Highlights from the National Healthcare Quality and Disparities Report (Continued)

A key Institute of Medicine (IOM) recommendation was that AHRQ highlight progress in selected priority areas that are expected to yield the greatest gains in health care quality. These priorities include six areas identified by the National Priorities Partnership (NPP), a coalition representing 48 key health care organizations, as well as two areas proposed by the IOM. In this section, we report on progress in each of these priority areas. Findings are organized around key goals for each priority and include information from both the NHQR and NHDR.

In addition, the IOM encouraged the reports to go beyond problem identification and to include information that might help users address the quality and disparities concerns we identify. To that end, we 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. For each priority area, stories of successful innovations were searched. Innovations that were most clearly described and yielded significant improvements in outcomes are displayed here.^v By demonstrating that improvement can be achieved, we hope that these anecdotes inspire others to act.

Five of the eight priorities recommended by the IOM aligned with existing chapters of the 2009 NHQR and NHDR; new chapters were developed to address care coordination and health system infrastructure. Detailed findings related to these seven priorities can be found in the body of the reports. One priority area, population health, cuts across many sections of the reports. Hence, a more detailed summary of this priority is presented here in the Highlights. Table H.4 aligns the priorities with this year's reports.

 

Table H.4. National Priorities Partnership priorities and location in NHQR and NHDR

National Priority Area	NHQR/NHDR Chapter
Population Health	Highlights only
Palliative and End-of-Life Care	Palliative and Supportive Care section of Effectiveness chapter
Safety	Patient Safety
Patient and Family Engagement	Patient Centeredness
Care Coordination	New Care Coordination chapter
Overuse	Efficiency
Access	Access to Health Care
Health System Infrastructure	New Health System Infrastructure chapter

National Priority: Population Health

Population health is influenced by many factors, including genetics, lifestyle, health care, and the physical and social environment. The reports 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. Nonetheless, 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.

The NPP envisioned "communities that foster health and wellness as well as national, state, and local systems of care fully invested in the prevention of disease, injury, and disability." Key goals include promoting effective preventive services, adopting healthy lifestyle behaviors, and developing a national index of health.

Progress Toward Key Goals

Figure H.10 shows progress on measures related to population health:

• Preventive services: The NHQR and NHDR track 10 measures related to screening recommended by the U.S. Preventive Services Task Force, 11 measures related to adult immunizations, and 6 measures related to childhood immunizations.^vi
  • Screening measures: Across the screening measures, most showed improvement. Median rate of improvement was 2.8% per year. In contrast, most disparities did not change, with the exception of mammography, in which the Asian-White gap was narrowing. In addition, the Black-White gap in rates of advanced stage breast cancer and the AI/AN-White, Hispanic-non-Hispanic White, and poor-high income gaps in colorectal cancer screening all widened.
  • Adult immunizations: Across the adult immunization measures, most showed improvement. Median improvement across measures was 11% per year. Receipt of adult immunizations varied dramatically by setting. Among outpatient measures, median rate of improvement was 0.8% per year, and most disparities did not change. Among inpatient measures, median rate of improvement was 22% per year, and most racial and ethnic disparities were getting smaller.
  • Childhood immunizations: Across the childhood immunization measures, most showed improvement. The childhood immunization measures all come from the Centers for Disease Control and Prevention's National Immunization Survey, so we can report them as a composite. The percentage of children who received the 4:3:1:3:3 vaccine^vii series peaked in 2004 and has fallen since that time. There are few racial or ethnic disparities in childhood immunization, but income-related disparities persist.
• Healthy lifestyles: The NHQR and NHDR track five measures related to obesity, diet, and exercise; four measures related to nicotine and other substance addictions; and four measures related to transportation safety for children.^viii Across these measures, most showed no improvement. Median rate of improvement was 0.9% per year. Most disparities did not change, but the Hispanic-non-Hispanic White and poor-high income gaps in counseling about smoking cessation narrowed.
• National index of health: The NHQR and NHDR track eight mortality measures.^ix Across these measures, most showed improvement. Median rate of improvement was 1.3% per year. Most disparities did not change; the Black-White gap in prostate cancer mortality narrowed while education-related disparities in lung cancer mortality widened.

Figure H.10. Change in measures of population health

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.

