Future Directions for the National Healthcare Quality and Disparities Reports

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Chapter 7: Implementing Recommended Changes

An enhanced role is envisioned for the NHQR and NHDR in helping drive health care quality improvement for the nation. The NHQR and NHDR can provide a valuable context and a potential focus for the hundreds of thousands of independent quality improvement activities occurring across the nation. The reports alone cannot generate improvement in the quality of U.S. health care, but they can clearly present compelling information that identifies gaps in care, describes the progress of the nation in closing those gaps, sets a direction for investments in improvement, and identifies evidence-based policies and practices that can assist in achieving higher quality and equitable care. The changes that the Future Directions committee envisions for the NHQR, NHDR, and associated products will require additional resources for the Agency for Healthcare Research and Quality.

Throughout this report, the IOM Future Directions committee has recommended changes in the content and presentation of the NHQR and NHDR. These changes are intended to make the reports more forward-looking and action-oriented by engaging national and state policy makers and other stakeholders in the quest to improve health care quality for the nation. The redesigned NHQR, NHDR, and their related products would continue to fulfill the congressional mandate to report on trends and prevailing disparities, but the focus would be more on driving improvement.¹

Despite the considerable strengths of the national healthcare reports, the committee assessed them as lacking:

A clear set of national priorities on which to focus quality measurement and highlight, through the presentation of data, how policies and practices support achievement of these priorities.
An affirmation in both the NHQR and NHDR that achieving equity is an essential part of quality improvement.
An assessment of which measurement areas could have the greatest impact if gaps between current and recommended levels of performance were closed.
Identification of important measurement and data gaps to set a research and data collection agenda.²
Best-in-class benchmarks that show the gap between current average performance and the best attained performance.

Overall, the presentation in the reports needs to tell a more complete quality improvement story.

In previous chapters, the Future Directions committee has recommended a number of steps to address these issues. Specifically, the committee suggests a set of national priority areas for quality improvement and disparities, and recommends that AHRQ ensure the NHQR and NHDR report on progress made toward these national priorities (Chapter 2). AHRQ should more closely align future iterations of the NHQR and NHDR to ensure a focus on equity in the NHQR; the relationship between quality and equity is underscored in the updated quality framework, which includes equity and value as crosscutting components (Chapter 3). Moreover, the committee recommends the use of a more quantitative and transparent process for ranking performance measures for use in the NHQR and NHDR and for documenting measurement and data gaps (Chapter 4). New data sources, including subnational ones, may be appropriate for inclusion in future national reports. Furthermore, to ensure the ability to measure and compare quality across all population groups, standardized data on race, ethnicity, and language need, as well as other sociodemographic descriptors, must be collected and analyzed (Chapter 5). Finally, the committee recommends that the current emphasis in the NHQR on comparing quality data to average national performance be modified so that greater emphasis is placed on outcomes that have been previously attained by health care providers, health care organizations, or states (i.e., best-in-class benchmark) (Chapter 6).

Performance gaps have been repeatedly documented by the national healthcare reports and other quality reporting entities. The Future Directions committee supports the broader dissemination of re-designed reports and associated products to spur the engagement of actors across the U.S. health care system in affecting substantial and accelerated progress on national priority areas. Change, however, will require a broad national commitment and engagement. Impetus for action, complementary to the reports, should come from a combination of federal and state leadership with broad stakeholder consensus on national priorities, from leadership and direction by public and private sector entities (particularly insurers and employers), and from the commitment of resources that aim to remove barriers to improving the quality of U.S. health care.

Resources Required to Implement Recommendations

The statement of task for the Future Directions committee (go to Chapter 1) specifically asked that the committee “take note of recommendations that are estimated to be a reach for the current resources of AHRQ” (IOM, 2008). The committee acknowledges that implementing most elements of the recommendations presented in this report will require additional funding.

