Chapter 1. Introduction and Methods

In 1999, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce an annual report, starting in 2003, on "national trends in the quality of health care provided to the American people."ⁱ With support from the Department of Health and Human Services and private-sector partners, AHRQ has designed and produced the National Healthcare Quality Report (NHQR) to respond to this legislative mandate. The NHQR provides a comprehensive overview of the quality of health care received by the general U.S. population and is designed to summarize data across a wide range of patient needs—staying healthy, getting better, living with chronic illness and disability, and coping with the end of life.

AHRQ was further tasked with producing an annual report that tracks "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations."ⁱⁱ The National Healthcare Disparities Report (NHDR) has also been produced since 2003. The referenced priority populations consist of groups with unique health care needs or issues that require special focus, such as racial and ethnic minorities, low-income populations, and people with special health care needs. AHRQ's charge includes a directive to examine disparities in health care access, utilization, costs, outcomes, satisfaction, and perceptions of care.

The NHQR and NHDR are complementary and are designed to be used together. Combined, they provide an annual snapshot of how our Nation's health care system is performing and the extent to which health care quality and disparities have improved or worsened over time.

With support from a Department of Health and Human Services (HHS) Interagency Work Group and AHRQ's National Advisory Council, AHRQ has designed and produced the NHQR and NHDR since 2003. This is the eighth in the series of reports. Over the years, the NHQR and NHDR have introduced refinements to the measure set and methodology, which has led to a focus on a subset of the most important and scientifically supported measures. These are referred to as the core measure set and are again the focus of the reports this year.

Refinements include the addition in 2004 of a second critical goal of the report series: tracking the Nation's quality improvement progress. The 2005 reports introduced a set of core measures and a variety of new composite measures. The 2006 reports continued to improve data, measures, and methods, adding databases and measures and refining methods for quantifying and tracking changes in health care. The 2007 reports launched a new chapter on health care efficiency. The 2008 reports included an expanded chapter on patient safety, while the 2009 reports included new sections on lifestyle modification, health care-associated infection, and care coordination.

From the beginning, the Institute of Medicine (IOM) has helped shape these reports. Early planning for the first NHQR benefited from the IOM reports Crossing the Quality Chasm and To Err Is Human. Similarly, early planning for the first NHDR profited from the extensive literature review included in the IOM report Unequal Treatment. Moreover, before the publication of the first reports, AHRQ specifically requested that the IOM assist the Agency in meeting its congressionally mandated charge. The IOM was tasked with developing a vision for the two quality reports. With rapid changes in health care, AHRQ saw the need to review the reports for their appropriateness to the current health care environment.

In 2008, AHRQ again commissioned the IOM to review past reports and offer recommendations for enhancing future reports and associated products. To this end, the IOM established a consensus committee, the Committee on Future Directions for the National Healthcare Quality and Disparities Reports.ⁱⁱⁱ The committee has offered recommendations on priority areas for health care quality improvement, measure selection, methodological approaches, and formatting and presentation of report findings.^iv

This chapter summarizes AHRQ's methodological approach to producing the 2010 reports. While the 2010 reports contain almost all of the same measures tracked in previous versions of the NHQR and NHDR, many of the IOM's recommendations have been implemented, and the organization and content of the reports have changed extensively. Significant enhancements have been made to the reports to strengthen understanding of performance across the multiple dimensions of health care quality, better capture and track trends in disparities, and quantify the potential for future progress in meeting quality goals.

Consistent with past reports, the 2010 reports focus on a specific theme. In the 2010 reports, analyses include contrasts along the urban-rural continuum wherever data are available. With these refinements, the 2010 NHQR and NHDR substantively advance our Nation's understanding of the progress that is being made in improving quality and reducing disparities in the U.S. health care system.

IOM Recommendations for Enhancing the NHQR and NHDR

The 2010 reports begin the process of incorporating suggestions from the IOM about how to maximize the utility of the reports and related products. AHRQ received recommendations from the IOM in April 2010. These recommendations guided the redesign of the 2010 NHQR and NHDR and are reflected throughout these reports. Some of the key recommendations from the IOM Committee are discussed below.