Successful Strategies From AHRQ Health Care Innovations Exchange

El Rio Health Center, AZ (2252)

• Intervention: Ongoing immunization training for pediatricians and nurses; nurse-run immunization clinics offered at the center and in the community; computerized data system tracking immunizations and reminders for both patients and providers.
• Impact: Program tripled childhood immunization rates, exceeding Federal standards.

Wayne Action Teams for Community Health (WATCH), NC (2929)

• Intervention: Created new processes to identify and provide individuals in need of colorectal cancer screening and smoking cessation education by forming partnerships with community-based organizations and providers. Patients participated in ongoing performance monitoring and evaluation.
• Impact: Over 1 year, colorectal cancer screening rose from 16% to 98%. Smokers receiving cessation education increased from 66% to 98%.

Bienestar Health Program, TX (2085)

• Intervention: Culturally competent school-based behavior modification program intended to prevent or delay the onset of type 2 diabetes among Mexican-American and other at-risk youth. The five key components of the program are: health education, physical education, family education, student health club, and lessons for the school cafeteria.
• Impact: Program increased physical fitness and dietary fiber intake and reduced blood sugar levels, changes that reduce the risk of type 2 diabetes.

National Priority: Palliative and End-of-Life Care

Disease cannot always be cured, and disability cannot always be reversed. For patients with long-term health conditions, relieving symptoms, enhancing quality of life, and preventing complications are important goals. Providing emotional and spiritual support to patients and their families during serious and advanced illness and honoring patient values and preferences for care is critical.

The NPP vision for this priority is health care "capable of promising dignity, comfort, companionship, and spiritual support to patients and families facing advanced illness or dying." Key goals include relief of suffering, help with emotional and spiritual needs, effective communication about options for treatment and dying, and high-quality hospice services.

Progress Toward Key Goals

• Relief of suffering: Among patients receiving home health care and nursing home care, management of symptoms, such as shortness of breath or pressure sores, is improving. However, most quality of care measures are far below achievable benchmarks, and considerable disparities persist related to age, gender, race, and ethnicity.
• Help with emotional support: Among hospice patients, fewer than 10% do not receive the right amount of help for feelings of anxiety or sadness. However, considerable disparities related to age, race, and ethnicity are observed.
• Communication about dying: Among family caregivers of hospice patients, about one in six wanted more information about what to expect while the patient was dying. In addition, considerable disparities related to age, gender, race, and ethnicity are observed.
• Palliative care and hospice services: Among hospice patients, few received care inconsistent with their stated end-of-life wishes. However, considerable disparities related to age, race, ethnicity, and education are observed. Availability of nonhospice palliative care providers also is a problem; roughly half of U.S. hospitals have yet to develop palliative care programs.

Successful Strategies From AHRQ Health Care Innovations Exchange

North Florida/South Georgia Veterans Health System Advanced Illness Palliative Care Program, FL (1850)

• Intervention: Multidisciplinary initiative that provides care management and palliative care to chronically or terminally ill veterans in their homes via telehealth technology.
• Impact: In a 2-year period, 98% of participants reported adherence to their medications; 92% felt more connected to their providers; overall health care expenditures for program participants decreased by 67%.

Dana-Farber Cancer Institute Pediatric Advanced Care Team (PACT), MA (2195)

• Intervention: Pediatric palliative care consultation service that addresses the physical, psychosocial, and spiritual needs of children with life-threatening illnesses and their families. PACT services focus on providing intensive symptom management, as well as honest, complete, and sensitive communication with patients and families.
• Impact: Improved communication and documentation related to care goals helped ease patient suffering at the end of life and helped parents feel more prepared for their child's end-of-life experience.

National Priority: Patient Safety

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 between 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 and efforts.

The NPP's vision is "a healthcare system that is relentless in continually reducing the risks of care, aiming for a 'zero' harm wherever possible—a system that can promise absolute care, guaranteeing that every patient, every time, receives the benefits of care based solidly on science." The vision sees health care leaders and professionals as leading this effort and being resolute in eliminating defects and errors in care, regardless of their current safety performance levels. Key goals are reducing healthcare-associated infections (HAIs) and serious adverse events (SAEs), reducing preventable and premature hospital-level mortality rates, and improving 30-day mortality rates following hospitalization for selected conditions (acute myocardial infarction, heart failure, pneumonia).

