Highlights From the 2011 National Healthcare Quality and Disparities R

Progress Is Uneven With Respect to National Priorities

In the 2010 Highlights, findings were summarized across eight priorities for quality improvement identified by the Institute of Medicine (IOM) for use until the Federal Government set national priorities for health care. With the passage of the Affordable Care Act of 2010, HHS was charged with identifying national priorities and developing and implementing a National Quality Strategy (NQS) to improve the delivery of health care services, patient health outcomes, and population health. The initial NQS, released in March 2011, is to pursue three broad aims: better care, healthy people/healthy communities, and affordable care and to focus initially on six priorities (HHS, 2011b). Therefore, in this year's Highlights, findings from the NHQR and NHDR are organized across these six new priorities:

• Making care safer.
• Ensuring person- and family-centered care.
• Promoting effective communication and care coordination.
• Promoting effective prevention and treatment of leading causes of mortality, starting with cardiovascular disease.
• Working with communities to promote wide use of best practices to enable healthy living.
• Making quality care more affordable.

The HHS Action Plan To Reduce Racial and Ethnic Health Disparities lists goals and strategies to move us toward the vision of "a Nation free of disparities in health and health care" (HHS, 2011a). While the action plan goes beyond the scope of the NHQR and NHDR, many of the strategies relate to health care and the NQS priorities and are discussed in that context. One critical strategy, increasing the availability and quality of data collected and reported on racial and ethnic minority populations, does not fit this framework and is addressed separately at the end of this section.

As in last year's report, we seek to go beyond problem identification to include information that would help users address the quality and disparities concerns we identify. To that end, we continue to present novel strategies for improving quality and reducing disparities, gathered from the AHRQ Health Care Innovations Exchange (HCIE). The HCIE is a repository of more than 1,500 quality improvement tools and more than 500 quality improvement stories about providers who developed better ways to deliver health care. For each priority area, stories of successful innovations that yielded significant improvements in outcomes are displayed.ⁱⁱⁱ

In addition, we recognize thrat accelerating the pace of health care quality improvement or disparities reduction will require the combined efforts of Federal, State, and private organizations. Hence, we have added examples of key Federal and State initiatives aimed at the six national priorities. By demonstrating that improvement is critical and can be achieved, we hope that these examples inspire others to act.

National Priority: Making Care Safer

An inherent level of risk is involved in performing procedures and services to improve the health of patients. Although degree of risk is often related to the severity of illness, variations in adverse event rates occur between different facilities and caregivers. Avoidable medical errors account for an immense number of deaths annually. Even if patients do not die from a medical error, they will often have longer and more expensive hospital stays. Clearly, some risk can be reduced and some cannot, but research has shown that large numbers of errors and adverse events can be markedly reduced if addressed with appropriate interventions.

This NQS priority aligns well with the chapters on Patient Safety in the NHQR and NHDR. The NQS identifies eliminating hospital-acquired infections and reducing the number of serious adverse medication events as important opportunities for success in making care safer. The HHS Disparities Action Plan includes this priority under its strategies to reduce disparities in the quality of health care

Progress in Patient Safety

Figure H.10. Number and proportion of measures that are improving, not changing, or worsening, hospital patient safety versus other hospital measures

Key: n = number of measures.
Improving = Quality is going in a positive direction at an average annual rate greater than 1% per year.
No Change = Quality is not changing or is changing at an average annual rate less than 1% per year.
Worsening = Quality is going in a negative direction at an average annual rate greater than 1% per year.
 

• Improvements in safety are lagging behind other hospital measures:
  • The reports track 26 safety measures related to healthcare-associated infections and other adverse events that can occur during hospitalization. Of these measures, 38% showed improvement. By comparison, among 16 hospital quality measures not related to safety, almost all demonstrated improvement over time.

Figure H.11. Number and proportion of hospital patient safety measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Key: NHW = non-Hispanic White; n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.

• Most disparities in patient safety mirror disparities in overall quality of care:
  • Racial and ethnic minorities experienced less safe care for about 40% of measures, similar to disparities in quality of care overall.
  • Income-related disparities in patient safety were less common than income-related disparities in overall quality.
  • Adults age 65 and over had higher rates of almost all patient safety events than adults ages 18-44 for all measures tracked.

Examples of Initiatives Making Care Safer

Federal: The Partnership for Patients is a new national patient safety and quality improvement initiative that has two goals: reducing preventable hospital-acquired conditions by 40% and reducing 30-day hospital readmissions by 20%. The program is led by the CMS Center for Medicare and Medicaid Innovation (CMMI) and was established in April 2011. Up to $1 billion in CMS funds are expected to be available for the program, which aims to fund regional or State-level initiatives that will support numerous evidence-based patient safety and quality improvement projects (http://www.healthcare.gov/center/programs/partnership).

