AHRQ Annual Highlights, 2008 (continued)

Developing Tools and Data for Research and Policymaking

Efforts to improve the quality and efficiency of health care and reduce disparities in the United States must be based on a thorough understanding of how the Nation's health systems work and how different organizational and financial arrangements affect health care. AHRQ has a broad portfolio of data on costs, access to health care, quality, and outcomes that can be used for research and policymaking.

Medical Expenditure Panel Survey

The Medical Expenditure Panel Survey (MEPS) is the only national source of annual data on the specific health services that Americans use, how frequently the services are used, the cost of the services, and the methods of paying for those services. MEPS is designed to help us understand how the growth of managed care, changes in private health insurance, and other dynamics of today's market-driven health care delivery system have affected health care in America. MEPS provides the foundation for estimating the impact of changes on different economic groups or special populations such as the poor, elderly, veterans, the uninsured, or racial/ethnic groups.

MEPS consists of a family of surveys, which includes families and individuals, their medical providers, and employers across the United States. The MEPS Household Component collects data on demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment. The MEPS Household Component public use data files released in 2008 cover the calendar year 2006. These data files included full-year population characteristics, job information, home health, other medical expenses, dental visits, emergency room visits, office-based provider, and outpatient visits.

The MEPS Insurance Component (MEPS-IC) collects data from a sample of private and public sector employers on the health insurance plans they offer their employees. The collected data include the number and types of private insurance plans offered (if any), premiums, contributions by employers and employees, eligibility requirements, benefits associated with these plans, and employer characteristics. In 2008, MEPS-IC data released included 2006 MEPS-IC Health Insurance Tables — National Estimates as well as State and Metro Area Estimates.

MEPS Publications

MEPS publishes various reports including statistical briefs, research findings, methodology reports, and chartbooks. These analytic publications are based on data collected through MEPS. For example:

• Only about 49 percent of Hispanics who are not comfortable speaking English have a regular source of medical care, such as a family doctor or community health clinic, compared to 63 percent of Hispanics who speak English proficiently. About 6 of every 10 Hispanics aged 18-64 with limited English proficiency are also uninsured compared with 3 of every 10 Hispanics who speak English proficiently. This analysis, based on 2004 statistics, also found that Hispanics with limited English proficiency were less likely to visit a doctor or clinic, go to an emergency room, have their prescriptions filled, or visit a dentist compared to those who spoke English proficiently (Figure 2).
• In 2005, about 6 of every 10 people in the United States age 18 and older had at least one chronic medical condition as did 9 of every 10 Americans aged 65 and older. Over three-fourths had two or more chronic conditions. Nine of every 10 dollars spent for medical care (excluding expenses for dental care and medical equipment and supplies) on adults in the United States was spent to treat persons with chronic conditions.
• U.S. adult consumers spent nearly $36 billion for prescription drugs to lower blood sugar, reduce cholesterol, or help with other metabolic problems in 2005. The four other classes of drugs that topped spending among adults were:
  • Cardiovascular drugs, for reducing high blood pressure and treating heart conditions ($33 billion).
  • Central nervous system drugs, which include pain killers, sleep aid medications and medications for attention deficit disorder ($26 billion).
  • Antidepressants and antipsychotic drugs ($17 billion).
  • Gastrointestinal drugs including antacids and laxatives ($15 billion).

Reports, data files, and additional information on MEPS are available online at http://meps.ahrq.gov.

Figure 2. Comparison of access to health care for Hispanics by proficiency in English

Source: Demographics and Health Care Access of Limited-English-Proficient and English-Proficient Hispanics, MEPS Research Findings #28.

Healthcare Cost and Utilization Project

The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and related software tools and products developed through a Federal-State-industry partnership and sponsored by AHRQ. HCUP databases bring together the data collection efforts of 39 State data organizations, hospital associations, private data organizations, and the Federal government to create a national information resource of patient-level health care data. HCUP includes the largest collection of all-payer encounter-level longitudinal hospital care data in the United States, beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.

