National Healthcare Quality Report, 2007

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Chapter 1. Introduction and Methods

This is the fifth annual report produced by the U.S. Department of Health and Human Services (HHS) on the state of health care quality nationally. It is designed to summarize data across a wide range of patient needs, from staying healthy, to getting better, to living with illness and disability, to coping with the end of life. It tracks quality across nine condition areas and tells the reader how effective, safe, timely, and patient centered care is in America today. The National Healthcare Quality Report (NHQR) presents data at the national level and at the State level where State level data are available. Most important, this fifth report presents how far the Nation has—or has not—come in the past 5 years in improving the quality of health care in the United States.

In 1999, Congress directed the Agency for Healthcare Research and Quality (AHRQ) to produce an annual report, starting in 2003, on health care quality in the United States. AHRQ, with support from HHS and private sector partners, designed and produced the NHQR to respond to this legislative mandate.

The first NHQR, released in 2003, was a comprehensive national overview of the quality of health care received by the general U.S. population. The 2004 NHQR initiated a second critical goal of the report series—tracking the Nation's quality improvement progress. The 2005 NHQR introduced a set of core measures and a variety of new composite measures. The 2006 NHQR continued to improve data, measures, and methods, adding new databases and measures and refining methods for quantifying and tracking changes in health care.

This 2007 NHQR continues to focus on a subset of core measures that includes the most important and scientifically supported measures in the full NHQR measure set. In addition, new supplemental measures are included that complement core measures in key areas. Finally, as in previous NHQRs, references have been systematically updated (that is, annual reports and other regularly released publications have been updated as appropriate, and a wide breadth of peer-reviewed journals and electronically published articles have been searched for inclusion as references).

This chapter summarizes the methodological approaches AHRQ has taken in producing the 2007 NHQR. Issues related to changes in measures, additional data sources, and modifications to presentation format are summarized below. Material that is new in this year's report is specifically highlighted and includes:

A new chapter and measures on the efficiency dimension of care.
New data sources and measures for:
- Cancer care.
- HIV testing.
- Nursing home, home health, and hospice care.

As in previous years, the 2007 NHQR was written by AHRQ staff, with the support of AHRQ's National Advisory Council and the Interagency Work Group for the NHQR.

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How This Report Is Organized

The basic structure of the report consists of the following:

Highlights summarizes key themes and highlights from the 2007 report.
Chapter 1: Introduction and Methods documents the organization, data sources, and methods used in the 2007 report and describes major changes from previous reports.
Chapter 2: Effectiveness examines the quality of health care in the general U.S. population, focusing on nine clinical conditions or care settings based largely on Healthy People 2010 condition areas. Measures of the quality of health care used in this chapter are identical to measures used in the National Healthcare Disparities Report (NHDR) except when data to examine disparities are unavailable for inclusion in the NHDR.
Chapter 3: Patient Safety tracks measures of patient safety, including postoperative complications, other complications of hospital care, and complications of medications.
Chapter 4: Timeliness examines the delivery of time-sensitive clinical care and patient perceptions of the timeliness and accessibility of their care.
Chapter 5: Patient Centeredness tracks patients' experiences with care in an office or clinic and satisfaction with communication during a hospital stay in order to incorporate the patient's experience and perspective into the report.
Chapter 6: Efficiency presents a conceptual view and an initial analysis of this dimension of health care performance that has been missing from previous releases of the NHQR.

Appendixes include the following:

Appendix A: Data Sources provides information about each database analyzed for the NHQR, including data type, sample design, and primary content.
Appendix B: Measure Specifications provides information about how to generate each measure analyzed for the NHQR. Measures highlighted in the report are described, as well as other measures that were examined but not included in the text of the report.
Appendix C: Data Tables provides detailed tables for most measures analyzed for the NHQR, including measures highlighted in the report text and measures examined but not included in the text. A few measures cannot support detailed tables and are not included in the appendix.ⁱ

ⁱ NHQR data can now be accessed through NHQRnet, an online tool that provides Internet users with an opportunity to specify dimensions of analysis and produce data tables. NHQRnet is available through the AHRQ Web site at http://nhqrnet.ahrq.gov/nhqr/jsp/nhqr.jsp.

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Measure Set for the NHQR and NHDR

Core and Composite Measures

As in previous years, the 2007 reports focus on a subset of core report measures. In addition, composite measures are included to provide readers with a summarized picture of some aspect of health care by combining information from multiple component measures.

