The evolution of healthcare quality measurement in the United States.

Quality measurement is fundamental to systematic improvement of the healthcare system. Whilst the United States has made significant investments in healthcare quality measurement and improvement, progress has been somewhat limited. Public and private payers in the United States increasingly mandate measurement and reporting as part of pay-for-performance programmes. Numerous issues have limited improvement, including lack of alignment in the use of measures and improvement strategies, the fragmentation of the U.S. healthcare system, and the lack of national electronic systems for measurement, reporting, benchmarking and improvement. Here, we provide an overview of the evolution of U.S. quality measurement efforts, including the role of the National Quality Forum. Important contextual changes such as the growing shift towards electronic data sources and clinical registries are discussed together with international comparisons. In future, the U.S. healthcare system needs to focus greater attention on the development and use of measures that matter. The three-part aim of effective care, affordable care and healthy communities in the U.S. National Quality Strategy focuses attention on population health and reduction in healthcare disparities. To make significant improvements in U.S. health care, a closer connection between measurement and both evolving national data systems and evidence-based improvement strategies is needed.

Veteran subjects willingness to participate in schizophrenia clinical trials.

Predictive characteristics of subjects agreeing to be randomized into clinical trials for the treatment of schizophrenia and schizoaffective disorder have been little studied. In this study, we used data from the recruitment phase of a randomized trial that compared long acting injectable (LAI) risperidone to oral antipsychotic medications. Basic socio-demographic and clinical data were gathered from eligible patients and clinicians at the time of screening for trial entry. Bivariate comparisons and multivariate logistic regression were used to compare those who agreed to participate and those who refused. Altogether 446 veterans were eligible on preliminary screening, of these 382 (86 %) agreed to participate and 64 (14 %) declined. Eligible patients who agreed to be randomized were more willing to change medications without regard to their level of satisfaction with their current medication. Subjects reported as currently taking LAI medication and taking risperidone, in particular, were more likely to agree to participate. Factors that did not significantly predict participation included age, years on current medication, reported medication compliance, race, and gender. Veterans with schizophrenia or schizoaffective disorder who were actually more satisfied with their current medications and who were currently taking the experimental agent were more likely to agree to participate in this randomized clinical trial in contrast to expectations that individuals who are unsatisfied with their current treatment would be more likely to enroll in such studies.

Reconstruction of New Orleans after Hurricane Katrina: a research perspective.

Four propositions drawn from 60 years of natural hazard and reconstruction research provide a comparative and historical perspective on the reconstruction of New Orleans after Hurricane Katrina. Decisions taken over its 288-year history that have made New Orleans so vulnerable to Katrina reflect a long-term pattern of societal response to hazard events--reducing consequences to relatively frequent events, and increasing vulnerability to very large and rare events. Thus Katrina's consequences for New Orleans were truly catastrophic--accounting for most of the estimated 1,570 deaths of Louisiana residents and $40-50 billion in monetary losses. A comparative sequence and timing of recovery provides a calendar of historical experience against which to gauge progress in reconstruction. Using this calendar, the emergency post-disaster period appears to be longer in duration than that of any other studied disaster. The restoration period, the time taken to restore urban services for the smaller population, is in keeping with or ahead of historical experience. The effort to reconstruct the physical environment and urban infrastructure is likely to take 8-11 years. Conflicting policy goals for reconstruction of rapid recovery, safety, betterment, and equity are already evident. Actions taken demonstrate the rush to rebuild the familiar in contrast to planning efforts that emphasize betterment. Because disasters tend to accelerate existing economic, social, and political trends, the large losses in housing, population, and employment after Katrina are likely to persist and, at best, only partly recover. However, the possibility of breaking free of this gloomy trajectory is feasible and has some historical precedent.

Quality or financing: what drives design of the health care system?

The scope and scale of problems in the quality of health service provision have been increasingly recognised in recent years. Policy and planning for financing are usually concerned with how funding is made available and allocated, rather than with what is being achieved, including the quality of health services delivered. A fundamental challenge is how to improve the delivery of health services to achieve improved patient outcomes and to optimize financial outcomes. To accomplish this it is essential that the debates on quality of care and financing are aligned. Approaches to improving the quality of care are drawn from Australia, the US, and the UK. Financing arrangements for care at a national level have a bearing on how payment incentives can be used to promote or impede quality. The level of overall expenditure is obviously important, as are the mechanisms for payment. Long term programs to build knowledge, standardise processes, provide credible performance data and foster accountability are required to ensure that further investments lead to improvement in care.

Sheila Leatherman on healthcare policy and evaluation and international quality agendas. Interview by Patti Klingel.

