2007 2007 National Healthcare Quality Report:National Healthcare Quality Report:

Overview of FindingsOverview of Findings

AcademyHealth Annual Research MeetingJune 10, 2008

Jeff Brady, M.D., M.P.H.Jeff Brady, M.D., M.P.H.Acting Director, US National Healthcare ReportsActing Director, US National Healthcare Reports

Presentation OutlinePresentation Outline

The National Healthcare Reports: The National Healthcare Reports: Background and PurposeBackground and Purpose

What’s New and Findings What’s New and Findings

– 2007 NHQR 2007 NHQR

– 2007 NHDR 2007 NHDR

2007 State Snapshots2007 State Snapshots

The National Healthcare Reports: The National Healthcare Reports: Background and PurposeBackground and Purpose

Origin of the NHQR / NHDROrigin of the NHQR / NHDR

Beginning in fiscal year 2003, Beginning in fiscal year 2003, the HHS Secretary, the HHS Secretary, acting through the Director, acting through the Director, shall submit to Congress: shall submit to Congress:

NHQRNHQR an annual report on an annual report on national trends in the national trends in the quality of health care quality of health care provided to the provided to the American people.American people.

NHDR to track NHDR to track prevailing disparities in prevailing disparities in health care delivery as health care delivery as it relates to racial factors it relates to racial factors and socioeconomic factors and socioeconomic factors in priority populations.in priority populations.

Mandated by CongressMandated by Congress in in Healthcare Research and Healthcare Research and Quality Act (PL. 106-129)Quality Act (PL. 106-129)

NHQR and NHDR GoalsNHQR and NHDR Goals

Provide a Provide a snapshotsnapshot of health care delivery of health care delivery

– 41 core measures of quality41 core measures of quality

– 211 total measures211 total measures

Indicate the Indicate the biggest gapsbiggest gaps in care in care

Show national and State Show national and State trendstrends

Suggest how we can reach our Suggest how we can reach our goalsgoals

Promote Promote alignment of measuresalignment of measures across public across public and private quality initiativesand private quality initiatives

NHQR and NHDR FrameworkNHQR and NHDR Framework

Consumer Consumer Perspectives on Perspectives on

Health Care NeedsHealth Care Needs Components of Health Care QualityComponents of Health Care Quality

   SafetySafety EffectivenessEffectivenessPatient Patient

CenterednessCenteredness TimelinessTimeliness

Staying healthyStaying healthy            

Getting betterGetting better            

Living with illness Living with illness or disabilityor disability            

Coping with the Coping with the end-of-lifeend-of-life            

Source:Source: Institute of Medicine Committee. “Envisioning the National Health Care Quality Institute of Medicine Committee. “Envisioning the National Health Care Quality Report,” 2001Report,” 2001

Relationship Between Relationship Between NHQR and NHDRNHQR and NHDR

NHQRNHQR NHDRNHDRSnapshot of Snapshot of qualityquality of of health care in Americahealth care in America

Snapshot of Snapshot of disparitiesdisparities in health care in Americain health care in America

QualityQuality Quality Quality + access+ accessSafety, effectiveness, Safety, effectiveness, timeliness, patient timeliness, patient centeredness, centeredness, efficiencyefficiency

Safety, effectiveness, Safety, effectiveness, timeliness, patient timeliness, patient centeredness, centeredness, + equity+ equity

Variation across Variation across StatesStates

Variation across Variation across populationspopulations

Content and OrganizationContent and Organization2007 NHQR/NHDR 2007 NHQR/NHDR

Effectiveness Effectiveness – Cancer Cancer – Diabetes Diabetes – End Stage Renal Disease (ESRD) End Stage Renal Disease (ESRD) – Heart Disease Heart Disease – HIV and AIDS HIV and AIDS – Maternal and Child Health Maternal and Child Health – Mental Health and Substance AbuseMental Health and Substance Abuse– Nursing Home, Home Health, Nursing Home, Home Health,

and Hospice Care and Hospice Care Patient SafetyPatient Safety Timeliness Timeliness Patient Centeredness Patient Centeredness Efficiency*Efficiency* Access to Health Care Access to Health Care Priority PopulationsPriority Populations