State: More than half of States have developed adverse event reporting systems to gather information about medical errors and serious complications of care. Most of these systems mandate reporting, require root cause analyses and corrective action plans for serious events, and make findings and aggregate data available to the public (Rosenthal & Takach, 2007). Other States promote safer care by denying payment to providers for preventable adverse events. Building on CMS nonpayment policies under Medicare, 12 States have implemented policies to refuse payment by Medicaid and other public purchasers for specific hospital-acquired conditions or serious reportable events. As more States begin nonpayment policies for adverse events, focus is shifting to alignment of activities across payers (Rosenthal & Hanlon, 2009).

Provider: In the Michigan Health & Hospital Association's Keystone: ICU project, Johns Hopkins University partnered with 120 participating intensive care units (ICUs) to reduce bloodstream infections and ventilator-associated pneumonia. Each participating ICU assembled an improvement team to lead a comprehensive unit-based safety program to enhance the culture of patient safety. The program prevented many catheter-associated bloodstream infections, leading to more than 1,800 lives saved, more than 140,000 hospital days avoided, and at least $270 million in savings over a 5-year period (HCIE #2668).

National Priority: Ensuring Person- and Family-Centered Care

To effectively navigate the complicated health care system, providers need to ensure that patients can access culturally and linguistically appropriate tools. Strategies to support patient and family engagement enable patients to understand all treatment options and to make decisions consistent with their values and preferences.

This NQS priority aligns with chapters on Patient Centeredness in the NHQR and NHDR. The NQS identifies opportunities to ensure person- and family-centered care: integrating patient feedback on preferences, functional outcomes, and experiences of care into all care delivery; increasing use of electronic health records (EHRs) to capture the patient's voice and integrate patient-generated data; and routinely measuring patient engagement and self-management, shared decisionmaking, and patient-reported outcomes. The HHS Disparities Action Plan includes this priority under its strategies to increase the ability of the health care system to address disparities and to increase the diversity of health care and public health workforces.

Progress in Patient Centeredness

• Patient centeredness is improving:
  • The NHQR and NHDR track 13 measures of patient perceptions of care, involvement in decisionmaking, and ability to get language assistance. Eleven of these measures show improvement over time (data not shown).

Figure H.12. Number and proportion of patient centeredness measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Key: AI/AN = American Indian or Alaska Native; NHW = non-Hispanic White; n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.

• Most disparities in patient centeredness mirror disparities in overall quality of care:
  • Most racial and ethnic minorities experienced less patient-centered care for about 40% of measures, similar to disparities in quality of care overall.
  • Income-related disparities in patient centeredness were significant for 77% of measures and were more common than income-related disparities in overall quality.
  • Adults age 65 and over had more patient-centered care than adults ages 18-44.
• Workforce diversity is limited:
  • Beginning in 2006, the reports have tracked workforce diversity among physicians and surgeons, registered nurses, licensed practical and licensed vocational nurses, dentists, dental hygienists, dental assistants, pharmacists, occupational therapists, physical therapists, and speech-language pathologists. For almost all of these occupations, Whites and Asians are overrepresented while Blacks and Hispanics are underrepresented.
  • Two exceptions were noted. Blacks are overrepresented among licensed practical and licensed vocational nurses while Hispanics are overrepresented among dental assistants. Of the health care occupations tracked, these two required the least amount of education and have the lowest median annual wages.

Examples of Initiatives Fostering Person- and Family-Centered Care

Federal: In the first large-scale initiative to include patient experience in quality reporting, CMS encouraged hospitals to collect and publicly report information using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The Affordable Care Act includes HCAHPS performance in calculating value-based incentive payments to hospitals and expands the use of patient experience information to assess physicians and other facilities, such as nursing homes (http://www.cms.gov/Hospital-Value-Based-Purchasing/). The Health Profession Opportunities Grants support education and training of low-income individuals in health care occupations that pay well and are expected to either experience labor shortages or be in high demand over the next 5 years (http://www.acf.hhs.gov/grants/open/foa/view/HHS-2010-ACF-OFA-FX-0126).

State: As part of the Strategic Plan To Eliminate Health Disparities in New Jersey, the State worked to improve language access. In collaboration with the Health Research and Educational Trust of New Jersey, bilingual hospital staff were trained to be medical interpreters. The Office of Minority and Multicultural Health supported training for community leaders to help interpret or act as liaisons for minority clients navigating the health care system. In response to increasing requests for information by Spanish speakers, the Bureau of Vital Statistics hired bilingual staff, added a Spanish customer service phone line, and translated their Web site and forms into Spanish (http://www.state.nj.us/health/omh/plan2012/index.shtml ).

