Closing the Quality Gap: Revisiting the State of the Science
In 2004, the Agency for Healthcare Research and Quality (AHRQ) launched a collection of evidence reports to bring data to bear on quality improvement opportunities identified by an Institute of Medicine (IOM) study, Priority Areas for National Action: Transforming Health Care Quality.1 The AHRQ 2004 to 2007 collection—Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies—summarized the evidence on quality improvement strategies related to chronic conditions (diabetes, asthma, hypertension), practice areas (prevention of healthcare-acquired infections, antibiotic prescribing behavior) and cross-cutting priorities (care coordination).2-8
This new series of reports, Closing the Quality Gap: Revisiting the State of the Science (CQG), continues the focus on improving the quality of health care through critical assessment of relevant evidence for selected settings, interventions, and clinical conditions. As before, this series aims to assemble the evidence about effective strategies to close the "quality gap"—the difference between what is expected to work well for patients based on known evidence, and what actually happens in day-to-day clinical practice across populations of patients. For every patient who receives optimal care, the evidence suggests that on average another patient does not.9,10 This series not only expands the topic terrain beyond that covered in the initial collection, but also marshals the knowledge of eight Evidence-based Practice Centers (EPC), with the goal of applying and advancing the state of the science for improving the health care system for the benefit of all patients.
Topic Selection and Scope Development
Topics for the CQG series, reflecting identified quality improvement issues, were solicited from the various portfolios at AHRQ. Among the topics that were nominated, the following considerations factored into selection for inclusion in the series: the ability to focus and clarify the topic area; the topic's relevance to quality improvement and a systems approach; the extent to which it is amenable to systematic review; its low likelihood for duplication and/or overlap with other known or ongoing work; its relevance and potential impact in terms of improving care; and the fit of the set of topics as a whole, as a reflection of AHRQ portfolios.
Eight topics comprise the current CQG series, which will apply the methodology and framework from the first series.
- Quality improvement measurement of outcomes for people with disabilities.
- Effects of bundled payment strategies on health care spending and quality of care.
- Public reporting as a quality improvement strategy.
- Quality improvement strategies to address disparities.
- End-of-life and hospice care.
- The Patient-Centered Medical Home.
- Prevention of healthcare-associated infections (HAI).
- Comparative effectiveness of medication adherence strategies.
Eight EPCs will further develop these topics, develop separate protocols for the evidence reviews, and then systematically review the literature, consistent with the methodology outlined in the AHRQ Methods Guide.1 These evidence reviews will be developed under common principles reflected in the series' Key Questions and organizing framework outlined below. A subsequent summary report will be developed to highlight commonalities and challenges seen across the spectrum of evidence reports.
For both the previous and forthcoming CQG series, the reports target multiple audiences and associated uses. For example, policymakers may be interested in the research evidence in order to be able to prioritize quality improvement strategies and choose how best to close the quality gaps within their purview. Research funders may be most interested in the gaps in the evidence base for quality improvement so that they can set funding priorities to fill these gaps. Those at the helm of health care delivery organizations may have similar interests to policymakers in terms of identifying what works and what does not within a particular topic area. Meanwhile, clinicians and patients may find these reports useful as an introduction to the broad spectrum of approaches to improving quality of care, and as a guide to those quality improvement activities that may fall within their control. All readers of these reports may expect a deeper understanding of the nature and extent of quality gaps, as well as the systemic changes necessary to close them.
Ultimately, the overarching hope for the series remains the same as that of the earlier collection: " to become an essential source of accessible and critical analyses of the evidence supporting techniques for implementing state-of-the-art best practices (related to each topic), while stimulating ideas for ongoing quality improvement activity nationally, in individual health systems, and among individual caregivers"(p. 3).6 In addition, this CQG series will culminate with a synthetic report on lessons learned that cut across the topics, with the goal of describing the state of the science of quality improvement, and the implications for each of the targeted audiences.
The IOM National Priorities Committee's work that catalyzed the earlier CQG series included development of specific criteria to vet and ultimately report on topics where actionable improvement could be anticipated in the near future with evidence-backed action.1 Each EPC team will consider scope options in light of specific prioritization criteria which were described by the earlier IOM Committee, and which have been extended based on additional considerations relevant to the current health care delivery system:
- Impact: What opportunities exist for a sizable improvement in health and well-being (the quality gap)? What are the economic implications?
- Improvability: What strategies might be expected to reduce quality gaps and value of care delivered?
- Inclusivity: What is the relevance of the topic to patients, conditions, or settings that are underrepresented in research?
Adding to these considerations, EPC teams will consider the "sweet spot" for their topic, where an evidence review has a reasonable expectation of netting useful information for specified stakeholders who have the power to act upon the information gleaned in an effort to close the identified quality gap. With this aim in mind, they will also identify likely audiences for their topic report.