NHQRNHDR

*NHQR only

NHQR/DR Data SourcesNHQR/DR Data Sources

Provider/facility sample surveysCDC,NCHS – NAMCSCDC,NCHS – NHAMCSCDC,NCHS – NHDSCMS – ESRD CPMPCSHSC – Community Tracking Study Physician Survey

Population sample surveysAHRQ – MEPSAHRQ – CAHPSCDC – BRFSSCDC,NCHS – National Asthma SurveyCDC,NCHS – NHANESCDC,NCHS – NHISCDC,NCHS – National Immunization Survey CMS – MCBSHRSA – Healthy Schools Healthy Communities User Visit SurveyNHPCO – Family Evaluation of Hospice CareSAMHSA – NSDUHU.S. Census Bureau – U.S. Census

Surveillance and vital statistics CDC – NPCRCDC – HIV/AIDS Surveillance SystemCDC – TB Surveillance SystemCDC,NCHS – NVSSNIH – SEER

Organizational data systems AHRQ – HCUPCMS – Hospital CompareCMS – Medicare Patient Safety Monitoring SystemCMS – OASISCMS – Nursing Home Minimum Data SetCMS – QIOHIVRN – 2001-2003IHS – NPIRSNCQA – HEDISNIH – USRDSSAMHSA – TEDS

2007 National Healthcare Quality 2007 National Healthcare Quality and Disparities Reportsand Disparities Reports

Released March 3rd

2007 NHQR 2007 NHQR What’s New What’s New

andandFindingsFindings

New in the 2007 NHQRNew in the 2007 NHQR

Chapter 2, EffectivenessChapter 2, Effectiveness

– Cancer: Cancer treatment measuresCancer: Cancer treatment measures

– HIV and AIDS: HIV testing measuresHIV and AIDS: HIV testing measures

– Nursing Home and Home Health: Pain Nursing Home and Home Health: Pain management for nursing home residentsmanagement for nursing home residents

Chapter 6, Efficiency Chapter 6, Efficiency

Annual Median Rate of Annual Median Rate of ChangeChange

The annual median The annual median rate of change rate of change from 1994 to from 1994 to 2005 was 2.3%2005 was 2.3%

From 2000 to 2005, From 2000 to 2005, the annual median the annual median rate of change was rate of change was 1.5%1.5%

n=number of measures

Improvement in Core Improvement in Core MeasuresMeasures

Most measures show some Most measures show some improvement improvement

Of the 41 core measures reported:Of the 41 core measures reported:

– 27 improved27 improved

– 6 declined6 declined

– 6 showed no change6 showed no change

Variation in Health Care Variation in Health Care QualityQuality

Variation in quality of health care across the Variation in quality of health care across the Nation is decreasing, but not for all measuresNation is decreasing, but not for all measures

More measures have seen progress in terms More measures have seen progress in terms of decreases in variation between the best of decreases in variation between the best performing State and the worst performing performing State and the worst performing State between 2000 and 2005:State between 2000 and 2005:

– Variability Variability decreaseddecreased for 28 measures for 28 measures

– Variability Variability increasedincreased for 13 measures for 13 measures

– There was There was no changeno change for 18 measures for 18 measures

Example of Decreased Example of Decreased VariationVariation

Heart attack patients given smoking cessation counseling while Heart attack patients given smoking cessation counseling while hospitalizedhospitalized

Source:Source: CMS, Medicare Quality Improvement Organization Program CMS, Medicare Quality Improvement Organization Program

Patient SafetyPatient Safety

The safety of The safety of health care health care has improved has improved since 2000, since 2000, but more but more needs to be needs to be donedone

n=number of measures

Patient Safety Improvements Patient Safety Improvements

Areas where significant attention has been Areas where significant attention has been concentrated, such as concentrated, such as appropriate timing of appropriate timing of antibiotics for surgeryantibiotics for surgery and and reducing reducing medication errorsmedication errors, have shown progress:, have shown progress:

– Over 30% more patients received appropriate Over 30% more patients received appropriate timing for antibiotics before and after surgery in timing for antibiotics before and after surgery in 2005 than in 20042005 than in 2004

– From 2004 to 2005, adverse drug events from From 2004 to 2005, adverse drug events from warfarin and low-molecular-weight heparin warfarin and low-molecular-weight heparin declined 21% and 28%, respectivelydeclined 21% and 28%, respectively

