The National Healthcare Quality Report, developed by the Agency for Healthcare Research and Quality (AHRQ) is the first national comprehensive effort to measure the quality of health care in America. The report includes a broad set of perfomance measures that can serve as baseline views of the quality of health care. The report presents data on the quality of services for seven clinical conditions, including cancer, diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory disease. It also includes data on maternal and child health, nursing home and home health care, and patient safety.
Background
High Quality Health Care Is Not Universal
Opportunities for Preventive Care Are Frequently Missed
Management of Chronic Diseases Presents Unique Quality Challenges
There Is More To Learn
Greater Improvement Is Possible
References
More Information
"Better health is an individual responsibility, and it is an important national goal. We're making great progress in preventing and detecting and treating many chronic diseases, and that's good for America.... We're living longer than any generation in history. Yet we can still improve. And we can do more." —President George Bush, June 2002.1 |
This first annual National Healthcare Quality Report (NHQR) echoes the President's message on the quality of health care in the Nation: We are making progress, we can improve, and we can do more.
Key Findings:
The Department of Health and Human Services (HHS) plays a critical role in ensuring that the American people have the safest, highest quality health care services. To that end, HHS has embarked on a multifaceted health care quality initiative. Strategies supported under this include:
The observation that quality of health care in America can be improved is not new. Lack of consistent provision of the best quality care means that not all Americans benefit from the Nation's investments in biomedical science.2
"As great as our health care system is, my friends, you know and I know that it can be even better." —Tommy G. Thompson, Secretary, U.S. Department of Health and Human Servicesa |
In many areas, the report shows that the health care system is performing very well. For example:b
In other areas, improvement can be made, including:
a Health Forum Leadership Summit, August 2, 2003, online at www.hhs.gov/news/speech/2003/030802.html.
b Source of data: Measure Specifications Appendix, National Healthcare Quality Report, 2003.
Too much of medicine today focuses on treatment of illness after it occurs, rather than preventing it before it begins. At the launch of the Steps to a Healthier U.S. initiative in April 2003, Secretary Thompson said the following about the importance of such preventive care:
"Approximately 95 percent of the $1.4 trillion that we spend as a Nation on health goes to direct medical services, while approximately 5 percent is allocated to preventing disease and promoting health. This approach is equivalent to waiting for your car to break down before you take it in for maintenance. By changing the way we view our health, the Steps initiative helps move us from a disease care system to a true health care system."
While we are justly proud of the progress made in the treatment of heart attacks, cancer, diabetes, and end stage renal disease, we neglect opportunities to stop these same diseases before they start. The report shows areas where more focus on prevention can save more lives and resources. For example, while smoking remains the single most preventable cause of mortality, rates of smoking cessation counseling of patients, both in the hospital and during office visits, are only 40 percent and 60 percent, respectively. Likewise, data on screening for high cholesterol show that 67 percent of adults have had their cholesterol checked within the past 2 years and can state whether it is normal or high. Screening for high cholesterol—which is also a risk factor for diabetes—can prevent the development of heart disease. The percentage of people 45 years of age and older on this same measure is over 80 percent; however the percentage for those under 45 years of age is 53 percent. Screening for colorectal cancer is 42.5 percent. Too many cancers are detected at a late stage, leading to suffering and premature death.
Of the specific conditions covered in this report, the vast majority—cancer, chronic kidney disease (CKD), diabetes, HIV and AIDS, depression, asthma, and congestive heart failure—are chronic diseases. Some are inextricably intertwined with one another. For example, diabetic patients have high rates of chronic kidney disease, and those with chronic kidney disease are at greater risk of developing cardiovascular problems. Tracking quality of care for chronic disease, therefore, involves not only examining individual measures of quality for these diseases, but the related measures as well. Data reported in the NHQR reinforce the challenges associated with ensuring quality preventive and curative health care for chronic conditions.
There is no one national survey tracking quality of health care in America. Rather, this report relies on a variety of existing national data sources to present and report quality information. Because of data and measures availability, this first quality report is uneven in its coverage of the areas selected for reporting. While measures for a number of areas have been thoroughly tested, widely accepted, and implemented by providers, in other areas this is not the case. For example, there are agreed on and commonly used measures to track quality-of-care performance for treating heart attacks, diabetes, respiratory disease, and end stage renal disease.
However, not all conditions tracked in the report have such developed, broadly accepted, and widely used measures (e.g., mental illness, HIV/AIDS, early stage chronic kidney disease). For several conditions, measures are currently being developed; for others, consensus among experts on a core set of measures is not imminent. Finally, even when there is widespread support for core measures, the national data needed for reporting oftentimes are not yet in place. The reasons for this unevenness follow:
Meeting the criteria for measure selection. Criteria for selection of quality measures include clinical importance, scientific soundness, and feasibility; all measurement and reporting efforts must strike a balance among the tensions inherent in meeting all three. When possible, measures presented in this report use assessments of performance that are consistent with current science and supported by professional consensus.
Rapid advances in knowledge. Part of this unevenness in measure development is due to rapid change in certain fields. As knowledge of optimal detection and treatment improves, quality measures must be updated to reflect the most current scientific knowledge.
