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Measuring health care quality
- 1. Figure 1 Measuring Health Care Quality Carolyn M. Clancy, MD Director U.S. Agency for Healthcare Research and Quality for KaiserEDU.org May 2008 Return to tutorials
- 2. Figure 5 Health Care Quality Varies A LOT; NOT clearly related to $$ spent Matters – can be measured and improved Measurement science is evolving: – Structure, process and outcomes – Broad recognition that patient experience is essential component Strong focus on public reporting – Motivates providers to improve – Not yet ‘consumer friendly’ Return to tutorials
- 3. Figure 6 70 Million Americans Benefit from Quality Measurement 96% of heart attack victims were prescribed beta-blocker treatment in 2005, up from 62% in 1996* 77.7% of children enrolled in private health plans received all recommended immunizations, up 5% from 72.5% in 2004* Evidence-based guidelines from the American College of Cardiology and the American Heart Association have reduced mortality among patients who have had a heart attack * National Committee for Quality Assurance Return to tutorials
- 4. Figure 7 AHRQ’s National Reports on Quality and Disparities New editions available – New efficiency chapter – Disability data added – More on health literacy Return to tutorials
- 5. Figure 8 2007 National Reports: Some Good News, Need for Improvement The rate of improvement in quality between 1994 and 2005 was 2.3%, down from 3.1% from 1994-2004 More than 60% of the disparities in quality of care have stayed the same or worsened for Blacks, Asians and the poor, and approximately 56% of disparities have not improved for Hispanics For Blacks, Asians, Hispanics and poor populations, about half of the core measures of quality used to track access to care are improving Return to tutorials
- 6. Figure 9 Uninsurance is a Major Barrier to Reducing Disparities Uninsured individuals do Better 100% Same worse than privately 1 Worse insured individuals on almost 90% of quality 75% measures Uninsured individuals do worse than privately 50% insured individuals on all access measures 25% 0 s ity es Q ual ) c c M) A R RM 2007 National Healthcare Disparities Report, AHRQ (9C (6C Return to tutorials
- 7. Figure 10 Overall Scope Patients receive the proper diagnosis and treatment only about 55% of the time* Overall, disparities in health care quality and access are not getting smaller ** Total health care expenditures in 2006 totaled $2.1 trillion (16% of GDP) and are projected to reach $4.1 trillion (19.6% of GDP) by 2016*** * McGlynn E, Asch S, et al. The Quality of Health Care Delivered to Adults in the United States N Engl J Med 2003;348:2635-45. ** AHRQ 2007 National Healthcare Disparities Report *** National Health Expenditure Accounts Return to tutorials
- 8. Figure 11 What? Return to tutorials
- 9. Figure 12 Why? The “why” is a systems challenge: – The U.S. has extremely talented and qualified health care professionals who have not been trained to work in teams – The delivery system is fragmented, so information doesn’t follow patients as they move from hospitals to other sites of care – Payment is quality neutral Light Figure Fragment Craig A. Kraft Washington, DC Return to tutorials
- 10. Figure 13 There Are Major Opportunities for Improvement: Examples Uptake of health information technology, while still relatively slow, is gaining traction Growing focus on comparative effectiveness research HHS Secretary Michael Leavitt’s Value-Driven Health Care Initiative Downtown USA – Chartered Value Exchanges Alejandra Vernon – National Learning Network Return to tutorials
- 11. Figure 14 Emerging Methods in Comparative Effectiveness & Safety A series of 23 articles by AHRQ researchers on new approaches in comparative effectiveness methods are compiled in a special October edition of Medical Care A valuable new resource for scientists committed to advancing the comparative effectiveness and safety research The Resource Center in Oregon led the development process, helped draft the document and manage work groups, and handled public comment Source: http://effectivehealthcare.ahrq.gov/reports/med-care-report.cfm Return to tutorials
- 12. Figure 16 Role Of IT In Reducing Medical Errors Percent who say… Have you or a family member ever created your own set of medical records to ensure that you and all The coordination among the of your health care providers have different health professionals 69% all of your medical information? that they see is a problem Yes They have seen a health care 32% professional and noticed that 48% they did not have all of their medical information They had to wait or come back for another appointment 1% 32% because the provider did not Don’t have all their medical know information No 67% Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005). Return to tutorials