Investing in National Quality Measurement Efforts

When considering the need for AHRQ to receive additional funding to implement the committee's recommendations, the committee used existing and expected health care spending and recent recommendations for funding quality measurement enterprises as a context for understanding the necessary degree of investment. With $2.3 trillion spent on U.S. health care in 2008, health care expenditures constitute more than 16 percent of the U.S. gross domestic product (GDP) (CMS, 2010; Cutler, 2009). Moreover, health care spending is projected to comprise 20 percent of the country's GDP by 2017 (Keehan et al., 2008) and up to 40 percent of the GDP by 2050 (CBO, 2007).

A number of proposals—elements of which are similar to activities proposed by the Future Directions committee—have estimated funding needed to enhance the nation's quality improvement infrastructure. For example,

The 2006 IOM report Performance Measurement: Accelerating Improvement (IOM, 2006) recommended the formation of a National Quality Coordination Board with a budget of $100-$200 million.³ This estimate constituted approximately 0.1 percent of the Medicare budget at the time.
In 2009, the organization Stand for Quality—supported by 165 organizations coalescing around the issues of setting national priorities, making “performance information available and actionable,” and supporting a “sustainable infrastructure for quality improvement”—estimated that $300 million is needed for each of the next 3 years⁴ (Stand for Quality, 2009).
Under the authority of the Medicare Improvements for Patients and Providers Act of 2008, HHS awarded $10 million over each of the next several years to the National Quality Forum (NQF) to identify the most important quality and efficiency measures that would reflect the high cost of chronic disease and the continuum of care across settings for those cared for under Medicare (NQF, 2009).⁵
A national health reform bill passed by the U.S. House of Representatives in November 2009 called for $4 million per year from fiscal years 2010 through 2014 for health care priority setting by the HHS Secretary; $50 million per year from fiscal years 2010 through 2014 for health care quality measure development; and $12 million per year from fiscal years 2010 through 2012 for a consensus-based entity to ensure multistakeholder input for measure development specific to public reporting and public health care programs.⁶ A national health reform bill passed by the U.S. Senate in December 2009 and that became law in March 2010 called for $75 million per year from fiscal years 2010 through 2014 for the development of new quality measures and for $20 million per year from fiscal years 2010 through 2014 for additional improvements in quality measurement.⁷

Congress has designated the NHQR and NHDR as the national reports on health care quality and disparities.⁸ Therefore, the reports are deserving of sufficient funding to ensure they have a more widespread impact on quality improvement.

Additional Funding Required for AHRQ for Implementation

When Congress mandated the NHQR and NHDR in 1999, it did not provide dedicated funding for the reports. Currently, the report-related effort is funded within AHRQ at an annual cost of approximately $3.7-$4.0 million. To implement the improvements recommended by the Future Directions committee, a substantial increase over current funding may be necessary. Transforming the report products, engaging national and state policy makers and other actors, strengthening performance metrics, improving data, and supporting the committee's recommended measure selection process are important avenues for improving health care quality for the Nation.

The Future Directions committee is not able to determine to what extent, if at all, AHRQ might be able to reprogram funds within its existing budget to cover some implementation needs. The committee urges AHRQ to continue to leverage its own resources by partnering with other entities and agencies to accomplish as much of the new vision set out by the committee as possible. The committee was not tasked with making specific budgetary recommendations or estimates; therefore, the wording of the committee's recommendation speaks to providing sufficient funds rather than a specific amount:

Recommendation 9: To the extent that existing resources cannot be reallocated, or AHRQ cannot leverage its resources by partnering with other stakeholders and HHS agencies, AHRQ should work to obtain additional funds to support the work of the Technical Advisory Subcommittee for Measure Selection, the upgrades and additions to AHRQ's national healthcare report-related products, and the development of new measures and supporting data sources.

An illustrative example of how the committee's recommended improvements might be funded is provided in Appendix I. The committee believes that given the need for health care quality improvement, an increase in funds available to AHRQ would be worthwhile, and that over time, upgrades to the NHQR and NHDR, Web-based resources, derivative products, engagement activities, prioritization analyses, measure development, and data acquisition may require specific additional funding beyond the illustrative amounts contained in Appendix I. For example, the work of the NAC Technical Advisory Subcommittee for Measure Selection will generate ideas for the development of health care quality measures or data sources for high-impact areas that would be tracked nationally; these developmental activities can be quite expensive and are not accounted for in the scenario outlined in the appendix.

