Re-Envisioning the NHQR and NHDR
The NHQR and NHDR have documented historical trends in U.S. health care quality and disparities,
but the Future Directions committee offers a vision for the reports that is more forward-looking and
action-oriented. To accomplish this vision, the committee recommends that AHRQ align the reports with
national priority areas, along with other strategies to foster change and inform policy. The committee
recommends eight national priority areas for use by AHRQ in guiding measure selection and prioritizing
content for the NHQR and NHDR. The Future Directions committee underscores the necessity of a
broader commitment to national priorities through policies and practices that support data collection on
key metrics, and support activities to address gaps in care identified in the national healthcare reports.
The Future Directions committee concludes that this broader commitment should at least come at the
le el of the Secretary of HHS, who can help set the national agenda for quality improvement. Progress
on this agenda could then be monitored by the national healthcare reports.
AHRQ charged the Future Directions committee to assess the national healthcare reports, provide guidance
on what the future generation of these reports should embody, and advise on national priority areas for health care
quality improvement and disparities elimination. The committee began its deliberations by clarifying the purpose
and audience for the reports, and identifying what those audiences could be in the future. Specifically, this chapter
assesses the general needs of the audiences, how data analysis might better inform users, the frequency of reporting,
and the naming of priority areas.
Noting that in an initial meeting with the committee, AHRQ Director Carolyn Clancy indicated that "a clear
signal and recommendation from this committee on actionability is something, frankly, we would welcome"
(Clancy, 2009), the committee deliberated on how such actionability might be achieved. One part of doing so is
to align the reports with national priority areas. In this chapter, the committee recommends a set of eight priority
AHRQ will also need to engage the community of actors who do the day-to-day work of quality improvement.
These public and private partners, including the whole HHS health care endeavor, would help inform the
best practices and intervention aspects of the reports, support data collection and direct service delivery, and help
provide solutions to barriers to improvement.
The Future Directions committee refrains from offering a specific recommendation that the Secretary adopt the offered national priority areas because the committee's charge was limited to advising AHRQ, but the committee
wants to underscore the importance of such a broader commitment to national priority areas. The committee
recognizes that health insurance reform legislation establishes a process and method for setting quality improvement
priorities in HHS,1 and it believes that the content of the two NHQR and NHDR should align as closely as possible with whatever priorities are ultimately established.
Purpose and Audiences
The Healthcare Research and Quality Act of 1999 called for AHRQ to "submit to Congress an annual report
on national trends in the quality of health care provided to the American people," which became the NHQR, and
"a report regarding prevailing disparities in health care delivery as it relates to racial factors and socioeconomic
factors in priority populations,"2 which became the NHDR. Thus, the legislation states the basic purpose is to report trends and makes clear that the primary intended audience is the U.S. Congress. AHRQ has expressed interest in increasing the visibility of its products among congressional staff and other policy makers as well as other
actors in the fields of quality improvement and disparity reduction (Social & Scientific Systems and UserWorks, 2009). AHRQ has interpreted the legislative guidance to mean that the national healthcare reports should report
on where the country stands today on selected performance measures and should look back over time (generally
the time period from 1998 to 1999 to the latest date for which data are available) to see how far the nation has
come. The Future Directions committee believes it is now time to report on trends and be forward-thinking, not
Previous IOM guidance viewed the audience for the NHQR and NHDR as reaching beyond Congress, and
envisioned the reports as vehicles for "educating the public, the media, and other audiences about the importance
of health care quality and the current level of quality" (IOM, 2001b, p. 31). Moreover, AHRQ has indicated that
today, five main types of users tend to consult the national healthcare reports' family of print and online products:
(1) federal policy makers and congressional staff; (2) associations of state and local agencies and state-based users
(e.g., state and local policy makers, Medicaid medical directors, health commissioners, data providers); (3) federal
researchers (e.g., researchers at the National Institutes of Health, the HHS Office of Minority Health staff); (4) private
sector quality improvement researchers (e.g., researchers at organizations such as The Commonwealth Fund or
Kaiser Family Foundation, health care providers, insurers, quality improvement organizations); and (5) advocacy
groups (e.g., groups representing priority populations, persons having specific diseases, and professional groups)
(Social & Scientific Systems and UserWorks, 2009). The Future Directions committee also believes these audiences
need to be aware not only of the current state of system performance, but also what the potential impact of
improvement is on the health of the nation and what each action can contribute to its achievement.
