Improving Quality and Safety Through Value-Driven Health Care

Improving Quality and Safety Improving Quality and Safety Through Value-Driven Health CareThrough Value-Driven Health Care

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDirectorDirector

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

The Sixth Annual Quality ColloquiumThe Sixth Annual Quality Colloquium

Cambridge, MA – August 20, 2007Cambridge, MA – August 20, 2007

Improving Quality and SafetyImproving Quality and Safety

Public Perceptions & the Public Perceptions & the Quality ChallengeQuality Challenge

AHRQ Roles & ResourcesAHRQ Roles & Resources Value-Driven Health CareValue-Driven Health Care Turning Evidence Into ActionTurning Evidence Into Action Q&AQ&A

JudgmentsJudgments

U.S. adults U.S. adults

whowho view view hospitals as hospitals as

generally generally trustworthy trustworthy and honestand honest

Harris Interactive Poll November 2006

2004

35%

2005

34%

2006

28%

Despite all of the quality improvement activities over the past few years, the public’s perception of the

health system is in decline

The Quality ChallengeThe Quality Challenge

What Is Quality?What Is Quality?

Health carecosts up 8%

per year

Health care quality up

3.1% in 2006

A Quality DisconnectA Quality Disconnect

The Right Care

For The Right Person

At The Right Time

Other specified antibiotics

3.2%

Opiates5.9%

Other specified analgesics/antipyretics

4.4%

Corticosteroids10.3%

Antineoplastic, immunosuppressant

agents8.5%

Antihypertensive agents

3.4%

Anticoagulants8.6%

Diuretics other than saluretics

3.2%

Cardiotonics3.2%

Sedatives and hypnotics

2.7%All other ADEs

46.5%

Most Common Specific Causes Most Common Specific Causes of ADEs in U.S. Hospitalsof ADEs in U.S. Hospitals

* More than one event can be recorded during a hospital stay. This is based on a total of 1,364,100 events in * More than one event can be recorded during a hospital stay. This is based on a total of 1,364,100 events in 1,211,100 hospital stays with at least one ADE event recorded - 1,211,100 hospital stays with at least one ADE event recorded - ARHQ – 2004 ARHQ – 2004

Coordination of CareCoordination of Care

Massachusetts: Overall Health Massachusetts: Overall Health Care Performance vs. All States, Care Performance vs. All States, One-Year Performance Change One-Year Performance Change

== Most Recent Year Most Recent Year = Baseline Year= Baseline Year

Performance MeterPerformance Meter

Very Very WeakWeak

WeakWeak

AverageAverage

StrongStrong

Very Very StrongStrong

2006 National Healthcare Quality Report, State Snapshots2006 National Healthcare Quality Report, State Snapshots

Examples: MA Snapshot

MeasureMeasure PerformancePerformance

% of Medicare AMI patients administered % of Medicare AMI patients administered beta blocker within 24 hours of admissionbeta blocker within 24 hours of admission

Better than Better than AverageAverage

% of adult surgery patients under Medicare % of adult surgery patients under Medicare who had prophylactic antibiotics who had prophylactic antibiotics discontinued within 24 hours of surgerydiscontinued within 24 hours of surgery

AverageAverage

% of Medicare pneumonia patients, age 50 % of Medicare pneumonia patients, age 50 years and older, who were screened for years and older, who were screened for influenza vaccine status and were influenza vaccine status and were vaccinated prior to discharge, if indicated vaccinated prior to discharge, if indicated

Lower than Lower than AverageAverage

**National Healthcare Quality Report, State Snapshots, 2006National Healthcare Quality Report, State Snapshots, 2006




AHRQ’s MissionAHRQ’s Mission

Improve the quality, safety, Improve the quality, safety, efficiency and effectiveness of efficiency and effectiveness of health care for all Americanshealth care for all Americans

AHRQ Roles and ResourcesAHRQ Roles and Resources

Health IT ResearchHealth IT ResearchFundingFunding

• Support advances that Support advances that improve patient improve patient safety/quality of caresafety/quality of care