Identify Priority Areas for Quality Improvement

The IOM recommended that AHRQ report on progress in selected priority areas. These priority areas are expected to yield the greatest gains in health care quality. Priorities include six areas identified by the National Priorities Partnership (NPP),^v as well as two areas proposed by the IOM Committee. Measures selected for reporting reflect concepts captured in the priority areas, as listed below:

Priority areas designated by the NPP

• Patient and family engagement.
• Population health.
• Safety.
• Care coordination.
• Palliative care.
• Overuse of services.

Priority areas designated by the IOM Committee

• Access to care.
• Health system infrastructure.

Some of these areas mapped directly into existing report sections and are included in those sections of each report. Patient and family engagement is covered in the chapter on Patient Centeredness. Safety is covered in the chapter on Patient Safety. Palliative care is covered in the section on Supportive and Palliative Care in the Effectiveness chapter.

Some areas mapped to sections in one report but not the other. Overuse is covered in the Efficiency chapter of the NHQR, but a corresponding chapter had to be developed for the NHDR. Access is covered in the Access to Care chapter of the NHDR, but a corresponding chapter had to be developed for the NHQR. Care coordination and health systems infrastructure were not covered well in any existing chapter, so new chapters were developed for both reports.

Population health measures cut across several of the quality dimensions and are included in multiple sections throughout both existing reports. Hence, performance on population health measures is not included as a separate chapter in this report. As appropriate, population health performance measures are reported in relevant chapters. For example, the population measure "adults with obesity who ever received advice from a health provider to exercise" is reported in Chapter 2, "Effectiveness," in the Lifestyle Modification section. The concept of population health is also presented as an important focus of the Highlights.

Adopt Updated Quality Framework

Measures selected for inclusion in the NHQR and NHDR examine performance in each of the priority areas listed above and are organized along the elements of a quality framework developed by the IOM Committee. The framework guiding the 2009 NHQR was focused around five dimensions of quality: (1) effectiveness, (2) patient safety, (3) timeliness, (4) patient/family centeredness, and (5) efficiency. The 2010 reports retain these quality dimensions and, in keeping with the suggestions offered by the IOM, introduce three others: access, care coordination, and health system infrastructure.

Similarly, the 2009 NHDR encompassed many of the NHQR measures focused on effectiveness of care, as well as access and care rendered to priority populations. The quality framework presented in Figure 1.1 applies equally well to the NHQR and NHDR. As such, the 2010 NHDR substantively expands the dimensions of quality by paralleling the structure and measures presented in the NHQR. "Efficiency," a dimension of quality that was not included in previous disparities reports, has been added to the 2010 NHDR.

The revised quality framework posits that care coordination and health system infrastructure are foundational components that must be in place to achieve quality objectives in each of the other quality areas. Measures corresponding to elements of this quality framework are further described below in the section titled "Measure Set for NHQR and NHDR."

Figure 1-1. Quality Framework for the 2010 NHQR and NHDR

[D] Select for Text Description.

Source: Ulmer C, Bruno M, Burke S, eds. Future directions for the National Healthcare Quality and Disparities Reports. Committee on Future Directions of the National Healthcare Quality and Disparities Reports, Institute of Medicine. Washington, DC: National Academies Press; 2010.

Use Subnational Data

National data to assess performance and the presence of disparities in health care are unavailable for several key measures of quality. In many cases, these data are simply not being collected. The IOM recommends the use of subnational data (e.g., State-level data) to construct performance measures when national data are unavailable. For example, national data on the quality of care rendered to people with HIV/AIDS are generally unavailable. Data from the HIV Research Network, which represents 18 medical practices across the United States treating more than 14,000 patients with HIV/AIDS, were used in both the NHQR and NHDR to gather information on the care received by this population. Although not nationally representative, the data provide some insight into the care received by people with HIV/AIDS and may serve as a catalyst to expanded data collection at the national level.

Expand Stratification

The IOM recommended that the NHDR stratify quality measures by the race and ethnicity categories identified by the Office of Management and Budget (OMB), primary language or English proficiency, and socioeconomic and insurance status. Past versions of the NHDR have reported quality measures according to these sociodemographic characteristic. The 2010 NHDR report continues to include these categories and to show economic and insurance strata. The NHQR expands assessments of performance based on geographic region, specifically, analyses of quality and disparities across the urban-rural continuum.

