AHRQ Annual Highlights, 2006

Eliminating Disparities in Health Care

The Agency for Healthcare Research and Quality (AHRQ) is leading Federal research efforts to develop knowledge and tools to help eliminate health care disparities in the United States. AHRQ supports and conducts research and evaluations of health care with emphasis on disparities related to race, ethnicity, and socioeconomic status. The Agency focuses on priority populations including minorities, women, children, the elderly, low-income individuals, and people with special health care needs such as people with disabilities or those who need chronic or end-of-life care.

National Healthcare Quality and Disparities Reports

The overall quality of the U.S. health care system is improving, but providers are missing chances to help Americans avoid disease or serious complications, according to AHRQ's 2006 National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR).

The findings from the two annual reports provide updated, congressionally mandated snapshots of the U.S. health care system. AHRQ's reports examine quality and disparities in four key areas of health care:

1. Effectiveness of health care.
2. Patient safety.
3. Timeliness of care.
4. Patient centeredness.

The NHQR tracks the health care system through quality measures, such as what proportion of heart attack patients received recommended care when they reached the hospital, or what percentage of children received recommended vaccinations. The NHDR summarizes which racial, ethnic, or income groups are most likely to benefit from improvements in health care.

Both reports found that the use of proven prevention strategies lags significantly behind other gains in health care:

• Only about 52 percent of adults reported receiving recommended colorectal cancer screenings.
• Only 68 percent of obese adults and 37 percent of overweight children were told they were overweight; blacks, Hispanics, and less educated individuals were less likely to be told.
• Only 48 percent of adults with diabetes received all three recommended screenings—blood sugar tests, foot exams, and eye exams—to prevent disease complications.
• Among people with asthma, 70 percent were taught to recognize early signs of an attack, 49 percent were told how to change their environment, 40 percent were given a controller medication, and 28 percent were given an asthma management plan.
• Only 6 percent of hospice patients did not receive the right amount of pain medicine and only 6 percent received care inconsistent with their stated end-of-life wishes.
• Only 6 percent of hospitalized patients reported communication problems with doctors and 7 percent reported communication problems with nurses. However, 26 percent of hospitalized patients reported problems with communications about medications and 21 percent reported problems with discharge information.

Both reports are available online at: http://www.ahrq.gov/qual/nhqr06/nhqr06.htm and http://www.ahrq.gov/qual/nhdr06/nhdr06.htm.

State Snapshots

AHRQ released a new interactive Web-based tool for States to use in measuring health care quality. The new State Snapshot Web tool is based on the 2005 NHQR, and it provides quick and easy access to the many measures and tables of the NHQR from each State's perspective.

The State Snapshot tool provides valuable information, including:

• Tables that rank the 50 States and the District of Columbia on 15 representative measures of health care quality culled from 179 measures contained in the 2005 NHQR.
• Summary measures of the quality of types of care (prevention, acute, and chronic), settings of care (hospital, ambulatory, nursing home, and home health), and clinical areas (cancer, diabetes, heart disease, maternal and child health, and respiratory diseases) for each State.
• Comparisons of each State's summary measures to regional and national performance, as well as comparison to the best performing States.
• Performance meters that show at a glance a State's performance relative to the region or nation.
• Data tables for each State's summary measures that show the NHQR detailed measures and numbers behind the performance meters.

Also, the State Snapshot tool features a special focus on each State's performance in the treatment of diabetes across three areas:

• Quality of diabetes care.
• Disparities in diabetes treatment.
• Cost savings that States might accrue by implementing disease management for diabetes for State government employees.

The State Snapshot tool is available at: http://statesnapshots.ahrq.gov.

Asthma Care Resource Guide

Asthma is a serious chronic respiratory illness that affects a growing number of Americans and disproportionately affects African Americans, children, and low-income individuals. AHRQ, in partnership with the Council of State Governments, released Asthma Care Quality Improvement: A Resource Guide for State Action and its companion Workbook. The Resource Guide and Workbook are designed to help State leaders identify measures of asthma care quality, assemble data on asthma care, assess areas of care most in need of improvement, learn what other States have done to improve asthma care, and develop a plan for improving the quality of care for their States.