• Continue work in Continue work in hospital settingshospital settings

• Step up use of health IT Step up use of health IT to improve ambulatory to improve ambulatory patient carepatient care

Develop Evidence Base Develop Evidence Base for Best Practices for Best Practices

Four key domains:Four key domains:

• Patient-centered carePatient-centered care• Medication managementMedication management• Integration of decision Integration of decision

support toolssupport tools• Enabling quality Enabling quality

measurementmeasurement

Promote CollaborationPromote Collaborationand Disseminationand Dissemination

• Support efforts of AHIC, Support efforts of AHIC, ONC, HRSA and CMSONC, HRSA and CMS

• Build on public and Build on public and private partnershipsprivate partnerships

• Use web tools to share Use web tools to share knowledge and knowledge and expertiseexpertise

Source: FY 2007 Budget Summary for HHS and BNA Health Care Policy Report 2-13-06Source: FY 2007 Budget Summary for HHS and BNA Health Care Policy Report 2-13-06

2008 Priorities2008 Priorities

Effective HealthEffective HealthCare ProgramCare Program

Medical ExpenditureMedical ExpenditurePanel SurveysPanel Surveys

AmbulatoryAmbulatoryPatient SafetyPatient Safety

Patient SafetyPatient Safety

Health IT Patient Safety

Organizations New Patient

Safety Grants Comparative Effectiveness Reports

Network of Research Centers

Clear Findings for Multiple Audiences

Quality & Cost-Effectiveness, e.g.Prevention and PharmaceuticalOutcomes

U.S. Preventive ServicesTask Force

Visit-Level Information on Medical Expenditures

Annual Quality & Disparities Reports

Safety & Quality Measures,Drug Management andPatient-Centered Care

Patient Safety ImprovementCorps

Other Research & Other Research & Dissemination ActivitiesDissemination Activities

Patient Safety and Health IT Patient Safety and Health IT Related ProgramsRelated Programs

FY 2008 $329.5 million request FY 2008 $329.5 million request includes $93.934 million for PS & includes $93.934 million for PS & Health IT(+$9.934 million over FY Health IT(+$9.934 million over FY 2007 CR)2007 CR)– Health IT = $44.8 million Health IT = $44.8 million

$3.4 million in new Health IT grants$3.4 million in new Health IT grants

– General PS = $49.114 (+ $15M)General PS = $49.114 (+ $15M)AHRQ has AHRQ has invested invested

$166M in HIT$166M in HIT $15 million for the Secretary’s $15 million for the Secretary’s Personalized Healthcare InitiativePersonalized Healthcare Initiative

ELECTRONIC MEDICAL RECORD

CLINICAL RESEARCH

CLINICAL RESEARCH

CLINICAL RESEARCH

CLINICAL RESEARCH

PUBLIC-PRIVATE PARTNERSHIP

PartnershipPartnership

The Promise of GenomicsThe Promise of Genomics

Drug Design

Gene Therapy

Disease Diagnosis

Secure Web-based Secure Web-based system for sharing gene-system for sharing gene-based data among based data among multiple organizationsmultiple organizations

Partnerships that Partnerships that encourage research, encourage research, development and development and increased implementationsincreased implementations

Shared decision-makingShared decision-making

Recent ActivitiesRecent Activities

AHRQ is funding a Randomized Control Trial to clarify the added AHRQ is funding a Randomized Control Trial to clarify the added value of genetic testing to improve warfarin dosing.value of genetic testing to improve warfarin dosing.