Upgrading the Reports and State Snapshots

In calendar year 2010, with a modest increase in staffing and resources, AHRQ should be able to include numerous upgrades in the 2010 NHQR, NHDR, and State Snapshots (which would be released in early 2011) by incorporating:

The topic of access into the NHQR and the State Snapshots.
Benchmarks that reflect best attained performance for each measure.
Extrapolation of when performance levels close the current gap between current practice and the recommended standard of care (goal or benchmark) will be met based on historical trends.
Recognition of the degree of variation among population groups on quality measures relative to best attained performance.
A summary of disparities data in the NHQR and an introductory exposition of the interrelationship between quality and equity in both reports.
A summary of performance by state in the NHQR and NHDR (not just in the State Snapshots).
Improved presentation (e.g., sharper key messages, identified data needs and best practices, redefined Highlights section).
Measures and new report sections that support the committee's recommended set of national priority areas and new framework components (e.g., care coordination and infrastructure).
Fuller exposition on the specific needs of priority populations.

While the first six of these suggestions may be able to be accomplished within existing resources, the movement from a statistical chartbook format to one that tells a more vivid and complete story of the current status of health care quality will require revamping the current products, conceptually and analytically (e.g., not just reporting overall performance on an individual measure, but producing analyses that include, for example, findings on specific program performance, the effect of health insurance by type, or relationships among process measures and outcomes). As recommended in Chapter 6, AHRQ should consult with communication and statistical experts to hone presentation methods for broad audiences while still providing sufficient information on analytic methods for specialized users. In the near term, AHRQ can begin to add new sorting functions in the State Snapshots and begin to drill down into the datasets to provide information on substate variation for some measures. The Future Directions committee observes that there is limited treatment of priority populations in the NHDR and feels that there should be some expansion of content relevant to those populations both within the reports and via spinoff products.

There will be occasions where new analyses and data acquisition will be required, whether national or subnational in character (e.g., multipayer databases, program-specific data). As new measures and data sources become available (e.g., data from the Centers for Medicare and Medicaid Services [CMS], data from electronic health records), the committee hopes that through collaborative partnerships, much of these data and their subsequent analyses can be supplied without charge to AHRQ as data and analysis already takes up at least half of the AHRQ report budget. Currently the NHQR and NHDR have limited reporting based on Medicare, Medicaid, and private sector data, and the committee urges AHRQ to expand these data in future editions.

Upgrading Online Resources, Adding Derivative Products, and Enhancing Dissemination

The committee has recommended AHRQ directly or via contracts update the State Snapshots and the NHQRDRnet to:

Include fact sheets, topic-specific derivative products (e.g., expanded mini-reports on priority populations), and capability to customize reports to user needs.
Ensure links between the NHQR and NHDR on the same measures.
Increase the visibility of AHRQ products through a better dissemination and engagement plan (e.g., meetings with stakeholders including organizations representing communities of color, Web optimization, targeting fact sheet topics to specific audiences, and translating some materials into user languages).
Provide tools that show AHRQ's analytic methods for users who want to manipulate primary datasets.
Develop the Guide to Using the NHQR and NHDR and other topic-specific derivative products.

In 2010, AHRQ should determine, in conjunction with a dissemination plan, a longer term development strategy for products that have priority for development. It is unlikely that all of the fact sheets, mini-reports, and tools can be developed within one year.

The committee's recommendation for expanded dissemination activities is not considered superfluous to AHRQ's work on the NHQR and NHDR. In fact, the committee believes it is essential to it. If the NHQR, NHDR, and related products are to serve as conduits for information that have the potential to drive change, that information needs to be properly distributed to relevant stakeholders and reflect their needs, engage them in improvement activities related to priorities and measures monitored in the reports, and assess the impact of the information and partnerships across time.

