This is the first event in a series of two Web assisted audio conferences on health care quality. These events are designed for State and local health policymakers and other decision makers interested in measuring and improving the quality of health care in the United States.
Cindy DiBiasi: Good afternoon. Welcome to Quality Improvement: Tools to Benchmark and Measure Quality. This is the first event in a series of two Web assisted audio conferences on health care quality. These events are designed for State and local health policymakers and other decision makers interested in measuring and improving the quality of health care in the United States.
The series is sponsored by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, often referred to by the acronym A-H-R-Q or AHRQ. My name is Cindy DiBiasi and I will be your moderator for today's session.
Healthcare quality is a timely and important topic in today's environment of rising health care costs. All players in the U.S. health care system are looking for ways to ensure that all Americans receive the safest, highest quality health care services possible and that these services are available to them when they are needed. In is an important first step, the U.S. Department of Health and Human Services released two national reports on quality. These reports were developed by AHRQ and represent the first national comprehensive effort to measure the quality of health care in America and differences in access to care.
The reports confirm that although progress has been made in improving health care quality, much remains to be done before health care quality is a universal reality and disparities are eliminated. The good news is that there is great potential to continue improving health care quality for all Americans. To be as effective as possible, it is critical that all decision makers in the health care process are able to measure, analyze and compare quality-related data. It also means that the use of these data becomes an integral part of the quality improvement process, ensuring the delivery of safe, high quality health care services to all Americans.
AHRQ has developed a number of tools to help State and local health policymakers, providers, purchasers and health plan and system decision makers better measure and improve quality. Today we will examine a number of AHRQ's tools and resources that can be used to benchmark and measure quality. On Wednesday, February 18th, we will take a look at some promising practices that demonstrate how these tools can be used to improve quality. I will tell you more about the February 18th call event later in the broadcast, but right now let's turn to today's call.
Let me begin by introducing today's panelists. In the studio with me I have Dr. Edward Kelley, director of the National Healthcare Quality Report in AHRQ's Center for Quality Improvement and Patient Safety. Jean Slutsky, acting director of the Center for Outcomes and Evidence at AHRQ and Dale Shaller, principal at Shaller Consulting, managing director of the National CAHPS® Benchmarking Database and member of the Harvard Medical School CAHPS® II Team. Welcome everyone.
Before we begin our discussion, I would like to tell the audience a bit about the format of this audio conference. First, we will talk with our three panelists, then open up the lines to take your questions. We will give instructions on how to send your questions to us later in the program. Although we don't anticipate that you will experience any technical problems, I would like to give you a few tips on dealing with them just in case they come up.
If you are on the Web and experience any problems viewing the slides, click the "Help" button in the bottom right hand corner of your screen to troubleshoot your Web connection. If it appears that the slides are not advancing, you may need to restart your browser and log on again. If you experience any difficulty with the audio stream, you may access the audio by phone by dialing 1-888-496-6261 and use the password "AHRQ tools." These dial-in instructions are posted on the right hand side of your screen in the small, black box.
If you are on the phone and need technical assistance, dial "*0". For people who are listening by phone but watching the slides on the Internet, please be aware that you will notice a delay in the slide changes because they are timed to match the Internet broadcast.
Now I think we are ready to discuss today's topic. Let's begin with Dr. Ed Kelley, director of the National Healthcare Quality Report at AHRQ. Ed, as we said, DHHS Secretary Thompson recently released two reports on health care quality in the United States. AHRQ has the lead in developing those reports. Can you tell me a little bit more about the reports and why they were developed?
Dr. Ed Kelley: Sure. Cindy, first of all, let me just say we are really excited to be here talking about the reports. It is one of our first opportunities to talk about them. They were just released on December 22nd of last year. They represent the broadest examination of health care quality and disparities in terms of the dimensions that are discussed in the reports, everything from effectiveness to patient-centeredness, as well as a number of measures that have ever been done in the U.S. and to our knowledge, have ever been done in any major industrialized country.
