NHLBI Workshop

Data Needs for Cardiovascular Events, Management, and Outcomes

Quality Improvement Measures for Cardiovascular Disease - Dr. Helen Burstin

Mission Statement: AHRQ

• The mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

Overview

• Focus on quality and cost measurement for CVD
  • The National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR)
• AHRQ's role in quality and cost measures for CVD
  • Healthcare Cost and Utilization Project (HCUP)
  • National CAHPS Benchmarking Database (NCBD)
  • Medical Expenditure Panel Survey (MEPS)
• Role of Health IT in quality measurement

RAND Study: Quality of Health Care Often Not Optimal

• Doctors provide appropriate health care only about half the time
• E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults in the United States, N Engl J Med, 2003

Congressional Mandate: Mandated by Congress in the Healthcare Research and Quality Act (PL. 106-129)

• "National trends in the quality of health care provided to the American people"
• "Prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations"

2004 National Reports on Quality and Disparities -- www.qualitytools.ahrq.gov

• Second annual reports focus on quality of and disparities in health care in America
• Measurement Topics
  • Quality of Health Care
    • Effectiveness
      • Cancer, Diabetes, ESRD, Heart Disease, HIV/AIDS, Maternal & Child Health, Mental Disease, Respiratory Disease, Nursing Home and Home Health Care
    • Safety
    • Timeliness
    • Patient centeredness
  • Access to Health Care
    • Getting into the system
      • Insurance, Usual Source of Care, Perceptions of Need
    • Getting care within the system
    • Perceptions of care
      • Patient-provider communication, relationship
    • Health care use
• Key Findings from the 2004 Reports
  • Disparities are pervasive.
  • Improvement is possible, but change takes time.
  • Gaps in information exist, especially for specific conditions and populations.
  • The gap between the best possible care and actual care remains large.
  • Quality is improving in many areas, but change takes time.
  • Further improvement in health care is possible.

CVD Prevention

• Screening for high blood pressure (NHIS)
  • % blood pressure measured within preceding 2 years and can state whether their BP is normal or high
• Lipid screening: % Adults (20+) (NHANES)
  • Ever had a cholesterol checked
  • Were told by a doctor that they had a high cholesterol
  • With high cholesterol taking cholesterol-lowering medication
  • With high cholesterol who have total cholesterol < 200
• Counseling on Risk Factors (MEPS)
  • Percent of smokers receiving advice to quit smoking

CVD Management

• Management of hypertension (NHANES)
  • Percent of people with hypertension who have blood pressure under control
• Management of CHF (NHDS/HCUP SID)
  • Hospital admissions for CHF

AMI Measures (QIO)

• AMI Measures:
  • % AMI patients administered aspirin w/in 24 hrs of admission
  • % AMI patients prescribed aspirin at discharge
  • % AMI patients administered beta blocker w/in 24 hrs of admission
  • % AMI patients prescribed beta blocker at discharge
  • % AMI patients with LV dysfunction prescribed ACE inhibitor at discharge
  • % AMI patients given smoking cessation counseling while hospitalized
  • Median time in minutes to thrombolysis
  • Median time in minutes to PTCA
• Aggregate Measures technical advisory panel supported the development of a composite measure of the 8 QIO AMI measures for 2005

Heart Disease Treatment (HCUP-NIS)

• Pediatric cardiac surgery mortality rate
• Abdominal aortic aneurysm (AAA) repair mortality rate
• CABG morality rate
• PTCA mortality rate
• AMI mortality rate
• CHF mortality rate

Patient-Provider Communication

• CAHPS Core Components (MEPS/NCBD)
  • How often their health providers listened to them?
  • How often their health providers explained things clearly?
  • How often their health providers showed respect for what they had to say?
  • How often their providers spent enough time with them?

National CAHPS® Benchmarking Database

• National repository for CAHPS® data
• Includes CAHPS® survey data and health plan descriptive data
  • Commercial, Medicare, Medicaid
  • Adult and child
• Facilitates comparisons of CAHPS® results
• Provides benchmarking information useful for evaluation and QI
• Offers primary data for research purposes

The Healthcare Cost and Utilization Project (HCUP)

• Federal, state, industry partnership
• Has 90% of all inpatient discharges
• Growing to include ED, ambulatory surgery, other
• Includes charge, payer, clinical data
• Extensive use by researchers and policy-makers
• New methodology converts charges to cost
  • Friedman, Journal of Health Care Finance, 2002
• Quality Indicators Usable with any discharge data

HCUP Has Five Databases

• State Inpatient Databases (SID)
• Nationwide Inpatient Sample (NIS)
• Kids' Inpatient Database (KID)
• State Emergency Department Databases (SEDD)
• State Ambulatory Surgery Databases (SASD)

State Inpatient Databases (SID)

• What is the SID?
  • Captures all inpatient visits in a state
  • In total, they encompass data from 90% of all inpatient visits in community hospitals
• What is in the SID?
  • ~55,000 - 3.9 million SID records
  • Data found on inpatient bills (UB-92)
• How can the SID be used?
  • Can be linked to AHA, ARF and other HCUP databases
  • Enumerate hospitals and discharges within market areas or a state
  • Compare of data from two or more states
  • Disparities and quality of care
  • State-specific trends in inpatient utilization, access, charges and outcomes
• What states are in the SID and released to the public through the Central Distributor?