Progress Toward Key Goals

Figure H.11 shows progress in measures related to patient safety:

• Reducing HAIs and SAEs: The reports track 36 safety measures related to HAIs and other SAEs that can occur during hospitalization. Of these measures, most showed improvement. Across all measures, median improvement was 3.6% per year. By comparison, among 14 hospital quality measures not related to safety, median improvement was 21% per year. While progress in safety is clearly being made, it lags behind improvement in other hospital quality measures. In both process and outcome measures, disparities have been observed mainly across geographic locations and among racial and ethnic groups and are especially prominent among Hispanics. Although progress has been made, with some gaps closing, disparities continue over time. In addition, we are unable to examine many adverse events outside of hospital settings due to insufficient data and measures.
• Reducing preventable and premature hospital-level mortality rates: To track preventable and premature hospital-level mortality rates, the NHQR and NHDR monitor failure to rescue (deaths per 1,000 discharges having developed specified complications of care during hospitalization). Although an overall trend cannot be drawn from this single measure, it is noteworthy to mention that this rate has been decreasing for a number of years. Disparities have been observed for failure to rescue, mainly among racial and ethnic populations and less so across income groups. Over time, these disparities have not changed significantly.
• Improving mortality rates for selected conditions: Data do not support tracking 30-day mortality rates for all payers across the Nation. Instead, the NHQR and NHDR track inpatient mortality, which correlates well with 30-day mortality rates. Across six inpatient mortality measures, all showed improvements. Significant disparities were observed across racial and ethnic populations, with gaps not changing over time.

Figure H.11. Change in measures of safety versus other hospital 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.

Successful Strategies From AHRQ Health Care Innovations Exchange

St. John Hospital and Medical Center, MI (2333)

• Intervention: Standardized, nurse-enforced protocols were developed to prevent catheter-related bloodstream infections, including tools to assist in following these protocols and an education program for physicians and nurses.
• Impact: Catheter-related bloodstream infections were reduced from 9.6 to 3 per 1,000 central line days, delaying the onset of infections in those who develop them; the reduction in such infections has led to substantial cost savings.

Barnes-Jewish Hospital, St. Louis, MO (2262)

• Intervention: Initiative integrates technology with a procedural checklist during the preoperative process to prevent wrong-site surgery. Checklist enables clinicians to confirm that the patient's history and physical examination reports are in the chart, circulating nurse visits the patient before surgery, and surgical site is inkmarked. An electronic patient wristband with an embedded sensor is deactivated when the correct surgical site is definitively marked.
• Impact: Program has eliminated wrong-site surgeries and near-misses at Barnes-Jewish Hospital's ambulatory center and the short-stay operating room suite has full compliance with required preoperative processes.

National Priority: Patient and Family Engagement

In order 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.

The vision of the NPP is health care "that honors each individual patient and family, offering voice, control, choice, skills in self-care, and total transparency, and that can and does adapt readily to individual and family circumstances, and to differing cultures, languages, and social backgrounds." Key goals include enabling patients to effectively navigate and manage their care and enabling patients to make informed decisions about their treatment options.

Progress Toward Key Goals

• Effectively navigating and managing care: More than 90% of U.S. adults were able to easily read their prescription instructions. However, disparities were observed among groups varying by insurance status, English proficiency, education, and income. Ethnicity, income, and education also were associated with the need for language assistance when navigating the health care system.
• Making informed decisions about treatment options: Most adults felt it was easy to understand written instructions from a doctor's office but nearly one-fifth of adults were sometimes or never asked to help with decisions on treatment. Disparities were observed related to insurance status, English proficiency, education, and race/ethnicity.

Successful Strategies From AHRQ Health Care Innovations Exchange

UC San Francisco Breast Care Center Decision Services Unit, CA (95)

• Intervention: Initiative offers a consultation planning, recording, and summarizing service in which trained interns help patients brainstorm and write down a list of questions and concerns for their providers.
• Impact: Program improved patient decisionmaking and communication between provider and patient. The preappointment planning session and the assistance during the appointment resulted in a 19% reduction in decisional conflict.

