National Advisory Council, November 4, 2011

Meeting Summary

Minutes from the November 4, 2011, meeting of the Agency for Healthcare Research and Quality's National Advisory Council are available on this page.

Contents

Call to Order and Approval of July 22, 2011, Summary Report
Director's Update
Message From the HHS Secretary
AHRQ's Patient-Centered Outcomes Research Dissemination/Implementation Activities
Briefing on the Institute of Medicine Future of Nursing Report and Campaign for Action
Exploratory Discussion: What Do We Want Out of Physician Performance Measures? Developing a Conceptual Frame
Public Comment
Chairman's Wrap-Up and NAC Input
Adjournment

National Advisory Council (NAC) Members Present

Bruce Siegel, M.D., M.P.H., National Association of Public Hospitals and Health Systems (Chair)
Mitra Behroozi, J.D., 1199SEIU Benefit and Pension Funds
Paul N. Casale, M.D., The Heart Group, Lancaster General Hospital
Helen Darling, M.A., National Business Group on Health
Louise-Marie Dembry, M.D., M.S., M.B.A., Yale-New Haven Hospital
Nancy E. Donaldson, D.N.Sc., R.N., Center for Nursing Research & Innovation, University of California, San Francisco
Arthur Garson, Jr., M.D., M.P.H., University of Virginia
Helen W. Haskell, Mothers Against Medical Error
Ardis Dee Hoven, M.D., University of Kentucky College of Medicine
Lisa M. Latts, M.D., M.B.A., M.S.P.H., WellPoint, Inc.
Andrea H. McGuire, M.D., M.B.A., American Enterprise Group, Inc.
Keith J. Mueller, Ph.D., The University of Iowa College of Public Health (by telephone)
Welton O'Neal, Jr., Pharm.D., Takeda Pharmaceuticals North America, Inc.
Christopher Queram, M.A., Wisconsin Collaborative for Healthcare Quality
Katherine A. Schneider, M.D., M.Phil., AtlantiCare Health System
Xavier Sevilla, M.D., Manatee County Rural Health Services, Inc.
Alan R. Spitzer, M.D., Pediatrix Medical Group
Jeffery Thompson, M.D., M.P.H., Washington State Medicaid Purchasing Administration
Janet S. Wyatt, Ph.D., R.N., Institute of Pediatric Nursing (by telephone)

Alternates Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Caroline Coleman, National Institutes of Health (for Nancy E. Miller, Ph.D.)
Patrick Conway, M.D., Centers for Medicare and Medicaid Services
Sandra L. Decker, Ph.D., Centers for Disease Control and Prevention

Agency for Healthcare Research and Quality (AHRQ) Staff Members Present

Carolyn M. Clancy, M.D., Director
Howard E. Holland, Director, Office of Communications and Knowledge Transfer
Jean R. Slutsky, P.A., M.S.P.H., Director, Center for Outcomes and Evidence
Karen Brooks, C.M.P., NAC Coordinator

 

Call to Order and Approval of July 22, 2011, Summary Report

Bruce Siegel, M.D., M.P.H., NAC Chair, called the group to order at 8:35 a.m., welcoming the NAC members, other participants, and visitors. He introduced new NAC ex officio alternate Sandra L. Decker, Ph.D., of the Centers for Disease Control and Prevention (CDC), and he asked the other NAC members to introduce themselves. Caroline Coleman, of the National Institutes of Health (NIH), was substituting for Nancy E. Miller, Ph.D. Seven NAC members are retiring from the council: Nancy E. Donaldson, D.N.Sc., R.N.; Arthur Garson, Jr., M.D., M.P.H.; Junius J. Gonzales, M.D., M.B.A.; Lisa M. Latts, M.D., M.B.A., M.S.P.H.; Keith J. Mueller, Ph.D.; Xavier Sevilla, M.D.; and Dr. Siegel.

Dr. Siegel referred to the draft minutes of the previous NAC meeting (July 22, 2011) and asked for changes and approval. The NAC members approved the July 22, 2011, meeting minutes with no changes.