Core measures. For the 2005 reports, the Interagency Work Group selected a group of core 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 NHQR uses alternating sets of core measures. These measures, which relate to cancer prevention and childhood preventive services, are listed in Table 1.1.

Reported in 2006 NHQR & NHDR^*	Reported in 2007 NHQR & NHDR

Colorectal cancer screening Colorectal cancer mortality Late stage colorectal cancer	Breast cancer screening (mammography) Breast cancer mortality Late stage breast cancers

Children who had a vision check	Children who had dental care

^* The measures listed in this column will be reported again in the 2008 reports.

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 always available. A complete list of the 2007 NHQR core measure set is presented in Table 1.2.

Section	Process measures	Outcome measures

Effectiveness—Cancer	Women age 40 and over who reported they had a mammogram within the past 2 years	Rate of breast cancer incidence per 100,000 women age 40 and over diagnosed at advanced stage Cancer deaths per 100,000 women per year for breast cancer

Effectiveness—Diabetes	Composite: Adults age 40 and over with diabetes who had all 3 recommended services for diabetes in the past year (at least 1 hemoglobin A1c measurement, a retinal eye examination, and a foot examination)	Hospital admissions for lower extremity amputation in patients with diabetes per 100,000 population

Effectiveness—End Stage Renal Disease	Dialysis patients registered on waiting list for transplantation	Hemodialysis patients with adequate dialysis (urea reduction ratio 65% or greater)

Effectiveness—Heart Disease	Composite: Patients with acute myocardial infarction (AMI) who received recommended hospital care for AMI (administered aspirin and beta blocker within 24 hours of admission, prescribed aspirin and beta blocker at discharge, and given smoking cessation counseling while hospitalized)^a Composite: Heart failure patients who received recommended hospital care for heart failure (evaluation of left ventricular ejection fraction and prescribed ACE inhibitor or ARB at discharge, if indicated, for left ventricular systolic dysfunction)^a Current smokers age 18 and over receiving advice to quit smoking Adults who were obese who were given advice about exercise	AMI mortality rate (number of deaths per 1,000 discharges for AMI)

Effectiveness—HIV and AIDS		New AIDS cases per 100,000 population age 13 and over

Effectiveness—Maternal and Child Health	Pregnant women receiving prenatal care in first trimester Children 19-35 months who received all recommended vaccines Children ages 2-17 who received advice from a doctor or other health provider about healthy eating Children ages 2-17 who had a dental visit in the past year	Infant mortality per 1,000 live births, birth weight <1,500 grams Hospital admissions for pediatric gastroenteritis per 100,000 population ages 4 months-17 years

Effectiveness—Mental Health and Substance Abuse	Adults age 18 and over with major depressive episode in the past year who received treatment for depression in the past year Persons age 12 and over who needed treatment for any illicit drug use and who received such treatment at a specialty facility in the past year	Deaths due to suicide per 100,000 population Persons age 12 and over receiving substance abuse treatment who completed treatment course

Effectiveness—Respiratory Diseases	Adults age 65 and over who ever received pneumococcal vaccination Composite: Pneumonia patients who received recommended hospital care for pneumonia (blood cultures collected before antibiotics administered, received initial antibiotic dose within 4 hours of hospital arrival and consistent with current recommendations, and received screening for influenza and pneumococcal disease vaccination status and vaccination, if indicated)^b Visits where antibiotics were prescribed for a diagnosis of common cold per 10,000 population	TB patients who complete a curative course of treatment within 12 months of initiation of treatment Hospital admissions for pediatric asthma per 100,000 population ages 2-17

Effectiveness—Nursing Home, Home Health, and Hospice Care	Long-stay nursing home residents who were physically restrained	High-risk long-stay nursing home residents who have pressure sores Low-risk long-stay nursing home residents who have pressure sores Home health care patients who get better at walking or moving around Home health care patients who had to be admitted to the hospital

Patient Safety	Composite: Adult Medicare patients having surgery who received appropriate timing of antibiotics Percent of community-dwelling adults age 65 and over who had at least 1 prescription (from a list of 33 medications) that is potentially inappropriate for the elderly	Composite: Adult surgery patients with postoperative complications (postoperative pneumonia, catheter-associated urinary tract infection,^c or venous thromboembolic events) Bloodstream infections or mechanical adverse events associated with central venous catheters

Timeliness		Adults who can sometimes or never get care for illness or injury as soon as wanted Emergency department visits where patients left without being seen

Patient Centeredness	Composite: Adults who sometimes or never received patient centered care (whose health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent enough time with them) Composite: Children who sometimes or never received patient centered care (whose health providers sometimes or never listened carefully, explained things clearly, respected what their parents had to say, and spent enough time with them)

^a Use of angiotensin converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction was changed to also include angiotensin receptor blockers (ARBs) as an acceptable alternative.

