Toward Quality Measures for Population Health and the Leading Health Indicators (2013) / Chapter Skim
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3 Measures of Quality
3 Measures of Quality
Pages 45-76
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From page 45... ...
; obesity, nutrition, and physical activity; and maternal, infant, and child health. As noted earlier, the committee believes that the purpose of measurement is threefold.
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From page 46... ...
However, the potential of disruptive innovation to dramatically increase access to population health data is undeniable. The committee did not conduct a systematic and comprehensive review of all potential measures related to the LHIs for several reasons.
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LHIs do not fit neatly into one level of the ecological model, and may be altered by interventions at both the individual and at the population level. Finally, the LHIs may be organized according to the committee's logic model provided above: resources and capacity, interventions, healthy conditions, and healthy outcomes, with a focus on the latter two categories, which can "house" most of the LHIs (see Figure 3-1)
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Organized According to the Logic Model and Showing Areas for and Examples of Potential Measures of Quality (in Regular Typeface) Resources and Capacity; Healthy Conditions Outcome Interventions Title X, Medicaid family Females receiving Infant deaths planning waivers reproductive health (MICH-1.3)
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exposure) Children exposed to State and local smoke- secondhand smoke free policies (TU-11.1)
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Percent of population under age 65 without health insurance* The Affordable Care Act Local public health mon- Adults with hyper- HALY/HALE itoring of hypertension tension under Cardiovascular rates and support to pro- control (HDS-12)
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) represent measures that are endorsed by NQF, met the criteria for inclusion in the County Health Rankings, or met other criteria (e.g., face validity in the case of measures that emerge from the evidence-based interventions recommended by the Guide to Community Preventive Services [population-based interventions]
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. h Guide to Community Preventive Services, 2004.
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2. The committee developed case studies that applied the report's health outcome logic model to the LHI topic areas of a.
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or an intermediate outcome, provides a detailed logic model to illustrate the possible measures under Healthy Conditions and Health Outcomes, depicts the likely relationships among them, and offers both a list of possible measures and a shorter list of candidate measures (endorsed by NQF; based on evidence from the Guide to Community Preventive Services, the USPSTF, or equivalent, and for which data sources are available)
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Because these actions and processes can be implemented at the state and local level, selecting one or more of them as the basis for a measure of state or local health system performance could provide more immediate feedback to local public health practitioners and stakeholders than relying on quality measures of conditions and outcomes, which change over a much longer time frame. The case studies gave the committee an opportunity to consider the nine characteristics of public health quality and the six drivers of public health quality improvement as they relate primarily to the Resources and Capacity component of the logic model.
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The drivers of quality (population health metrics and information technology; evidence-based practices, research, and evaluation; systems thinking; sustainability and stewardship; policy; and public health workforce and education) are consistent with the foundational capabilities of public health described in the 2012 IOM report For the Public's Health: Investing in a Healthier Future.
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From page 57... ...
Fac tors contributing to smoking and other tobacco use behavior in clude social norms; the existence of adequate laws and policies and their enforcement, the availability of counseling and other smoking-cessation supports, health insurance coverage of smoking cessation services including access to pharmacologic products (nicotine replacement therapy and others) ; and multiple actors who can influence tobacco use, such as the mass media, employ ers, local governments, and schools.
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This included reviewing the evidence base on effective interventions, such as clinical services, programs, laws, and policies among other system inputs, the healthy conditions needed to decrease poor tobacco use–related outcomes, and finally, the intermediate and ultimate outcomes of decreased tobacco use. The committee identified a set of quality measures, and also explained how consideration of the six drivers of improvement of quality in public health would influence action to reduce tobacco use.
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Examples include evidence that taxes and other policies are effective and may even bring in revenue and evidence that greater spending by states on specific types of tobacco interventions leads to the desired health outcomes, which are reductions in tobacco use, reductions in health conditions that result from tobacco use, and ultimately, increased healthy life expectancy. Research has shown that states and localities that have made substantial investments in comprehensive tobacco control programs have realized faster decreases in cigarette sales and smoking prevalence (HHS, 2010)
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Tobacco Use: Example Measures of Quality Measures of Healthy Outcomes (Outcome Measures) Lung cancer mortality Prevalence of chronic obstructive pulmonary disease Measures of Healthy Conditions (Intermediate Outcome Measures)
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Screening for abdominal aortic aneurysm in adult male smokers (ActiveHealth Management) Nutrition, Physical Activity, and Obesity There are four LHIs under the LHI topic Nutrition, Physical Activity, and Obesity: adults who meet guidelines on physical activity (aerobic and muscle strengthening)
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62 Resources & Capacity Increase tax on tobacco companies; lawsuits against tobacco companies (e.g., tobacco settlement Reduced exposure to secondhand smoke TOWARD QUALITY MEASURES FOR POPULATION HEALTH FIGURE 3-2 Applying the logic model to the LHI topic Tobacco Use.