Sheila Leatherman has broad experience in health management, public policy, and academic research. She has held positions in federal and state healthcare agencies and served as CEO of a large HMO and as an executive of one of the largest managed care companies in the United States. Ms. Leatherman's time is currently devoted to healthcare research, both in the United States and the United Kingdom. In the United States, she is founder and chair of the Center for Health Care Policy Evaluation, an independent private-sector research institute, and adjunct professor in the Department of Health Policy and Management, School of Public Health at the University of North Carolina. In the United Kingdom, she is a senior adviser to The Nuffield Trust, which commissioned her to evaluate the National Health Service strategy for quality of care management (1997-1998 and 2002-2003), and in which she is involved in an ongoing policy and research program in quality evaluation. She is a Senior Associate at the Judge Institute of Management Studies and Distinguished Associate at Darwin College, both at Cambridge University. Her areas of research are quality of care, health policy, and managed care, and she has written more than 25 articles, which have been published in such prestigious journals as the Journal of the American Medical Association, Health Affairs, Medical Care, and the International Journal of Quality.

Improving performance using indicators. Recent experiences in the United States, the United Kingdom, and Australia.

This article describes recent national performance improvement initiatives in the United States, United Kingdom, and Australia. This comparison is of particular interest because each of these three countries faces similar challenges in delivering health care and improving health. Each has elevated a focus on safety and quality improvement to a national level. Marked differences in the organization and financing of health care across these three countries provide a unique opportunity to compare and contrast approaches. Drawing on the experience of the authors in each of the three countries and publicly available data sources about specific national initiatives, we describe the national context for improvement and outline recent performance improvement initiatives and emerging issues and challenges. Similarities and differences in the current evolution of national performance initiatives are described and conclusions are drawn about challenges that all three countries face, particularly in terms of developing meaningful sets of national indicators of health system performance. The challenges for future work include the importance of information infrastructure, the paucity of accurate and accessible clinical data, the need for effective performance measurement processes at a local level to capture useful data, and the tensions of balancing accountability and improvement agendas for measurement.

A framework for evaluating government quality initiatives: the Wimpole Street principles.

Quality is increasingly on the clinical, management and policy agenda internationally. It is indeed important for quality initiatives to be scrutinized against explicit criteria to ascertain their effectiveness, utility, and evidence base. Quality initiatives in the USA and the UK, as well as a growing number of other countries, are beginning to garner attention for governmental funding thus increasing the onus and responsibility to evaluate the contribution of quality initiatives to the goals of the health system(s).

The public release of performance data: what do we expect to gain? A review of the evidence.

CONTEXT: Information about the performance of hospitals, health professionals, and health care organizations has been made public in the United States for more than a decade. The expected gains of public disclosure have not been made clear, and both the benefits and potential risks have received minimal empirical investigation. OBJECTIVE: To summarize the empirical evidence concerning public disclosure of performance data, relate the results to the potential gains, and identify areas requiring further research. DATA SOURCES: A literature search was conducted on MEDLINE and EMBASE databases for articles published between January 1986 and October 1999 in peer-reviewed journals. Review of citations, public documents, and expert advice was conducted to identify studies not found in the electronic databases. STUDY SELECTION: Descriptive, observational, or experimental evaluations of US reporting systems were selected for inclusion. DATA EXTRACTION: Included studies were organized based on use of public data by consumers, purchasers, physicians, and hospitals; impact on quality of care outcomes; and costs. DATA SYNTHESIS: Seven US reporting systems have been the subject of published empirical evaluations. Descriptive and observational methods predominate. Consumers and purchasers rarely search out the information and do not understand or trust it; it has a small, although increasing, impact on their decision making. Physicians are skeptical about such data and only a small proportion makes use of it. Hospitals appear to be most responsive to the data. In a limited number of studies, the publication of performance data has been associated with an improvement in health outcomes. CONCLUSIONS: There are several potential gains from the public disclosure of performance data, but use of the information by provider organizations for quality improvement may be the most productive area for further research.

Health of the public: The private-sector challenge.

The rapid growth of managed care poses challenges and opportunities for the health of the public. The fundamental risk is that both mission and accountability will be defined too narrowly; the opportunity lies in broadening both. What would a socially responsible managed care system look like? Such a system would provide excellent individual care to its enrollees, yet it would also include programs and activities that address broader populations and policies. We propose 8 attributes of such a system that can be used as a guide by managed care systems and to judge whether a managed care system is a responsible, accountable, and responsive contributor to the health of its community. As the role of the public sector shrinks, the private sector must expand its responsibility. It is both prudent and reasonable for managed care systems to seize their unique opportunity to improve the health of the public.

Using report cards to grade health plan quality.

Judging the quality of health care that a plan delivers so consumers can make informed purchasing decisions is at the heart of the major federal health reform proposals. Health care "report cards" are an important step in this direction. But they cannot, by themselves, inform consumers or improve health system performance.