^b Appropriate antibiotic selection was changed to exclude patients with health-care-associated pneumonia from the denominator used in the calculation. Collection of samples for blood culture within 24 hours of hospital arrival was changed so that only those patients who were admitted to the intensive care unit within 24 hours of hospital arrival are included in the denominator.

^c The individual measure for postoperative urinary tract infection was refined to include only patients with catheter-associated urinary tract infections.

Composite measures. More than one measure can be combined to form a single composite measure of health care quality. A composite measure summarizes care that is represented by individual measures that are often related in some way, such as components of care for a particular disease or illness. 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, in 2006, a number of new composite measures were added.ⁱⁱ Composite measures, which now make up about 20% of the core measures, are listed in Table 1.3.

Composite measures in the NHQR are created based on two different models—the appropriateness model or the opportunities model. When possible, an appropriateness model is used to create composite measures. It is sometimes referred to as the "all-or-none" approach, because it is calculated based on the number of patients who received all appropriate care. One example of this model is the diabetes composite, in which a patient who receives only one or two of the three services would not be counted as having received the recommended care.

ⁱⁱ Go to Chapter 1, Introduction and Methods, in the 2006 NHQR for more detailed information about these and other methods used to calculate composite measures used in the reports.

In cases where insufficient data are available to apply an appropriateness model, an opportunities model may be applied. The opportunities 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. Composite measures that use this model summarize the proportion of appropriate care that is delivered. The denominator for an opportunities model composite is the sum of opportunities to receive appropriate care across a panel of process measures. The numerator is the sum of the components of appropriate care that are actually delivered. The composite measure of recommended hospital care for heart attack is an example where this model is applied. The total number of patients who actually receive treatments represented by individual components of the composite measure (e.g., aspirin therapy within 24 hours, beta blocker within 24 hours, smoking cessation counseling) is divided by the sum of all of these opportunities to receive appropriate care.

Measures from the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) 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. They are typically presented as the proportion of respondents who reported that providers sometimes or never, usually, or always performed well.

Composite measures that relate to rates of complications of hospital care are postoperative complications and complications of central venous catheters. For these complication rate composites, an additive model is used that 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 among them (regardless of their distribution), the composite score would be 30%.

Composite measure	Individual measures forming composite	Model

Receipt of three recommended diabetic services	Adults age 40 and over with diabetes who had a hemoglobin A1c measurement at least once in the past year Adults age 40 and over with diabetes who had a retinal eye examination in the past year Adults age 40 and over with diabetes who had a foot examination in the past year	Appropriateness

Childhood immunization	Children 19-35 months who received 4 doses of diphtheria-pertussis-tetanus vaccine Children 19-35 months who received at least 3 doses of polio vaccine Children 19-35 months who received at least 1 dose of measles-mumps-rubella vaccine Children 19-35 months who received 3 doses of Haemophilus influenzae type B vaccine Children 19-35 months who received 3 doses of hepatitis B vaccine	Appropriateness

Recommended hospital care for heart attack^a	Acute myocardial infarction (AMI) patients administered aspirin within 24 hours of admission AMI patients with aspirin prescribed at discharge AMI patients administered beta blocker within 24 hours of admission AMI patients with beta blocker prescribed at discharge AMI patients with left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge AMI patients with a history of smoking in the past year who received smoking cessation counseling	Opportunities

Recommended hospital care for heart failure^a	Heart failure patients who received evaluation of left ventricular ejection fraction Heart failure patients with left ventricular systolic dysfunction prescribed ACE inhibitor or ARB at discharge	Opportunities

Recommended hospital care for pneumonia^b	Patients with pneumonia who received the initial antibiotic dose within 4 hours of hospital arrival Patients with pneumonia who received the initial antibiotic consistent with current recommendations Patients with pneumonia who had blood cultures collected before antibiotics were administered Patients with pneumonia who received influenza screening or vaccination Patients with pneumonia who received pneumococcal screening or vaccination	Opportunities

Timing of antibiotics to prevent postoperative wound infection	Adult Medicare patients having surgery who received prophylactic antibiotics within 1 hour prior to surgical incision Adult Medicare patients having surgery who had prophylactic antibiotics discontinued within 24 hours after surgery end time	Opportunities

