Asthma Care Quality Improvement
G. Benchmarks from the National Healthcare Quality Report (NHQR)
The National Healthcare Quality Report (NHQR) provides a national set of estimates and, often, State estimates that can be used as benchmarks for quality improvement. A benchmark can be a baseline or point from which you start, not necessarily representing a goal or target; or it can be the best current rate, something achievable; or it can represent a consensus of what should be achieved. It is a basis for making comparisons.
Key Messages on Benchmarks:
Methods matter: They can have a large impact on comparisons.
The NHQR provides a national set of estimates and, often, State estimates that can be used as benchmarks for quality improvement. A benchmark can be a baseline or point from which you start, not necessarily representing a goal or target; or it can be the best current rate, something achievable; or it can represent a consensus of what should be achieved. It is a basis for making comparisons.
Several types of benchmarks can be derived from the NHQR:
- Theoretic limit benchmark—The theoretic limit refers to the maximum or minimum level that a measure can take on. For example, 100 percent for positive outcomes or 0 percent for negative, avoidable events. In an ideal world, these would be achievable, but in a world where so many factors are involved in achieving a maximum result, those benchmarks may be unrealistic. Also, some concepts might feasibly come closer to the theoretic limit than others.
- Best-in-class benchmark—The rate for the top State or top tier of States can be used for what manufacturers call a "best in class" benchmark. (The top tier can be defined as the top 5 or 10 percent of States averaged together.) Using influenza vaccination as an example, the highest rate of flu vaccination for people with diabetes across the States (64 percent) may be assumed to be a feasible goal for States to achieve. However, some may view the top State rate as an impractical target given their population and circumstances. Others may view that goal as inadequate depending on the value of the rate and the state of medical knowledge and practice, and they may view the 100-percent goal as their target. These judgments will vary across States because States face different circumstances and environments. This Resource Guide uses the top 10 percent of States, combined in a simple average, to derive the best-in-class estimate. A simple average, rather than weighted average, was used because the denominators from the Behavioral Risk Factor Surveillance System (BRFSS) estimates were not available in the NHQR.
- A national consensus-based goal—Some organizations propose targets that should be achieved to improve the health status of the overall population and vulnerable subgroups. For example, two decades ago, the Centers for Disease Control and Prevention developed diabetes-related goals for a healthier U.S. population. Each decade those goals are reviewed and reestablished.
- National average—The overall average indicates where the average member of a group stands. For example, the average of influenza vaccination rates for people with diabetes in States (37 percent according to the BRFSS data source) is the "norm" for States or is the rate for the "average" State. States with rates below the average would prefer to be at or above the average. But the average may not be an indicator of quality health care.
- Regional norm—States may prefer a regional estimate for comparison because they want to see how they perform compared to medical practice within the region. Given the wide regional variation in U.S. medical practice, regional estimates may be weak goals for regions where practice should change to enhance the health care quality for people with asthma. For this Resource Guide, the regional averages are calculated for the four Census regions, Northeast, Midwest, South, and West. (The averages are simple averages because the denominators for BRFSS estimates were not available from the NHQR.)
- State rate—The State's own rate may serve as a benchmark for various purposes, such as tracking changes over time, evaluating the effect of a statewide intervention to improve quality, or reporting the norm for local communities and providers to use as a comparison with their own performance. Concerns noted above about using national or regional averages as goals also apply to State rates. For provider-level estimates, the best-in-class providers may be a better indication of what is achievable and should be used as a goal rather than the State average rate. Severity adjustments are an important issue at the provider level, where populations of patients with varying severity and comorbidity levels are unlikely to be distributed evenly across providers.