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 Future Directions for the National Healthcare Quality
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Cheryl Ulmer, Michelle Bruno, and Sheila Burke,
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Future directions for the national healthcare quality and disparities reports / Committee on Future Directions for the
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COMMITTEE ON FUTURE DIRECTIONS FOR THE NATIONAL

HEALTHCARE QUALITY AND DISPARITIES REPORTS
SHEILA P. BURKE (Chair), Faculty Research Fellow, Malcolm Weiner Center for Social Policy, John F.
Kennedy School of Government, Harvard University, Cambridge, MA
IGNATIUS BAU, Program Director, The California Endowment, Oakland, CA
ANNE C. BEAL, President, Aetna Foundation, Inc., Hartford, CT
E. RICHARD BROWN, Professor, UCLA School of Public Health; Director, UCLA Center for Health Policy
Research; Principal Investigator, California Health Interview Survey, Los Angeles, CA
MARSHALL H. CHIN, Professor of Medicine, University of Chicago, Chicago, IL
JOSÉ J. ESCARCE, Professor of Medicine, Division of General Internal Medicine and Health Services
Research, UCLA School of Medicine, Los Angeles, CA
KEVIN FISCELLA, Professor, Family Medicine and Community & Preventive Medicine, University of
Rochester School of Medicine, University of Rochester, Rochester, NY
ELLIOTT S. FISHER, Professor of Medicine and Community and Family Medicine, Dartmouth Medical
School; Director, Center for Health Policy Research, Dartmouth Institute for Health Care Policy and Clinical
Practice, Lebanon, NH
DAWN M. FITZGERALD, Chief Executive Officer, QSource, Memphis, TN
FOSTER GESTEN, Medical Director, Office of Health Insurance Programs, New York State Department of
Health, Albany, NY
BRENT C. JAMES, Chief Quality Officer and Executive Director, Institute for Health Care Delivery Research,
Intermountain Health Care, Inc., Salt Lake City, UT
JEFFREY KANG, Chief Medical Officer and Senior Vice President, Medical Strategy and Policy, CIGNA
Corporation, Hartford, CT
DAVID R. NERENZ, Director, Center for Health Services Research, Henry Ford Health System, Detroit, MI
SHARON-LISE T. NORMAND, Professor, Department of Health Care Policy, Harvard Medical School;
Professor, Department of Biostatistics, Harvard School of Public Health, Boston, MA
CHRISTOPHER QUERAM, President and Chief Executive Officer, Wisconsin Collaborative for Healthcare
Quality, Middleton, WI
SARAH HUDSON SCHOLLE, Assistant Vice President for Research, National Committee for Quality
Assurance, Washington, DC
PAUL M. SCHYVE, Senior Vice President, The Joint Commission, Oakbrook Terrace, IL
BRUCE SIEGEL, Director, Center for Health Care Quality, The George Washington University School of
Public Health and Health Services, Washington, DC

Study Staff
CHERYL ULMER, Project Director
MICHELLE BRUNO, Senior Program Associate (until February 2010)
BERNADETTE McFADDEN, Research Associate
CASSANDRA L. CACACE, Research Assistant
ROGER C. HERDMAN, Board Director, Board on Health Care Services

 Served through November 9, 2009.

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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical
expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee.
The purpose of this independent review is to provide candid and critical comments that will assist the institution
in making its published report as sound as possible and to ensure that the report meets institutional standards for
objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain
confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for
their review of this report:

