Francis Chesley

Variation in quality of men's health care by race/ethnicity and social class.

Background:Until recently, minority and poor men have been characterized as “an invisible population,” overlooked by public and private efforts to improve the health status of women, children, and the elderly. Objective:This study compares the health care experiences of racial and ethnic minority men with that of white men, and low socioeconomic status with those of higher status. Measures/Subjects:Quality-of-care measures in multiple clinical domains are evaluated. The authors use data from several databases, including the National Health Interview Survey, Medical Expenditure Panel Survey, and Health Care Cost and Utilization Project State Inpatient Database. The relative difference between each racial/ethnic and socioeconomic group and a fixed reference group is used to assess differences in use of services. Statistical significance is assessed using z tests. Results:Hispanic men were much less likely to receive colorectal cancer screening (relative risk [RR] range, 0.61–0.69), cardiovascular risk factor screening and management (RR, 0.84–0.88), and vaccinations (RR, 0.47–0.94). Black and Asian men were significantly less likely to have received selected preventive services (adult immunization and colorectal cancer screening). The differences in end-stage renal disease care that black and white men received were statistically significant (RR, 0.39–0.97), with black men consistently receiving worse care. For some measures of management of end-stage renal disease, Asian men received care that was similar to or better than that received by non-Hispanic whites. Conclusion:Minority men are at a markedly elevated risk for the receipt of poor health care quality. However, generalizations about “minority” men are likely to be misleading and incomplete. There is a considerable variation in the magnitude, direction, and significance of these risks.

The Economic and Clinical Efficiency of Point-of-Care Testing for Critically Ill Patients: A Decision-Analysis Model

Our study objective was to assess economic and clin ical outcomes of use of a point-of-care (POC) blood analy sis device for postoperative coronary artery bypass graft (CABG) patients. A decision analytic model was devel oped for patients with high expected use of blood analy sis, high potential benefit from rapid turn around time of results, a large annual volume of patients, and sub stantial expense associated with surgery. Published lit erature and clinical experts provided incidence, outcome, and cost estimates associated with four clinical scenar ios potentially influenced by POC testing (ventricular arrhythmias, cardiac arrest, severe postoperative bleed ing, and iatrogenic anemia). We found that changes in clinical outcomes were predominantly dependent on com parative turn around time or CABG patient volume. The positive clinical impact of using POC testing was con sistently associated with a positive economic impact. POC blood gas analysis may be associated with decreased incidence of adverse clinical events or earlier detection of such events, resulting in significant cost savings. This study also supports previous findings that the costs of STAT blood analysis are more personnel-related than equipment-related.

Advancing Children's Health Care and Outcomes Through the Pediatric Quality Measures Program

In 2009 Congress passed the Childrens Health Insurance Program Reauthorization Act (CHIPRA), which presented an unprecedented opportunity to measure and improve health care quality and outcomes for children. The Agency for Healthcare Research and Quality, in partnership with the Centers for Medicare & Medicaid Services, has worked to fulfill a number of quality measurement provisions under CHIPRA, including establishing the Pediatric Quality Measures Program (PQMP). The PQMP was charged with establishing a publicly available portfolio of new and enhanced evidence-based pediatric quality measures for use by Medicaid/Childrens Health Insurance Program and other public and private programs and to also provide opportunities to improve and strengthen the Child Core Set of quality measures. This article focuses on the PQMP and provides an overview of the programs goals and related activities, lessons learned, and future opportunities.

The third National Reports on Healthcare Quality and Disparities in the United States: national data for targeting improvements.

THE 2005 National Healthcare Quality Report (NHQR)1 and National Healthcare Disparities Report (NHDR)2 from the Agency for Healthcare Research and Quality (AHRQ) present the third annual opportunity to measure healthcare quality in the United States and track changes over time. These congressionally mandated reports were first released in 2003 to provide annual data on the “vital signs” of the nation’s healthcare quality and disparities. Nurses in a variety of professional settings can use the information in the reports to validate, modify, and design policy, clinical practice, and quality improvement initiatives in support of the progress and challenges highlighted in the reports.

Systematic Evidence-Based Quality Measurement Life-Cycle Approach to Measure Retirement in CHIPRA

OBJECTIVE In 2009, Centers for Medicare and Medicaid Services (CMS) publicly released an initial child core set (CCS) of health care quality measures for voluntary reporting by state Medicaid and Childrens Health Insurance Program (CHIP) programs. CMS is responsible for implementing the reporting program and for updating the CCS annually. We assessed selected CCS measures for potential retirement. METHODS We identified a 23-member external advisory group to provide relevant expertise. We worked with the group to identify 4 major criteria with multiple subcomponents for assessing the measures. We provided information corresponding to each criterion and subcriterion, using a variety of sources such as the 2009 Medicaid Analytic eXtract (MAX), state-level Medicaid and CHIP data submitted to the CMS, and summaries of published literature on clinical and quality improvement effectiveness related to the CCS topics. Using this information, the group: 1) used a modified Delphi process to score the measures in 2 anonymous scoring rounds (on a scale of 1 to 9 in each round); 2) voted on whether each measure should be retired; and 3) provided narrative explanations of their choices (which formed the basis of our qualitative findings). Recommendations were reviewed by CMS before promulgation to state programs. RESULTS The Subcommittee of the National Advisory Council on Healthcare Research and Quality (SNAC) recommended that the 4 major criteria be importance, scientific acceptability, feasibility, and usability. The SNAC recommended 3 measures for retirement: access to primary care; testing for strep before recommending antibiotics for pharyngitis; and annual HbA1c testing of children with diabetes. Explanations for suggesting retirement of the measures included: views that the well-visit measures were a better measure of access than the primary care measure; a likely ceiling effect (pharyngitis); and the paucity of clinical evidence and low prevalence (both for HbA1c). CMS recommended that state Medicaid and CHIP programs retire 2 of the recommended measures from the CCS, but retained the access to primary care measure. CONCLUSIONS Periodic reassessment of the value of health care quality measures can reduce reporting burden and allow measure users to focus on measures with higher likelihood of leading to improvements in quality of care and child health outcomes.

Health care for children and youth in the United States: 13 years of evidence.

From the Office of the Director (Dr Clancy) and the Office of Extramural Research, Education, and Priority Populations (Drs Chesley and Dougherty), Agency for Healthcare Research and Quality, and Department of Health and Human Services (Dr Clancy), Rockville, MD Address correspondence to Denise Dougherty, PhD, Agency for Healthcare Research and Quality, 540 Gaither Rd, Rockville, MD 20850 (e-mail: denise.dougherty@ahrq.hhs.gov).