Limitations and advances in information technology. Limitations in the availability of data constrain the ability to track certain conditions. Data can come from several different sources: medical charts, patient surveys, facility surveys, vital statistics, surveillance systems, and administrative and claims records. The degree to which data are collected from any of these sources varies widely. Expected gains in information technology, including the adoption of electronic medical records, will directly address this dearth of data by providing one data source without imposing any additional burden of collection on providers. Such gains in quality of care have been seen in large systems such as the Veterans Health Administration following the implementation of an electronic medical records system and efforts to track and use quality of care data coming from those medical records.10
HHS is making a substantial investment and providing leadership for the development of a national health information infrastructure. For example, on July 1, 2003, Secretary Thompson announced that a standardized medical vocabulary system (SNOMED, developed by the College of American Pathologists) would be made available free of charge to all health care providers. This will facilitate the sharing of electronic information.
Improvement comes about not through mandates, but rather through innovation that is led by "champions" with the vision to customize improvements to local circumstances. Many provider organizations offer quality health care. They strive to achieve the best health care practices as described by experts in the field. While the reasons for superior performance are complex, high scores are often achieved because a group of providers and other stakeholders have identified a quality problem and committed resources and personnel to fix it. In the process they may discover something that works, which in turn can be learned and adopted by others.
One approach the NHQR focuses on is the variation across States or regions that may indicate the possibility for cross-learning (Figure 1).
The report also presents examples of how efforts to improve quality in the measurement areas covered in the report have achieved results. For example, the Assistant Secretary for Health has recently showcased some outstanding examples of best practices in States across the Nation, many of which correspond to the priority areas of this report. These interventions include:
Additional inspiring best practices show us how to provide cost-effective, high quality care. For example, the SSM Health Care system sponsored by the Franciscan Sisters of Mary and based in St. Louis, MO, was recently awarded the Malcolm Baldrige Award for excellence in quality of care.c SSM simultaneously exceeded national performance goals, strengthened its bottom line, and empowered its employees.12 Similarly, the National Committee on Quality Assurance (NCQA), which accredits managed care plans, produced Quality Profiles: In Pursuit of Excellence in Managed Care, a publication containing over 38 examples of exemplary practices and designed to help plans "fine tune their own quality improvement (QI) efforts."13 These are only some of the excellent examples of programs that are making greater improvement possible.
This is the first of what will be an annual report on the state of health care quality in the United States. As such, there is much that can be improved upon in future reports. The annual nature of the report not only will allow for updating and improving the report, it will also provide ongoing information on a core set of quality measures. The primary role of the report is to provide the data and information that can tell us how the Nation's health care system is performing in terms of quality of care. The hope is that this information will be used to help focus efforts to change health care quality for the better. In this way, the report, as an ongoing tracking tool, will provide the foundation for the translation of research and evidence into action and practice.
c Established by Congress in 1987 to enhance the competitiveness of U.S. organizations, the Malcolm Baldrige National Quality Award is given to organizations in manufacturing, service, small business, education and health care, that have exemplary achievements and can serve as a model and inspiration to others (National Institute of Standards and Technology News Release, 2003).
1. President outlines health and fitness initiative. Remarks by the President at White House Fitness Expo, the South Lawn, June 2002, online at www.whitehouse.gov/news/releases/2002/06/20020620-2.htm.
2. Lenfant C. Shattuck lecture—clinical research to clinical practice—lost in translation? N Engl J Med 2003 Aug 28;349(9):868-74.
3. Erzati M, Lopez AD. Estimates of global mortality attributable to smoking in 2000. Lancet 2003 Sep 13;362(9387):847-52.
4. Seltzer V. Smoking as a risk factor in the health of women. Int J Gynaecol Obstet 2003 Sep;82(3):393-7.
5. Jemal A, Cokkinides VE, Shafey O, Thun MJ. Lung cancer trends in young adults: an early indicator of progress in tobacco control (United States). Cancer Causes Control 2003 Aug;14(6):579-85.
6. Cromwell J. Cost effectiveness of the clinical practice recommendations in the AHCPR smoking cessation guidelines. JAMA 1997;278:1759-66.
7. McCullough PA. Scope of cardiovascular complications in patients with kidney disease. Ethn Dis 2002, Autumn; 12:S3-44-8.
8. Berman SJ. Infections in patients with chronic renal failure. Infect Dis Clin North Am 2001, Sept;15(3):709-20.
9. Bommer J. Prevalence and socio-economic aspects of chronic kidney disease. Nephrol Dial Transplant 2002;17(Suppl 11):8-12
10. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003; 348:2218-27.
11. Soumerai, SB, McLaughlin TJ, Spiegelman D, et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997 Jan 8; 277(2):115-21.
12. National Institute of Standards and Technology, Award Recipient Profile, Malcolm Baldrige National Quality Award, 2002 Award Recipient, Health Care Category, SSM Health Care, November 2002, online at www.nist.gov/public_affairs/releases/ssmhealth.htm.
13. National Committee on Quality Assurance, NCQA Issues Quality Profiles, A New Resource for Health Plans; Volume Showcases 38 Model Quality Improvement Efforts. NCQA Press Release, November 3, 1999, online at www.ncqa.org/communications/news/qprel.htm.
Prepublication copies of the full National Healthcare Quality Report are available free from the AHRQ Publications Clearinghouse. To order, call 800-358-9295 or E-mail ahrqpubs@ahrq.gov and request AHRQ Publication No. 04-RG003. The report is also available online at http://qualitytools.ahrq.gov/qualityreport/download_report.aspx.
Current as of December 2003
AHRQ Publication No. 04-RG004
Internet Citation:
National Healthcare Quality Report: Summary. December 2003. AHRQ Publication No. 04-RG003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nhqr03/nhqrsum03.htm
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