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|National Healthcare Quality Report, 2009|
Key Themes and Highlights From the National Healthcare Quality Report
Health care seeks to diagnose, treat, and improve the physical and mental well-being of all Americans. Across the lifespan, health care helps people stay healthy, recover from illness, live with chronic disease or disability, and cope with death and dying. Quality health care delivers these services in a way that is safe, timely, patient centered, efficient, and equitable.1 Unfortunately, Americans too often do not receive care that they need, or they receive care that causes harm. Care can also 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 can be used to address three critically important questions:
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.2 Spending on health care is escalating relentlessly, threatening the financial security of families and businesses. Quality and value are increasingly considered in the decisions patients and payers make. To help patients choose doctors and hospitals prudently, tools have been produced that gather information about hospitals and rate health care providers. To motivate providers to deliver high-quality care, some purchasers reward superior performance. In addition, some refuse to pay for additional care needed to correct hospital-acquired conditions that could reasonably have been prevented through the application of evidence-based medicine. Monitoring the success of these efforts is crucial to help stakeholders refine quality improvement activities and to lead Americans toward the optimal health care they need and deserve.
The NHQR is built on more than 200 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 the NHQR focuses on a group of core report measures that represent the most important and scientifically credible measures of quality for the Nation. By focusing on core measures, the NHQR provides a readily understandable summary and explanation of the key results derived from available data.
Three themes from the 2009 NHQR emphasize the need to accelerate progress if the Nation is to achieve higher quality health care in the near future:
We also summarize AHRQ and HHS efforts to accelerate the pace of improvement by:
Health Care Quality Needs To Be Improved, Particularly for Uninsured Individuals, Who Are Less Likely To Get Recommended Care
The key function of the NHQR is to summarize the state of health care quality for the Nation. 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 come from a wide range of sources that focus on different populations and data years.
Despite the data limitations, we find that health care quality in America is suboptimal. The gap between best possible care and that which is routinely delivered remains substantial across the Nation. Receipt of quality health care also varies widely. For example, caregivers reported that 95% of hospice patients received the right amount of pain medication, but only 8% of patients needing care for alcohol problems received such treatment at a specialty facility. Across the core report measures tracked in the NHQR, the median level of receipt of needed services was 58%. We can and should do better.
Moreover, 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 and therapeutic care in response to acute medical problems. Our system achieves higher performance on hospital measures, such as acute treatment for heart attacks, than on outpatient measures, such as cancer screening and diabetes management. For example, between the 2008 and 2009 reports, five measures attained overall performance levels exceeding 95%.ii Four of these five measures relate to hospital care for heart attack. In addition, all 10 of the worst performing process measures tracked in this NHQR are measures of outpatient care, and 6 of these relate to preventive services.
For individuals without health insurance, quality of care is even worse. For many years, the National Healthcare Disparities Report (NHDR) has examined disparities in care related to insurance. In this NHQR, we report on the relationship between uninsurance and quality of care. Insurance status of individuals could be identified for 35 process measures the NHQR tracks.iii Across these measures, the median level of receipt of services was 50% among uninsured individuals compared with 65% among privately insured individuals.
Table 1 shows the 10 measures with the largest difference between individuals with private insurance and those with no insurance. Individuals age 65 and over are excluded because almost all have Medicare. Also, these data do not reflect the current economic recession, which may exacerbate insurance-related differences in care.
Uninsured people are less likely to get recommended care for disease prevention and management (Table H.1). Large differences were observed between individuals with private insurance and no insurance for measures related to:
Table H.1. Measures with largest differences between individuals with private insurance and no insurance
Note: All differences in this table are statistically significant.
Table H.2 shows the 10 measures with the smallest differences between individuals with private insurance and no insurance. Uninsured individuals are only slightly less likely to receive counseling about booster seats and passive smoking; adequate time with health providers; pneumococcal vaccination; and appropriate breast cancer treatment. Uninsured and privately insured individuals are about equally likely to have discussions with their regular doctors about medications and treatments from other doctors and to receive care related to HIV disease.
