AHRQ Annual Highlights, 2009 (continued)

Value Portfolio and Related Activities

AHRQ's Value Portfolio and related activities aim to find a way to achieve greater value in health care—reducing unnecessary costs and waste while maintaining or improving quality—by producing the measures, data, tools, evidence, and strategies that health care organizations, systems, insurers, purchasers, and policymakers need to improve the value and affordability of health care. The goal is to create a high-value system, in which providers produce greater value, consumers and payers choose value, and the payment system rewards value.

Community Quality Collaboratives

In FY09, AHRQ continued its partnership with a set of 24 Community Quality Collaboratives (formerly known as Chartered Value Exchanges). As vehicles for community-wide improvement, these are regional and State collaboratives, consisting of representatives of at least four stakeholder groups (public and private purchasers, providers, health plans, and consumers), and in some cases State data organizations, Quality Improvement Organizations, and health information exchanges. These organizations work in tandem to improve community-wide quality and value through public reporting, payment incentives, and quality improvement initiatives.

AHRQ recompeted a contract for a Learning Network to provide the collaboratives with technical assistance and new evidence-based tools for quality/efficiency measurement, public reporting, and quality improvement. This Learning Network gives all the collaboratives access to organized peer learning, Web conferences, one-on-one consulting, and other support by top researchers and consultants.

Medical Expenditure Panel Survey

In FY09, the Medical Expenditure Panel Survey (MEPS) posted employer-based health insurance tables for private-sector establishments for the year 2008. Without major improvements in the data collection process, these data would have not been released until July 2010. Also, projected household expenditure data are now available aligning the 2002 MEPS Household Component (HC) file with the 2002 National Health Expenditure Accounts. In addition, three new files drawn from the 2007 MEPS have been released for public use: HC-110H 2007 Home Health; HC-110C 2007 Other Medical Expenses; and, HC-110B 2007 Dental Visits.

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 the health care system 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 health policy 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 gather information about families and individuals, their medical providers, and employers across the United States. The MEPS-HC 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. MEPS-HC public use data files released in FY09 cover the calendar year 2007. 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 FY09, MEPS-IC data released included 2008 MEPS-IC Health Insurance Tables-National Estimates as well as State and Metro Area Estimates. These data were released a full-year earlier than previously possible due to major improvements in the data collection process.

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. Findings in these publications include:

• Expenditures for outpatient prescription medicines that treat pain increased from $4.2 billion in 1996 to $13.2 billion in 2006. These medications include narcotic analgesics, non-steroidal anti-inflammatory drugs, and Cox-2 inhibitors, among others. Between 1996 and 2006, the average annual expenditure jumped from $83 to $232 for people who purchased one or more prescription pain killers. The total number of prescription purchases increased from about 164 million to 231 million.
• Private-sector employers and their employees have seen their health insurance premium costs go up by more than 100 percent since 1996. By contrast, employee compensation (wages and benefits) experienced an average increase of 42.2 percent. The data also show that for employment-based health insurance between 1996 and 2006, the average premium cost of a single plan rose from $1,992 to $4,118 with employers paying for most of the increases for single coverage (from $1,650 to $3,330 a year). Costs for a family plan increased even more. (Figure 1).
• In 2005, 1 percent of the population accounted for 23.3 percent of total health care expenditures, and 18.1 percent of the population in the top 1 percent retained this ranking in 2006.
• While 14.3 percent of people under age 65 were uninsured for all of 2006, the full-year uninsured comprised 22.1 percent of those in the bottom half of spenders for both 2005 and 2006.
• U.S. adult consumers spent about $38 billion for prescription drugs to lower blood sugar, reduce cholesterol, or help with other metabolic problems in 2006. 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 ($28 billion).
  • Antidepressants and antipsychotic drugs ($17.5 billion).
  • Hormones that are used for osteoporosis, menopausal symptoms, cancer treatment, and other medical problems: ($14 billion).

