This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical
expertise, in accordance with procedures approved by the National Research Council's Report Review Committee.
The purpose of this independent review is to provide candid and critical comments that will assist the institution
in making its published report as sound as possible and to ensure that the report meets institutional standards for
objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain
confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for
their review of this report:
- David Carlisle, Office of Statewide Health Planning and Development, State of California, Sacramento, CA
- Carmen R. Green, Department of Anesthesiology, University of Michigan, Ann Arbor, MI
- Cara V. James, Kaiser Family Foundation, Washington, DC
- Edward Kelley, World Health Organization, Geneva, Switzerland
- Dushanka V. Kleinman, Department of Epidemiology and Biostatistics, University of Maryland, College Park, MD
- Judith R. Lave, Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
- Elizabeth A. McGlynn, The RAND Corporation, Santa Monica, CA
- Thomas G. McGuire, Department of Health Care Policy, Harvard Medical School, Boston, MA
- Lee Partridge, National Partnership for Women and Families, Washington, DC
- Ruth T. Perot, Summit Health Institute for Research and Education, Inc., Washington, DC
- Patrick Romano, Center for Studying Health System Change, Washington, DC
- Barbara Rudolph, Center for Health Systems Research and Analysis, University of Wisconsin, Madison; The Leapfrog Group, Madison, WI
- Ellen Wartella, University of California, Riverside, Riverside, CA
- Milton C. Weinstein, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
Although the reviewers listed above provided many constructive comments and suggestions, they were not
asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release.
The review of this report was overseen by Neal A. Vanselow, IOM member, and Caswell A. Evans,
Jr., University of Illinois at Chicago. Appointed by the National Research Council and Institute of Medicine, they
were responsible for making certain that an independent examination of this report was carried out in accordance
with institutional procedures and that all review comments were carefully considered. Responsibility for the final
content of this report rests entirely with the authoring committee and the institution.
Copyright© 2010 by the National Academy of Sciences (NAS). All rights reserved. Posted to the Agency for Healthcare Research and Quality Web site with the consent of NAS.
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Ten years after the publication of the Institute of Medicine's landmark Quality Chasm series of reports, we
often do not know to what extent quality of care has improved. A range of studies and reports indicate that the
quality of health care received in our nation is less than optimal, but we continue to lack sufficient information to
determine how well new programs, changes in processes, and other interventions improve the quality and equity
The National Healthcare Quality and Disparities Reports play a fundamental role in examining quality
improvement and disparities reduction. In this report, prepared at the request of the Agency for Healthcare Research
and Quality, the Institute of Medicine suggests ways to reformulate and enhance our Nation's essential measures
of quality and equity, to facilitate informed decision-making, and to help set the strategic direction of the nation's
quality improvement enterprise.
I am grateful for the support of our sponsor and to the committee, ably led by Sheila Burke, which grabbled
with complex issues involving the selection and prioritization of different measures, the needs of users, and
advances in the field of quality measurement. Their work was reinforced by staff working under the direction of
Cheryl Ulmer and including Michelle Bruno, Bernadette McFadden, and Cassandra Cacace. I commend both committee
and staff for this product and believe it provides a sound basis for strengthening the National Healthcare
Quality and Disparities Reports.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
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In 1998, the President's Advisory Commission on Consumer Protection and Quality of Care in the Health Care
Industry called for a national commitment to improving quality and reducing disparities at every level of the health
care system. To reinforce this commitment, annual reports to Congress from the Agency for Healthcare Research
and Quality (AHRQ) were initiated to document national trends, identify gaps in care, and paint a picture of the
state of health care quality and disparities. These reports—the National Healthcare Quality Report (NHQR) and
the National Healthcare Disparities Report (NHDR)—are consulted by health services researchers, state health
officials, organizations implementing quality improvement and disparity elimination programs, advocates for
specific health conditions or priority populations, and other stakeholders. Five years after the reports were first
published, AHRQ turned to the Institute of Medicine (IOM) to evaluate the current NHQR and NHDR and to
present a vision for their future content and presentation.
