Priority Areas for National Action Transforming Health Care Quality (2003) / Chapter Skim
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3 Priority Areas for Quality Improvement
3 Priority Areas for Quality Improvement
Pages 41-114
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From page 41... ...
Children with special health care needs Diabetes- focus on appropriate management of early disease End of life with advanced organ system failure focus on congestive heart failure and chronic obstructive pulmonary disease ~ A · —~,~ Frailty associated with old age preventing falls and pressure ulcers, maximizing function, and developing advanced care plans Hypertension focus on appropriate management of early disease Immunization—children and adults .
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From page 42... ...
For example, ischemic heart disease figures prominently in preventive care, inpatient/surgical care, chronic 2 An emerging area is one of high burden (impact) that affects a broad range of individuals (inclusiveness)
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From page 43... ...
· l~lajor depression · Medication management · Nosocomial infections · Obesity · Pregnancy and childbirth · Cancer screening (colorectaUcervical) · End of life with advanced organ systems failure · Hypertension · Ischemic heart disease · Pain control in advanced cancer · Stroke · Severe and persistent mental illness · Tobacco dependence · Frailty 43
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From page 44... ...
Asthma Children with special health care needs - Diabetes End of life with advanced organ system failure Frailty Hypertension Ischemic heart disease Major depression (treatment) Medication management Medication errors Overuse of antibiotics Pain control in advanced cancer Severe and persistent mental illness Stroke Tobacco dependence Obesity (emerging area)
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From page 45... ...
Self-managemenVhealth literacy (cross-cutting) ~ ~ ~ End of life with :advanced organ system failure : Ischemic heart disease Medication management Medication errors Overuse of antibiotics Nosocomial infections Pain control in advanced cancer Pregnancy and childbirth Severe and persistent mental illness Stroke 45
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From page 46... ...
For all of the recommenced conditions, such as diabetes, hypertension, and ischemic heart disease, there are known, effective interventions that can be applied to improve health outcomes, reduce disease burden, and prevent more serious health problems later in life. Moreover, the enormous and rapid growth in the prevalence and burden of chronic disease over the past two decades has been a major force in clarifying the limitations of the current health care system which evolved primarily to meet acute and emergency health care needs thus motivating broad action for health care system redesign (Bodenheimer et al., 2002; Institute of Medicine, 2001a)
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From page 47... ...
Since there are over 430,000 tobacco-related deaths each year from heart disease, stroke, lung cancer, and chronic lung disease among U.S. adults, the impact of this simple intervention, combined with other effective modes of tobacco treatment, would be dramatic (Max, 2001; United States Department of Health and Human Services, 2000~.
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From page 48... ...
The committee's goal was to provide a starting point for experts in the field to undertake effective national health care quality improvement efforts over the next 3 to 5 years. Each priority area is discussed with reference to the committee's three selection criteria impact, improvability, and inclusiveness.
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From page 49... ...
, congestive heart failure (Ni et al., 1998) , chronic atrial fibrillation (Samsa et al., 2000)
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From page 50... ...
These areas include children with special health care needs, diabetes, end of life with advanced organ system failure, frailty, pregnancy and childbirth, and severe and persistent mental illness (Institute of Medicine, 2002~.
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From page 51... ...
Illness (:=r" In~nr~nr~t=H thin c~l~rYl~ ~r `~ ~ ~ - - -I- - - ~ ~ — ——· _ I ·~~ Eve ~~— ·1 1= =1~1 1 1~1 art Al t11~; Chronic Care Model to enhance recognition and treatment of depression in patients with congestive heart failure. This collaborative is an excellent example of how effective care coordination, or clinical integration of services, improved health outcomes for the chronically ill, particularly for patients with multiple chronic conditions.
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From page 52... ...
. Improvability Self-management support is critical because patients and their families are the primary caregivers in chronic illness (don Korff et al., 1997)
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From page 53... ...
adults aged 60 and over and approximately 45 percent of all adults who live in poverty. Thus, the populations most in need of health care are least able to read and understand information needed to function as a patient (American Medical Association, 2002; United States Department of Health and Human Services, 2000~.
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From page 54... ...
, through its Healthy People 2010 initiative, calls for reductions in asthma hospitalization rates (United States Department of Health and Human Services, 2000~. The National Committee for Quality Assurance (NCQA)
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From page 55... ...
It also is an important health care concern for two subspeciaTty groups- allergistsandpulmonolgists. Within asthma care, there are important lessons for outpatient, emergency department, and hospitalbased care.
