Updating the Framework for the NHQR and NHDR

The Future Directions committee's updated framework for health care quality builds on previous IOM recommendations for measuring the state of health care in the NHQR and NHDR. The revised framework encompasses both well-established and emerging components of high-quality health care. The framework is a tool for examining AHRQ's portfolio of measures for comprehensi eness and for categorizing measures presented in the NHQR and NHDR. The framework's quality of care components are effectiveness, safety, timeliness, patient-centeredness, access, efficiency, care coordination, and health systems infrastructure capabilities. The committee includes in the framework the crosscutting dimensions of value and equity, which are to be reported for each of the quality of care components and to be considered when ranking measures for inclusion in the NHQR and NHDR.

Before beginning to publish the annual NHQR and NHDR in 2003, AHRQ sought the IOM's guidance regarding the overall content and organization for the reports (Appendix A). The IOM reportsEnvisioning the National Healthcare Quality Report (IOM, 2001b) and Guidance for the National Healthcare Disparities Report (IOM, 2002) provided the original conceptual framework for quality measurement in the NHQR and NHDR (Appendix C), upon which the Future Directions committee has built. This chapter provides the rationale for an expanded framework and, in a complementary Appendix D, explores measurement possibilities for the new framework components.

The framework is intended to define "dimensions and categories of measurement that will outlast any specific measures used at particular times. In essence, it lays down an enduring way of specifying what should be measured while allowing for variation in how it is measured over time" (IOM, 2001b, p. 42). In this sense, the framework presents a performance measure classification matrix that is of use not only for the NHQR and NHDR but also for all national healthcare report-related products. Because the framework components accommodate a broad spectrum of measures, and the universe of potential measures is voluminous and ever expanding, the priority areas discussed in the previous chapter are one element in helping define a narrower set of measures within the framework components. (Chapter 4 includes the Future Directions committee's recommendations on further defining the set of measures according to their potential health care quality impact.)

The Original Framework for the NHQR and NHDR

The original conceptual framework put forth in the 2001 Envisioning the National Healthcare Quality Report highlighted four components of health care quality: (1) safety, (2) effectiveness, (3) patient-centeredness, and (4) timeliness. These components corresponded to four of the six aims of quality health care set forth in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21^st Century (go to Box 3-1). At the time, measurement of efficiency was considered underdeveloped and thus omitted from the framework. The component of equitable care was deemed a crosscutting dimension (go to Appendix C for the framework originally adopted by AHRQ for the NHQR and NHDR).

Envisioning the National Healthcare Quality Report recommended that the performance measures presented in the NHQR be framed in consumer categories (i.e., in terms of "staying healthy, getting better, living with illness or disability, and coping with end-of-life care") (IOM, 2001b, p. 6). Subsequently, AHRQ found it more useful to frame the presentation of data by clinical stages of care (i.e., prevention, acute treatment, management) because that is the context in which most measures are currently developed. Although AHRQ's clinical stages of care are less patient-focused than the consumer categories, the committee agrees that the clinical stages of care are easily understood by patients as well as the policymakers, health care professionals, and researchers to whom the information in the NHQR and NHDR is primarily directed. Moreover, although data in the reports are not presented by the consumer categories, AHRQ indicated that these categories are implicitly considered when identifying potential measures for inclusion in its full measure set.¹

Envisioning the National Healthcare Quality Report acknowledges that the conceptual framework should be dynamic in nature in order to adjust to "changes in conceptualization of quality or significant changes in the nature of the U.S. health care system" (IOM, 2001b, p. 42). Indeed, since the development of the original conceptual framework, new areas for health care performance measurement have emerged, as have attributes of what constitutes high-quality care, thus leading the Future Directions committee to update the framework.