Implementing a More Quantitative and Transparent Measure Selection Process

The committee has recommended that AHRQ establish an external advisory process for the selection and ranking of measures for the national reports—a Technical Advisory Subcommittee for Measure Selection within the existing structure of AHRQ's National Advisory Council for Healthcare Research and Quality (NAC). This subcommittee should be established in calendar year 2010 to begin planning for the assessment of measures. New funds would be required to staff the subcommittee and conduct its public deliberations when prioritizing among measures to be featured in the AHRQ reports. In addition, AHRQ will need specific funds to hire staff or contract for the systematic review and analyses required to apply quantitative techniques toward assessing how much closing specific gaps in performance will benefit the overall health of the nation and that of specific priority populations.⁹

Funding Measure and Data Infrastructure for the NHQR and NHDR

Oft-cited quality improvement axioms are, “What gets measured gets done/managed,” and “You cannot improve what you do not measure.”¹⁰ But there is a third cautionary saying: “Be careful what you measure.” In view of this latter sentiment, the committee recognizes that naming national measures of health care quality carries potential risks, because doing so can divert resources from other potentially valuable initiatives.

The Future Directions committee believes it important for AHRQ to have resources to support not only the activities of the NAC Technical Advisory Subcommittee for Measure Selection in evaluating and ranking quality improvement measures for the greatest health benefit, but also to examine new evidence related to the performance measures it uses in the NHQR and NHDR and to support the evaluation of alternative or new measures and the development of data.

Questions raised previously with regard to specific measures endorsed by NQF and used by The Joint Commission and CMS illustrate the importance of making this investment. In recent years, for example, there has been debate in the literature over whether increased adherence to a set of heart failure process measures results in improved patient outcomes (Fonarow and Peterson, 2009; Fonarow et al., 2007; Kfoury et al., 2008) and whether measures related to antibiotic timing in patients with pneumonia have unintended adverse effects (Dean, 2009; Wachter et al., 2008). AHRQ will need to partner with others to ensure that the strength of the science of measures remains high and up-to-date, but the agency may need to be able to promote and potentially fund some separate investigations.

The IOM reports published in 2001 and 2002 to advise AHRQ on the NHQR and NHDR encouraged the development of quality measures and data sources that were not immediately feasible (IOM, 2001, p. 83, 2002). The Future Directions committee agrees that such development needs to occur, particularly in concert with consideration of measurement areas and their prioritization. Such investigation of future measure and data possibilities is less likely to happen without the investment of funds. Health insurance reform bills considered in the U.S. Congress in 2009 and early 2010 lodged the responsibility for funding the development of quality improvement measures with the HHS Secretary. The Senate version, which was signed into law in March 2010, specifically stipulates measure development is to be done in consultation with AHRQ, CMS, and NQF.¹¹

When existing health care quality measures and data sources are insufficient to track national progress in the identified national priority areas, AHRQ should directly or indirectly support the development of needed measures and the acquisition of relevant data sources. For report purposes, AHRQ tends to pay data use fees but does not pay for infrastructure development (e.g., data collection), partially because AHRQ has had limited funds available for this purpose. As illustrated by the development of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, there is precedent for AHRQ leadership when a demonstrated measurement need has not been filled elsewhere.

The Centers for Disease Control and Prevention (CDC) develops critical data infrastructure needs through a granting process, an approach that AHRQ might consider for key areas determined to be a priority (for example, providing some support in selected states for all-payer claims databases; other developmental areas might include patient registries and all-patient databases derived from provider rather than insurance sources).¹²

To date, AHRQ has lacked the resources to fully take advantage of public administrative data (e.g., Medicare and Medicaid data) or to obtain more timely data from existing report sources, so the benefit of developing new databases will need to be weighed against the benefit of more comprehensively using existing sources. The principles for prioritizing the selection of quality measures discussed in Chapter 4 can also be used to prioritize areas for developing measures and data sources.

