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State of the Field Disparities and Quality

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									The National Healthcare Reports



              Ernest Moy
          Ernest.moy@ahrq.hhs.gov
                  301-427-1329
        www.ahrq.gov/qual/qrdr09.htm
        http://statesnapshots.ahrq.gov
             Origins of NHQR & NHDR

 Health and Human Services
   Secretary required to submit
   annual report to Congress:
    –   National trends in health care
        quality (National Healthcare
        Quality Report, or NHQR)
    –   Prevailing disparities in
        health care delivery as it
        relates to racial factors and
        socioeconomic factors in
        priority populations (National
        Healthcare Disparities           Mandated by Congress in
        Report, or NHDR)                 Healthcare Research and
                                         Quality Act (PL. 106-129)
 First reports released in
   2003.
           Reporting Assumptions
                & Trade-offs
 Assumptions
   – 1º Audience: Policymakers; NOT QI
   – 1º Use: Tracking; NOT public reporting, P4P
   – 1º Analytic Unit: Area; NOT individual provider
 Measurement Implications
   – Broad & Shallow > Narrow & Deep
   – Consensus > Cutting Edge
   – Composite > Granular
 Reporting Implications
   – Analysis: Simple > Complex
   – Examples: Typical > Exceptional
   – Products: Family > One
          Organization of NHQR & NHDR
   Effectiveness
    –   Cancer
    –   Diabetes
    –   End Stage Renal Disease (ESRD)
    –   Heart Disease
    –   HIV & AIDS
    –   Maternal and Child Health
    –   Mental Health & Substance Abuse     NHQR
    –   Lifestyle Modification
    –   Functional Status Preservation & Rehabilitation   NHDR
    –   Supportive & Palliative Care
   Patient Safety
   Timeliness
   Patient Centeredness
   Efficiency
   Access to Health Care
   Priority Populations
                        Track 250 measures
                        from ~40 databases
   Survey data collected from populations (N=11)
    –   AHRQ, Medical Expenditure Panel Survey (MEPS)
    –   CDC-NCHS, National Health Interview Survey (NHIS)
    –   CMS, Medicare Current Beneficiary Survey (MCBS)
    –   SAMHSA, National Survey of Drug Use and Health (NSDUH)
   Data collected from samples of health care facilities (N=8)
    –   American Cancer Society-American College of Surgeons, National Cancer Data Base
        (NCDB)
    –   CDC-NCHS, National Ambulatory Medical Care Survey (NAMCS)
    –   CMS, End-Stage Renal Disease Clinical Performance Measurement Program
   Data extracted from data systems of health care organizations (N=13)
    –   AHRQ, Healthcare Cost and Utilization Project State Inpatient Databases (HCUP SID)
    –   CMS, Quality Improvement Organization (QIO) program.
    –   Indian Health Service, National Patient Information Reporting System (NPIRS)
    –   NIH, United States Renal Data System (USRDS)
   Data from surveillance and vital statistics systems (N=5)
    –   CDC-National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System
    –   CDC-NCHS, National Vital Statistics System (NVSS)
    –   NIH-National Cancer Institute, Surveillance, Epidemiology, and End Results (SEER)
        program
        Linkage Between NHQR & NHDR

         NHQR                       NHDR
Snapshot of quality of    Snapshot of disparities
health care in America    in health care in America
Quality: Safety,         Quality + Access: Equity
effectiveness,           across race, ethnicity,
timeliness, patient      SES
centeredness, efficiency

Variation across States   Variation across
                          populations
                             New in 2009
 QR & DR
  – Focus on the uninsured
  – New
        Healthcare-associated infections
        Care coordination
  – Improved
          Retired measures
          Lifestyle modification
          Functional status preservation & rehabilitation
          Supportive & palliative care
 QR
  – Patient safety culture in hospitals
  – More efficiency measures
 DR
  – Financial burden of health care costs
           2009 NHQR Key Findings

 Quality is
  improving, but the
  pace is slow,
  especially for
  preventive care
  and chronic
  disease
  management.
                           2009 NHQR Findings
 Health care quality needs to be improved,
  particularly for uninsured individuals who are less
  likely to get recommended care.
                                                            Private      No
                                                          insurance   insurance
Measure                                                       (%)        (%)      Difference
Women ages 40-64 who had a mammogram in the last            74.2        38.3         35.9
2 years
Children ages 2-17 who had a dental visit in the            59.6        27.9         31.7
calendar year
Adults ages 40-64 with diagnosed diabetes who               64.1        35.4         28.7
received a dilated eye examination in the calendar year
Adults ages 50-64 who ever received a colonoscopy,          47.5        20.7         26.8
sigmoidoscopy, or proctoscopy
Adults with obesity who received advice from a               61         41.2         19.8
provider to exercise
             2009 NHQR Findings