Patient experience of care	Adults whose providers sometimes or never listened carefully to them Adults whose providers sometimes or never explained things in a way they could understand Adults whose providers sometimes or never showed respect for what they had to say Adults whose providers sometimes or never spent enough time with them Children whose parents report that their child's providers sometimes or never listened carefully to them Children whose parents report that their child's providers sometimes or never explained things in a way they could understand Children whose parents report that their child's providers sometimes or never showed respect for what they had to say Children whose parents report that their child's providers sometimes or never spent enough time with them	CAHPS®

Communication with doctors in the hospital (for adults with a hospitalization)	Adults whose doctors sometimes or never showed respect for what they had to say Adults whose doctors sometimes or never listened carefully to them Adults whose doctors sometimes or never explained things clearly	CAHPS®

Communication with nurses in the hospital (for adults with a hospitalization)	Adults whose nurses sometimes or never treated them with courtesy and respect Adults whose nurses sometimes or never listened carefully to them Adults whose nurses sometimes or never explained things in a way they could understand	CAHPS®

Communication about medications in the hospital (for adults with a hospitalization)	Hospital staff sometimes or never had good communication about what a new medication was for Hospital staff sometimes or never described possible side effects of a new medicine in a way patients could understand	CAHPS®

Discharge information from the hospital (for adults with a hospitalization)	Hospital staff talked about whether patient would have needed help after leaving the hospital Hospital staff provided information in writing about what symptoms or health problems to look for after leaving the hospital	CAHPS®

Postoperative complications^c	Adult surgery patients with postoperative pneumonia events Adult surgery patients with catheter-associated urinary tract infection Adult surgery patients with postoperative venous thromboembolic events	Additive

Complications of central venous catheters	Bloodstream infections associated with central venous catheters Mechanical adverse events associated with central venous catheters	Additive

^c The individual measure for postoperative urinary tract infection was refined to include only patients with catheter-associated urinary tract infections.

Presentation. As in past reports, the NHQR and its companion NHDR continue to be formatted as chartbooks. Each section in the 2007 report begins with a description of the importance of the section's topic in a standardized format. After introductory text, charts 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 often 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.

As in last year's report, findings presented in the text meet report criteria for importance.ⁱⁱⁱ 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.

ⁱⁱⁱ 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.

Measures of effectiveness for each condition or care setting area are organized further into categories that reflect the patient's need for preventive care, treatment of illness, and management of chronic conditions. Further detail on each of these categories and the measures included can be found in Chapter 2, Effectiveness.

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Changes to the Measure Set

The measure sets used in the 2007 NHQR and NHDR have been improved in several ways. A handful of measures were modified to reflect changing standards of care or improved information about care. Although no additional core measures were added, some supplemental measures are being presented in the reports for the first time in 2007.

Modifications of existing composite measures. Some individual components of composite measures were modified for the 2007 reports. The changes affect the comparability of data over time for each measure to varying degrees. This year, the following core composite measures of effectiveness and patient safety underwent modifications:

Recommended hospital care received by patients with acute myocardial infarction—The individual measure on use of angiotensin converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction was changed to also include angiotensin receptor blockers (ARBs) as an acceptable alternative.
Recommended hospital care received by patients with heart failure—The individual measure on use of ACE inhibitors in patients with left ventricular systolic dysfunction was changed to also include ARBs as an acceptable alternative.
Recommended hospital care received by patients with pneumonia—Two component measures underwent revision:
- The individual measure of appropriate antibiotic selection for community-acquired pneumonia was changed to exclude patients with health-care-associated pneumonia from the denominator used in the calculation.
- The individual measure for the collection of samples for blood culture within 24 hours of hospital arrival was changed so that only those patients who were admitted to the intensive care unit within 24 hours of hospital arrival are included in the denominator.
Postoperative care composite—The individual measure for postoperative urinary tract infection was refined to include only patients with catheter-associated urinary tract infections.