Outpatient Data Initiatives

In FY2008, HCUP added a number of outpatient databases, including additional State Ambulatory Surgery Databases (SASD) and State Emergency Department Databases (SEDD). It also began the development of a new nationwide emergency department sample (NEDS) database. Analysis concluded in 2008 determined that creating the NEDS would be a valuable resource for examining emergency department (ED) services. In 2008, 27 States contributed data on ambulatory surgery and other outpatient services for a combined total of 45,759,433 visits in over 4,087 facilities. In addition, 25 States contributed outpatient ED data, for a combined total of 52,268,817 visits in 2,486 hospitals.

2006 Kids' Inpatient Database

In 2008, HCUP released data from the Kids' Inpatient Database (KID)—the only dataset on hospital use, outcomes, and charges designed to study children, and includes all patients under age 21 regardless of payer (privately insured, Medicaid, uninsured). The data, which is released every 3 years, can be weighted to produce national estimates, allowing researchers and policymakers to use the KID to identify, track, and analyze national trends in pediatric health care issues on utilization, access, charges, quality, and outcomes. Such topics include:

• Rare conditions, such as congenital anomalies.
• Common conditions, such as asthma.
• Economic burden of pediatric conditions, such as adolescent pregnancy.
• Access to services.
• Quality of care and patient safety.
• Impact of health policy changes.

The KID for 2006 includes 3,739 hospitals from 38 States. As part of the HCUP database family, the KID is considered to be one of the most reliable and affordable databases for studying important pediatric health care topics.

2006 Nationwide Inpatient Sample

The Nationwide Inpatient Sample (NIS) featuring 2006 data was released in May 2008. This inpatient care database includes all patients, regardless of payer—including people covered by Medicare, Medicaid, private insurance, and the uninsured. The data can be weighted to produce national estimates, allowing researchers and policymakers to use the NIS to identify, track, and analyze national trends in health care utilization, access, charges, quality, and outcomes.

Health statistics and information from the 2006 KID and the 2006 NIS can be accessed via HCUPnet at http://hcupnet.ahrq.gov, the free online data query system.

2006 State Data

State data for the 2006 data year was released in 2008. This database release includes the State Inpatient Databases (SID), SASD, and SEDD of selected States. Researchers and policymakers can use these State-specific HCUP databases to investigate questions unique to one State, compare data from two or more States, conduct market area research or small area variation analyses, and identify State-specific trends in utilization, access, quality, charges, and outcomes.

• SID data from the 2006 data year are available for 24 of the HCUP Partner States.
• The SASD feature ambulatory surgeries performed on the same day in which patients are admitted and released. They contain the ambulatory surgery encounter abstracts from hospital-affiliated, and in some cases, freestanding, ambulatory surgery sites within participating States. SASD data for 15 of the HCUP Partner states are available through the HCUP Central Distributor at http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp.
• The SEDD contain discharge information on all emergency department visits that do not result in a hospital admission. AHRQ added 2006 data files for California to the existing collection of 12 State SEDD files that are already available to the through the HCUP Central Distributor.

U.S. Hospital Bill is Approaching $1 Trillion U.S. hospitals charged $873 billion in 2005—a nearly 90 percent increase from the $462 billion charged in 1997. The 2005 bill, which is adjusted for inflation, represents the total amount charged for 39 million hospital stays. The average yearly rate of increase over the last several years in the national hospital bill was 4.5 percent. At this rate, researchers estimate that the annual national hospital bill may reach $1 trillion by 2008. Medicare paid the bulk of the national hospital bill ($411 billion), followed by private insurance ($272 billion) and Medicaid ($124 billion). Uninsured hospital stays accounted for $38 billion in charges. The remaining $28 billion was for other insurers, including Workers' Compensation, TRICARE, Title V, and other government programs. One-fifth of the national hospital bill was for treatment of just five conditions—coronary artery disease ($46 billion), pregnancy and childbirth ($44 billion), newborn infant care ($35 billion), heart attack ($32 billion), and congestive heart failure ($30 billion). For 10 conditions, the growth was greater than the average of all hospital stays: Sepsis—189 percent. Chest pain—181 percent. Respiratory failure—171 percent. Back pain—170 percent. Osteoarthritis—165 percent. Irregular heart beat—131 percent. Procedure complications—120 percent. Congestive heart failure—117 percent. Medical device complications—113 percent. Diabetes—97 percent. Source: The National Hospital Bill: Growth Trends and 2005 Update on the Most Expensive Conditions by Payer, Statistical Brief No. 42.