AHRQ is funding a DEcIDE project to review databases focusing AHRQ is funding a DEcIDE project to review databases focusing on utilization and outcomes ofon utilization and outcomes of gene-based tests and therapiesgene-based tests and therapies

EPC Reports:EPC Reports:

– Genomic testing in ovarian cancer Genomic testing in ovarian cancer (completed)(completed)

– CYP450 testing in depression CYP450 testing in depression (completed)(completed)

– HNPCC testing in colorectal HNPCC testing in colorectal patients (completed)patients (completed)

– Horizon scan on cancer genetic Horizon scan on cancer genetic tests for CMS (completed)tests for CMS (completed)

– BRCA testing in breast and BRCA testing in breast and ovarian cancers (w/USPSTF ovarian cancers (w/USPSTF recommendation)recommendation)

– HER-2-Neu testing in breast HER-2-Neu testing in breast cancer (ongoing)cancer (ongoing)

– Expression profile tests in breast Expression profile tests in breast cancer (ongoing)cancer (ongoing)

– Family history in breast, ovarian, Family history in breast, ovarian, colorectal and prostate cancers colorectal and prostate cancers (ongoing)(ongoing)

– Screening for hemochromatosis Screening for hemochromatosis (w/USPSTF recommendation)(w/USPSTF recommendation)




Quality StandardsQuality StandardsDesign systems to collect quality Design systems to collect quality

of care information and define of care information and define what constitutes quality health carewhat constitutes quality health care

IncentivesIncentivesReward those who provide and Reward those who provide and

purchase high-quality and purchase high-quality and competitively priced health carecompetitively priced health care

Price StandardsPrice StandardsAggregate claims information to Aggregate claims information to

enable cost comparisons between enable cost comparisons between specific doctors and hospitalsspecific doctors and hospitals

InteroperabilityInteroperabilitySet common technical standards Set common technical standards

for quick and secure for quick and secure communication and data exchangecommunication and data exchange

Cornerstones of Value-Driven Cornerstones of Value-Driven Health CareHealth Care

Getting to Value-Driven Getting to Value-Driven Quality Health CareQuality Health Care

"All health care is local, and "All health care is local, and we need cooperative local we need cooperative local action just as we need action just as we need common national goals." common national goals."

Michael O. Leavitt, SecretaryMichael O. Leavitt, SecretaryUS Dept. of Health and Human ServicesUS Dept. of Health and Human Services

January 5, 2007January 5, 2007

Value Exchanges:Value Exchanges:The Core PrinciplesThe Core Principles

1.1. At its core, health care is “local” At its core, health care is “local” 2.2. Broad access to accurate, meaningful information will improve the value of Broad access to accurate, meaningful information will improve the value of

healthcare services by: healthcare services by: – stimulating provider improvement,stimulating provider improvement,– engaging consumers in provider selection and treatment choices, and engaging consumers in provider selection and treatment choices, and – enabling purchasers to align consumer and provider incentives.enabling purchasers to align consumer and provider incentives.

3.3. A nationwide learning network will foster market-based health care reformA nationwide learning network will foster market-based health care reform

What Will This Take?What Will This Take?

Good measures and dataGood measures and data

– Local data, but national Local data, but national benchmarksbenchmarks

Strong local coalitionsStrong local coalitions Evidence-based reporting, Evidence-based reporting,

payment strategiespayment strategies Evidence, tools, strategies for improvementEvidence, tools, strategies for improvement Collaboration, TA across sitesCollaboration, TA across sites

The Role for CommunitiesThe Role for Communities

Regional/local public-private collaboration is essential to Regional/local public-private collaboration is essential to the success of the Value-Driven Health Care Initiative the success of the Value-Driven Health Care Initiative

HHS is building a system of Community Leaders and Value HHS is building a system of Community Leaders and Value Exchanges that recognize local organizations which are Exchanges that recognize local organizations which are engaged in the Value-Driven Health Care Initiativeengaged in the Value-Driven Health Care Initiative

5656 state and local state and local

government government entities have entities have

signed pledgessigned pledges

8484 organizations have organizations have applied to become applied to become

Community Community LeadersLeaders (79 have (79 have been confirmed)been confirmed)

