2014 National Healthcare Quality & Disparities Report

National Quality Strategy

National Quality Strategy

Mandated by the Affordable Care Act, the NQS was developed through a transparent and collaborative process with input from a range of stakeholders. More than 300 groups, organizations, and individuals, representing all sectors of the health care industry and the general public, provided comments. Based on this input, the NQS established a set of three overarching aims that builds on the Institute for Healthcare Improvement's Triple Aim®.

These aims are consistent with and supportive of HHS's delivery system reform initiatives to achieve better care, smarter spending, and healthier people through incentives, information, and the way care is delivered. The aims are used to guide and assess local, state, and national efforts to improve health and the quality of health care:

  • Better Care: Improve overall quality by making health care more patient centered, reliable, accessible, and safe.
  • Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher quality care.
  • Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

To advance these aims, the NQS focuses on six priorities that address the most common health concerns that Americans face:

  • Patient Safety: Making care safer by reducing harm caused in the delivery of care.
  • Person-Centered Care: Ensuring that each person and family is engaged as partners in their care.
  • Care Coordination: Promoting effective communication and coordination of care.
  • Effective Treatment: Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
  • Healthy Living: Working with communities to promote wide use of best practices to enable healthy living.
  • Care Affordability: Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

To align with NQS, stakeholders can use nine levers to align their core business or organizational functions to drive improvement on the aims and priorities. Each of the levers represents a core business function, resource, or action that stakeholders can use to align to the NQS: Measurement and Feedback; Public Reporting; Learning and Technical Assistance; Certification, Accreditation, and Regulation; Consumer Incentives and Benefit Designs; Payment; Health Information Technology; Innovation and Diffusion; and Workforce Development.

Each year, a progress report is produced. The 2014 NQS progress report (http://www.ahrq.gov/workingforquality/reports/annual-reports/nqs2014annlrpt.htm) features Priorities in Action, which highlights promising and transformative quality improvement programs and spotlights organizations that have adopted the NQS as a framework for quality improvement. To complement this activity, the 2014 QDR begins tracking progress along each of the six NQS priorities.

In this section, an illustrative measure tracked by the QDR is presented for each priority. Information on trends and disparities is also shown for each priority with sufficient data to summarize. Tracking of all QDR measures will be included in a series of statistical chartbooks that will be posted online after the release of the 2014 QDR.

NQS: Measures of Patient Safety improved, led by a 17% reduction in hospital-acquired conditions.

Hospital-acquired conditions have been targeted for improvement by the CMS Partnership for Patients initiative, a major public-private partnership working to improve the quality, safety, and affordability of health care for all Americans. As a result of this and other federal efforts, such as Medicare's Quality Improvement Organizations and the HHS National Action Plan to Prevent Health Care-Associated Infections, as well as the dedication of practitioners, the general trend in patient safety is one of improvement.

Distribution of hospital-acquired conditions based on national rates per 1,000 hospital adult discharges, 2010-2013

Chart shows distribution of hospital-acquired conditions based on national rates per 1,000 hospital adult discharges. Go to table below for details.

Hospital-Acquired Condition 2010 2011 2012 2013
Adverse Drug Events 49.5 48.7 41.9 40.3
Catheter-Associated Urinary Tract Infections 12.2 11.3 10.6 8.8
Central Line-Associated Bloodstream Infections 0.55 0.52 0.51 0.28
Falls 7.9 7.8 7.2 7.2
Obstetric Adverse Events 2.5 2.5 2.4 2.4
Pressure Ulcers 40.3 40.4 39.4 32.5
Surgical Site Infections 2.9 2.5 2.5 2.4
Ventilator-Associated Pneumonia 1.2 1.1 1.0 1.1
Venous Thromboembolism 0.85 0.72 0.99 0.71
All Other Hospital-Acquired Conditions 27.3 26.7 25.7 25.1
Total 145 142 132 121

 

Source: Agency for Healthcare Research and Quality, Medicare Patient Safety Monitoring System, 2010-2013; Centers for Disease Control and Prevention, National Healthcare Safety Network, 2010-2013; and Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2010-2012.

