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May 11, 2015

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The 2014 Quality and Disparities Report and the National Quality Strategy: Working Together to Improve Health Care. May 11, 2015 [Slide 1]

Operator: Ladies and gentlemen, thank you for standing by and welcome to the National Quality Strategy National Healthcare Quality and Disparities Report.

Ms. Plochman, please go ahead.

Housekeeping [Slide 2]

Heather Plochman: Thank you for joining this National Quality Strategy Webinar. Before we get started we have a few housekeeping notes which you can see on the slide. If you have any webinar-related technical questions, please submit them via the chat box; if you lose your internet connection please reconnect using the link emailed to you; and if you lose your phone connection please redial the phone number listed to rejoin. ReadyTalk support can be reached at 800-843-9166 and the closed captioning link is also up on the slide there as well as in the chat box.

Agenda [Slide 3]

Heather Plochman: Here is today's agenda. First, Dr. Nancy Wilson will touch on the importance of the National Quality Strategy, then Dr. Ernest Moy will provide some background on the revised Quality and Disparities Report and some of the highlights of the report. Our presenters will then spotlight the importance of patient safety. Then we will open the line for questions and answers.

If you'd like to join the conversation on Twitter, please use the hashtag #QualityStrategy, which should also be in the chat box. You will have time for questions after the presentation portion, but feel free to enter any questions to our presenters into the chat box and we will try to answer them at the end of the webinar.

Now, we will hear from Dr. Nancy Wilson, who serves as the Executive Lead for the National Quality Strategy on behalf of the ������Ƶ at the U.S. Department of Health and Human Services.

Nancy.

Importance of the National Quality Strategy, Nancy Wilson, B.S.N., M.D., M.P.H. [Slide 4]

Nancy Wilson: Thanks, Heather. Can you believe it's actually been five years since the Affordable Care Act was passed?

Background on the National Quality Strategy [Slide 5]

Nancy Wilson: One of the things that the Affordable Care Act mandated was to improve the delivery of healthcare services, patient health outcomes, and population health. It took us some time to come up with the first strategy, but we did publish that in 2011 and the important thing is that it is really a nationwide strategy.

It's not an ������Ƶstrategy, it's not an HHS strategy, it's really a nationwide galvanizing effort to come together; and it was designed through a back and forth process by public and private stakeholders to identify priorities that we really wanted to focus on for improvement activities and for aligning measurement monitoring activities.

So now that it's in its fourth year, we found that we're really getting some traction, and that public and private organizations of all sizes have adopted the National Quality Strategy to help them focus and drive their health improvement.

HHS Delivery System Reform Goals [Slide 6]

Nancy Wilson: So one of the things that's new on the horizon is that in January, Secretary Burwell, the Secretary of Health and Human Services, set very ambitious goals to get to 30 percent of all Medicare payments in alternative payment models—such as accountable care organizations, bundled payments, and payments that are in medical homes—by 2016 and then get to 50 percent by 2018.

So, focusing on the fact that we've still been in a primarily fee for service system, she's really saying we have to move faster, we've got to be paying for value, and we have to do that more quickly and get to greater percentages between now and 2018. And of course, the Secretary reinforces the National Quality Strategy by saying that it's in our best interest to build a healthcare system that delivers better care, spends our healthcare dollars more wisely, and results in healthier people. So I hope you hear the National Quality Strategy in that, because that's the foundation of this accelerated push on delivery system reform.

HHS Delivery System Reform Goals [Slide 7]

Nancy Wilson: So the National Quality Strategy set the goals initially to improve the quality of healthcare and to achieve health in a better healthcare system. Since the launch, we've really been able to push the use of incentives and changing healthcare delivery and the power of information, with public reporting, to improve the system.

I think some results prove where we are, and some of the citations that we have include that we've contributed to 50,000 fewer patient deaths in hospitals due to avoidable harms, and 150,000 fewer preventable hospital readmissions since 2010. Ernie's going to touch on that a little bit later in our presentation.

So I think that the reform goals and the National Quality Strategy really are aligned and we're talking about an acceleration that's happening over the next couple of years.

National Quality Strategy: How It Works Graphic [Slide 8]

Nancy Wilson: In a nutshell, this slide explains how the National Quality Strategy works. So critically important is the outer circle, that indicates that everyone needs to be involved and has a role to play: individuals, family members, payers, providers, employers, and the community.