Health Literacy Collaborative of the Iowa Health System, IA (1855)

• Intervention: Educates staff on the importance of communicating health information clearly to patients and families regardless of reading ability, creates easy-to-understand materials based on patients' needs and preferences, and trains health care workers to use these materials with their patients.
• Impact: Patients have access to more understandable health information and report high levels of satisfaction with provider-patient communication.

University of Massachusetts Memorial Medical Center's Language Services Department, MA (2657)

• Intervention: Developed a comprehensive process to ensure that patients with limited English proficiency and patients who are deaf or hard of hearing have timely access to interpreter services.
• Impact: Program reduced patient waiting time for an interpreter; 86% of patients waited 15 minutes or less. The number of languages in which interpreter services are available increased from 51 in 2007 to 75 in 2009.

National Priority: Care Coordination

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.

The NPP envisioned health care that "guides patients and families through their healthcare experience, while respecting patient choice, offering physical and psychological supports, and encouraging strong relationships between patients and the healthcare professionals accountable for their care." Key goals include coordinating transitions of care, communicating medication information, and reducing hospital readmissions and preventable emergency department visits.

Progress Toward Key Goals

• Transitions of care: Among patients hospitalized for heart failure, the quality of patient discharge instructions is improving. However, race-related disparities are observed.
• 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 for a condition related to heart failure within 30 days. Considerable variation across States and by race is also observed.
• Medication information: Most providers ask patients about medications prescribed by other providers, and rates are improving. However, age- and education-related disparities are observed. Moreover, few hospitals currently support the electronic exchange of medication information with ambulatory care providers outside of their own system.
• 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.

Successful Strategies From AHRQ Health Care Innovations Exchange

University of Colorado at Denver Care Transitions Interventions, CO (1833)

• Intervention: A transition coach works directly with patients and family members for 30 days after discharge to help them understand and manage their complex postdischarge needs and ensure continuity of care across settings.
• Impact: The program reduced hospital readmissions and costs.

Aurora Health Care, WI (1766)

• Intervention: A communitywide medication collaborative, involving health care consumers, providers, pharmacists, and community stakeholders, to give elderly patients and their providers the tools and education needed to assemble and verify accurate medication lists, and communicate effectively to prevent medication errors.
• Impact: The rate of accurate medication lists among patients improved from 55 to 72%.

National Priority: Overuse of Services

Some diagnostic tests, procedures, and other services are performed even when they are unlikely to benefit the patient. 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 increase costs.

The NPP's vision is "healthcare that promotes better health and affordable care by continually and safely reducing the burden of unscientific, inappropriate, and excessive care including tests, drugs, procedures, visits, and hospital stays." The key goal is that all health care organizations will continually strive to improve the delivery of appropriate patient care and substantially and measurably reduce extraneous services and treatment.

Progress Toward Key Goals

• Inappropriate medication use: Inappropriate medication use among older adults has been stable over time. No significant disparities among groups persisted over the observed study period for inappropriate medications for older adults.
• Preventable emergency department visits and hospitalizations: Preventable emergency department visits and hospitalizations have decreased gradually over the past decade. However, hospitalizations within 30 days of admission to nursing homes have not markedly changed. Significant disparities are observed for potentially avoidable hospitalization rates among different racial, ethnic, and income groups.
• Potentially harmful preventive services with no benefit: A preventive service without benefit tracked in the NHQR and NHDR is prostate-specific antigen (PSA) testing of men age 75 and over to screen for prostate cancer. During the time measured, there has been a slight increase in testing. Disparities among racial, ethnic, and income groups are observed although typically the reference groups experienced higher rates of PSA testing.

Successful Strategies From AHRQ Health Care Innovations Exchange

MaineHealth AH! (Asthma Health) Program, ME (2476)

• Intervention: Initiative uses hospital-based educators to support providers and other caregivers in providing quality asthma care. Asthma educators meet one on one with patients and their families to promote better asthma self-management.
• Impact: Asthma-related hospitalizations declined from 23.8% to 0% after the education sessions, and the percentage of children and parents who missed school or work declined from 49.4 to 7.8%.