Overview of Products and Recommended Changes
Although there is little comprehensive evidence on how users take the information in the NHQR and NHDR
and put it into action, there is some limited information on the number of copies ordered and the degree of internet
traffic, which at a minimum suggest the products are consulted and quoted to document specific quality problems
and disparities. Besides the annual print and Web-based versions of the NHQR and NHDR, report-related products
developed by AHRQ include annual State Snapshots (which rate each state's performance overall and on selected
measures relative to other states), an online data query system called the NHQRDRnet, and a limited number of
topical fact sheets.
The Future Directions committee finds the print and Web versions of the NHQR and NHDR and their associated
online resources are solid compendia of data about the quality of health care and related disparities in the
United States. Their strengths have been in their use of "measures and datasets that meet rigorous scientific standards"
(IOM, 2002a, p. 6) and promotion of a common understanding of the domains of quality. Nevertheless, the Future Directions committee recommends modifying the national healthcare reports in a number of ways, and
further specifies, in Chapter 6, changes to the presentation of existing products and expansion to others. The committee
offers a number of objectives that AHRQ's reporting effort should strive to achieve (Box 2-1).
Here, the committee would like to call attention to several overall questions that it considered: whether to
continue annual reporting, whether there should continue to be two reports, and how the Highlights section of the
two reports might be designed to engage more readers.
Continuing Annual Reporting
The committee believes annual reporting, which is required by law, sustains the visibility of the NHQR and
NHDR. To help address AHRQ staff concerns about workload, the committee suggests that every measure need
not be reported each year (particularly when the data do not change from year to year) as long as the reporting
between the NHQR and NHDR are on the same content areas. Adopting this suggestion would open opportunities
for more in-depth treatment of certain topics (e.g., patient safety or a priority population). Similarly, several
priorities might get more in-depth treatment in one year but not necessarily the next.
Box 2-1. Objectives for AHRQ's Reporting Effort in the NHQR, NHDR, and Related Products
The IOM Future Directions committee believes that the NHQR, NHDR, and related products should play a vital role in
U.S. health care quality improvement and disparity elimination efforts. Thus, AHRQ should make sure that the reports:
- Incorporate a set of national priorities for U.S. health care quality improvement and disparities elimination and generate
data to monitor progress toward achieving those priority area goals.
- Identify for policy makers the problem areas in health care quality that most need their attention and action, with
the understanding that these priorities may change over time and differ by geographic location, population, or other
- Identify aspects of the health care system that improve or impede quality for all, and specify that disparities elimination
is an integral part of quality improvement.
- Supply a common understanding of quality, as reflected by the framework for quality, that considers value, equity, effectiveness,
safety, timeliness, patient-centeredness, access, efficiency, care coordination, and capabilities of health
- Identify measures that reflect the best current approaches, practices, and opportunities for measurement improvement
even when data are not yet available nationally.
- Stimulate the refinement of existing measures and the development of new ones and identify opportunities for data
- Stimulate data collection and analysis efforts at the state and local levels (mirroring the national effort) to facilitate
and monitor targeted quality improvements.
- Identify credible data sources that will support national reporting and allow subnational (state and local) and subgroup
analyses by race, ethnicity, language need, and socioeconomic status.
- Stimulate the collection of standardized race, ethnicity, language need, and socioeconomic status data in all health
care quality data sources.
- Provide policy makers, purchasers, health care providers, and others with benchmarks for quality of care by showcasing
the best attained performance in a class.
