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Priority Areas for National Action: Transforming Health Care Quality Chapter 3 Priority Areas for Quality Improvement The committee’s deliberations led to the selection of 20 priority areas for health care quality improvement: Care coordination (cross-cutting) Self-management/health literacy (cross-cutting) Asthma—appropriate treatment for persons with mild/moderate persistent asthma Cancer screening that is evidence-based—focus on colorectal and cervical cancer. Children with special health care needs1 Diabetes—focus on appropriate management of early disease End of life with advanced organ system failure—focus on congestive heart failure and chronic obstructive pulmonary disease Frailty associated with old age—preventing falls and pressure ulcers, maximizing function, and developing advanced care plans Hypertension—focus on appropriate management of early disease Immunization—children and adults Ischemic heart disease—prevention, reduction of recurring events, and optimization of functional capacity 1 The Maternal and Child Health Bureau defines this population as “those (children) who have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally” (McPherson et al., 1998:138).
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Priority Areas for National Action: Transforming Health Care Quality Major depression—screening and treatment Medication management—preventing medication errors and overuse of antibiotics Nosocomial infections—prevention and surveillance Pain control in advanced cancer Pregnancy and childbirth—appropriate prenatal and intrapartum care Severe and persistent mental illness—focus on treatment in the public sector Stroke—early intervention and rehabilitation Tobacco dependence treatment in adults Obesity (emerging area)2 The committee made no attempt to rank order the priority areas selected. The first 2 listed above—care coordination and self-management/health literacy—are cross-cutting areas in which improvements would benefit a broad array of patients. The 17 that follow represent the continuum of care across the life span and are relevant to preventive care, inpatient/surgical care, chronic conditions, end-of-life care, and behavioral health, as well as to care for children and adolescents. Finally, obesity is included as an “emerging area” that does not at this point satisfy the selection criteria as fully as the other 19 priority areas. This chapter first reviews the breadth of opportunities for health care improvement represented by the committee’s recommended list of priority areas. The three types of areas included on the list—cross-cutting areas, specific conditions, and emerging areas—are then described. The chapter next profiles each area in detail, including the aim of intervention in that area and the rationale for the area’s selection in light of the three criteria discussed in Chapter 2—impact, improvability and inclusiveness. Breadth of Opportunities Represented by Priority Areas The priority areas selected by the committee can be viewed through a variety of lenses. They represent a range of health care services and challenges, including: The full spectrum of health care, from preventive and acute care, to chronic disease management, to long-term and palliative care at the end of life. Thus they encompass a wide variety of health care services, spanning both reactive acute, emergency, and surgical care and the proactive planned care required to prevent and manage chronic disease, pain, and disability. Care provided for a variety of populations representing Americans of all ages and demographic groups, including care that is oriented to individuals and families, as well as populations. Care delivered in a range of publicly and privately financed ambulatory and inpatient health care settings (outpatient and community health centers, home-based care, emergency departments, hospitals, and nursing homes) by a variety of health care practitioners (physicians, nurses, pharmacists, allied health professionals), including both generalists and specialists. The Full Spectrum of Health Care As noted, the priority areas recommended by the committee represent health care quality improvement challenges and opportunities across the full spectrum of health care. In fact, having relevance to multiple domains of care strengthened an area’s chances of being included on the final list. Boxes 3–1 to 3–6 show how the priority areas relate to a wide range of health care needs. For example, ischemic heart disease figures prominently in preventive care, inpatient/surgical care, chronic
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Priority Areas for National Action: Transforming Health Care Quality care, and end-of-life care. Similarly, medication management cuts across inpatient/ surgical care, chronic care, end-of-life care, and child/adolescent care. Obesity—the emerging area—touches on preventive care, chronic care, behavioral health, and child/adolescent care. The Entire Life Span The committee made a concerted effort to ensure that the priority areas selected would represent issues pertinent to all age groups. Figure 3–1 shows how the priority areas cut across the stages of a typical life span. As demonstrated, only a few areas are unique to certain age groups, such as children with special health care needs and frailty prevention and management. Many areas, such as cancer screening and hypertension, cluster around adulthood and extend into end of life. Additionally, nine of the priority areas encompass the entire life span. Figure 3–1: Priority areas across the life span. Diverse Health Care Settings and Professions The set of priority areas recommended by the committee involves care that is provided in multiple health care settings and organizations, care that is both privately and publicly funded, and care that is provided by a variety of health care professionals. For example, effective asthma management requires integration of care among primary care providers, pediatricians, schools, hospitals (particularly emergency rooms), and pharmacists. Adequate pain control in advanced cancer and stroke rehabilitation require a continuum of care that includes home, community, clinic, and hospital. Improving quality of care for severe and persistent mental illness, such as psychosis, provides an opportunity to focus on the effectiveness of mental health services provided by the public sector (Narrow et al., 2000; Wells, 2002a). To close the gaps between best practice and usual care for the full set of proposed areas will require the collective expertise of a vast array of doctors, nurses, pharmacists, allied health professionals, social workers, and vested laypersons. Virtually every conventional medical specialty will need to develop strategies for one or more of these priority areas.