2007 State Data

Release of the 2007 Statewide databases including the SID, SASD, and SEDD for selected States began in July 2008. In the past, the HCUP Statewide databases were typically available 12 to 18 months following the end of a calendar year. Due to new process improvements and strong relationships with HCUP State Partners, AHRQ was able to begin releasing 2007 databases in half that time.

HCUP Statistical Briefs

The HCUP Statistical Briefs are a series of Web-based publications containing information from HCUP. These publications provide concise, easy-to-read information on hospital care, costs, quality, utilization, access, and trends for all payers (including Medicare, Medicaid, private insurance, and the uninsured). Each Statistical Brief covers an important health care issue. For example:

• Between 1997 and 2006, there were substantial increases in hospitalizations for skin and subcutaneous tissue infections (81 percent), blood infections (48 percent), degenerative joint disease (76 percent), and non-specific chest pain (59 percent). This compares to a 14 percent increase in all discharges.
• Blood transfusions occurred in one out of every ten hospital stays that included a procedure in 2006. Discharges with blood transfusions have increased 117 percent from 1997 to 2006, making this the largest as well as the fastest growing of the most common procedures performed during a hospital stay.
• Between 1993 and 2006, the number of infants born by C-section grew at an average annual rate of 4 percent. Several complications of C-section births grew more quickly, including post-birth respiratory problems (6 percent), jaundice (7 percent), and feeding problems (11 percent).

For more information on HCUP, go to https://www.ahrq.gov/data/hcup.

AHRQ Quality Indicators

AHRQ has developed an array of health care decisionmaking and research tools that can be used by audiences such as program managers, purchasers, researchers, government agencies, and others. The AHRQ Quality Indicators (QIs) tool is widely used to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time.

The AHRQ QIs are organized into four modules, each of which measures quality associated with the delivery of care occurring in either an outpatient or an inpatient setting. In 2008, AHRQ released Version 3.2, an update of all four modules:

• Prevention Quality Indictors (PQIs) are ambulatory care-sensitive conditions that identify adult hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.
• Inpatient Quality Indicators (IQIs) reflect quality of care for adults inside hospitals and include: inpatient mortality for medical conditions; inpatient mortality for surgical procedures; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures may be associated with lower mortality.
• Patient Safety Indicators (PSIs) also reflect quality of care for adults inside hospitals, but focus on potentially avoidable complications and iatrogenic events.
• Pediatric Quality Indicators (PedQIs) are indicators of children's health care that can be used with inpatient discharge data. They are designed to help hospitals examine both the quality of inpatient care and the quality of outpatient care that can be inferred from inpatient data, such as potentially preventable hospitalizations.

The AHRQ QIs are being used for reporting and tracking at the international, national, State, and local levels:

• The Paris-based Organization for Economic Cooperation and Development (OECD) has adapted AHRQ's QIs as part of its effort to track the quality of health in nations around the world. OECD intends to use the indicators to explore why the quality of health care varies widely among nations. Currently, 32 nations are participating in the project, ranging from the Czech Republic to Japan to Mexico. The HCQI Project reports are available from the OECD Web site at www.oecd.org/health/hcqi.
• AHRQ's National Healthcare Quality and Disparities Reports and their derivative products incorporate many PQIs and PSIs for tracking and reporting at the national level.
• Currently, 12 States that report some or all of the AHRQ QIs: Vermont, Texas, New York, Wisconsin, Massachusetts, Oregon, California, Utah, Florida, Kentucky, Ohio and Iowa.
• Using AHRQ's Inpatient Quality Indicators (IQIs), the Dallas-Fort Worth Hospital Council helped identify a significant relationship between amphetamine use and inpatient stroke deaths in Texas hospitals.