The bottom line as to why we did it, Congress told us to. We had a mandate that was in our reauthorization legislation that is up on the screen and the key points about that being that it is an annual report. This is the first one that we undertook and it is supposed to be examining national trends in quality of health care provided to America.
But the disparities report has some specific language as well, which looks at trends across racial and ethnic groups and different socioeconomic groups. The legitimate question that could be asked though, I think, is why do we need a national report? I think that most of America is used to perennial and weekly reports that come out of the Federal Government that are huge tomes and don't necessarily mean something for their lives. The response to that is that a whole group of organizations, starting with the Institute of Medicine as well as studies that have been published in major journals, such as The New England Journal of Medicine and what the gap between what the actual and the ideal performance of the American health care system and have called it a "chasm." There is an overwhelming amount of health care information that is out there available to doctors and patients. All of us every day come across stories that are in the newspaper. There are many, many Web sites, some legitimate, some a little bit less so that provide health care information to American consumers, yet the amount of usable, quality information is really lacking.
Finally, in part, this is witness with the number of Web sites that are out there and the number of publications that are out there on health care. Consumers are caring about the quality and are increasingly demanding more information about health care quality. For all of those reasons, we put together this national report. The bottom line is that you can't manage something that you don't measure.
Cindy DiBiasi: Let's talk about some of the key themes that are raised in the report.
Dr. Ed Kelley: Sure. What I can go through is a real kind of overview of some of these findings. In the particular reports themselves, which we will talk about a little bit later, are available both off AHRQ's Web sites and through AHRQ directly. So in terms of getting the pre-publication version, which is out right now, there is a range of key findings. Now we don't have time to go through all of them, so what I thought I would do is just sum up some of the major pieces in four main messages.
The first being, for some of us who work in health care quality and even for any of us who ever has been a patient, surprise, surprise, health care quality is not perfect. It is not a given in the U.S. health care system. We looked at a whole range of measures across, like I mentioned earlier, a range of dimensions including effectiveness, patient safety, timeliness and patient centeredness. Some of those measures we had trend data for. In future reports, we will have trend data for all of those. But in 37 of 57 areas with trend data, there was no improvement or there has been some deterioration in national performance. That is not exactly where we would like to be.
A few other examples of where we are falling short. Fewer than one in five people with hypertension have it under control. As we know, hypertension is linked to a whole bunch of chronic illnesses and advancement in those illnesses.
Finally, an example from our patient safety area, about one in five elderly Americans are prescribed inappropriate or potentially harmful medications. This comes from a study we had done work on and had published from one of our researchers in The Journal of the American Medical Association. The slide that we have provided today does have some information that shows the graph looks at a group of different drugs. You are seeing first in the smallest shaded area, eleven drugs that should always be avoided for the elderly. Then in the dark area, eight drugs that are rarely appropriate and then in the White, fourteen drugs that have some indication that they are often misused. The conclusion overall is that one in five Americans does have, elderly Americans, may be prescribed these inappropriate medications.
Secondly, there are gaps. These gaps in health care quality are particularly acute for certain racial or ethnic and socioeconomic groups. We tried to summarize across the measure set and by and large, this is some of the findings that we had from the National Healthcare Disparities Report. Blacks and Hispanics scored lower than Whites on about half of the quality measures. By that I mean, for instance, if you were to look at immunization measures, Black children are less likely than White children to get full immunizations by the time they reach 35 months. That is a scenario that there is sort of no excuse for that. Hispanics and Asians score lower than Whites on about 2/3 of access measures. These are things like difficulty getting to appointments, difficulty getting specialist appointments as well as certain aspects of communication.
Finally, poor people scored lower on about 2/3 of quality and access measures. If you look across the whole measure set, which like I said covers a lot of ground, poor patients, and this was defined using census calculations, as to percentage of the Federal poverty level. They don't score better on one single measure throughout the entire 147 to about 250 measures. Again, I think that should wake up people.
