Chartbook on Healthy Living

Acknowledgments

The National Healthcare Quality and Disparities Report (QDR) is the product of collaboration among agencies across the Department of Health and Human Services (HHS). Many individuals guided and contributed to this report. Without their magnanimous support, the report would not have been possible.

Specifically, we thank:

Primary AHRQ Staff: Richard Kronick, Jeff Brady, Amy Helwig, Ernest Moy, Karen Chaves, Sebastiana Gianci, Veronica Soileau, Vera Rosenthal, Elizabeth Bishop, Darryl Gray, Nancy Wilson, and Doreen Bonnett.

HHS Interagency Workgroup for the NHQR/NHDR: Girma Alemu (HRSA), Chisara N. Asomugha (CMS), Kirsten Beronio (ASPE), Nancy Breen (NCI), Miya Cain (ACF), Victoria Cargill (NIH), Steven Clauser (NCI), Wayne Duffus (CDC), Olinda Gonzalez (SAMHSA), Kirk Greenway (IHS), Chris Haffer (CMS-OMH) , Linda Harlan (NCI), Rebecca Hines (CDC-NCHS), Edwin Huff (CMS), Deloris Hunter (NIH), Sonja Hutchins (CDC), Ruth Katz (ASPE), Tanya Telfair LeBlanc (CDC), Shari Ling (CMS), Darlene Marcoe (ACF), Tracy Matthews (HRSA), Karen McDonnell (CMS), Curt Mueller (HRSA), Karen Nakano (CMS), Iran Naqvi (HRSA), Ann Page (ASPE), Kimberly Proctor (CMS-OMH), D.E.B. Potter (ASPE), Asel Ryskulova (CDC-NCHS), Adelle Simmons (ASPE), Alan Simon (CDC-NCHS), Marsha Smith (CMS), Caroline Taplin (ASPE), Emmanuel Taylor (NCI), Sayeedha Uddin (CDC-NCHS), Nadarajen Vydelingum (NIH), Chastity Walker (CDC), Barbara Wells (NHLBI), Valerie Welsh (OASH-OMH), and Tia Zeno (ASPE).

AHRQ QDR Team: Roxanne Andrews (CDOM), Barbara Barton (SSS), Doreen Bonnett (OCKT), Cecilia Casale (OEREP), Karen Chaves (CQuIPS), Frances Chevarley (CFACT), Beth Collins-Sharp (OEREP), Denise Dougherty (OEREP), Noel Eldridge (CQuIPS), Zhengyi Fang (SSS), Sebastiana Gianci (CQuIPS), Erin Grace (CQuIPS), Darryl Gray (CQuIPS), Kevin Heslin (CDOM), Anika Hines (Truven), Leif Karell (SSS), Anil Koninty (SSS), Eric Lui (CQuIPS), Atlang Mompe (SSS), Ernest Moy (CQuIPS), Janet Pagán-Sutton (SSS), Susan Raetzman (Truven), Vera Rosenthal (CQuIPS), Veronica Soileau (CQuIPS), Lily Trofimovich (SSS), Yi Wang (SSS), Nancy Wilson (CQuIPS), Sean Yin (SSS), and Chava Zibman (CFACT).

HHS Data Experts: Clarice Brown (CDC-NCHS), Anjani Chandra (CDC-NCHS), Laura Cheever (HRSA), Frances Chevarley (AHRQ), Robin Cohen (CDC-NCHS), Steven Cohen (AHRQ), Rupali Doshi (HRSA), Paul Eggers (NIH), John Fleishman (AHRQ), Elizabeth Goldstein (CMS), Beth Han (SAMHSA), Haylea Hannah (CDC), Kimberly Lochner (CMS), Marlene Matosky (HRSA), William Mosher (CDC-NCHS), Cynthia Ogden (CDC-NCHS), Robert Pratt (CDC), Asel Ryskulova (CDC-NCHS), Alek Sripipatana (HRSA), Alan Simon (CDC-NCHS), and Xiaohong (Julia) Zhu (HRSA).