762762 employers & employers &

providers have providers have signed signed

statements of statements of supportsupport

As of August 15, 2007As of August 15, 2007

Next Step for Value ExchangesNext Step for Value Exchanges

““Chartering Value Exchanges for Chartering Value Exchanges for Value-Driven Health Care,” 2Value-Driven Health Care,” 2ndnd Federal RegisterFederal Register notice August 3 notice August 3rdrd – Comments due September 4Comments due September 4thth

AHRQ to establish learning AHRQ to establish learning networks that: networks that: – Collaboratively produce public reports Collaboratively produce public reports

on health care qualityon health care quality

– Foster pay-for-performance (P4P)Foster pay-for-performance (P4P)

– Improve qualityImprove quality

First Community Leaders to be Announced this FallFirst Community Leaders to be Announced this Fall

Downtown USA Alejandra Vernon

Medicare Physician Group Medicare Physician Group Practice DemonstrationPractice Demonstration

The promise of P4P is revealed in The promise of P4P is revealed in a demonstration project involving a demonstration project involving 10 large physician practices10 large physician practices

– The practices were asked to The practices were asked to implement care management implement care management improvements for treatment of improvements for treatment of diabetes that would lead to diabetes that would lead to higher quality of carehigher quality of care

– In return, practices were eligible to receive In return, practices were eligible to receive as bonuses a portion of the money that as bonuses a portion of the money that Medicare saved by improving patient care Medicare saved by improving patient care within the target groupswithin the target groups

P4P

Source: Centers for Medicare & Medicaid ServicesSource: Centers for Medicare & Medicaid Services

First Year Results of First Year Results of the Physician Demothe Physician Demo

All participants met or All participants met or exceeded standards for exceeded standards for at least seven of the 10 at least seven of the 10 diabetes measuresdiabetes measures

Two generated results Two generated results that qualified for that qualified for bonusesbonuses

Congestive heart Congestive heart failure, coronary artery failure, coronary artery disease and preventive disease and preventive care measures will be care measures will be added in the pilot’s 2added in the pilot’s 2ndnd and 3and 3rdrd years years

HbA1c Management 10

HbA1c Control 10

LDL Cholesterol Level 10

Urine Protein Testing 10

Pneumonia Vaccination 9

Lipid Measurement 9

Eye Exam 9

Foot Exam 7

Influenza Vaccination 7

Blood Pressure Mgt 4

MeasureMeasureMet Met

StandardStandard

Better Quality InformationBetter Quality Information (2006 AQA Pilot Project*) (2006 AQA Pilot Project*)

Massachusetts Massachusetts Health Quality Health Quality PartnersPartners

California California CooperativeCooperativeHealthcare Healthcare ReportingReportingInitiativeInitiative Phoenix Regional Phoenix Regional

Healthcare Value Healthcare Value Measurement InitiativeMeasurement Initiative

Indiana Health Indiana Health Information ExchangeInformation Exchange

Wisconsin Wisconsin Collaborative Collaborative for Healthcare for Healthcare QualityQuality

Minnesota Community Minnesota Community MeasurementMeasurement

*Supported by funding from CMS and AHRQ

HQA and AQA CollaborateHQA and AQA Collaborate

National Quality Alliance Steering CommitteeNational Quality Alliance Steering Committee– Formed by two key health care quality alliances, the Formed by two key health care quality alliances, the

AQA Alliance and the Hospital Quality AllianceAQA Alliance and the Hospital Quality Alliance

Purpose:Purpose: To better coordinate the promotion of To better coordinate the promotion of quality measurement, transparency and quality measurement, transparency and improvement in care improvement in care

First Step:First Step: Expand pilot project sites to identify, Expand pilot project sites to identify, collect and report data on the quality of physician collect and report data on the quality of physician performance across care settings, including performance across care settings, including hospital and cost-of-care. Will work closely with hospital and cost-of-care. Will work closely with AHRQ and CMSAHRQ and CMS




Patient Involvement CampaignPatient Involvement Campaign

AHRQ’s campaign with The Advertising Council AHRQ’s campaign with The Advertising Council uses a series of TV, radio, and print public uses a series of TV, radio, and print public service announcementsservice announcements

