Changes to Report Format

The 2006 NHQR and its companion, the NHDR, continue to be formatted as chartbooks. Although needed to assess health care in America comprehensively, the large number of measures tracked in the reports may sometimes be confusing and overwhelming for users. Hence, the 2006 reports continue to focus on a smaller subset of core measures. Other modifications have also been made to make the information in the reports easier to understand.

Core measures. For the 2005 reports, the Interagency Work Group was convened to select a group of measures from the full measure sets on which the reports would present findings each year. In 2006, the work group made additional changes to the core measure set.

For some topics, the group favored alternating sets of core measures. These measures relate to cancer prevention and childhood preventive services. Alternating measures are listed in Table 1.1, below.

^a The measures listed in this column will be reported again in the 2007 reports.

The core measures of patient safety also underwent modifications. Several measures included in last year's report were not available this year. New composite measures were developed to summarize information across several individual patient safety measures (described below). Other new measures became available that cover important aspects of patient safety. The combination of these changes yielded this year's patient safety core measures:

• Timing of antibiotics to prevent postoperative wound infection composite measure from the Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization (QIO) program.
• Postoperative complications composite measure from the Medicare Patient Safety Monitoring System (MPSMS).
• Complications of central venous catheter composite measure from the MPSMS.
• Deaths following complications of care from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS).
• Inappropriate medication use among the elderly from the Medical Expenditure Panel Survey (MEPS).

All core measures fall into two categories: process measures, which track receipt of medical services, and outcome measures, which in part reflect the results of medical care. Both types of measures are not reported for all conditions due to data limitations. For example, data on HIV care are suboptimal; hence, no HIV process measures are included as core measures. In addition, not all core measures are included in trending analysis because 2 or more years of data were not available. A complete list of the 2006 NHQR core measure set is presented in Table 1.2.

Presentation. As in past reports, each section in the 2006 report begins with a description of the importance of the section's topic in a standardized format. New this year is an assessment of the cost effectiveness of different clinical preventive services. These estimates come from a recent review by the National Commission on Prevention Priorities.¹ Cost effectiveness is measured as the average net cost of each quality adjusted life year (QALY)ⁱ that is saved by the provision of a particular health intervention. A lower cost per QALY saved indicates a greater degree of cost effectiveness while beneficial preventive services that fully cover their costs are labeled as cost saving.

After introductory text, chart figures and accompanying findings highlight a small number of measures relevant to the topic. Sometimes these charts show contrasts by age when age data are available and relevant. Age comparisons are always made to a reference group, which is the age group with the largest population (for most measures, adults ages 18-44).

Almost all core measures and composite measures have multiple years of data, so figures typically illustrate trends over time. Figures include a notation about the “reference population” for population-based measures and about the “denominator” for measures based on services or events from provider- or establishment- based data collection efforts.

ⁱ QALYs are a measure of survival adjusted for its value: 1 year in perfect health is equal to 1.0 QALY and a year in poor health would be something less than 1.0.

As in last year's report, findings presented in the text meet report criteria for importance.ⁱⁱ Often, large differences between age groups did not meet criteria for statistical significance because of small sample sizes.

In addition, significance testing used in this report does not take into account multiple comparisons. To place findings in the context of other Federal reporting initiatives, this report indicates where NHQR measures are also included in Healthy People 2010.

Addition of New Data Sources

NHQR data sources include surveys of individuals and health care facilities and extract from surveillance, vital statistics, and health care organization data systems (Table 1.3). Standardized suppression criteria were applied to all databases to support reliable estimates.ⁱⁱⁱ New data added this year come from:

• National Asthma Survey. This survey, sponsored by the Centers for Disease Control and Prevention (CDC) National Center for Environmental Health and conducted by the National Center for Health Statistics (NCHS) in 2003, is the most comprehensive national data set on asthma prevalence and asthma care. It examines the health, socioeconomic, behavioral, and environmental predictors that relate to control of asthma. Because it is not an ongoing survey, findings are presented in this year's report only.
• National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care. This survey examines the quality of hospice care for patients and their family members.² Family respondents report how well hospices respect patient wishes, communicate about illness, control symptoms, support dying on one's own terms, and provide family emotional support. The survey is administered by about 800 hospices each year, and about 120,000 completed surveys are returned each year for an overall response rate of about 40%. Participation is voluntary; although participating hospices span the Nation, they are not nationally representative. Demographic information is often incomplete. Despite these limitations, this survey is the most comprehensive source of information about hospice care.
• CAHPS® Hospital Survey. This survey, developed by CMS and AHRQ, captures information about patients' experiences of care when hospitalized.³ In 2005, 254 hospitals across the United States volunteered to use this survey. In total, completed surveys were received from 84,779 respondents with an average response rate of 44%. Although it is not nationally representative, the sample of hospitals and respondents is comparable to the national distribution of hospitals registered with the American Hospital Association.

