January 17, 2003

Carolyn Clancy, M.D.
Acting Director
Agency for Healthcare Research and Quality
2101 E. Jefferson St., Suite 501
Rockville, MD 20852

Dear Dr. Clancy:

The National Committee on Vital and Health Statistics (NCVHS) is pleased to offer its recommendations on the proposed measure set for the National Healthcare Quality Report (NHQR) to the Agency for Healthcare Research and Quality (AHRQ). As you are aware, AHRQ asked the NCVHS to serve as a vehicle for eliciting public comment on the proposed measure set for the NHQR from key stakeholder groups. In response, the NCVHS Quality Workgroup convened a public hearing on the proposed measure set in Chicago on July 25, 2002. A transcript of the testimony taken at that hearing was previously submitted to AHRQ for review. Since that time, the NCVHS Quality Work Group has also had an opportunity to review AHRQ’s summary of comments received in response to its solicitation of broader public commentary. At this time, the NCVHS would like to offer its own recommendations, based on the testimony of key stakeholders, the AHRQ summary of public comments, and the observations and opinions of NCVHS members.

As stated by many of those who testified and commented on the proposed draft measure set for the NHQR, AHRQ has done an excellent job of identifying and evaluating potential measures for inclusion in the NHQR measure set. However, it is clear that the pool of candidate measures from which AHRQ could draw was severely limited in several areas, leaving some important gaps in the proposed measure set.

It is also apparent that AHRQ’s ability to produce the proposed measures for geographic units below the national level is highly constrained by the available data. This will limit its utility for states and market-based provider organizations in determining whether performance gaps identified at the national level exist in their state and/or market. At the least, this will delay the adoption of quality improvement strategies in response to deficiencies identified in the NHQR while states and providers assess whether the identified deficiencies exist in their particular geographic area or organization.

In the spirit of continuous quality improvement, the NCVHS offers the following recommendations for improving future versions of the NHQR:

1. Improve the balance within the measure set by:

a. Increasing the number and scope of measures that are relevant to care provided to children;

b. Increasing the number and scope of measures that are relevant to the delivery of mental health and substance abuse services;

c. Expanding the scope of measures of ambulatory/outpatient care and services beyond those relevant to screening and prevention to encompass important areas of acute and chronic illness care identified as priority conditions in the recent IOM report;

d. Expanding the scope of measurement to include more population-based measures that pertain to many diseases or conditions which may each occur too infrequently to support condition-specific measurement, but which depend upon similar, cross-cutting, care processes (such as follow-up rates for abnormal tests, adequacy of medication monitoring, patient education and empowerment, etc.); and

e. Increasing the number and scope of measures of adverse effects and unintended consequences of health care.

2. Increase the number of measures that are available at the state, county and/or metropolitan market area level. Action on areas of deficiency in a climate of increasing healthcare costs and severe shortfalls in state budgets will depend in large part on the availability of compelling data on state and local performance measures.

3. Further expand the framework beyond the IOM recommendations. We applaud AHRQ’s decision to add efficiency measures to the NHQR. We believe that AHRQ should further consider adopting the category of “Changing Needs”, as defined in the framework developed by the Foundation for Accountability, which considers life stage-relevant care issues beyond the current NHQR category of End of Life care. This would include measures of care that are applicable across the age spectrum, such as promoting healthy development in infants and toddlers, providing anticipatory guidance during puberty and adolescence, managing stress; managing menopause, and maintaining and improving functional status in elders, as well as end of life care.

4. Consider adding evidence-based “systems” measures, which could be incorporated into the NCHS provider surveys. Examples include adoption rates of proven systems, processes and technologies, such as patient registries with reminder systems capabilities, electronic medical records, and clinician point of order entry systems, that have been shown to increase the receipt of recommended care and/or reduce the occurrence of medical errors.

5. Present measures in a manner that reflects the degree of variation, as well as average performance.

6. Given that the focus of this report is on health care, rather than health, acknowledge the contributions of other important influences outside of heath care when reporting measures of health outcomes.

7. While the primary audience for the NHQR is policy-makers, consider adapting the report for additional audiences, with varying needs and sophistication in the area of quality assessment (e.g. payers, providers, consumers) and/or develop companion guides for these audiences. Consider using talkingquality.gov as a vehicle for doing this in an efficient, low-cost way.

Thank you for the opportunity to comment on AHRQ’s plans for producing a National Healthcare Quality Report. We congratulate you on your efforts thus far and look forward to publication of the current and future versions of this report.



John Lumpkin, M.D., M.P.H.
Chair, National Committee on Vital and Health Statistics

cc: Co-chairs, DHHS Data Council

Edward J. Sondik, Director, National Center for Health Statistics