Summa Health System Care Coordination Network, OH (2162)

• Intervention: Ensures smooth transitions between the hospitals and 37 local skilled nursing facilities. The network uses a simplified transfer form, an electronic referral system, regular meetings, and other communication tools to boost patients' discharge to a facility that meets their medical needs. The network also works to ensure smooth transitions when patients need to return to a hospital for surgery or testing.
• Impact: Program has led to fewer patients being readmitted to hospitals, lower hospital length of stay for patients transferred to skilled nursing facilities (which increased the bed capacity to an additional 130 inpatient admissions each year), and fewer cancellations of tests and surgeries for patients transferred from skilled nursing facilities.

National Priority: Access

Access to care is defined as "the timely use of personal health services to achieve the best health outcomes." The NPP's vision for the access priority is a health care system that is "accessible and affordable for all segments of the U.S. population." 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. Individuals with limited or no access to care (uninsured and underinsured people and those without a usual source of care) experience poor health outcomes, as well as worse quality of care. The NHQR and NHDR examine disparities in care related to insurance status, usual source of care, and financial barriers to care.

Progress Toward Key Goals

• Health insurance: Adults ages 18-44 were least likely to have health insurance compared with other age groups. Hispanics were least likely to have health insurance compared with other racial and ethnic groups. While the percentage of people with health insurance increased for poor people, the percentage worsened for middle-income people. The percentage of poor people and near-poor people who were uninsured all year was about four times as high as that for high-income people.
• Usual source of care: Slightly more than one-half of uninsured people had a specific source of ongoing care. Blacks and Hispanics were much less likely than Whites and non-Hispanic Whites to have a specific source of ongoing care. About one in five uninsured children did not have a usual source of care. Minority children were also less likely than White children to have a usual source of care.
• Financial burden: Individuals with private nongroup insurance were 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 were five times as likely as high-income individuals to have high health care expenses. Overall in 2007, 1 in 10 individuals reported that they were unable to receive or were delayed in receiving needed medical care, dental care, or prescription medicines due to financial or insurance reasons. Poor people were twice as likely as high-income people to report that they had this problem.

Successful Strategies From AHRQ Health Care Innovations Exchange

CarePartners, ME (1689)

• Intervention: Program matches uninsured Maine residents with local primary care physicians, specialists, and hospitals that are willing to provide free care and helps patients access free or low-cost drugs through prescription assistance programs.
• Impact: Program has helped to reduce emergency department visits, hospitalizations, and costs among participants to levels that are well below the average for Medicaid patients.

MinuteClinic, MN (1772)

• Intervention: Walk-in primary care clinics are located within retail stores. Staffed by nurse practitioners and physician assistants, clinics use electronic health records and decision-support tools to provide low-cost, evidence-based primary care services, including diagnosis and treatment of common illnesses and routine vaccinations.
• Impact: Patients are highly satisfied with the quality and convenience of services. Various studies suggest that clinic services cost less than similar services provided in other settings and conform with evidence-based guidelines.

National Priority: Health System Infrastructure

Health system infrastructure is a priority area that requires national attention. The development of organizational capacity, adoption of health information technology (IT), and provision of a sufficient, culturally competent workforce are important areas of infrastructure that are central to improving health care quality and reducing disparities. The vision for this priority is to improve the foundation of health care systems, including infrastructure for data and quality improvement, culturally diverse workforce capacity and distribution, and systems to coordinate care.

Progress Toward Key Goals

• Organizational capacity: In surveys of patient safety culture, Teamwork Within Units and Supervisor Expectations and Actions Promoting Patient Safety were the two areas that consistently received the most positive response regardless of the hospital's teaching status, ownership, geographic region, or bed size. Handoffs and Transitions and Nonpunitive Response to Error were the two areas that had the lowest percentage of positive response. This observation was consistent across hospitals, even after controlling for teaching status, ownership, size, and geographic region.
• Health IT: Currently, less than half of office-based providers have fully implemented e-prescribing. Physicians practicing in urban areas, the western United States, and larger groups had the highest adoption rates, as did younger physicians. Among hospitals, size, location, ownership, and teaching status were shown to be determinants of the adoption of e-prescribing. Larger hospitals, hospitals in urban areas, government-owned hospitals, and hospitals that were members of the Council of Teaching Hospitals (COTH) had higher rates of adoption.
• Workforce: Previous reports have examined the physician and nursing workforce; this year, the focus is on pharmacists. The pharmacy workforce is distributed in proportion to population across all four regions of the United States. In contrast, relative to population, Hispanics and non-Hispanic Blacks are underrepresented in the pharmacy workforce while non-Hispanic Whites and Asians are overrepresented.