Changes to the Measure Set

New measures. The measure sets used in the 2006 NHDR and NHQR have been improved in several ways. First, a handful of measures were modified to reflect more current standards of care or improved information. For example, this year's NHQR tracks a new measure on adults ages 18-64 with a history of a major depressive episode who received treatment for depression in the past year, which replaces last year's less specific measure related to serious psychological distress.

ⁱⁱ Criteria for importance are that the difference is statistically significant at the alpha=0.05 level, two-tailed test and that the relative difference is at least 10% different from the reference group when framed positively as a favorable outcome or negatively as an adverse outcome.

ⁱⁱⁱ Estimates based on sample size fewer than 30 or with relative standard error greater than 30% are considered unreliable and suppressed. Databases with more conservative suppression criteria are allowed to retain them.

Second, age adjustment^iv for a number of measures was updated. For example, to enhance the comparability of measures of diabetes care from MEPS, the Behavioral Risk Factor Surveillance System (BRFSS), and the National Health and Nutrition Examination Survey (NHANES), these measures now apply the same age adjustment methodology among persons age 40 and over with diabetes.^v Finally, a number of new measures were added to fill identified gaps, including:

• Four measures of care for obesity from MEPS and NHANES:
  • Obese adults age 20 and over who were told by their provider that they were overweight (NHANES).
  • Overweight children and teens ages 2-19 who were told by their provider that they were overweight (NHANES).
  • Obese adults who were given counseling from their provider about exercise (MEPS).^vi
  • Obese adults who were given counseling from their provider about diet (MEPS).
• Two measures of hospice care from the National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey:
  • Hospice patients who did not receive the right amount of medicine for pain.
  • Hospice patients who received care inconsistent with their stated end-of-life wishes.
• Two measures of patient safety from the CMS Quality Improvement Organization program and the Medicare Patient Safety Monitoring System:
  • Timing of antibiotics to prevent postoperative wound infection (QIO).^vii
  • Medication related adverse drug events (MPSMS).
• Four measures of patient centeredness of hospital care from the CAHPS® Hospital Survey:
  • Communication with doctors in the hospital (whether or not doctors listened carefully, explained things clearly, and treated the patient with respect).
  • Communication with nurses in the hospital (whether or not nurses listened carefully, explained things clearly, and treated the patient with respect).
  • Communication about medications in the hospital (combines patient responses on two questions: “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?” and “Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand?”).
  • Discharge information from the hospital (combines patient responses on two questions: “During your hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital?” and “During your stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?”).

^iv Age-adjusted measures are labeled as such. All other measures are not age adjusted.

^v Prior to 2006, these measures tracked persons age 18 and over.

^vi This is a new core measure.

^vii This is a new core measure.

As noted earlier, the 2006 reports also include measures of asthma care management for long-term control from the National Asthma Survey. However, because this is not a periodic survey, the four measures from this survey are not permanently added to the measure set. The measures include persons with current asthma who were:

• Taught to recognize early signs of an asthma attack.
• Told how to change their environment.
• Given an asthma controller medication.
• Given an asthma management plan.

Measure revisions were proposed and reviewed in meetings of the Interagency Work Group for the NHQR, which includes representation from across HHS.

Composite measures. Composite measures provide readers with a summarized picture of some aspect of health care by combining information from multiple component measures. Policymakers and others have voiced their support for composite measures because they can be used to facilitate understanding of information from many individual measures. The effort to develop new composites is ongoing; and this year, a number of new composite measures were added. Composite measures now make up about 20% of the core measures. New composite measures included in the 2006 reports and the individual component measures they aggregate are shown in Table 1.4. Future reports will include more composite measures.

^a This composite measure was modified between the 2004 and 2005 reports. Starting with the 2005 composite, two tests, flu vaccination and lipid profile, were omitted due to differences in the manner in which they were collected. The current composite measure on diabetes care focuses on the receipt of three processes for which the best data are available: HbA1c testing, retinal eye examination, and foot examination in the past year. Starting in 2006, the target age group for this measure changed from age 18 and older to age 40 and older.