The resource guide uses data from AHRQ's NHQR and NHDR and Web-based State Snapshots to help inform the Nation and States about the quality of asthma care. The workbook is designed for State policymakers, including officials in State health departments, asthma prevention and control programs, and Medicaid offices. It includes five modules, some of which are targeted to senior leaders responsible for making the case for asthma care quality improvement and taking action. Other modules provide the information necessary for program staff to develop and implement a quality improvement strategy. The goal is for all groups involved in asthma care to work together as a team to improve the quality of asthma care.

Asthma Care Quality Improvement: A Resource Guide for State Action and its companion workbook can be found online at http://www.ahrq.gov/qual/asthmaqual.htm.

Improving Diabetes Care in Communities Collaborative

According to the NHQR and NHDR, only 48 percent of adults with diabetes received all three recommended screenings—blood sugar tests, foot exams, and eye exams—to prevent disease complications. AHRQ estimates about $2.5 billion could be saved each year by eliminating hospitalizations related to diabetes complications. AHRQ formed a new partnership with three of the Nation's leading business coalitions that is designed to help improve the quality of diabetes care within and across communities. The new partnership, Improving Diabetes Care in Communities Collaborative, brings AHRQ together with the Greater Detroit Area Health Council, the MidAtlantic Business Group on Health, and the Memphis Business Group on Health.

The goal of this partnership is to support local communities in their efforts to reduce the rate of obesity and other risk factors that can lead to diabetes and its complications. The partners are working together to ensure that people with diabetes receive appropriate health care services. Each of the coalitions has convened stakeholders, including businesses, providers, health plans, insurers, consumers, and academics, to set priorities in their efforts to improve diabetes care and develop solutions that fit within the community's needs and capabilities.

Cross-cutting strategies for addressing diabetes quality improvement include a return on investment calculator for estimating financial returns from disease management, application of the chronic care model, and an employer guide on managing diabetes care with health plans. The strategies and tools developed under the partnership and any lessons learned will be disseminated broadly for communities around the Nation to use in improving the quality of diabetes care.

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Ensuring the Value in Health Care

According to the most recent data from the Medical Expenditure Panel Survey (MEPS), 85 percent of people under age 65 and 96 percent of the elderly had some expenditure for health care in 2003. About one dollar for every five dollars spent on health care (excluding health insurance premiums), was paid out of pocket by individuals and families. It is vitally important to help Americans achieve access to high-quality, safe, and effective health care, with the best possible outcomes, and help maximize the value realized for each dollar spent.

AHRQ is playing a key role in one of the Department of Health and Human Services' Secretary Michael Leavitt's priority initiatives—the Value-Driven Health Care Initiative. The goal of the initiative is to encourage the health care system to provide better quality and better value for our health care dollars. Value is the intersection of cost and quality.

In August 2006, President Bush signed an executive order committing the Federal government to the "four cornerstones" of value-driven care: health information technology, public reporting of provider quality information, public reporting of cost information, and incentives for value comparison. The cornerstones are the center of the initiative, and AHRQ is working closely with the Department and other Agencies to promote and support them.

To accomplish the goals of a value-driven health care system, consumers need transparent and reliable information on the quality and cost of health care services. The public reporting created by the initiative will give consumer what they need to make comparisons and choices based on value, and providers can know how they measure up against accepted standards of care.

Pay-for-Performance Decision Guide

AHRQ released a new resource to help employers, health plans, Medicaid agencies, and others who are considering starting a pay-for-performance program make decisions about how to design, implement, and evaluate the activity.

The free tool, Pay for Performance: A Decision Guide for Purchasers, poses 20 key questions that leaders from an employer group, health plan, or other health care purchasing group should ask themselves as they consider a pay-for-performance program. Included are questions such as whether or not to partner with other purchasers, focus on clinicians or hospitals first, make provider participation mandatory or voluntary, how much money to allot to the activity, and how to address provider concerns about risk adjustment for severity of illness. The decision guide also includes special advice for Medicaid agencies and Medicaid managed care plans. Each question is followed by a discussion that includes possible options and potential unintended consequences.