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Priority Areas for National Action: Transforming Health Care Quality Box 3–1 Priority Areas That Relate to Preventive Care Care coordination (cross-cutting) Self-management/health literacy (cross-cutting) Cancer screening Hypertension Immunization Ischemic heart disease (prevention) Major depression (screening) Pregnancy and childbirth Tobacco dependence Obesity (emerging area) Box 3–2 Priority Areas That Relate to Behavioral Health Care coordination (cross-cutting) Self-management/health literacy (cross-cutting) Major depression Severe and persistent mental illness Tobacco dependence Obesity (emerging area) Box 3–3 Priority Areas That Relate to Chronic Conditions Care coordination (cross-cutting) Self-management/health literacy (cross-cutting) Asthma Children with special health care needs Diabetes End of life with advanced organ system failure Frailty Hypertension Ischemic heart disease Major depression (treatment) Medication management Medication errors Overuse of antibiotics Pain control in advanced cancer Severe and persistent mental illness Stroke Tobacco dependence Obesity (emerging area)
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Priority Areas for National Action: Transforming Health Care Quality Box 3–4 Priority Areas That Relate to End of Life Care coordination (cross-cutting) Self-management/health literacy (cross-cutting) Chronic conditions End of life with advanced organ system failure Frailty Medication management Medication errors Overuse of antibiotics Nosocomial infections Pain control in advanced cancer Box 3–5 Priority Areas That Relate to Children and Adolescents Care coordination (cross-cutting) Self-management/health literacy (cross-cutting) Asthma Children with special health care needs Diabetes Immunization (children) Major depression Medication management Medication errors Overuse of antibiotics Obesity (emerging area) Box 3–6 Priority Areas That Relate to Inpatient/Surgical Care Care coordination (cross-cutting) Self-management/health literacy (cross-cutting) End of life with advanced organ system failure Ischemic heart disease Medication management Medication errors Overuse of antibiotics Nosocomial infections Pain control in advanced cancer Pregnancy and childbirth Severe and persistent mental illness Stroke
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Priority Areas for National Action: Transforming Health Care Quality Three Types of Priority Areas Cross-Cutting Areas There was strong consensus among the committee members on the critical need to improve care coordination, support for self-management, and health literacy for all patients and their families. System and policy changes to achieve improvement in these cross-cutting priority areas would involve most health care organizations and practitioners, could impact all types of conditions, and could provide a means of dramatically improving health care for all Americans. Improved care coordination would, if applied broadly, have an especially important impact on improving health care processes and outcomes for children and adults with serious chronic illness and multiple chronic conditions (Anderson and Knickman, 2001; Anderson, 2002b). Efforts to improve health literacy are in turn essential for effective self-management and collaborative care. For example, a recent study found that diabetics with poor health literacy, unable to read and/or comprehend directions on their pill bottles, had worse blood sugar control and higher rates of preventable vision impairment (Schillinger et al., 2002). Devising strategies to improve health literacy—both at the micro level, where patients and health care professionals interact, and at the macro level, where population health is the target—would not only improve diabetes outcomes, but also form part of a package of improvements for nearly all inadequate aspects of health care. Specific Priority Conditions Chronic Care In keeping with the Quality Chasm report, which notes the critical need to close quality gaps for the growing numbers of Americans with chronic disease (Institute of Medicine, 2001a), the majority of the specific priority conditions recommended are chronic. For all of the recommended conditions, such as diabetes, hypertension, and ischemic heart disease, there are known, effective interventions that can be applied to improve health outcomes, reduce disease burden, and prevent more serious health problems later in life. Moreover, the enormous and rapid growth in the prevalence and burden of chronic disease over the past two decades has been a major force in clarifying the limitations of the current health care system—which evolved primarily to meet acute and emergency health care needs—thus motivating broad action for health care system redesign (Bodenheimer et al., 2002; Institute of Medicine, 2001a). Acute Care One priority area within the realm of acute care—effective medication management— focuses on preventing medication errors and the overprescribing of antibiotics, particularly for acute respiratory infections in children. This area provides an excellent opportunity for designing interventions that can