Other Data Experts: Dana Auden (Oklahoma Foundation for Medical Quality [OFMQ]), Timothy Chrusciel (OFMQ), Mark Cohen (American College of Surgeons National Surgical Quality Improvement Program [ACS NSQUIP]), Sheila Eckenrode (MPSMS-Qualidigm), Beth Forrest (USRDS), Selena Gonzalez (CDC-HIV), David Grant (UCLA), Michael Halpern (American Cancer Society), Matthew Haskins (National Hospice and Palliative Care Organization), Clifford Ko (ACS NSQIP), Allen Ma (OFMQ), Richard Moser (NCI), Wato Nsa (OFMQ), Nicholas Okpokho (OFMQ), Robin Padilla (University of Michigan), Bryan Palis (American College of Surgeons, NCBD), Pennsylvania Patient Safety Authority, Royce Park (UCLA), William Ross (Fu Associates), Scott Stewart (OFMQ), VA National Center for Patient Safety, Yolanta Vucic (OFMQ), Reda Wilson (CDC-ONDIEH-NCCDPHP), Richard Wolitski (CDC-HIV), and Claudia Wright (OFMQ).

Other AHRQ Contributors: Cindy Brach, Monique Cohen, James Kirby, Biff LeVee, Iris Mabry-Hernandez, Edwin Lomotan, Gerri Michael-Dyer, Karen Migdail, Shyam Misra, Laura Nawrocki, Pamela Owens, Mamatha Pancholi, Larry Patton, Wendy Perry, Richard Ricciardi, Mary Rolston, and Randie Siegel.

Data Support Contractors: Booz Allen Hamilton, Fu Associates, Social & Scientific Systems, Truven Health Analytics, and Westat.

Healthy Living

Organization of the Chartbook on Healthy Living

• Part of a series related to the National Healthcare Quality and Disparities Report (QDR).
• Contents:
  • Overview of the QDR.
  • Overview of Healthy Living, one of the priorities of the National Quality Strategy.
  • Summary of trends and disparities in Healthy Living from the QDR.
  • Tracking of individual measures of Healthy Living:
    • Maternal and Child Health Care.
    • Lifestyle Modification.
    • Clinical Preventive Services.
    • Rehabilitation.
    • Supportive and Palliative Care.

National Healthcare Quality and Disparities Report

This Healthy Living chartbook is part of a family of documents and tools that support the National Healthcare Quality and Disparities Reports (QDR). The QDR includes annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). These reports provide a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial, ethnic, and socioeconomic groups.  The purpose of the reports is to assess the performance of our health system and to identify areas of strengths and weaknesses in the health care system along three main axes: access to health care, quality of health care, and priorities of the National Quality Strategy.

The reports are based on more than 250 measures of quality and disparities covering a broad array of health care services and settings.  Data are generally available through 2012, although rates of uninsurance have been tracked through the first half of 2014. The reports are produced with the help of an Interagency Work Group led by the Agency for Healthcare Research and Quality (AHRQ) and submitted on behalf of the Secretary of Health and Human Services (HHS).

Changes for 2014

Beginning with this 2014 report, findings on health care quality and health care disparities are integrated into a single document. This new National Healthcare Quality and Disparities Report highlights the importance of examining quality and disparities together to gain a complete picture of health care. This document is also shorter and focuses on summarizing information over the many measures that are tracked.

Key Findings of the 2014 QDR

The report demonstrates that the Nation has made clear progress in improving the health care delivery system to achieve the three aims of better care, smarter spending, and healthier people, but there is still more work to do, specifically to address disparities in care.

