Better results are achievable
According to Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD, escaping the health care quality “hook” is impossible. “We know we can do better,” she noted. “None of us has all the answers, but when it comes to quality and health care delivery, we actually have many answers about best practices and what works, proven science-based answers.
“What we don’t have yet is results,” Clancy told attendees at AHRQ’s first national summit on health care quality and disparities held recently in Washington, DC. The conference, Improving Healthcare for All Americans: Celebrating Success, Measuring Progress, Moving Forward, focused on reports released by the agency in late February on national health care quality and disparities in care delivery.
The second-annual reports, the “2004 National Healthcare Quality Report” and the “2004 National Healthcare Disparities Report,” identified areas of improving quality and areas needed for improvement, in addition to gaps in care related to race, ethnicity, and socioeconomic status. “This is the state of health care quality in America today,” Clancy explained.
Unfortunately, she added that quality is “stubbornly short of where we want it to be, agonizingly short of where we know it could be, and still slow in making improvement.”
The reports measured quality and disparities in four areas:
1. Outcomes effectiveness.
2. Patient safety.
3. Timeliness of care.
4. Patient-centeredness.
They outlined data on the quality and differences in access to services for clinical conditions, including cancer, diabetes, end-stage renal disease, heart disease, and respiratory diseases, as well as for nursing home and home health care.
Clancy said she sees a “fundamental change” occurring in health care as a result of measuring quality. “We are measuring health care quality as never before, and that is step one — establishing a baseline expectation,” she said. “What athlete ever broke a performance record without first knowing what the record was?”
But overall, the message seems to be that quality, while improving in many areas, often is slow. Key findings are that the gap between the best possible care and actual care remains large and quality of care remains highly variable across the United States. Out of the 98 trends measured in the report, 67 improved, 30 deteriorated, and one did not change, Clancy said.
Compared to results from last year’s report, some of the more notable improvements included a 37% decrease from 2002 to 2003 in the percentage of nursing home patients who have moderate or severe pain. The report also cited a 34% decrease from 1994 to 2001 in the hospital admission rate for uncontrolled diabetes, as well as a 34% drop from 1996 to 2000 in the percentage of elderly patients who were given potentially inappropriate medications. Clancy said the hope is quality will “drive a change in health care culture” among professionals.
She downplayed the need to look at quality variables and rank performance by state. “These data are a tool, not a grade. Improvement is needed in every state and is one part of a bigger, hopeful picture as part of the quality challenge before us.”
There were a few notable improvements at the state level. Minnesota had the largest improvement in state rank for mammogram testing rates, and Alabama was the only state to significantly increase screening rates for two recommended tests for colorectal cancer, the report pointed out.
The 2004 disparities report presented data on the same clinical conditions and measures as the quality report but focuses on priority populations, including women, children, the elderly, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with special health care needs, specifically children with special needs, people in need of long-term care, and people requiring end-of-life care.
Disparities are pervasive, according to the data, and gaps in information exist, especially for specific conditions and populations. Blacks received poorer quality of care than whites for about two-thirds of quality measures and had worse access to care than whites for about 40% of access measures. Asians received poorer quality of care than whites for about 10% of quality measures and had worse access to care than whites for about a third of access measures. American Indians and Alaska natives received poorer quality of care than whites for about a third of quality measures and had worse access to care than whites for about half of access measures. Hispanics received lower quality of care than non-Hispanic whites for half of quality measures and had worse access to care than non-Hispanic whites for about 90% of access measures. The poor received lower quality of care for about 60% of quality measures and had worse access to care for about 80% of access measures compared to those with high incomes.
The report did find improvement in care provided to the poor, uninsured, and minorities through federally supported health centers. In 2004, more than 3,600 health centers delivered primary and preventive care to 13.2 million people, according to AHRQ.
The proposed 2006 fiscal year budget includes creation of 1,200 new or expanded health center sites, which are expected to increase the delivery of primary and preventive health care to 6.1 million more people.
Clancy offered “four Cs” to describe the quality challenge for U.S. health care:
1. Candor: Truly acknowledges the need for improvement.
2. Comparison: Enables patients to choose the right care for themselves, and clinicians needing to compare themselves and their facilities with others in order to know where they stand.
3. Consequences: Are important because “When our shortcomings become known, we find the energy and the know-how to correct them,” Clancy said.
4. Courage: Is “most needed to make the rest possible,” she said.
Donald Berwick, MD, president and CEO of the Institute for Healthcare Improvement in Cambridge, MA, at the meeting said the reports “really turn the light on. “As a nation, we need to have the guts to set standards. We are far behind other major Western democracies, and it is foolish for this country to believe that we have the answers alone when other countries have grappled with these problems and have closed the gap far more effectively,” he added. It is a “politically correct mantra” to claim that the United States has the best health care in the world, Berwick said. “But we do not.”
Clancy also reported that her agency would commit $1 million this year to a new initiative called AHRQ QualityConnect in an effort to “help uncover what works and share lessons learned with those at the front line of improvement.”
She said new information on quality from examples nationwide will be shared through publications, on-line resources, meetings, and other research networks. The hope is to have the program in place this summer.
According to the director of the Agency for Healthcare Research and Quality, escaping the health care quality “hook” is impossible. “We know we can do better,” she noted. “None of us has all the answers, but when it comes to quality and health care delivery, we actually have many answers about best practices and what works, proven science-based answers.”
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