To access Pay for Performance: A Decision Guide for Purchasers, go to http://www.ahrq.gov/qual/p4pguide.htm.

Recent Research Findings on Health Care Costs and Improving Performance

• More than half (52 percent) of the Nation's health maintenance organizations (HMOs) used pay-for-performance programs in their contracts with doctors or hospitals in 2005. Researchers found that nearly 90 percent of health plans with pay-for-performance programs included these arrangements as part of their physician compensation and 38 percent included them in their hospital contracts. HMOs that required enrollees to designate a primary care physician as a gatekeeper to specialty services were more likely to use pay-for-performance programs compared with those who did not require this designation (61 vs. 25 percent).
• A new study found no ill effects of HMOs on the health status of the near-elderly (those aged 55 to 64). Patients with chronic health conditions actually fared better upon enrolling in managed care plans. Adults in this age group who had serious and longstanding chronic health conditions were 1.26 times as likely to report very good as opposed to good health when they were enrolled in HMOs. For relatively healthy near-elders, however, being in a particular type of plan-whether HMO, PPO, or fee-for-service—had no bearing on health status.
• Insuring adults in middle to late middle age now could lead to improved health status and reduce costs later in life. A prospective study of adults aged 51 to 61 years found that people who were uninsured at baseline had a 35 percent higher mortality rate than those with private insurance over a 10-year period of time. However, when the outcomes were analyzed over 2-year intervals, individuals who were uninsured at the start of each interval were 43 percent more likely to have a major decline in their overall health, and they were as likely to die as the privately insured. The average annual health care expenditure in 2001 for someone aged 51 to 61 was $12,578 for those in poor health and $6,938 for those in fair health. In contrast, the average annual total health care costs for healthier adults in this same age group were $3,922 for those in good health and $1,791 for those in excellent health.

Medicare Drug Benefit Caps Are Associated with Lower Drug Consumption and Worse Clinical Outcomes A study, supported in part by AHRQ, examined the impact of drug benefit caps on Medicare beneficiaries who had hypertension, hyperlipidemia, or diabetes. Researchers found that limits on drug benefits resulted in negative consequences. Overall, Medicare beneficiaries whose benefits were capped at $1,000 used fewer prescription drugs than those beneficiaries whose benefits were not capped. Beneficiaries receiving long-term drug therapy whose benefits were capped had lower levels of drug adherence (Figure 1). They also had worse physiological outcomes. Those whose benefits were capped, when compared with beneficiaries who did not have caps, had a systolic blood pressure of 140 mm Hg or more (39.5 percent vs. 38.5 percent), LDL cholesterol greater than 130 mg/dl (21.3 percent vs. 19.6 percent), and blood sugar levels greater than 8 percent (19.7 percent vs. 17 percent).

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Developing Tools and Data for Research and Policymaking

Efforts to improve the quality and efficiency of health care and reduce disparities in the United States must be based on a thorough understanding of how the Nation's health systems work and how different organizational and financial arrangements affect health care. AHRQ has a broad portfolio of data on costs, access to health care, quality, and outcomes that can be used for research and policymaking.

Medical Expenditure Panel Survey

The Medical Expenditure Panel Survey (MEPS) is the only national source of annual data on the specific health services that Americans use, how frequently the services are used, the cost of the services, and the methods of paying for those services. MEPS is designed to help us understand how the growth of managed care, changes in private health insurance, and other dynamics of today's market-driven health care delivery system have affected, and are likely to affect, the kinds, amounts, and costs of health car that Americans use.