• Access improved.
  • After years without improvement, the rate of uninsurance among adults ages 18-64 decreased substantially during the first half of 2014.
  • Through 2012, improvement was observed across a broad spectrum of access measures among children.
• Quality improved for most NQS priorities.
  • Patient Safety improved, led by a 17% reduction in rates of hospital-acquired conditions between 2010 and 2013, with 1.3 million fewer harms to patients, an estimated 50,000 lives saved, and $12 billion in cost savings.
  • Person-Centered Care improved, with large gains in provider-patient communication.
  • Many Effective Treatment measures, including several measures of pneumonia care in hospitals publicly reported by the Centers for Medicare & Medicaid Services (CMS), achieved such high levels of performance that continued reporting is unnecessary.
  • Healthy Living improved, led by doubling of selected adolescent immunization rates from 2008 to 2012.
• Few disparities were eliminated.
  • People in poor households generally experienced less access and poorer quality.
  • Parallel gains in access and quality across groups led to persistence of most disparities.
  • At the same time, several racial and ethnic disparities in rates of childhood immunization and rates of adverse events associated with procedures were eliminated, showing that elimination is possible.
• Many challenges in improving quality and reducing disparities remain.
  • Performance on many measures of quality remains far from optimal. For example, only half of people with high blood pressure have it controlled. On average, across a broad range of measures, recommended care is delivered only 70% of the time.
  • As noted above, disparities in quality and outcomes by income and race and ethnicity are large and persistent, and were not, through 2012, improving substantially.
  • Some disparities related to hospice care and chronic disease management grew larger.
  • Data and measures need to be improved to provide more complete assessments of two NQS priorities, Care Coordination and Care Affordability, and of disparities among smaller groups, such as Native Hawaiians, people of multiple races, and people who are lesbian, gay, bisexual, or transgender.

2014 Chartbooks

The 2014 QDR is supported by a series of related chartbooks that:

• Present information on individual measures.
• Are updated annually.
• Are posted on the Web (https://archive.ahrq.gov/research/findings/nhqrdr/2014chartbooks/).

The order and topics of the chartbooks are:

• Access to care.
• Priorities of the National Quality Strategy.
• Access and quality of care for different priority populations.

The new QDR and supporting chartbooks are further integrated with the National Quality Strategy (NQS). The NQS has three overarching aims that build on the Institute for Healthcare Improvement's Triple Aim^® and that support HHS's delivery system reform initiatives to achieve better care, smarter spending, and healthier people through incentives, information, and the way care is delivered. These aims are used to guide and assess local, State, and national efforts to improve health and the quality of health care.

To advance these aims, the NQS focuses on six priorities that address the most common health concerns that Americans face. Quality measures tracked in the QDR have been reorganized around these priorities, and a chartbook will be released marking progress for each NQS priority. Healthy LIving is one of these NQS priorities and the topic of this chartbook.

Priority populations are noted in the legislation that requires AHRQ to report on health care disparities (42 U.S.C. 299a-1(a)(6)). These populations consist of groups with unique health care needs or issues that require special focus, such as racial and ethnic minorities, low-income populations, and people with special health care needs.

Chartbooks Organized Around Priorities of the National Quality Strategy

1. Making care safer by reducing harm caused in the delivery of care.
2. Ensuring that each person and family is engaged as partners in their care.
3. Promoting effective communication and coordination of care.
4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
5. Working with communities to promote wide use of best practices to enable healthy living.
6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Healthy Living is one of the six national priorities identified by the National Quality Strategy (http://www.ahrq.gov/workingforquality/index.html).

Go to: National Quality Strategy Priority in Action: Boston Children's Hospital Community Asthma Initiative.

National Quality Strategy Priority 5

The broad goal of promoting better health is one that is shared across the country, whether it is promoting healthy behaviors, such as being tobacco free, or fostering healthy environments that make it easier to exercise and get access to healthy food. Successful efforts to improve these health factors rely on deploying evidence-based interventions through strong partnerships between local health care providers, public health professionals, and individuals.

Chartbook on Healthy Living

• This chartbook includes:
  • Summary of trends across measures of Healthy Living from the QDR.
  • Figures illustrating select measures of Healthy Living.
• Introduction and Methods contains information about methods used in the chartbook.
• Appendixes include information about measures and data.
• A Data Query tool (http://nhqrnet.ahrq.gov/inhqrdr/data/query) provides access to all data tables.

