The County Health Rankings show us that where we live matters to our health. The health of a community depends on many different factors - ranging from health behaviors, education and jobs, to quality of health care, to the environment.

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Quality of Care

What Is It?

Quality of care is a broad term that has many definitions. A basic way of explaining quality health care is that it is the right care, for the right person, at the right time.[1] The Institute of Medicine (IOM) further defines the quality of health care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”[2] The IOM lists six characteristics of quality care: health care needs to be safe, timely, effective, efficient, equitable, and patient-centered.[3]

Why Do We Measure It?

The County Health Rankings reports quality of care for several important reasons. First, while there have been modest improvements in the overall quality of care provided in recent years, disparities remain for certain populations.[1] Sixty percent of disparities in health care quality have stayed the same or worsened for African-American, Asian, and low-income populations.[1] Second, a study from 2003 that looked at a large number of quality of care measures reported that patients receive the correct diagnosis and subsequent treatment only 55% of the time.[4] Third, health care quality can be affected by individual and community involvement. Patient empowerment and chronic disease management depend on collaboration between providers, insurers, and individuals.[1]
 

Measurement Strategies

There are hundreds of potential quality measures, with no consensus on the best set of measures to use when assessing quality of health care. However, certain guidelines should be applied when choosing measures. Quality indicators should ideally focus on measures that provide the greatest benefit to patient outcomes, help bridge the gaps seen among different populations, and can be implemented in a safe, efficient, and cost-effective way.[1]
 

What Is the County Health Rankings Measurement Strategy?

The County Health Rankings uses three separate measures to report health care quality for each county. The first measure is preventable hospitalizations, or the hospitalization rate for ambulatory-care sensitive conditions per 1,000 Medicare enrollees. Ambulatory-care sensitive conditions (ACSC) are usually addressed in an outpatient setting and do not normally require hospitalization if the condition is well-managed. The second measure, diabetic screening, records the percent of diabetic Medicare enrollees that receive HbA1c screening. Regular HbA1c screening among diabetic patients is considered the standard of care. It helps assess the management of diabetes over the long term by providing an estimate of how well a patient has managed his or her blood sugar over the past two to three months. When high blood sugar, or hyperglycemia, is addressed and controlled, complications from diabetes can be delayed or prevented.[5] The third measure, mammography screening, is the percent of female Medicare enrollees age 67-69 having at least one mammogram over a two-year period. Evidence suggests that screening reduces breast cancer mortality, especially among older women.[6-7] A physician’s recommendation or referral—and satisfaction with physicians—are major facilitating factors among women who obtain mammograms.[8-11] The data underlying all three measures comes from the Dartmouth Atlas, a project that documents variations in health care throughout the country through use of Medicare claims data. 
 

Measure Strengths & Limitations

A weakness of all three measures is that they use Medicare claims data, which limits the population evaluated to mostly individuals ages 65 and older. These measures, therefore, may potentially miss trends and disparities present among younger age groups.
 

Preventable Hospitalizations

This indicator is often used to assess the effectiveness and accessibility of primary health care.[12-14] A study using the National Hospital Discharge Survey found that 12% of all hospitalizations in 1990 (3.1 million) were for potentially preventable conditions.[15] Additionally, the same study found disparities regarding which populations were hospitalized for these conditions. Rates of hospitalization were higher for individuals in middle and low income areas compared to high income areas, and hospitalization rates were higher for African Americans compared to whites.

This indicator is also useful for indirectly reporting the quality of primary health care in the county. Evidence shows that a higher density of primary care providers is associated with lower probability of hospitalization for ambulatory-care sensitive conditions.[12] Therefore, a community can improve its potentially preventable hospitalization rates through increasing access to high quality primary health care providers.