In fiscal year 2008, the National Quality Forum endorsed over 30 AHRQ Quality Indicators for public reporting bringing the total number of endorsed AHRQ Quality Indicators to 44.

AHRQ's Patient Safety Indicators May Be Useful for Comparing Quality of Care Across Delivery Systems A study of Veterans Health Administration (VA) hospitals shows excess deaths, longer hospital stays, and higher costs in all groups of patients who experienced potentially preventable safety problems indicated by patient safety indicators (PSIs) developed by AHRQ. Researchers applied 9 PSIs to all 439,537 acute inpatient hospitalizations at 125 VA hospitals. They then compared these findings with those based on similar data on PSIs and adverse events at U.S. community hospitals from AHRQ's Healthcare Cost and Utilization Project Nationwide Inpatient Sample. All nine PSIs were significantly associated with increased length of stay (LOS), cost, and mortality in similar patterns among both VA and non-VA hospitals. The three PSIs that occurred most often—decubitus ulcer, postoperative pulmonary embolism/deep vein thrombosis, and accidental puncture/laceration—were associated with relatively smaller excess mortality, LOS, and cost. The three PSIs that occurred least often—postoperative sepsis (blood infection), respiratory failure, and dehiscence (disruption of the wound) were associated with the greatest excess mortality, LOS, and cost. See "Using patient safety indicators to estimate the impact of potential adverse events on outcomes," by Peter E. Rivard, Ph.D., Stephen L. Luther, Ph.D., Cindy L. Christiansen, Ph.D., and others, in the February 2008 Medical Care Research and Review 65(1), pp. 67-87.

AHRQ Preventable Hospitalization Costs, a County Level Mapping Tool

In 2008, AHRQ released a free, new software program that maps AHRQ's Prevention Quality and Pediatric Quality indicators for a State or county and estimates the expected cost savings that could be achieved by reducing potentially avoidable hospitalizations. The Preventable Hospitalization Costs (http://qualityindicators.ahrq.gov/mappingtool.htm) assists health care decisionmakers in identifying communities for future interventions, such as improving preventive and primary care services or improving patient safety, and tracking the impact of such interventions over time. By overlaying residence data, the program shows where interventions can have the biggest impact for certain health plan enrollees or other target populations. The program can also be useful to employers, employer coalitions, Medicaid programs, health departments, hospitals, health systems, health plans, and researchers interested in improving health care quality in the community.

TalkingQuality's Report Card Compendium AHRQ developed a new Web tool demonstrating a variety of approaches for health quality report cards. The new Health Care Report Card Compendium is a searchable directory of over 200 samples of report cards produced by a variety of organizations. It can inform and support the various organizations that develop health care quality reports, provide easy access to examples of different approaches to content and presentation, and meet the needs of health services researchers. The compendium was developed as a resource for report sponsors to supplement guidance provided on AHRQ's TalkingQuality Web site (http://talkingquality.ahrq.gov).

Consumer Assessment of Healthcare Providers and Systems (CAHPS®)

AHRQ has been the lead Federal agency in developing and distributing standardized, evidence-based surveys and related tools for assessing patients' experiences with the U.S. health care system. The Agency's Consumer Assessment of Health Care Providers and Systems (CAHPS®) program has become the focal point of a national effort to measure, report on, and improve the quality of health care from the perspective of consumers and patients. CAHPS® develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care.

The CAHPS® Web site is at http://cahps.ahrq.gov.