And the role that they play is that next green circle, and that's looking at what your core business functions or your resources are, the things that you might be able to do in the work that you do on a day-to-day basis that promotes the National Quality Strategy. So whether it's setting up a payment initiative, or it's on your workforce development, or measurement and feedback, whether it's in quality improvement work, there's always a lever that you can pull to address the six priorities of the National Quality Strategy and the three aims that we have.

So the focus of the National Quality Strategy, as I've mentioned before, is the six priorities. So when you're thinking about what it is that you could do based on your core business work, the focus should really be on the six priorities. And those priorities are patient safety, person- and family- centered care, affordable care, health and well-being, care coordination, and preventing the leading causes for mortality and morbidity. These are the things that we want to focus on, and they're not going to disappear unless we all begin to work on those areas. And then at that point, we're really hoping that by our achieving improvements in these six areas, we get to this, the three aims of the National Quality Strategy and the ultimate goal: healthier people, to have better care, to have more affordable care.

Background on the Revised Quality and Disparities Report, Ernest Moy, M.D., M.P.H. [Slide 9]

Nancy Wilson: So now, I'd like to turn it over to my colleague, Dr. Ernest Moy, Medical Officer in the Center for Quality Improvement and Patient Safety at the ������Ƶ. He has been directing the development of the annual National Healthcare Disparities Report and the National Healthcare Quality Report for some 10 years.

He has been the guiding light in terms of identifying and reporting on how we're doing as a nation in achieving the aims and the priorities of the National Quality Strategy, even when it wasn't stated as such before we had an actual strategy.

He is now going to discuss the results from the 2014 Quality and Disparities Report and tell you a little bit about how this report is set up and how we're trying to do additional alignment with the NQS.

Ernie, let me turn it over to you.

Background on the National Healthcare Quality and Disparities Report [Slide 10]

Ernest Moy: Thank you, Nancy. And so I'm going to jump on the punch line, because you're probably wondering what I'm doing talking about the National Healthcare Quality and Disparities Report in this webinar that's run by the National Quality Strategy. So, the punch line is that this year for the first time we're integrating the National Healthcare Quality and Disparities Report with the National Quality Strategy so that we're all pulling together to improve quality.

Nancy and I have worked together for a long, long time and we have been complementary and consistently working with each other, but for this year we're really, really trying to get them to be totally on the same page so that the reports can track progress of the National Quality Strategy priorities and, in turn, feedback information to the National Quality Strategy about how implementation is occurring. So that's the punch line, and that's why I'm talking today.

And I'm going to jump back and give you a little bit of background about the Quality and Disparities Report.

So Nancy was very generous in giving me only ten years here—actually, this is the 12th year of the report and they started about fifteen years ago and I was there at the start, but time flies when you're having fun! The Quality and Disparities Report are two congressionally mandated reports that provide an overview of the quality of health care and disparities and focus on race, ethnicity, and socio-economic status but also study other identified priority populations for us and for the nation so a very, very long list of virtually any kind of disparity I think is fair game for us to look at.

The function, again, is to assess the performance of the healthcare system and in particular to look for strengths and weaknesses in the access to healthcare and in the quality of healthcare that is delivered. Over time, we've tracked a massive number of measures to meet the charge to provide Congress with a national report, which we interpreted to mean that they wanted to know about quality broadly and not just narrow pieces of it. So we set about trying to cover the entire domain of healthcare, and we wound up with a high number of measures—about 250 measures of quality—and then we look at the disparities, along those exact same quality measures, cut up by race, ethnicity, and socio-economic status. They cover a broad range of services and settings, so we have hospitals, nursing homes, home health, hospices, doctor's offices, emergency departments—you name it, I think it's pretty much in there. The most recent report, we had data run roughly to 2012 with a couple of exceptions.

The Structure of the 2013 Report [Slide 11]

Ernest Moy: So, that's been the report from the very beginning. By last year's report in 2013, we had evolved it to consist of a couple of different components. We, very foolishly at the start, thought that a single report can meet all needs and we quickly realized that that's not the case and so, by the 2013 report, which again was last year's report, we had three different components. We had a highlight section that summarized the most important information for policymakers, we had the main body of the report itself which went through all the different 250 measures tracking them over time and highlighting the disparities element.