Third, the quality and disparity gaps are worse in preventive services. Now this is something that is a big concern obviously for all of us. There has been increased emphasis on what we should be doing in terms of taking personal responsibility for our health in terms of getting preventive health care. There has been an increased emphasis on what doctor's offices and hospitals can be doing in terms of making sure they are not missed opportunities for preventive care. Unfortunately, this is one of the areas where there are still some major gaps. For instance, we have a graph here on smoking cessation counseling that will show you, that talks about the quit rate for smoking. Only about 40% of people get smoking cessation counseling in the hospital. Only about 60% get counseling during office visits. Many of us have folks in our families that smoke and know how difficult that counseling can be to try to get them to quit, but that figure of 40% of people getting smoking cessation counseling in the hospital, the quit rate, according to research that has been done on this is extraordinarily high for folks that are in the hospital that have come in, for instance, who have had a heart attack. That is a major tipping point for getting people to change their lifestyle. Unfortunately it is extremely low.
Black and Hispanic and poor adults are less likely to receive colorectal and breast cancer screening. Black, Hispanic and American Indian women are less likely to receive prenatal care. Black, Hispanic and poor children are less likely to receive dental care and Black, Hispanic and poor elderly are less likely to receive pneumococcal vaccinations.
The kind of thing that we try to do is to avoid the listing of one right after another in terms of these findings, but all of the pieces that we have tried to highlight here are areas that should not exist, where we can do a lot better.
Finally, improvement in quality and disparities is possible. I think that that is something that we looked at very deeply in terms of putting together this report. We didn't want it to just be a report about a bunch of gaps that existed in the American health care system. We routinely describe, not just AHRQ, but the Secretary and other officials in HHS, describe our health care system as one of the best in the world. Having worked internationally, I know that is true.
In each chapter of the report, we pull out pieces that talk about where we are doing well and some of the best practices that exist. A few of them are presented today. For instance, the Medicare, the Centers for Medicare and Medicaid has been working through their quality improvement organization program on improving the use of beta-blockers for heart attack patients. That has risen from 21% of eligible patients in the early 1990's to 79%. About 45 States are at or above 70% on this measure. Now the math you see here, given all that is going on in the news right now, it is not a political map. Red and blue are both equally good here because the red signifies no different from the national average and the blue is significantly above the national average. So what we are trying to highlight here is that this is an area where we have improved in virtually every State in the country, with some exceptions for some good reasons that have not improved.
Seventy percent of women over age 40 get mammograms for breast cancer. This already exceeds the Healthy People 2010 objective. For those who don't know, Healthy People 2010 is one of the benchmarks for this country in terms of health status and this is one of the measures that they also have set an objective for. Black women have higher screening rates for cervical cancer and death rates among Black women are falling at twice the rate of White women, although they are still higher. So we are making progress in some of the disparities that exist within health care quality.
Finally, quality improvement efforts have resulted in reductions in Black/White differences in hemodialysis. Some of this has been through some of the work that Medicare and Medicaid Services have done.
Cindy DiBiasi: Now Ed, we know that these are the first of what are to become annual reports, but how do you see these reports playing a role in helping the nation improve the delivery of health care?
Dr. Ed Kelley: Sure. Well, the purpose of the reports themselves is to promote awareness in the status of health care quality and disparities in America. That is the real bottom line. I think that it would be a mistake to think that a large kind of compendium of cables and data can instantaneously sort of change the health care that you would receive or I would receive or our parents would receive. I think we have to be careful about overshooting the mark in terms of this changing the world. However, I also think that it would be a mistake not to expect that this report should be used. Our main goal when we put this together, and it was when I came to AHRQ to work on this report, I nearly didn't take the job to work on this report because I was worried about that. Our main goal was to ensure that the reports didn't gather dust on the shelf. So concurrent with a refocusing at AHRQ on implementation and action related to health care quality in our sort of new mission statement is we present here, these reports are designed to lead to action.
