Future Directions for the National Healthcare Quality and Disparities Reports (2010)

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2 Re-Envisioning the NHQR and NHDR The NHQR and NHDR have documented historical trends in U.S. health care quality and disparities, but the Future Directions committee offers a vision for the reports that is more forward-looking and action-oriented. To accomplish this vision, the committee recommends that AHRQ align the reports with national priority areas, along with other strategies to foster change and inform policy. The committee recommends eight national priority areas for use by AHRQ in guiding measure selection and prioritiz- ing content for the NHQR and NHDR. The Future Directions committee underscores the necessity of a broader commitment to national priorities through policies and practices that support data collection on key metrics, and support activities to address gaps in care identified in the national healthcare reports. The Future Directions committee concludes that this broader commitment should at least come at the level of the Secretary of HHS, who can help set the national agenda for quality improvement. Progress on this agenda could then be monitored by the national healthcare reports. AHRQ charged the Future Directions committee to assess the national healthcare reports, provide guidance on what the future generation of these reports should embody, and advise on national priority areas for health care quality improvement and disparities elimination. The committee began its deliberations by clarifying the purpose and audience for the reports, and identifying what those audiences could be in the future. Specifically, this chapter assesses the general needs of the audiences, how data analysis might better inform users, the frequency of report- ing, and the naming of priority areas. Noting that in an initial meeting with the committee, AHRQ Director Carolyn Clancy indicated that “a clear signal and recommendation from this committee on actionability is something, frankly, we would welcome” (Clancy, 2009), the committee deliberated on how such actionability might be achieved. One part of doing so is to align the reports with national priority areas. In this chapter, the committee recommends a set of eight priority areas. AHRQ will also need to engage the community of actors who do the day-to-day work of quality improve- ment. These public and private partners, including the whole HHS health care endeavor, would help inform the best practices and intervention aspects of the reports, support data collection and direct service delivery, and help provide solutions to barriers to improvement. The Future Directions committee refrains from offering a specific recommendation that the Secretary adopt 21 

22 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS the offered national priority areas because the committee’s charge was limited to advising AHRQ, but the commit- tee wants to underscore the importance of such a broader commitment to national priority areas. The committee recognizes that health insurance reform legislation establishes a process and method for setting quality improve- ment priorities in HHS, and it believes that the content of the two NHQR and NHDR should align as closely as possible with whatever priorities are ultimately established. PURPOSE AND AUDIENCES The Healthcare Research and Quality Act of 1999 called for AHRQ to “submit to Congress an annual report on national trends in the quality of health care provided to the American people,” which became the NHQR, and “a report regarding prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations,” which became the NHDR. Thus, the legislation states the basic purpose is to report trends and makes clear that the primary intended audience is the U.S. Congress. AHRQ has expressed inter- est in increasing the visibility of its products among congressional staff and other policy makers as well as other actors in the fields of quality improvement and disparity reduction (Social & Scientific Systems and UserWorks, 2009). AHRQ has interpreted the legislative guidance to mean that the national healthcare reports should report on where the country stands today on selected performance measures and should look back over time (generally the time period from 1998 to 1999 to the latest date for which data are available) to see how far the nation has come. The Future Directions committee believes it is now time to report on trends and be forward-thinking, not just historical. Previous IOM guidance viewed the audience for the NHQR and NHDR as reaching beyond Congress, and envisioned the reports as vehicles for “educating the public, the media, and other audiences about the importance of health care quality and the current level of quality” (IOM, 2001b, p. 31). Moreover, AHRQ has indicated that today, five main types of users tend to consult the national healthcare reports’ family of print and online products: (1) federal policy makers and congressional staff; (2) associations of state and local agencies and state-based users (e.g., state and local policy makers, Medicaid medical directors, health commissioners, data providers); (3) federal researchers (e.g., researchers at the National Institutes of Health, the HHS Office of Minority Health staff); (4) pri- vate sector quality improvement researchers (e.g., researchers at organizations such as The Commonwealth Fund or Kaiser Family Foundation, health care providers, insurers, quality improvement organizations); and (5) advocacy groups (e.g., groups representing priority populations, persons having specific diseases, and professional groups) (Social & Scientific Systems and UserWorks, 2009). The Future Directions committee also believes these audi- ences need to be aware not only of the current state of system performance, but also what the potential impact of improvement is on the health of the nation and what each action can contribute to its achievement. Overview of Products and Recommended Changes Although there is little comprehensive evidence on how users take the information in the NHQR and NHDR and put it into action, there is some limited information on the number of copies ordered and the degree of internet traffic, which at a minimum suggest the products are consulted and quoted to document specific quality problems and disparities. Besides the annual print and Web-based versions of the NHQR and NHDR, report-related products developed by AHRQ include annual State Snapshots (which rate each state’s performance overall and on selected measures relative to other states), an online data query system called the NHQRDRnet, and a limited number of topical fact sheets. The Future Directions committee finds the print and Web versions of the NHQR and NHDR and their associ- ated online resources are solid compendia of data about the quality of health care and related disparities in the United States. Their strengths have been in their use of “measures and datasets that meet rigorous scientific stan- dards” (IOM, 2002a, p. 6) and promotion of a common understanding of the domains of quality. Nevertheless,  Patient Protection and Affordable Care Act, Public Law 111-148 § 399HH, 111th Cong., 2d sess. (March 23, 2010).  Health Research and Quality Act of 1999, Public Law 106-129 § 902 and § 913, 106th Cong., 1st sess. (December 6, 1999). 