Provider: The Howard University Diabetes Treatment Center offers patients a free online personal health record to help monitor blood sugar and other clinical indicators, communicate with physicians between visits, and share health information. The program enhances levels of patient engagement in self-management and improves blood glucose control (HCIE #3081). The University of California San Francisco Breast Care Center Decision Services Unit offers a visit planning, recording, and summarizing service in which trained interns help patients brainstorm and write down a list of questions and concerns for their providers. The program improves patient-provider communication and patient self-efficacy and decisionmaking and reduces decisional conflict (HCIE #95).

National Priority: Promoting Effective Communication and Coordination of Care

Care coordination is a conscious effort to ensure that all key information needed to make clinical decisions is available to patients and providers. Health care in the United States was not designed to be coordinated. Patients commonly receive medical services, treatments, and advice from multiple providers in many different care settings, each scrutinizing a particular body part or system. Attending to the patient as a whole is rare. Less than sufficient provider-provider and provider-patient communication is common and may lead to delays in treatment and inaccuracies in medical information. Enhancing teamwork and increasing use of health information technologies to facilitate communication among providers and patients can improve care coordination.

This NQS priority aligns well with the chapters on Care Coordination in the NHQR and NHDR. The NQS identifies several important opportunities for success in promoting effective communication and coordination of care: reducing preventable hospital admissions and readmissions, preventing and managing chronic illness and disability, and ensuring secure information exchange to facilitate efficient care delivery. The HHS Disparities Action Plan includes this priority under its strategies to reduce disparities in access to primary care services and care coordination.

Progress in Care Coordination

Data and measures to assess care coordination are limited. Hence, an effort to summarize across this domain would be incomplete. Instead, we show findings for selected measures.

• Hospital readmissions: While not all rehospitalizations can be prevented, better coordination at the point of discharge can prevent some readmissions. About 20% of patients hospitalized for heart failure are rehospitalized within 30 days for a condition related to heart failure. Considerable variation across States and by race is also observed.
• Preventable emergency department visits: In patients with asthma, emergency department visits are five times as likely as hospitalizations, and some of these emergency department visits could be prevented with better coordination of outpatient care. Residents of inner cities and low-income neighborhoods have particularly high rates of emergency department visits.
• Transitions of care: Among patients hospitalized for heart failure, the quality of patient discharge instructions is improving. However, race-related disparities are observed.
• Medication information: Most providers ask patients about medications prescribed by other providers, and rates are improving. However, age- and insurance-related disparities are observed. Moreover, only one-third of hospitals currently support the electronic exchange of medication information with ambulatory care providers outside their own system.

Examples of Initiatives Promoting More Effective Care Coordination

Federal: The Health Information Technology for Economic and Clinical Health (HITECH) Act promotes the adoption of health information technology, including EHRs and electronic health information exchange. Eligible providers can receive incentive payments when they adopt and meaningfully use certified EHR technology to make needed clinical information accessible to all providers in a more complete and timely fashion. Altogether, more than $27 billion in incentive payments is available (http://www.cms.gov/ehrincentiveprograms/). The HHS Initiative on Multiple Chronic Conditions seeks to improve the quality of life and health status of individuals with multiple chronic conditions consistent with the Strategic Framework on Multiple Chronic Conditions issued in December 2010. This initiative promotes care coordination across multiple chronic conditions by fostering systems change, empowering individuals, equipping providers with tools and information, and enhancing research (http://www.hhs.gov/ash/initiatives/mcc/).

State: The Assuring Better Child Health and Development Learning Collaborative brings together five States to improve linkages between pediatric primary care providers and community resources for young children. Arkansas, Illinois, Minnesota, Oklahoma, and Oregon are working to maximize use of staff to ensure effective linkages, integrating data across programs, monitoring quality related to referrals, and supporting cross-system planning (Hanlon & Rosenthal, 2011). In Rhode Island's Pediatric Practice Enhancement Project, trained parent consultants work in pediatric practices. Providers refer families with children with special health care needs requiring care coordination. Parent consultants then work to match these families with appropriate community resources and ensure that needed services are received (Silow-Carroll, 2009).

Provider: When referring patients to the Northwestern Memorial Hospital Emergency Department, community physicians send an electronic handoff note with pertinent clinical information. The note is entered into the EHR system and made available to emergency providers. Both referring and emergency physicians believe the system improves care coordination and quality of care (HCIE #3107). At the Chelsea and Westminster Hospital's Sexual Health Clinics, standardized text messages are used to relay test results and instructions. The program led to quicker diagnosis and treatment for those testing positive and reduced staff time spent on followup care, allowing clinics to handle more new cases (HCIE #3019).