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From page 56... ...
annually; flexible sigmoidoscopy every 5 years; annual FOBT plus flexible sigmoidoscopy every 5 years; double contrast barium enema every 5 years; or colonoscopy every 10 years (American Cancer Society, 2001~. The United States Preventive Services Task Force strongly recommends screening for men and women 50 years of age and or older for colorectal cancer.
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From page 57... ...
Fourteen states and the District of Columbia have adopted ACS guidelines for cervical cancer screening whereas seven states have elected to use nonconforming guidelines (Rathore et al., 2000~. Inclusiveness African Americans have the highest incidence of and mortality from colorectal cancer among racial/ethnic groups.
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From page 58... ...
Improvability and Inclusiveness The process of developing, implementing, and monitoring a care plan that involves the active participation of the family and health professionals is the most effective vehicle for ensuring comprehensive, culturally sensitive, patient/family-centered care for this population. Developing a care plan using a collaborative, interactive process is important to help families gain an adequate understanding of their child's chronic illness.
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From page 59... ...
Services are provided in the home, office, emergency room, and hospital. Home care, which continues to evolve, is a major component of health care delivery that must be integrated into the planning process (Guidelines for home care of infants, children, and adolescents with chronic disease.
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From page 60... ...
Diabetes predisposes individuals to many long-term, serious medical complications, including heart disease, stroke, hypertension, blindness, kidney disease, neurological disease and increased risk of lower-limb amputation. For example, diabetics have at least twice the risk of heart disease and stroke of their nondiabetic counterparts (American Diabetes Association, 2002~.
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From page 61... ...
Diabetes could serve as a model for improving quality of care for other chronic diseases, particularly with regard to facilitating patient self-management and the active involvement of a multidisciplinary health care team. Improved care for this condition could also stimulate an approach that involves treating other risk factors (cardiovascular disease, hypertension, renal disease)
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From page 62... ...
However, the conditions still cause death eventually, and living for a long time in perilous circumstances poses its own challenges. Heart failure is one of the most common hospitalization diagnoses in Medicare, and lung failure is close behind (Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease.
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From page 63... ...
In the current system, an elderly man lives with his wife in a small duplex, and their son lives nearby. As the man Has become More disabled with heart attacks and progressive heart failure, his living arrangements have become more constrained.
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From page 64... ...
Advance care planning averts the inappropriate implementation of rescue efforts not desired by patient and family and offering little benefit. In some parts of the country, virtually all persons living in nursing homes or receiving regular home care for frailty have advance care plans that address what is to be done about 64
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From page 65... ...
et al., 2002~. Improving care for the frail elderly and the provision of support for their family caregivers will require transforming much of health care for this population to a chronic illness model.
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From page 66... ...
Overall, 32 percent of people with high blood pressure are unaware they have the disease. If left untreated hypertension can lead to several life-threatening complications, such as stroke, heart attack, heart failure, and kidney failure (American Heart Association, 2002~.
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From page 67... ...
A systematic review of 18 long-term randomized controlled trials revealed that the use of low-dose diuretic therapy was effective in reducing stroke, coronary artery disease, congestive heart failure, and total mortality. Additionally, beta blockers were demonstrated to decrease the incidence of congestive heart failure and stoke (Psaty et al., 1997~.
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From page 68... ...
i.- ~~..~ . ~ -a ~~.~ ~~ ~ ~ ~~ ~ ~ ~ j ~ -; ; - - ~ ; Death Rates per 100,000 Population by High Blood Pressure [ Race/Ethnicity l M ale | Female Caucasians 12.8 12.8 African Americans ~ 44 ,.8 ~ 40.3 SOURCE: (American Heart Association, 2002)
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From page 69... ...
In a study produced by the Partnership for Prevention (2002) , vaccinating children is cited as the number one priority among recommended clinical preventive services (Partnership for Prevention, 20021.
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From page 70... ...
Pneumococcal disease causes 10,000 to 14,000 deaths annually; influenza causes an average of ~ 10,000 hospitalizations and 20,000 deaths annually (United States Department of Health and Human Services, 2000~. Approximately 30~3 percent of elderly people who have invasive pneumonia will die from the disease (United States Preventive Services Task Force, 1996~.
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From page 71... ...
. The highest incidence rates of pneumonia are among people over age 65, nursing home residents, and certain ethnic groups, including Native Americans and Alaskan Natives (United States Preventive Services Task Force, 1996~.
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From page 72... ...