Key Questions for the CQG Series
Figure 1 summarizes the sequence of key questions (KQ) for the series, which will provide guidance about topic scope, technical expert panel composition, analysis, and reporting:
KQ1 for the Series: What is the quality gap (or gaps) targeted by this review, and how might each gap be approached to lead to improvements?
KQ2 for the Series: Who are the likely stakeholders who could act upon the gap, and what evidence will they need? What are the likely level(s) for implementation of results from the topic report? Consider macro level (e.g., public policymaking, markets, or organizational policymaking) and micro level (e.g., clinician, patient) audiences, and their potential leverage in using the evidence.
KQ 3 for the Series: From an initial exploration of the potential literature, what is the state of the science for the topic area and gap? What populations, interventions, comparators, outcomes, timing, and setting ("PICOTS") are relevant to the topic? How has the topic been studied in terms of concepts (e.g., logic models, relevant theories), methods (e.g., primary data collection study designs available), and context-sensitivity?
Each topic for the series is broad and requires choices among numerous scope options. The purpose of the series' Key Questions is to help each EPC develop a full range of possibilities and then select a reasonable set of Key Questions for a given topic. As specified in Figure 1, the theoretical ways to address a quality gap build from a quote from Victor Fuchs that raises the idea of "3 I's": According to Fuchs, real reform "requires changes in the organization and delivery of care that provide physicians with the information, infrastructure, and incentives they need to improve quality and control costs."12 These leverage points for improvement apply beyond the physician and include other clinicians, systems managers, and patients themselves. As a result, the following three general approaches are hypothesized to address quality gaps (KQ1):
- Measuring quality: gathering information/data on quality.
- Influencing quality: creating incentives for better quality.
- Improving quality: implementing changes to infrastructure, processes, and other elements of the delivery system. (Often, interventions in this category are aimed at changing clinician or organizational behavior at a local level.)
For each topic, these approaches may be matched to the applicable target audience(s) (KQ2) at the level(s) of implementation expected, as described in Figure 1. Further, the review of literature about each topic will build from the state of the science (KQ3) available on the specific strategies to implement the general approach.
Organizing Framework for the Closing the Quality Gap Series
An overarching organizing framework (Figure 2) for all of the topics was developed to serve as a tool to specify all of the potentially relevant areas (the boxes in Figure 2) for a topic, and then assist in making decisions about a practical scope that will limit the boxes covered. This framework is also intended to convey the relationships among the topics, and support drawing cross-cutting lessons for quality improvement science, which will be outlined in the summary report.
1. Institute of Medicine (U.S.). Committee on Identifying Priority Areas for Quality Improvement. Adams K, Corrigan J. Priority areas for national action: transforming health care quality. Washington, D.C.: National Academies Press; 2003.
2. Bravata DM, Sundaram V, Lewis R, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 5—Asthma Care. Technical Review 9 (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center). AHRQ Publication No. 04-005101-5. Rockville, MD: Agency for Healthcare Research and Quality. 2007.
3. McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7—Care Coordination. Technical Review 9 (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center). AHRQ Publication No. 04(07)-0051-7. Rockville, MD: Agency for Healthcare Research and Quality. 2007.
4. Ranji SR, Shetty K, Posley KA, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 6—Prevention of Healthcare-Associated Infections. Technical Review 9. (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center). AHRQ Publication No. 04(07)-005101-6. Rockville, MD: Agency for Healthcare Research and Quality. 2007.
5. Ranji SR, Steinman MA, Shojania KG, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 4—Antibiotic Prescribing Behavior. Technical Review 9. (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center). AHRQ Publication No. 04-005101-4. Rockville, MD: Agency for Healthcare Research and Quality. 2006.
6. Shojania KG, McDonald KM, Wachter R, Owens DK. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1—Series Overview and Methodology. Technical Review 9. (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center). AHRQ Publication No. 04-005101. Rockville, MD: Agency for Healthcare Research and Quality. 2004.
7. Shojania KG, Ranji SR, Shaw LK, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 2—Diabetes Mellitus Care. Technical Review 9. (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center). AHRQ Publication No. 04-005101-2. Rockville, MD: Agency for Healthcare Research and Quality. 2004.
8. Walsh J, McDonald KM, Shojania KG, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 3—Hypertension Care. Technical Review 9. (Contract No. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center). AHRQ Publication No. 04-005101-3. Rockville, MD: Agency for Healthcare Research and Quality. 2005.
11. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Agency for Healthcare Research and Quality, 2011. Accessed Jan 24, 2011, at http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=318.