- 13. Figure 17 Personal Experience Have you been personally involved Did the error have serious health in a situation where a preventable consequences, minor health medical error was made in your own consequences, or no health medical care or that of a family consequences at all? member? Yes Serious health 21% consequences 34% No Minor health 65% 10% consequences 3% No health consequences 1% Don’t Know Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005). Return to tutorials
- 14. Figure 18 Guidelines & Measures More emphasis needs to be placed on what’s most important Identifying what We measure Rather Than counts and what we can determining how it can be measured Return to tutorials
- 15. Figure 19 Guidelines Measures Incentives “You can get 60% of the improvement from 15% of the change” Don Berwick Where should the busy primary care practice begin? Where should policy makers target their incentives? To changes that: Produce the greatest benefit Address the biggest quality gap Can be implemented most easily, cheaply and safely Return to tutorials
- 16. Figure 20 Reconciling Guidelines and Quality Measures Developing guidelines that address a wide range of needs… Low-Risk Patients Higher Risk Patients Return to tutorials
- 17. Figure 21 Challenges in Addressing Multiple Conditions Interactions between illnesses Multiple Interactions between medications treatments Multiple providers Tension between therapeutic goals Return to tutorials
- 18. Figure 22 Setting Priorities for Patients with Multiple Conditions Address the need for clinicians to set priorities, weighing the benefits and burdens of increasingly complex medical regiments Make sure guidelines keep up with unique issue of treating older and more frail patients Return to tutorials
- 19. Figure 23 “Patient-Centered” Guidelines If care is to be patient centered, guidelines need to reflect this goal – Quality measures must accommodate differences in: Patient values Patient preferences Return to tutorials
- 20. Figure 24 What Level of Collaboration Is Practical? Globalize the evidence, localize the decision-making Guidelines may need to reflect local values, disease burdens, priorities and resources BUT WE NEED TO SHARE… Information on how to develop clear and practical guidelines Evidence on barriers and facilitators to implementing guidelines Evidence about integration of guidelines in electronic health records Return to tutorials
- 21. Figure 25 The Goal Historically, the focus has been on structure In recent years, there has been more interest in process – the right care Tomorrow’s goal? Outcomes and end results Return to tutorials
- 22. Figure 26 The Information Exists Information on topics including guidelines, measures, incentives and outcomes are available for a wide range of uses. Included is information about: – Hospitals: Hospital Compare – Nursing Homes: Nursing Home Compare – Health Plans: National Committee for Quality Assurance – Various Health Care Organizations: Quality Check ® Return to tutorials
- 23. Figure 27 CBO Report on Comparative Effectiveness Congressional Budget Office Report: Discusses several mechanisms for organizing and funding additional comparative effectiveness research efforts Reviews the different types of research that could be pursued and the likely benefits and costs Considers the potential effects that such research could have on health care spending Return to tutorials
- 24. Figure 28 Reasons for Optimism Multiple stakeholders are working together – AQA & HQA established the Quality Alliance Steering Committee to promote quality measurement, transparency and improvement in care There is clear recognition that there should be one set of measures – A move is underfoot toward real standardization across agencies and organizations A shared sense of urgency exists on improving patient outcomes, workforce productivity and costs – The National Quality Forum is bringing stakeholders together to establish priorities for moving forward Return to tutorials
- 25. Figure 29 Future Opportunities The primary opportunity involves patients – We will not improve chronic illness care without active, informed patients – Patients as shoppers – Women are key Return to tutorials
- 26. Figure 30 This is not a Political Issue, It’s a Practical Issue Quality and access are linked Quality will be a major theme of multiple reform proposals Quality is central to getting better value for what we’re spending on health care Return to tutorials