Nationwide Inpatient Sample (NIS)

• Years of Data
  • 1988 - 2002; 2003 - Coming in Summer, 2005
• Enables
  • National and regional estimates of all hospitalizations
• Sample:
  • All discharges from a sample of short-term community hospitals from the SID
  • Hospitals sampled based on region, location, ownership, teaching, bed size
• Description for 2003 NIS
  • 36 states and ~ 1,000 hospitals
  • ~ 7.8 million records (unwgt) = ~ 37.8 million records (wgt)
• Price in Central Distributor
  • $160-$322 per year, depending on the year
  • $20 per year for a student/trainee

Kids' Inpatient Database (KID)

• Years of Data
  • 1997 and 2000 available; 2003 -- Coming October, 2005
• Enables
  • National and regional estimates of pediatric hospitalization
  • Studies of common and rare pediatric conditions
• Sample:
  • 10% stratified sample of in-hospital births from the SID
  • 80% of other pediatric discharges from the SID
• Description for 2003 KID
  • Data on hospitalizations for children < or = 20 years
  • 36 states and > 2,800 hospitals
  • ~ 2.5 million records (unwgt) = ~ 7.3 million records (wgt)
• Price in Central Distributor
  • $200 per year
  • $20 per year for a student/trainee

State Emergency Department Databases (SEDD)

• What is the SEDD?
  • Captures all ED visits in a state that do not result in admission
  • With the SID, captures all ED visits in the state
• What is in the SEDD?
  • 190,000 - 2.7 million ED records
  • Includes data found on outpatient bills
• How can the SEDD be used?
  • Can be linked to AHA, ARF, other HCUP databases
  • Injury surveillance
  • Trends in ED use
  • Ambulatory care sensitive conditions
  • Enumerate ED visits and re-visits
  • Disparities in ED utilization
• What states are in the SEDD?

State Ambulatory Surgery Databases (SASD)

• What is the SASD?
  • All hospital-based AS visits in a state
  • Includes some free-standing AS visits
• What is in the SASD?
  • ~75,000 - 2.9 million AS records per state
  • Includes data found on outpatient bills
• How can the SASD be used?
  • Can be linked to AHA, ARF, other HCUP databases
  • State-specific trends in ambulatory surgery utilization, access, charges, and outcomes
  • Compare IP and AS data
  • Examine complications of AS
• What states are in the SASD?

AHRQ Quality Indicators (QIs)

• Developed through contract with UCSF-Stanford Evidence-based Practice Center
• Use existing hospital discharge data, based on readily available data elements
• Incorporate severity adjustment methods (APR-DRGs, comorbidity groupings) in Inpatient QIs
• Current modules: Prevention QIs, Inpatient QIs, and Patient Safety Indicators

Overview of AHRQ QIs

• Prevention Quality Indicators
  • Ambulatory care sensitive conditions
• Inpatient Quality Indicators
  • Mortality following procedures
  • Mortality for medical conditions
  • Utilization of procedures
  • Volume of procedures
• Patient Safety Indicators
  • Post-operative complications
  • Iatrogenic conditions

AHRQ Health IT Initiatives

• Transforming Healthcare Quality through Information Technology (THQIT) Grant Program
• The AHRQ National Resource Center for Health IT
• State and Regional HIT Demonstrations ( 6 states)
• CMS - AHRQ collaboration
• Indian Health Service - EHR Project
• Privacy and Legal Framework

Transforming Healthcare Quality through Information Technology

• Promoting access to Health IT:
  • Over 100 grants to communities, hospitals, providers, and health care systems to help in all phases of the development and use of health information technology.
  • The grants are spread across 38 states
  • Special focus on small and rural hospitals and communities.
  • First year funding is $41 million and will total nearly $96 million over three years.

Medicare Prescription Drug, Improvement, and Modernization Act

• Health IT Provisions
  • Electronic Prescription Program
  • Grants to Physicians - ePrescribing systems
  • Telemedicine Demonstrations Projects
  • Medicare Care Management Performance Demonstration
  • Council for Technology and Innovation
  • Commission on Systemic Interoperability

Practice-Based Research Networks (PBRNs)

• 36 new PBRN grants awarded in 2002
• 19 PBRN grants awarded in 2000

Contact Information: For additional questions, please contact Dr. Helen Burstin hburstin@ahrq.gov

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