Requests for assistance on health initiatives

MEPS is as an important data source to inform health care policy at the State and national level. In FY09, MEPS data were provided to the Office of Health Reform, HHS, House Ways and Means Committee, House Committee on Veteran's Affairs, Joint Taxation Committee, Congressional Budget Office, Congressional Research Service, and the General Accountability Office. A summary of how AHRQ responded to these requests can be found at https://www.ahrq.gov/data/mreqahi.htm. MEPS data were also used extensively by State governments.

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

Healthcare Cost and Utilization Project

In FY09, the Healthcare Cost and Utilization Project (HCUP) added a number of exciting tools that will help the health care system improve the quality of and access to hospital care. These include outpatient data initiatives such as the newest HCUP database, the National Emergency Department Sample (NEDS), which is the largest all-payer emergency department database in the United States. Also expected for release in early 2010 is MONAHRQ (My Own Network, powered by AHRQ), a Web-based application enabling State and local data organizations, regional health improvement collaboratives, hospitals, health plans, and providers to input their own hospital administrative data and generate a data-driven Web site.

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 41 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.

Nationwide Emergency Department Sample (NEDS)

In July 2009, the National Emergency Department Sample (NEDS), the newest HCUP database, was released. It is the largest all-payer emergency department database in the United States, and is constructed using records from both the State Emergency Department Database (SEDD) and State Inpatient Databases (SID) to capture information both from emergency department visits where the patient was treated and released and ones that resulted in an admission to the same hospital. The NEDS contains more than 25 million records for emergency department visits at about 1,000 U.S. community hospitals and approximates a 20-percent stratified sample of U.S. hospital-based emergency departments. It contains information on hospital characteristics, patient characteristics, geographic region, and the nature of the emergency department visits (e.g., common reasons for visits, including injuries).

The database includes information on all emergency visits, regardless of payer—including persons covered by Medicare, Medicaid, private insurance, and the uninsured. For example, according to recently released NEDS data, more than 40 percent of the 120 million visits that Americans made to hospital emergency departments in 2006 were billed to public insurance. Files are available beginning with data year 2006. Further information is available at: https://www.ahrq.gov/research/data/hcup/index.html.

MONAHRQ-Input your data-Output your Web site

MONAHRQ (My Own Network, powered by AHRQ) is a Web-based application that AHRQ is developing to enable State and local data organizations, regional health improvement collaboratives, hospitals, health plans, and providers—to input their own hospital administrative data and generate a data-driven Web site. MONAHRQ is built on the Windows version of AHRQ's Quality Indicators but expands its capability to analyze, summarize, and present information on health care utilization, rates of conditions and procedures, and quality of care in a format ready for use by consumers and other decisionmakers. MONAHRQ will be available in early 2010.

New data added to HCUP

In FY09, AHRQ added new 2007 data to its HCUP State databases. The new data reflects updates in the State Ambulatory Surgery Databases (SASD), the SID, and the SEDD databases 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 for the 2007 data year are now available for 20 of the HCUP partner States. SASD 2007 data for 12 of the HCUP partner states, and AHRQ has also added 2007 data files for 9 States. The updated data are available through the HCUP Central Distributor at http://www.hcup-us.ahrq.gov/tech_assist/centdist.jsp.
• In FY09, AHRQ also added new 2007 data to its HCUP national database. For example, the 2007 NIS contains data from over 8 million hospital stays. Data from NIS are available from 1988 to 2007, allowing analysis of trends over time. The NIS is nationally representative of all short-term, non-Federal hospitals in the United States. It approximates a 20-percent stratified sample of hospitals in the United States and is drawn from the HCUP SID, which include 90 percent of all discharges in the United States. The NIS includes all patients from each sampled hospital, regardless of payer—including persons covered by Medicare, Medicaid, private insurance, and the uninsured. It encompasses all discharge data from more than 1,000 hospitals in 40 States.