- 27. Figure 31 21st Century Health Care Improving quality by promoting a culture of safety through Value-Driven Health Care Information-rich, patient- focused enterprises Information and Evidence is evidence transform continually refined 21st Century interactions from as a by-product of Health Care reactive to care delivery proactive (benefits and harms) Actionable information available – to clinicians AND patients – “in real time” Return to tutorials
- 28. Figure 32 Measuring Health Care Quality AHRQ Mission To improve the quality, safety, efficiency, and effectiveness of health care for all Americans AHRQ Vision As a result of AHRQ's efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest cost http://www.ahrq.gov Return to tutorials
- 29. Figure 33 Resources To learn more about health care quality, visit these websites: Agency for Heathcare Research and Quality, http://www.ahrq.gov/ Quality of Care, Reference Library, KaiserEDU.org http://www.kaiseredu.org/topics_reflib.asp?id=139&parentid=70&rID=1 The Commonwealth Fund, http://www.commonwealthfund.org/topics/topics_list.htm?attrib_id=15312 Institute for Healthcare Improvement, http://www.ihi.org/ihi National Committee on Quality Assurance, http://www.ncqa.org/ Robert Wood Johnson Foundation, http://www.rwjf.org/pr/topic.jsp?topicid=1053 Return to tutorials
Hinweis der Redaktion
- We know that health care quality varies a great deal and is not clearly related to the amount of money spent on health care. In fact, some regions where health care spending is higher have poorer quality of care. We’re getting much smarter about how to measure quality and how to improve it. Traditionally we have thought about measuring quality in terms of the structures of care (for example, the people who provide care and the facilities where that care is provided) the processes of care (such as what types of services are offered) and the outcomes…that is to say the end results that patients experience and care about. There has been a strong focus in recent years on public reporting on selected aspects of quality of care. There are many report cards nationally and at the state level on selected aspects of care. By and large, this has been a positive development. Providers have been motivated to improve. It’s very fair to say it’s not yet very easy to understand for most consumers, including me.
- For the past 10 or 15 years, health plans have been reporting voluntarily on selected aspects of quality of care. What we’ve seen from that experience is steady improvement over time. If you begin to calculate what this means we know that 96% of heart attack patients received a treatment in a form of a beta blocker drug which is associated with a subsequent decreases in overall mortality and that’s up from 62% 10 years ago. Almost 80% of children enrolled in private health plans received almost all recommended immunizations. That is up 5% from 2004 We’ve also seen that evidence-based guidelines from the professional organizations in cardiology have significantly reduced overall death rates among patients who have had a heart attack.
- Every year, the Agency for Health Care Research and Quality reports to the Congress on how we’re doing in quality of care and disparities in health care. The covers of these two reports for 2007 are shown here.
- Our most recent report showed some good news, as well as some need for improvement. For all populations and all setting of care, overall improvement went up 2.3 %, which is down from the previous year. That is to say the rate of improved slowed. However, what we saw is that 60% of disparities in care and in quality have stayed the same or gotten worse for blacks, Asians and the poor and approx. 56% of disparities have not improved for Hispanics. In addition to that, for these same populations, about half of the core measures used to track access to care are actually improving.
- It stands to reason and it’s actually true that people who don’t have insurance tend to do worse than privately insured individuals on almost 90% of quality measures. That makes a great deal of sense. We can’t get to quality of care for everyone until we get to a point where uninsurance is something we no longer have to count.
- In general terms, we know from a ground-breaking study published almost 5 years ago that using a very large and robust set of measures, overall, Americans receive proper diagnosis and treatment a little over half the time. We also know from our annual reports on disparities that disparities in health care quality and access. That is to say, differences in quality of care associated with patient race, ethnicity, income and education are not getting smaller and at the same time, what we’re spending on health care continues to increase very steadily. So we’re not getting the full return on investment in health care that we could get.