Table H.2. Measures with smallest differences between individuals with private insurance and no insurance
Note: None of the differences in this table are statistically significant.
For almost all measures, uninsured people were less likely to receive recommended care compared with privately insured people. As shown in the tables, gaps were particularly large for preventive care and diabetes management and smaller gaps were observed for cancer treatment. Cancer is typically treated in hospitals and associated outpatient facilities that may be more able and committed to providing charity care. The Ryan White HIV/AIDS Program, which provides HIV-related services to individuals who are uninsured or unable to afford these services, may help explain why uninsured patients receive HIV care similar in quality to privately insured patients. In addition, uninsured patients may be more willing to pay out of pocket for treatment of cancer or HIV disease than for preventive services.
Some Areas Merit Urgent Attention, Including Patient Safety and Health Care-Associated Infections
After determining that quality is suboptimal, the next step toward improvement, and the second key function of the NHQR, is to identify which areas are in greatest need of intervention. Potential problem areas can be defined in terms of types of services and geography. In this section, we focus on one aspect of care that is performing particularly poorly: patient safety. Then, we examine some areas of the country where performance is lagging.
Improvement is important across all dimensions of health care quality. It is critically important in the area of patient safety. Patients have a reasonable expectation that they will not be harmed by the health care they receive. For more than 6 years, the NHQR has presented a summary of the safety of health care provided to the American people.
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 and methods, a clearer picture of trends in health care safety is emerging. In previous reports, we used the most recent data year compared with a baseline data year to calculate rate of change. This year, we introduced a new methodology for quantifying change by entering estimates for all available data years into a regression model to calculate rate of change. In addition, we retired measures that have achieved a rate of 95% or higher. We believe these changes yield more stable and robust estimates of rate of change.
Analysis of patient safety has been based on a set of databases that were created in response to the need for information documented in such publications as the Institute of Medicine's landmark 2000 report To Err Is Human: Building a Safer Health System.3 Some of our findings are disturbing. For example, last year we reported that approximately one out of seven adult hospitalized Medicare patients experienced one or more adverse events. This year, we see problems specifically in the area of HAIs.
Figure H.1. Change in hospital quality over time, safety measures versus other hospital measures
Worse = Quality is going in a negative direction at an average annual rate greater than 1% per year.
Health Care-Associated Infections
Infections acquired during hospital care, also known as nosocomial infections, are one of the most serious patient safety concerns. It is unfortunate that HAI rates are not declining. Of all the measures in the NHQR measure set, the one worsening at the fastest rate is postoperative sepsis (Table H.3). The two process measures related to HAIs tracked in the NHQR, both covering timely receipt of prophylactic antibiotics for surgery, are improving steadily. However, HAI outcome measures are lagging; only one shows improvement over time while three are worsening and one shows no change. This may, in part, reflect improving detection of HAIs.
Table H.3. Measures of health care-associated infections, annual rates of improvement
Key: QIO = Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization Program; MPSMS = CMS Medicare Patient Safety Monitoring System; HCUP = AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample.
It is evident that more attention devoted to patient safety is needed to 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 confidential data 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). Under this legislation, these entities can receive and analyze patient safety data and work with providers to improve care without fear of legal discovery. PSOs also can report deidentified data to a Network of Patient Safety Databases, and findings from this resource will be published in future NHQRs and NHDRs. Currently, 69 organizations have been listed by HHS as PSOs.
The Patient Safety and Quality Improvement Act also addresses an issue that has plagued data collection related to patient safety: the lack of standardized vocabularies that ensure a common definition of specific terms.4 AHRQ coordinated the development of common definitions and reporting formats for patient safety events. The beta version of the Common Formats was released in 2008 and supports data aggregation, analysis, and learning throughout the quality improvement cycle. The National Quality Forum (NQF) then solicited feedback from private-sector organizations and convened an expert panel to provide recommendations to AHRQ. The revised Common Formats Version 1.0 was subsequently released in September 2009.