Two studies analyzing the association between self-reported accounts of individuals’ access to medical care with hospital admissions rates for ambulatory-care sensitive conditions (ACSC) found that individuals who reported poor access to medical care had higher hospitalization rates for ACSC.[16-17]

The literature surrounding use of Medicare claims as a representative sample for hospitalization among the larger population is inconclusive. One study that showed higher rates of hospitalization based on income level and racial group found that after age 65 these disparities cease to exist.[15] This is presumably because after age 65, every individual has some access to health care through Medicare. However, another study found that African Americans and Hispanics have a higher preventable hospitalization rate for all age groups in both genders.[18]

This measure could be classified as both a quality and an access measure, as some literature describes hospitalization rates for ambulatory-care sensitive conditions primarily as a proxy for access to primary health care.[19]

Diabetic Screening

Evidence suggests that improvements in quality of care can be seen through implementation of disease management programs that target multiple components of chronic diseases.[20] The use of HbA1c testing to measure glycated hemoglobin for long-term monitoring of diabetes is widely accepted as one component of a comprehensive disease management program.[21] HbA1c testing is recommended for all patients with diabetes as part of the initial assessment after a diabetes diagnosis, and then on a routine basis as a part of the patient’s comprehensive diabetes care plan.[22] Widespread acceptance of the HbA1c test as a standard component of competent diabetes care makes it an ideal indicator to estimate the quality of care provided.
 
A limitation to using this measure is patients must have access to the health care system to be tested and then accurately diagnosed with diabetes. The Centers for Disease Control and Prevention (CDC) estimated in 2007 that in the United States approximately 18 million people had diagnosed diabetes and approximately 6 million people had undiagnosed diabetes.[23] This means that a county could report a high percentage of HbA1c testing, but simultaneously could have a large undiagnosed diabetic population.

Mammography Sreening

Breast cancer is the second most common type of cancer among women in the United States and cost nearly $7 billion to treat in 2007.[24] The three most common forms of breast cancer screening include self breast exam, clinical breast exam, and mammogram. Mammograms, which use X-ray to identify breast cancer before a lump can be felt, afford greater treatment options, can reduce the risk of dying from breast cancer, and can reduce the cost of treatment.[25-26] An estimate based on the most rigorous randomized trials suggests that screening reduces breast cancer mortality by 15% [25] whereas other estimates suggest reductions of roughly 20-35%.[6]

For over a decade, the National Committee on Quality Assurance has used the rate of biennial mammograms to measure the performance of managed care plans.[26]  The United States Preventive Services Task Force, Veterans Administration National Center for Health Promotion and Disease Prevention, National Quality Forum, American Academy of Family Physicians, American College of Physicians, American College of Preventive Medicine, America’s Health Insurance Plans, and the Agency for Healthcare Research and Quality have all endorsed this guideline (for women age 40-69) as a performance measure.[27-28]

There is, however, debate around the effectiveness and cost/benefit of regular mammograms for women under 50, and whether screening for breast cancer ultimately does more harm than good.  Some researchers point out that while screening reduces breast cancer mortality by 15%, it also leads to 30% overdiagnosis and overtreatment.[25] This means that for every 2,000 women screened over a 10-year period, one death due to breast cancer will be prevented, 200 women will experience psychological distress because of false positive findings, and 10 healthy women—who would not have been diagnosed if they had not been screened—will be treated unnecessarily.[25]

That said, there is agreement that the sensitivity and specificity of mammograms are highest among older women, and the benefit-to-harm ratio of screening increases as women age because screening accuracy improves and prevalence of breast cancer increases.[6,25] Thus, the Rankings’ use of data on women age 67-69 avoids some of the debated issues su mmarized above.