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Director's Update

Carolyn M. Clancy, M.D., AHRQ Director, welcomed the NAC members, speakers, and other guests. She noted that former NAC member Jane Sisk, Ph.D., had retired from the CDC.

The Big Picture

Dr. Clancy stated that the Agency continues to await approval of a new budget. The current process features key decisions by the new federal budget "Super Committee," which is scheduled to make recommendations by November 23, 2011. President Obama's fiscal year 2012 budget proposal for AHRQ includes $65 million for patient safety research (of which $34 million is for reducing and preventing healthcare–associated infections), $46 million for patient-centered health care research, and $28 million for health information technology (IT).

Recent Accomplishments

Dr. Clancy reviewed the following recent accomplishments:

  • An AHRQ comparative effectiveness report (systematic review) on sleep apnea found the continuing positive airway pressure breathing machine to be the best treatment. A mouthpiece worn at night is also effective. All current treatments have possible side effects.
  • AHRQ created new Spanish-language guides that support treatment decisions for conditions such as heart disease, broken hip pain, and rotator-cuff tears. Spanish-language guides for 23 conditions are now available.
  • AHRQ produced a guide comparing treatments for gastroesophageal reflux disease (GERD, also known as acid reflux). The guide (an update) notes that proton pump inhibitors are effective, with no observed differences between types and dosages.
  • An AHRQ comparative effectiveness report on treating juvenile arthritis found that disease-modifying antirheumatic drugs improve treatment; that is, they are more effective than traditional treatments in improving symptoms.
  • An Effective Health Care (EHC) Program report found there is little evidence supporting off-label use of atypical antipsychotic medications (APMs) for treating substance abuse, eating disorders, and insomnia. Evidence supports the use of some atypical APMs for treating dementia, anxiety, and obsessive-compulsive disorder.
  • Another study from the EHC Program found that the use of angiotensin-converting enzyme inhibitors in the first trimester of pregnancy posed no greater risk for birth defects compared with the use of other high blood pressure medications or no drugs.
  • An AHRQ comparative effectiveness review found that 5 percent of children worldwide are diagnosed with attention deficit hyperactivity disorder (ADHD). Evidence to support the use of drugs such as methylphenidate to treat children age 6 years and younger is weak.
  • AHRQ issued 3-year grants totaling $4.5 million for three Research Centers for Excellence in Clinical Preventive Services to support research on improving clinical preventive services. The sites are Northwestern University (focusing on equity), University of North Carolina at Chapel Hill (focusing on safety), and University of Colorado, Anschutz Medical Campus (focusing on implementation).
  • AHRQ announced a $34 million program of awards to support efforts to reduce healthcare–associated infections.
  • The Dallas Morning News featured a report about patient safety in Texas hospitals. The report incorporated AHRQ Patient Safety Indicators.
  • In a Knowledge Transfer Case Study, the Washington State Medicaid Program used products from AHRQ's EHC Program (cesarean delivery, GERD). In another Case Study, the Hawaii Department of Human Services used survey findings from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) for public reporting and pay-for-performance initiatives.
  • Medical Expenditure Panel Survey (MEPS) data were used in many new cases (e.g., Henry J. Kaiser Family Foundation, Duke University, the Deloitte Center for Health Solutions, Johns Hopkins University).
  • The Mayo Clinic used MEPS data to describe the incidence of transitions to and from Medicaid, to characterize populations, and to observe links between insurance instability and health care utilization. The Oregon Department of Consumer and Business Services used MEPS data in a yearly report for policymakers.
  • The Missouri Department of Health and Senior Services used data from the Healthcare Cost and Utilization Project (HCUP) to develop a report on Missouri's safety net. The University of Missouri's Center for Health Policy employed AHRQ's Health Literacy Universal Precautions Toolkit in a management module for health literacy training for physicians.
  • In Vermont, Fletcher Allen Health Care incorporated AHRQ's "Staying Healthy and Active With Blood Thinners" video in an educational program used in anticoagulation clinics and one hospital.
  • The Spanish Catholic Center of Catholic Charities, in the District of Columbia, developed a preventive health-screening flowchart using recommendations from the U.S. Preventive Services Task Force (USPSTF) and the CDC, and trained clinicians in the use of handheld devices containing such information.