RE-ENVISIONING THE NHQR AND NHDR 23 the Future Directions committee recommends modifying the national healthcare reports in a number of ways, and further specifies, in Chapter 6, changes to the presentation of existing products and expansion to others. The com- mittee offers a number of objectives that AHRQ’s reporting effort should strive to achieve (Box 2-1). Here, the committee would like to call attention to several overall questions that it considered: whether to continue annual reporting, whether there should continue to be two reports, and how the Highlights section of the two reports might be designed to engage more readers. Continuing Annual Reporting The committee believes annual reporting, which is required by law, sustains the visibility of the NHQR and NHDR. To help address AHRQ staff concerns about workload, the committee suggests that every measure need not be reported each year (particularly when the data do not change from year to year) as long as the reporting between the NHQR and NHDR are on the same content areas. Adopting this suggestion would open opportuni- ties for more in-depth treatment of certain topics (e.g., patient safety or a priority population). Similarly, several priorities might get more in-depth treatment in one year but not necessarily the next. BOX 2-1 Objectives for AHRQ’s Reporting Effort in the NHQR, NHDR, and Related Products The IOM Future Directions committee believes that the NHQR, NHDR, and related products should play a vital role in U.S. health care quality improvement and disparity elimination efforts. Thus, AHRQ should make sure that the reports: • Incorporate a set of national priorities for U.S. health care quality improvement and disparities elimination and gener- ate data to monitor progress toward achieving those priority area goals. • Identify for policy makers the problem areas in health care quality that most need their attention and action, with the understanding that these priorities may change over time and differ by geographic location, population, or other contextual factors. • Identify aspects of the health care system that improve or impede quality for all, and specify that disparities elimina- tion is an integral part of quality improvement. • Supply a common understanding of quality, as reflected by the framework for quality, that considers value, equity, ef- fectiveness, safety, timeliness, patient-centeredness, access, efficiency, care coordination, and capabilities of health systems infrastructure. • Identify measures that reflect the best current approaches, practices, and opportunities for measurement improve- ment even when data are not yet available nationally. • Stimulate the refinement of existing measures and the development of new ones and identify opportunities for data source improvement. • Stimulate data collection and analysis efforts at the state and local levels (mirroring the national effort) to facilitate and monitor targeted quality improvements. • Identify credible data sources that will support national reporting and allow subnational (state and local) and sub- group analyses by race, ethnicity, language need, and socioeconomic status. • Stimulate the collection of standardized race, ethnicity, language need, and socioeconomic status data in all health care quality data sources. • Provide policy makers, purchasers, health care providers, and others with benchmarks for quality of care by show- casing the best attained performance in a class. • Educate the public, the media, and other audiences about the importance of health care quality and the current level of quality by making the AHRQ products more accessible in terms of presentation and more extensive dissemination. • Stimulate the development of a health care data infrastructure to support quality measurement and reporting across systems and payers for comparison. • Refine quantitative methods for prioritizing measures of health care quality. • Include linkages to successful interventions to make the reports more actionable. • Make it easier to compare the performance outcomes of the U.S. health care system with that of other nations. SOURCE: Updated from IOM, 2001b, p. 30. 

24 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS Clarifying the Connection Between Quality and Disparities The committee wants to ensure that the issue of disparities in health care is regarded as an integral part of any overall health care quality improvement strategy. The recent IOM report State of the USA Health Indicators underscored this point: “The very existence of a disparity implies that the overall national level for the corre- sponding indicator is not optimal” (IOM, 2008, p. 49). Thus, the committee considered whether the NHQR and NHDR should be merged into one report to strengthen the connection between issues of quality and disparity in the minds of users. Advocacy groups expressed to the committee that they depend on the NHDR as a reliable source of analyses to paint a picture of the state of quality by demographic factors; this observation is supported by the fact that there tend to be more downloads from the NHDR website than the NHQR website (59,272 and 49,223, respectively, in FY 2007-2008). These users expressed concern about diminishing the visibility of disparity issues if the reports were merged. At the same time, the committee noted that the audiences for the NHQR and NHDR were often different sets of stakeholders, and that attention to disparities was often given short shrift in quality improvement efforts, or the composition of the population was given as a rationale for why quality metrics were not higher. In fact, some stakeholders noted that it is quite possible to raise national performance levels without ever addressing disparities. On the other hand, focusing solely on closing the disparity gap between one population and another, as reported in the NHDR, often does not set the bar for performance achievement on specific quality metrics high enough for any population. As a result of these considerations, the committee does not recommend a change in statutory requirements for the annual production of the two reports, but suggests ways to build in stronger connections between the two reports (discussed in more detail in Chapter 6). For example, the Future Directions committee advocates for comparing population groups in the NHDR to a quality benchmark or goal, not just to each other. A case in point is the pre- sentation of data in the 2008 NHDR for diabetes preventive services. While it might be statistically valid to report that the Hispanic/non-Hispanic difference in care is narrowing for diabetes preventive services, as reported in the Priority Population section of the 2008 NHDR (AHRQ, 2009b, p. 211), it is misleading—although the difference may be narrowing, both groups are doing worse over time in the use of services (AHRQ, 2009b, p. 49). Another way to build stronger connections between the reports is developing a shared Highlights section for both reports. Producing a Shared Highlights Section As previously discussed, the primary intended audiences for the Highlights sections of the NHQR and NHDR include Congress, congressional staff, and other federal and nonfederal policy makers (Moy, 2009; Social & Sci- entific Systems and UserWorks, 2009). The committee suggests that AHRQ develop a common Highlights sec- tion that would serve as the introduction to both the NHQR and NHDR and as a separate stand-alone document that can be distributed more broadly. This can become an effective vehicle for engaging public and private policy makers, the media, foundations and other funders of research, and the public. Wider distribution and readership of the Highlights section of the national healthcare reports could also pique the interest of new audiences to the more detailed reports and the Web-based resources that AHRQ provides. The committee finds that the current approach in the Highlights sections of summarizing the number of per- formance measures that improve, stay the same, or decline does not engage readers to understand what is most important; indeed, all measures are given equal value. Moreover, the key messages in the Highlights section have thus far remained much the same from year to year—specifically, that the quality of health care in the United States is suboptimal, the pace of improvement is slow, and disparities persist. (Key messages from each year of the reports are summarized in Appendix B.) One of the committee’s observations is that the messages conveyed in the Highlights tend to be couched in general terms and not be related to specific priorities or actions. As a result, the messages are not very compelling and provide a limited vision or roadmap for improving quality and promoting equity. Accordingly, key messages should become more targeted and action-oriented. Personal communication, Ernest Moy, Agency for Healthcare Research and Quality, November 1, 2009, based on a summary from Jeff Hardy dated February 11, 2009. 