An Updated Framework for the NHQR and NHDR

The six quality aims expressed in the 2001 IOM Crossing the Quality Chasm report (go to Box 3-1) have become the basic vernacular for discussing health care quality improvement and disparities elimination. Many other organizations, ranging from providers to health plans to quality improvement organizations, have used the six aims to organize their own measurement or reporting efforts. For example, Aetna's High Performance Provider Initiatives and Hudson River Health Care (a safety net clinical setting) track performance measurement based on these aims (Aetna, 2008; Hudson River Healthcare, 2009). Because continuity is important to preserve and because the original conceptual framework for the national healthcare reports stems from the IOM's six aims, the committee decided to build on the pre-existing framework rather than propose an entirely new one. The framework remains applicable to both the NHQR and NHDR.

The Future Directions committee looked to prominent organizations and collaboratives engaged in health care quality improvement and disparities elimination for their informed perspectives on the latest advancements in and concerns about the current state of health care. Sources included the Healthy People 2020 Consortium, the National Quality Forum (NQF), the Institute for Healthcare Improvement, the Centers for Medicare and Medicaid Services (CMS), the HHS Office of Minority Health, the Kaiser Family Foundation, the World Health Organization (WHO), the Robert Wood Johnson Foundation, the Health Care Quality Indicators Project of the Organisation for Economic Co-operation and Development (OECD), The Commonwealth Fund's Commission on a High Performance Health System, the Quality Alliance Steering Committee, the National Committee for Quality Assurance, the Out of Many One Health Data Task Force, and the AQA alliance.

Box 3-1. The Six Aims of Quality Care from the IOM's Crossing the Quality Chasm Report The IOM's 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century found that the U.S. health care delivery system does not provide consistent, high-quality care to all people. The report says that between the health care that Americans have now and the care that they could have "lies not just a gap, but a chasm"(p. 1). The Quality Chasm report strongly recommends that all health care constituencies—health professionals, federal and state policy makers, public and private purchasers of care, regulators, organization managers and governing boards, and consumers—commit to adopting a shared vision for improvement based on six specific aims for health care: Safe—avoiding injuries to patients from the care that is intended to help them. Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively). Patient—centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Source: IOM, 2001a, pp. 5-6.

Framework Additions

Figure 3-1 shows the expanded conceptual framework for health care quality and disparities reporting. First, the committee explicitly includes access and efficiency as quality care components. These components are currently presented in one report or the other (access measures are reported in the NHDR but not the NHQR, and efficiency measures are beginning to be reported in the NHQR but not the NHDR). The inclusion of these two components in the framework reflects their relevance for reporting in both the NHQR and NHDR.

The Future Directions committee identified care coordination and capabilities of health systems infrastructure as necessary health care components to include in the national healthcare reports. These components are not necessarily health care aims/attributes in themselves, but are a means to those aims since they are elements of the health care system that better enable the provision of quality care. Care coordination and health systems infrastructure are of interest to the extent that they improve effectiveness, safety, timeliness, patient-centeredness, access, or efficiency. For this reason, these components are depicted as foundational, supporting the performance measurement of the other quality components and spanning across the different types of care. Measures and data sources for care coordination and systems infrastructure tend to be at a developmental stage,² and evidence of the impact on quality improvement for many measures in these areas has yet to be strongly established. Therefore, for these foundational components, the committee suggests that only measures that have demonstrated improvement in at least one of the other six components of care be reported in the national healthcare reports. For example, the Care Transitions Measure (often referred to as the CTM-3 measure) is a validated care coordination measure that quantifies hospital performance based on patient or caregiver experience with hospital transitions (Coleman, 2006; Parry et al., 2008). The care process captured by this measure has demonstrated positive health outcomes including reduced readmissions of patients discharged from hospitals and improved self-management and recovery of symptoms (Care Transitions Program, 2009). Reporting of this measure is not yet national in scope, but it holds promise as a care coordination measure that could be reported in the national healthcare reports at some point in the future.