- Educate the public, the media, and other audiences about the importance of health care quality and the current level of
quality by making the AHRQ products more accessible in terms of presentation and more extensive dissemination.
- Stimulate the development of a health care data infrastructure to support quality measurement and reporting across
systems and payers for comparison.
- Refine quantitative methods for prioritizing measures of health care quality.
- Include linkages to successful interventions to make the reports more actionable.
- Make it easier to compare the performance outcomes of the U.S. health care system with that of other nations.
Source: Updated from IOM, 2001b, p. 30.
Clarifying the Connection Between Quality and Disparities
The committee wants to ensure that the issue of disparities in health care is regarded as an integral part of
any overall health care quality improvement strategy. The recent IOM report State of the USA Health Indicators
underscored this point: "The very existence of a disparity implies that the overall national level for the corresponding
indicator is not optimal" (IOM, 2008, p. 49). Thus, the committee considered whether the NHQR and
NHDR should be merged into one report to strengthen the connection between issues of quality and disparity in
the minds of users.
Advocacy groups expressed to the committee that they depend on the NHDR as a reliable source of analyses
to paint a picture of the state of quality by demographic factors; this observation is supported by the fact that there
tend to be more downloads from the NHDR Web site than the NHQR Web site (59,272 and 49,223, respectively, in
FY 2007-2008).3 These users expressed concern about diminishing the visibility of disparity issues if the reports were merged. At the same time, the committee noted that the audiences for the NHQR and NHDR were often
different sets of stakeholders, and that attention to disparities was often given short shrift in quality improvement
efforts, or the composition of the population was given as a rationale for why quality metrics were not higher. In
fact, some stakeholders noted that it is quite possible to raise national performance levels without ever addressing
disparities. On the other hand, focusing solely on closing the disparity gap between one population and another,
as reported in the NHDR, often does not set the bar for performance achievement on specific quality metrics high
enough for any population.
As a result of these considerations, the committee does not recommend a change in statutory requirements for
the annual production of the two reports, but suggests ways to build in stronger connections between the two reports
(discussed in more detail in Chapter 6). For example, the Future Directions committee advocates for comparing population groups in the NHDR to a quality benchmark or goal, not just to each other. A case in point is the presentation of data in the 2008 NHDR for diabetes preventive services. While it might be statistically valid to report
that the Hispanic/non-Hispanic difference in care is narrowing for diabetes preventive services, as reported in the
Priority Population section of the 2008 NHDR (AHRQ, 2009b, p. 211), it is misleading—although the difference
may be narrowing, both groups are doing worse over time in the use of services (AHRQ, 2009b, p. 49). Another
way to build stronger connections between the reports is developing a shared Highlights section for both reports.
Producing a Shared Highlights Section
As previously discussed, the primary intended audiences for the Highlights sections of the NHQR and NHDR
include Congress, congressional staff, and other federal and nonfederal policy makers (Moy, 2009; Social & Scientific Systems and UserWorks, 2009). The committee suggests that AHRQ develop a common Highlights section
that would serve as the introduction to both the NHQR and NHDR and as a separate stand-alone document
that can be distributed more broadly. This can become an effective vehicle for engaging public and private policy
makers, the media, foundations and other funders of research, and the public. Wider distribution and readership
of the Highlights section of the national healthcare reports could also pique the interest of new audiences to the
more detailed reports and the Web-based resources that AHRQ provides.
The committee finds that the current approach in the Highlights sections of summarizing the number of performance
measures that improve, stay the same, or decline does not engage readers to understand what is most
important; indeed, all measures are given equal value. Moreover, the key messages in the Highlights section have
thus far remained much the same from year to year—specifically, that the quality of health care in the United
States is suboptimal, the pace of improvement is slow, and disparities persist. (Key messages from each year of the
reports are summarized in Appendix B.) One of the committee's observations is that the messages conveyed in the Highlights tend to be couched in general terms and not be related to specific priorities or actions. As a result, the messages are not very compelling and provide a limited vision or roadmap for improving quality and promoting equity. Accordingly, key messages should become more targeted and action-oriented.