HCUP Statistical Briefs

In FY09, AHRQ continued to issue HCUP Statistical Briefs, 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:

• The number of hospital stays that ended with patients leaving against the advice of medical staff increased from 264,000 cases to 368,000—about 39 percent—between 1997 and 2007. For cases in which patients left against medical advice in 2007:
  • The top five reasons were chest pain with no determined cause (25,600); alcohol-related disorders (25,300); substance-related disorders (21,000); depression or other mood disorders (13,900); and diabetes with complications (12,500).
  • Medicaid and Medicare patients each accounted for about 27 percent, and privately insured patients accounted for 19 percent. About 22 percent of the cases in 2007 involved uninsured patients.
  • In the Northeast, patients left hospitals against medical advice at twice the rate of that of the rest of the country—2 per 1,000 population versus an average of 1 per 1,000 population in all other regions. (Hospitalizations in which Patients Leave the Hospital against Medical Advice (AMA), 2007 http://www.hcup-us.ahrq.gov/reports/statbriefs/sb78.jsp.)
• U.S. hospitals spent roughly $56 billion in 2007-16 percent of their overall patient care costs-treating people ages 55 to 64. Further analysis found that in 2007:
  • Hospitals' costs to treat people ages 55 to 64 were nearly equal to the older generation of 65- to 74 year-olds, $56 billion and $59 billion, respectively. In contrast, those ages 55 to 64 cost hospitals $10 billion more than the younger generation of patients 45 to 54 years old.
  • The average hospital cost for a 55- to 64-year-old patient was $11,900 compared with $10,400 for 45- to 54-year-olds.
  • People age 55 to 64 were 2 to 3 times more likely than 45- to 54-year-olds to be hospitalized for osteoarthritis, stroke, respiratory failure, irregular heartbeat, chronic obstructive pulmonary disorder, blood infections, and congestive heart failure as well as undergo knee and hip replacements and have heart bypass surgery.
  • About 37 percent of patients ages 55 to 64 were covered by public insurance, mainly Medicaid, 52 percent had private insurance, and 6 percent were uninsured. (Go to: Hospital Utilization among Near-Elderly Adults, Ages 55 to 64 Years, 2007 http://www.hcup-us.ahrq.gov/reports/statbriefs/sb79.jsp.)

For more information about HCUP, go to https://www.ahrq.gov/research/data/hcup/index.html.

AHRQ Quality Indicators

In FY09, AHRQ released the beta version of its Quality Indicators (QIs) software 4.0a (QI SAS®). The AHRQ QIs are used to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time. They are also used in comparative hospital reporting and basing payment on quality. 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:

• Prevention Quality Indicators (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 patient safety events.
• Pediatric Quality Indicators (PedQIs) are indicators of children's health care that can be used with inpatient discharge data. They are designed to 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.

Currently, 45 AHRQ QIs are endorsed by the National Quality Forum as well as 4 AHRQ composites of AHRQ QIs.

Also in FY09, AHRQ released a new report, Guidance on Using the AHRQ Quality Indicators for Comparative-Level Hospital Reporting. AHRQ plans to release the final 4.0a version of the AHRQ QIs by December, FY09. For more information, see http://www.qualityindicators.ahrq.gov.

The National Healthcare Quality and Disparities Reports

In May 2009, AHRQ released the 2008 National Healthcare Quality Report (NHQR) and the 2008 National Healthcare Disparities Report (NHDR). This represents the sixth consecutive annual editions of these congressionally mandated reports. The reports found that patient safety measures have worsened and that a substantial number of Americans do not receive recommended care.

National Healthcare Quality Report (NHQR)

The NHQR shows that health care quality continues to improve at a slow pace. For example, during the first half of this decade:

• Care delivered in hospitals improved at an annual rate of nearly 3 percent, the highest among care settings.
• Care provided in doctors' offices and other outpatient settings improved at a rate slightly above 1 percent.
• Patient safety rates (protecting patients from injury due to medical care or medical errors) declined by nearly 1 percent.

Receipt of needed services varied widely. For example:

• Forty percent of recommended care was not received by patients.
• Heart attack patients received 95 percent of recommended services, but only 15 percent of dialysis patients were on a transplant waiting list.
• Seven out of 10 adults with mood, anxiety, or impulse disorders received inadequate or no treatment.
• Only 40 percent of patients with diabetes received the three recommended preventive exams: the hemoglobin A1c test, a dilated eye exam, and a foot exam.