Another enhancement to the conceptual framework is the presence of equity and value, which are displayed in a manner that conveys their applicability to each quality component, including the foundational elements of care coordination and health systems infrastructure. The committee views the dimensions of equity and value as ideals that can and should be achieved by improvement in each of the other framework components. Although the committee has added components to the framework on which AHRQ should report, AHRQ should have flexibility to provide a more in-depth focus on some, but not necessarily all, of the identified priorities and their component parts from one year to the next, as long as there is comparability between the NHQR and NHDR for the measures selected for that year's report.

Application of the Care Components

As noted in Envisioning the National Healthcare Quality Report, "The framework is a tool for organizing the way one thinks about health care quality. It provides a foundation for quality measurement, data collection, and subsequent reporting" (IOM, 2001b, p. 42). The Future Directions committee's expanded matrix of care components and types of care provides a way for AHRQ to continue categorizing potential and existing measures, ensure a balance in measure selection across the framework components, and identify gaps in its portfolio of measures selected for tracking—including those featured in the NHQR, NHDR, and the online resources, such as the State Snapshots and NHQRDRnet. For example, if the NPP priority area to "eliminate overuse while ensuring the delivery of appropriate care"were adopted for the national healthcare reports, then overuse measures would fall within the efficiency component of the framework. Likewise, measures for the priority of palliative care would help fill the current gap in the reports related to patient-centered performance measures for the management of chronic conditions.

The committee's recommended framework is not intended to specify the priority areas for quality measurement discussed in Chapter 2. There is currently some overlap between priority areas and framework components. Priorities might, at times, place more emphasis on one area of the framework than another, and measures applicable to one priority might apply to a single or multiple framework component(s) (go to Figure 4-3). AHRQ has strived for breadth by covering much of the framework's matrix in the annual healthcare reports and maintaining a more comprehensive measure set in derivative products. AHRQ acknowledges that maintaining and reporting on such a vast collection of measures has limited its ability to provide more in-depth treatment of the topics covered (Moy, 2009). Therefore, the committee presents priorities that can be used as a first step in whittling the measurement possibilities, and then followed by more quantitative steps described in Chapter 4.

Application of Equity and Value

Equity and value apply to each of the care components, including the foundational elements, and the results of equity and value assessments should be reported for each measure in the NHQR and NHDR. Findings can be included in graphics or text describing whether equity has been achieved and the value (based on the costs and benefits) that would accrue if quality gaps between current and desired levels of performance were closed (for example, if all persons, rather than 55 percent,³ received preventive services) and if equity gaps were closed.

AHRQ currently applies the concept of equity by presenting quantitative differences in performance levels by geographic areas (NHQR) and different populations (NHDR). The Future Directions committee observes this has been useful for dividing the content between the two reports, but that at times the separation can lead to misleading conclusions about the progress of the country in achieving quality. As noted in Chapter 2, the committee believes that the NHQR should include population equity findings and the NHDR should include additional information on the potential impact of closing the quality gap.

Presenting value for each component is a complex endeavor because value can mean various things to different people. (For the broad definition of value used in this report, go to Box 3-2.) AHRQ has begun to incorporate total and indirect costs for medical conditions, and estimates of the cost effectiveness of interventions (e.g., quality adjusted life years [QALYs]). The Future Directions committee lauds this movement, but also encourages AHRQ to report for each measure the potential quantifiable value of closing the gap between current and desired performance levels. Depending on the data available to describe the impact of closing the gap, findings might be presented in terms such as net health benefit, the size of the population affected, or estimated expenditure and possible cost savings.

The committee believes that using its updated framework provides AHRQ with a matrix to classify its current and future portfolio of measures to examine where measurement gaps might exist, while accommodating shifting priorities for the nation's health care system. Additionally, since equity and value are criteria in the proposed measure selection process (go to Chapter 4), quantification of these concepts should be included in the data presented in the national healthcare reports. As a result, the committee recommends:

Recommendation 2: AHRQ should adopt the committee's updated framework for quality reporting to reflect key measurement areas for health care performance and use it to ensure balance among the eight components of quality care in AHRQ's overall measure portfolio. AHRQ should further use its crosscutting dimensions of equity and value to rank measures for inclusion in the reports.