New measures. A number of new supplemental (non-core) measures have been included in the 2007 NHQR to fill identified gaps, including:

Three measures of recommended care for breast or colon cancer from the American Cancer Society and American College of Surgeons National Cancer Data Base (NCDB):
- Radiation therapy within 1 year of diagnosis for women with breast cancer receiving breast-conserving surgery.
- Axillary node dissection or sentinel lymph node biopsy at the time of lumpectomy or mastectomy for women with Stage I-IIb breast cancer.
- Surgical resection of colon cancer that included at least 12 lymph nodes.
Three measures of HIV testing from the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) National Survey of Family Growth (NSFG):
- Women ages 15-44 who completed a pregnancy in the last 12 months and had an HIV test as part of prenatal care.
- People ages 15-44 who ever had an HIV test outside of blood donation.
- People ages 15-44 with any HIV risk behaviors in the last 12 months who had an HIV test outside of blood donation in the last 12 months.
An individual measure of the adequacy of pain management for nursing home residents from the CDC-NCHS National Nursing Home Survey (NNHS):
- Pain management for nursing home residents with moderate, severe, or excruciating pain. Because this is not a periodic survey, findings are presented in the 2007 report only.

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

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Other Improvements in This Report

Consistent with the goal of improving the quality of and access to health care for all Americans, a number of improvements in the value and accessibility of the NHQR are made from year to year. Improvements this year include the addition of new data sources, a new chapter on the efficiency of health care, and expanded analysis of trends.

Addition of New Data Sources

NHQR data sources include surveys of individuals and health care facilities; data are also extracted from surveillance, vital statistics, and health care organization data systems (Table 1.4). Standardized suppression criteria were applied to all databases to support reliable estimates.^iv New data added this year come from the following:

National Cancer Data Base. The NCDB, jointly sponsored by the American College of Surgeons and the American Cancer Society, is a national hospital-based cancer registry. The NCDB includes approximately 75% of U.S. cancer cases and collects data from more than 1,400 hospitals that have cancer treatment programs approved by the Commission on Cancer. The NCDB serves as a comprehensive clinical surveillance resource for cancer care in the United States, with the intention of improving the quality of cancer care by providing physicians, cancer registrars, and others with the means to compare their management of cancer patients with the way in which similar patients are managed in other cancer centers around the country. Data about treatment of breast and colon cancer are included in the 2007 NHQR.
National Survey of Family Growth. This survey gathers information on family life, marriage and divorce, pregnancy, infertility, use of contraception, and men's and women's health. Survey data are collected by NCHS, and the results are used by HHS and others to plan health services and health education programs, as well as to perform statistical analyses of families, fertility, and reproductive health. Data about HIV testing rates from the NSFG are included in the 2007 NHQR.

^iv Estimates based on sample sizes fewer than 30 or with relative standard error greater than 30% are considered unreliable and suppressed. Databases with more conservative suppression criteria retain their own standards.

National Nursing Home Survey. The NNHS provides information on nursing homes from two perspectives: that of the provider of services and that of the recipient of care. For recipients, data were collected on demographic characteristics, health status and medications taken, services received, and sources of payment. Survey data were obtained through personal interviews with facility administrators and designated staff who used administrative records to answer questions about the facilities, staff, services, and programs; medical records were used to answer questions about the residents. The total number of nursing home facilities that participated in the 2004 NNHS is 1,174. Data about the management of pain for nursing home residents are included in the 2007 NHQR.