Modify Benchmarking Strategy

Performance and the potential for quality improvement are best evaluated relative to the evidence on what is achievable. Achievable benchmarks, which demonstrate the "best" attained performance on individual quality measures, were incorporated into the 2010 reports, per the recommendation of the IOM Committee. Identical benchmarks were used to characterize performance in both the NHDR and NHQR.

Benchmarks have been identified based on data from the top-performing States. In identifying the top-performing States, we calculated performance on selected measures separately with data from each of the 50 States.

States were ranked in order of performance and the top 10% were identified. The average performance among these top-ranking States was designated as the measure benchmark. Because data were not always available to estimate performance for each State, the 10% criterion was used only when data for a minimum of 30 States were reported.

Create Action-Oriented Products

The NHQR and NHDR and related products should guide or support action. These reports may be made more actionable by including priority areas and benchmarks. Including examples of "best practices" would further emphasize the opportunities available to improve quality and reduce disparities.

Track Access Better

The NHDR has traditionally included a chapter on access to care, identifying the facilitators and barriers to care and health care utilization experiences of subgroups defined by race and ethnicity, income, education, and type of health insurance. Pursuant to the IOM's recommendations, a chapter on access to care, which has not been specifically tracked in the NHQR, has been added to the 2010 NHQR.

How This Report Is Organized

NHQR and NHDR chapters are organized along the elements of the quality framework. Several of the proposed priority areas that are reflected in this framework have been monitored in previous quality and disparities reports; however, labels and organization of measures within chapters slightly differed. Measures that reflect the concepts underlying the newly defined priority list have been carried over to the 2010 reports and organized in chapters corresponding to the revised quality framework. Measures corresponding to priority areas that are new to the 2010 reports were identified with the assistance of the Interagency Work Group and are noted in the description of chapters below.

For the first time, key findings from the NHDR are incorporated into relevant sections of the NHQR and major findings from the NHQR are mentioned in the NHDR. Integration of findings across the two reports emphasizes the interrelatedness of the two reports and provides a more robust description of the health care system's performance overall and for population subgroups.

Continuing Chapters From Past Reports

• Highlights, which precedes this chapter, provides information to understand patterns of performance within priority areas, insight on the progress that has been made in advancing health care quality in the United States, and implications of report findings for meeting national performance objectives. The Highlights incorporate findings from both the NHQR and NHDR and the same Highlights chapter is used in both reports.
• Chapter 1: Introduction and Methods describes changes that have occurred between the 2009 and 2010 reports, such as modifications to the quality framework, measures added and excluded, and methodological changes in estimating and presenting data. An overall description of the measure set is also presented.
• Chapter 2: Effectiveness examines effectiveness of health care in the general U.S. population. The 2010 report is organized around eight clinical areas: cancer, diabetes, end stage renal disease (ESRD), heart disease, HIV and AIDS, maternal and child health, mental health and substance abuse, and respiratory diseases. Three types of health care services that typically cut across clinical conditions are also examined: lifestyle modification, functional status preservation and rehabilitation, and supportive and palliative care.
• Chapter 3: Patient Safety tracks measures of safety, including healthcare-associated infections, postoperative and other hospital complications, and preventable hospital deaths.
• Chapter 4: Timeliness examines the delivery of time-sensitive clinical care and patient perceptions of how quickly they receive care.
• Chapter 5: Patient Centeredness examines patients' experiences with care in an office or clinic setting, as well as during a hospital stay. Measures reported in this chapter focus on perceptions of communication with providers and satisfaction with the physician-patient relationship.
• Chapter 10: Priority Populations continues to be unique to the NHDR. This chapter summarizes quality and disparities in care for populations identified as particularly significant to quality improvement efforts:
  • Racial and ethnic minorities.
  • Low-income groups.
  • Women.
  • Children.
  • Older adults.
  • Residents of rural areas and inner cities.
  • Individuals with disabilities or special health care needs

New Chapters for the 2010 Reports

• Chapter 6: Care Coordination is new to both the NHQR and NHDR. This chapter presents data to assess the performance of the U.S. health care system in coordinating care across providers or services. The quality framework identifies care coordination as a foundational dimension of quality, a component that facilitates the achievement of other health care system goals. Care coordination is represented by systems and processes that help patients successfully navigate across often disconnected health care components (e.g., physicians, hospitals, postacute services, social services) to meet their ongoing health needs. Measures of care coordination in the 2010 NHQR and NHDR address NPP goals, focusing on the adequacy of medical information received or obtained by providers, facilitators and barriers to care coordination, and outcomes associated with poorly coordinated care.

