Priority Areas for National Action

Transforming Health Care Quality

Karen Adams and Janet M.Corrigan, Editors

Committee on Identifying Priority Areas for Quality Improvement

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C. www.nap.edu



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Priority Areas for National Action: Transforming Health Care Quality Priority Areas for National Action Transforming Health Care Quality Karen Adams and Janet M.Corrigan, Editors Committee on Identifying Priority Areas for Quality Improvement Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Priority Areas for National Action: Transforming Health Care Quality THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Agency for Healthcare Research and Quality (AHRQ). The views presented in this report are those of the Institute of Medicine Committee on Identifying Priority Areas for Quality Improvement and are not necessarily those of the funding agencies. International Standard Book Number 0-309-08543-8 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC20055; (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Priority Areas for National Action: Transforming Health Care Quality “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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Priority Areas for National Action: Transforming Health Care Quality THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V.Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. Wm. A.Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Priority Areas for National Action: Transforming Health Care Quality COMMITTEE ON IDENTIFYING PRIORITY AREAS FOR QUALITY IMPROVEMENT GEORGE J.ISHAM(Chair), Medical Director and Chief Health Officer, HealthPartners Inc., Minneapolis, MN BRIAN AUSTIN, Deputy Director, Improving Chronic Illness Care, Macoll Institute for Healthcare Innovation, Group Health Cooperative Puget Sound, Seattle, WA STEPHEN BERMAN, Professor of Pediatrics and Director of Children’s Outcomes Research Center; Head Section of Academic General Pediatrics, University of Colorado Health Sciences Center, The Children’s Hospital, Denver, CO KAREN A.BODENHORN, President and CEO, Center for Health Improvement, Sacramento, CA DAVID M.CUTLER, Professor of Economics, Harvard University, Cambridge, MA JAIME A.DAVIDSON, Endocrinologist at Medical City Dallas Hospital; Clinical Associate Professor of Internal Medicine, University of Texas Southwestern Medical School, Dallas, TX BENJAMIN G.DRUSS, Associate Professor of Psychiatry and Public Health, Yale University School of Medicine, New Haven, CT JACK C.EBELER, President and CEO, Alliance of Community Health Plans, Washington, D.C. LISA I.IEZZONI, Professor of Medicine, Harvard Medical School, Boston, MA CHARLES B.INLANDER, President, People’s Medical Society, Fogelsville, PA JOANNE LYNN, Director, The Washington Home Center for Palliative Care Studies; Senior Researcher, RAND Health; and President, Americans for Better Care of the Dying, Washington, DC C.TRACY ORLEANS, Senior Scientist and Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ GREG PAWLSON, Executive Vice President, National Committee for Quality Assurance, Washington, D.C. PAUL D.STOLLEY, Clinical Professor of Medicine, University of Maryland School of Medicine, Department of Epidemiology and Preventive Medicine, Baltimore, MD A.EUGENE WASHINGTON, Professor and Chair, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA KEVIN WEISS, Director, Midwest Center for Health Services and Policy Research, Hines, VA; and Professor of Medicine and Director, Center for Healthcare Studies, Northwestern University Fineberg School of Medicine, Chicago, IL GAIL WILENSKY, John M.Olin Senior Fellow, Project HOPE, Bethesda, MD

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Priority Areas for National Action: Transforming Health Care Quality Study Staff JANET M.CORRIGAN, Director, Board on Health Care Services KAREN ADAMS, Program Officer and Study Director DANITZA VALDIVIA, Senior Project Assistant Auxiliary Staff ANTHONY BURTON, Administrative Assistant SHARI M.ERICKSON, Research Associate Editorial Consultant RONA BRIERE, Briere Associates, Inc.

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Priority Areas for National Action: Transforming Health Care Quality 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 NRC’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: GERARD ANDERSON, Professor of Health Policy, Management and International Health, The Johns Hopkins School of Public Health, Baltimore, MD LONNIE R.BRISTOW, former President, American Medical Association, Walnut Creek, CA ADAMS DUDLEY, Assistant Professor of Medicine, Health Policy, Epidemiology and Biostatistics, Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA VALENTIN FUSTER, Director, Cardiovascular Institute and Richard Gorlin, M.D. Heart Research Foundation, Mount Sinai Medical Center, New York, NY DAVID B.GRAY, Associate Professor of Neurology and Occupational Therapy, Washington University School of Medicine, St. Louis, MO HURDIS M.GRIFFITH, former Dean and Professor, Rutgers, The State University of New Jersey, Arlington, VA SAM HO, Vice President Corporate Medical Director, Pacific Health Systems, Santa Ana, CA STEVEN E.HYMAN, Provost, Harvard University, Cambridge, MA ELIZABETH A.MCGLYNN, The RAND Corporation, Center for Research on Quality in Health Care, Santa Monica, CA BILL ROPER, Dean, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC ED WAGNER, Director, W.A.McColl Institute for Healthcare Innovation, Group Health Cooperative Puget Sound, Seattle, WA Although the reviewers listed above have 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. The review of this report was overseen by DONALD M.STEINWACHS, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD and CHARLES E.PHELPS, University of Rochester, Rochester, NY. 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.