Summary of Trends Across National Quality Strategy Priorities

Summary of trends: Number and percentage of all quality measures that are improving, not changing, or worsening through 2012, overall and by NQS priority

Key: n = number of measures.
Note: For the majority of measures, trend data are available from 2001-2002 to 2012. For each measure with at least four estimates over time, weighted log-linear regression is used to calculate average annual percentage change and to assess statistical significance.  Measures are aligned so that positive change indicates improved access to care.

• Improving = Rates of change are positive at 1% per year or greater and statistically significant.
• No Change = Rate of change is less than 1% per year or not statistically significant.
• Worsening = Rates of change are negative at -1% per year or greater and statistically significant.
• About half of Healthy Living measures improved compared with 60% of all quality measures.

Summary of Trends Across National Quality Strategy Priorities

Summary of trends: Average annual rates of change of quality of care measures through 2012, by National Quality Strategy priority

Key: n = number of measures.
Note: Large red diamonds indicate median values. For each measure with at least four estimates over time, weighted log-linear regression is used to calculate average annual percentage change.  Measures are aligned so that positive change indicates improved quality of care.

• Median change in quality was 1.1% per year among measures of Healthy Living.

Healthy Living Measures That Improved Quickly

• Four Healthy Living measures improved quickly, defined as an average annual rate of change greater than 10% per year:
  • Adolescents ages 16-17 years who received 1 or more doses of tetanus-diphtheria-acellular pertussis vaccine.
  • Adolescents ages 13-15 years who received 1 or more doses of tetanus-diphtheria-acellular pertussis vaccine.
  • Adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine.
  • Adolescents ages 13-15 years who received 1 or more doses of meningococcal conjugate vaccine.

Healthy Living Measures That Showed Worsening Quality

• Four Healthy Living measures showed worsening quality:
  • Maternal deaths per 100,000 live births.
  • Children ages 19-35 months who received 3 or more doses of Haemophilus influenzae type B vaccine.
  • Women ages 21-65 years who received a Pap smear in the last 3 years.
  • Women ages 50-74 years who received a mammogram in the last 2 years.

Healthy Living Measures With Elimination of Disparities

• Five Healthy Living measures showed elimination of disparities for different groups:
  • Children ages 19-35 months who received 1 or more doses of measles-mumps-rubella vaccine.
  • Adults age 65 years and over who received an influenza vaccination in the last 12 months.
  • Children ages 19-35 months who received 3 or more doses of hepatitis B vaccine.
  • Adults with obesity who ever received advice from a health professional about eating fewer high-fat foods.
  • Adolescent females ages 13-15 years who received 3 or more doses of human papillomavirus vaccine.

Healthy Living Measures With Widening of Disparities

• Two Healthy Living measures showed widening of Black-White disparities:
  • Adult current smokers with a checkup in the past year who received advice in the last 12 months to quit smoking.
  • Breast cancer diagnosed at advanced stage per 100,000 women age 40 years and over.

Measures of Healthy Living

• This chartbook tracks measures of Healthy Living through 2012 and 2013, overall and for populations defined by age, race, ethnicity, income, education, insurance, and number of chronic conditions.
• Measures of Healthy Living include:
  • Receipt of processes that reflect high-quality preventive and supportive care.
  • Outcomes related in part to receipt of high-quality preventive and supportive care.

Services That Promote Healthy Living

• Much valuable health care is delivered to prevent disease, disability, and discomfort rather than to treat specific clinical conditions.
• These services improve health and quality of life and are often better characterized by stage over a lifespan rather than by organ system.

Services Covered in This Chartbook

• This chartbook is organized around five types of health care services that support healthy living but typically cut across clinical conditions:
  • Maternal and Child Health Care.
  • Lifestyle Modification.
  • Clinical Preventive Services.
  • Functional Status Preservation and Rehabilitation.
  • Supportive and Palliative Care.

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