How that happens though, how people read something and then decide to do something is a real questionable process. I think it is one that has been written about in communication theory for a long time. We have gone back to theory, I know it is sort of not popular necessarily to situate yourself in theoretical models as a way to move forward, but we have put together the idea that you start with data, move to understanding that data into knowledge and that then translates into action and improvement. Some of the different stages that go along with that are based on theories like diffusion of innovation comes from Roger's seminal work in 1995 where you move through being aware about something, being persuaded to do it, making a decision to actually doing it and them implementing it. I think that there is a relevant lesson here for a large report like this where people would sum that process up moving to actually working on improvement.
Cindy DiBiasi: What types of State data are tracked and how are the reports relevant to State, local and health system planning and decision makers?
Dr. Ed Kelley: Well, the overall conceptual framework for the reports, as I mentioned earlier, has a range of dimensions as well as a range of health care needs. This conceptual framework was given to us by The Institute of Medicine. So the task then is to put into that framework, which we felt like was a real strong framework, a bunch of usable, valid measures that are backed up by data. The State data that exist in NHQR are presented in this presentation, and they range from survey-type data, which are behavioral risk factors, surveillance system, other survey information such as the National Immunization Survey as well as chart review-type data with the Medicare Quality Improvement Organization where medical record charts are extracted all the way down to vital statistics. The point being that we have a real wide range of data that is available and a real wide range of data types in order to triangulate our findings.
Cindy DiBiasi: Now you have mentioned AHRQ's work on the Crossing the Quality Chasm Workbook. What is the purpose of this tool and how do you see that workbook being used?
Dr. Ed Kelley: The workbook itself was, it came out of a real need that was asked to us by our State partners that work with us on the Healthcare Costs and Utilization project. The purpose mainly is to provide an overview of the factors affecting quality of care and it focuses on diabetes as well as provides some information on core elements of quality improvement, best practices and really trying to help State policymakers and health care leaders use the report data to plan State-level quality improvement initiatives.
Now the audience, as I mentioned, are State elected leaders, State executive branch officials and non-governmental State and local health care leaders. So a real wide range, but it is targeted towards our State partners.
Cindy DiBiasi: And how exactly does the workbook help you use the report data?
Dr. Ed Kelley: Well the draft of the report as it has been put together now and some of the information that is in this presentation, shows some draft language and some draft figures, but it basically walks you through once you get through some of the introductory points, walks you through taking information about your State, comparing it to other States and understanding areas where gaps exist as well as some of the performance levels of States who were regarded as "best in class" or ones that have the highest rates.
Cindy DiBiasi: Before I move on to Jean Slutsky, just could you tell our listeners where they could get copies of and find out more about the National Healthcare Quality Disparities Report and Workbook?
Dr. Ed Kelley: Sure thing. There is contact information for me, but probably the best spot for people to go to, and this will touch on work that Jean is doing, is the www.qualitytools.ahrq.gov, which is the Web site where the report resides. There are drafts of the reports as well as large files of the report tables. With the final release of the reports, which will happen sometime in March with the final copy, that revised section of the Web site, will have a little bit more interactivity in terms of getting all that information.
Cindy DiBiasi: Great. We will be back to you in a few minutes because I am sure there are going to be lots of questions about these reports but first we are going to go to Jean Slutsky, the acting director of the Center for Outcomes and Evidence at the Agency for Healthcare Research and Quality. Jean, you are here to talk to us about the number of AHRQ-sponsored quality improvement and measurement tools that can be used to assess and address quality of care issues. Now, the Quality Report and the National Healthcare Disparities Report have highlighted some key areas where, as Ed was saying, we know we can do better. What kind of help can AHRQ offer in addressing these areas?
Jean Slutsky: Thanks, Cindy. One of the things that AHRQ has done is develop some web-based tools to showcase work that AHRQ has done and our grantees and contractors have done in areas of quality improvement. The first Web site I would like to talk to you about is the National Quality Measures Clearinghouse™, which can be found at www.qualitymeasures.ahrq.gov. This clearinghouse was actually launched almost a year ago. We have had a really fabulous response from users. Thousands have signed up for the weekly update, which sends them an E-mail letting them know what new measures have been added to this site. It really serves as a public repository for evidence-based quality measures and measure sets.