RE-ENVISIONING THE NHQR AND NHDR 25 The Highlights section needs to present a quality improvement strategy. The committee’s newly imagined, common Highlights section for the two reports would feature areas with the greatest potential for quality improve- ment impact and detail the value of closing those gaps, along with providing key messages to different audiences such as policy makers, health providers and payers, and the public on what they can do to spur improvement on priority areas and associated high impact measurement areas (e.g., include findings from data analyses on evidence- based policies that are proven to support better performance or remove barriers that prevent better performance; inclusion of a State Scorecard; assessment of the state of disparities). Need for Data Analyses to Better Inform Policy and Practice AHRQ’s role as a research agency is not to develop policy for all of HHS with regard to quality improvement activities; setting policy is an executive leadership and legislative function, but AHRQ can provide data to inform policy decisions. AHRQ has indicated that the NHQR and NHDR are awareness-raising documents, and that func- tion will continue but needs to be supported by additional analyses that inform actions and actors. Providing Analyses by Accountable Actors The committee suggests that the NHQR and NHDR include more information about how performance compares across public and private health systems, payers, programs, and other accountable actors. To date, the inclusion of such comparative information has been limited, and little analysis has been presented beyond straight reporting on individual measures; some limited stratification and multivariate analyses are included in the NHDR by population but not by entities providing care or paying for it. The Future Directions committee recommends sufficient resources be provided to AHRQ for the data collection and analysis necessary to provide such compara- tive information (Chapter 7). The committee believes that federal and state policy makers are most likely to be interested in performance data—reported according to units of accountability (e.g., payment streams, federally funded programs, state program performance)—on health care areas and programs for which they have some public responsibility. Specifically, Congress would be interested in programs of HHS and other federally funded programs for which Congress has responsibility. Such programs include the Medicare and Medicaid programs overseen by the Centers for Medicare and Medicaid Services (CMS); programs of the Indian Health Service; health care service delivery programs of the Health Resources and Services Administration (HRSA); and other service delivery programs under the auspices of other federal agencies, including the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DOD). Similarly, state legislators are likely to be interested in the performance of the Medicaid program and the Children’s Health Insurance Program (CHIP). This list is not meant to limit AHRQ’s data presentation to federally sponsored programs; indeed there is interest, for example, in having data from all payer databases. Members of Congress are also interested in how their own state performance in the public and private sec- tors compares to others, and while AHRQ has a wealth of state-based data available, it is not easily summarized in one place. Such data could be summarized in the Highlights section using information from the online State Snapshots dashboard (perhaps in a way similar to that used in The Commonwealth Fund State Scorecard) (The Commonwealth Fund Commission on a High Performance Health System, 2008). Using Data to Inform Policy and Practice The committee urges AHRQ to analyze and present its data in ways that better inform users of where per- formance is better, how long it will take to get to goal levels, and what the best programs or drivers might be to attain higher achievement. For example, • AHRQ could analyze and present data by accountable units (e.g., payers, programs, states) so that it is possible to more closely identify where the best performance exists and how different actors perform. 

26 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS • The performance trend data that AHRQ has collected thus far should now be used to project how long it would take to close quality gaps between current performance on the measure and achieving the recom- mended standard of care (e.g., 100 percent of target population receiving care or some other goal that is set). • New approaches to thinking about policy-relevant outcome measures may be necessary, such as determin- ing whether there has been a reduction of readmission rates on acute myocardial infarction (AMI) since public reporting by CMS, or whether there is an actual increase in receipt of needed services or patient disease management adherence when uninsurance is removed as a barrier. • Further analyses would be useful to increase understanding of the implications of differences among populations; for example, what are the implications of the differences found in access to preventive ser- vices between Hispanic and non-Hispanic Whites for diabetes care in the NHDR (AHRQ, 2009b, p. 49), particularly in view of the projected growth of the Hispanic population in the United States and studies showing that for Hispanics born in 2000, 53 percent of girls and 45 percent of boys will develop diabetes during their lifetimes (CDC, 2007). • The National Priorities Partnership has suggested a quality improvement goal of: “All Americans will receive the most effective preventive services recommended by the U.S. Preventive Services Task Force” (NPP, 2008, p. 26). It is known, however, that only 50 percent of adults received the screenings and preven- tive care appropriate to their age and gender (The Commonwealth Fund Commission on a High Perfor- mance Health System, 2008; McGlynn et al., 2003; NPP, 2008). In addition to AHRQ reporting the average national performance for receipt of preventive services, related analyses might be proffered that would inform policies and practices in both the public and private sector: (1) comparing payers that include such services in benefit packages with reduced or no co-payments with those that do not, (2) comparing those who are insured with those who are uninsured, (3) comparing the quality improvement impact of focusing interventions on specific at risk groups or age groups, and/or (4) comparing use among low-income users across state Medicaid programs or by community health centers. • A finding in the NHDR that low-income persons consistently fall behind on health quality measures should lead to examination of program-specific data that might illuminate if any specific health care delivery system is making important strides to close that gap (for instance, interventions that have improved care in community health centers might benefit other settings that serve low-income populations [Chin et al., 2007; Landon et al., 2007]). Because AHRQ primarily tracks health care process measures, there needs to be an assessment of the benefit of improved access to or adherence to processes of care on health outcomes to help determine whether expanded investment in specific areas of care is warranted. To the extent possible, data should be presented in ways that inform potential policy directions and program practices by being more outcome oriented. The committee builds into its recommended measure selection process an assessment of the potential impact of closing performance gaps on the ultimate outcome of improving population health. CALLS FOR NATIONAL PRIORITY AREAS In past years, the IOM and other entities have called for the establishment of national priority areas and goals for coordinated health care quality improvement efforts. Examples of these calls for national priorities are described below, along with discussion of the limited actions taken by AHRQ with respect to incorporating priority areas into the NHQR and NHDR. In its 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM recom- mended establishing specific goals to enhance the usefulness of a national health care quality report “as a stimulus for performance improvement” (IOM, 2001a, p. 7). No specific overall goals have been set for each aim, although for some individual measures, Healthy People 2010 targets are displayed. The IOM’s 2001 and 2002 guidance on the development of the NHQR and NHDR emphasized that these reports should identify “for policy makers the problem areas in health care quality that most need their attention 