DAVID CARLISLE, Office of Statewide Health Planning and Development, State of California,
Sacramento, CA
CARMEN R. GREEN, Department of Anesthesiology, University of Michigan, Ann Arbor, MI
CARA V. JAMES, Kaiser Family Foundation, Washington, DC
EDWARD KELLEY, World Health Organization, Geneva, Switzerland
DUSHANKA V. KLEINMAN, Department of Epidemiology and Biostatistics, University of Maryland,
College Park, MD
JUDITH R. LAVE, Department of Health Policy & Management, Graduate School of Public Health,
University of Pittsburgh, Pittsburgh, PA
ELIZABETH A. McGLYNN, The RAND Corporation, Santa Monica, CA
THOMAS G. McGUIRE, Department of Health Care Policy, Harvard Medical School, Boston, MA
LEE PARTRIDGE, National Partnership for Women and Families, Washington, DC
RUTH T. PEROT, Summit Health Institute for Research and Education, Inc., Washington, DC
PATRICK ROMANO, Center for Studying Health System Change, Washington, DC
BARBARA RUDOLPH, Center for Health Systems Research and Analysis, University of Wisconsin,
Madison; The Leapfrog Group, Madison, WI
ELLEN WARTELLA, University of California, Riverside, Riverside, CA
MILTON C. WEINSTEIN, Department of Health Policy and Management, Harvard School of Public
Health, Boston, MA

Although the reviewers listed above provided many constructive comments and suggestions, they were not
asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release.

vii

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viii REVIEWERS

The review of this report was overseen by NEAL A. VANSELOW, IOM member, and CASWELL A. EVANS,
JR., University of Illinois at Chicago. Appointed by the National Research Council and Institute of Medicine, they
were responsible for making certain that an independent examination of this report was carried out in accordance
with institutional procedures and that all review comments were carefully considered. Responsibility for the final
content of this report rests entirely with the authoring committee and the institution.

Copyright © National Academy of Sciences. All rights reserved.

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Foreword

Ten years after the publication of the Institute of Medicine’s landmark Quality Chasm series of reports, we
often do not know to what extent quality of care has improved. A range of studies and reports indicate that the
quality of health care received in our nation is less than optimal, but we continue to lack sufficient information to
determine how well new programs, changes in processes, and other interventions improve the quality and equity
of care.
The National Healthcare Quality and Disparities Reports play a fundamental role in examining quality
improvement and disparities reduction. In this report, prepared at the request of the Agency for Healthcare Research
and Quality, the Institute of Medicine suggests ways to reformulate and enhance our nation’s essential measures
of quality and equity, to facilitate informed decision-making, and to help set the strategic direction of the nation’s
quality improvement enterprise.
I am grateful for the support of our sponsor and to the committee, ably led by Sheila Burke, which grabbled
with complex issues involving the selection and prioritization of different measures, the needs of users, and
advances in the field of quality measurement. Their work was reinforced by staff working under the direction of
Cheryl Ulmer and including Michelle Bruno, Bernadette McFadden, and Cassandra Cacace. I commend both com-
mittee and staff for this product and believe it provides a sound basis for strengthening the National Healthcare
Quality and Disparities Reports.

Harvey V. Fineberg, M.D., Ph.D.

President, Institute of Medicine
April 2010

ix

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Preface

In 1998, the President’s Advisory Commission on Consumer Protection and Quality of Care in the Health Care
Industry called for a national commitment to improving quality and reducing disparities at every level of the health
care system. To reinforce this commitment, annual reports to Congress from the Agency for Healthcare Research
and Quality (AHRQ) were initiated to document national trends, identify gaps in care, and paint a picture of the
state of health care quality and disparities. These reports—the National Healthcare Quality Report (NHQR) and
the National Healthcare Disparities Report (NHDR)—are consulted by health services researchers, state health
officials, organizations implementing quality improvement and disparity elimination programs, advocates for
specific health conditions or priority populations, and other stakeholders. Five years after the reports were first
published, AHRQ turned to the Institute of Medicine (IOM) to evaluate the current NHQR and NHDR and to
present a vision for their future content and presentation.
Our IOM committee felt it essential to think about how the reports’ content and presentation could best foster
action by various audiences to close health care quality gaps, particularly in measurement areas that represent the
greatest opportunities for creating a high-quality, high-value, equitable health care system. It is through a lens of
actionability and better matching of products to audience needs that the committee evaluated the current reports
and made its recommendations. Embedded in the pages of this report are discussions of the ways to transform
future iterations of the NHQR and NHDR. AHRQ could:

• track national priorities for quality improvement and high impact measurement areas to inform collective
action across federal and other public and private sector health care delivery programs;
• conceptually and operationally link quality improvement and disparities elimination in the NHQR and
NHDR;
• highlight quality achievement by presenting best-in-class benchmarks;
• move from only presenting historical trend data to also extrapolating rates of change to indicate when gaps
might be closed at the existing pace;
• present an assessment of the effect on population health of bridging quality and equity gaps;
• analyze and present data in meaningful ways that identifies for Congress, states, and others the results of
and prospects for evidence-based policies and interventions; and
• support broader and sustained dissemination of report content.

xi

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xii PREFACE

We hope this report will be of help to AHRQ in promoting progress toward achieving optimal health care for the
American people.
As chair of this committee, I would like to thank my fellow committee members for giving their time and
expertise so generously toward the completion of this report. Their spirited deliberations and contributions are
greatly appreciated. On behalf of the committee, I would also like to thank the staff of the Board on Health Care
Services who ably supported the committee in its endeavor. In particular, Cheryl Ulmer, study director, should be
thanked for steering the committee throughout the process.

Sheila Burke, Chair

Committee on Future Directions
for the National Healthcare
Quality and Disparities Reports

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Acknowledgments

The committee and staff are grateful to many individuals and organizations who contributed to this study. The
committee would like to thank the Institute of Medicine Subcommittee on Standardized Collection of Race/Ethnic-
ity Data for Healthcare Quality Improvement. The subcommittee members  were:

MARGARITA ALEGRÍA, Director, Cambridge Health Alliance, Center for Multicultural Mental Health
Research, Somerville, MA
JOHN Z. AYANIAN, Professor of Medicine and Health Care Policy, Harvard Medical School,
Boston, MA
RODERICK J. HARRISON, Senior Research Scientist, Office of the Vice President for Research and
Compliance, Howard University, Washington, DC
ROMANA HASNAIN-WYNIA, Director, Center for Healthcare Equity; Associate Professor of Research,
Northwestern University, Feinberg School of Medicine, Chicago, IL
NINEZ PONCE, Associate Professor, Department of Health Services, UCLA School of Public Health,
Los Angeles, CA
WAYNE S. RAWLINS, National Medical Director, Aetna Government Health Plans, Aetna, Hartford, CT
ALAN M. ZASLAVSKY, Professor of Statistics, Department of Health Care Policy, Harvard Medical
School, Boston, MA

Funding for this study was provided by the Agency for Healthcare Research and Quality (AHRQ). The com-
mittee appreciates AHRQ’s support for this project and wishes to especially thank Carolyn Clancy, Ernest Moy,
Jeff Brady, Farah Englert, Karen Ho, and Allan Lazar for sharing their expertise about the development and dis-
semination of the NHQR and NHDR.
In addition, the committee benefited from the testimony of the following individuals before the committee
and subcommittee during public workshops: Karen Adams (National Quality Forum), Donald Berwick (Institute
for Healthcare Improvement), Andrew Bindman (University of California, San Francisco, and CA Medicaid
Research Institute), Kathryn L. Coltin (Harvard Pilgrim Health Care), Brenda Edwards (Division of Cancer Control
& Population Sciences, National Cancer Institute), Marc Elliott (RAND Corporation), Irene Fraser (Agency for

 Committee members Ignatius Bau, David Nerenz, and Paul Schyve were also members of the subcommittee.