National Priority: Promoting Effective Prevention and Treatment of Leading Causes of Mortality, Starting With Cardiovascular Disease

Providing care to patients for whom the expected benefits, based on scientific evidence, exceed the expected risks is at the heart of health care. Focusing national quality improvement efforts on diseases that kill the most Americans is logical and places cardiovascular disease at the top of the list. Moreover, knowledge of how to prevent and treat heart disease and stroke is well documented.

This NQS priority aligns well with the sections on cardiovascular disease in the Effectiveness chapters in the NHQR and NHDR. The NQS identifies several important opportunities for success in promoting effective prevention and treatment of cardiovascular disease: increasing blood pressure control in adults, reducing high cholesterol levels in adults, increasing the use of aspirin to prevent cardiovascular disease, and decreasing smoking among adults. The HHS Disparities Action Plan includes this priority under its strategies to reduce disparities in the quality of health care.

Progress in Care for Cardiovascular Disease

• Cardiovascular care has improved dramatically:
  • Measures are retired from the reports when performance exceeds 95%. Of the dozen report measures that have been retired in the past 3 years, almost all related to the management of cardiovascular risk factors or disease.
  • Of the seven remaining cardiovascular disease quality of care measures that could be trended, all showed improvement (data not shown).

Figure H.13. Number and proportion of cardiovascular disease measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Key: NHW = non-Hispanic White; n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.

• Racial and ethnic disparities in cardiovascular care are less common:
  • Racial and ethnic minorities often experienced better cardiovascular care than Whites. For example, Blacks received better quality care than Whites for more than half of cardiovascular measures.
  • Income-related disparities in cardiovascular care were significant for about 60% of measures, which is more than income-related disparities in overall quality.

Examples of Initiatives Promoting Effective Prevention and Treatment of Cardiovascular Disease

Federal: Million Hearts™ is a campaign led by CMS and the Centers for Disease Control and Prevention (CDC) to prevent a million heart attacks and strokes over the next 5 years. The campaign focuses and coordinates cardiovascular disease prevention activities such as improving control of high blood pressure and high cholesterol, using aspirin to prevent cardiovascular events in high-risk populations, reducing sodium and artificial trans fat intake, and quitting smoking (http://millionhearts.hhs.gov). The HHS Office on Women's Health Make the Call, Don't Miss a Beat campaign educates women about the signs and symptoms of a heart attack and encourages them to call 911 first (http://www.womenshealth.gov/heartattack/). The Know Stroke campaign led by the National Institute of Neurological Disorders and Stroke educates the public about the signs and symptoms of stroke and the importance of seeking emergency care (http://stroke.nih.gov). The associated Brain Attack Coalition promotes best practices to prevent and combat stroke (http://www.stroke-site.org ).

State: The Ohio Plan To Prevent Heart Disease and Stroke outlines an approach to reducing the burden of cardiovascular disease through lifestyle improvement, risk factor reduction, acute care, rehabilitation, and surveillance. Objectives include increasing State laws, partners, and schools that promote physical activity, healthy eating, and a smoke-free environment; increasing work site programs to control high blood pressure and cholesterol; improving prehospital and inpatient treatment of cardiovascular events; increasing facilities that provide cardiac and stroke rehabilitation; and increasing reporting of and access to data related to quality and disparities (Edwards, et al., 2009).

Provider: In the HealthyHeartClub.com program, pharmacists help patients reduce cardiovascular risk and reach goals related to diet, physical activity, and medication adherence. Support includes group classes, Email check-ins, and Web tools to track progress toward goals. Participants have increased physical activity and reduced weight and blood pressure (HCIE #3182). For older patients after a heart attack or bypass surgery, Massachusetts General Hospital and University of California San Francisco combine followup phone calls from an advanced practice nurse with home visits from a trained elder to encourage compliance with medications and lifestyle changes. The program improves medication adherence and reduces readmissions due to cardiac-related complications (HCIE #1823).

National Priority: Working With Communities To Promote Wide Use of Best Practices To Enable Healthy Living

Population health is influenced by many factors, including genetics, lifestyle, health care, and physical and social environments. The NHQR and NHDR focus on health care and counseling about lifestyle modification and do not address biological and social determinants of health that are currently not amenable to alteration through health care services. Still, it is important to acknowledge that the fundamental purpose of health care is to improve the health of populations. Acute care is needed to treat injuries and illnesses with short courses, and chronic disease management is needed to minimize the effects of persistent health conditions. But preventive services that avert the onset of disease, foster the adoption of healthy lifestyles, and help patients to avoid environmental health risks hold the greatest potential for maximizing population health.