References

[1] Clancy C. Measuring Health Care Quality [online tutorial]. http://www.kaiseredu.org/tutorials/quality/player.html. Menlo Park, CA: KaiserEDU, Henry J. Kaiser Family Foundation; 2008. Accessed December 17, 2009.
[2] Institute of Medicine. Medicare: A Strategy for Quality Assurance, Volume I. Washington, DC: The National Academy Press; 1990.
[3] Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
[4] McGlynn EA, Asch SM, Kerr EA. Quality of health care delivered to adults in the United States - Reply. N Engl J Med. 2003;349:1867-1868.
[5] Aubert R, Herman WH, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: A randomized, controlled trial. Ann Intern Med. 1998;129:605-612.
[6] Elmore, J. G., Armstrong, K., Lehman, C. D., Fletcher, S. W. Screening for breast cancer. JAMA. 2005;293(10):1245-1256)
[7] Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ernster VL. Efficacy of screening mammography. A meta-analysis. JAMA. 1995;273(2):149–54
[8] Rimer, B.K., Trock, B., and Engstrom, P.F.: Why Do Some Women Get Regular Mammograms? American Journal of Preventive Medicine. 1991;7(2):69-74, as cited in Barr, J .K., Reisine, S., Want, Y., Holmboe, E. F., Cohen, K. L., Van Hoof, T. J., Meehan, T. P. Health Care Financing Review. 2001;22(4):49-61.
[9] Lerman, C., Rimer, B., Trock, B., et al.: Factors Associated with Repeat Adherence to Breast Cancer Screening. Preventive Medicine. 1990;19(3):279-290, as cited in Barr, J .K., Reisine, S., Want, Y., Holmboe, E. F., Cohen, K. L., Van Hoof, T. J., Meehan, T. P. Health Care Financing Review. 2001;22(4):49-61.
[10] Friedman, L.C., Woodruff, A., Lane, M., et al.: Breast Cancer Screening Behaviors and Intentions Among Asymptomatic Women 50 Years of Age and Older. American Journal of Preventive Medicine. 1995;11(4):218-223, as cited in Barr, J .K., Reisine, S., Want, Y., Holmboe, E. F., Cohen, K. L., Van Hoof, T. J., Meehan, T. P. Health Care Financing Review. 2001;22(4):49-61.
[11] Barr, J .K., Reisine, S., Want, Y., Holmboe, E. F., Cohen, K. L., Van Hoof, T. J., Meehan, T. P. Health Care Financing Review. 2001;22(4):49-61.
 [12] Basu J, Friedman B, Burstin H. Primary care, HMO enrollment, and hospitalization for ambulatory care sensitive conditions: A new approach. Med Care. 2002;40:1260-1269.
[13] Laditka JN, Laditka SB, Probst JC. More may be better: Evidence of a negative relationship between physician supply and hospitalization for ambulatory care sensitive conditions. Health Serv Res. 2005;40:1148-1166.
[14] National Quality Measures Clearinghouse. Ambulatory care sensitive conditions: Complete summary. National Quality Measures Clearinghouse, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Accessed January 27, 2010 from www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=9984. Updated January 25, 2010.
[15] Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially avoidable hospitalizations: Inequalities in rates between US socioeconomic groups. Am J Public Health. 1997;87:811-816.
[16] Ansari Z, Laditka JN, Laditka SB. Access to health care and hospitalization for ambulatory care sensitive conditions. Med Care Res Rev. 2006;63:719-741.
[17] Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274:305-311.
[18] Laditka JN, Laditka SB, Mastanduno MP. Hospital utilization for ambulatory care sensitive conditions: Health outcome disparities associated with race and ethnicity. Soc Sci Med. 2003;57:1429-1441.
[19] Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55:993-1000.
[20] Villagra VG, Ahmed T. Effectiveness of a disease management program for patients with diabetes. Health Aff. 2004;23:255-266
[21] Arsie MP, Marchioro L, Lapolla A, et al. Evaluation of diagnostic reliability of DCA 2000 for rapid and simple monitoring of HbA1c. Acta Diabetol. 2000;37:1-7.
[22] Goldstein D, Little RR, Lorenz R, et al. Tests of glycemia in diabetes. Diabetes Care 2004;27:1761-1773.
[23] Centers for Disease Control and Prevention. National diabetes fact sheet: General information and national estimates on diabetes in the United States, 2007. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention; 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed January 12, 2010.
[24] Center for Disease Control, U.S. Department of Health and Human Services. Preventing Chronic Diseases: Investing Wisely in Health—Screening to Prevent Cancer Deaths. 2008; http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/cancer.pdf
[25] Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2009,Issue 4. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub3
[26] National Committee for Quality Assurance. The State of Health Care Quality 2009: Value, Variation, and Vulnerable Populations. Washington, DC; 2009.
 [27] National Quality Measures Clearinghouse. Breast cancer screening: Percentage of women 40 to 69 years of age who had one or more mammograms during the measurement year or the year prior to the measurement year. National Quality Measures Clearinghouse, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2009.  Accessed October 28, 2010, from http://www.qualitymeasures.ahrq.gov/content.aspx?id=14931&search=breast+cancer+screening%3a.
[28] The Ambulatory Care Quality Alliance Recommended Starter Set: Clinical Performance Measures for Ambulatory Care. Agency for Healthcare Research and Quality, Rockville, MD; 2005 http://www.ahrq.gov/qual/aqastart.htm