Our IOM committee felt it essential to think about how the reports' content and presentation could best foster
action by various audiences to close health care quality gaps, particularly in measurement areas that represent the
greatest opportunities for creating a high-quality, high-value, equitable health care system. It is through a lens of
actionability and better matching of products to audience needs that the committee evaluated the current reports
and made its recommendations. Embedded in the pages of this report are discussions of the ways to transform
future iterations of the NHQR and NHDR. AHRQ could:
- Track national priorities for quality improvement and high impact measurement areas to inform collective action across federal and other public and private sector health care delivery programs.
- Conceptually and operationally link quality improvement and disparities elimination in the NHQR and NHDR.
- Highlight quality achievement by presenting best-in-class benchmarks.
- Move from only presenting historical trend data to also extrapolating rates of change to indicate when gaps might be closed at the existing pace.
- Present an assessment of the effect on population health of bridging quality and equity gaps.
- Analyze and present data in meaningful ways that identifies for Congress, states, and others the results of and prospects for evidence-based policies and interventions.
- Support broader and sustained dissemination of report content.
We hope this report will be of help to AHRQ in promoting progress toward achieving optimal health care for the
As chair of this committee, I would like to thank my fellow committee members for giving their time and
expertise so generously toward the completion of this report. Their spirited deliberations and contributions are
greatly appreciated. On behalf of the committee, I would also like to thank the staff of the Board on Health Care
Services who ably supported the committee in its endeavor. In particular, Cheryl Ulmer, study director, should be
thanked for steering the committee throughout the process.
Sheila Burke, Chair
Committee on Future Directions for the National Healthcare Quality and Disparities Reports
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The committee and staff are grateful to many individuals and organizations who contributed to this study. The
committee would like to thank the Institute of Medicine Subcommittee on Standardized Collection of Race/Ethnicity
Data for Healthcare Quality Improvement. The subcommittee members1 were:
- Margarita Alegría, Director, Cambridge Health Alliance, Center for Multicultural Mental Health Research, Somerville, MA
- John Z. Ayanian, Professor of Medicine and Health Care Policy, Harvard Medical School, Boston, MA
- Roderick J. Harrison, Senior Research Scientist, Office of the Vice President for Research and Compliance, Howard University, Washington, DC
- Romana Hasnain-Wynia, Director, Center for Healthcare Equity; Associate Professor of Research, Northwestern University, Feinberg School of Medicine, Chicago, IL
- Ninez Ponce, Associate Professor, Department of Health Services, UCLA School of Public Health, Los Angeles, CA
- Wayne S. Rawlins, National Medical Director, Aetna Government Health Plans, Aetna, Hartford, CT
- Alan M. Zaslavsky, Professor of Statistics, Department of Health Care Policy, Harvard Medical School, Boston, MA
Funding for this study was provided by the Agency for Healthcare Research and Quality (AHRQ). The committee
appreciates AHRQ's support for this project and wishes to especially thank Carolyn Clancy, Ernest Moy,
Jeff Brady, Farah Englert, Karen Ho, and Allan Lazar for sharing their expertise about the development and dissemination
of the NHQR and NHDR.
