AHRQ Quality Indicators Irene Fraser, Ph.D. Director, Center for Delivery, Org. and Markets September 26, 2005

AHRQ Quality IndicatorsAHRQ Quality Indicators

Irene Fraser, Ph.D.Irene Fraser, Ph.D.

Director, Center for Delivery, Org. and MarketsDirector, Center for Delivery, Org. and Markets

September 26, 2005September 26, 2005

How Hazardous Is Health Care?How Hazardous Is Health Care?

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

To

tal

liv

es

lo

st

pe

r y

ea

r

DANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

Source: Berwick, D.M.

Systems Often Fail…Systems Often Fail…

System Designfor Quality

& Value

The Goal:The Goal:System ImprovementSystem Improvement

(microsystems & macrosystems)

Measure and Document Results

• Quality • Patient Safety• Efficiency• Access• ROI

IncentThrough aligned payment, public reporting, etc.

Facilitateby improved

HIT

Informby evidence andmodels of successful design strategies

Measurement Challenges (1):Measurement Challenges (1):Measure All DimensionsMeasure All Dimensions

EffectivenessEffectiveness SafetySafety TimelinessTimelinessPatientPatient

CenterednessCenteredness

StayingStayingHealthyHealthy

GettingGettingBetterBetter

Living withLiving withIllness/disabilityIllness/disability

End ofEnd ofLife CareLife Care

Source: Institute of Medicine. Source: Institute of Medicine. Envisioning the National Health Care Envisioning the National Health Care Quality ReportQuality Report. 2001.. 2001.

Measurement Challenges (2): Measurement Challenges (2): Align MeasuresAlign Measures

Horizontally, within efforts forHorizontally, within efforts for National trackingNational tracking

– NHQR and NHDRNHQR and NHDR

Public reportingPublic reporting– Hospital Quality Alliance Hospital Quality Alliance – Ambulatory Quality AllianceAmbulatory Quality Alliance– National Quality Forum National Quality Forum

Pay-for-performancePay-for-performance Quality improvementQuality improvement

Vertically, so these efforts are nestedVertically, so these efforts are nested

Measurement Challenges (3):Measurement Challenges (3):Data, Data, DataData, Data, Data

Measures and data can improve with use – “good” measures and Measures and data can improve with use – “good” measures and data can get better (though not perfect) data can get better (though not perfect) – BUTBUT – Even good measures with bad data can create mischief – Even good measures with bad data can create mischief

Need local data, but national benchmarksNeed local data, but national benchmarks There is no gold standardThere is no gold standard

– Clinical, administrative, patient experience of care data all Clinical, administrative, patient experience of care data all have strengths, weaknesseshave strengths, weaknesses

– EHR no data panaceaEHR no data panacea

Measurement Challenges (4):Measurement Challenges (4):Need Usable ProductsNeed Usable Productsand Strategies for Useand Strategies for Use

AHRQ Measurement AHRQ Measurement InitiativesInitiatives

National tracking and benchmarksNational tracking and benchmarks– National Healthcare Quality/ Disparities ReportsNational Healthcare Quality/ Disparities Reports

Measuring local experience of careMeasuring local experience of care– CAHPS for plans, hospitals, nursing homes etc.CAHPS for plans, hospitals, nursing homes etc.

Measuring culture of safetyMeasuring culture of safety Physician Measures – Ambulatory Quality AlliancePhysician Measures – Ambulatory Quality Alliance Measuring hospital quality and safetyMeasuring hospital quality and safety

– Inpatient Quality Indicators, Patient Safety Indicators, Healthcare Cost and Util. Inpatient Quality Indicators, Patient Safety Indicators, Healthcare Cost and Util. ProjectProject

Measuring potentially avoidable admissionsMeasuring potentially avoidable admissions– Prevention Quality IndicatorsPrevention Quality Indicators

Vision for Quality Indicators Vision for Quality Indicators InitiativeInitiative

1.1. Develop, maintain, evolve measuresDevelop, maintain, evolve measures

2.2. Strengthen administrative Strengthen administrative datadata at federal, at federal, state, local levelsstate, local levels

