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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.

Overview

  • 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 -- http://www.innovations.ahrq.gov/innovations_qualitytools.aspx

  • 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?
AZ MA NE UT
CO MD NJ WA
FL ME NY WI
IA MI OR WV
KY NC SC

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?
CT MA MN TN
GA MD* NE* UT*
HI ME* NH VT
IN MO SC

*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?
CO MD* NC* UT*
CT ME* NJ* VT
FL* MN NY* WI*
GA MO PA
IN NE* SC
KY* NH TN

*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 hburstin@ahrq.gov

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