In addition, the committee benefited from the testimony of the following individuals before the committee
and subcommittee during public workshops: Karen Adams (National Quality Forum), Donald Berwick (Institute
for Healthcare Improvement), Andrew Bindman (University of California, San Francisco, and CA Medicaid
Research Institute), Kathryn L. Coltin (Harvard Pilgrim Health Care), Brenda Edwards (Division of Cancer Control
& Population Sciences, National Cancer Institute), Marc Elliott (RAND Corporation), Irene Fraser (Agency for Healthcare Research and Quality), Allen Fremont (RAND Corporation), Ron Hays (Division of General Internal
Medicine and Health Services Research, UCLA), Karen Humes (U.S. Census Bureau), Deeana Jang (Asian &
Pacific Islander American Health Forum, speaking on behalf of Out of Many, One's Health Data Taskforce),
Marjorie Kagawa-Singer (UCLA School of Public Health), Karen Kmetik (American Medical Association and
The Physician Consortium for Performance Improvement), David Lansky (Pacific Business Group on Health),
Nicole Lurie (RAND Corporation, Center for Population Health and Health Disparities), Jennifer Madans (National
Center for Health Statistics), Paul McGann (Office of Clinical Standards and Quality, Centers for Medicare and
Medicaid Services), Marsha Regenstein (The George Washington University), Thomas Reilly (Office of Research,
Development and Information, Centers for Medicare and Medicaid Services), Michael Rodriguez (Department of
Family Medicine, David Geffen School of Medicine, UCLA), Patrick Romano (Divisions of General Medicine and
General Pediatrics, Center for Healthcare Policy and Research, University of California, Davis), Joachim Roski
(Engelberg Center for Health Care Reform, The Brookings Institution), Maribeth Shannon (Market and Policy
Monitor Program, California HealthCare Foundation), Gayle Tang (National Diversity, Kaiser Permanente), Kalahn
Taylor-Clark (Engelberg Center for Healthcare Reform, The Brookings Institution), Grace Ting (Health Equities
Programs, Wellpoint, Inc.), Katherine K. Wallman (U.S. Office of Management and Budget), Thomas Williams
(Integrated Healthcare Association), and Mara Youdelman (National Health Law Program).
Others also provided valuable advice on the issues under study; these include Kirsten Anderson (Aetna),
Douglas Boenning (U.S. Department of Health and Human Services), Arleen F. Brown (UCLA Division of General
Internal Medicine), Helen Burstin (National Quality Forum), Pat Callaghan (Minnesota Department of Human
Services), Eric Coleman (University of Colorado, Denver), Janet Corrigan (National Quality Forum), William
Golden (Arkansas Medicaid, Department of Human Services), Sheldon Greenfield (University of California,
Irvine), William E. Hammond (Duke University), W. David Helms (AcademyHealth), Catherine Hess (National
Academy for State Health Policy), Bill Imada (IW Group, Inc.), George Isham (HealthPartners), Francine Jetton
(Society of General Internal Medicine), Sherrie Kaplan (University of California, Irvine), Paul Kaye (Hudson River
Health Care, Inc.), Alison Kirchgasser (Massachusetts Office of Medicine), Ann Kohler (National Association of
State Medicaid Directors), Chris Lee (Kaiser Family Foundation), Lisa Lee (Kentucky Children's Health Insurance
Program), Dave Michalik (Delaware Division of Medicaid and Medical Assistance), Jeannette Noltenius (Out of
Many, One), Nancy A. Rigotti (Massachusetts General Hospital), J. James Rohack (American Medical Association),
Barbara Rudolph (The Leapfrog Group), Adam Schickedanz (University of California, San Francisco, and
National Academy of Sciences Mirzayan Science and Technology Fellow through May 2009), Cathy Schoen (The
Commonwealth Fund), Susan Schow (Maine Health Data Organization), Sora Park Tanjasiri (Center for Cancer
Disparities Research), Caroline Taplin (U.S. Department of Health and Human Services), Alan Weil (National
Academy for State Health Policy), and Judy Womack (Quality Oversight Bureau of TennCare).
In addition, we would like to thank Suzanne Niemeyer and Chris Shreeve (Ketchum), Jeanette Chung and
David Meltzer (University of Chicago), and Howard Wainer (National Board of Medical Examiners) who acted
as consultants during the project and drafted additional materials for the report.
Lastly, many individuals within the IOM were helpful throughout the study process including Clyde Behney,
Patrick Burke, Rosemary Chalk, Janice Mehler, Abbey Meltzer, Christine Stencel, Vilija Teel, Jackie Turner, and
Jordan Wyndelts. We would also like to thank Kerry Kemp for assisting in copyediting this report.
1. Committee members Ignatius Bau, David Nerenz, and Paul Schyve were also members of the subcommittee.
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