Successful Strategies From AHRQ Health Care Innovations Exchange

HealthSpring, TN (2080)

• Intervention: Program offers financial bonuses to selected medical practices, onsite practice coordinators, and dedicated disease management support. Bonuses equal to 20% of health plan payments are awarded if physicians meet clinical care improvement goals.
• Impact: In eight practices, the program led to significant improvements in a broad range of clinical quality indicators, along with decreases in members' emergency department visits, hospitalizations, and total medical expenses.

Arizona Medical Information Exchange, AZ (2599)

• Intervention: Enables clinicians to immediately access hospital discharge, laboratory test, and medication data on specific patients from other providers, allowing them to make more fully informed clinical decisions, avoid test duplication, ensure safe medication prescribing, and provide continuity of care.
• Impact: Users report that it has led to greater efficiency, increased safety, and a reduction in costs associated with unnecessary procedures and laboratory tests.

Table H5 summarizes progress on the national priorities, categorizing each as making progress, progress lagging, or lacking sufficient data to assess.

 

Table H5. Summary of progress on national priorities

Making Progress	Progress Lagging	Need More Data
Palliative and End-of-Life Care Patient and Family Engagement	Population Health Safety Access	Care Coordination Overuse Health System Infrastructure

• Palliative and End-of-Life Care: Quality generally high; more problems with access to palliative care.
• Patient and Family Engagement: Quality generally high; most measures improving.
• Population Health: Most measures improving slowly; healthy lifestyles not improving.
• Safety: Most measures improving but more slowly than other hospital measures.
• Access: Not improving.
• Care Coordination, Overuse, Health System Infrastructure: Measures and data are limited; more information is needed to assess performance.
• Disparities: Present in all national priorities with little evidence of improvement.

Conclusion

Improving quality and reducing disparities require measurement and reporting, but these are not the ultimate goals. 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 eighth NHQR and NHDR, AHRQ stands ready to contribute to efforts that encourage and support the development of national, State, Tribal, and "neighborhood" 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. Future reports will track the success of the National Health Care Quality Strategy, the National Prevention and Health Promotion Strategy, and the National Plan for Action to End Health Disparities.

We need to improve access to care, reduce disparities, and accelerate the pace of quality improvement, especially in the areas of preventive care, chronic disease management, and safety. More data are needed to assess progress in care coordination, efficiency, and health system infrastructure. 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, we believe that 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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ⁱ The HHS Interagency Work Group represents 18 HHS agencies and offices.
ⁱⁱ The full report of this committee's recommendations can be found at https://www.ahrq.gov/research/iomqrdrreport.
ⁱⁱⁱ A list of core measures can be found in the Introduction and Methods chapter. Analyses of disparities presented in these Highlights focus on core measures and are so labeled. Other analyses use the entire measure set.
^iv Throughout these highlights and reports, unless otherwise specified, poor indicates individuals whose household income is below the Federal poverty level and high income indicates individuals whose household income is at least four times the Federal poverty level.
^v 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=
^vi Screening: Mammogram, Pap test, colonoscopy/sigmoidoscopy; late-stage breast, cervical, and colorectal cancer screening; blood pressure, cholesterol, and osteoporosis screening; and vision check. Adult immunizations: Influenza and pneumococcal vaccine among elderly, high-risk, and diabetic patients; patients hospitalized for pneumonia; and long-stay and short-stay nursing home residents. Childhood immunizations: 4 doses of diphtheria-tetanus-acellular pertussis (DTaP), 3 doses of polio, 1 dose of measles-mumps-rubella (MMR), 3 doses of Haemophilus influenzae B (Hib), and 3 doses of hepatitis B vaccines, and 1 dose of varicella vaccine.
^vii Number of children ages 19-35 months receiving first five childhood immunizations listed above.
^viii Screening, diet counseling, exercise counseling for children and obese adults; smoking cessation and treatment for alcohol and other substance abuse; car seat, booster seat, seat belt, and bicycle helmet use.
^ix Breast, colorectal, prostate, and lung cancer; HIV; suicide; and infant and maternal mortality.

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