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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.


  • 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 --

  • 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?

*Available to the public through the Central Distributor

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?

*Available to the public through the Central Distributor

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

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