Total expenditures for heart disease were approximately $112 billion in 2002, with direct costs, such as hospitals/ nursing homes and prescription drugs, totaling $58 billion and indirect costs, including lost productivity/morbidity, totaling $54 billion (American Heart Association, 2001~. A 50-year retrospective study found that the incidence of heart failure has declined by onethird for women but has remained unchanged for men.
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From page 73... ...
The National Cooperative Cardiovascular Project found that use of beta blockers among patients aged 65 or older varied significantly by state, ranging from 30 to 77 percent (Kn~mho~z et al., 1998; O'Connor et al., 1999~. A study examining the treatment of Medicare patients with acute myocardial infarction revealed that a significantly higher proportion of patients received aspirin, IV nitroglycerin, and heparin in urban as compared with rural hospitals.
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From page 74... ...
These models are grounded in principles drawn from Wagner's Chronic Care Model for improving the care of individuals with serious mental illnesses (Wagner et al., 200Ic)
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From page 75... ...
~..~_I~l~..:l~l,-'v-~. Ills cloy lalluulilly d~ly~l~:~o clinics Ireating~1 356 patients to either this quality improvement program or usual care.
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From page 76... ...
With regard to inappropriate antibiotic use treatment of acute respiratory infections accounts for 75 percent of all antibiotics prescribed in ambulatory settings. Although the majority of these illnesses are viral in nature and do not benefit from antimicrobial drug therapy, antibiotics are prescribed during over 50 percent of visits for colds and upper respiratory tract infections in the United States annually (Gonzales et al., 1999; Gonzales et al., 1997; McCaig and Hughes, 1995; Schappert, 19971.
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From page 77... ...
A randomized controlled trial of 12 practices in Massachusetts and Washington State showed that educational outreach to providers and parents resulted in a 16 percent decrease in antibiotic dispensing for children under 3 years of age and a 12 percent decrease for children aged 3 to 6 years. The physician/practice group interventions included two meetings of the group with a physician peer leader who promoted CDC guidelines and feedback on prescribing rates.
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From page 78... ...
With regard to antibiotic overuse, since children and adolescents have the highest rates of antibiotic use and infection with antibioticresistant microorganisms, they are a subgroup warranting particular attention (McCaig and Hughes, 1995; Nyquist et al., 1998; Perz et al., 2002; Whitney et al., 2000~. The increased distribution of antimicrobial-resistant bacteria also poses a threat to the elderly, who are more vulnerable to nosocomial infections as they are more likely to be hospitalized or in a nursing home (Norman, 2002~.
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From page 79... ...
, overseen by CDC, was established in ~ 970 to collect data on hospital-acquired infections. The goal of this initiative was to establish a national database to better understand the epidemiology of nosocomial infections, to track antimicrobial resistance trends, and to provide nosocomial infection rates for use by hospitals as benchmarks for quality improvement efforts.
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From page 80... ...
As of 2000, 3 ~ 5 hospitals were participating in the NNISS, representing only a small fraction of the 5,810 hospitals in the United States (American Hospital Association, 2001~. Although the importance of actions of individuals, such as hand washing, should not be understated, prevention of nosocomial infections through the implementation of evidence-based guidelines and a surveillance program demonstrates how effective systems interventions can lead to more widespread improvements in quality of care.
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From page 81... ...
Approximately 550,000 Americans will die of cancer in 2002, greater than 1,500 people per day (American Cancer Society, 2002~. Many with cancer experience substantial pain throughout the course of their illness and that pain is widely dreaded (Cleeland et al., 1994; Sloan et al., ~ 999~.
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From page 82... ...
die of it both more often and earlier, than Caucasians, Asians, or Hispanics (American Cancer Society, 2002; Hodgson et al., 20011. Some evidence indicates that minorities are less likely to be treated effectively for pain (Anderson et al., 20021.
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From page 83... ...
Effective management of pregnancy, including prenatal and intrapartum care, offers opportunities and challenges for quality improvement given the diverse group of conditions and interventions involved, such as infectious diseases (particularly sexually transmitted diseases and HIV/AIDS) ; chronic diseases (particularly diabetes and hypertension)
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From page 84... ...
The percent of women receiving prenatal care in the first trimester varies by race, with African Americans and Hispanics being 14 percent less likely to receive prenatal care than Caucasians (Hoyert et al., 2001~. Marked geographic variations in prenatal care also exist.
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From page 85... ...
About 3 percent of the adult population in the United States experiences severe mental disorders in a 1-year period. During 1990, these patients accounted for an estimated $74 billion in national expenditures (Health care reform for Americans with severe mental illnesses: Report of the National Advisory Mental Health Council, 1993~.