– Deaths following complications of care declined Deaths following complications of care declined 2.4% from 1994 to 20042.4% from 1994 to 2004

Disparities Report Findings Disparities Report Findings

Disparities in Disparities in health care health care qualityquality are are staying the staying the same or same or increasing increasing

n=number of core measures

2007 State Snapshots2007 State Snapshots

http://statesnapshots.ahrq.gov

State Snapshots -- OverviewState Snapshots -- Overview

Summary Summary performance performance metersmeters

Individual Individual measuresmeasures

Focus on clinical Focus on clinical issuesissues

State contextState context

Methods & Methods & Interpretation Interpretation GuidesGuides

Web tool for State policymakers to viewWeb tool for State policymakers to viewNHQR/NHDR health care quality, State-by-State:NHQR/NHDR health care quality, State-by-State:

State Snapshots: State Snapshots: Summary Performance MetersSummary Performance Meters

Summary meters – a State’s performance Summary meters – a State’s performance compared to its region and the nation for:compared to its region and the nation for:

– All Available MeasuresAll Available Measures

– Care by Clinical Care by Clinical AreaArea Cancer Cancer DiabetesDiabetes Heart DiseaseHeart Disease Maternal and Child Maternal and Child

Health Health Respiratory DiseaseRespiratory Disease Clinical preventive Clinical preventive

servicesservices

– Types of CareTypes of Care Preventive Preventive Acute Acute ChronicChronic

– Settings of Care Settings of Care HospitalHospital Ambulatory Ambulatory Nursing Home Nursing Home

Home HealthHome Health

Summary Performance Meters: Summary Performance Meters: State Compared to Region or NationState Compared to Region or Nation

Click meter to view data

State Snapshots:State Snapshots: What’s New for 2007 What’s New for 2007

State State DashboardsDashboards– All of a State’s summary metersAll of a State’s summary meters

Focus on Focus on Healthy People 2010Healthy People 2010 Table Table– State’s performance on goalsState’s performance on goals

Focus on Focus on Clinical Preventive ServicesClinical Preventive Services Meter Meter– State’s performance on recommended servicesState’s performance on recommended services

Contextual DialsContextual Dials of State’s environment: of State’s environment: – Demographics (age, income, race, education) Demographics (age, income, race, education) – Population health status (obesity, mental health)Population health status (obesity, mental health)– Health care resources (specialist physicians, Health care resources (specialist physicians,

admission rate, HMOs)admission rate, HMOs)

State Dashboard: Performance State Dashboard: Performance Meters all in one PlaceMeters all in one Place

• Click meter to view metrics compared to all states

State Performance on State Performance on Healthy People 2010 GoalsHealthy People 2010 Goals

State Performance in State Performance in Clinical Preventive Services Clinical Preventive Services

State Contextual Factors State Contextual Factors

• Click dial to view data

NHQR/NHDR NHQR/NHDR Resources & ContactsResources & Contacts

http://www.ahrq.gov/qual/qrdr07.htmhttp://www.ahrq.gov/qual/qrdr07.htm

Request Reports: Request Reports: 1-800-358-9295 1-800-358-9295

ahrqpubs@ahrq.govahrqpubs@ahrq.gov Jeff Brady, Jeff Brady, Jeff.Brady@ahrq.hhs.govJeff.Brady@ahrq.hhs.gov

Acting Director, National Healthcare ReportsActing Director, National Healthcare Reports

Lead Staff, NHQR Lead Staff, NHQR

Karen Ho, Karen Ho, Karen.Ho@ahrq.hhs.govKaren.Ho@ahrq.hhs.gov

Lead Staff, NHDR Lead Staff, NHDR

Ernest Moy,Ernest Moy, Ernest.Moy@ahrq.hhs.govErnest.Moy@ahrq.hhs.gov

NHQR/NHDR TeamNHQR/NHDR Team

EXTRA SLIDES FOLLOWEXTRA SLIDES FOLLOW

Postoperative ComplicationsPostoperative Complications

From 2003 to 2005, From 2003 to 2005, the percentage of surgical patients…the percentage of surgical patients…

With With postoperative pneumoniapostoperative pneumonia or or a a venous thromboembolic eventvenous thromboembolic event did NOT change significantly did NOT change significantly

Who developed a Who developed a urinary tract urinary tract infectioninfection increased slightly; increased slightly; however, it should be noted that this however, it should be noted that this measure changed in 2005 to measure changed in 2005 to include only patients with catheter-include only patients with catheter-associated urinary tract infection. associated urinary tract infection.