The other Web site that I want to talk to you about is one that Ed already mentioned which is called Quality Tools. This is really a flagship Web site for us that is going to help to translate best practices for users of the reports. It is located at www.qualitytools.ahrq.gov. We released this when we released the reports. It is really a clearinghouse for practical, ready-to-use tools. It hosts both the reports as they become ready and final, there will be an interactive Web site for the reports themselves so you can search and move through these reports with ease.
Cindy DiBiasi: Let's talk a little bit more about how each resource can be used.
Jean Slutsky: Great. For qualitymeasures.ahrq.gov, or the National Quality Measures Clearinghouse™, it really has a lot of different features that users will find very helpful. There are structured abstracts of each measure in the database and you actually have a feature where you can compare measures so you can develop a shopping cart of measures, sort of like on Amazon.com where you can compare different measures. There are advance search techniques that you can use to look at the IOM care needs, domains and other attributes that are included in a National Healthcare Disparity and Quality Report. You can browse by organization or other measure attributes and there are links to the full text of the quality measures and ordering details.
Also, you can link back to The National Guideline Clearinghouse when a measure has been developed from a guideline. It has a glossary that people who use quality measures can use that defines terms that they may need to know. It also has the update service that I told you about earlier. On the screen, users can see the Web address to sign up for that.
Cindy DiBiasi: Once a measure is used from the NQMC, are there steps that the providers, purchasers, payers or policymakers could take to address the problem area in question?
Jean Slutsky: Well, if you talk about qualitytools.ahrq.gov, you will find that it has some of the same utilities that the National Quality Measures Clearinghouse™ does. We actually have an update service as well for that. You can actually search the database using searches, browsers and there is also a glossary. But you can enter the Quality Tools database or Web site by identifying yourself as a provider, policymaker, a patient or a consumer or a purchaser. If you take a look at the Web site, you will see that we have entered here as a provider. You can tell at the top bar that that looks a little bit different in color. If you were to continue on after that click, you will see that there are a series of questions that come up that actually guide your defining different tools. The first one actually talks about the first question about how can I identify clinical recommendations and so forth that can improve the quality of care for my patients?
Cindy DiBiasi: Are there any synergies between the two resources?
Jean Slutsky: Yes, there are. Actually there are some really nice synergies. If you click on the tool that says "National Quality Measures Clearinghouse™", and this is in the Quality Tools Web site, you will see that it actually links you directly back to the National Quality Measures Clearinghouse™.
Cindy DiBiasi: Is it possible to submit new quality measures to the National Quality Measures Clearinghouse™ and new tools for the Quality Tools?
Jean Slutsky: Yes. For example, there is a way to submit new measures to NQMC or the National Quality Measures Clearinghouse™ and the Web address is up there. It is http://www.qualityindicators.ahrq.gov/support.htm.
Cindy DiBiasi: OK, and because we haven't quite given you enough URLs today, why don't you tell our listeners where they can find out more about The Quality Tools Toolbox and The National Quality Measures Clearinghouse™.
Jean Slutsky: I'd like to give you some inclusion criteria for the National Quality Measures Clearinghouse™ as well. You really need to just give us a rationale for the measure, a description of the denominator, a numerator description on the primary measure domain as well as evidence supporting the measure and the data source and the current use or if there was pilot testing done.
If you have more questions about either Web site, you can also contact http://www.qualityindicators.ahrq.gov/support.htm or the support@qualityindicators.ahrq.gov for the National Quality Measures Clearinghouse™ you can go to the Web site itself or support@qualityindicators.ahrq.gov.
I'd also like to highlight that the National Guideline Clearinghouse, although we haven't talked about it today, is located at www.guideline.gov. It also is synergistic with both of these Web site.
Cindy DiBiasi: Great. We will be back to talk to you about some more information, but before we do that, let's turn now to Dale Shaller who is principal of Shaller Consulting. Dale also is managing director of The National CAHPS® benchmarking database and a member of the Harvard Medical School CAHPS® II Team. Dale, can you start off by telling us about The CAHPS® Improvement Guide and why it was developed?