MEPS provides the foundation for estimating the impact of changes on different economic groups or special populations such as the poor, elderly, veterans, the uninsured, or racial/ethnic groups. For example:

• Overall outpatient prescription drug expenses for the U.S. civilian non-institutionalized population grew from $65.3 billion in 1996 to $177.7 billion in 2003—a 172 percent increase.
• Outpatient prescription drugs' share of all health care spending rose from 12 percent to 20 percent from 1996 to 2003.
• The cost of caring for U.S. adults with diabetes rose sharply between 1996 and 2003, a period in which the number of patients soared from 9.9 million to 13.7 million and the average annual inflation-adjusted treatment costs rose from $1,299 to $1,714. The average annual spending for prescription medicines jumped nearly 86 percent during the time period, from $476 to $883.
• The percentage of employees at large companies who were eligible for health insurance and who enrolled in plans fell from 87 percent in 1996 to 80 percent in 2004, with the steepest decline occurring among employees of large retail firms, from 81.5 percent to 69 percent.
• In 2004,the most expensive average cost for family health insurance coverage—$11,742—was in the District of Columbia and the least—$7,800—was in North Dakota. The national average cost for family coverage was $10,006.

More information on MEPS can be found online at http://www.meps.ahrq.gov.

Vermont Uses MEPS Data To Assess Options for Covering the Uninsured State officials and legislators working on health reform measures in Vermont used reports containing MEPS data. In May 2006, Governor Jim Douglas signed the Health Care Affordability Act into law. The centerpiece of this legislation is a new program called Catamount Health, which establishes coverage at group rates for uninsured individuals and offers income-related subsidies to help them purchase that coverage. MEPS data that were used in the discussion of this legislation include data on the prevalence of chronic illness among the uninsured; data on insurance coverage, health spending, and demographics to calculate cost impacts for a proposed buy-in to the Vermont Health Access Plan (VHAP, which offers coverage for uninsured adults who are not eligible for Medicaid); data to derive the average employer-based health insurance premium costs per worker for Vermont and other states, self-reported health status of insured and uninsured Americans, health services utilization of Americans by insured status, and estimates of the impact of various health reform initiatives in Vermont; and data on firm size and provision of health insurance.

Healthcare Cost and Utilization Project

The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by AHRQ. HCUP databases bring together the data collection efforts of 38 State data organizations, hospital associations, private data organizations, and the Federal government to create a national information resource of patient-level health care data.

HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.

Outpatient Data Initiatives

The largest growth in HCUP has been in outpatient data initiatives—the acquisition of additional State Ambulatory Surgery Databases and State Emergency Department Databases, partnership discussions about improving outpatient data collection and measurement of the quality of outpatient care, and dissemination of outpatient data and its capacity.

In 2006, 21 States contributed ambulatory surgery data for a combined total of 16 million discharges in over 2,900 facilities (mostly hospital-based but including some free-standing sites). In addition, 17 States contributed outpatient emergency department data, for a combined total of 24 million discharges in 2,400 hospitals.

HCUP Statistical Briefs

In 2006, AHRQ launched a new series of Web-based publications, the HCUP Statistical Briefs containing information from HCUP. These publications provide concise, easy-to-read information on hospital care, costs, quality, utilization, access, and trends for all payers (including Medicare, Medicaid, private insurance, and the uninsured).

Each Statistical Brief covers an important health care issue. For example:

• Hospital stays of obese patients increased by 112 percent between 1996 and 2004, rising from 797,000 to 1.7 million. Women accounted for about 82 percent of all patients admitted for treatment of their obesity. Hospital costs for patients admitted for obesity treatment were an average of $11,700 per stay.
• Hospital admissions for breast cancer fell by a third between 1997 and 2004. The hospitalization rate for women with breast cancer dropped from 90 per 100,000 women to slightly fewer than 61 per 100,000 women during the period, and the number of hospital stays for the disease declined from about 125,000 to 90,000. In 2004, mastectomies accounted for 70 percent of breast cancer surgeries in the hospital.
• Nearly 8 percent of patients age 85 and older who are hospitalized for influenza do not survive the disease. This death rate is more than twice the 3 percent for hospitalized patients aged 65 to 84. More than 21,000 people were hospitalized specifically for influenza in 2004—a 62 percent decrease from 2003, but double the number of hospitalizations in 2001.
• The first Federal analysis in a decade of sickle cell disease hospitalizations shows that admissions of adults remained stable from 1997 to 2004. In 2004, approximately 83,000 hospital stays were for adults and 30,000 were for children. Patients spent about 5 days in the hospital, at an average cost of $6,223 per stay. Total hospital costs were nearly $500 million overall in 2004.
• Falls were the most frequent cause of injury hospitalizations, accounting for over 38 percent of injury stays. There were 474,000 hospital stays for falls among patients age 65 and older-this age group made up about two-thirds of hospital stays for falls. Nearly 15 percent of injury-related stays resulted from motor vehicle traffic accidents and about 12 percent resulted from poisonings.