- So that’s the “what” of quality care. All of these descriptions I’m giving you a much more important question…
- … which is “why?” We’ve got terrific facilities here in the U.S., very well-trained professionals, so what’s going on here. What’s very clear from numerous reports from the Institute of Medicine and others, is that we haven’t begun to think and implement a health care delivery system. Health care delivery remains very fragmented, and what that means is that information doesn’t necessary easily follow individual patients as they move from one point of care another. And at best, how we pay for care is quality neutral. In other words, we don’t pay for value or quality, we pay for volume. If you do more things, you get more money.
- So there are major opportunities for improvement that we’re seeing on the horizon that give us cause for great optimism. It’s very clear that we’re not going to close the gap between best possible care and the care that’s routinely provided without using health IT. Now the uptake for health information technology, including computerized records, has been relatively modest but it is growing steadily over time. In addition to that, there is a growing focus and interest on what is called comparative effectiveness research understanding when there are two or more options to treat a particular condition, which options are best for which patients. And a focus on value has been a strong focus of health and human services for the past several years, working very collaboratively with the private sector.
- As more and more parts of the health delivery system make investments in health IT, there’s going to be huge opportunity to take advantage from the data that are generated that as a byproduct of providing care to give us good information about which treatments are most effective for individual patients under specific circumstances. To do that well, we’re going to need continued improvements in the methods we use to take advantage of all of these data. That has been a very strong focus of the work at AHRQ in comparative effectiveness.
- In terms of the importance of information technology, several years ago, the agency partnered with the Kaiser Family Foundation to ask patients what they saw as a result of the poor flow of information in health care and what you see here is what patients told us. Most strikingly, when asked the question, have you and your family member created your own set of medical records to ensure that you and all of your health care providers have all the right information, 1/3 of the patients said yes. We were quite stunned by that. Similarly, 70% said the coordination among different health care professionals they see is a problem. So clearly there are opportunities to improve how information can follow patients as they move from one point of care to another.
- When asked about issues related to medical errors, almost 1/3 of patients said they had been in a situation where preventable medical error was made in their own medical care or that of a family member. Of those patients, 21% said that there were serious health care consequences involved. So there’s a huge opportunity to improve patient safety as well.
- What’s very, very clear is that we need to continually improve measuring quality from an exercise that focuses on what’s easy to measure to one that focusing on what’s important. Focusing on the what are the most important priorities to improve the health of the American people.
- We know that right now there are literally hundreds of measures out there and what many professionals are struggling with is what are the most important measures. If we’re going to make policies that reward delivery of higher quality of care, which measures should we be using. What’s clear is that we need to identify which measures produce the greatest improvements in patient’s health, which addresses the greatest gaps in quality of care, and which can be the most easily implemented so they can be a part of the routine delivery on care.
- Most quality measures that are used now derive from clinical practice guidelines that are most often developed by professional organizations, medical professional organizations, nursing and so forth. It’s also clear that there needs to be a tighter link between the guidelines that specify how care should be provided under certain circumstances with the measures that tell us whether in fact those recommendations were followed. In addition to that, if you’re going to be focusing on improving care, you want to make sure the guidelines in quality measures address the patients, for whom there’s the greatest opportunity for improvement-those at the highest risk for poor quality.
- One of the growing challenges for our heath care system overall is the challenge of people with multiple chronic illnesses. And the reason this is so important as these people often, they see multiple providers, take multiple medications, which means there is a potential for not only interactions between illnesses but also potential interaction between treatments and sometimes in actually tensions between therapeutic goals. Now beyond showing you pretty overlapping circles, this becomes incredibly important and it says to me that the greatest opportunity for developing better quality measures is going to be to address the needs of complex patients with multiple chronic illnesses. To a large extent, this remains a future tense activity.