Quality of care varies not only across types of care but also across geographic areas. Knowing where to focus efforts improves the efficiency of interventions. 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 tool (http://statesnapshots.ahrq.gov) was launched in 2005. This Web site helps State health leaders, researchers, consumers, and others understand the status of health care quality in individual States and the District of Columbia. The State Snapshots are based on more than 100 NHQR measures, each of which evaluates a different aspect of health care performance and shows each State's strengths and weaknesses.
Although we observe wide variation across States, those in the upper Midwest and New England tend to achieve the highest overall quality of care while States in the Southwest and South Central parts of the country tend to have the lowest quality and may benefit from more urgent attention. Although the measures are often the products of complex statistical formulas, results 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.
In addition to maps showing variation in quality of care, this NHQR introduces a new type of State map to help target interventions. These maps combine information about processes of care and associated outcomes. For example, we include a map that shows information about a process typically needed to keep the glucose level of patients with diabetes under control, receipt of hemoglobin A1c testing, and an outcome of poor control of glucose, hospitalizations for short-term complications, such as diabetic ketoacidosis. These maps do not imply causality because processes of care may not affect outcomes for many years. However, by linking related measures, we hope information in these maps will help motivate specific States to act. States with poor outcomes for which a specific performance issue has been identified may be well positioned to improve quality of care.
Quality Is Improving, But the Pace Is Slow, Especially in Preventive Care and Chronic Disease Management
Suboptimal quality of care is undesirable, but we may be less concerned if we observe evidence of vigorous improvement. Hence, the third key function of the NHQR is to examine change over time. 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 quality of services delivered by the health care system is improving or declining based on the report's measures. Another way to describe this is the speed of improvement or decline in the quality of the U.S. health care system
Figure H.2. Change in quality over time
Worse = Quality is going in a negative direction at an average annual rate greater than 1% per year.
Figure H.3. Change in quality over time by setting and type of measure
Worse = Quality is going in a negative direction at an average annual rate greater than 1% per year.
In the analysis of trends for this year's NHQR, it is clear that quality improvements continue to be unevenly spread across the settings of care. 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 6%, which continues to be the highest rate of quality improvement among the major health care delivery settings. In contrast, care in outpatient settings improved at a rate that only slightly exceeded 1%.
Significant improvement in hospital care has occurred since the Centers for Medicare & Medicaid Services (CMS) began reporting consensus-based quality measures on the Hospital Quality Compare Web site (http://www.hospitalcompare.hhs.gov). Of the 10 fastest improving measures tracked in the NHQR, 8 were measures published on the CMS Web site.
Similarly, improvement in preventive services and chronic disease management lagged behind improvement in acute disease treatment. Of the nine process measures tracked in the NHQR that got worse instead of better, four were preventive services, including mammography, Pap testing, and fecal occult blood testing. Four services were related to chronic disease management, including three services for patients with diabetes.
When examining change across types of care 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 CMS measures, may influence broad system change and subsequent quality improvements. Institutional health care settings, such as hospitals and nursing homes, are more likely to have structured quality improvement programs and staff that help raise performance in these organizations. Staff exert a high degree of influence over patient behaviors and the therapeutic milieu during a patient stay. The greater availability of HIT as part of institutional infrastructure may also contribute to improvements in quality in these settings. In contrast, doctors' offices often do not have sufficient resources, staff, and training to apply quality improvement techniques efficiently and rely upon patients to implement care recommendations.
Efforts Are Needed To Accelerate Improvement
This 2009 report summarizes areas where progress in health care quality has excelled and where it has lagged. But national reports do not improve quality by themselves. Measures need to be adapted to guide local interventions. Barriers to quality care, such as uninsurance, need to be overcome. Providers need to be empowered with HIT and training. Community partnerships that bring together all the stakeholders who 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 working on an exciting range of programs that seek to accelerate the pace of health care quality improvement nationwide.
New quality measures are needed. 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 existing 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 when viewed through a patient's eyes. Patients see problems from a personal perspective and may observe deficiencies that busy providers do not notice. For example, 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 AHRQ's Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys capture some aspects of patients' experiences with care, but more work is urgently needed to expand patient-focused measures of health care quality.