AHRQ Program Updates

Dr. Clancy provided the following Program updates:

  • AHRQ's Health Care Innovations Exchange, available through the Web site of the U.S. Department of Health and Human Services (HHS), now allows users to search for innovations by State. The site features information on many AHRQ resources.
  • Major medical journals ran AHRQ's "Questions Are the Answer" advertisements during fall 2011. AHRQ's Web site was updated to include videos featuring patients and clinicians and materials focusing on patient-doctor communication. Dr. Clancy presented two of the videos to the NAC, one targeting patients and one targeting clinicians.
  • In September 2011, AHRQ awarded four 2-year grants in its Infrastructure for Maintaining Primary Care Transformation Program to assist in primary care redesign and transformation. The awardees are the University of New Mexico Health Sciences Center, University of North Carolina at Chapel Hill, Penn State Hershey College of Medicine, and University of Oklahoma Health Sciences Center.
  • The USPSTF made five draft recommendation statements available for comment: screening and management of obesity in adults, screening for cervical cancer, screening for prostate cancer, screening for hearing loss in older adults, and screening for coronary heart disease with electrocardiography.
  • AHRQ will support briefings (via telephone) on prostate and cervical cancer, focusing on the USPSTF process and recommendations. In another effort to provide transparency, AHRQ will post draft research plans for public comment beginning in December 2011.
  • AHRQ, with the USPSTF, presented the "First Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services" in October 2011.
  • Six research centers were awarded 5-year cooperative agreements (about $850,000 per year) in the Centers for Education and Research on Therapeutics Program: Kaiser Permanente Center for Health Research, Brigham and Women's Hospital, Cincinnati Children's Hospital Medical Center, Rutgers University, University of Alabama at Birmingham, and University of Illinois at Chicago.
  • A study and report from the EHC Program on the safety and efficacy of drug-eluting stents focused on patients with chronic kidney disease and found an associated reduction in the rates of myocardial infarction and death.
  • Another study from the EHC Program, in collaboration with the U.S. Food and Drug Administration, found no evidence of increased risk of serious cardiovascular effects in children and young people who use medications to treat ADHD.
  • A new report reviews methodological decision points that sponsors might encounter when generating provider performance scores (available at http://www.ahrq.gov/qual/value/perfscoresmethods).
  • A groundbreaking study is testing alternative public reporting approaches for provider costs and resource use. More than half of the States now produce a public report using AHRQ Quality Indicators.
  • AHRQ's work in collaboration with Mathematica Policy Research features environmental scans of past and current data collection on physicians. A prototype instrument will be developed.
  • AHRQ's HIV Research Network has observed increasing guideline compliance in the tracking of CD4 counts and medications. The program has found that the cost of care has remained constant over the past 3 years.
  • AHRQ's HCUP welcomed Alaska as the 45th State partner. The project found septicemia to be the single most expensive condition treated in U.S. hospitals, with a cost of about $15.4 billion in 2009.
  • AHRQ funded a National Research Council guide on home health care and the use of consumer health IT. AHRQ also supported a report by the Council about trends in home health care services, the integration of human factors and design, and implementation of devices, technologies, and practices.
  • AHRQ supported an Active Aging Research Center (P50 award) at the University of Wisconsin-Madison to improve the health and functioning of aging persons with the help of health IT.
  • AHRQ is offering a new Pathways to Quality Award for the application of health IT scanning.
  • MEPS family premium estimates for 2010 were made available for use in setting state tax credits for small private-sector firms under the current health care reform.
  • AHRQ supported the HHS Data Council to advance HHS data strategy, featuring research and development and data integration and alignment.
  • The Centers for Medicare and Medicaid Services has worked to ensure that CAHPS supports its patient experience survey for home- and community-based services. The Health Resources and Services Administration is developing a CAHPS survey for use in its health centers.
  • The draft 2011 "National Healthcare Quality and Disparities Reports" are in the final clearance stages and will be released in January 2012. Work on the 2012 reports has begun.
  • There are now 79 Patient Safety Organizations (PSOs) in 31 States. A beta version of common formats was published in October 2011. AHRQ has many current and planned activities in its Patient Safety Portfolio, including grants for health care simulation research, a perinatal safety program, patient/consumer reporting of safety events, and risk assessment of clinical laboratory testing processes.
  • The 2011 AHRQ Annual Conference, held September 18–21, 2011, was a success, attracting more than 1,800 attendees. The 2012 conference will take place September 9–12, 2012, again at the Bethesda North Marriott Hotel and Conference Center.