For more information about HCUP and to view the Statistical Briefs, please visit http://www.ahrq.gov/data/hcup/.

Bariatric Surgery Is Emerging as the Leading Method of Weight Loss Among Americans Who Are Morbidly Obese Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for 1998 and 2003, show that from 1998 to 2003, the total number of bariatric surgeries increased by more than 740 percent from 13,386 to 112,435. National hospital costs for bariatric surgeries increased by more than 10-fold from $173 million in 1998 to $1.74 billion in 2003, with the largest cost increase among the privately insured. On the other hand, long-term health benefits may outweigh the costs of bariatric surgery. One meta-analysis found that diabetes (for which care cost nearly $11,000 per person with diabetes in 2002) was resolved in 77 percent of patients who received bariatric surgery, cholesterol problems were improved in 70 percent, and hypertension was resolved in 62 percent of patients. Source: National trends in the costs of bariatric surgery, by William E. Encinosa, Ph.D., Didem M. Bernard, Ph.D., and Claudia A. Steiner, M.D., M.P.H., in Bariatrics Today 3, pp. 10-12, 2005.

AHRQ Quality Indicators

AHRQ has developed an array of health care decisionmaking and research tools that can be used by audiences such as program managers, purchasers, researchers, government agencies, and others. One tool, the AHRQ Quality Indicators (QIs), is widely used to:

• Highlight potential quality concerns.
• Identify areas that need further study and investigation.
• Track changes over time.

The AHRQ QIs are a set of indicators organized into three modules, each of which measures quality associated with the delivery of care occurring in either an outpatient or an inpatient setting:

• Prevention Quality Indictors (PQIs) are ambulatory care-sensitive conditions that identify adult hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.
• Inpatient Quality Indicators (IQIs) reflect quality of care for adults inside hospitals and include: inpatient mortality for medical conditions; inpatient mortality for surgical procedures; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures may be associated with lower mortality.
• Patient Safety Indicators (PSIs) also reflect quality of care for adults inside hospitals, but focus on potentially avoidable complications and iatrogenic events.

The AHRQ QIs are being used for national, State-level, and hospital-level public reporting and tracking:

• AHRQ's National Healthcare Quality and Disparities Reports and their derivative products incorporate many PQIs and PSIs for tracking and reporting at the national level. Selected IQIs and composite measures are planned for inclusion in future reports.
• The demand for information to better inform consumers has increased, specifically demand for standardized hospital-level comparative data as a result of concern over quality and patient safety in the hospital setting. Currently, there are eight States that report some or all of the AHRQ QIs: Texas, New York, Wisconsin, Massachusetts, Oregon, California, Utah, and Florida. Kentucky and Iowa are both planning to publicly report the AHRQ QIs in the next year or so.