  Measures included in both the quality and disparities reports are:

  • Heart failure patients who receive complete discharge information.
  • Readmissions for congestive heart failure.
  • Provider communication with other physicians concerning a patient's medications.
  • Hospital electronic exchange of information.
  • Preventable emergency department visits for asthma.

• Chapter 7: Efficiency focuses in part on overuse of health services. Measures of health system efficiency, which capture information on how well the health care system promotes quality, affordable care, and appropriate use of services, have typically been reported in the NHQR but not the NHDR.

  For the first time, the 2010 NHDR includes a chapter focusing on efficiency measures. These measures capture information on overuse, underuse, and misuse of health care among population subgroups. Efficiency measures reported in the 2010 NHDR are:

  • Rates of potentially avoidable hospitalizations.
  • Hospitalizations for conditions covered in AHRQ's Prevention Quality Indicators (PQIs).
  • Potentially avoidable hospitalizations among home health and nursing home patients.
  • Unnecessary services and costs, as measured by the percentage of males over age 75 who had a prostate-specific antigen test or a digital rectal exam within the previous year.

• Chapter 8: Health Systems Infrastructure, which explores the capacity of health care systems to support high-quality care, is new to both reports. The IOM recommended including health system infrastructure as a priority area because measuring performance in terms of health care infrastructure capacity can "[i]mprove the foundation of health care systems (including infrastructure for data and quality improvement; communication across settings for coordination of care; and workforce capacity and distribution�to support high-quality care."

  Unlike most measures, health system capabilities were not assessed at the person level but according to region and provider characteristics. Infrastructure measures, which are primarily structural measures of quality, include:

  • Distribution of U.S. pharmacy professionals.
  • Adoption of office-based computerized systems.
  • Hospital use of fully implemented computerized systems, by key functions.
  • Presence of hospital patient safety culture components (e.g., teamwork within units).

• Chapter 9: Access includes measures that focus on barriers to care, such as the U.S. population that is uninsured, financial barriers to care experienced by the population with health insurance, and people with a usual source of care. The NHDR has traditionally included a chapter on access to care, identifying facilitators and barriers to care and health care utilization of subgroups defined by race and ethnicity, income, education, and type of health insurance. Pursuant to the IOM's recommendations, a chapter on access to care, which has not been specifically tracked in the NHQR, has been added to the 2010 NHQR. Access is measured based on the following:
  • Availability of health insurance.
  • Availability of a usual source of care.
  • Patient assessment of how easy it is to gain access to health care.
  • Successful receipt of needed services.

Appendixes will be available online for both the NHQR and NHDR at . These appendixes include:

• Data Sources, which provides information about each database analyzed for the reports, including data type, sample design, and primary content.
• Measure Specifications, which provides information about how measures are generated and analyzed for the reports. Measures highlighted in the report are described, as well as other measures that were examined but not included in the text of the report.
• Detailed Methods, which provides detailed methodological and statistical information about selected databases analyzed for the reports.
• Data Tables, which contains detailed data tables for most measures analyzed for the reports, including measures highlighted in the report text and measures examined but not included in the text. A few measures cannot support detailed tables and are not included in the appendix.

Theme of 2010 Reports

This year's focus on health care performance in rural and inner-city areas required the identification of a standardized approach to identifying communities by level of urbanization. With input from the Interagency Work Group, AHRQ selected the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme to guide analyses involving geographic location. The 2006 NCHS classification system is derived from data gathered from three sources: the OMB metropolitan and nonmetropolitan designations, the Rural-Urban Continuum and Urban Influence coding systems, and the U.S. Census. NCHS includes six urbanization categories, including four metropolitan and two nonmetropolitan county designations. Definitions of metropolitan and nonmetropolitan designations are shown in Table 1.1.

Although an effort was made to standardize reporting of data according to the NCHS classification system, a number of data sources collected this information using alternative classification models. For example, data in the National Survey on Drug Use and Health (NSDUH) were organized according to the classification system shown in Table 1.2. To the extent feasible, this classification system was modified to correspond to the 2006 NCHS classification scheme. Because correspondence between the NSDUH's nonmetropolitan subgroups and that of the NCHS classification system was poor, for purposes of analysis, nonmetropolitan regions were not subset. Thus, NSDUH performance measures are reported for three metropolitan subgroups and for nonmetropolitan regions as a whole. In other cases, where source data did not provide sufficient detail to adapt to the NCHS model, analyses of performance used aggregated categories (e.g., metropolitan versus nonmetropolitan.)