enhance the use and capacity of management information systems. For example, lecturing to physicians about medical errors yields small gains, but technological advances, such as the electronic medical record tied to computerized medication orders with acceptable dosage ranges and interactions, can dramatically reduce errors arising from incorrect orders (Bates et al., 1999; Kaushal et al., 2001). Computerized alerts of potential drug interactions, prompts and reminders for required services, and electronic physician order entry for prescriptions could all be put in place to safeguard health and improve quality of care (Hunt et al., 1998). Corrective measures that redesign work so that errors are “engineered out” are repeatedly found to have high leverage. Preventive Care The committee explicitly included preventive services among the domains of health care that should be represented by the priority areas. Doing so reflected a growing body of evidence that early detection and timely
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Priority Areas for National Action: Transforming Health Care Quality intervention for risk factors or diseases in their preclinical stages are effective in reducing both disease burden and costs. Selected priority areas represent a range of clinical preventive services involving immunization, screening, and counseling for lifestyle changes, which would singly and collectively reduce morbidity and mortality due to the nation’s leading chronic illnesses and infectious disease threats. Specifically, childhood/adult immunization, improved screening for colorectal and cervical cancers, and brief primary care interventions for adult tobacco dependence have been identified as major opportunities for cost-effective improvements in the nation’s health care system (Coffield et al., 2001). For example, just 3–5 minutes of counseling and medication advice given to adult smokers by their physician could more than double the quitting success rates smokers achieve on their own (Fiore et al., 2000). Since there are over 430,000 tobacco-related deaths each year from heart disease, stroke, lung cancer, and chronic lung disease among U.S. adults, the impact of this simple intervention, combined with other effective modes of tobacco treatment, would be dramatic (Max, 2001; United States Department of Health and Human Services, 2000). Unfortunately, only about 50 percent of patients who smoke receive such advice and assistance, largely because supports such as office-based reminder systems and insurance coverage for smoking cessation services are not widely in place (Goodwin et al., 2001; Thorndike et al., 1998). Treating tobacco dependence is critical to preventing disease in healthy populations of smokers, the progression of illnesses caused by tobacco use, poor pregnancy outcomes associated with smoking, and pediatric asthma in infants and adolescents whose parents smoke. Furthermore, there is growing evidence that the types of system and policy changes needed to spur broader use of evidence-based tobacco interventions are similar to those required to support the wider delivery of other proven interventions for changes in health behavior in primary care, such as counseling on physical activity and diet and on the importance of reducing risky consumption of alcohol (Glasgow et al., 2001). Palliative Care Between 2010 and 2030, America’s baby boomers will move beyond the age of 65 and swell the number of older persons to approximately 70 million, representing 20 percent of the population (Administration on Aging, 2002). Accordingly, the committee placed particular emphasis on addressing the complex care issues that surface after age 65 and particularly after age 80. One of the priority areas in the category of palliative care is frailty. Nearly everyone who survives past age 80 experiences a period of frailty involving decreased functional status as a result of multiple health problems, such as heart and lung disease, as well as cognitive deficits resulting from dementia or stroke. As more and more Americans face the physical and social challenges of frailty, systems of care must adapt in ways that allow them to live comfortably and safely at home. Advanced care plans should be put in place that are respectful of both the patient’s and family’s wishes. This priority area can serve as an exemplar for health care quality improvements that incorporate changes at various levels of the health care delivery system to provide integrated, dignified care for those of advanced age. Emerging Areas Obesity was intentionally placed last on the committee’s list and classified as an “emerging area.” The prevalence of overweight and obesity among Americans has reached epidemic proportions (Mokdad et al., 2001; Yanovski and Yanovski, 2002). Obesity represents an important medical condition in its own right and contributes to morbidity and mortality for other diseases, including heart disease, type II diabetes, osteoarthritis, hypertension, and cancer. Addressing growing rates of obesity and obesity-related disease in children and adults has been identified as an urgent national health care priority (Squires, 2001).