The Highlights section needs to present a quality improvement strategy. The committee's newly imagined,
common Highlights section for the two reports would feature areas with the greatest potential for quality improvement
impact and detail the value of closing those gaps, along with providing key messages to different audiences
such as policy makers, health providers and payers, and the public on what they can do to spur improvement on
priority areas and associated high impact measurement areas (e.g., include findings from data analyses on evidence-based
policies that are proven to support better performance or remove barriers that prevent better performance;
inclusion of a State Scorecard; assessment of the state of disparities).
Need for Data Analyses to Better Inform Policy and Practice
AHRQ's role as a research agency is not to develop policy for all of HHS with regard to quality improvement
activities; setting policy is an executive leadership and legislative function, but AHRQ can provide data to inform
policy decisions. AHRQ has indicated that the NHQR and NHDR are awareness-raising documents, and that function
will continue but needs to be supported by additional analyses that inform actions and actors.
Providing Analyses by Accountable Actors
The committee suggests that the NHQR and NHDR include more information about how performance
compares across public and private health systems, payers, programs, and other accountable actors. To date, the
inclusion of such comparative information has been limited, and little analysis has been presented beyond straight
reporting on individual measures; some limited stratification and multivariate analyses are included in the NHDR
by population but not by entities providing care or paying for it. The Future Directions committee recommends
sufficient resources be provided to AHRQ for the data collection and analysis necessary to provide such comparative
information (Chapter 7).
The committee believes that federal and state policy makers are most likely to be interested in performance
data—reported according to units of accountability (e.g., payment streams, federally funded programs, state program
performance)—on health care areas and programs for which they have some public responsibility. Specifically,
Congress would be interested in programs of HHS and other federally funded programs for which Congress has
responsibility. Such programs include the Medicare and Medicaid programs overseen by the Centers for Medicare
and Medicaid Services (CMS); programs of the Indian Health Service; health care service delivery programs of the
Health Resources and Services Administration (HRSA); and other service delivery programs under the auspices of
other federal agencies, including the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense
(DOD). Similarly, state legislators are likely to be interested in the performance of the Medicaid program and the
Children's Health Insurance Program (CHIP). This list is not meant to limit AHRQ's data presentation to federally
sponsored programs; indeed there is interest, for example, in having data from all payer databases.
Members of Congress are also interested in how their own state performance in the public and private sectors
compares to others, and while AHRQ has a wealth of state-based data available, it is not easily summarized
in one place. Such data could be summarized in the Highlights section using information from the online State
Snapshots dashboard (perhaps in a way similar to that used in The Commonwealth Fund State Scorecard) (The Commonwealth Fund Commission on a High Performance Health System, 2008).
Using Data to Inform Policy and Practice
The committee urges AHRQ to analyze and present its data in ways that better inform users of where performance
is better, how long it will take to get to goal levels, and what the best programs or drivers might be to
attain higher achievement. For example,
- AHRQ could analyze and present data by accountable units (e.g., payers, programs, states) so that it is
possible to more closely identify where the best performance exists and how different actors perform.
- The performance trend data that AHRQ has collected thus far should now be used to project how long it
would take to close quality gaps between current performance on the measure and achieving the recommended
standard of care (e.g., 100 percent of target population receiving care or some other goal that is
- New approaches to thinking about policy-relevant outcome measures may be necessary, such as determining
whether there has been a reduction of readmission rates on acute myocardial infarction (AMI) since
public reporting by CMS, or whether there is an actual increase in receipt of needed services or patient
disease management adherence when uninsurance is removed as a barrier.