3.3. Create Create toolstools to facilitate use to facilitate use

4.4. Bring change through Bring change through strategies and strategies and partnershipspartnerships

Current AHRQ Quality Current AHRQ Quality IndicatorsIndicators

Prevention Quality Prevention Quality

IndicatorsIndicators

Inpatient Quality Inpatient Quality Indicators Indicators

Patient Safety Patient Safety IndicatorsIndicators

Ambulatory care sensitive Ambulatory care sensitive

conditionsconditions

Mortality following procedures Mortality following procedures Mortality for medical conditionsMortality for medical conditions Utilization of proceduresUtilization of procedures Volume of proceduresVolume of procedures

Post-operative complicationsPost-operative complications Iatrogenic conditionsIatrogenic conditions

For Discussion: Other For Discussion: Other Potential Quality Indicators ?Potential Quality Indicators ?

Pediatric Measures – under wayPediatric Measures – under way Women’s Health Measures?Women’s Health Measures? Readmissions?Readmissions? Emergency Department Quality?Emergency Department Quality? OthersOthers

On the Horizon: Evidence On the Horizon: Evidence Review of Efficiency MeasuresReview of Efficiency Measures

New Initiative: Identify, New Initiative: Identify, Categorize, and Categorize, and Evaluate Health Care Evaluate Health Care Efficiency MeasuresEfficiency Measures– Conduct thorough Conduct thorough

literature reviewliterature review

– Create typology for Create typology for measuresmeasures

– Develop evaluation Develop evaluation criteria for measurescriteria for measures

– Timeline: 1 yearTimeline: 1 year



2.2. Strengthen administrative data at federal, Strengthen administrative data at federal, state, local levelsstate, local levels

3.3. Create Create toolstools to facilitate use to facilitate use


HI

AZ

CAUT

CT

FL

GA

IA

ILKS

MA

MDMO

NJ

NYOR

PA

SCTN

CO

WA

WI

VA

ME

MI

TX

WVKY

NC

VT

RINE

MN

AL

DE

MT

ID

MS

NV

ND

SD

NM

OHIN

LA

AROK

NH

Data: Most States Have Inpatient Data: Most States Have Inpatient Datasets, Are HCUP PartnersDatasets, Are HCUP Partners

AK

WY

HCUP Partner

Does Not Collect Inpatient Data

Legend

DC

Enhancing Administrative Enhancing Administrative Data: Adding More Clinical Data: Adding More Clinical

Data ElementsData Elements

EHRHCUP

• Add clinical data elements

• Provide timely benchmarks

• Connect Partners with EHR community

• Universe of hospitalcare in a state

• Hospitalcharacteristics

• Link to contextualfactors

• Patient episode ofcare

• Real time• Additional clinical

data elements

• Data• Clinical data

elements




3.3. Create tools to facilitate useCreate tools to facilitate use


Uses of AHRQ Quality Uses of AHRQ Quality Indicators: Original GoalIndicators: Original Goal

Create indicators at all levels: national, state, Create indicators at all levels: national, state, community and hospital for use incommunity and hospital for use in– National tracking – AHRQ and NHQRNational tracking – AHRQ and NHQR

– Quality and safety improvement – hospital Quality and safety improvement – hospital associations in many statesassociations in many states

– Identifying areas of preventable hospitalizations Identifying areas of preventable hospitalizations – many regional efforts– many regional efforts

Example: Targeting Interventions for Example: Targeting Interventions for Potentially Preventable AdmissionsPotentially Preventable Admissions

National Cost: $29 billionNational Cost: $29 billion Diabetes: $2.5 billionDiabetes: $2.5 billion

– Short-term complicationsShort-term complications

– Long-term complicationsLong-term complications

– Uncontrolled diabetesUncontrolled diabetes

Changing Times Brought Changing Times Brought Expanded UsesExpanded Uses

QIs have demonstrated big impactQIs have demonstrated big impactin short timeframe:in short timeframe:

Hospital-level report cards Hospital-level report cards – Texas, New York State, ColoradoTexas, New York State, Colorado