RE-ENVISIONING THE NHQR AND NHDR 27 and action, with the understanding that these priorities may change over time” and “should continually reflect and be used to shape goals for quality improvement by presenting information that is useful to policy makers and others to define clear objectives, assess progress, and define appropriate actions” (IOM, 2001b, pp. 31-32, 2002a). When AHRQ summarizes the nation’s progress, all measures are given equal weight. More recently, in March 2009, Stand for Quality, a diverse public-private coalition of 165 diverse organi- zations, issued six recommendations to improve both the quality and affordability of health care. Noting that performance measurement is a core building block to providing high-quality, affordable care, Stand for Quality urged the executive branch and Congress to expand public investment in performance measurement, and called for the establishment of priorities as part of the need to strengthen the “performance measurement, reporting and improvement enterprise” (Stand for Quality, 2009). Similarly, recent health insurance reform bills have called for the formulation of a national strategy for quality improvement, including naming priority areas and a mechanism for choosing them. Despite the many calls for national priorities, HHS has yet to establish national priority areas for health care performance measurement and quality improvement that could help focus the collective efforts across HHS pro- grams and be adopted by other federal agencies and entities engaged in health care quality improvement, including the elimination of disparities. HHS has a strategic planning process in place that sets goals for HHS programs and offers targets for monitoring progress on specific performance indicators. Most of the strategic plan indicators are for program management rather than setting goals for achievement of health care process or outcome measures. Thus, for example, under the HHS strategic objective of “Broaden health insurance and long-term coverage,” the performance indicators deal with increasing the percentage of Medicare beneficiaries with Part D coverage and reducing the percentage of improper payments under the fee-for-service program (HHS, 2008, p. 48). In response to a 2007 congressional request for the IOM to assess whether HHS was “ideally organized to meet the enduring and emerging health challenges facing our nation” (IOM, 2009, p. 2), the IOM recommended improvements in HHS’s strategic planning process—specifically, improving alignment across HHS on a small set of measurable goals. The IOM Future Directions committee, while recognizing that HHS has many missions other than health care performance measurement, believes that improving health care performance measurement is fundamental to  Supporting entities include national organizations such as the Federation of American Hospitals, the National Partnership for Women & Families, Aetna, the American Academy of Family Physicians, The Leapfrog Group, as well as local, state, and regional organizations such as the Pacific Business Group on Health, the Puget Sound Health Alliance, and the Oklahoma Foundation for Medical Quality. A full list of sup- porting organizations is available at www.standforquality.org (accessed May 13, 2010).  The final bill, the Patient Protection and Affordable Care Act (Public Law 111-148 § 3011, 111th Cong., 2d sess. (March 23, 2010)) has the following provisions: • The Secretary, through a transparent collaborative process, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health. • The Secretary shall identify national priorities for improvement in developing the strategy. • The Secretary shall ensure that priorities identified under subparagraph (A) will—(i) have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations; (ii) iden- tify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care; (iii) address gaps in quality, efficiency, comparative effectiveness information, and health outcomes measures and data aggregation tech- niques; (iv) improve Federal payment policy to emphasize quality and efficiency; (v) enhance the use of health care data to improve qual- ity, efficiency, transparency, and outcomes; (vi) address the health care provided to patients with high-cost chronic diseases; (vii) improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections; (viii) reduce health disparities across health disparity populations (as defined in section 485E) and geographic areas; and (ix) address other areas as determined appropriate by the Secretary. • The national strategy shall include a comprehensive strategic plan to achieve the priorities. Not later than January 1, 2011, the Secretary shall create an Internet website to make public information regarding—(1) the national priorities for health care quality improvement established under subsection (a)(2); (2) the agency-specific strategic plans for health care quality described in subsection (b)(2)(B); and (3) other information, as the Secretary determines to be appropriate. Earlier versions contained the same or similar provisions: The Affordable Health Care for America Act passed by the U.S. House of Repre- sentatives in November 2009 would require the Secretary of Health and Human Services (HHS Secretary) to establish national priorities for health care quality improvement (Affordable Health Care for America Act (H.R. 3962), Section 1441 (pp. 883-885), and the Patient Protection and Affordable Health Care Act passed by the U.S. Senate in December 2009 would require the HHS Secretary to develop a national strategy for health care quality improvement (Patient Protection and Affordable Health Care Act (H.R. 3590 amended Section 3011)) (pp. 692-698)). 

28 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS ensuring an effective and efficient U.S. health care system. HHS has contracted with the National Quality Forum (NQF) to formulate a “national strategy and priorities for health care performance measurement” over the next few years under the authority of Section 183 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (HHS, 2009a). The Future Directions committee concludes that the United States needs national priorities and measures of quality that will address the health care needs of the entire U.S. population, not just individuals covered by Medicare. THE COMMITTEE’S RECOMMENDED PRIORITY AREAS As required by its statement of task (see Chapter 1), the Future Directions committee identifies a set of eight national priority areas for focusing national health care quality improvement efforts and for use in selecting mea- sures for the NHQR and NHDR. Before presenting the committee’s recommendations, however, it is important to define and distinguish among the terms aim, priority area, goal, benchmark, and target as they are used by this committee (see Box 2-2). Over time, setting an ideal level of performance in a priority area (aspirational goal) would be informed by progress on the highest quantifiable level of performance achieved so far (benchmark) so that realistic levels of actual performance can be utilized in setting national targets for achievement. (The use of benchmarking in health care is discussed further in Chapter 6.) Previously Identified National Priorities The committee considered efforts by various entities that have identified priority areas specifically for health care quality improvement, developed scorecards on key quality performance areas, or focused resources on health care quality improvement and disparities elimination. As discussed below, these efforts include work by previous IOM committees, the National Priorities Partnership (NPP) convened by NQF, HHS, and others. BOX 2-2 Definitions Used in This Report In the interest of clarity, the IOM Future Directions committee defines the terms aim, priority area, goal, benchmark, and target as they are used in this report. • A im. A desired state or characteristic of health care. As indicated in the 2001 IOM report Crossing the Quality Chasm, the aims for quality health are safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity (IOM, 2001a). • Priority area. An area of health care having importance or urgency over others that is expected to result in “substan- tial improvements in health and healthcare”a (NPP, 2008). • Aspirational goal. The ideal level of performance in a priority area (e.g., no patients are harmed by a preventable health care error; all diabetes patients receive a flu shot—unless contraindicated).a • Benchmark. The quantifiable highest level of performance achieved so far (e.g., the benchmark among states would be set at 66.4 percent of diabetes patients receiving a flu shot because that represents the highest performance level of any state).b • Target. A quantifiable level of actual performance to be achieved relative to a goal, usually by a specific date (e.g., by January 1, 2015, 75 percent of diabetes patients will receive an annual influenza shot). a This definition was adopted by the Future Directions committee to be consistent with how the term is used by the National Priorities Partnership (NPP). b National average for noninstitutionalized, high-risk adults ages 18-64 with diabetes who had a flu shot in the last 12 months, 2006, with a range of 24.4 percent to 66.4 percent (Table 2_1_6.3). Available at http://www.ahrq.gov/qual/qrdr08/2_diabetes/T2_1_6-3.htm. 