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Priority Areas for National Action: Transforming Health Care Quality Preface In the 2001 report Crossing the Quality Chasm: A New Health System for the 21stCentury, the Institute of Medicine (IOM) called for fundamental change in a troubled and ailing health care system. The change requires substantial improvements in six major aims outlined in that report—that health care be safe, effective, patient-centered, timely, efficient, and equitable. The report further suggested that the Agency for Healthcare Research and Quality (AHRQ) identify not fewer than 15 priority conditions for the purpose of developing strategies, goals, and action plans for achieving substantial improvements in quality in the next 5 years for each of the priority conditions. In response, the Department of Health and Human Services (DHHS) contracted with the IOM to convene a committee of experts that would establish a process and a set of criteria for determining the priority conditions, identify potential candidates, and recommend to DHHS a final list of priority conditions. The committee presenting this report was constituted for that purpose. This committee was propelled forward by a short timeline for the work, as this was a “fast-track” study. The findings of this study are wanted by a number of groups that are working on projects to push transformation of the health system forward. In particular, it is envisioned that the priority areas will become subjects of AHRQ’s National Health Care Quality Report. The recently released IOM report Leadership by Example: Coordinating Government Roles in Improving Health Care Quality, calls for the government to take the lead in promulgating standardized performance measures and points to the priority areas as the springboard for this effort. I know this committee shares a sense of urgency around the need to move forward without delay with the required re-design of the health care system. Although chronic conditions are important candidates for quality improvement, the committee was charged and constituted to take a broader approach. The committee concluded that a purely disease based approach would not accomplish the needed transformation that the list of priority conditions intended to bring about. Thus, our scope was broader than the original focus on “priority conditions” as suggested in the Quality Chasm report and included other essential “priority areas” of health care, such as preventive care and behavioral health. Our list of recommended priority areas reflects this broader perspective of our task. The committee is mindful of the dilemma presented by the fact that there are many more than the 20 areas recommended as priorities that are in need of substantial quality improvement. Nevertheless we believe that the 20 areas recommended represent a good starting point for this work because they collectively represent 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. It is our hope that progress in quality of care in these areas will lead to changes in the underlying systems that support care and this progress will also benefit those with many conditions that are not included in this first list of recommended priority areas. I am grateful to have had the opportunity to work with a dedicated, talented and energetic committee on this project. We were well supported by Karen Adams, program officer and Danitza Valdivia, project assistant both staff of the IOM. The generous insights of our workshop presenters and those members of the public giving testimony and communication assisted us in great measure. With these priority areas as a starting point, it’s now time to get on with the implementation of changes that are necessary to transform our health care system into something of which we can truly be proud. George Isham, M.D., M.S. Chair January 2003

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Priority Areas for National Action: Transforming Health Care Quality Foreword This report is one in a series spearheaded by the Institute of Medicine (IOM) to improve the quality of health care in America. The IOM’s quality initiative has gone through three stages since its genesis 6 years ago. In its first phase, the National Roundtable on Health Care Quality, convened by the IOM, highlighted serious problems in the quality of care and noted them to be pervasive throughout the country. The work of this group heightened awareness of the overuse, misuse, and underuse of health care services that harm large numbers of Americans every day. The second phase of our quality initiative, from 1999–2001, was marked by the release of two reports To Err is Human and Crossing the Quality Chasm, both of which called for drastic redesign of our health care delivery system to narrow the gap between the best clinical practice and the usual practice today. We are now fully immersed in phase three of our quality initiative and have begun to lay the groundwork for implementing the recommendations set forth in Crossing the Quality Chasm. This report responds to the call in Crossing the Quality Chasm, for a limited set of priority areas, predominately chronic conditions, which would serve as the starting point for restructuring our health care delivery system. It was envisioned that stakeholders from health care organizations, purchasers, professional groups, and most importantly, consumers would join forces and take action to improve quality in these select areas within the next five years. The majority of priority areas recommended in this report are chronic conditions; however, the final list also represents the many realms of health care, including preventive care, acute care, and end of life care. Many of the priority areas targeted are the leading causes of death in the United States. Their toll on human life is great. Behind each of these priority areas are many individuals who are not receiving optimal care. Each of these priority areas can be a locus to transform our health care system into one that is more fully integrated and responsive to patient needs. This will require the collective efforts of organizations and individuals, many of which have already begun hard work in these areas. In addition to restructuring how care is delivered, the priority areas can also be the warp to weave information technology into the fabric of daily clinical decision-making and set the stage for linking payment incentives to the quality of care. These priority areas are thus important in their own rights and as focal points to improve the quality of health care. Harvey Fineberg, M.D., PhD President, Institute of Medicine January 2003