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The logic model can also be used to assess local resources and capacities to implement interventions to improve nutritional status and physical activity, and to reduce obesity.
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Number of programs that promote physical activity for children Availability of fresh fruits and produce Nutritious meals available in school, day care, and assisted-living housing Space available for physical activity in child care and school facilities Menu labeling regulations Average calories per meal purchased at chain restaurants The following measures have been endorsed by NQF (measure steward provided in parentheses) : Child overweight or obesity status based on parental report of body mass index (Maternal and Child Health Bureau, HRSA)
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Resources & Capacity MEASURES OF QUALITY Resources to implement strategies to improve nutrition, reduce obesity, & increase physical activity Reduced rates of diabetes, cardiovascular disease, & cancer Programs that implement strategies to improve nutrition, reduce obesity, & increase physical activity FIGURE 3-3 Applying the logic model to the LHI topic Nutrition, Physical Activity, and Obesity.
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. The set of objectives under the Environmental Quality topic includes the subtitles Outdoor Air Quality, Water Quality, Toxics and Waste, Healthy Homes and Healthy Communities, and Infrastructure and Surveillance.
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Each community, state, or measure-endorsing entity could use the logic model described below to generate a portfolio of measures for comparison and improvement in the area of environmental quality. The logic model can also be used to assess local resources and capacities to implement interventions to improve air quality.
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Measures of Outcome Mortality due to respiratory complications Asthma incidence in children Inhaler use (as proxy for frequency of asthma attacks) Hospital visits for asthma attacks Emergency visits with respiratory related complications Measures of Healthy Conditions (e.g., Intermediate Outcome)
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Examples of reducing mobile sources of air pollution include improvements in fuel efficiency through Corporate Average Fuel Economy standards and reductions in diesel fuel–related emis 69 sions through the use of low-sulfur diesel fuel and particulate filters.
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to influence factors linked with infant survival at various points in the causal network. Reviewing the literature on infant deaths, including the extensive information provided in Healthy People 2020, the committee found that the top causes include, in order: birth defects, prematurity and low birth weight, and Sudden Infant Death Syndrome (SIDS)
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However, there are considerable gaps in the evidence base. The existing evidence-based interventions to address one or more of the causes of infant mortality and preterm birth include: folic acid supplementation, tobacco use cessation counseling, tobacco use interventions used in combination (excise taxes, campaigns, education)
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Measures Related to Healthy Outcomes Infant mortality rate Percent of overweight and obesity in pregnant women and women of childbearing age Number of stillbirths and miscarriages Number of preterm births Number of children with congenital conditions Percent of early elective deliveries Measures Related to Healthy Conditions Prevalence of infant exposure to environmental tobacco smoke in the home (HHS, 2006) The existence of laws related to indoor air quality, such as municipal ordinances prohibiting or restricting smoking in multi-family housing (Environmental Law Institute, 2013)
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Percentage of infants and children exposed to secondhand smoke Percentage of vaccinated (up to date) infants and children Percentage of mothers following nutritional guidelines Percentage of infants visiting the emergency room Measures Related to Resources and Interventions Availability of prenatal care Availability of family planning services The following are measures that have been endorsed by NQF (measure stewards provided in parentheses)
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74 TOWARD QUALITY MEASURES FOR POPULATION HEALTH Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the 2-year meas urement period and who received tobacco cessation counseling intervention if identified as a tobacco user (AMA-convened Phy sician Consortium for Performance Improvement) The HRSA Maternal and Child Health Bureau measures children exposed to secondhand smoke inside their homes (fits under Healthy Conditions)
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Resources & Capacity MEASURES OF QUALITY Implement policies to Reduced exposure of reduce exposure of children children to secondhand to secondhand smoke smoke FIGURE 3-5 Applying the logic model to the LHI topic Maternal, Infant, and Child Health.
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