RE-ENVISIONING THE NHQR AND NHDR 29 Previous IOM Committees’ Recommended Priorities The 2001 Crossing the Quality Chasm report (IOM, 2001a) delineated six aims for quality health care (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity) and recommended that goals be set for each of the aims. That report also identified 16 priority conditions on the basis of their high cost to the system, although the report set no specific goals with regard to these conditions and none were set subsequently. AHRQ has used four of the six aims specified in the Crossing the Quality Chasm report as a way to frame the organization of the NHQR and NHDR (see Chapter 3). In the 2003 report Priority Areas for National Action: Transforming Health Care Quality, the IOM proffered 20 priority areas for national action (IOM, 2003). That report stressed a mix of early interventions, self-management, and care coordination for conditions or populations that had a high impact from the burden of the condition (dis- ability, mortality, and economic costs) on “patients, families, communities, and societies” (p. 4) and that had a probability that the gap between current practice and desired levels of recommended care could be improved. AHRQ has included many of these priority areas in its portfolio of measures (IOM, 2003). More recently, conversations about transforming the U.S. health care system and its quality have stressed the significance of looking at the whole patient experience over time and across sites of care (e.g., episodes of care, care coordination) instead of just looking at single condition-specific process measures (HHS, 2009a; McKethan et al., 2009; NPP, 2008). The National Priorities Partnership’s Six Recommended Priority Areas In 2008, the NPP was convened by NQF as a cross-section of 28 public and private stakeholders, including AHRQ, the IOM, CMS, and the Centers for Disease Control and Prevention.  That same year, the NPP reached consensus on a set of six national priority areas considered to be “the work of many to achieve the transforma- tional change that is needed for the United States to have a high-performing, high value healthcare system” (NPP, 2008, p. 7). The NPP focused on national priorities—as well as on what the NPP considered to be aspirational but ultimately achievable goals for each priority—that would, if implemented broadly, reduce harm, improve patient- centered care, eliminate health care disparities, and remove waste from the U.S. health care system. The six NPP priorities for the U.S. health care system are: (1) patient and family engagement, (2) population health, (3) safety, (4) care coordination, (5) palliative care, and (6) overuse (NPP, 2008). The NPP’s identification of these six national priorities has several attractive features: • The NPP priority areas involve measuring health care quality in new ways that represent the whole patient rather than a single disease, look across settings of care, and trace care and outcomes longitudinally (i.e., patient-focused episodes of care). • The NPP priority areas and goals were established through a robust, consensus-based process involving a broad variety of public and private stakeholders.  The NPP consisted of 28 members when the initial priorities and goals were established in 2008 (http://www.nationalprioritiespartnership. org/Partners.aspx [accessed May 14, 2010]). The Partnership has since grown and now consists of 32 members. They represent multiple stake- holder groups in both the public and private sectors (e.g., health plans, providers, medical associations, workforce interest groups). Stakeholders include AARP, AFL-CIO, Agency for Healthcare Research and Quality, Aligning Forces for Quality, Alliance for Pediatric Quality, American Board of Medical Specialties, American Health Care Association, American Nurses Association, America’s Health Insurance Plans, AQA, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, Certification Commission for Health Information Technology, Consumers Union, Hospital Quality Alliance, Institute for Healthcare Improvement, Institute of Medicine, Johnson & Johnson, The Joint Commission, The Leapfrog Group, National Association of Community Health Centers, National Business Group on Health, National Committee for ­Quality ­Assurance, National Governors Association, National Institutes of Health, National Partnership for Woman & Families, National Quality ­Forum, Pacific Business Group on Health, Physician Consortium for Performance Improvement convened by the American Medical Association, PQA, Quality Alliance Steering Committee, and the U.S. Chamber of Commerce.  The goals are aspirational because they typically set a high bar for achievement—for example, “All Americans will receive the most effec- tive preventive services recommended by the U.S. Preventive Services Task Force”; or “Seek to eliminate all healthcare-associated infections and serious adverse events.” (Note: Emphasis added.) 