Dale Shaller: Sure. Thank you, Cindy. The CAHPS® Improvement Guide is not about data; it is actually about action, the kind of thing that Ed was talking about earlier that you can't manage what you can't measure. What this guide focuses on is how to actually manage, at least in those areas that relate to the domains of quality measured by the CAHPS® survey. The guide was funded by CMS Medicare and developed by members of The Harvard Medical School CAHPS® Team that have a lot of experience in working with surveys and measurements and quality improvement.
It is hard to talk about what the guide does without first talking about what CAHPS® does. CAHPS® was funded by AHRQ since 1995. It was developed by a consortium of researchers from Harvard and from Rand and from the American Institutes for Research with support from Medstat. It is all about designing surveys, initially at the health plan level that measure aspects of care that can thus be reported on and in some cases can only be reported on by patients and consumers. Incidentally, CAHPS® originally stood for the Consumer Assessment of Health Plan Study, but it has graduated from the study phase and is not into full implementation and basically just stands for the full set of surveys that are now being developed not only at the health plan level, but also now at the hospital, medical group and soon to be developed at the individual clinician level.
CAHPS® covers certain topics like access to care, doctor communication, coordination of care, customer service. Things, again, that patients can best report on. Medicare has begun to use CAHPS® at the plan level to assess quality of care for Medicare Managed Care Plans. State Medicaid agencies use CAHPS® with Medicaid Managed Care Plans. Hundreds of commercial plans use CAHPS® to assess their performance and report it to NCQA, the National Committee on Quality Assurance for accreditation purposes and also to public and private purchasers. There is a lot of use of CAHPS® going on in the system today. So much so that estimates suggest that about 125 million Americans are enrolled in health plans that are in some way getting measured by the CAHPS® survey.
So with all this measurement going on, we thought, and CMS agreed and so did AHRQ, that it would be very helpful to have a tool that actually helps plans and medical groups do something about the scores that they were getting. So again, it is designed for action and for improvement and it is a guide to help plans and groups do just that.
Cindy DiBiasi: How was the guide developed?
Dale Shaller: We worked for over a year reviewing the published literature on improvement methods related to ambulatory care, matching resources that we could find in the literature to the specific domains that are measured by the CAHPS® Health Plan Survey. In many cases, the published literature just doesn't go far enough so we got out into the field and had a lot of conversations with quality managers in health plans and medical groups who are actually on the frontlines doing this kind of work that doesn't get into the published literature. We talked to them. We talked to them to make sure that what we're putting in the guide had practical relevance and significance to people that actually have to do this and who are accountable for making those improvements happen in the organizations.
We also had an expert panel of about a dozen individuals, either with extensive knowledge in specific substantive areas that we recovered or in the quality improvement process in general.
Cindy DiBiasi: So how was the guide organized?
Dale Shaller: It has four main sections and as the chart on the screen shows, this is actually a map that comes right out of the improvement guide. Section One begins with the fundamentals of making the kind of organizational culture happen that is really necessary for encouraging and sustaining quality improvement. This is really important because unless leadership at the very top is committed to making change happen, it just won't.
The second part of the guide is addressing ways that the CAHPS® data can be further analyzed to point to specific strengths or areas of weakness that might be the subject of the quality improvement intervention and to help plans and groups target specific areas for intervention.
The third section focuses on a kind of cycle that has now become the standard really for quality improvement in health care. It is also referred to as Plan, Do, Study, Act and it talks about basically walking through an improvement process from setting aims to measuring progress and re-evaluating and setting goals again based on how well you did with that specific intervention.
Finally, the fourth section is really the biggest part of the guide. It is the heart of the guide because it describes specific ideas and strategies and plans that group practices can use to improve the patient experience with care. These interventions are mapped exactly to the domains of performance that are measured by the CAHPS® survey. So that is how it is laid out.