Trends:

  • From 2010 to 2013, the overall rate of hospital-acquired conditions declined from 145 to 121 per 1,000 hospital discharges.
  • This decline is estimated to correspond to 1.3 million fewer hospital-acquired conditions, 50,000 fewer inpatient deaths, and $12 billion savings in health care costs.3
  • Large declines were observed in rates of adverse drug events, healthcare-associated infections, and pressure ulcers.
  • About half of all Patient Safety measures tracked in the QDR improved.
  • One measure, admissions with central line-associated bloodstream infections, improved quickly, at an average annual rate of change above 10% per year.
  • One measure, postoperative physiologic and metabolic derangements during elective-surgery admissions,got worse over time

Disparities Trends (Table 1)

  • Black-White differences in four Patient Safety measures were eliminated.
  • Asian-White differences in admissions with iatrogenic pneumothorax grew larger.

NQS: Measures of Person-Centered Care improved steadily, especially for children.

Effective and respectful provider-patient communication is at the core of person-centered care. The 2013 enhanced National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53) provides a framework to help organizations deliver services that are responsive to patients' diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers, by race/ethnicity and income, 2002-2012

Chart shows children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers, by race/ethnicity. Go to table below for details.   Chart shows children who had a doctor's office or clinic visit in the last 12 months whose parents reported poor communication with health providers, by income. Go to table below for details.

Upper Chart:

Race / Ethnicity 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Total 6.7 6.1 5.7 5.5 4.8 4.9 4.4 4.9 4.0 3.8 3.7
White 5.6 4.8 4.8 4.4 4.2 4.2 4.0 3.6 3.1 2.7 3.3
Black 7.1 7.5 6.3 5.7 4.8 5.1 4.0 5.1 4.3 5.2 4.1
Hispanic 10.2 8.4 7.9 8.8 7.0 6.8 5.8 7.4 5.9 5.1 4.8



Lower Chart:

Income 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
High Income 3.4 3.3 3.0 2.5 2.6 3.4 3.6 2.2 1.7 1.6 1.7
Middle Income 6.2 5.4 5.4 5.3 4.4 4.3 3.1 4.7 3.3 3 3.4
Low Income 9.3 8.8 7.5 7.3 6.8 6.3 5.6 6.1 6.5 4.3 4.2
Poor 11.3 9.5 9.1 9.3 7.7 7.5 6.8 8.0 5.9 7 6.4

 

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.

Note: Parents who report that their child's health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.

Trends:

  • From 2002 to 2012, the percentage of children whose parents reported poor communication significantly decreased overall and among all racial, ethnic, and income groups.
  • Almost all Person-Centered Care measures tracked in the QDR improved; no measure got worse.

Disparities:

In almost all years, the percentage of children whose parents reported poor communication with their health providers was:

  • Higher for Hispanics and Blacks compared with Whites.
  • Higher for poor, low-income, and middle-income families compared with high-income families.

Disparities Trends (Table 1):

  • Asian-White differences in two measures related to communication were eliminated.
  • Four Person-Centered Care disparities related to hospice care grew larger.

NQS: Measures of Care Coordination improved as providers enhanced discharge processes and adopted health information technologies.

Effective care coordination requires explicit attention to the many settings in which patients receive care as well as the infrastructure to support information exchange across these sites. The Community-based Transitions Program coordinates discharge from hospitals to other care settings and seeks to reduce hospital readmissions. Care coordination also is facilitated by the meaningful use of health information technologies. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 gives HHS the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health information technology, including electronic health records and private and secure electronic health information exchange.

Hospital patients with heart failure who were given complete written discharge instructions, by sex and race/ethnicity, 2005-2012

Chart shows hospital patients with heart failure who were given complete written discharge instructions, by sex. Go to table below for details.   Chart shows hospital patients with heart failure who were given complete written discharge instructions, by race/ethnicity. Go to table below for details.

Upper Chart:

Sex 2005 2006 2007 2008 2009 2010 2011 2012
Total 57.4 68.7 76.0 82.0 86.4 89.7 92.0 93.5
Male 58.3 69.6 76.8 82.7 86.9 90.0 92.3 93.7
Female 56.4 67.8 75.1 81.3 85.9 89.4 91.7 93.3



Lower Chart:

Race / Ethnicity 2005 2006 2007 2008 2009 2010 2011 2012
White 58.6 69.5 76.6 82.2 86.3 89.6 91.9 93.4
Black 56.7 68.1 75.8 81.7 86.4 89.8 92.4 93.9
Hispanic 53.0 65.6 72.6 81.8 88.2 89.8 92.0 93.2
AI/AN 48.2 59.7 65.0 69.8 76.3 81.9 84.1 86.1
Asian 49.1 61.5 74.6 83.7 87.1 91.6 92.9 94.1

 

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2012.