Additional justification for including equity and value, as well as each of the added quality of care components, is discussed in the following sections. To complement the justifications, Appendix D explores measurement possibilities for access, efficiency, care coordination, and health systems infrastructure.

Rationale for the Dimensions of Equity and Value

Equity and value represent dimensions of quality integral to all aspects of health care; each represents a larger goal of quality improvement that should be reflected in assessing individual quality measurement data.

Box 3-2. Definitions of Equity and Value as Used in This Report Because the committee proposes a new approach for assessing equity and value in future iterations of the NHQR and NHDR, and because there are many interpretations of the term value, the committee thought it important to define the terms equity and value as they are used in this report. The Future Directions committee bases its definition of equity on the previous IOM definition of what is equitable: providing health care to all individuals in a manner "that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status." (IOM, 2001a, p. 6) The committee defines value as: a measure of stakeholder utility (subjective preference by a group or individual) for a particular combination of quality and cost of care or performance output.

Equity

Envisioning the National Healthcare Quality Report and Guidance for the National Healthcare Disparities Report recommended the inclusion of equity in the framework (IOM, 2001b, p. 62, 2002, p. 11), and the Future Directions committee's framework retains it as a crosscutting element. Although the illustrated framework in the IOM's Envisioning the National Healthcare Quality Report did not explicitly include equity, the report specifically recommended that "equity be examined as an essential crosscutting issue"and that variations in the quality of care by race, ethnicity, gender, age, income, geographic location, insurance status, or socioeconomic status "have to be considered within each cell of the classification matrix in order to examine equity" (IOM, 2001b, p. 62). Guidance for the National Healthcare Disparities Report reiterated that AHRQ should use the framework recommended in Envisioning the National Healthcare Quality Report as the basis for the NHDR and that the NHDR was to "highlight health care issues related to equity and the extent to which health care disparities undermine its achievement" (IOM, 2002).

AHRQ focuses the NHQR on geographic differences by state and the NHDR on differences by gender, ethnicity, and socioeconomic status, as well as rural and metropolitan differences. Usually, the terms equity and disparities are more closely aligned in the literature with the quality of care, or lack thereof, being delivered to the populations featured in the NHDR. AHRQ has indicated that it defines disparities for the NHDR as "simple differences" and that its use of the term "disparities" does not have any more detailed implications. Others researchers and quality stakeholders distinguish the meaning of differences and disparities (go to Figure 3-2 for one such example). The IOM report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003b) describes a disparity as a difference in health or clinical outcomes that is not attributable to clinical appropriateness or patient preferences.

A body of literature identifies inequities in health care for different populations, primarily for low-income or certain racial and ethnic groups (Asch et al., 2006; Baicker et al., 2004; Blendon et al., 2007; Doescher et al., 2001; Fiscella et al., 2000). The Census Bureau projects that by 2045, half of the people living in the United States will be members of racial minority population groups (U.S. Census Bureau, 2008). Given these demographic changes, disparities may affect an even greater number of individuals in the future. Studies have assessed the implications of such demographic trends, coupled with known disparities, on costs to the health care system (LaVeist et al., 2009; Waidmann, 2009).

Equity has often been viewed separately from quality when in fact, the two concepts are interconnected. Equity for minority, low-income, and other populations should be on the nation's quality improvement agenda to ensure "equal access to available care for equal need, equal utilization for equal need, equal quality of care for all" (Whitehead, 1990, p. 8). Achieving equity should not be the sole purview of those working to address the core needs of low-income populations or communities of color. The interconnectedness of equity and qual ity has been recognized by numerous entities and individuals within the quality enterprise (Chin and Chien, 2006; Disparities Solution Center, 2009; Frist, 2005; RWJF, 2010), indicating that equity is an "integral part of quality improvement scholarship" (Chin and Chien, 2006, p. 79). This connection should be made more visible by quality improvement programs (Chin et al., 2007; Watson, 2005), and the NHQR can play a role in doing so. As Chin and Chien stated: "We know a considerable amount about the mechanisms causing these [racial] disparities. There is therefore a crying need for solutions to reduce disparities, and QI [quality improvement] interventions must play a key role," (Chin and Chien, 2006, p. 79). Integrating equity information into the NHQR and spotlighting promising interventions can assist in linking disparities elimination to quality improvement.