This NQS priority aligns best with the lifestyle modification sections in the Effectiveness chapters in the NHQR and NHDR. However, screening for cancer and cardiovascular risk factors are found in the Cancer and Cardiovascular Disease sections of the chapter, respectively. Childhood vaccinations are found in the Maternal and Child Health section while adult vaccinations are found in the section on Respiratory Diseases. The NQS identifies several important opportunities for success in promoting healthy living: increasing the provision of clinical preventive services for children and adults and increasing the adoption of evidence-based interventions to improve health. The HHS Disparities Action Plan includes this priority under its strategies to reduce disparities in population health by increasing the availability and effectiveness of community-based programs and policies.

Progress in Healthy Living

Figure H.14. Number and proportion of measures that are improving, not changing, or worsening, immunizations versus screening and counseling

Key: n = number of measures.
Improving = Quality is going in a positive direction at an average annual rate greater than 1% per year.
No Change = Quality is not changing or is changing at an average annual rate less than 1% per year.
Worsening = Quality is going in a negative direction at an average annual rate greater than 1% per year.
Note: Screening includes screening for cancer and high cholesterol; counseling includes advice from a provider about exercise and diet.

• Immunization rates are improving while clinical preventive services are lagging:
  • Trends could be assessed for 6 childhood and 11 adult vaccination measures. Of these, 59% were improving, similar to health care quality overall (56%).
  • Trends could be assessed for 6 screening and 12 counseling services related to healthy living. Of these measures, 39% showed improvement, a lower rate than health care quality overall.

Figure H.15. Number and proportion of healthy living measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group

Key: AI/AN = American Indian or Alaska Native; NHW = non-Hispanic White; n = number of measures.
Better = Population received better quality of care than reference group.
Same = Population and reference group received about the same quality of care.
Worse = Population received worse quality of care than reference group.

• Most disparities in healthy living mirror disparities in overall quality of care:
  • Most racial and ethnic minorities received less preventive care for about 30% of measures, similar to disparities in quality of care overall.
  • Income-related disparities in healthy living were significant for 50% of measures, similar to income-related disparities in overall quality.

Examples of Initiatives Promoting Healthy Living

Federal: The National Prevention Strategy was released by the Surgeon General in June 2011. This national plan seeks to increase the number of Americans who are healthy at every stage of life by creating healthy and safe community environments, improving clinical and community preventive services, empowering people to make healthy choices, and eliminating health disparities (http://www.healthcare.gov/prevention/nphpphc/strategy/). The First Lady's Let's Move! Campaign is combating the epidemic of childhood obesity by providing schools, families, and communities with tools to help children be more active, eat better, and get healthy. A Presidential Task Force on Childhood Obesity reviewed all Federal policies related to child nutrition and physical activity and developed a national action plan to reduce the prevalence of childhood obesity to 5% by 2030 (http://www.letsmove.gov).

State: The Maryland Minority Outreach and Technical Assistance program uses tobacco settlement funds to support activities to prevent and control tobacco use in minority communities. Grantees worked with local health departments and faith-based groups to increase awareness and form alliances to prevent smoking. Participants attended tobacco coalition meetings and health fairs and received referrals to the Maryland Quitline and local health department smoking cessation programs (http://dhmh.maryland.gov/mhhd/mota/SitePages/MOTA%20Home.aspx ).

Provider: The Healthy Weight Collaborative is a partnership of the National Initiative for Children's Healthcare Quality and the Health Resources and Services Administration (HRSA). It brings together 10 teams of primary care, public health, and community sector participants to implement evidence-based interventions to achieve communitywide healthy weight and health equity. The collaborative will use the Breakthrough Series methodology to spread successful change rapidly (http://www.collaborateforhealthyweight.org ). Eight primary care practices of the Practice Partner Research Network adopted standing orders for preventive care services. During visits, nonphysician staff discuss preventive care needs with patients and then arrange for their provision. The program led to increased receipt of preventive services (HCIE #3140).

National Priority: Making Quality Care More Affordable

Access to care is defined as "the timely use of personal health services to achieve the best health outcomes." Many Americans have poor access to care because they cannot afford to purchase health insurance or pay for services not covered by their insurance. Individuals with limited access to care receive worse quality of care and experience poor health outcomes. Access to health care has a significant effect on health disparities. There is substantial evidence that access to the health care system varies by socioeconomic factors and geographic location. The NHQR and NHDR examine disparities in care related to insurance status, usual source of care, and financial barriers to care.

Inefficiencies in the health care system contribute to the high cost of health care. Some therapies are given even when they are unlikely to benefit the patient. Diagnostic tests and procedures are repeated when original results are misplaced. These instances represent overuse of health services. Apart from causing discomfort and distress for patients, overuse can be harmful to the patient's health and make health care unaffordable.