Web site features a “Question Builder” for Web site features a “Question Builder” for patients to enhance their medical appointmentspatients to enhance their medical appointments

– www.ahrq.gov/questionsaretheanwserwww.ahrq.gov/questionsaretheanwser

New User’s Guide New User’s Guide to Patient Registries to Patient Registries

The first government-supported The first government-supported handbook for establishing, handbook for establishing, managing and analyzing patient managing and analyzing patient registriesregistries– Designed so patient registry data Designed so patient registry data

can be used to evaluate the real-life can be used to evaluate the real-life impact of health care treatmentsimpact of health care treatments

– A milestone in growing efforts to A milestone in growing efforts to better understand what treatments better understand what treatments actually work best, and for whomactually work best, and for whom

– http://effectivehealthcare.ahrq.govhttp://effectivehealthcare.ahrq.gov, , print versions coming soonprint versions coming soon

Registries for Evaluating Patient Outcomes: A User’s GuideRegistries for Evaluating Patient Outcomes: A User’s Guide**

* * Co-funded by AHRQ & CMSCo-funded by AHRQ & CMSEHC Research Report May 16, 2007EHC Research Report May 16, 2007

More Program OutputsMore Program Outputs

Research Research ReportsReports

Systematic Systematic ReviewsReviews

Consumer Consumer GuidesGuides

AHRQ Health Care AHRQ Health Care Innovations Exchange Innovations Exchange

National electronic learning National electronic learning hub for sharing health care hub for sharing health care service innovations, service innovations, bringing innovators and bringing innovators and adopters togetheradopters together

Searchable database Searchable database featuring innovation featuring innovation successes and failures, successes and failures, expert commentaries, expert commentaries, lessons learned, etc., lessons learned, etc.,

Designed to help health Designed to help health care “Agents of Change” care “Agents of Change” improve qualityimprove quality

Web-based Repository of Cutting-Edge Service InnovationsWeb-based Repository of Cutting-Edge Service Innovations

www.innovations.ahrq.govwww.innovations.ahrq.gov

Transparency and TransformationTransparency and Transformation

More transparentMore transparentcost/qualitycost/qualityinformationinformation

More More collaboration collaboration

for for improvementimprovement

More trust between purchasers, providers and consumersMore trust between purchasers, providers and consumers

More effortlessMore effortlessinformationinformationsharing withsharing withHealth ITHealth IT

Near-Term FrontierNear-Term Frontier

Focus on disparities reduction as core Focus on disparities reduction as core component of quality improvementscomponent of quality improvements

Combine administrative data with selected Combine administrative data with selected clinical IT data elements (e.g., lab, pharmacy) clinical IT data elements (e.g., lab, pharmacy) to enhance efficiency of data aggregationto enhance efficiency of data aggregation**

Build quality reporting functionality – and Build quality reporting functionality – and decision support – into certified electronic decision support – into certified electronic health recordshealth records**

Engineer value-driven health care on a Engineer value-driven health care on a national scale via regional/local public-private national scale via regional/local public-private collaborationcollaboration

**AHIC Quality WGAHIC Quality WG

2007 AHRQ Annual Conference2007 AHRQ Annual Conference

““Improving Health Care, Improving Lives”Improving Health Care, Improving Lives”

September 26-28, 2007 September 26-28, 2007 Bethesda North Marriott Convention Center Bethesda North Marriott Convention Center

Bethesda, MDBethesda, MD

Sessions on topics including the following:Sessions on topics including the following:

- AHRQ’s patient safety and health IT portfoliosAHRQ’s patient safety and health IT portfolios

- Implementation of research findings into changes in Implementation of research findings into changes in practice and policypractice and policy

- HHS’ Value-Driven Health Care InitiativeHHS’ Value-Driven Health Care Initiative

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Improving Quality and Safety Through Value-Driven Health Care