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Priority Areas for National Action: Transforming Health Care Quality Acknowledgments The Committee on Identifying Priority Areas for Quality Improvement wishes to acknowledge the many people whose contributions made this report possible. We appreciate how willingly and generously these individuals contributed their time and expertise to assist the committee with their deliberations. The following individuals participated in a workshop panel or addressed the committee: Gerard Anderson, the Johns Hopkins School of Public Health; Brian Austin, Macoll Institute for Healthcare Innovation; Dan Brock, Brown University; Carolyn Clancy, Agency for Healthcare Research and Quality; Ashley Coffield, Partnership for Prevention; Steve Cohen, Agency for Healthcare Research and Quality; Helen Darling, Washington Business Group on Health; Suzanne Delbanco, Leapfrog Group; Benjamin Druss, Yale School of Medicine; Charlene Harrington, University of California, San Francisco; Brent James, Intermountain Health Care; Bob Kafka, American Disabled for Accessible Public Transit; Joanne Lynn, Americans for Better Care of the Dying; Michael Maciosek, HealthPartners; Ali Mokdad, Centers for Disease Control and Prevention; James Perrin, Harvard Medical School; Kip Piper, National Healthcare Purchasing Institute; Nico Pronk, HealthPartners; David Stevens, Health Resources and Services Administration; Mary Tinetti, Yale School of Medicine; and Kenneth Wells, University of California, Los Angeles. Other individuals who made important contributions to the committee’s work: Karen Beauregard, Steve Cohen and Nancy Kraus from the Agency for Healthcare Research and Quality, who provided technical assistance with MEPS survey data. Support for this project was provided by the Agency for Healthcare Research and Quality.

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Priority Areas for National Action: Transforming Health Care Quality Contents     EXECUTIVE SUMMARY   1     Study Purpose and Scope   2     Guiding Principles   2     Criteria   4     Final List of Priority Areas   5     Process for Identifying Priority Areas   8     Next Steps   10 1   INTRODUCTION   15     Study Approach   17     How Might the List of Priority Areas Be Used?   19     What Can Be Expected from Those in the Field?   23     Organization of the Report   25 2   CRITERIA FOR SELECTION   29     General Considerations in Determining Criteria   30     Criteria for Selecting the Priority Areas   32     Impact: How Big Is the Problem?   34     Improvability: Can the Problem Be Fixed?   35     Cost-Effectiveness Analysis in Priority Setting   36     Inclusiveness: Breadth, Reach, and Equity   37     Transformative Potential   37 3   PRIORITY AREAS FOR QUALITY IMPROVEMENT   41     Breadth of Opportunities Represented by Priority Areas   42     Three Types of Priority Areas   46     Cross-Cutting Areas   46     Specific Priority Conditions   46     Emerging Areas   47     Priority Areas: Detailed Descriptions   48     Care Coordination   49     Self-Management/Health Literacy   52     Appropriate Treatment for Persons with Mild/Moderate Persistent Asthma   54     Cancer Screening That Is Evidence-Based   56     Children with Special Health Care Needs   58     Diabetes   60     End of Life with Advanced Organ System Failure   62     Frailty Associated with Old Age   64     Hypertension   66     Immunization (Children)   69     Immunization (Adult)   70     Ischemic Heart Disease   72

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Priority Areas for National Action: Transforming Health Care Quality     Major Depression   74     Medication Management   76     Nosocomial Infections   79     Pain Control in Advanced Cancer   81     Pregnancy and Childbirth   83     Severe and Persistent Mental Illness   85     Stroke   87     Tobacco Dependence Treatment in Adults   89     Obesity   92 4   PROCESS FOR IDENTIFYING PRIORITY AREAS   115     Guiding Principles   115     Process Use by the Committee   116     Recommended Process for Determining Priority Areas   120     Discussion of Limitations   124 APPENDIX A       127 APPENDIX B       135 APPENDIX C       139