And then we have a large website presence. In particular, we had a website that focused on state contrasts, so you could look to see how your state is doing from a quality perspective as well as disparities perspective and see how your state compares to the other states.

And we put up all of the data tables, and all of the methods that we used in producing the reports and the website in the appendixes, which again are also available on the website. This included some applications that allow one to generate customized tables and through this package of products we thought that we're meeting the needs of all the people that use the reports: policymakers, researchers, educators, et cetera.

Integrate Three Parts into Whole (http://nhqrnet.ahrq.gov/inhqrdr/) [Slide 12]

Ernest Moy: And one of the things that we've worked on in the last couple of years was to take all of these different pieces that we'd produced and try to put them together, and this is where they actually currently reside. You see the website up there, and this is the link to our integrated site that allows you to go to the reports, the national perspective, the state perspective and all of our data tables though the data query function as well as the resources that support the generation of the reports.

Reasons for Recent Changes in the QDR [Slide 13]

Ernest Moy: But last year, we were also issued a challenge. So, we had a new Director, as you may well know, and so he asked us a couple of questions. First of all, he said, well two reports? Can't they just be one report? The whole emphasis, he said, is that quality and disparities need to be viewed together and that they're really meaningless concepts on understanding the healthcare system separately, so can you put this together into one document? Can you tie it to National Quality Strategy? Here, you have this tracking of quality and we have the National Quality Strategy telling us what is important to improve quality, doesn't it make sense to put these two together? And lastly, can we make these reports more visible and more actionable?

So those are the challenges that our Director asked us to consider.

And we went and we got feedback from our Interagency Working Group, which is a federal-wide group that supports the development of the reports. We asked the ������ƵNational Advisory Council for their guidance.

We also have a couple of special resources that we were able to tap into this past year. We won an HHS Ignite Award; this is a part of an HHS Idea Lab which brings innovators into the department and we were able to learn about design thinking through this activity. And I spent a couple of months down at AcademyHealth as part of their Translation and Dissemination Institute as an Innovator-in-Residence. These two unique experiences, I think, allowed us to tap into a lot of additional stakeholders and people who are experts at taking information and communicating to different kinds of audiences.

What's New in 2014 [Slide 14]

Ernest Moy: So we took all that in, and of course we told our Director that the answer is yes, we can do all these wonderful things or at least make an effort along those lines. We came up with a totally, totally different idea for the reports. And so, the 2014 reports, which were just released in April, are totally different from anything that has been produced in the past from our team.

It's a single report and it focuses on summarizing information over the many measures that are tracked. It's been totally reorganized, so it's now organized around the National Quality Strategy priorities, so the six quality priorities as well as the concept of access to care. It summarizes quality and disparities across access and the six priorities and tries to communicate that in a way that is easily understandable and integrated, so that a person looking at it will have a full understanding of healthcare quality and disparities as they work together and understand the problems that exist with those two concepts together.

We took two 250-plus page reports, and we made them into a single 30-page document and we also really sped up our production process. So historically, from most of the data sources that we had, we only had up through 2012 but for some of the data sources we took them all the way through the end of 2014, so just a couple of months prior to the release of this reports. That way we can really inform the access to care issues that were going on. Earlier data would not be able to say very much about the Affordable Care Act, but because we pushed the cycle so late we're actually able to provide some information about the impact of the Affordable Care Act.

What's New in 2014 [Slide 15]

Ernest Moy: But we knew that our researchers would really be mad at us if we didn't also produce all the detailed information that they have gotten used to seeing in our report. And so, complementary to the report itself, we have our series of related chartbooks where the detailed information about tracking of individual quality measures will be found. And they are being released now, and the access to healthcare chartbook pictured there was the first one that was released in April.

And now we're going through the different National Quality Strategy priorities, for example, the Patient Safety Chartbook was just released at the end of April. And we're going through the other five priorities and then during the summer we'll be releasing chartbooks that focus on the different priority populations that were tracked in the report.

The chartbooks are primarily electronic, and again posted on our website. They're available as a word document, but also available as PowerPoints so people can go ahead and use our slides. Like I said, they're going to be released and have been released every two weeks for the next six months. So, we're also hoping that this will bring attention to the reports and the chartbooks and to the National Quality Strategy by having these intermittent blurbs of information going out there for the public to view on different topics.