Discussion

Dr. Garson cited the issue of resource overuse associated with frequent changes in health care coverage for individuals. Janet Wyatt, Ph.D., R.N., stressed that Advanced Practice Registered Nurses ought to be included as resources for high-quality care, especially as we move toward the medical home idea. Dr. Garson added that his institution's grant aids program has supported nurse extenders and has found success. Dr. Latts wondered whether the Active Aging Research Center project includes a focus on incontinence. Ardis Dee Hoven, M.D., noted that the American Medical Association produced a large review about care for elderly persons.

Jeffery Thompson, M.D., M.P.H., encouraged AHRQ to look upstream regarding perinatal safety—various early problems contribute to costs. Helen Darling, M.A., wondered about the differences between PSOs and Quality Improvement Organizations (QIOs). Dr. Clancy noted that there is alignment between the two operations. PSOs are voluntary organizations, while QIOs focus on Medicare populations.

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Message From the HHS Secretary

Kathleen Sebelius, HHS Secretary, joined the NAC members briefly, thanking them for their efforts and recognizing that NAC deliberations serve to inform the work of HHS. She stressed that AHRQ's support for matching in treatment and patient protocols is critical. The experience of NAC members is important and is leveraged by HHS to advance its programs.

Secretary Sebelius stated that we are in precarious financial times, yet current legislation offers an opportunity to improve our health care system, allowing it to be informed by expertise and by a testing of policies. The work of the NAC resonates and can inform these efforts.

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AHRQ's Patient-Centered Outcomes Research Dissemination/Implementation Activities

Jean R. Slutsky, P.A., M.S.P.H., AHRQ; Howard E. Holland, AHRQ; and Barry Patel, Pharm.D., Total Therapeutic Management, Inc.

Ms. Jean Slutsky introduced a session on AHRQ's efforts to support patient-centered outcomes research (PCOR). AHRQ seeks to disseminate, translate, and implement the results, as well as to:

  • Foster awareness and use of PCOR findings, products, and tools by various audiences.
  • Inform professional and consumer audiences about AHRQ's EHC Program and its processes and products.
  • Drive toward greater degrees of shared decisionmaking by clinicians, patients, and caregivers.

The EHC Program informs health care professionals, consumers, health care system decisionmakers, business leaders, government policymakers, and advocates. Ms. Slutsky described how AHRQ's Eisenberg Center relates to various EHC Program components at AHRQ and noted the many products for translation and dissemination that have been developed by the Center. In 2009, stimulus funds were used to build a portfolio of research demonstration products and to disseminate comparative effectiveness research summary guides, with the goal of stimulating innovative adaptations. A community forum project served to expand and systematize public and stakeholder involvement in AHRQ's EHC Program.

Mr. Howard Holland provided more details of the stimulus-supported efforts, including contracts for a national initiative, regional offices, online continuing education, academic detailing, and systematic program evaluation. The national effort includes a multimedia awareness campaign and partnerships. About 120 partners hold meetings, create newsletter articles, and distribute thousands of copies of 47 print publications. By September 30, 2011, 10 online modules for continuing education had been released. They have been utilized by nurses, case managers, pharmacists, physicians, nurse practitioners, and others. Mr. Holland described current efforts to evaluate the ongoing dissemination methods.