Healthy People (http://www.healthypeople.gov) provides science-based, 10-year national objectives for promoting health and preventing disease. Since 1979, Healthy People has measured and tracked national health objectives to encourage collaborations, guide individuals toward making informed health decisions, and assess the impact of prevention activity. Healthy People 2020 is currently under development. Through a national consensus process, it is identifying specific objectives for improving the health of the Nation, establishing baseline values for the objectives, and setting specific targets to be achieved by 2020. Overarching goals for Healthy People 2020 are: (1) Eliminate preventable disease, disability, injury, and premature death; (2) Achieve health equity, eliminate disparities, and improve the health of all groups; (3) Create social and physical environments that promote good health for all; and (4) Promote healthy development and healthy behaviors across every stage of life.
Measure sets need to be coordinated. 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, irritation, and unnecessary labor for providers trying to supply quality information to multiple stakeholders. Calls for new measures may also be hampered by resource constraints.5,6
The work of the 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 all payers and stakeholders will use 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 needed. The HHS Measure Inventory (available through the National Quality Measures Clearinghouse™ at http://www.qualitymeasures.ahrq.gov/hhs/hhs.index.aspx) is a step in this direction. Released in 2008, this tool provides specifications of measures that HHS uses for quality measurement, reporting, and improvement. It is designed to help synchronize measurement and advance collaboration within the quality improvement community toward a uniform set of performance measures.
Remove Barriers to Quality Care
Lack of health insurance is a major hindrance to quality care and should be reduced. As demonstrated in this NHQR, quality of care is considerably and consistently worse for patients with no insurance compared with patients who have private insurance. In addition, nearly two-thirds of patients who are unable to get or delayed in getting needed care report a reason related to cost or insurance. Quality improvement will be impeded as long as more than 46 million Americans are uninsured and face barriers to quality health care.7
The Office of Health Reform (http://healthreform.gov) leads and coordinates the Federal Government's comprehensive effort to improve health care so that it is high quality, affordable, accessible, and sustainable. The Office envisions reform that will reduce long-term growth in health care costs for businesses and government; protect families from bankruptcy or debt because of health care costs; guarantee choice of doctors and health plans; invest in prevention and wellness; improve patient safety and quality of care; ensure affordable, quality health coverage for all Americans; maintain coverage when individuals change or lose their job; and end barriers to coverage for people with preexisting medical conditions.8 Achieving these goals could dramatically reduce the number of uninsured Americans and improve health care quality.
Empower Providers With Health Information Technology and Training
HIT needs to support quality improvement. Providers need reliable information about their performance to guide improvement activities. Realistically, HIT infrastructure is needed to ensure that relevant data are collected regularly, systematically, and unobtrusively while protecting patient privacy and confidentiality. Patients, including individuals with limited English proficiency or disabilities, need to have meaningful access to their health records to ensure accuracy and completeness. Systems need to generate information that can be understood by end users and that are interoperable across different institutions' data platforms, policies, and procedures.9 In addition, information systems are necessary but insufficient for ensuring high-quality health care.10
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 recordkeeping.11 Ideally, performance measures should be calculated automatically from health records in a format that can be easily shared and compared across all providers involved with a patient's care.
The American Recovery and Reinvestment Act (ARRA) provides reimbursement incentives for providers to adopt electronic health records and to achieve meaningful use of them. CMS and the Office of the National Coordinator are currently working on the operational definition of meaningful use. The conceptual framework recognizes that meaningful use may begin with data capture and sharing but must progress to decision support of care processes and ultimately yield improvements in health outcomes.
Training is also critical. Improving quality is a "team sport." TeamSTEPPS™ (Team Strategies and Tools to Enhance Performance and Patient Safety, http://teamstepps.ahrq.gov) is an evidence-based teamwork system aimed at optimizing patient outcomes by improving health professionals' communication and teamwork skills. It includes a comprehensive set of ready-to-use materials and a training curriculum to integrate teamwork principles into any health care system. In collaboration with AHRQ, the Department of Defense 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.