NQS and QDR as Integrated Resources for Improving Care [Slide 16]

Ernest Moy: And I think what we have achieved is that we are very well integrated with the National Quality Strategy. The strategy and the reports are pulling in exactly the same direction and I think we're now like a one-stop-shopping place, where you can go and the strategy will tell you what's important to improve from a quality perspective. And then the reports track and tell you how we're actually doing along those priorities from both the overall tracking perspective as well as the disparities perspective. And these two together then provide insight, I think into the rest of our agency about what needs improving, what tools need to be developed to support the National Quality Strategy priorities and make sure that improvements are made, that we can then measure and demonstrate through the tracking and the reports.

Highlights of the 2014 Quality and Disparities Report, Ernest Moy, M.D., M.P.H. [Slide 17]

Ernest Moy: Okay. So that's the origins of the reports, and the evolution that it's undergone recently. I'm now going to get into the key findings from the report. I think I'll probably go through this relatively quickly, since you can look in our report and see them. I of course encourage you to do so, and they're probably hardly surprising to people familiar with the healthcare system.

Key Findings of the 2014 National Healthcare Quality and Disparities Report [Slide 18]

Ernest Moy: So at the very, very highest level, aspects of the report demonstrate that access has improved, in particular after the Affordable Care Act. Quality is improving along those priorities of the National Quality Strategy that we can track, but there's still some challenges and one of the biggest challenges is that the disparities generally are not going away. Many of the disparities that we've observed in the past persist today.

Adults ages 18-64 who were uninsured at the time of interview, 2000-2014 [Slide 19]

Ernest Moy: And so, this is one of our access-to-care findings, so this is tracking the rate of un-insurance over time from 2000 through the first half of 2014. And you see that between 2000 and 2010, un-insurance is getting worse; it was on the rise, it was going up. With the passage of the Affordable Care Act in 2010, we see a little bit drifting down, some populations were affected early by the Act. And in 2013, with the opening of the health care exchanges, you see a dramatic decrease in the un-insurance rate and also during the first part of 2013 and the first half of 2014.

Now as we know from the news, those downward trends have continued, so one of the main findings of the report and the benefits of the report is being able to track the impact of the Affordable Care Act and I think it's pretty clear, evidently, that access is finally improving after a decade of access really deteriorating.

Disparities: Access measures for which members of selected groups experienced better, same, or worse access to care compared with reference group, 2012 [Slide 20]

Ernest Moy: And we, of course, always look at the disparities perspective for whatever we track, so we've tracked access which is getting better overall, but when we look at the disparities the picture is not so good. So here we take a panel of different kinds of access to care measures that we've tracked and we looked at different disparities.

On the left, it's poor people versus high-income people, and then moving to the right, it's black versus white, then Hispanic versus white, and Asians versus white, and then American-Indian/Alaskan Natives versus whites, and we take the measures and we categorized them.

The green color shows the measures where the group is receiving or has the worse access to care compared to the reference group. The blue shows where they're roughly the same. And the black shows where that group is actually better.

And we see that there is a lot of green and the green indicates that there is a disparity for which the poor group or the minority group is disadvantaged relative to the majority group.

So disparities—even though we're getting better, even though we are getting better more quickly among low income and minority people—still are pretty prevalent, at least during the 2012 time period.

Number and percentage of all quality measures that are improving, not changing, or worsening through 2012, overall and by NQS priority [Slide 21]

Ernest Moy: And then we've also of course tracked quality of care. So we weren't able to track all six priorities of the National Quality Strategy, but here we show the overall total measures that we tracked and we have bucketed them into four different categories where there are enough measures to track.

First, person-centered care, effective treatment, healthy living, and then patient safety. When we categorized these measures and look now at change over time, what we're showing here is in black, the measures that are improving over time. The blue is where there's no change, and the green is getting worse. And for the vast majority of measures we see that they are improving over time, overall about 60 percent of measures are getting better over time with only tiny proportions getting worse over time. We've also seen it's fairly well distributed across the different National Quality Strategy priorities that we are able to talk about. You see most of the person-centered care measures getting better, and you see about half of the other measures getting better over time.

Disparities: Number and percentage of quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group [Slide 22]

Ernest Moy: And then from a disparities perspective, similar to access to care, I think we still see a lot of that green, a lot of the indications that there are disparities that are persisting even as quality of care is getting better. So how does that make sense? How – if quality of care is getting better, how come disparities persist? And the reason we typically see is, what we see is that there's a disparity at the beginning of the time period that the improvements that occur are occurring in parallel. We see parallel lines, showing improvements but that simply means that at the end of the time period there's still a disparity that's persisting there. That's how we can see this very widespread disparities in the context of overall improvement in quality of care.