Dr. Barry Patel described the academic detailing, provided by his organization, Total Therapeutic Management, Inc. (TTM). The firm's academic detailing service includes onsite sessions that feature interactive education, clinician-clinician interaction, and dissemination of comparative effectiveness reviews. The academic detailing project disseminates key messages from the EHC Program to primary care providers and heath system directors nationwide. Dr. Patel outlined topics that have been covered (e.g., diabetes, heart conditions), target audiences, and recruitment and training of academic detailers. He stated that, as of October 28, 2011, the program had conducted 1,562 visits with 1,612 audience members in 35 States. A large fraction of the audience members ordered materials, especially consumer guides for patients. Dr. Patel stressed that health plans, health systems, and large medical groups can serve as a valuable resource in gaining access to busy clinicians and other health care professionals.

Discussion

Dr. Siegel wondered about the potential use of social media strategy. Mr. Holland noted that tactics are being developed (e.g., smart phone messaging). Dr. Patel stated that his company's efforts extend into the offices of clinicians and various ancillary health care professionals.

Dr. Donaldson encouraged the creation of "meta-partnerships"; that is, developing partnerships with groups that already have bundled relevant members and registries. She also encouraged multidisciplinary audiences, including nurses. Dr. Patel noted that, for the AHRQ project, TTM does not target particular individuals beyond those the health system proposes. Welton O'Neal, Jr., Pharm.D., suggested that TTM consider a long-term focus regarding evaluation and regular updates. Mr. Holland added that the academic detailing program seeks to serve as a complementary tool for other systems and activities in dissemination. One grant will target issues of methodology. Ms. Slutsky noted that the issue of medication adherence is not in the portfolio.

Katherine A. Schneider, M.D., M.Phil., noted an opportunity for the project to feature data-driven targeting, focusing on both consumers and providers and using social media. Dr. Sevilla suggested that a patient focus be incorporated into the diagram for the project's overall framework and that the project include a focus on maintaining certification.

Dr. Patel reported that the project has produced significant changes in clinician behavior. David Atkins, M.D., M.P.H., noted a challenge to sustaining the program beyond the grant period—the need to demonstrate a business case. Future efforts will likely target profitable cases, with detailers as a regular presence and emphasis on the development of rapport. Mr. Holland cited actions to publicize and explain the effort, including its options. Dr. Patel added that the landscape will always change, with new formats and metrics.

Dr. Hoven suggested that AHRQ use a term other than "academic detailing"—because of potential confusion with other activities (e.g., pharmaceutical industry detailing). She wondered how regional partnerships will operate. Mr. Holland noted that there are five regional development offices, with staff, experts, and local advisory panels assigned to each. Dr. Patel noted that his program does not use the term "academic detailing." Small and large institutions are approached in different ways.

Alan R. Spitzer, M.D., cautioned that many small clinical practices are not computerized. Perhaps the project is an opportunity to encourage computerization. Dr. Latts wondered about the cost-effectiveness of the program. How might it interact with the developing presence of patient-centered medical homes and other new structures? Mr. Holland expressed hope that the program would develop channels for distributing information and responding to changes in the health care scene. Helen W. Haskell encouraged the project administrators to obtain concrete numbers with which to account for the dissemination efforts.

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Briefing on the Institute of Medicine Future of Nursing Report and Campaign for Action

Nancy E. Donaldson, D.N.Sc., R.N., University of California, San Francisco, and Janet S. Wyatt, Ph.D., R.N., Institute of Pediatric Nursing (presenting via telephone)

Dr. Donaldson briefed the NAC on the recent Institute of Medicine (IOM) report "The Future of Nursing: Leading Change, Advancing Health." The report suggests that the nursing profession will serve as a leader for change, as one of the many aspects of health care that will experience change toward high-quality, patient-centered care. Current health system challenges include fragmentation, high costs, disparities, medical errors, a primary care shortage, and an aging and sicker population. The IOM Committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing envisions a transformed health system that begins with health promotion, wellness, and primary care and proceeds through levels of chronic illness management, home care, long-term care, and acute care. For nursing's future role, the IOM report recommends:

  • Removing scope-of-practice barriers.
  • Expanding opportunities for nurses to lead and diffuse collaborative improvement efforts.
  • Implementing nurse residency programs.
  • Increasing the proportion of nurses with a B.S.N. degree to 80 percent by 2020.
  • Doubling the number of nurses with a doctoral degree by 2020.
  • Ensuring that nurses engage in lifelong learning.
  • Preparing and enabling nurses to lead change to advance health.
  • Building an infrastructure to collect and analyze health care workforce data.