Note: Measure is labeled "Heart failure patients given discharge instructions" on Hospital Compare.

Trends:

  • From 2005 to 2012, the percentage of hospital patients with heart failure who were given complete written discharge instructions increased overall, for both sexes, and for all racial/ethnic groups.
  • There are few measures to assess trends in Care Coordination.

Disparities:

  • In all years, the percentage of hospital patients with heart failure who were given complete written discharge instructions was lower among American Indians and Alaska Natives compared with Whites.

NQS: Many measures of Effective Treatment achieved high levels of performance, led by measures publicly reported by CMS on Hospital Compare.

The Centers for Medicare & Medicaid Services began publicly reporting measures of hospital quality on the Hospital Compare Web site in 2005. CMS Compare Web sites are now available to assess performance of physicians, nursing homes, home health agencies, and dialysis facilities. Concurrent with public reporting, many CMS measures achieved overall performance levels of 95% or better. At this level, additional improvement is limited, so these measures are no longer reported in the QDR.

Hospital patients with heart attack given percutaneous coronary intervention within 90 minutes of arrival, by sex and race/ethnicity, 2005-2012

Chart shows hospital patients with heart attack given percutaneous coronary intervention within 90 minutes of arrival, by sex. Go to table below for details.   Chart shows hospital patients with heart attack given percutaneous coronary intervention within 90 minutes of arrival, by race/ethnicity. Go to table below for details.

Upper Chart:

Sex 2005 2006 2007 2008 2009 2010 2011 2012
Total 42.1 53.8 71.8 81.3 87.5 91.1 93.7 95.1
Male 44.4 56.2 73.6 82.7 88.7 92.0 94.4 95.6
Female 36.3 47.8 67.1 77.4 84.1 88.6 91.9 93.7



Lower Chart:

Race / Ethnicity 2005 2006 2007 2008 2009 2010 2011 2012
White 43.4 55.1 73.0 82.1 88.1 91.7 94.2 95.4
Black 29.1 42.2 62.2 74.3 81.5 86.3 90.7 93.0
Hispanic 33.8 46.7 66.4 77.5 85.1 89.0 92.1 93.2
AI/AN 43.2 53.5 66.2 69.3 84.7 89.8 89.7 91.8
Asian 39.6 49.8 69.5 80.9 87.2 91.3 93.3 95.4

 

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2012.

Note: Measure is labeled "Heart attack patients given PCI within 90 minutes of arrival" on Hospital Compare.

Trends:

  • From 2005 to 2012, the percentage of hospital patients with heart attack given percutaneous coronary intervention within 90 minutes of arrival increased overall, for both sexes, and for all racial/ethnic groups.
  • In 2012, the overall rate exceeded 95%; the measure will no longer be reported in the QDR.
  • Eight other Effective Treatment measures achieved overall performance levels of 95% or better this year, including five measures of pneumonia care and two measures of HIV care.
  • About half of all Effective Treatment measures tracked in the QDR improved.
  • Two measures, both related to cancer treatment, improved quickly, at an average annual rate of change above 10% per year.
  • Three measures related to management of chronic diseases got worse over time.

Disparities:

  • As rates topped out, absolute differences between groups became smaller. Hence, disparities often disappeared as measures achieved high levels of performance.

Disparities Trends (Table 1):

  • Asian-White differences in three chronic disease management measures were eliminated but income-related disparities in two measures related to diabetes and joint symptoms grew larger.

NQS: Healthy Living improved in about half of the measures followed, led by selected adolescent vaccines from 2008 to 2012.

Promoting healthy lifestyles that prevent disease and disability is better for people and more efficient than treating conditions after organ damage has been done.

Adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine, by residence location and income, 2008-2012

Chart shows adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine, by residence location. Go to table below for details.   Chart shows adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine, by income. Go to table below for details.

Upper Chart:

Location 2008 2009 2010 2011 2012
Total 38.6 51.8 59.5 69.0 74.4
Metropolitan 42.1 54.9 63.3 72.8 76.6
Nonmetropolitan   35.1 39.6 54.0 62.6



Lower Chart:

Income 2008 2009 2010 2011 2012
Poor 33.9 52.0 60.2 69.4 72.6
Low income 31.9 44.5 52.6 65.4 71.2
Middle income 36.3 47.5 54.7 63.8 71.7
High income 46.8 60.0 66.2 75.2 79.9

 

Source: Centers for Disease Control and Prevention, National Center for Immunizations and Respiratory Diseases and National Center for Health Statistics, National Immunization Survey—Teen, 2008-2012.