States Sorted by Overall Quality [Slide 23]

Ernest Moy: Another function of the report, as I've said, is that we try to search for strengths and weaknesses. One of ways we do this in addition to showing populations that are lagging behind is looking at this variation across states. And so, this takes more information on quality of care where we have state data and it simply sorts them into quartiles. So in this sorting, the states in blue are the ones that have the best overall quality of care across all the measures that we can track with state data. And then the red is the lowest quartile of care, and green and yellow are in between.

States Sorted by Racial/Ethnic Disparities [Slide 24]

Ernest Moy: And this one again takes the states and slices them into quartiles but now we're looking at the concept of racial and ethnic disparities. So here, in blue are the states where there is the smallest difference between the races and in red are the states that have the largest gaps in between the races in terms of the quality of care that they receive.

The thing I like to emphasize is that the images on this slide and the slide before it, number 23, don't look the same. So lot of times, people assume that disparities are located in states that are poor performers, that the states that have poor quality of care are the ones who have the largest disparity, and the answer is no. The two are really separate concepts, that there are some states that are bad in both quality and disparities but there are also states that have very high quality overall but large disparities and there are states that have very poor quality overall but small disparities. Everyone is receiving equally bad care there.

And we think – looking at these state maps, they give us some insights for state policymakers. If you're in the state with high quality but large disparities, you would probably want to go focusing your efforts on particular geographic areas or population in your state, wherein if you have poor quality care but huge disparities you want to try to improve care for everybody.

Spotlight: The Importance of Patient Safety: Presenters [Slide 25]

Ernest Moy: So that's what the report looks like, and there's more in the report, so I encourage you again to look at it but I also wanted to give you a quick taste of what the chartbooks look like and the chartbooks again are around access to care, each of the National Quality Strategy priorities, as well as priority populations and the most recently published one was related to patient safety.

Patient Safety Chartbook, Ernest Moy, M.D., M.P.H. [Slide 26]

Ernest Moy: And so we try to highlight what's important to patient safety and one of the things that's been in the news is the dramatic improvements made in patient safety related to the Partnership for Patients campaign and we have that information in the chart book.

Quality improvements in patient safety have saved 50 thousand lives and 12 billion dollars [Slide 27]

Ernest Moy: We also try to summarize like we do in the reports. So in the reports you saw summaries of disparities across all of the quality measures, and now this is a summary of disparities looking just at the patient safety measures we track and it doesn't show that much difference. That is, we still see that across all of the populations we look at related to income, as well as racial and ethnic status, that there are disparities in patient safety, that minorities and low income people typically experience more patient safety issues when they receive care compare to majority populations.

Number and percentage of patient safety measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group [Slide 28]

Ernest Moy: And then I want to show you that this is just an example of what most of the chartbooks look like. So in most of the chartbooks, we're not summarizing, we're rather tracking individual measures and you can see how they change over time and typically they change over time for different populations.

Home health patients with improvement in surgical wounds, by age and race/ethnicity, 2010-2012 [Slide 29]

Ernest Moy: So in this particular chartbook, you see the overall trends, but then you'll also see the variations by age and by race/ethnicity, and the other thing that we often put in when it's available is an achievable benchmark. The achievable benchmark is an average of the best performing states, so what has been able to – what has been able to be achieved in best performing states and we put it up there as a target which people can try to achieve. We can also calculate things like time to benchmark for different groups, so here for example you'd see that the number of years before the 0-64 group reaches a benchmark will be far, far longer than the number of years for the 85 and older group for instance to reach a benchmark. Sometimes people find that to be informative and help them understand the importance of these gaps and that they really do result in significant differences across different populations even as care is improving. Here you'll see what I've said earlier, which is the concept of improving in parallel still leading to the persistence of disparities.

Priorities in Action: Children's Hospital of Pittsburgh of UPMC, Nancy Wilson, B.S.N., M.D., M.P.H. [Slide 30]

Ernest Moy: And with that I think I will turn it back over to Nancy to talk about Priorities in Action.