Dr. Donaldson described the Campaign for Action, supported by RWJF and AARP, responding to the IOM recommendations. The campaign targets education, leadership, access to care, and workforce data. In the first year, action coalitions were launched in 36 States. They include or will include long-term alliances, networking, capturing of best practices, and field strategies for moving nursing issues forward.

Dr. Wyatt stated that Advanced Practice Registered Nurses provide high-quality primary care, should be recognized as playing an important role in improving quality of care, and can support efforts to expand access to care. She reported that the action coalitions will emphasize issues of nurse education, practice, collaboration, leadership, and diversity. Dr. Donaldson stressed that sustaining progress will require input from government, business, health care institutions, academia, the insurance industry, and other health professions. She urged NAC members to learn about the initiative and to consider the IOM recommendations.

Discussion

Dr. Siegel raised the issue of capacity and how it can be a barrier to the efforts described. Dr. Donaldson responded that capacity differs among States. Other barriers for nursing are regulations and the inability to bill. Dr. Wyatt cited challenges in recognition and limitations on practice. Dr. Garson raised the issue of physician opposition. Louise-Marie Dembry, M.D., M.S., M.B.A., acknowledged barriers in the doctor-nurse relationship, yet noted opportunities for leadership by nurses. Dr. Sevilla suggested a focus on the education and training of both nurses and doctors, stressing medicine as a team sport.

Dr. Thompson brought up the issue of system conflicts that arise for patients with multiple ailments. It is difficult to find the proper expertise for such patients, especially experts with in-depth knowledge. Dr. Wyatt suggested a role for nurse practitioners in such situations. Ms. Darling noted the ongoing issue of nurses leaving the profession.

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Exploratory Discussion: What Do We Want Out of Physician Performance Measures? Developing a Conceptual Frame

Lisa M. Latts, M.D., M.B.A., M.S.P.H., WellPoint, Inc.; Carolyn M. Clancy, M.D., AHRQ Director; and NAC Members

Dr. Latts began an extended discussion about performance measures by describing the evolving relationship between doctors and patients. She noted the following trends:

  • We are entering an era featuring consumerism and a movement toward shared decisionmaking.
  • Research has demonstrated a strong relationship between patient-centered communication and higher levels of satisfaction and trust.
  • Patients whose physicians communicate poorly have a 19 percent higher risk of nonadherence compared with patients whose physicians communicate well.

Dr. Latts provided a timeline and summary of efforts to improve patient engagement during the past dozen years (beginning with the 1999 IOM report "To Err Is Human"). She stressed a potential conflict between patient engagement and quality improvement efforts. That is, we should not accept the idea that patients will always make the right medical choices, based on evidence. Physicians sometimes "fire" noncompliant patients (those who choose not to follow the doctor's treatment recommendation) so that quality targets can be reached.

Discussion

Ms. Darling wondered whether there should be codes for physicians to use to indicate that a patient has chosen not to receive a certain treatment. Dr. Thompson stressed a need to reward providers who do great work. Dr. Schneider cautioned that documenting exceptions could become burdensome for providers. An individualized care plan is beneficial, but resources are required. Dr. Thompson suggested that documentation be required only when applications are two or more standard deviations in either direction from a mean. This raises the issue of the management of variations of all kinds.

Mitra Behroozi, J.D., noted that some States are experimenting with certain documentation, for example, to ensure that patients have been informed by physicians of standard practices. Dr. Sevilla stated that his practice features a strong interest in the opinions of patients; however, this has resulted in a lowering of immunization rates, because of patients who decline. He suggested that the provider is not necessarily the best person to perform academic detailing for patients. How might we affect the sources of information for patients? Dr. Clancy noted that some health care plans facilitate decisionmaking (for providers) for cases in which patients do not follow the advice of the provider.