Trends:

  • From 2008 to 2012, the percentage of adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine increased overall, for residents of both metropolitan and nonmetropolitan areas, and for all income groups.
  • About half of all Healthy Living measures tracked in the QDR improved.
  • Four measures, all related to adolescent immunizations, improved quickly, at an average annual rate of change above 10% per year (meningococcal vaccine ages 13-15 and ages 16-17; tetanus-diphteria-acellular pertussis vaccine ages 13-15 and ages 16-17).
  • Two measures related to cancer screening got worse over time.

Disparities:

  • Adolescents ages 16-17 in nonmetropolitan areas were less likely to receive meningococcal conjugate vaccine than adolescents in metropolitan areas in all years.
  • Adolescents in poor, low-income, and middle-income households were less likely to receive meningococcal conjugate vaccine than adolescents in high-income households in almost all years.

Disparities Trends (Table 1):

  • Four disparities related to child and adult immunizations were eliminated.
  • Black-White differences in two Healthy Living measures grew larger.

NQS: Measures of Care Affordability worsened from 2002 to 2010 and then leveled off.

From 2002 to 2010, prior to the Affordable Care Act, care affordability was worsening. Since 2010, the Affordable Care Act has made health insurance accessible to many Americans with limited financial resources.

People unable to get or delayed in getting needed medical care, dental care, or prescription medicines due to financial or insurance reasons, by insurance and income, 2002-2012

Chart shows people unable to get or delayed in getting needed medical care, dental care, or prescription medicines due to financial or insurance reasons, by income. Go to table below for details.   Chart shows people unable to get or delayed in getting needed medical care, dental care, or prescription medicines due to financial or insurance reasons, by income. Go to table below for details.

Upper Chart:

Insurance 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Total 61.2 63.7 63.8 65.6 65.2 64.6 65.2 69.2 71.4 68.7 69.3
Uninsured 86.2 90.3 88.6 91.1 91.5 89.7 90.0 92.2 89.9 91.4 93.3
Public Only 65.6 69.6 72.0 72.7 73.5 69.3 72.6 73.3 76.7 73.5 72.1
Any Private 54.0 54.6 54.4 57.2 56.7 55.7 55.5 59.4 63.6 59.0 61.5



Lower Chart:

Income 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Poor 73.4 77.6 77.5 78.0 78.9 76.3 78.3 79.2 81.8 78.4 77.8
Low Income 73.2 74.4 75.5 79.6 78.1 72.5 76.6 76.1 81.2 77.8 75.7
Middle Income 64.3 62.5 66.4 65.3 66.4 68.6 69.0 73.3 71.2 71.8 68.4
High Income 40.4 44.9 39.2 44.2 44.8 45.9 44.0 48.8 53.9 47.1 56.0

 

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2012.

Trends:

  • From 2002 to 2010, the overall percentage of people who were unable to get or were delayed in getting needed medical care, dental care, or prescription medicines and who indicated a financial or insurance reason rose from 61.2% to 71.4%.
  • From 2002 to 2010, the rate worsened among people with any private insurance and among people from high- and middle-income families; changes were not statistically significant among other groups.
  • After 2010, the rate leveled off, overall and for most insurance and income groups.
  • Data from the Commonwealth Fund Biennial Health Insurance Survey indicate that cost-related problems getting needed care fell from 2012 to 2014 among adults.4
  • Another Care Affordability measure, people without a usual source of care who indicate a financial or insurance reason for not having a source of care, also worsened from 2002 to 2010 and then leveled off.
  • There are few measures to assess trends in Care Affordability.

Disparities:

  • In all years, the percentage of people unable to get or delayed in getting needed medical care, dental care, or prescription medicines who indicated a financial or insurance reason for the problem was:
    • Higher among uninsured people and people with public insurance compared with people with any private insurance.
    • Higher among poor, low-income, and middle-income families compared with high-income families.

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Page last reviewed April 2015
Page originally created April 2015
Internet Citation: National Quality Strategy. Content last reviewed April 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/key3.html