30 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS • The NPP’s national priority areas and goals represent areas in which the NPP thought it possible to achieve substantial progress by beginning with measures that are available now and adding to them as new measures become available. • The NPP was convened by the NQF, which is recognized as “a neutral convener of consumers, purchasers, providers, practitioners, government and oversight agencies, supporting industries and other interested par- ties to identify and standardize ‘best-in-class’ measures of clinical quality and health system performance” (RWJF, 2009b). • Each of the NPP priority areas is supported by an extensive evidence base reviewed by the partners.  (Note: This evidence base is not repeated in this report; for more information see the 2008 NPP report National Priorities & Goals. Aligning Our Efforts to Transform America’s Healthcare [NPP, 2008].) • The NPP priorities are ones to which the public and policy makers can easily relate. • Within the first year of the release of the NPP priority areas, numerous groups outside the original circle of developers found that the NPP priorities reflect their own priorities and are moving to align activities. Such activities include (1) strategic planning (e.g., nursing and pediatric groups), (2) operations (e.g., Aligning Forces for Quality’s regional health care collaborative in Maine), (3) research (e.g., Regenstrief Center for Healthcare Engineering), and (4) public outreach (e.g., the development by the National Business Group on Health of consumer-friendly fact sheets around NPP-identified areas of unnecessary overuse of health care).10 Since its inception, the NPP has grown in membership to broaden the engagement of more than the initial core of partners. It also has established a workgroup for each priority area (NPP, 2009c). These workgroups are continuing to identify strategies such as promoting the adoption of the Consumer Assessment of Healthcare Pro- viders and Systems (CAHPS) and measures that support the priorities, and attempting to achieve parsimony in designating measures (e.g., a single rather than multiple care coordination measures or a palliative care measure applicable for multiple diseases). No one organization or single initiative can bring about the degree of change necessary to address the substantial gaps in the quality of U.S. health care, but collaborative efforts are expected to have greater reach (NPP, 2009a,b). Although the NPP plans to conduct an evaluation of the uptake of its recommended priority areas and goals in the activities of various entities, neither the NPP nor NQF have plans to be a central repository of data for national tracking related to the priorities.11 It is quite conceivable, therefore, that AHRQ’s future NHQRs and NHDRs could play important roles by relaying these national priorities to audiences, and providing a means for reporting on the progress made toward achieving priorities and goals. Moreover, just as the NPP and the nation can benefit from having the priorities tracked in the AHRQ reports, AHRQ can benefit from the ongoing work of the NPP and its expanding networks of actors. Other Entities’ Recommended Priority Areas Numerous entities in the United States, apart from the NPP and previous IOM committees, have sought to identify priority areas for health care quality improvement, develop scorecards on performance, or focus resources on health care quality improvement. The committee scanned articulated priority areas for health care quality improvement across a variety of these entities and has summarized them, along with priority areas identified by the previous IOM committees and the NPP, in Table 2-1.  The NPP did not limit selection of national priority area goals to areas where proven interventions are available (e.g., obesity is a problem, but there is not a clear-cut intervention strategy).  The NPP’s 2008 report is available online at http://www.nationalprioritiespartnership.org/AboutNPP.aspx (accessed May 13, 2010). 10 Personal communication, Karen Adams, National Priorities Partnership, National Quality Forum, November 15, 2009. 11 Personal communication, Janet Corrigan, National Quality Forum and Karen Adams, National Priorities Partnership, National Quality Forum, May 11, 2009. 

RE-ENVISIONING THE NHQR AND NHDR 31 The IOM Future Directions Committee’s Eight Priority Areas The eight national priority areas recommended after considerable deliberation by the Future Directions com- mittee are shown in Box 2-3. The committee thought that the NPP’s six priorities captured most of the key priori- ties for health care quality improvement. Thus, six of the committee’s eight recommended priorities for health care quality improvement are the priorities recommended by the NPP (NPP, 2008). In addition, the committee added two priority areas not included in the NPP’s recommended priorities—access to care and health systems infrastructure capabilities. The NPP’s priorities presuppose access to care. Yet access to health care remains a challenge for a large segment of the U.S. population and is a fundamental dimension of health care quality for all populations. Conse- quently, the committee believes that it is vital to single out access to care, especially in light of upcoming changes to health insurance coverage.12 Lack of coverage is a well-documented barrier to care, but it is not the only one (others include transportation, ability to take time off from work to seek care, lack of a regular source of care, unwillingness of providers to accept specific types of insurance, and affordability of coverage, co-payments, and deductibles) (Ahmed et al., 2001; Cummingham et al., 2008; Goins et al., 2005; Goldman and McGlynn, 2005; Grumbach and Mold, 2009; Hall et al., 2008; Lofland and Frick, 2006; RWJF, 2002; Wang et al., 2009). The development of health systems infrastructure, also not included in the NPP’s national priorities, is similarly considered by the committee to be an area demanding national attention. With the health care data sources that are available today, AHRQ has been stymied in its ability to obtain data that are more directly related to care pro- cesses and outcomes. The adoption of electronic health records and establishment of health information exchanges spurred through the American Recovery and Reinvestment Act of 200913 will eventually open up new possibilities for obtaining clinical data across areas and payers (Arrow et al., 2009; Blumenthal, 2009; Kern et al., 2009) (see Chapter 5). These investments in data development and “meaningful use” of that data for quality improvement could eventually support national-level reporting in the NHQR and NHDR. Strengthening standardized collection of race, ethnicity, and language need data will assist in identifying the nature and scope of disparities in health care related to these factors. Furthermore, the development of organizational capacity to coordinate care (e.g., e-prescribing, patient-centered medical homes) and provision of a sufficient workforce are important areas of infra- structure that are relevant to health care quality and disparities (these components of infrastructure are examined further in Chapter 3 and Appendix D). Thus, the committee makes the following recommendation: Recommendation 1: AHRQ should ensure that both the NHQR and NHDR report on the prog- ress made on the priority areas for health care quality improvement and disparities elimination, and should align selection of measures with priority areas. Until a national set of priority areas is established, AHRQ should be guided by the Future Directions committee’s recommended priority areas. While the committee has recommended eight national priority areas that are crosscutting in nature, that does not mean that tracking disease-specific measures of health care quality will no longer be necessary. There will still be audiences for whom that level of detail is important, but the print versions of the AHRQ reports do not always have to feature each disease-specific element; some elements can be included in expanded data featured online via an appendix to the report or other Web-based product. FOCUSING RESOURCES AND ATTENTION ON NATIONAL PRIORITY AREAS Priority setting is a systematic approach to distributing available resources among multiple demands in the effort to create the best health care system possible given economic constraints. Priority setting is also a first step toward actionability by focusing attention on areas that are considered most important (McGlynn, 2004; McMahon and Heisler, 2008; Ranson and Bennett, 2009; Sabik and Lie, 2008; Whitlock et al., 2010). Priorities matter because 12 Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong., 2d sess. (March 23, 2010). 13 American Recovery and Reinvestment Act of 2009, Public Law 111-5, 111th Cong., 1st sess. (February 17, 2009). 