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Priority Areas for National Action: Transforming Health Care Quality Obesity was selected as a priority area based on strong evidence for its impact and inclusiveness, but still emerging evidence for improvability. That is, there was relatively limited evidence for the efficacy of existing best-practice treatments for obesity in children and adults, such as behavioral counseling and drug and surgical interventions (Epstein et al., 2001). In addition, effective treatment for obesity will need to integrate many other aspects of society, such as housing, exercise opportunities, food supply, and work patterns, often considered outside the traditional realm of health care. The committee’s aim in denoting obesity as “emerging” was to accelerate the rate at which research generates the evidence needed to identify effective interventions and to develop evidence-based treatment guidelines and valid performance measures. Since this area would serve as a model for potential future emerging priority areas, formal reviews of progress on obesity would be conducted more frequently than for other priority areas, perhaps as often as yearly, to determine future directions. Priority Areas: Detailed Descriptions The following brief descriptions are intended as illustrative rather than exhaustive profiles for each of the 20 recommended priority areas. The committee’s goal was to provide a starting point for experts in the field to undertake effective national health care quality improvement efforts over the next 3 to 5 years. Each priority area is discussed with reference to the committee’s three selection criteria—impact, improvability, and inclusiveness. A vignette is also provided for selected areas to illustrate how a transformed health care system would provide quality care in that area.
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Priority Areas for National Action: Transforming Health Care Quality Care Coordination Aim To establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by the proactive delivery of evidence-based care and follow-up. Clinical integration is further defined as “the extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of services delivered to patients” (Shortell et al., 2000:129). Rationale for Selection Impact Nearly half of the population—125 million Americans—lives with some type of chronic condition. About 60 million live with multiple such conditions. And more than 3 million—2.5 million women and 750,000 men—live with SOURCE: Reprinted with permission from Gerard Anderson, Ph.D. (2002). Figure 3–2. Hospitalizations among Medicare beneficiaries with multiple chronic conditions. five such conditions (Partnership for Solutions, 2001). For those afflicted by one or more chronic conditions, coordination of care over time and across multiple health care providers and settings is crucial. Yet in a survey of over 1,200 physicians conducted in 2001, two-thirds of respondents reported that their training was not adequate to coordinate care or education for patients with chronic conditions (Partnership for Solutions, 2001). More than 50 percent of patients with hypertension (Joint National Committee on Prevention, 1997), diabetes (Clark et al., 2000), tobacco addition (Perez-Stable and Fuentes-Afflick, 1998), hyperlipidemia (McBride et al., 1998), congestive heart failure (Ni et al., 1998), chronic atrial fibrillation (Samsa et al., 2000), asthma (Legorreta et al., 2000), and depression (Young et al., 2001) are currently managed inadequately. Among the Medicare-eligible population, the average beneficiary sees 6.4 different physicians in a year, 4.6 of those being in the outpatient setting (Anderson, 2002a).
