Priority Areas for National Action: Transforming Health Care Quality (2003)

The Medical Expenditure Panel Survey (MEPS) provides national and regional annual estimates of health care utilization, expenditures, sources of payment, and insurance coverage for the U.S. noninstitutionalized population. AHRQ and the National Center for Heath Statistics cosponsor this initiative. MEPS comprises four survey components: the Household Component (HC), the Medical Provider Component (MPC), the Insurance Component, and the Nursing Home Component. The MEPS HC collects data on health conditions both at an individual and a household level. Other data drawn from this survey include demographics, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment. Medical providers are contacted using the MEPS MPC to augment and verify the self-reported medical care events obtained from the MEPS HC (Medical Expenditure Panel Survey, 2002).

In planning for the MEPS health care quality enhancements, it was decided that a set of medical conditions would need to receive heightened attention. As a result, expansion of the HC was necessary to include individuals with illnesses that were of national concern. To facilitate the decision-making process or the selection of these conditions, the following criteria were established (Cohen, 2001):

• Prevalence—national prevalence rate for the medical condition (at least 3%)

• Availability of standardized questions used in other national surveys

• Accuracy of conditions households could report

• Availability of evidence-based quality measures

• Burden to society in terms of expenditures

Using these criteria, the following medical conditions were targeted by the MEPS healthcare quality enhancement effort: diabetes, asthma, hypertension, ischemic heart disease, arthritis, stroke, and chronic obstructive pulmonary disease.

QUERI is an integrated quality improvement program in use at the VA. QUERI’S underlying goals are to identify best practices, to incorporate them into daily use, and to provide a feedback mechanism to ensure continuous quality improvement. QUERI functions to translate findings in the research setting into improved patient care and system redesign (Demakis et al., 2000; Feussner et al., 2000; Kizer et al., 2000). A six-step process is employed to ensure systematic adherence to quality improvement efforts:

1. Identify high-risk/volume diseases among veterans.

2. Identify best practices.

3. Define existing practice patterns and outcomes across the VA and current variation from best practices.

4. Identify and implement interventions to promote best practices.

5. Document that best practices improve outcomes.

6. Document that outcomes are associated with improved health-related quality of life.

Eight targeted conditions were selected as the focal point for QUERI: chronic heart failure, diabetes, HIV/AIDS, ischemic heart disease, mental health (depression and schizophrenia), spinal chord injury, and stroke. Criteria used to determine this group of conditions included the number of veterans affected, the burden of illness, and known health risks within the veteran population.

BPHC, part of HRSA within the Department of Health and Human Services (DHHS), provides funding for programs that expand access to high-quality, culturally and linguistically competent health care—both primary and preventive—for underserved, uninsured, and underinsured Americans. In 1998, BPHC organized five regional clusters of states and then funded one primary care association/clinical network team in each of these five clusters, along with the national clinical networks focused on oral health, migrant farm worker health care, and homeless health care (Health Disparities Collaboratives, 2002). These organizations then worked with the Institute for Healthcare Improvement (IHI) to develop the infrastructure for the Health Disparities Collaboratives.

The intent of these Collaboratives is to change primary health care practices in order to improve the care provided to everyone and eliminate health disparities. To meet this goal, it was determined that the Collaboratives should focus on a subgroup of the entire population and then, if successful, spread to the rest of the patients in a community.

The first collaborative, initiated in January 2000, focused on diabetes; it was quickly followed by the asthma and depression collaborative in March 2000. The program then expanded to cardiovascular disease in April 2001: future Collaboratives are expected to include cancer, prevention, infant mortality, and immunizations (Health Disparities Collaboratives, 2002; Stevens, 2002).

CMS manages a national network of contractors known as quality improvement organizations (QIOs; formerly known as peer review organizations or PROs). The purpose of these QIOs is to systematically improve the quality of care received by Medicare beneficiaries in participating hospitals and now in an expanding group of providers in nonhospital settings. To provide guidance to the QIOs, CMS’ Quality Improvement Program conducts an involved process to identify priority topic areas (Schulke, 2002). This process uses seven main criteria to assess the significance of proposed topics:

• Importance to Medicare population—How many people have the condition or receive the service? How many associated disabilities and/or deaths are associated with it?

• Science—Are there treatments that make a difference and measurements of their success?

• Performance gap—Does a gap exist between actual performance and what is achievable that results in substantial harm to the health of Medicare beneficiaries?

• Interventions—Are there interventions that QIOs can undertake to reduce the performance gap?

• Partnerships—Are there outside partners interested in this priority area that can contribute to its improvement? Are there internal department priorities that may make a topic more appealing?

• Cost—Can the cost to QIOs, providers, practitioners, and plans be reduced by focusing on this condition? Will the project increase or reduce Medicare trust fund outlays?

• Applicability to nonhospital settings

CMS applied these criteria to 31 proposed clinical topics that were listed for field implementation by QIOs in the Seventh QIO Statement of Work (Centers for Medicare and Medicade Services, 2002). Based on this assessment, CMS ultimately instructed the QIOs to focus on reducing clinical system failures for six priority topics: acute myocardial infarction, heart failure, pneumonia, postoperative infections, diabetes, and breast cancer.

The Partnership for Prevention, a national nonprofit organization supported by both the Centers for Disease Control and Prevention (CDC) and CMS, convened the Committee on Clinical Preventive Service Priorities to undertake the following two tasks: develop an approach for comparing clinical preventive services based on their relative value to society, and rank services recommended by the U.S. Preventive Services Task Force (Coffield et al., 2001; Maciosek et al., 2001).