This NQS priority cuts across the Access and Efficiency chapters in the NHQR and NHDR. The affordability of health care is covered in the Access chapter while the inefficiencies that raise health care costs are covered in the Efficiency chapter. The NQS identifies several important opportunities for success in making quality care more affordable: building cost and resource use measurement into payment reforms, establishing common measures to assess the cost impact of new programs and payment systems, reducing the amount of health care spending that goes to administrative burden, and making costs and quality more transparent to consumers. The HHS Disparities Action Plan includes this priority under its strategies to reduce disparities in health insurance coverage and access to care.

Progress in Affordable Health Care

Data and measures to assess health care affordability are limited. Hence, an effort to summarize across this domain would be incomplete. Instead, we show findings for selected measures.

• Financial burden: Individuals with private nongroup insurance are nearly three times as likely as individuals with private employer-sponsored insurance to have high health insurance premiums and out-of-pocket medical expenses. Poor individuals are five times as likely as high-income individuals to have high health care expenses. Of individuals who report that they were unable to get or delayed in getting needed medical care, dental care, or prescription medicines, two-thirds indicate a financial or insurance cause of the problem. Hispanics and non-Hispanic Blacks are more likely than non-Hispanic Whites to report a financial or insurance problem.
• Usual source of care: Of individuals without a usual source of care, 18% indicate a financial or insurance reason for not having one. Poor individuals are five times as likely as high-income individuals and Hispanics are twice as likely as non-Hispanic Whites to report financial and insurance reasons for not having a usual source of care.
• Inappropriate medication use: Inappropriate medication use is wasteful of resources. Inappropriate medication use among older adults has been stable over time. In addition, no significant disparities among groups persist over the observed study period.
• Potentially harmful preventive services with no benefit: A preventive service without benefit tracked in the NHQR and NHDR is prostate-specific antigen testing of men age 75 and over to screen for prostate cancer. During the time measured, there has been a slight increase in testing.
• Potentially avoidable hospitalization costs: While not all potentially avoidable hospitalizations can be prevented, rates can be reduced through better primary care. In total, potentially avoidable hospitalizations cost Americans $26 billion in 2008. If rates could be reduced to the achievable benchmark rate (the rate achieved by the best performing State; see Chapter 1 for benchmarking methods), $11 billion could be saved per year.

Examples of Initiatives Making Care More Affordable

Federal: Individuals and small businesses buying health insurance often have few options. The Affordable Care Act creates State-based Health Insurance Exchanges that will lower costs and improve health care quality by creating a more transparent and competitive marketplace. Insurers in exchanges will provide information on price and quality, promoting competition. By pooling people together, exchanges will also give individuals and small businesses purchasing power similar to that of large businesses (HHS Press Office, 2011).

State: As States face tightening budgets, some have reformed payment. Minnesota bundles payments for seven common "baskets of care" (Rosenthal, et al., 2010). Other States have begun to scrutinize health care costs, including costs associated with disparities. The Virginia Health Equity Report includes an examination of excess costs associated with different disparities. Metrics include direct costs of hospital care and indirect costs of morbidity and premature mortality. A key finding is that disparities cost Virginia huge sums of money each year (http://www.vdh.state.va.us/healthpolicy/2008report.htm ).

Provider: Intermountain Healthcare developed a system to alert labor and delivery charge nurses when medical indications do not support early elective induction and to cancel these procedures. Performance reports are also shared with obstetric providers. The program greatly reduced early elective induction as well as neonatal complication rates and saved $1.7 million over 5 years (HCIE #3161). Via Christi Health developed a telepharmacy program for 14 hospitals. The program allows offsite pharmacists to review medication orders and patient medical records via computer and authorize hospital pharmacy systems to dispense the medications. Pharmacists cover multiple hospitals simultaneously, expanding hours of pharmacy services. The program reduced order processing times and saves $1 million per year.

National Priority: Increasing the Availability and Quality of Data Collected and Reported on Racial and Ethnic Minority Populations

Identifying problems, targeting resources, and designing interventions all depend on reliable data. Unfortunately, data on underserved populations are often incomplete. Some data sources do not collect information to identify specific groups. Other data sources collect this information, but the numbers of individuals from specific groups included are too small to allow reliable estimates. The HHS Disparities Action Plan includes this priority as part of its goal to advance scientific knowledge and innovation.

Progress in Disparities Data

In the 2006 NHDR, we presented a chart showing the percentage of core quality measures for which an estimate that met our reliability criteria could not be generated for single-race Asians, Native Hawaiians and Other Pacific Islanders, AI/ANs, multiple-race individuals, Hispanics, and poor people. Except for one measure related to language assistance, all measures provided reliable estimates for Blacks, so they were not shown. Below we include the percentage of all quality measures in the 2011 reports for which a reliable estimate could not be generated for these same groups. Again, except for the one measure of language assistance,^iv reliable estimates could be generated for Blacks for all other measures, so they are not shown.

