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4 Taking the First Steps
Pages 89-110

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From page 89...
... Common chronic conditions should serve as a starting point for the restructuring of health care delivery because, as noted in Chapter 1, chronic conditions are now the leading cause of illness, disability, and death in the United States, affecting almost half of the population and accounting for the majority of health care resources used (Hoffman et al., 1996~. Chronic conditions affect people of all ages.
From page 90...
... In collaboration with the National Quality Forum, the agency should convene stakeholders, including purchasers, consumers, health care organizations, professional groups, and others, to develop strategies, goals, and action plans for achieving substantial improvements in quality in the next 5 years for each of the priority conditions. Identifying priority conditions represents a starting point to support the organization of care, bring the evidence base into practice, develop information technology and infrastructure to support care, and develop mechanisms to measure and pay for quality care.
From page 91...
... In identifying and convening stakeholders, AHRQ should work with the National Quality Forum, a public-private partnership charged with development of a comprehensive quality measurement and public reporting strategy. Input should also be obtained from organizations that have made significant efforts to improve quality, such as the Institute for Healthcare Improvement, the Quality Center at the Bureau of Primary Health Care in the Health Resources Services Administration, the Veterans Health Administration, local delivery systems, and others.
From page 92...
... and to redesign care processes for the priority conditions, making best use of information technology and engineering design concepts (Chapters 5 and 7~. There must be a strong commitment to evaluating the impact and cost-effectiveness of innovative programs, and to the rapid diffusion of programs proven successful throughout the field.
From page 93...
... Defining care processes around specific conditions can also establish a suitable level of focus for significant quality improvement in health care. To achieve such improvement, it will be necessary to develop information about the processes and outcomes of care for specific population groups (Friedman, 1995~.
From page 94...
... A study in one health maintenance organization found that 38 percent of enrollees had at least one chronic condition, and their costs averaged twice those of people with no chronic condition (Fishman et al., 1997~. A study at another health maintenance organization found that 78 percent of direct medical costs were attributable to just 25 acute and chronic conditions and that three cardiovascular conditions (ischemic heart disease, hypertension, and congestive heart failure)
From page 95...
... , the committee believes these simple techniques have been available for many years and have not been sufficient to achieve broad-based quality improvements. While any type of progress is welcome, at some point the health care system will need to embrace more automated methods and greater use of information technology to make significant progress.
From page 96...
... APPLICATIONS OF PRIORITY CONDITIONS Figure 4-1 illustrates the multiple ways in which the priority conditions, once identified, can be applied. First, they can be used to synthesize the evidence base and delineate practice guidelines.
From page 97...
... is a quality improvement program that focuses on eight priority conditions: chronic heart failure, diabetes, HIV/AIDS, ischemic heart disease, mental health (depression and schizophrenia) , spinal cord injury, stroke, and substance abuse (Demakis et al., 2000~.
From page 98...
... By examining where current practice departs from the evidence base and best practice, suggestions for improving care may emerge that can direct changes in provider actions, patient responsibilities, or organizational approaches. It would be difficult to use this multifaceted, comprehensive care approach except at the level of a specific condition.
From page 99...
... Disease management programs share some of the features envisioned for organization around priority conditions as described above, but also differ in important ways. The two are similar in that disease management represents a systematic approach to designing care, uses multidisciplinary teams to deliver care, and potentially includes services across the entire continuum of care.
From page 100...
... The approach is dissimilar in that it is focused primarily on selected complex procedures with a strong emphasis on costs, rather than being solely a quality-driven strategy (Cromwell et al., 1997; Health Care Financing Administration, 1999~. Coronary artery bypass graft surgery, pediatric cardiac surgery, carotid endarterectomy, abdominal aortic aneurysm repair, cancer surgery, percutaneous transluminal coronary angioplasty, acute myocardial infarction, and acquired immunodeficiency syndrome (AIDS)
From page 101...
... The current payment system often reinforces fragmentation by paying separately according to the setting of care and provider type, and by not giving providers the flexibility needed to customize care for individual patients. Furthermore, common payment methods can inhibit quality improvement to the extent that organizations that improve certain aspects of quality (e.g., by reducing readmission rates or office visits)
From page 102...
... The Joint Commission on Accreditation of Healthcare Organizations (2000) has identified five specific areas for the development of indicators to assess hospital care: acute myocardial infarction, heart failure, pneumonia, surgical procedures and complications, and pregnancy and related conditions.
From page 103...
... Finally, the National Quality Forum is developing a comprehensive quality measurement and reporting strategy that will address priorities for quality measurement that are consistent with the national aims for quality improvement in health care set forth in this report (National Quality Forum for Health Care Quality Measurement and Reporting, 2000~. CRITERIA FOR IDENTIFYING PRIORITY CONDITIONS Various criteria can be used to identify the priority conditions.
From page 104...
... Possible areas requiring additional organizational research include understanding how financial and other types of incentives relate to organizational setting, how physician and nonphysician members of the care team can optimally interact and complement each other, what components and interactions of systems of care are most important for improving quality, and how to organize care for people with chronic conditions. The committee views public support as important for catalyzing the needed changes for several reasons.
From page 105...
... The Robert Wood Johnson Foundation has sponsored the Changes in Health Care Financing and Organization Program since 1988. It has provided over $50 million to stimulate research into new strategies in the financing and organization of health care and the impact of changes in the delivery system on quality, access, and costs.
From page 106...
... This dilemma will likely worsen in the future with expected advances in genome research, tissue reengineering, pharmacogenetics, and other areas. As noted earlier, the committee has not recommended a specific amount for a Health Care Quality Innovation Fund, but believes that an amount on the order of $1 billion over 3 to 5 years is needed.
From page 107...
... Example 2 A Partnership to Improve Chronic Care A hospital, two small primary care practices, and an endocrinologist decided to collaborate on the development of a state-of-the-art diabetic care program. They began by reviewing the practice guidelines and agreeing on the key elements of preventive, acute, and chronic care.
From page 108...
... Few health care professionals and organizations can undertake such drastic steps to substantially reorganize their care processes without special (and temporary) assistance.
From page 109...
... . Medicare's Health Care Quality Improvement Program v5-2." Online.
From page 110...
... . National Quality Forum for Health Care Quality Measurement and Reporting.


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