Children's Hospital of Pittsburgh of UPMC [Slide 31]

Nancy Wilson: That sounds great. Thanks so much. I think I'm going to pause here for a second and just try and reiterate a little bit and if there are questions because we've given you a lot of information, but I think part of what we're trying to convey is that we've identified a strategy, which is going after the three aims, which is very consistent with the triple aim from the IOM. For those of you who are not aware of that, it's really based on that.

We've identified priorities to focus on and what we're sharing with you is where you can get information on how we're doing as a nation on each of those priorities. Hopefully, that will begin to guide your prioritization of actions that you might want to take, or your intervention to improve the various priorities.

One of the things with the information that Ernie's giving you that we also wanted to relate is that we want to be able to identify promising practices and share them with you as we identify them to give you some help in trying to figure out what you might want to do in your particular organization or your setting.

So one of the first priorities that we've identified in relationship to patient safety is the Children's Hospital of Pittsburgh, which is doing some great work in introducing their EHR over the past years, I think it is now, and in so doing they've been able to demonstrate great results in decreasing adverse medication events.

I think that for details on the particular intervention, I'd encourage you to go to the Working for Quality website, where you can read all about it and a lot of other interventions of folks that have been doing really great work on the priorities and what we called the priorities in action.

Discussion/Question and Answer [Slide 32]

Nancy Wilson: So I think with that, I'm going to ask if there are questions that we might have of folks. I mean we've really given you a lot of info – a lot of quantitative information in a short period of time so are there questions that people have, that you'd like us to go over, or reiterate, or if they're not related at all, that's fine too.

Heather Plochman: We can go ahead and open up the line for questions and then we'll go ahead and take some of their questions that have been asked through the chat box.

Questions and Answers [Slide 33]

Heather Plochman: Great. So we have a few from our chat box. The first question is, why is equity not included in the National Quality Strategy?

Nancy Wilson: Yes, that's a really good question. I guess that's mine. There was an enormous debate when we came up with the original National Quality Strategy and everybody was passionate about equity and disparities. The debate was, do we single it out and make it like a priority? You know, do we identify it? Or do we say it's a part of everything that we do?

And the equity for every priority, every aim is critically important. The consensus of the group that was working on this, and I was part of it, but I'm only one member, was that we really want to incorporate equity in and as part of the language for everything that we do, for every aim, for every priority and not make it a separate thing. I don't know what the right answer is, but that's how we went. That's part of why I'm so excited that we're really connecting with the Quality and Disparities Reports more because it promotes and flags and highlights information about disparities much more than I think we have in the original write up of the National Quality Strategy.

Heather Plochman: Great, thanks. The next question is for Ernie. While some disparities are improving, many are not. Have you seen examples of success in reducing disparities? And what advice would you give the folks in the field working towards that goal?

We've seen quite a few comments in the chat box in terms of folks that've been working in healthcare quality and disparities for the last 30 or so years and I think they want some encouragement as well as what you've seen working.

Ernest Moy: Ok, and I don't mean to be discouraging. So disparities can be reduced, and in fact they can be eliminated and if you go to our report we actually provide a list of disparities that have been eliminated over our tracking period.

And so it does happen, it just seems like it happens almost accidentally and that is that as long as we have policies that try to reduce disparities and to eliminate disparities by improving quality what we typically see are the improvements in parallel that don't actually eliminate disparities. Maybe they eliminate disparities when they get to the highest levels when they're maxing out, when they're hitting 95 percent or 100 percent, but a lot of times that's pretty late in the process. I think that one of the things the National Quality Strategy and the reports strove to do is to try to make that case more strongly, that it's pretty simple, I think, actually. If you wanted to reduce disparities then you actually need to develop interventions that are geared towards reducing disparities and if you wanted to track what's happening to this disparity, you actually have to measure it. As long as we have policies that focus more on the quality side, and not how that plays out in different kinds of communities and for different populations, the “improving quality for everybody” just doesn't cut it. It might improve quality but it does not actually close the gap between different populations.

Heather Plochman: Thank you, another one for you Ernie. Have you considered looking at urban versus rural disparities?

Ernest Moy: Yes, so both intercity as well as rural populations are two of our core priority populations. They are groups that we do track and you will see displays of information about them that are in the different chartbooks. It's not the main focus of the disparities report, so it's not in the main report itself, but in the chartbooks we show displays that are related to things other than socio-economic status and race/ethnicity. Our priority populations are women, children, urban, intercity, rural, people with disabilities, people at the end of life and minorities as well as low income people. So yes, look into our reports, there should be urban-rural contrast there.