The causes of both quality problems and disparities are often context-specific. Bias might be a significant problem in one area whereas access or costs might predominate in another. Arguably, access-related issues (e.g., insurance, costs, geography, health literacy, language) are among the most important drivers of health care disparities. The Future Directions committee agrees that AHRQ can primarily report differences among population groups without determining the cause, but that AHRQ should examine, whenever data allow, the effect of possible drivers so that analyses will better inform policy. Fully understanding the degree of disparities is often made difficult by data limitations, a topic further addressed in Chapter 5.

Value

The term value is used in varied ways in contemporary health care parlance. Some definitions are deceptively simple (e.g., "quality for cost"). Correspondingly, some observers take the term high value to be synonymous with a good cost-effectiveness ratio—the best achievable health outcomes per dollar spent (Porter, 2009). The committee recognizes that in the quality improvement literature, value-based care often refers to developing quality health care that is cost effective (CMS, 2008a; HHS, 2009; Patrick, 2009; Wong et al., 2009), or optimizing the "the ratio of benefits to cost" (IOM, 2010, p. 29). Other definitions of value are more complex and encompassing, and attempt to incorporate subjective attributes of value in the health care system, such as positive patient experiences with desired health outcomes (Wharam and Sulmasy, 2009).

The Future Directions committee presents value as a crosscutting dimension of health care quality such that a high-value health care system is one that maximizes all the components of quality care outlined in the proposed conceptual framework (Figure 3-1). For the purposes of this report, the committee defines value as "a measure of stakeholder utility (subjective preference by a group or individual) for a particular combination of quality and cost of care or performance output" (go to Box 3-2). This is a broad concept, not limited to enhancing economic value but also enhancing health impact and patient experience. Assessing value is not to be confused with measuring the efficiency of health care services, which refers to maximizing objective performance (health care outcomes) by producing the best possible outputs from a given set of resources or inputs (McGlynn, 2008). While more difficult to measure and more subjective, the broad concept of value is ultimately the key overarching utility placed on health care, and thus the committee believes that it is important to include in its framework this concept explicitly and distinctly from efficiency.

A high-value health care system involves providing care whose benefits "are worth"or exceed their costs by being appropriate and affordable to society, and where treatment has large aggregate health benefits, measured, for example, using the concept of clinically preventable burden. (Cost-effectiveness and clinically preventable burden are discussed further in Chapter 4.) For some health care services and some dimensions of care, it will be difficult to quantify cost-effectiveness or clinically preventable burden. Examples include making care more patient-centered and improving care coordination, which can be fundamental to a patient's perception of experiences with care (Wharam and Sulmasy, 2009). The fact that quantifying cost-effectiveness and clinically preventable burden may be difficult for these dimensions of health care does not mean that improving these dimensions does not enhance value. So while the committee wants increased consideration in the NHQR and NHDR of the quantitative benefits that would accrue from closing the gap based on available value metrics (e.g., cost-effectiveness analysis), the committee acknowledges that such quantitative data are just one facet of assessing value.

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¹ Personal communication, Future Directions committee chair's site visit to AHRQ, April 30, 2009.
² In the context of this report, the term de elopmental refers to measures that are currently partially developed but not yet well tested or validated, or measures that have been validated but still lack sufficient national data on which to report. Aspirational refers to performance areas for which no measures yet exist—at best, there is a proposed way to measure performance.
³ In an examination of the quality of care delivered to a random sample of patients nationwide, McGlynn and colleagues estimated that only 55 percent of the population was receiving the recommended level of care (McGlynn et al., 2003).

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