Pay-for-Performance Pay-for-Performance – CMS Premier Demo, Anthem of VirginiaCMS Premier Demo, Anthem of Virginia

Hospital profilingHospital profiling– Blue Cross Blue Shield of IllinoisBlue Cross Blue Shield of Illinois

At Least 12 States Use or Plan to Use AHRQ At Least 12 States Use or Plan to Use AHRQ QIs for Public Hospital ReportingQIs for Public Hospital Reporting

States using AHRQ QIs for public reporting at hospital levelStates using AHRQ QIs for public reporting at hospital level

(CA, CO, FL, KY, ME, MN, NY, OR, TX, UT, VT, parts of WI)(CA, CO, FL, KY, ME, MN, NY, OR, TX, UT, VT, parts of WI)

Source: Preliminary Data from NAHDO Survey, September 2005Source: Preliminary Data from NAHDO Survey, September 2005

QI Analyses QI Analyses Show Big Variations inShow Big Variations in

Cost AND QualityCost AND Quality

AHRQAHRQReporting Template ProjectReporting Template Project

Lit review of effective templates for Lit review of effective templates for comparative quality infocomparative quality info

Conduct interviews and focus groups w/ key Conduct interviews and focus groups w/ key audiences, including:audiences, including:– PurchasersPurchasers

– ProvidersProviders

– ResearchersResearchers

– Quality Measurement OrganizationsQuality Measurement Organizations

– Hospital Associations, etc.Hospital Associations, etc.

Based on evidence, develop and test Based on evidence, develop and test templatestemplates




3.3. Create tools to facilitate useCreate tools to facilitate use

4.4. Bring change through strategies and Bring change through strategies and partnershipspartnerships

Partnerships Partnerships

HCUP partnersHCUP partners– state data organizations, hospital associations, private associationsstate data organizations, hospital associations, private associations

NAHDONAHDO State governmentsState governments Other hospital associationsOther hospital associations Employer coalitions and employer groupsEmployer coalitions and employer groups CMS, others in DHHSCMS, others in DHHS ResearchersResearchers

StrategiesStrategies

Partnering with users to identify and share best practicesPartnering with users to identify and share best practices– Annual Quality Indicators Users MeetingsAnnual Quality Indicators Users Meetings– National, regional meetings through Knowledge Transfer Contracts on Payment, National, regional meetings through Knowledge Transfer Contracts on Payment,

MeasurementMeasurement Technical Assistance and TrainingTechnical Assistance and Training

– SQI ContractSQI Contract– RTI Curriculum GuideRTI Curriculum Guide– Patient Safety Improvement CorpsPatient Safety Improvement Corps– Training sessions at state, national meetingsTraining sessions at state, national meetings– WebcastsWebcasts

What else????What else????

Goals for this meetingGoals for this meeting

Help us learn from each other.Help us learn from each other. Provide input as we refine our strategic Provide input as we refine our strategic

vision so that we can vision so that we can deliver what’s most deliver what’s most useful to you.useful to you.

Help Us Identify and Prioritize Help Us Identify and Prioritize Activities to:Activities to:

Develop, maintain, evolve measuresDevelop, maintain, evolve measures Strengthen administrative data at federal, Strengthen administrative data at federal,

state, local levelsstate, local levels Create tools to facilitate useCreate tools to facilitate use Partner with usersPartner with users Monitor and evaluate impactMonitor and evaluate impact

……and Help Us with Strategic and Help Us with Strategic Issues:Issues:

How to Balance InvestmentHow to Balance Investment

Tools, Best Tools, Best Practices,Practices,

Implement Implement

What We KnowWhat We Know

New New Measures,Measures,

Evidence Evidence Base for Base for FutureFuture

Irene Fraser:Irene Fraser: [email protected]@ahrq.gov

Home PageHome Pagehttp://www.AHRQ.govhttp://www.AHRQ.gov

Documents

AHRQ Quality Indicators Irene Fraser, Ph.D. Director, Center for Delivery, Org. and Markets September 26, 2005