- Further analyses would be useful to increase understanding of the implications of differences among
populations; for example, what are the implications of the differences found in access to preventive services
between Hispanic and non-Hispanic Whites for diabetes care in the NHDR (AHRQ, 2009b, p. 49),
particularly in view of the projected growth of the Hispanic population in the United States and studies
showing that for Hispanics born in 2000, 53 percent of girls and 45 percent of boys will develop diabetes
during their lifetimes (CDC, 2007).
- The National Priorities Partnership has suggested a quality improvement goal of: "All Americans will
receive the most effective preventive services recommended by the U.S. Preventive Services Task Force"
(NPP, 2008, p. 26). It is known, however, that only 50 percent of adults received the screenings and preventive
care appropriate to their age and gender (The Commonwealth Fund Commission on a High Performance Health System, 2008; McGlynn et al., 2003; NPP, 2008). In addition to AHRQ reporting the average
national performance for receipt of preventive services, related analyses might be proffered that would
inform policies and practices in both the public and private sector: (1) comparing payers that include such
services in benefit packages with reduced or no co-payments with those that do not, (2) comparing those
who are insured with those who are uninsured, (3) comparing the quality improvement impact of focusing
interventions on specific at risk groups or age groups, and/or (4) comparing use among low-income users
across state Medicaid programs or by community health centers.
- A finding in the NHDR that low-income persons consistently fall behind on health quality measures should
lead to examination of program-specific data that might illuminate if any specific health care delivery
system is making important strides to close that gap (for instance, interventions that have improved care
in community health centers might benefit other settings that serve low-income populations [Chin et al., 2007; Landon et al., 2007]).
Because AHRQ primarily tracks health care process measures, there needs to be an assessment of the benefit
of improved access to or adherence to processes of care on health outcomes to help determine whether expanded
investment in specific areas of care is warranted. To the extent possible, data should be presented in ways that
inform potential policy directions and program practices by being more outcome oriented. The committee builds
into its recommended measure selection process an assessment of the potential impact of closing performance
gaps on the ultimate outcome of improving population health.
Calls for National Priority Areas
In past years, the IOM and other entities have called for the establishment of national priority areas and goals
for coordinated health care quality improvement efforts. Examples of these calls for national priorities are described
below, along with discussion of the limited actions taken by AHRQ with respect to incorporating priority areas
into the NHQR and NHDR.
In its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM recommended
establishing specific goals to enhance the usefulness of a national health care quality report "as a stimulus
for performance improvement" (IOM, 2001a, p. 7). No specific overall goals have been set for each aim, although
for some individual measures,
2010 targets are displayed.
The IOM's 2001 and 2002 guidance on the development of the NHQR and NHDR emphasized that these
reports should identify "for policy makers the problem areas in health care quality that most need their attention and action, with the understanding that these priorities may change over time" and "should continually reflect
and be used to shape goals for quality improvement by presenting information that is useful to policy makers and
others to define clear objectives, assess progress, and define appropriate actions" (IOM, 2001b, pp. 31-32, 2002a).
When AHRQ summarizes the nation's progress, all measures are given equal weight.
More recently, in March 2009, Stand for Quality, a diverse public-private coalition of 165 diverse organizations,
issued six recommendations to improve both the quality and affordability of health care. Noting that
performance measurement is a core building block to providing high-quality, affordable care, Stand for Quality
urged the executive branch and Congress to expand public investment in performance measurement, and called
for the establishment of priorities as part of the need to strengthen the "performance measurement, reporting and
improvement enterprise" (Stand for Quality, 2009).4 Similarly, recent health insurance reform bills have called for the formulation of a national strategy for quality improvement, including naming priority areas and a mechanism for choosing them.5
Despite the many calls for national priorities, HHS has yet to establish national priority areas for health care
performance measurement and quality improvement that could help focus the collective efforts across HHS programs
and be adopted by other federal agencies and entities engaged in health care quality improvement, including
the elimination of disparities. HHS has a strategic planning process in place that sets goals for HHS programs and
offers targets for monitoring progress on specific performance indicators. Most of the strategic plan indicators are
for program management rather than setting goals for achievement of health care process or outcome measures.