 Some areas
  merit urgent
  attention,
  including patient
  safety and health
  care-associated
  infections.
         2009 NHDR Key Findings
 Disparities are common and not improving.
              Core Measures Getting Worse

Topic         Measure                                Blacks   Asians   AI/ANs   Hispanics
              Adults age 50 and over who
              report they ever received a
              colonoscopy, sigmoidoscopy,
              proctoscopy, or fecal occult blood
                                                       *        *        *         *
Cancer        test
              Cancer deaths per 100,000
              population per year for colorectal
              cancer
                                                       *                           *
              Hospital patients with heart failure
Heart
disease
              who received recommended
              hospital care
                                                                         *         *
              Adults age 65 and over who ever
Respiratory
diseases
              received pneumococcal
              vaccination
                                                                *                  *
              Hospital patients with pneumonia
              who received recommended
              hospital care
                                                       *        *        *         *
The National Healthcare Reports:
      Focus on Maryland


              Ernest Moy
          Ernest.moy@ahrq.hhs.gov
                  301-427-1329
        www.ahrq.gov/qual/qrdr09.htm
        http://statesnapshots.ahrq.gov
                Reports ≠ Better Health Care



                 How?



                 Local
QRDR                            QI
                 Benchmarks
Know             Plan           Do          Better
                                Make it     Health
See it happen    Help it happen
                                happen       Care
                 Health
Policy Makers                   Providers
                 Organizations
                 Target States with Poorest Care:
                         State Snapshots

      Web tool for State policymakers to view
      NHQR/NHDR health care quality, State-by-State:
   Summary
    performance
    meters
   Individual
    measures
   Focus on clinical
    issues
   State context
   Methods &
    Interpretation
    Guides
                Screening Lower Endoscopy
                         by State

80                                                       Time to
     2008 Achievable Benchmark = 72.5%                 Benchmark

70                                                        ½ yr


                                                          5 yrs
60

       MD
50
        US

40


30
         2001            2002            2004   2006   2008
             Flu Shot among Elderly by State

80                                                               Time to
     2008 Achievable Benchmark = 77%                           Benchmark




70                                                                 17 yrs
     MD                                                            21 yrs

     US


60




50
      2001      2002     2003      2004   2005   2006   2007    2008
              Black-White Differences in Flu Shot
                    among Elderly by State
35
                                                Worst
30

25
                          U.S.
20     State Gap
                    MD

15

10
     Best
 5

 0    Best           MD    U.S.                     Worst
                      Hispanic-White Differences in
                         Mammography by State
25
                                                      Worst

20       State Gap

15

10
 5                               U.S.

 0     Best      MD               U.S.                  Worst




 -5
                 MD
-10

-15
      Best
-20
                Pneumococcal Vaccine among
                  Elderly by Race/Ethnicity
70                                                  Time to
     2008 Achievable Benchmark = 63.9%              Benchmark
                                                    2 yrs
60
                                                    8 yrs


50
                                                    14 yrs

40

                                                    87 yrs
30
                                                        Total
                                                        Hispanic
20
                                                        Black
     1999 2000 2001 2002 2003 2004 2005 2006 2007
                                                        White
                 Pneumococcal Vaccine among
                     Elderly by Insurance
70
     2008 Achievable Benchmark = 63.9%                         Time to Benchmark
                                                               3 yrs
60                                                             8 yrs
                                                               3 yrs

50                                                             22 yrs


40
                                                                   Total
                                                                   Medicare & private
30
                                                                   Medicare & public
                                                                   Medicare only
20
  99

         00

                01

                       02

                              03

                                     04

                                            05

                                                   06

                                                          07
19

       20

              20

                     20

                            20

                                   20

                                          20

                                                 20

                                                        20
                    Conclusions
 Many trade-offs in developing national reports;
  QRDR driven by 1º assumptions.
 QRDR not designed to direct action but can
   – Make case for action
   – Identify QI opportunities: Populations, services,
      communities
   – Benchmark against best States
 Quality and disparities problems are apparent at
  the national and States levels.
 Local teams with local data do the actual
  improvement.

								
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