Heather Plochman: Okay, another question here. I'm curious to hear more about the distinction between quality and disparities or equity. What makes sense is that one doesn't lead to the other, because organizations focus on quality and struggle to address equity. How can be organizations be more equity based?

Ernest Moy: I think I'll tie it back to my previous answer, which is that I think organizations should look explicitly at the concept of disparities. They shouldn't be just tracking overall quality but they should be looking at their quality as it relates to different kinds of populations and that might have formed some insights for improving care for specific populations but they might be generalized as well. So for instance, often people will focus on the language barriers that exist in real life. It's not just Spanish speakers that are having language problems but other people as well, like people who use sign language or people who speak English but actually don't understand the information being conveyed. So I think looking at disparities often can improve quality overall.

Heather Plochman: This question is both for Nancy and Ernie. In your opinion, what are the most important quality improvements or disparity reductions that have occurred in the past few years?

Ernest Moy: Ok. Well I can give the quantitative approach for, I think, one of the things that we have seen, two areas that we've seen improve dramatically. So one area we've seen improve dramatically are in the measures that are publicly reported by CMS. So you know CMS requires hospitals to track certain measures and boom, they have been tracking it, putting it on their Hospital Compare website, and we see the fastest improvements among those measures. We also see a very rapid reduction in disparities for those measures often but not right away, so they kind of lagged behind a little bit.

Another area that we've seen a lot of improvement is things related to person centered care. So I think over time, maybe not everybody will believe this, but people seem to be reporting that doctors are communicating with them better, that they are listening better, being shown a lot more respect. These are the things also that we're seeing improvements from the disparities perspective.

Nancy Wilson: Yes, I would agree, I mean, how can I refuse the data? I think that where we've put our attention is where we've gotten improvement so, you know, the Partnership for Patients was a nationwide initiative and everybody started focusing on patient safety, with readmissions in particular, and the infections, the hospital based infections, and so we've gotten real improvement on that. And I think that's a great story to tell, that when we set our focus on things, when we set our hearts and minds on things we actually can make significant improvement. I mean, the little part, the little cynical part of me says that part of the reasons that we've made such an improvement in person and family centered care is because we tie 30 percent of the CAHPS score to value based purchasing. We've incentivized that behavior and I don't believe, I refuse to believe that simply incentivizing things automatically makes it better but I will say that in this case I think that having tracked cap scores over the years, over 20 to 30 years, we've seen a dramatic improvement and those once have become incentivized with value based purchasing.

So I think again, as a nation if we agree that things are really critically important and we're going to focus on them, to make improvement, that we can do so. I think that's the really positive story.

Heather Plochman: Great, thank you. Nancy, the next question is for you. Will there be a 2015 update or report to Congress on the National Quality Strategy's progress? And if so, when will it be released?

Nancy Wilson: Yes it will. We just published the last one, I think it was in September, so we're aiming for September of this year for the next one and yes, we are diligently working on it right now. We are pulling together stories of priorities in action and people doing great things and trying to convey how we're working and how well we're achieving these long term goals that we have as a nation set for each of these priorities.

Heather Plochman: So, what resources are available to help primary care practices as they work to improve healthcare quality and reduce disparities?

Nancy Wilson: That's a good one. I mean, I think that we've got some resources that ������Ƶhas been working and has invested some funds in working with primary care practices. I think we need to pull our heads together and think about what are some of the other resources that are available to help folks out in tools and information.

Ernest Moy: I think the CAHPS scores. The survey and the scores go a long way to help practices understand some of the communication flaws that they might have, and along those lines is AHRQ's new Universal Health Literacy Precautions Toolkit, which I think is something generally usable. You assume that everybody does not understand what providers are saying, and providers need to probe deeply to make sure that the information communicated is fully understood. I'm sure we have other tools as well but that's what popped in my mind.

Nancy Wilson: Yes, those are great. I was just thinking about the, teach back, what I used to call in survey research, you know the cognitive testing, but it's basically, what is it that I just told you? And you tell me back what you think that I said. You know, we've focused more on patient safety with specific small but significant interventions. I think they've been hospital based, and it sounds like maybe we need to be really focusing on studying what are the couple of interventions that can be used in communication and maybe care coordination as well to yield significant positive effects. So I know we have some stuff here in our archives, we'll pull that stuff together for you and post it on the web as well but that's a challenging, interesting question as a former primary care doctor.