National Healthcare Disparities Report (NHDR)

Findings from the NHDR show that most of the largest disparities have not changed significantly, and many racial, ethnic, and income-based disparities persist in American health care. For example:

• The proportion of new AIDS cases was 9.4 times as high for blacks and more than three times as high for Hispanics as for whites.
• American Indian and Alaska Native women were twice as likely to lack prenatal care as white women.
• At least 60 percent of quality measures have not improved for minorities compared with whites in the past 6 years.
• Among people with less than a high school education, blacks were more likely than whites to report communication problems with their doctors (18.6 percent vs. 12.5 percent).
• Just 43 percent of blacks and 38 percent of Mexican-Americans with diabetes had their blood sugar levels under control, compared with 61 percent of non-Hispanic whites with diabetes.

However, increases in preventive services, chronic care, and access to care have led to decreases in disparities for various populations, such as:

• Rates of mammography in Asian, American Indian, and Alaska Native women.
• Smoking cessation counseling in low-income adults.
• Appropriate timing of antibiotics to prevent surgery-related infections among American Indians and Alaska Natives.
• Hispanic long-stay nursing home residents with physical restraints.

Data from the NHQR and NHDR are available on the AHRQ Web site at . The Web site also includes an online Data Query System—NHQRDRNet—that provides access to data from both reports: http://nhqrnet.ahrq.gov/nhqrdr/.

State Snapshots

AHRQ's annual State Snapshots provide State-specific health care quality information, including strengths, weaknesses, and opportunities for improvement. The State-level information used to create the State Snapshots is drawn from the 2008 NHQR.

For FY09, there are new or revised features on this Web site that provide more ways to analyze the quality of health care in a State compared with all States and with States in the same region. These include:

• Focus on Disparities—shows differences in hospital-based quality indicators related to race and income for a number of States. These analyses show the large variation in the size of disparities across States and that some States with overall high-quality care have large disparities.
• Focus on Asthma—summarizes quality of care for asthma and includes estimates of cost savings that could be realized by States that achieve better control of asthma as well as links to the Asthma Care Quality Improvement: A Resource Guide for State Action and asthma-related best practices in the AHRQ Innovations Exchange.
• The revised State Dashboard—summarizes information such as types of care, settings of care, and care by clinical areas on one page for each State and includes a link to other report cards available for a given State.

As in previous years, AHRQ's 2008 State Snapshots show that no State does well or poorly on all quality measures. For example:

• Kansas ranked 3rd among all 50 States and the District of Columbia for its low rate of HIV-related deaths, but 48th for its high numbers of patients with heart failure who did not receive recommended care while in the hospital.
• Oregon ranked 1st for its large numbers of adults age 65 and over who received a pneumonia vaccine, but 46th for the low number of home health patients who got better at walking or moving around.
• The District of Columbia ranked 1st for its low suicide rate but 51st for the highest colorectal cancer death rate.

To access this year's State Snapshots tool, go to http://statesnapshots.ahrq.gov/snaps08/index.jsp.

Recent research findings on disparities and minority health

In addition to its work on the NHDR, AHRQ is leading Federal research efforts to develop knowledge and tools to help eliminate health care disparities in the United States. AHRQ supports and conducts research and evaluations of health care with emphasis on disparities related to race, ethnicity, socioeconomic status, and geographic variation. The Agency focuses on priority populations: minorities, women, children, elderly adults, low-income individuals, and people with special health care needs such as people with disabilities or those who need chronic or end-of-life care. Several studies, published during FY09, are summarized below.