- What’s clear is that clinicians today need to set priorities for patients with multiple chronic conditions. It's very clear that if we’re going to be supporting and improving health care, we need to make sure that the guidelines and measures keep up with the needs of patients with multiple complex conditions.
- What this means in essence is the guidelines themselves need to be patient-rather than disease-focused. By that, I mean the quality measures and outcomes of guidelines need to accommodate differences in what patients value and in what they prefer. Some patients do not want surgery ever under any circumstances, if it can be avoided. Others are willing to do so if it means stop taking medicines. We have the science to be able to accommodate those preferences.
- One of the questions that comes up all the time is that, are guidelines and measures actually mandates or are they guidance to practice? What’s clear is that we have room to go in terms of make sure guidelines are actually practical tools in the delivery of care everyday. It’s also clear that guidelines need to be flexible enough so that the individual needs of patients who are very unique can be accommodated and the capacity of local communities can also be accommodated. We also know that there is a great deal of opportunity to continue to work to integrate practice guidelines into electronic health records so they’re routinely available at the point of care when clinicians and patients are making decisions together.
- The goal of measuring and assessing quality is ultimately to get to the outcomes and results that people experience and care about. Historically we focused on structure; for example, are there fire extinguishers in the hospital, do we have the right facilities in the operating room, and so forth. In the past 10-15 years there’s been a lot more focus on process. Are we doing the right thing? Where we ultimately need to get to is, are the end results what we want?
- We know right now that you can go and search for information on quality. The Hospital Compare website provides a growing array of information on quality of care in hospitals. Similarly, there are sites that give you information on nursing homes, health plans, and various other health care organizations shown here on this slide.
- Now the Congressional Budget Office, interestingly enough, as they look to the future and understand the implications of rising health care costs for the federal budget, have become increasingly interested in comparative effectiveness research because they understand if we’re going to get more value in return for our substantial investments in health care, then we need to make sure that we’re matching the science that’s available to the care that patients get.
- One of the reasons I’m optimistic, even though we have so many opportunities for improvement, is that over the past 5 years we’ve seen a growing recognition among multiple stakeholders that we can only improve quality of care if we’re using common, consistent measures that are valid and based on the best sense of science; and that we share a sense of urgency on helping patients getting the best care possible.
- The future opportunities I see on the horizon are, first and foremost, giving patients information that they can understand so they can become an effective part of the health care team as well. We will not improve chronic illness care dramatically without the help of active informed patients. We know that a proportion of patients are increasingly interested in knowing which health care facilities and practitioners are best equipped to meet their needs. We expect that women are likely to be taking the lead here more than men because they are often the people who make health care decisions on their own behalf and on behalf of their families.
- At the end of the day, this is not a political issue-it’s a highly practical issue that has great importance to all of us. We can’t get to quality of care for everyone unless we’ve got access to care for everyone. Conversely, getting access to care for everyone without knowing the quality of that care is likely to put a lot of stresses on a system that’s already stressed. It may not get us the results we want. It’s my hope and expectation that a focus on quality is likely to be a very major theme of multiple proposals to reform our health care system and it is clearly central to getting better value for what we’re spending on health care.
- At the end of the day where I think we need to be going for 21st century health care is to get to an enterprise that is information-rich but patient-focused. What I mean by that is by having information that is based on the best science available at the point of care. We can actually transform the enterprise of providing health care from one that is currently reactive to one that’s proactive that anticipates individual’s needs and actually is able to give them information about benefits and harms of potential treatments customized to their own individual circumstances. That actionable information has to be available to clinicians and patients in real time, in the same way that if you logged on to amazon.com, it give you information that is helpful to you right now, not 6 months from now. That same infrastructure can also give us the capacity to refine and improve evidence as a byproduct of care delivery so that we are continually doing a better job of making sure patients get the best care possible.
- Our job at AHRQ is to improve the safety, quality, efficiency and effectiveness in health care for all Americans. Our highest aspiration is that as results of our efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest possible cost.