AHRQ reports a slowdown in overall quality gains

'Health care quality is improving only modestly'

The latest edition of the Agency for Healthcare Research and Quality's (AHRQ) National Healthcare Quality Report contained some disappointing news for quality professionals: The quality of health care improved by an average 2.3% a year between 1994 and 2005, compared with the 3.1% average annual improvement rate published in the 2006 reports. While some important advances were noted, the overall report showed that "health care quality is improving only modestly, at best," according to AHRQ Director Carolyn M. Clancy, MD, commenting in a prepared statement released to coincide with the report.

The AHRQ report noted that during the same time period the Centers for Medicare & Medicaid Services estimated health care expenditures rose by a 6.7% average annual rate. "Given that health care spending is rising much faster, these findings about quality underscore the urgency to improve the value Americans are getting for their health care dollars," said Clancy in her statement.

"People might want to be careful to not over-emphasize that linkage," adds Jeff Brady, MD, MPH, acting director, U.S. National Healthcare Reports, and lead manager of the AHRQ report. "But what we're talking about there is really value. While quality and costs may not be directly related, you start raising questions about what value we are getting for these increased costs. At a very high, superficial level, it should be concerning to everyone that those two figures are not moving at the same rate."

There were, however, some improvements noted in the report. For example, more than 93% of heart attack patients received the recommended hospital care in 2005, up from about 77% in 2000/2001. The percent of heart attack patients who were counseled to quit smoking increased from about 43% in 2000/2001 to about 91% in 2005.

However, measures of patient safety showed an average annual improvement of just 1%. This reflected such measures as what portion of elderly patients had been given potentially harmful prescription drugs and how many patients developed post-surgery complications.

The report measures quality and disparities in four areas: effectiveness of care, patient safety, timeliness of care, and patient centeredness.

Bucking the trend?

The overall tenor of the report seems to run counter to the more upbeat reviews of nationwide collaborative QI efforts issued by several leading organizations. "Very simply, you can make data look however you want," says Brady. "What we try to do is not only report individual measures [but provide an overall picture]. We use federal statistics plus private data; for example, we use [the Centers for Disease Control and Prevention] and others, and AHRQ data for individual measures, but we also try to put it together in a meaningful way. Our scope of review is the entire country — to give one simple indication of how we are doing."

This report, he continues, is AHRQ's charge from Congress. "In its simplest form, this is our report to Congress," he says. "Hopefully, not only folks like your readers but also people at the state level and the health plan level will all have interest in what we report."

For quality managers, he continues, this represents a benchmarking opportunity. "We are reporting national numbers, and we'd like to see folks take those numbers and, to the extent they can, report the same kinds of things with the same sorts of specifications," says Brady. "There is a whole field of study considering what is appropriate [for benchmarking] and what is not, but one simple fact is your study is more valid if you compare apples and apples."

AHRQ, he adds, has tried to make its report as transparent as possible. "The subset of measures that relates to care in hospitals is clearly of most interest [to quality managers]," he notes. "If they are interested in more specific levels of analysis, they can possibly determine which measures contribute [to quality issues]."

Ongoing commitment needed

As to why improvement has been so modest, Brady notes that his group "generally stops short of providing a lot of interpretation of what drives these numbers, but among the suppositions we have is that it takes a continual, renewed commitment to make significant progress — it does not happen automatically.

"Those things that are attended to are the things we change the way we like to see them change. For example, look at inpatient care for heart attack and heart failure; over this period we have seen some pretty dramatic improvements."

In addition, he says, it's important to focus on identifying recommended (evidence-based) care, delivering the care recommended, and measuring results. "It sounds simple and straightforward, but your commitment needs to be constant, because when you get to the individual hospital level there is a whole set of complex factors," he says.

At the bottom line, he adds, the report has a fairly simple message — there is clearly still opportunity for improvement. "Quality managers are really the champions on the front lines for these issues as they try to make their case across whole systems of care," says Brady. "They are the leverage point where a lot of the improvement will happen."

[The AHRQ report is available at www.ahrq.gov/qual/qrdr07.htm, by calling 1-800-358-9295, or by sending an e-mail to ahrqpubs@ahrq.hhs.gov.]