Release of CAHPS® Hospital Survey Results

In late March 2008, the Centers for Medicare & Medicaid Services (CMS) released results of the CAHPS® Hospital Survey (H-CAHPS) for the first time on the Hospital Compare Web site. These measures of the patient-centeredness of care at over 2,500 hospitals throughout the country complement existing information on the clinical quality of specific aspects of hospital care. The publication of the H-CAHPS data introduces a new element of transparency and accountability for hospitals. To view the results, go to http://www.hospitalcompare.hhs.gov.

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Preparing for Public Health Emergencies

AHRQ supports research and the development of models, tools, and reports to assess, plan, and improve the ability of the U.S. health care system to respond to public health emergencies that result from natural, biological, chemical, nuclear, and infectious disease events. These initiatives focus on an array of issues related to clinicians, hospitals, and health care systems, including the need to establish linkages among these providers with local and State public health departments, emergency management personnel, and others preparing to respond to events that have the potential to cause mass casualties.

New Tool Helps Hospitals Evaluate Disaster Drills

In 2008, AHRQ released a tool that helps hospitals identify the most important strengths and weaknesses in their disaster response plans. As of September 2008, hospitals participating in the Hospital Preparedness Program, administered through HHS, will be required to provide executive summaries of the results of disaster drills they conduct. AHRQ's new Tool for Evaluating Core Elements of Hospital Disaster Drills (https://www.ahrq.gov/prep/drillelements) can help hospitals meet this requirement.

The tool is a series of evidence-based modules that provide standardized checklists to document observations during a disaster drill. Using the observations, hospitals can identify areas for improvement, make appropriate changes and set benchmarks to track those changes over time. The individual modules assess the adequacy of response by different functional "zones" set up within a hospital during a disaster: command center, decontamination, triage, and treatment. A pre-drill module is also included, and a debrief module helps capture feedback from all participants, including observations that occur across multiple functional zones.

Resources for Home Health Care Response During a Flu Pandemic

AHRQ also released Home Health Care During an Influenza Pandemic: Issues and Resources (http://www.flu.gov/professional/hospital/homehealth.html), a report identifying home health care as a critical component in providing care during a pandemic influenza event and offering resources to home health care providers and community planners to prepare for such an event. The report emphasizes the home health care sector's potential to help handle a surge in patients during a biologic event and stresses the need for involvement of home health care agencies in advance planning and coordination at the local level. It offers resources and suggestions on addressing key elements of home health care preparedness and includes lists of existing tools and models. Examples of issues and strategies addressed in the report include:

• Exploring the use of technology to monitor patients at a distance.
• Collaboration with community partners.
• Legal and ethical considerations of providing care under emergency conditions.
• Home health care workforce issues, including training.
• Recommendations for additional action and research at the Federal, State, and local levels.

The report is based on the findings of an expert panel meeting, including representatives of home health care, emergency and disaster planning, professional organizations, and Federal and State government agencies.

AHRQ has funded more than 60 emergency preparedness-related studies, workshops, and conferences to help hospitals and health care systems prepare for public health emergencies. More information about these projects can be found online at http://www.arrchive.ahrq.gov/prep.

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Health Care Innovations Exchange

The Health Care Innovations Exchange (http://www.innovations.ahrq.gov) is a Web resource that allows users to learn, share, and adopt innovations in the delivery of health services. Innovations are new or perceived as new to a particular context or setting relative to the usual care processes. They have potential for high impact on the delivery of patient care, whether preventive, emergent, chronic, acute, rehabilitative, long-term, or end-of-life. In addition, they are designed to address the need for the reduction of health disparities in populations of interest to AHRQ, which include low income groups, minority groups, women, children, the elderly, and individuals with special health care needs.

Serving as the Federal government's repository for successful health care innovations, the Health Care Innovations Exchange also includes descriptions of attempts at innovation that failed, and is a useful tool for health care leaders, physicians, nurses, and other health professionals who seek to reduce health care disparities and improve health care overall. Users can read articles and perspectives on the creation and adoption of innovation, read expert-generated commentaries on specific innovations, comment on innovations, participate in Webinars and discussions, and join online forums that connect innovators with organizations that adopt them.

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