Heather Plochman: So this next question is for Ernie. How are achievable benchmarks and overall indexes of quality determined? Similarly how were disparities measured and where can folks go to learn more about the terminology?

Ernest Moy: Ok. So, if you go to our website, in one of the appendixes we've put out there are detailed methods and then related to our chartbooks section, the first one is called Introduction and Methods and it goes into more detail about each of the methods that are used. The achievable benchmarks are pretty straight forward: we do state-based benchmarks so it's not done at the institutional level, probably the first, most important thing to emphasize. So we simply take the data where we have state estimates and we take the top 10 percent of the states or usually five states and we take the average across those five states so it's a rate that has been achieved in some geographic areas, some states, five states, in the nation.

In terms of disparities, again the intro and methodology will go into much more detail but we typically look at disparities simply as the difference between two populations. We usually have standard reference populations, so, we usually compare everything to the majority population or the largest population. So, for racial contrast we usually compare blacks versus white, Asian versus white, etcetera. For ethnicity we usually compare against non-Hispanic whites, so either non-Hispanic blacks versus non-Hispanic whites or Hispanic versus the non-Hispanic whites. For income, we usually compare against the high income group, different variations of income, poverty level relative to high income which is four times poverty. And again the income methods will tell you the explicit contrast that we make for different groups.

Heather Plochman: So great, thank you. Another question here, are you finding that access to care is still a large source of disparities in care? If so, how can the primary care community work to improve this with limited number of students going into this field?

Ernest Moy: So, I'll take the first stab at it, if it's ok with you Nancy. So historically, we have found that access to care is probably the single largest contributor to disparities in care. And so whenever we run our multi-variable models you know, un-insurance is the big, huge factor although there are typically still racial, ethnic and income effects as well. But the insurance is by far the largest, and we hope that with the Affordable Care Act the rapid reduction in the rate of the un-insured will go a long way in terms of taking that off the table. Hopefully, that would no longer be the reason why we observe all these disparities.

For primary care providers I know it's a challenge, because probably people are coming in now who never had insurance before or don't necessarily know how to use it in an effective way, who don't necessarily know how to shift out of let's say the emergency room and departments, to primary care or into the proper kind of care and I think the primary care providers can help the system a lot by helping to educate the new people with insurance about how to use the system effectively.

Nancy Wilson: Well, I also think that access is going to require us to change our habits. As a former primary care physician, it's easy for me to say, but access, at times, we have made access automatically mean nine to five. Part of the history of this issue has been the primary care docs have not been accessible for patients except during routine business hours, at least when I was working. And so you would send people to the emergency room, I mean, there's other care now but I mean I think as physicians we need to be thinking a lot more about email, and phone and accessibility across hours. I think that's happening and I just think that's part of the process.

Heather Plochman: And we have one last question which segues nicely to our next slide, and that is where can we find additional resources on this topics that we've discussed during our webinar?

Thanks for attending today's event [Slide 34]

Nancy Wilson: Well, you've got four different things, clearly our Working for Quality website is going to be your source for a lot of information on the National Quality Strategy, and our Priorities in Action and our toolkit and the Quality and Disparities Report which is connected but has its own website as you can see there. And then if you want more information, or if you want high resolution graphics, if you want the stakeholder toolkit go to our Working for Quality website, and we'll be happy to share this with you so that you can pick up any slides that you may want. If you want to put one slide into a presentation that you're giving, for your own group or if want to pick up a couple of slides or all of them, all of this is going to be available for you to access and utilize.

So, and if your questions haven't been answered, just send them to the email addressNQStrategy@ahrq.hhs.gov. I have access to this mailbox and I'll look at it and we'll try to make sure that we answer your questions, and those of you that had questions that we haven't answered, I want to reassure you that we make a list of those and we answer them.

So, thank you all very, very much for attending and for your interest and again I'm excited for you to be able to probe the National Quality and Disparities Report because they give you the information in what's really going on. Over the years we can track that as we make improvements, slowly but surely. So, anyway, thank you all for all the work that you do because I know you're on the front line, actually making improvement happen.

I think with that we'll close.

Thank you very much.

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