When possible, an appropriateness model is used to create composite measures. In this model, the denominator is the number of patients who should receive the services included in the composite; the numerator is the number of patients who receive all of these services. The composite measure is presented as the percentage of patients who receive all services recommended to them. Because no partial credit is given for incomplete care, this model is sometimes referred to as an “all-or-none” approach. The appropriateness model is attractive to patients, who naturally desire to receive every appropriate service.⁴ One example of this model is the diabetes composite, in which a patient that receives only one or two of the three services would not be counted as having received the recommended care.

Sometimes, insufficient data are available to apply an appropriateness model. In these instances, an opportunities model developed by Qualidigm⁵ and used in the CMS Premier Hospital Quality Incentive Demonstration⁶ and for public reporting by the Rhode Island Department of Health⁷ is used. The model assumes that each patient needs and has the opportunity to receive one or more processes of care but that not all patients need the same care. The denominator for an opportunities model composite is the sum of these opportunities to receive appropriate care across a panel of process measures. The numerator is the sum of the appropriate care that is actually delivered. The composite measure is typically presented as the proportion of appropriate care that is delivered.

For example, recommended hospital care for heart failure includes evaluation of left ventricular ejection fraction and ACE inhibitor for patients with left ventricular systolic dysfunction. This represents two opportunities for providing appropriate care. The number of patients who should have an evaluation of left ventricular ejection fraction is added to the number of patients who should receive an ACE inhibitor to calculate the total number of opportunities for providing appropriate care. The number of patients who actually receive an evaluation of left ventricular ejection fraction is added to the number of patients who actually receive an ACE inhibitor to calculate the number of opportunities for providing care for which appropriate care was actually delivered. The composite is created by dividing the number of opportunities for care for which appropriate care was actually delivered by the total number of opportunities for care.

Measures from the CAHPS® (Consumer Assessment of Healthcare Providers and Systems⁸) surveys have their own method for computing composite measures that has been in use for many years. These composite measures average individual components of patient experiences of care. These composite measures are typically presented as the proportion of respondents who reported that providers sometimes or never, usually, or always performed well.

Two new composite measures relate to rates of complications of hospital care-postoperative complications and complications of central venous catheters. For these complication rate composites, an additive model is used, which sums together individual complication rates. Thus, for these composites, the numerator is the sum of individual complications and the denominator is the number of patients at risk for these complications. The composite rates are presented as the overall rate of complications. The postoperative complications composite is a good example of this type of composite measure; if 50 patients had a total of 15 complications between them (regardless of their distribution), the composite score would be 30%.

Analysis of Trends

As in previous NHQRs, the 2006 report calculates the average annual rate of change between the earliest and the most recent NHQR data estimates for all core measures. Consistent with Health, United States, the geometric rate of change, which assumes the same rate each year between the two time periods, has been calculated for the 2005 NHQR and NHDR.^viii

^viiiThe geometric rate of change assumes that a measure increases or decreases at the same rate during each year between two time periods. It is calculated using the following formula: [(V_y/ V_z)^1 / N-1] X 100, where V_y is the most recent year's value, V_z is the most distant year's value and N is the number of years in the interval.

Two criteria are applied to determine whether a significant trend in quality exists:

• First, the difference between the earliest and most recent estimates must be statistically significant with alpha=0.05.
• Second, the magnitude of average annual rate of change must be at least 1% per year, when framed as an adverse outcome.

Only changes over time that meet these two criteria are discussed in the 2006 reports.

Summary of Quality

In the 2006 NHQR, efforts to summarize quality have been further refined. There have been a number of changes in measure selection. The focus on the Nation's progress in health care quality improvement is evident throughout the report. In the Highlights, the annual rate of quality improvement across all core measures is summarized; and, in Chapters 2-5, trend data for the core measures are also examined in detail. As noted in Table 1.4, new composite measures are included for appropriate timing of antibiotics, postoperative complications, complications of central venous catheters, communication with doctors in the hospital, communication with nurses in the hospital, communication about medications in the hospital, and receipt of discharge information from the hospital. These measures provide a summary description of the present state of quality as well as progress over time; these are complemented by information on each of the measures which comprise the composite.

These and other changes have been made in response to requests from many constituencies who use the NHQR, including policy makers, clinicians, health system administrators, State and community leaders, and other users.