xiii

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xiv ACKNOWLEDGMENTS

Healthcare Research and Quality), Allen Fremont (RAND Corporation), Ron Hays (Division of General Internal
Medicine and Health Services Research, UCLA), Karen Humes (U.S. Census Bureau), Deeana Jang (Asian &
Pacific Islander American Health Forum, speaking on behalf of Out of Many, One’s Health Data Taskforce),
­Marjorie Kagawa-Singer (UCLA School of Public Health), Karen Kmetik (American Medical Association and
The Physician Consortium for Performance Improvement), David Lansky (Pacific Business Group on Health),
Nicole Lurie (RAND Corporation, Center for Population Health and Health Disparities), Jennifer Madans (National
Center for Health Statistics), Paul McGann (Office of Clinical Standards and Quality, Centers for Medicare and
Medicaid Services), Marsha Regenstein (The George Washington University), Thomas Reilly (Office of Research,
Development and Information, Centers for Medicare and Medicaid Services), Michael Rodriguez (Department of
Family Medicine, David Geffen School of Medicine, UCLA), Patrick Romano (Divisions of General Medicine and
General Pediatrics, Center for Healthcare Policy and Research, University of California, Davis), Joachim Roski
(Engelberg Center for Health Care Reform, The Brookings Institution), Maribeth Shannon (Market and Policy
Monitor Program, California HealthCare Foundation), Gayle Tang (National Diversity, Kaiser Permanente), Kalahn
Taylor-Clark (Engelberg Center for Healthcare Reform, The Brookings Institution), Grace Ting (Health Equities
Programs, Wellpoint, Inc.), Katherine K. Wallman (U.S. Office of Management and Budget), Thomas Williams
(Integrated Healthcare Association), and Mara Youdelman (National Health Law Program).
Others also provided valuable advice on the issues under study; these include Kirsten Anderson (Aetna),
Douglas Boenning (U.S. Department of Health and Human Services), Arleen F. Brown (UCLA Division of General
Internal Medicine), Helen Burstin (National Quality Forum), Pat Callaghan (Minnesota Department of Human
Services), Eric Coleman (University of Colorado, Denver), Janet Corrigan (National Quality Forum), ­William
Golden (Arkansas Medicaid, Department of Human Services), Sheldon Greenfield (University of California,
Irvine), William E. Hammond (Duke University), W. David Helms (AcademyHealth), Catherine Hess (National
Academy for State Health Policy), Bill Imada (IW Group, Inc.), George Isham (HealthPartners), Francine Jetton
(Society of General Internal Medicine), Sherrie Kaplan (University of California, Irvine), Paul Kaye (Hudson River
Health Care, Inc.), Alison Kirchgasser (Massachusetts Office of Medicine), Ann Kohler (National Association of
State Medicaid Directors), Chris Lee (Kaiser Family Foundation), Lisa Lee (Kentucky Children’s Health Insurance
Program), Dave Michalik (Delaware Division of Medicaid and Medical Assistance), Jeannette Noltenius (Out of
Many, One), Nancy A. Rigotti (Massachusetts General Hospital), J. James Rohack (American Medical Associa-
tion), Barbara Rudolph (The Leapfrog Group), Adam Schickedanz (University of California, San Francisco, and
National Academy of Sciences Mirzayan Science and Technology Fellow through May 2009), Cathy Schoen (The
Commonwealth Fund), Susan Schow (Maine Health Data Organization), Sora Park Tanjasiri (Center for Cancer
Disparities Research), Caroline Taplin (U.S. Department of Health and Human Services), Alan Weil (National
Academy for State Health Policy), and Judy Womack (Quality Oversight Bureau of TennCare).
In addition, we would like to thank Suzanne Niemeyer and Chris Shreeve (Ketchum), Jeanette Chung and
David Meltzer (University of Chicago), and Howard Wainer (National Board of Medical Examiners) who acted
as consultants during the project and drafted additional materials for the report.
Lastly, many individuals within the IOM were helpful throughout the study process including Clyde Behney,
Patrick Burke, Rosemary Chalk, Janice Mehler, Abbey Meltzer, Christine Stencel, Vilija Teel, Jackie Turner, and
Jordan Wyndelts. We would also like to thank Kerry Kemp for assisting in copyediting this report.