Dr. Dembry cited arguments about defining improvement and wondered whether outliers are most important, while some details are not. A good deal of medical practice remains a form of art. There are shades of gray. Dr. Thompson noted that the State of Washington stepped in to mandate education for patients in some cases. Although, added Dr. Sevilla, in a case such as vaccination, patient pushback features multiple types and reasons.

Dr. Latts wondered whether it is unreasonable to seek 100 percent improvement for some quality issues. Dr. Atkins gave the example of hypertension treatment. People are sometimes overtreated or undertreated, making a single measure unhelpful. Perhaps an imperfect measure should be applied, with an allowance for variation. The goal is to improve quality of care. Ms. Darling cited the problem of bad consequences that arise when some quality indicators are eliminated—that is, frustration for the good performers. Patrick Conway, M.D., posed the question of which core measures drive improvement. Dr. Hoven stressed variability in provider processes of care.

Dr. Spitzer raised the issue of health care financial expense. In that light, the application of quality measures can acquire a punitive aspect. Dr. Spitzer called for more education of patients and more incentives for them. Ms. Haskell cautioned that recommendations with a clinical aspect can lead to overuse or overtreatment. We should not penalize providers for offering individualized treatment. Paul N. Casale, M.D., added that, with process measures, one can become mired in the details and lose sight of the patient. The patient's attitude can be lost.

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Public Comment

Lisa Klein, M.S.N., R.N.C., a clinical nurse specialist with Inova Health System, addressed the NAC in response to the session on nursing trends. She called for sensitive measures of outcomes related to nursing. The resulting information should be collected and stored so that nurses might access and benefit from it. Dr. Donaldson noted that some benchmarks have been published. She is involved in an upcoming paper on the prevention of pressure ulcers.

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Chairman's Wrap-Up and NAC Input

Dr. Siegel reviewed the day's agenda and expressed enthusiasm for the scope and perspectives of the presentations. He encouraged the NAC to synthesize the results of the academic detailing initiative when they become available. Dr. Siegel asked the NAC members for final thoughts.

  • Dr. Casale stressed the need to communicate risk to patients.
  • Ms. Darling and Dr. Thompson agreed on the need to engage patients and to stress patient-centered care. Perhaps the NAC should discuss the use of decision aids and liability at a future meeting.
  • Drs. Donaldson and O'Neal encouraged the NAC to address interdisciplinary opportunities and perspectives.
  • Dr. Schneider proposed a continuation of the discussion of performance measures.
  • Dr. Dembry encouraged the NAC to continue to discuss the academic detailing issue. What data are contradictory? What is unknown?
  • Dr. Atkins encouraged the NAC to address issues of the medical home and team-based care. How should we train teams in patient-centered health care? How can we arrive at value and efficiency in systems?
  • Dr. Decker called for discussions of data (e.g., HCUP) and issues such as workforce capacity. For example, there is a need to enumerate the types of health care providers. We need more data about Medicaid patients.
  • Dr. Spitzer stressed the need for patient education.
  • Dr. Latts encouraged the NAC to investigate upstream issues such as training the health care workforce. The Council might consider the phenomenon of rising to the level of a performance measure.
  • Andrea H. McGuire, M.D., M.B.A., supported the use of the Chair's call prior to the meeting.
  • Ms. Haskell encouraged the NAC to continue discussing issues of dissemination, knowledge of risk, variability in care, and the use of flexible measures.

Dr. Clancy expressed optimism about the potential for measurement to add value to health care practice. She cited the ability of inspiration to stimulate good results and encouraged discussion of the interdisciplinary aspects of patient-centered care.

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Adjournment

Dr. Siegel thanked the NAC members, invited speakers, and guests and adjourned the meeting at 3:25 p.m.

Current as of November 2011
Internet Citation: National Advisory Council, November 4, 2011: Meeting Summary. November 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/nac/2011-11-nac/meeting-summary.html