2007 National Healthcare Quality Report, Source: CMS, Medicare Patient Safety Monitoring System

Adverse Drug Events Adverse Drug Events

In 2005, adverse drug events In 2005, adverse drug events in the hospital related to some in the hospital related to some frequently used medications …frequently used medications …

Ranged from 6.89% of Medicare Ranged from 6.89% of Medicare patients who received patients who received warfarinwarfarin to to 13.0% of Medicare patients who 13.0% of Medicare patients who received received intravenous heparinintravenous heparin. .

The rates of adverse events The rates of adverse events associated with associated with low-molecular-low-molecular-weight heparinweight heparin and and warfarinwarfarin decreased significantly between decreased significantly between 2004 and 2005. 2004 and 2005.

2007 National Healthcare Quality Report, Source: CMS, Medicare Patient Safety Monitoring System

State Snapshots: State Snapshots: What’s behind each meter?What’s behind each meter?

A State’s relative performance A State’s relative performance compared to a group – region / compared to a group – region / all statesall states – A subset of NHQR measures (e.g., hospital measures)A subset of NHQR measures (e.g., hospital measures)– Classify each state’s performance for each measure: Classify each state’s performance for each measure:

First, calculate all-state and regional averagesFirst, calculate all-state and regional averages Then, determine if state is statistically Then, determine if state is statistically better thanbetter than average, average,

averageaverage, or , or worse thanworse than average average

– Score state for results across all NHQR measures in subsetScore state for results across all NHQR measures in subset Each better than average measure = 1 point Each better than average measure = 1 point Each average measure = 0.5 point Each average measure = 0.5 point Each worse than average = 0 points Each worse than average = 0 points

– Sum points and divide by the number of measuresSum points and divide by the number of measures

State Snapshots: State Snapshots: Individual MeasuresIndividual Measures

Strongest and Weakest Measures for a Strongest and Weakest Measures for a State compared to all States reportingState compared to all States reporting– Strongest demonstrate where a State may be Strongest demonstrate where a State may be

leading the way in qualityleading the way in quality– Weakest highlight some of the opportunities Weakest highlight some of the opportunities

for improvementfor improvement

State Rankings for 15 MeasuresState Rankings for 15 Measures– Ordinal rank on individual measures of each Ordinal rank on individual measures of each

State’s performance out of 50 States + DCState’s performance out of 50 States + DC

Downloadable table of all measures for a Downloadable table of all measures for a State and for all StatesState and for all States

2007 NHDR 2007 NHDR FindingsFindings

Access to Health CareAccess to Health Care

Disparities in Disparities in accessaccess to to care are care are staying the staying the same or same or increasing increasing

n=number of core measures

NHDR FindingsNHDR Findings

Over 60% of disparities in Over 60% of disparities in quality of carequality of care have stayed the same or worsened for have stayed the same or worsened for Blacks, Asians, and poor populationsBlacks, Asians, and poor populations

Nearly 60% of disparities have stayed Nearly 60% of disparities have stayed the same or worsened for Hispanicsthe same or worsened for Hispanics

For Blacks, Asians, Hispanics, and poor For Blacks, Asians, Hispanics, and poor populations, disparities in at least half populations, disparities in at least half the core measures of the core measures of access to careaccess to care are are not improving. not improving.

Recent Uses by Statewide Recent Uses by Statewide Data OrganizationsData Organizations

Utah Health Data Committee Utah Health Data Committee – Challenges in Utah’s Health Care Challenges in Utah’s Health Care

(released June 2007)(released June 2007)

Maine Quality ForumMaine Quality Forum– Developing “Maine Snapshots” to report at Developing “Maine Snapshots” to report at

the hospital-levelthe hospital-level

Arkansas Center for Health Arkansas Center for Health ImprovementImprovement– Establish baseline for tracking Establish baseline for tracking

improvementimprovement