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Priority Areas for National Action: Transforming Health Care Quality Among this same population, as the number of chronic conditions a person has increases, so, too, does the number of hospitalizations that are inappropriate or avoidable because outpatient treatment would have been effective: from 7 per 1,000 for those with one chronic condition to 95 per 1,000 for those with five chronic conditions and 261 per 1,000 for those with ten or more such conditions (Anderson, 2002a). See Figure 3–2. Improvability In a randomized controlled trial of 970 patients with diabetes cared for by over 450 primary care providers, usual care was compared with a program utilizing regular follow-up, decision support, reminder systems, and modern self-management support. After 6 years, patients in the intervention group had significantly better outcomes, including lower HbAlc, blood pressure, and cholesterol levels (Olivarius et al., 2001). A recent review of ambulatory-care diabetic management programs found that patient education and an expanded role for a nurse in the intervention strategy also improved patient outcomes (Renders et al., 2001). According to a meta-analysis of adult immunization and cancer screening programs, interventions that had the largest impact involved organizational changes, such as the use of a planned care visit for prevention, and designation of nonphysician staff to carry out specific prevention activities (Stone et al., 2002). There is also a growing body of evidence that planned (e.g., proactive, structured) care at set intervals makes a difference, and can be accomplished using nonstandard models, such as group visits (Beck et al., 1997; Sadur et al., 1999). The Chronic Care Model, described in Chapter 1, provides a structure for planned, clinically integrated care. There are promising indications that a wide variety of health systems can reorganize themselves to deliver such care (The National Coalition on Health Care and the Institute for Healthcare Improvement, 2002; Wagner et al., 2001a). Inclusiveness The Institute of Medicine’s 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care documents racial and ethnic disparities in several of the priority areas recommended in this report, all of which could benefit from a more integrated approach to care. These areas include children with special health care needs, diabetes, end of life with advanced organ system failure, frailty, pregnancy and childbirth, and severe and persistent mental illness (Institute of Medicine, 2002).
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Priority Areas for National Action: Transforming Health Care Quality Box 3–7 Care Coordination One participating organization, Care Management Group of Greater NY, Inc. (CMGNY), in the Institute for Healthcare Improvement and The Robert Wood Johnson Foundation’s National Program on Improving Chronic Illness Care incorporated the elements of the Chronic Care Model to enhance recognition and treatment of depression in patients with congestive heart failure. This collaborative is an excellent example of how effective care coordination, or clinical integration of services, improved health outcomes for the chronically ill, particularly for patients with multiple chronic conditions. First, there was strong organizational support from key leaders at CMGNY, a subsidiary of the North Shore Long Island Jewish Health System. Second, clinical information systems were used to extract claims data and a disease registry was built to identify patients within the plan who had been diagnosed with congestive heart failure (CHF). Physicians participating in the program were given the names of their CHF patients for systematic screening for depression. Patients with recent hospitalizations, patients identified through care management, and patients whose annual costs exceeded $50,000 per year, were all targeted for depression assessment as well. Third, decision support was provided at many levels. Physicians within the plan were invited to attend “managed care college” where they were trained to recognize the classic signs of depression and coached to administer the Patient Health Questionnaire (PAQ), a screening tool for depression. Notably, clinicians were given financial incentives for incorporating the PAQ into their daily practice. Additionally, primary care physicians had access to a psychiatrist by telephone for consultation regarding medication dosage and depression management. Fourth, a nurse practitioner used telephone self-management support techniques to facilitate partnerships between patients and their providers. The hallmark of this relationship was active listening and empathy with the overarching goal to educate the patient about their condition and to monitor and encourage adherence to their treatment plan, including medications and appointments. In addition, goal-setting strategies were developed with the patient to encourage exercise and engagement in pleasant events as well as to resolve treatment-emergent problems such as side effects from antidepressant medications, attitudinal issues and social barriers. Fifth, the overall delivery of care was redesigned to incorporate elements of the chronic illness care model, including care management, decision support and development of community relationships. This included providing services outside the doctor’s office such as home health evaluations, home psychiatric evaluations, physical therapy and a home health aide. A nurse practitioner figured prominently in coordinating, monitoring and following-up of care. Lastly, patients were linked with community resources both on the local and national level. Outcomes from this study were dramatic. After 6 months a 50 percent or greater improvement in depression severity was observed among participants. In the words of one patient with CHF who was clinically depressed and on 20 medications “you have turned my life around” (Cole et al., 2002; Cole, 2002).
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