The State of Connecticut Used AHRQ's PQIs To Assess its Health Care System The Connecticut Office of Health Care Access (OHCA) used AHRQ's Prevention Quality Indicators (PQIs) for its databook, Preventing Hospitalizations in Connecticut: Assessing Access to Community Services, FYs 2000-2004. The databook uses all 16 of AHRQ's PQIs to assess the quality of the State's health care system outside the hospital setting. Comparing State acute care hospital discharge data to national data provided by AHRQ, OHCA found that Connecticut had a better record of preventable hospitalizations for 15 of the 16 PQIs. Of particular significance is the databook's conclusion that preventable hospitalizations are increasing in the State, underscoring the need for timely intervention. Hospitals, community health centers, and local departments of public health are using this information to design community outreach services, particularly those for the care and management of chronic illnesses such as diabetes and asthma. Local providers are also incorporating data into grant applications for disease management programs, chronic illness awareness education, and increased specialist care at community health centers. The databook is available at: http://www.ct.gov/ohca/lib/ohca/publications/acsc_databook00-04.pdf (PDF Help).

Pediatric Quality Indicators Software

In 2006, AHRQ released the Pediatric Quality Indicators (PedQIs). The PedQIs are indicators of children's health care that can be used with inpatient discharge data. They are designed to help hospitals examine both the quality of inpatient care and the quality of outpatient care that can be inferred from inpatient data, such as potentially preventable hospitalizations. The module consists of 13 provider-level indicators, such as accidental puncture or laceration and postoperative respiratory failure, plus 5 area-level indicators, including admission rates for children with asthma, gastroenteritis, perforated appendix, and urinary tract infections as well as diabetes short-term complication rates.

More information on the AHRQ QIs can be found on the Web site at http://www.qualityindicators.ahrq.gov.

Consumer Assessment of Healthcare Providers and Systems

The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers, such as the communication skills of providers and the accessibility of services. CAHPS® originally stood for the Consumer Assessment of Health Plans Study, but as the products have evolved beyond health plans, the name has evolved as well to capture the full range of survey products and tools.

CAHPS® Hospital Survey Chartbook

In 2006, CAHPS® released the CAHPS® Hospital Survey Chartbook, which presents summary-level results from the CAHPS® Hospital Survey, commonly referred to as H-CAHPS. H-CAHPS was tested by 254 hospitals across the country in 2005. A total of 84,779 people responded to the survey.

Highlights of the survey results presented in this report include:

• High ratings for hospital care by a majority of survey respondents: 56 percent rated their hospitals either "9" or "10" on a 10-point scale where "0" is the "worst possible hospital" and "10" is the "best possible hospital."
• Highest scores for communication with doctors and nurses: 87 percent and 81 percent reported that doctors and nurses (respectively) always treated them with courtesy and respect.
• Lowest scores for communication about medications and discharge information: 26 percent reported that hospital staff never described possible side effects of new medications in a way they could understand, and 24 percent reported that hospital staff never talked with them about whether they would have the help they needed when they left the hospital.
• High to moderate scores for pain management: 77 percent reported that hospital staff always did everything they could to help with pain; however, only 64 percent reported that their pain was always well controlled when they needed pain medication.

In January 2006, the U.S. Office of Management and Budget (OMB) officially approved the use of the CAHPS Hospital Survey. OMB's approval allows the Centers for Medicare & Medicaid Services and the Hospital Quality Alliance to begin national implementation of the instrument.

CAHPS® In-Center Hemodialysis Survey

In November 2006, the CAHPS® Consortium, in cooperation with the Centers for Medicare & Medicaid Services (CMS), released the CAHPS® In-Center Hemodialysis Survey for public use. This standardized questionnaire was designed to help dialysis facilities and End Stage Renal Disease (ESRD) Networks assess and improve the experiences of their patients with in-center hemodialysis.

CAHPS® 4.0 Version of Health Plan Survey

CAHPS® Health Plan Survey 4.0, the newest version of the questionnaire that first put the CAHPS® program on the map, was released in 2006. The survey has been revised after careful testing and solicitation of stakeholder input by the CAHPS® Consortium and the National Committee for Quality Assurance (NCQA). Like all CAHPS® surveys, the Health Plan Survey 4.0 assesses those aspects of care for which the patient is the best or only judge, and has undergone rigorous testing and analysis by the CAHPS® grantees in order to ensure its reliability.

These products and additional information on CAHPS® can be found on the Web site at: http://www.cahps.ahrq.gov

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