• Hispanics with limited English proficiency (LEP) were 2.4 times more likely to suffer an asthma episode requiring outpatient treatment and 4.4 times more likely to suffer an episode requiring an emergency department visit or hospitalization compared with non-Hispanic patients. LEP was also associated with more worries about side effects or becoming addicted to inhaled corticosteroids (ICS), beliefs that asthma is an acute (rather than chronic) disease, decreased self-efficacy in ability to control asthma and use (ICS), and lower adherence to controller medications. (Medical Care, February 2009).
• In treating nonsmall cell lung cancer, blacks were less likely to receive surgery and chemotherapy when compared with whites. Researchers at the University of Texas in Houston analyzed 83,101 Medicare patients aged 65 and older, who were diagnosed with stages I to IV nonsmall cell lung cancer. The researchers placed the patients into one of two groups: early disease (stages I and II) and late disease (stages III and IV). They then looked at who received surgery, chemotherapy, and radiation therapy. In the early disease group, blacks were 37 percent less likely to receive surgery compared with whites. They were also 42 percent less likely to undergo chemotherapy for their cancer. This disparity was even greater for late disease patients. Blacks in this group were 57 percent less likely to receive chemotherapy compared with whites. Patient characteristics associated with greater treatment disparities included being older, female, and having a lower socioeconomic status. (Cancer, May 2009).
• Blacks report far more difficulty in affording prescription medications than whites, even after accounting for income, education, health insurance status, and coexisting medical conditions. Blacks were twice as likely as whites to not fill a medication prescription (50 percent vs. 25 percent) and were far more likely to report inadequate income to meet basic needs (61 percent vs. 17 percent). Most of the differences attributed to race/ethnicity were mediated by perceived income inadequacy. Furthermore, the inability of blacks to afford prescription medications may be better predicted by perceived income inadequacy than more traditional measures of socioeconomic status such as income, education, and insurance status. (American Journal of Health-System Pharmacy, November 2008)

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 Healthcare 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 different aspects of the health care system.

Initiation of an online reporting system for CAHPS® survey results

In FY09, AHRQ initiated a new online interactive system for viewing CAHPS survey results. The CAHPS® Database will be the comprehensive repository for aggregated data from the CAHPS® Health Plan, Hospital and Clinician and Group surveys. This site currently contains data for the CAHPS® Health Plan and Hospital Surveys and summary level results from the CAHPS® Clinician and Group Survey will also be added to the site in the near future. This site cannot be used to make comparisons and decisions about individual health plans, hospitals, and clinicians.

For more information about CAHPS®, go to http://cahps.ahrq.gov.

National Guideline Clearinghouse™

This is the second year in which AHRQ's National Guideline Clearinghouse™ (NGC), in conjunction with the AHRQ's National Quality Measures Clearinghouse™ (NQMC), has published a series called Expert Commentary. Together, the two resources published six new Expert Commentaries. The topics of the commentaries ranged from guidelines on using second-generation antidepressant medications to treat depressive disorders to the evidence on endocarditis prophylaxis. Also covered were such topics as multiple sclerosis guidelines and uniform evidence-based guideline development in relation to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. These commentaries were authored either by members of the NGC/NQMC Editorial Board or by experts working in conjunction with the board.

A new feature to NGC and NQMC is "Recommended Readings"—brief annotations of articles of interest to the guideline and measure development communities that provide a brief overview of the main points of each article and why it would be of interest to NQMC/NGC users. The editorial and publication process are similar to those for the expert commentaries and the annotations are authored by the Senior Physician Reviewer. NGC and NQMC published 11 "Recommended Readings."

The NGC is a Web-based resource for information on over 2,300 evidence-based clinical practice guidelines. Since becoming fully operational in 1999, the NGC has had over 56 million visits and receives approximately 700,000 visits each month. The NGC helps health care providers, health plans, integrated delivery systems, purchasers, and others obtain objective, detailed information on clinical practice guidelines.

The Children's Health Insurance Program Reauthorization Act

The Children's Health Insurance Program Reauthorization Act (CHIPRA), signed into law in January FY09, promised a new day for children's health care quality, especially for the 36 million children covered by Medicaid and the Children's Health Insurance Program (CHIP). The Agency worked with the Centers for Medicare & Medicaid Services (CMS) to implement the quality provisions of CHIPRA. The first task around quality measures was the identification of an initial core quality measurement set for voluntary use by Medicaid and CHIP. The initial core quality measurement set is to be posted for general comment by January 1, 2010. To help us identify and prioritize the core quality measurement set, sought the advice of AHRQ's National Advisory Council on Healthcare Research and Quality (NAC). The NAC has created the Subcommittee on Quality Measures for Children's Healthcare in Medicaid and CHIP.

For more information on AHRQ's work on CHIPRA, go to .