**Table 1.4. Databases used in the 2007 reports (new databases in *italics*)**
Survey data collected from populations: AHRQ, Medical Expenditure Panel Survey (MEPS), 2002-2004 CAHPS® (Consumer Assessment of Healthcare Providers and Systems) Hospital Survey, 2007 California Health Interview Survey, 2001-2005 Centers for Disease Control and Prevention (CDC), Behavioral Risk Factor Surveillance System (BRFSS), 2001-2005 CDC-NCHS, National Health and Nutrition Examination Survey (NHANES), 1999-2004 CDC-NCHS, National Health Interview Survey (NHIS), 1998-2005 CDC-NCHS/National Immunization Program, National Immunization Survey (NIS), 1998-2005 CDC-NCHS, National Survey of Family Growth (NSFG), 2002 Centers for Medicare & Medicaid Services (CMS), Medicare Current Beneficiary Survey (MCBS), 1998-2003 National Center for Education Statistics, National Assessment of Adult Literacy, Health Literacy Component, 2003 National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2005 Substance Abuse and Mental Health Services Administration (SAMHSA), National Survey on Drug Use and Health (NSDUH), 2002-2005 U.S. Census Bureau, American Community Survey, 2004
Data collected from samples of health care facilities and providers: American Cancer Society and American College of Surgeons, National Cancer Data Base (NCDB), 1999-2004 CDC-NCHS, National Ambulatory Medical Care Survey (NAMCS), 1997-2004 CDC-NCHS, National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED), 1997-2004 CDC-NCHS, National Hospital Ambulatory Medical Care Survey-Outpatient Department (NHAMCS-OPD), 1997-2004 CDC-NCHS, National Hospital Discharge Survey (NHDS), 1998-2005 CDC-NCHS, National Nursing Home Survey (NNHS), 2004 CMS, End Stage Renal Disease Clinical Performance Measures Project (ESRD CPMP), 2001-2005 National Sample Survey of Registered Nurses, 2004
Data extracted from data systems of health care organizations: AHRQ, Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample, 1994, 1997, 2000-2004 and State Inpatient Databases,^a 2003 and 2004 CMS, Home Health Outcomes and Assessment Information Set (OASIS), 2002-2005 CMS, Hospital Compare, 2006 CMS, Medicare Patient Safety Monitoring System, 2003-2005 CMS, Nursing Home Minimum Data Set, 2002-2005 CMS, Quality Improvement Organization (QIO) program, Hospital Quality Alliance (HQA) measures, 2000-2004 HIV Research Network (HIVRN) data, 2001-2003 Indian Health Service, National Patient Information Reporting System (NPIRS), 2002-2004 National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS®), 2001-2005 National Institutes of Health (NIH), United States Renal Data System (USRDS), 1998-2003 SAMHSA, Treatment Episode Data Set (TEDS), 2002-2004
Data from surveillance and vital statistics systems: CDC-National Center for HIV, STD, and TB Prevention, HIV/AIDS Surveillance System, 1998-2005 CDC-National Center for HIV, STD, and TB Prevention, TB Surveillance System, 1999-2003 CDC-National Program of Cancer Registries (NPCR), 2000-2004 CDC-NCHS, National Vital Statistics System (NVSS), 1999-2004 NIH-National Cancer Institute, Surveillance, Epidemiology, and End Results (SEER) program, 1992-2004

^aNot all States participate in HCUP. For details, go to HCUP entry in Appendix A, Data Sources.

Note: Measures from the California Health Interview Survey, the American Community Survey, the National Assessment of Adult Literacy, and the National Sample Survey of Registered Nurses are used only in the 2007 NHDR. For details on these surveys, go to Chapter 1, Introduction and Methods, in the 2007 NHDR.

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Initial Findings on the Efficiency Dimension

For the first time, the 2007 NHQR presents information related to the efficiency of the U.S. health care system. Chapter 6 is the initial attempt to address this topic, which the Institute of Medicine includes as one of the six major "aims" of the health care system.^v AHRQ staff and the advisers and partners who contribute to production of the NHQR realize that this is an area still in early development.

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Expanded Analysis of Trends

In this year's report, AHRQ and its Federal partners have concentrated on refining the discussion of trends to improve the NHQR's ability to summarize progress in improving health care quality made over the past 5 years. In the Highlights section of this report, as in past NHQRs, the average annual rate of change was calculated between the earliest and the most recent estimates for all core measures. Consistent with Health, United States, a formula that produces the geometric rate of change is used for this calculation.^vi In addition, AHRQ has analyzed the set of "core measures" for the report and attempted to obtain a common baseline data year and common comparison year to fix the trends analysis to a particular period of time. This approach differs from past reports, in which these analyses provided an annualized rate of change in quality across all the core report measures. (That rate was not linked to a particular period but was a generalized "rate of improvement.")

^v The others are effectiveness, safety, timeliness, patient centeredness, and equity. The six aims are discussed in the 2001 Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century.

The primary reason for this addition is that the data sources for the NHQR are diverse, and each has particular years of data available. AHRQ has received feedback that its past trend analysis, although useful, is difficult to operationalize because the improvement rates are not fixed to particular points in time to permit analysis of particular policy initiatives. In addition to providing the general rate of change for measures that span the years 1994 (for a few measures) to 2005, this year's report therefore fixes the baseline analysis year as 2000-2001 and the comparison year as 2004-2005. In particular, an effort has been made to ensure that wherever trend data are available, a discussion is presented of whether performance has improved. Paired data years were used to allow the trend analysis to include the maximum number of core measures. The geometric rate of change, which assumes the same rate of change each year between the two time periods, has been calculated. In addition to the above changes made to improve the presentation of trends, two criteria are applied to determine whether a significant trend exists:

First, the difference between the earliest and most recent estimates shown must be statistically significant with p<0.05.
Second, the magnitude of average annual rate of change must be at least 1% per year. Only changes over time that meet these two criteria are discussed in the 2007 reports, unless otherwise noted.

^vi This calculation is consistent with those in Health, United States, published annually by the Centers for Disease Control and Prevention, National Center for Health Statistics.

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