To carry out the first task, two criteria were selected by the committee for evaluating the relative value clinical preventive services: clinically preventable burden (CPB), the proportion of disease & injury prevented by the service if it were delivered to 100 percent of the population at the recommended intervals; and cost effectiveness (CE), the costs of prevention minus costs averted divided by the number of quality-adjusted life years saved. Each clinical preventive service was assigned a separate CPB and CE score. These two scores were then summed and subsequently used to rank the 30 services being evaluated.

The majority of the highest-ranking scores turned out to be screening services. Vaccine services, such as the childhood mumps, measles, rubella vaccine received the highest overall ranking. Counseling services, including tobacco cessation counseling for adults and antitobacco messages for children, also figured prominently.

Seven services were highlighted from this final ranking to assist decision makers in determining how to target spending of limited health care dollars in this area most judiciously.

These rankings were compared with the current delivery rates at the national level.

The following services ranked high on the scale and were delivered to less than 50 percent of their targeted populations nationally:

• Assess adults for tobacco use, and provide counseling.

• Screen for vision impairment among adults older than age 65.

• Assess adolescents for drinking and drug use and provide counseling on abstinence

• Screen for colorectal cancer among persons older than age 50.

• Screen for chlamydia among women aged 15–24.

• Screen for problem drinking among adults, and provide counseling.

• Vaccinate adults older than age 65 against pneumococcal disease.

In response to pressure from advocacy groups and other stakeholders in biomedical science research, the NIH formed a working group to address priority setting for funding extramural research. Subsequently, Congress requested the Institute of Medicine (IOM) to review the priority setting process and criteria employed by NIH; the latter included public health needs, scientific quality of the research, probability of success, maintenance of a diverse portfolio, and maintenance of an adequate scientific infrastructure. Although the IOM supported the criteria chosen, recommendations for improvement were made. These included NIH increasing its use of health data, such data on disease as burden and cost, and gathering more input from the public (Gross et al., 1999).

NIH considers the following criteria for measuring health needs:

• Number of people with the disease (prevalence)

• Number of deaths caused by the disease

• Degree of disability caused by the disease

• Degree to which the disease shortens a normal productive lifetime

• Economic and social costs of the disease

• Need to respond rapidly to control the spread of a disease

NIH affirms that there are limitations to relying solely on any one of the mentioned criteria. Individually, they often lead to unintended outcomes. For example, if prevalence of disease were the dominant criteria, common diseases such as the common cold would receive the most attention. However, this approach could depress research on childhood cancers. Another case in point is mortality. By focusing on number of deaths, one may overlook chronic diseases, the very area on which the committee is focusing for efforts to restructure health care delivery restructuring efforts (National Institutes of Health (NIH), 1997).

Centers for Medicare and Medicade Services. 2002. “Quality Improvement Organizations (QIOs).” Online. Available at http://cms.hhs.gov/qio/2.asp [accessed Oct. 15, 2002].

Coffield, A.B., M.V.Maciosek, J.M.McGinnis, J. R.Harris, M.B.Caldwell, S.M.Teutsch, D. Atkins, J.H.Richland, and A.Haddix. 2001. Priorities among recommended clinical preventive services. Am J Prev Med21 (1):1–9.

Cohen, S.B.2001. Enhancements to the Medical Expenditure Panel Survey to improve health care expenditure and quality measurement. In Proceedings of the Statistics in Epidemiology Section, American Statistical Association.

Demakis, J.G., L.McQueen, K.W.Kizer, and J.R. Feussner. 2000. Quality Enhancement Research Initiative (QUERI): A collaboration between research and clinical practice. Med Care38 (6 Suppl 1):I17–25 .

Feussner, J.R., K.W.Kizer, and J.G.Demakis. 2000. The Quality Enhancement Research Initiative (QUERI): From evidence to action. Med Care38 (6 Suppl 1):I1–6.

Gross, C.P., G.F.Anderson, and N.R.Powe. 1999. The relation between funding by the National Institutes of Health and the burden of disease. N Engl J Med340 (24): 1881–7.

Health Disparities Collaboratives. 2002. “Health Disparities Collaboratives.” Online. Available at http://www.healthdisparities.net/ [accessed June 4, 2002].

Kizer, K.W., J.G.Demakis, and J.R.Feussner. 2000. Reinventing VA health care: Systematizing quality improvement and quality innovation. Med Care38 (6 Suppl 1):I7–16.

Maciosek, M.V., A.B.Coffield, J.M.McGinnis, J. R.Harris, M.B.Caldwell, S.M.Teutsch, D. Atkins, J.H.Richland, and A.Haddix. 2001. Methods for priority setting among clinical preventive services. Am J Prev Med21 (1):10– 9.

Medical Expenditure Panel Survey. 2002. “Medical Expenditure Panel Survey Website.” Online. Available at http://www.meps.ahcpr.gov [accessed July 1, 2002].

National Institutes of Health (NIH). 1997. “Setting Research Priorities at the National Institutes of Health.” Online. Available at http://www.nih.gov/news/ResPriority/priority.htm [accessed June 4, 2002].

Schulke, David Executive Vice President (American Health Quality Association). 30 April 2002. Process for Designating National Priority Clinical Topics for Medicare’s Quality Improvement Program (Letter). Personal communication to George Isham, Chair (IOM Priority Areas for Quality Improvement Committee).

Stevens, D.M.2002. Changing Practice/Changing Lives.Presented at May 9–10, 2002 Priority Areas for Quality Improvement Meeting.