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Contents

SUMMARY 1

1 INTRODUCTION 11
Study Charge and Approach, 11
National Reporting on the State of Quality and Disparities, 12
Key Issues Addressed by the Committee, 15
Limitations of the Study, 16
Organization of the Report, 16
References, 19

2 RE-ENVISIONING THE NHQR AND NHDR 21

Purpose and Audiences, 22
Calls for National Priority Areas, 26
The Committee’s Recommended Priority Areas, 28
Focusing Resources and Attention on National Priority Areas, 31
Summary, 36
References, 36

3 UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 39

The Original Framework for the NHQR and NHDR, 40
An Updated Framework for the NHQR and NHDR, 40
Rationale for the Dimensions of Equity and Value, 43
Rationale for the Four New Quality of Care Components, 46
Summary, 53
References, 53

4 ADOPTING A MORE QUANTITATIVE AND TRANSPARENT MEASURE

SELECTION PROCESS 59
AHRQ’s Approach to Selecting Measures, 60
Improving Measure Selection, 63

xv

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xvi CONTENTS

Principles and Criteria for Selection, 68

Quantitative Tools for Prioritizing Measures, 76
Summary, 85
References, 85

5 ENHANCING DATA RESOURCES 89

Building a National Data Infrastructure, 90
Filling Measurement and Data Needs, 91
Improving Race, Ethnicity, Language Need, Socioeconomic, and Insurance Status Data, 96
Summary, 105
References, 106

6 IMPROVING PRESENTATION OF INFORMATION 111

Matching Products to Audience Needs, 112
Telling a Story in the NHQR and NHDR, 120
Using Benchmarks to Show Achievement, 122
Refining the Presentation of Data, 126
Summary, 134
References, 134

7 IMPLEMENTING RECOMMENDED CHANGES 137

Resources Required to Implement Recommendations, 138
Evaluation of the AHRQ Report-Related Endeavor, 143
Timeline for Implementing Recommendations, 143
Conclusion, 145
References, 145

ACRONYMS 147

APPENDIXES

A Previous IOM Recommendations for the National Healthcare Reports 151

B Key Findings of the NHQRs and NHDRs 155
C Previous Conceptual Framework 157
D Measurement Opportunities for the Framework’s Components of Quality Care 159
E HHS Interagency Workgroup for the NHQR and NHDR 171
F The Expected Population Value of Quality Indicator Reporting (EPV-QIR): A Framework for
Prioritizing Healthcare Performance Measurement 175
G IOM Subcommittee on Standardized Collection of Race/Ethnicity Data for Healthcare
Quality Improvement: Recommendations 207
H Additional Assessments of Data Presentation in the NHQR and NHDR 211
I An Illustrative Funding Example 217
J Committee Member and Staff Biographies 219

Copyright © National Academy of Sciences. All rights reserved.

Future Directions for the National Healthcare Quality and Disparities Reports
http://www.nap.edu/catalog/12846.html

Figures, Tables, and Boxes

Summary
Figure
S-1 An updated conceptual framework for categorizing health care quality and disparities measurement, 4
Table
S-1 Tailoring Products to Meet the Needs of Multiple Audiences, 8
Boxes
S-1 The Committee’s Eight Recommended National Priority Areas for Health Care Quality Improvement, 3
S-2 Proposed Roles in Selecting Measures and Developing a Research Agenda, 5

Chapter 1
Figures
1-1 Overall reliability of the U.S. health system: Percentage of recommended care delivered, 14
1-2 Conceptual framework for a national quality measurement and reporting system, 15
Table
1-1 Issues Raised and Potential Solutions Related to the National Healthcare Reports and Their Related
Products, 17
Box
1-1 Statement of Task for the IOM Committee on Future Directions for the National Healthcare Quality
and Disparities Reports, 12

Chapter 2
Table
2-1 Overview of Priority Areas for Improving Health Care Identified by Leading Organizations,
­Initiatives, and Reports, 32

xvii

Copyright © National Academy of Sciences. All rights reserved.

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