32 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS TABLE 2-1  Overview of Priority Areas for Improving Health Care Identified by Leading Organizations, Initiatives, and Reports Centers for Medicare and Medicaid Services The Commonwealth Institute for Health HHS Roadmap HHS Fund National Priorities Care Improvement Strategic Plan—FY for Quality Meaningful Use (Commission on a Partnership Triple Aim 2007–2011 Measurement Matrix High Performance (NPP, 2008) (IHI, 2009) (HHS, 2008) (CMS, 2008) (HHS, 2009b) Health System, 2008) Increase patient and Improve patient Confident, informed Patient engagement family engagement experience of care consumers; (quality, access, and transparency reliability) Improve population Improve population Public health Improved population Healthy lives; health (Reducing health promotion and health prevention and disease burden) protection (including treatment promotion of preventive health care) Improve safety and Improve safety of Safety, transparency Improved safety Safe and quality care reliability of health health care system (Eliminating harm) Guarantee compassionate care for persons with life- limiting illnesses Ensure well Smooth transitions Coordination of care coordinated care of care Eradicating Eliminating Reduction of racial Equity for all disparities disparities disparities (geography, race, income, language, diagnosis) Improve patient Improve quality, Access for all experience of care affordability and (access) accessibility to health care Eliminating Reduce the per Efficiency; Increased efficiency Efficient care; overuse and ensure capita costs of health effectiveness; high- avoidable hospital use appropriate care care value health care and cost Effectiveness (ensuring care is evidence-based) Ensure adequate System capacity privacy and security protections for personal health information 

RE-ENVISIONING THE NHQR AND NHDR 33 Robert Wood IOM Johnson Quality State of Foundation Alliance IOM USA Health Aligning Forces Steering Priority Areas for IOM Indicators for Quality Committee National Action Crossing the Quality Chasm (IOM, 2008) (RWJF, 2009a) (QASC, 2009) (IOM, 2003a) (IOM, 2001a) Increasing Help Self-management/ health literacy Patient-centered health care consumer consumers engagement make informed choices Improve Immunization for children and population health adults; pregnancy and childbirth; outcomes and tobacco dependence; obesity reduce risky behaviors Safer care Medication management; Safe health care nosocomial infections End-of-life care; frailty with old age; pain control in advanced cancer Well coordinated Care coordination care Addressing equity Help reduce Equitable health care (e.g., gender, and recognizing large racial race, ethnicity, geographic location, and that language and ethnic socioeconomic status) matters disparities in care Access Timely health care (insurance coverage) Cost (per capita More effective care Structure Efficient health care expenditures; payment preventable to improve hospitalizations) quality and efficiency Effective health care Improving the Help providers “how to” of quality improve improvement; quality of care increasing public reporting Indicators for Priority conditions: asthma, Priority conditions: cancer, diabetes, health outcomes, cancer screening, diabetes, emphysema, high cholesterol, HIV/AIDS, health-related hypertension, ischemic heart hypertension, ischemic heart disease, stroke, behaviors, and disease, major depression, severe arthritis, asthma, gall bladder disease, health systems and persistent mental illness, stomach ulcers, back problems, Alzheimer’s stroke, children with special needs disease and other dementias, depression and anxiety disorders 

34 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS BOX 2-3 The Committee’s Eight Recommended National Priority Areas for Health Care Quality Improvement The IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports recommends a set of eight national priority areas for health care quality improvement for use in the NHQR and NHDR; it believes these priorities can guide the national healthcare reports. The recommended areas include six priority areas identified by the National Priorities Partnership (NPP, 2008), as well as two additional priorities that the committee believes are important to highlight. The six NPP priority areas included in the committee’s set of national priority areas are: 1. P atient and family engagement: Engage patients and their families in managing their health and making deci- sions about their care. 2. Population health: Improve the health of the population. 3. Safety: Improve the safety and reliability of the U.S. health care system. 4. Care coordination: Ensure patients receive well-coordinated care within and across all health care organiza- tions, settings, and levels of care. 5. Palliative care: Guarantee appropriate and compassionate care for patients with life-limiting illnesses. 6. Overuse: Eliminate overuse while ensuring the delivery of appropriate care. The two additional priority areas in the committee’s set are: 7. A ccess: Ensure that care is accessible and affordable for all segments of the U.S. population. 8. Health systems infrastructure capabilities: Improve the foundation of health care systems (including infra- structure for data and quality improvement; communication across settings for coordination of care; and workforce capacity and distribution, among other elements) to support high-quality care. resources of all of kinds (e.g., labor/time, funding for research on measures, data development and analysis) are limited. The setting of national priority areas for the measurement of health care quality improvement can be viewed as having the potential for influencing the “allocation of limited resources among many desirable but competing programs or people;” thus, “it is highly political and can be controversial” (AHRQ, 2009a; McKneally et al., 1997; Whitlock et al., 2010, p. 493). As the Future Directions committee’s charge read to “establish national priority areas,” the committee con- sidered its role to be to advise AHRQ on a set of priorities. At the same time, AHRQ asked for advice on making the national healthcare reports more actionable, and others who came before the Future Directions committee or whose reports the committee reviewed also stressed the need for greater progress. Many are frustrated with the slow progress toward improvement despite repeated documentation of the same quality shortcomings and persis- tent disparities. However, focusing the combined efforts of many actors and various intervention techniques on the same priorities could be expected to enhance progress, whether they are the priorities that are recommended in this report or a set that emerges as a result of developing the national quality improvement strategy pursuant to health reform legislation.14 While AHRQ can use the priority areas offered in this report to select measures and guide the content of the NHQR and NHDR, it is not AHRQ’s role to set intervention-related policies for a national quality improvement agenda that can have implications for resource allocation across HHS and external sources. Since AHRQ falls under the direction of the Secretary of HHS, the Future Directions committee concludes that HHS leadership is needed to establish national priorities and set clear goals that can be featured in the national healthcare reports and thereby bring to bear the resources of the department. 14 Patient Protection and Affordable Care Act, Public Law 111-148 § 3012, 111th Cong., 2d sess. (March 23, 2010). 