Table 1.1. 2006 NCHS Urban-Rural Classification System

Source: Ingram D, Franco S. 2006 Rural-Urban Classification Scheme for Counties. Centers for Disease Control and Prevention, NCHS, 2006. Available at http://www.cdc.gov/nchs/data_access/urban_rural.htm.

Table 1.2. NSDUH data classification and modified classification for metropolitan and nonmetropolitan communities

Measure Set for the 2010 NHQR and NHDR

Retired Measures

Previous reports have demonstrated that some measures of health care quality have improved. Since the first NHQR and NHDR, significant improvements in a number of measures of quality of care have occurred, with U.S. health care providers achieving overall performance levels exceeding 95%. The success of these measures limits their utility for tracking improvement over time. Because these measures cannot improve further to a significant degree, including them in the measure set creates a ceiling effect that may distort quantification of rate of change over time. Data on retired measures will continue to be collected and these measures will be added back to the reports if their performance falls below 95%. For the 2010 report, no measures have been retired or added back.

The measures that were retired in 2009 and therefore not presented in the 2010 report are:

• Adults with diabetes who had their blood cholesterol checked.
• Hospital patients with heart attack who received aspirin within 24 hours of admission.
• Hospital patients with heart attack who were prescribed aspirin at discharge.
• Hospital patients with heart attack who were prescribed a beta blocker at discharge.
• Smokers with heart attack who received smoking cessation counseling while hospitalized.

Core Measures

The NHQR and NHDR track a broad array of health care measures and have added measures each year. The 2010 reports continue to focus on a consistent subset of measures, the "core" measures, which includes the most important and scientifically supported measures in the full measure set. In 2005, the Interagency Work Group selected the core measures from the full measure set. For most core measures, findings are presented each year. A subset of the core measure group is presented on an alternating basis, typically rotating across odd or even years of the report. All alternating core measures are included in trend analyses. "Noncore" measures are included in summary statistics and may be presented to complement core measures in key areas.

Examples of alternating measures include the set of measures focusing on breast cancer and colorectal cancer. While measures are annually tracked, breast cancer measures are presented in odd calendar years; these measures were contained in the 2009 reports. Colorectal cancer measures are also tracked annually, but results are presented in even calendar years, such as in the 2010 quality and disparities reports.

Composite Measures

Policymakers and others have voiced their support for composite measures of quality because they can be used to facilitate understanding of information from many different measures. A composite measure summarizes care that is represented by individual measures that are often related in some way, such as components of care for a particular disease or illness. Composite measures are composed of two or more process^vi or outcome^vii measures that have been recommended or identified as a "best practice" in the treatment or prevention of complications associated with specific conditions, such as diabetes. Since measures used to construct composites represent various dimensions or processes of care, they provide a more complete understanding of the quality of the U.S. health care system. To ensure that actionable information is available, estimates of performance on the individual measures that make up a composite measure are available in an appendix to these reports.

Decisions concerning the appropriateness of pooling data to generate a composite measure were discussed with data sources. Several of the composite measures included in the reports were developed, tested, and estimated by the data source or other public or private organizations for use in quality assessment, monitoring, and improvement activities.

Composite measures in the NHQR and NHDR are created in a variety of different ways. The appropriateness model is sometimes referred to as the "all-or-none" approach because it is calculated based on the number of patients who received all of the services they needed. One example of this model is the diabetes composite, in which a patient who receives only one or two of the three recommended services would not be counted as having received all recommended care.

The opportunities model assumes that each patient needs and has the opportunity to receive one or more processes of care, but not all patients need the same care. Composite measures that use this model summarize the proportion of appropriate care that is delivered. The denominator for an opportunities model composite is the sum of opportunities to receive appropriate care across a panel of process measures. The numerator is the sum of the components of appropriate care that are actually delivered.

The composite measure of recommended hospital care for heart failure is an example of the use of the opportunities model. The total number of patients who receive treatments represented by individual components of the composite measure (e.g., evaluation of left ventricular ejection fraction and use of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) among patients with left ventricular systolic dysfunction) is divided by the sum of all of the opportunities to receive appropriate care.