The committee believes the development of additional data sources and sound quality measures in national priority areas for the national healthcare reports can be supported by all federal agencies that conduct research and collect health care-related data (e.g., AHRQ, CMS, CDC, the U.S. Department of Defense, the Department of Veterans Affairs, and the National Institutes of Health). Additionally, measure development is an important area for strategic partnerships, including, perhaps, jointly funded research with AHRQ's non-federal partner organizations (e.g., NQF, the National Committee for Quality Assurance, The Joint Commission, the Physician Consortium for Performance Improvement convened by the American Medical Association, The Leapfrog Group, organizations representing communities of color). Regional consortia, academic institutions, health plans, and professional societies, among others, also play roles in measure development and adaptation, and a two-way interchange between these entities and AHRQ through the selection and prioritization process of the NAC Technical Advisory Subcommittee for Measure Selection would be beneficial.

¹ Health Research and Quality Act of 1999, Public Law 106-129 § 902, 913, 106th Congress, 1st sess. (December 6, 1999).
² The 2008 NHDR lists the population groups (e.g., Asian or Pacific Islander, American Indian/Alaska Native, and poor) for which data are not available for its core measures (p. 287).
³ The National Quality Coordination Board was conceived as an independent body housed in the Office of the Secretary with a proposed $100-$200 million budget. Its functions included specifying the purpose and aims for American health care; establishing short- and long-term national goals for improving the health care system; and identifying and funding a research agenda for the development of new measures to address gaps in performance measurement. Other functions included designating, or if necessary developing, standardized performance measures for evaluating the performance of current providers; monitoring the nation's progress toward these goals; ensuring the creation of data collection, validation, and aggregation processes; establishing public reporting methods responsive to the needs of all stakeholders; and evaluating the impact of performance measurement on pay for performance, quality improvement, public reporting, and other policy levers.
⁴ The major activities cited include setting national priorities and providing coordination; endorsing and maintaining national standard measures; developing measures to fill gaps in priority areas; consulting with stakeholders; collecting, analyzing, and making performance information available and actionable; and supporting a sustainable infrastructure for quality improvement. The $300 million includes at least $100 million for translational research on payment models.
⁵ Medicare Improvements for Patients and Providers Act of 2008, Public Law 110-275, 110th Cong., 2d sess. (July 15, 2008).
⁶ Affordable Health Care for America Act, HR 3962 §1441, 1442, 1445, 111th Cong., 1st sess. (November 7, 2009).
⁷ The Senate bill was passed into law in March 2010 as the Patient Protection and Affordable Care Act (Public Law 111-148 §3013, 3014, 111th Cong., 2d sess. (March 23, 2010)).
⁸ The strategic plan reporting requirement in the Patient Protection and Affordable Care Act would inform but not duplicate AHRQ's national healthcare reports (Patient Protection and Affordable Care Act, Public Law 111-148 §3011, 111th Cong., 2d sess. (March 23, 2010)).
⁹ Personal communication, Michael Maciosek, HealthPartners. January 6, 2010. Estimates for conducting these types of quantitative reviews vary depending on the depth of the literature review, experience with the methods and availability of data, options for intervention, complexity of technology being assessed, and other factors. For example, a de novo cost-effectiveness evaluation with a thorough but not necessarily systematic review might cost $100,000. Reports from the Health Technology Assessment program in the United Kingdom, which tend to be very thorough, typically cost between £100,000 and £500,000 per technology assessment (go to http://www.hta.ac.uk/project/htapubs.asp).
¹⁰ The scientist Lord Kelvin said, “When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind; it may be the beginning of knowledge, but you have scarcely in your thoughts advanced to the stage of science” (Thompson, 1889, p. 73). Later, this statement was abbreviated to “if you can measure it, you can manage it” and “if you cannot measure it, you cannot manage it;” these statements are often attributed to Peter Drucker.
¹¹ Patient Protection and Affordable Care Act, Public Law 111-148 § 3013 and 3023, 111th Cong., 2d sess. (March 23, 2010). Quality measure development was also addressed in the Affordable Health Care for America Act, HR 3962 §1442, 111th Cong., 1st sess. (November 7, 2009).
¹² After the Future Directions committee concluded its deliberations, HHS announced its intent to build a universal claims database for health research; go to https://www.fbo.gov/?s=opportunity&mode=form&id=71d119aea45a6f2efdc5862cac9cb6e2&tab=core&_cview=0 (accessed January 12, 2010).

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