RE-ENVISIONING THE NHQR AND NHDR 35 Leadership in Establishing National Priorities and Goals Although measures and reports such as the national healthcare reports cannot improve the quality of U.S. health care directly, they provide context and motivation for quality improvement (Moy, 2009). Reports can also present data in ways that better inform policy and practice. Complementary policies and practices that would help close priority area quality gaps and support more widespread implementation of programmatic initiatives are essential to drive progress. As noted in Chapter 1, the concept of a national quality measurement and reporting system outlined by the Strategic Framework Board depends not only on reporting, but also on the setting of goals, adoption of comparable measures, and interventions to change the state of quality and disparities (McGlynn, 2003). Thus, other incentives and collaborative efforts are needed to get to higher levels of performance (see Box 2-4 for examples of mechanisms and actors). Having AHRQ alone adopt priority areas for use in the national healthcare reports without support across HHS is less likely to advance quality than if these other actors become engaged. Having common priority areas can help drive concerted national and local action toward the same ends. Part of the Future Directions committee’s logic in adopting the six NPP priority areas was the NPP’s ability to draw consensus from a reputable group of private and public sector members and the NPP’s continuing engagement in fostering progress on those priority areas. The NPP has recommended priority areas and goals; the Future Directions committee’s charge only extended to the naming of priority areas for quality improvement, not goals, although it heartily endorses the setting of goals and/or targets by HHS. Furthermore, the word “national” is part of the names of the NHQR and NHDR, and the Future Directions committee observes that no report could present a full picture of national health care delivery without consider- ing how priorities and goals are integrated and implemented in the health systems under the auspices of the VA, DOD, the Federal Employees Benefit Program, and the federal Bureau of Prisons. Under the Patient Protection and Affordable Health Care Act, the President would convene an interagency working group to foster collaboration between departments and agencies with respect to developing and disseminating strategies and goals for national health care quality priorities. The working group would be comprised of representatives from various HHS agen- cies, the Department of Commerce, the Office of Management and Budget, the Social Security Administration, the Department of Labor, the U.S. Office of Personnel Management, DOD, the VA, and the Department of Education, among others.15 The IOM report Leadership by Example: Coordinating Government Roles in Improving Health Care Quality stressed that if the federal government could take collective action across programs for which it has accountability, it would lead the way to action elsewhere (IOM, 2002b). To make substantial progress on national priorities and associated goals, there needs to be unequivocal endorsement and commitment at least at the level of the HHS Secretary to make substantial change in performance levels. Such a commitment could be embodied through a range of regulations and policies, including systematic reporting on quality metrics by federally sponsored direct health care service programs. The HHS Secretary is positioned to direct HHS programs to focus on the achieve- ment of national priorities and goals through policies that support a stronger quality improvement infrastructure (i.e., measure development and the collection and analysis of evidence-based performance information), health care interventions (e.g., changes in insurance coverage, support of preventive and care coordination services), public reporting, incentive payments, demonstration projects, benefit design, and health professions education, as well as refining performance measures through research and funding of data sources (IOM, 2009). These HHS-wide efforts would complement efforts by the NPP. Implementation by the HHS Secretary of initiatives for expanding health insurance coverage and reforming payment for services will require monitoring to ensure that the initiatives and existing programs will have the desired effect on quality of care, its costs, equitable treatment, and ultimately the health of the nation. 16 Addition- ally, substantial federal funds are being invested in strengthening electronic health records and providing for their meaningful use in quality improvement.17 The NHQR and NHDR are natural vehicles for tracking the effect of 15 Patient Protection and Affordable Care Act, Public Law 111-148 § 3012, 111th Cong., 2d sess. (March 23, 2010). 16 Patient Protection and Affordable Care Act, Public Law 111-148, 111th Cong., 2d sess. (March 23, 2010). 17 American Recovery and Reinvestment Act of 2009, Public Law 111-5, 111st Cong., 1st sess. (February 17, 2009). 

36 NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS BOX 2-4 Health Care Quality Improvement: Illustrative Mechanisms of Influence and Actors • P ayment incentives—Centers for Medicare and Medicaid Services (CMS), private health plans • P ublic reporting—CMS, states, National Committee for Quality Assurance (NCQA), health plans, private purchasers • Accreditation—NCQA, The Joint Commission, American Board of Medical Specialties for credentialing/recredentialing • Leadership within institutions—hospitals, provider groups • Compatible measurement, benchmarking, and feedback on performance—CMS, states, NCQA, health plans, hospitals, Department of Veterans Affairs, Department of Defense, Health and Human Services direct service deliv- ery programs (e.g., community health centers, Indian Health Service), provider groups, The Leapfrog Group, Con- sumer Reports • Entities influencing other entities involved in quality improvement and disparities reduction—National Quality Forum, National Priorities Partnership, Out of Many, One, patient advocates these changes, utilizing the data that emerge for national reporting, and reporting on designated priority areas. The NHQR and NHDR should contain a strategic vision for U.S. health care quality improvement efforts by reporting on areas with the potential to achieve the best value and equity for the dollars invested while having the greatest impact on population health. This strategic vision is the basis for the measure selection process for the NHQR and NHDR outlined in Chapter 4. The results of quantitative assessments of quality improvement impact for measure- ment areas and the identification of benchmarks based on best-in-class performance (Chapter 6) would additionally inform realistic goal- and target-setting for priority areas. SUMMARY To meet the needs of Congress and various other users for information on health care quality and to articulate a vision for national health care quality improvement, the committee believes that the NHQR and NHDR should do more than reporting on what has already transpired. The NHQR and NHDR and related products have the potential to articulate a vision for health care quality improvement and engage others to achieve quality improve- ment goals. Because disparities in care are a health care quality issue, greater integration between the NHQR and NHDR is recommended. As required by its charge, the committee recommends a set of eight priority areas for national health care improvement: (1) patient and family engagement, (2) population health, (3) safety, (4) care coordination, (5) pal- liative care, (6) overuse, (7) access, and (8) capabilities of health systems infrastructure. While the Future Direc- tions committee believes AHRQ can incorporate the offered priority areas into the NHQR and NHDR, especially through its messaging and measure selection process, more progress will be made toward achieving priority area goals if there is more widespread adoption and integration of national priority areas into a common quality and disparities improvement strategy. REFERENCES Ahmed, S. M., J. P. Lemkau, N. Nealeigh, and B. Mann. 2001. Barriers to healthcare access in a non-elderly urban poor American population. Health & Social Care in the Community 9(6):445-453. AHRQ (Agency for Healthcare Research and Quality). 2009a. Identifying, selecting and refining topics for comparative effectiveness systematic re- views. http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=326 (accessed December 14, 2009). ———. 2009b. National Healthcare Disparities Report, 2008. Rockville, MD: Agency for Healthcare Research and Quality. 

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