The CAHPS® (Consumer Assessment of Healthcare Providers and Systems) surveys have their own method for computing composite measures that has been in use for many years. These composite measures average individual components of patient experiences of care and are presented as the proportion of respondents who indicate that providers sometimes or never, usually, or always performed well.

Composite measures that relate to rates of complications of hospital care are postoperative complications and complications of central venous catheters. For these complication rate composites, an additive model is used that sums individual complication rates. Thus, for these composites, the numerator is the sum of individual complications and the denominator is the number of patients at risk for these complications. The composite rates are presented as the overall rate of complications. The postoperative complications composite is a good example of this type of composite measure: if 50 patients had a total of 15 complications among them (regardless of their distribution), the composite score would be 30%.

Other Measure Characteristics

Core and noncore measures may be characterized as "process" or "outcome" measures. Process measures track receipt of medical services and whether providers rendered care according to accepted standards. Outcome measures are indicative of the result or impact of medical care. Many factors other than the care received affect health outcomes; these include lifestyle, social and physical environment, and genetic predisposition to disease. Therefore, outcome measures are typically adjusted for risk or patient characteristics that may influence outcomes.

Both process and outcome measures are included in the 2010 NHQR and NHDR; both types of measures are not reported for all conditions due to data limitations. For example, data on HIV care are suboptimal, so no HIV process measures are included as core measures. In addition, not all core measures are included in trending analysis, because 3 or more years of data are not always available. Ideally, process measures and related outcome measures would be tracked in tandem. In reality, data are typically unavailable to examine the relationship between structural, process, and outcome measures.

Process measures reported in the NHQR and NHDR, particularly in the chapter on effectiveness, are grouped into categories related to the type of care: prevention, acute treatment, and chronic disease management. There is a sizable overlap among the care types and some measures may be considered to belong in more than one type of care category.

• Prevention. Caring for healthy people is an important component of health care. Educating people about healthy behaviors and lifestyle modification can help to postpone and avoid illness and disease. In addition, detecting health problems at an early stage increases the chances of effectively treating them, often reducing suffering and costs. Many of the preventive measures tracked in the reports come from the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.
• Treatment. Even when preventive care is ideally implemented, it cannot entirely avert the need for acute care. Delivering optimal treatment for acute illness can help reduce the effects of illness and promote the best recovery possible.
• Management. Some diseases, such as diabetes and ESRD, are chronic, which means they cannot simply be treated once; they must be managed across a lifetime. Management of chronic disease often involves lifestyle changes and regular contact with a provider to monitor the status of the disease. For patients, effective management of chronic disease can mean the difference between healthy living and frequent medical problems.

A list of core measures included in the 2010 NHQR and NHDR is shown in Table 1.3 at the end of this chapter. Measures are identified according to the priorities addressed, dimension or type of care, and focus on structure (access), process (prevention, acute care, chronic care), or outcome of care. The table also notes whether a measure is a composite measure.

ⁱ 42 U.S.C. 299b-2(b)(2).
ⁱⁱ 42 U.S.C. 299a-1(a)6).
ⁱⁱⁱ The committee's report is available at: https://www.ahrq.gov/research/iomqrdrreport/.
^iv In addition to guidance specific to the reports, the IOM provided recommendations about standardizing collection and coding of data on race, ethnicity, and language in the report Race, Ethnicity, and Language Data. We continue to seek opportunities to show data in the reports on disparities related to granular ethnicity and language preference, but such health care data are rare.
^v The NPP is a partnership of public and private health care stakeholders who have come together to establish priorities and goals to eliminate harm to patients, eliminate health care disparities, and reduce disease burden and health system waste. More information on the National Priorities Partnership is available at: http://www.qualityforum.org/npp/.
^vi Receipt of three recommended diabetes services" is one example of a composite process measure. This composite was formed by combining information on adults with diabetes who received the following clinical preventive services: hemoglobin A1c measurement, a dilated eye exam, and a foot exam.
^vii "Adults with ambulatory visits who reported poor communication with health providers" is an example of a composite outcome measure. This composite was formed by combining information on patient perceptions of their providers, including the extent to which the provider listened to the patient, respect shown by the provider, time spent with the patient, and explanations offered by providers.

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