Thus, for example, under the HHS strategic objective of "Broaden health insurance and long-term coverage," the
performance indicators deal with increasing the percentage of Medicare beneficiaries with Part D coverage and
reducing the percentage of improper payments under the fee-for-service program (HHS, 2008, p. 48). In response to
a 2007 congressional request for the IOM to assess whether HHS was "ideally organized to meet the enduring and
emerging health challenges facing our nation" (IOM, 2009, p. 2), the IOM recommended improvements in HHS's
strategic planning process—specifically, improving alignment across HHS on a small set of measurable goals.
The IOM Future Directions committee, while recognizing that HHS has many missions other than health
care performance measurement, believes that improving health care performance measurement is fundamental to ensuring an effective and efficient U.S. health care system. HHS has contracted with the National Quality Forum
(NQF) to formulate a "national strategy and priorities for health care performance measurement" over the next
few years under the authority of Section 183 of the Medicare Improvements for Patients and Providers Act of
2008 (MIPPA) (HHS, 2009a). The Future Directions committee concludes that the United States needs national
priorities and measures of quality that will address the health care needs of the entire U.S. population, not just
individuals covered by Medicare.
1 Patient Protection and Affordable Care Act, Public Law 111-148 § 399HH, 111th Cong., 2d sess. (March 23, 2010).
2 Health Research and Quality Act of 1999, Public Law 106-129 § 902 and § 913, 106th Cong., 1st sess. (December 6, 1999).
3 Personal communication, Ernest Moy, Agency for Healthcare Research and Quality, November 1, 2009, based on a summary from Jeff Hardy dated February 11, 2009.
4 Supporting entities include national organizations such as the Federation of American Hospitals, the National Partnership for Women & Families, Aetna, the American Academy of Family Physicians, The Leapfrog Group, as well as local, state, and regional organizations such as the Pacific Business Group on Health, the Puget Sound Health Alliance, and the Oklahoma Foundation for Medical Quality. A full list of supporting organizations is available at www.standforquality.org (accessed May 13, 2010).
5 The final bill, the Patient Protection and Affordable Care Act (Public Law 111-148 § 3011, 111th Cong., 2d sess. (March 23, 2010)) has the following provisions:
- The Secretary, through a transparent collaborative process, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.
- The Secretary shall identify national priorities for improvement in developing the strategy.
- The Secretary shall ensure that priorities identified under subparagraph (A) will—(i) have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations; (ii) identify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care; (iii) address gaps in quality, efficiency, comparative effectiveness information, and health outcomes measures and data aggregation techniques; (iv) improve Federal payment policy to emphasize quality and efficiency; (v) enhance the use of health care data to improve quality, efficiency, transparency, and outcomes; (vi) address the health care provided to patients with high-cost chronic diseases; (vii) improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections; (viii) reduce health disparities across health disparity populations (as defined in section 485E) and geographic areas; and (ix) address other areas as determined appropriate by the Secretary.
- The national strategy shall include a comprehensive strategic plan to achieve the priorities.
Not later than January 1, 2011, the Secretary shall create an Internet Web site to make public information regarding—(1) the national priorities for health care quality improvement established under subsection (a)(2); (2) the agency-specific strategic plans for health care quality described in subsection (b)(2)(B); and (3) other information, as the Secretary determines to be appropriate.
Earlier versions contained the same or similar provisions: The Affordable Health Care for America Act passed by the U.S. House of Representatives in November 2009 would require the Secretary of Health and Human Services (HHS Secretary) to establish national priorities for health care quality improvement (Affordable Health Care for America Act (H.R. 3962), Section 1441 (pp. 883-885), and the Patient Protection and Affordable Health Care Act passed by the U.S. Senate in December 2009 would require the HHS Secretary to develop a national strategy for health care quality improvement (Patient Protection and Affordable Health Care Act (H.R. 3590 amended Section 3011)) (pp. 692-698)).
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