille Packard Foundation, has led to the development of a CAHPS® survey to identify children with chronic illness and collect additional information on the extent to which health plans are meeting their special health care needs. This tool is projected to be part of HEDIS requirement in 2002 and is already requested by numerous State Medicaid and SCHIP agencies to assist them in meeting the requirements set forth in the 1997 Balanced Budget Act.
• Continuing to add to the family of CAHPS® surveys, HCFA and AHRQ are also collaborating on the development of a CAHPS® survey to obtain consumers' assessments of health and services received in nursing homes. The data, collected from nursing home residents and next of kin, will be used to help persons who are choosing a nursing home.

Small Business Innovation Research (SBIRs) and Consumer Choice

In addition to CAHPS®, projects funded under the Small Business Innovation Research (SBIR) Program are developing innovative computer software and other materials to help consumers—including those who are members of minority groups, are disabled, or have poor reading skills—make informed choices about health care plans and providers. New products often emerge from these projects that put research in informatics into the marketplace. The following table highlights some of the SBIR projects.

Attention Deficit Hyperactivity Disorder (ADHD). This project will create a set of tools for families in which a child is diagnosed with ADHD. ADHD impacts school performance, relationship development, family structure and future occupational success. In most cases, symptoms continue into adulthood. This project will carefully evaluate what factors are most important to family members, teachers and health providers in treating children with ADHD. Once the data are obtained, they will be used to create the "ADHD Living Guide," a communication tool to coordinate the care of a child with ADHD and to inform parents, teachers and health providers. The project will also create "My ADHD Success Book," a tool for children. Phase I will focus on gathering input and creating a prototype. Phase II will gather further input and develop final versions of the guides. The product will be designed such that a similar methodology can be easily used to create materials for other childhood illnesses, such as asthma, cystic fibrosis, childhood cancer, and sickle-cell disease. (Clinical Tools, Inc., Pittsburgh)

A Home-based Cardiac Rehabilitation Program. Health care costs continue to spiral at twice the rate of inflation and currently exceed $1 trillion annually. Coronary heart disease (CHD) alone accounted for $259.1 billion in 1998. HeartLinks, an Internet case management program for CHD patients, could be part of a solution to control these costs while improving quality of care. HeartLinks has the potential to reach a significant proportion of the 80 percent of CHD patients who do not participate in traditional cardiac rehabilitation (CR), and to do so effectively at considerably lower cost. This project has demonstrated the feasibility of HeartLinks with 20 CHD patients in Phase I and will further develop and evaluate HeartLinks during Phase II. (Health Management Consultants of Virginia)

Automating the Management and Delivery of Clinical Preventive Health Services. The Preventive Service Information System (PSIS) is an automatic, comprehensive, customizable and secure Internet-based system for the management, delivery and follow-up of preventive services. Patients, physicians, medical staff and administrators will use the system. The PSIS reduces the manpower, time and cost required for establishing preventive services at a health care facility. It automatically generates necessary reminders based on the patient risk factors and a set of preventive rules. A rule builder is used to build the rules recommended by the U.S. Preventive Services Task Force (USPSTF), other groups, or experts in the health care facility. The PSIS is used as a stand-alone system or is integrated with existing clinical information systems to extract the available information needed for delivering preventive care. (Infotech Soft, Miami)

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