AHRQ is also supporting training of multidisciplinary hospital teams to address HAIs. The Keystone ICU Project helped 108 intensive care units in Michigan reduce rates of bloodstream infections associated with central venous catheters. AHRQ is currently working to develop tools to teach additional hospitals how to reduce these types of complications.
Think Cultural Health (http://www.ThinkCulturalHealth.org ), developed by the Office of Minority Health (OMH), offers a suite of cultural competency training programs, including A Physician's Practical Guide to Culturally Competent Care, Culturally Competent Nursing Care, and the Health Care Language Services Implementation Guide. These free online programs allow busy health professionals to earn continuing education credits in an atmosphere of their choosing and at their own pace. Institutions can follow a small group format that allows a team to train, discuss, and plan together based on the organization's needs and experiences. In addition to continuing education, the Web site houses up-to-date information on cultural competency legislation, health disparities, and health care for racial and ethnic minorities.
Establish and Sustain Partnerships To Lead Change
Partnerships need to build health care quality and cost information systems nationwide. Quality measures often provide narrow views of system performance rather than the comprehensive picture needed to optimize care. The Quality Alliance Steering Committee (http://www.healthqualityalliance.org ) is a partnership of quality and health care leaders that is building an infrastructure for gathering and reporting consistent, effective, and efficient information on health care quality and costs. Through its High-Value Health Care Project, the committee is devising solutions that will allow efficient aggregation and integration of health care data from public and private sectors, developing measures of costs and efficiency, and supporting consistent collection of standardized race and ethnicity identifiers that will advance understanding of equity in health care quality.
Partnerships are needed to effect change and do the actual work of making improvements. The National Priorities Partnership (http://www.nationalprioritiespartnership.org ) is a collaborative effort of key public and private health care stakeholders. The partners have agreed on a core set of national health care priorities and goals that they will work together to achieve. These priorities include patient and family engagement, population health, safety, care coordination, palliative and end-of-life care, and overuse.
The National Partnership for Action (NPA) To End Health Disparities (http://minorityhealth.hhs.gov/npa), launched by OMH, is a multifaceted effort to mobilize and connect individuals and organizations across the country to create a Nation free of health disparities, with quality health outcomes for all people. The NPA is composed of three components: (1) National Plan for Action; (2) 10 Regional Blueprints aligned with the National Plan for Action that include strategies and actions most pertinent to communities in each region; and (3) targeted initiatives that will be undertaken by partners across the public and private sectors in support of the NPA.
An example of an NPA initiative is the National Business Group on Health Racial and Ethnic Health Disparities Advisory Board. This advisory board facilitates alliances between business, medicine, and public health organizations to improve the quality of health care for racial and ethnic minority populations while promoting beneficiary health and employee productivity. Products include issue briefs on topics such as why companies are making health disparities their business and how health plans view health disparities. The board holds several Web conferences featuring best practices by a wide range of employers.
Quality improvement requires measurement and reporting, but these are not the ultimate goals. The fundamental purpose of quality improvement in health care is to make patients' and families' lives better. The NHQR concentrates on tracking health care quality at the national level, but the statistics reported in the NHQR and NHDR reflect the aggregated everyday experiences of patients and their providers 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.
With the publication of this seventh 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. It also points to important opportunities that still exist.
We need to accelerate the pace of quality improvement, especially related to patient safety. Barriers to quality health care, such as uninsurance, need to be overcome. The success of CMS reporting initiatives may serve as a guide, but more work is needed to improve, standardize, and coordinate quality measurement. Information on quality then needs to be shared with partners who have the skills and commitment to change health care. Building on data in the NHQR, NHDR, and the State Snapshots, we believe that policymakers can design and target strategies and clinical interventions to ensure that patients receive the highest quality care that makes their lives better.
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.
i The HHS Interagency Work Group, which represents 18 HHS agencies and offices, provides advice and support to AHRQ and the National Reports Team.