Figure H.16. Percentage of quality measures in the 2006 and 2011 reports for which a reliable estimate could not be generated

Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.

• Data on disparities are improving but still suboptimal:
  • The percentage of quality measures that could not be used to assess disparities decreased for all groups.
  • For Native Hawaiians and Other Pacific Islanders and multiple-race individuals, reliable estimates were not available for more than half of the measures, making any assessment of disparities incomplete. Reliable estimates for AI/ANs and poor populations also could not be generated for a large percentage of measures.

Examples of Initiatives Increasing Data on Racial and Ethnic Minority Populations

Federal: The Affordable Care Act requires that all federally funded health programs and population surveys collect and report data on race, ethnicity, and primary language and supports use of data to analyze and track health disparities (Andrulis, et al., 2010). To improve the quality of data collected in population surveys, HHS published Data Standards for Race, Ethnicity, Sex, Primary Language, and Disability in October 2011 (Office of Minority Health, 2011). New standards for race and ethnicity expand upon but roll up to the 1997 Office of Management and Budget data collection standards (http://minorityhealth.hhs.gov/templates/content.aspx?ID=9227&lvl=2&lvlID=208). To strengthen data collection in Medicaid and Children's Health Insurance Programs, HHS evaluated these programs and recommended improvements in the report Approaches for Identifying, Collecting, and Evaluating Data on Health Care Disparities in Medicaid and CHIP. Recommendations include aligning the Medicaid Statistical Information System, Medicare Current Beneficiary Survey, and Consumer Assessment of Healthcare Providers and Systems with the new data standards (http://www.healthcare.gov/law/resources/reports/disparities09292011a.pdf; Plugin Software Help).

State: In Massachusetts, all acute care hospitals are required to collect information on race and ethnicity from every patient with an inpatient stay or emergency department visit. Hospitals must use a standardized set of race categories as well as 31 ethnicity categories, and the State provides a tool to assist with collection (Weinick, et al., 2007). The Wisconsin Health Care Information Section has collaborated with various stakeholders to improve collection of information on race and ethnicity. It worked with AI/AN Tribes and the State's cancer database to cross-reference tribal clinic data. It also worked with a leading Hmong organization to distribute a patient brochure in English and Hmong highlighting the importance of reporting ethnicity to hospitals (Hanlon & Raetzman, 2010).

Provider: Aetna began collecting data on race and ethnicity from members in 2002, the first major health plan to do so. Information is collected electronically and on paper forms. More than 60 million Aetna members have provided data on race, ethnicity, and primary language. The Alliance of Chicago Community Health Services developed an EHR that merges clinical data with standardized race and ethnicity data stored in the practice management system. This allows assessments of disparities across the four participating community health centers (IOM, 2009).

Table H.5. Summary of progress on national priorities

Table H.5 summarizes progress on national priorities identified in the National Quality Strategy and Disparities Action Plan, categorizing each as making progress, progress lagging, or lacking sufficient data to assess.

Summary Across National Priorities and Next Steps

• Making Care Safer: Most measures improving but more slowly than other hospital measures.
• Ensuring Person- and Family-Centered Care: Quality generally high; most measures improving.
• Promoting Effective Prevention and Treatment of Cardiovascular Disease: Quality generally high; almost all measures improving.
• Promoting Healthy Living: Most measures improving, but screening and counseling about lifestyle modification improving more slowly than other quality measures.
• Promoting Effective Care Coordination and Making Quality Care More Affordable: Measures and data are limited; more information is needed to assess performance.
• Increasing Data on Racial and Ethnic Minority Populations: Availability of data is improving slowly but data are still insufficient to assess disparities for many groups.
• Disparities: Persistent in all national priorities.

Critical steps to advance the NQS and achieve further gains on the priorities include stakeholder engagement, agency-specific quality improvement plans, and harmonization and alignment of metrics for ongoing benchmarking and reporting of progress.

Stakeholder Engagement and Goal Setting

Legislation requires the NQS to be shaped by input from stakeholders wielding collective national influence to ensure a nationally achievable, impact-oriented strategy. A large focus over the past year has been work by the National Quality Forum (NQF) to convene the multistakeholder National Priorities Partnership (NPP), a partnership of 48 public-and private-sector partners. NPP provided collective input on specific goals, measure concepts with illustrative measures, and highest value strategic opportunities to accelerate improvement across all priorities to NQF, which wrote the draft report. Released in September 2011, the final report, Input to the Secretary of Health and Human Services on Priorities for the National Quality Strategy (NPP, 2011), provides valuable suggestions for moving forward. Work over the coming year will include alignment of efforts on specific goals, measures, and strategic opportunities.