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From page 86... ...
mental health system perpetuates both the stigma and the social disadvantages experienced by patients treated in the public mental health sector (Hogan, 1998~. One of the best-validated models for improving care for patients with severe mental illness is the Program of Assertive Community Treatment model, or PACT.
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From page 87... ...
Analyses of the 199~1995 National Health Interview Survey Disability supplement (NHIS-D) found that among persons aged 70 and older, cerebrovascular disease was the third leading cause of major mobility problems, after arthritismusculoskeletal conditions and ischemic heart disease (Iezzoni et al., 2001~.
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From page 88... ...
Younger African Americans have two to three times the risk of stroke of Caucasians, and African Americans of both genders are more likely to die of a stroke (American Heart Association, 2001; Centers for Disease Control and Prevention, 2002b)
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From page 89... ...
adults, including deaths due to heart disease, smoke, lung cancer, and chronic Jung disease, accounting for approximately ~ in S deaths overall (United States Nepal lenient of Health and Human Services, 2000~. Maternal smoking in pregnancy is the single most important preventable cause of poor pregnancy outcomes, resulting in Tow birth weight, perinatal mortality, and sudden infant death syndrome (United States Department of Health and Human Services, 200Ib)
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From page 90... ...
for improving the management of chronic disease (Glasgow et al., 2001~. Inclusiveness Americans with the fewest educational and economic resources are most likely to smoke; there are also important variations in tobacco use based on race, ethnicity, and gender (Centers for Disease Control and Prevention, 2001c; United States Department of Health and Human Services, 2000~.
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From page 91... ...
of Puget Sound undertook a well-documented organizational effort to integrate screening and treatment for tobacco use and dependence into routine health care for~all its members. This effort has recently been described with: reference to the~elements of the Chronic Care Model ~(GIasgow et al.' 2001)
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From page 92... ...
Obesity is a major risk factor for the leading causes of death and disability: heart disease, including high blood pressure; stroke; some forms of cancer; and diabetes, including insulin resistance and metabolic syndrome (which encompasses some combination of insulin resistance, hypertension, and abdominal obesity and affects an estimated 42 million adults) (Must et al., 1999; United States Department of Health and Human Services, 2001a)
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From page 93... ...
Preventive Services Task Force recommend intensive dietary behavioral counseling for atrisk adult patients with known risk factors, including obesity, for diet-related disease. The guidelines conclude, however, that there is currently insufficient evidence to support recommending for or against routine behavioral counseling to promote healthy diet or physical activity among general populations of primary care patients (United States Preventive Services Task Force, 2002a; 2003~.
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From page 94... ...
2001. Cardiac rehabilitation and secondary prevention of coronary heart disease.
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From page 95... ...
2002. Increasing cervical cancer screening among underserved women in a large urban county health system: Can it be done?
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From page 96... ...
2001. California Prevention Report: Delivery of High-Yield Clinical Preventive Services by Managed Health Care Plans in California.
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From page 97... ...
1996. Correlates of major complications or death in patients admitted to the hospital with congestive heart failure.
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From page 98... ...
1992. Cervical cancer screening.
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From page 99... ...
1998. Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults.
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From page 100... ...
2002. Self-management aspects of the improving chronic illness care breakthrough series: Implementation with diabetes and heart failure teams.
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From page 101... ...
JAmGeriatrSoc 48 (6~:651 -7. Health care reform for Americans with severe mental illnesses: Report of the National Advisory Mental Health Council.
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From page 102... ...
2001. Case management and quality of life: Assessing treatment and outcomes for clients with chronic and persistent mental illness.
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From page 103... ...
1998. National use and effectiveness of beta-blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project.
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From page 104... ...
1997. A randomized trial of assertive community treatment for homeless persons with severe mental illness.
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From page 105... ...
2001. Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: The Minnesota Heart Survey.
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From page 106... ...
2001. Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trials.
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From page 107... ...
Preventive Services Task Force. Ann Intern Med 137 (2~:96-104.
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From page 108... ...
2001. Timelimited assertive community treatment for homeless persons with severe mental illness.
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From page 109... ...
2001. Cost-effectiveness of practice-initiated quality improvement for depression: Results of a randomized controlled trial.
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From page 110... ...
1997. Delivering clinical preventive services is a systems problem.
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From page 111... ...
~4nn Intern Med 137:205-8. United States Preventive Services Task Force.
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From page 112... ...
2001a. Quality improvement in chronic illness care: A collaborative approach.
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From page 113... ...
2000. Impact of disseminating quality improvement programs for depression in managed primary care: A randomized controlled trial.
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