HHS also convened the Interagency Working Group (IWG), as mandated by the ACA, for its inaugural meeting in March 2011. The IWG, composed of representatives from 24 Federal agencies with quality-related missions, is responsible for coordinating with private-sector stakeholders and aligning Federal and State efforts to eliminate duplication of quality-related initiatives. Primary activities of the IWG will be to share experiences and discuss ways to leverage activities across private and Federal-level initiatives. In the coming months, the IWG will review the recommendations of the NPP and will identify a set of discrete and actionable short- and long-term goals, with common metrics where possible. These goals will set the stage for corresponding goals, strategies, and timelines created by Federal agencies and States, and thus will require applicability, feasibility, and relevance to a broad audience of diverse stakeholders. The IWG will also build upon its initial observations regarding the need to align efforts on chronic disease care management, health information technology implementation, disparities, and patient safety.

Agency-Specific Plans

HHS will coordinate with Federal agencies to ensure their agency-specific plans, as required by Section 3011 of the ACA, align to the overarching NQS goals. HHS created a template to guide agencies in the development of these plans, with broad, recommended categories to create consistency across the plans and ensure alignment with the NQS. Agencies will be asked to explain how their own principles, priorities, and aims correspond with those of the NQS; elaborate on their existing and future efforts to implement the NQS; and discuss the methodology for evaluating these efforts. The harmonization of these agency-specific plans will ensure that relevant agencies' activities support rather than conflict with the NQS.

Some agencies have begun incorporating the NQS into their strategic planning and programmatic activities. The Substance Abuse and Mental Health Services Administration (SAMHSA) developed a draft National Behavioral Health Quality Framework (NBHQF), incorporating two rounds of public comments, and is in the process of identifying and finalizing a set of core measures. The NBHQF successfully aligns SAMHSA's mission with the NQS and retains the three aims of NQS as an overarching guideline, while outlining six unique priorities that parallel those in the NQS. In this document, SAMHSA defines its role in fighting national substance abuse, explains how its efforts directly align with the aims of NQS, and illustrates how its own priorities will advance the quality of care in behavioral health. The NBHQF provides a model that HHS will leverage as an example for future agency-specific plans and demonstrates a successful approach for executing the aims of the NQS while achieving measurable improvement across all six priority areas.

Harmonization and Alignment of Metrics

The National Healthcare Quality and Disparities Reports provide an initial set of benchmarks on the six priorities. However, sufficient measures and data are lacking for several priority areas. Over time, new metrics will be developed and current metrics used to track progress on priorities will evolve as HHS aligns, harmonizes, and consolidates measures for evaluating major programmatic initiatives among the various agencies. Minimizing the burden of data collection while supporting an appropriate infrastructure for collecting data and for analyzing and reporting performance will require efforts among all stakeholders.

Conclusion

Improving quality and reducing disparities require measurement and reporting, but these are not the ultimate goals of the NHQR, NHDR, National Quality Strategy, or Disparities Action Plan. The fundamental purpose of improvement in health care is to make all patients' and families' lives better. The NHQR and NHDR concentrate on tracking health care quality and disparities at the national level, but the statistics reported in the reports reflect the aggregated everyday experiences of patients and their providers across the Nation.

It makes a difference in people's lives when breast cancer is diagnosed early; when a patient suffering from a heart attack is given the correct lifesaving treatment in a timely fashion; when medications are correctly administered; and when doctors listen to their patients and their families, show them respect, and answer their questions in a culturally and linguistically skilled manner. All Americans should have access to quality care that helps them achieve the best possible health.

With the publication of this ninth NHQR and NHDR, AHRQ stands ready to contribute to efforts that encourage and support the development of national, State, tribal, and local solutions using national data and achievable benchmarks of care. These documents identify areas where novel strategies have made a difference in improving patients' quality of life, as well as many areas where much more should be done. These reports begin to track the success of the National Quality Strategy and the HHS Disparities Action Plan.

We need to improve access to care, reduce disparities, and accelerate the pace of quality improvement, especially in the areas of preventive care and safety. More data are needed to assess progress in care coordination and efficiency. Information needs to be shared with partners who have the skills and commitment to change health care. Building on data in the NHQR, NHDR, and State Snapshots, stakeholders can design and target strategies and clinical interventions to ensure that all patients receive the high-quality care needed to make their lives better.

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^iii. Identification numbers of items from the HCIE are included to help users find more information. To access detailed information about each novel strategy, insert the identification numbers at the end of this link and copy it into your browser window: http://www.innovations.ahrq.gov/content.aspx?id=
^iv. The measure is the percentage of adults with limited English proficiency and a usual source of care who had language assistance.

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