Joint Comments to AHRQ on the Preliminary Measure Set for the National Healthcare Disparities Report - Dec. 13, 2002

December 13, 2002 Helen Burstin, MD Director, Center for Primary Care Research Agency for Healthcare Research and Quality 2101 E. Jefferson St., Suite 501 Rockville, MD 20852 Re: AHQA, CHQ joint comments on the preliminary measure set for the National Healthcare Disparities Report. Dear Dr. Burstin: On behalf of the American Health Quality Association (AHQA), the membership organization of national network of Quality Improvement Organizations (QIOs), and the Center for Healthcare Quality (CHQ), CMS’ Quality Improvement Organization Support Contractor for Underserved Populations based in Memphis, Tennessee, thank you for the opportunity to provide comments on the preliminary measure set for the National Healthcare Disparities Report. We commend the Agency for Healthcare Research and Quality for defining a robust set of measures to monitor health care disparities in terms of access to care, utilization of services, cost of services, and quality. Scrutinizing disparities in health care treatment is imperative if the gap in care is to be eliminated, and the QIOs support the federal government’s efforts to eradicate health care disparities. We also applaud the interagency workgroup that selected the measures for including CMS measures used by QIOs under the Medicare Health Care Quality Improvement Program. For the last eight years, QIOs have used preventive services measures (addressing diabetes, mammography and immunizations) included in the NHDR preliminary measure set to conduct local projects that modified consumer and provider behavior and reduced healthcare disparities among African Americans, American Indians, Asian/Pacific Islanders, Hispanics and dual eligible, Medicare and Medicaid enrollees. Below are some successful examples of such QIO initiatives. FMQAI reduced the gap between older Caucasian and African Americans in HbA1c (long-term blood sugar level) testing needed for proper care of diabetes from 9.8% to 7.3% between July 1999-June 2001. FMQA analyzed claims data to determine disparities for quality indicators including annual HbA1c testing, biennial eye exams, and biennial lipid profiles for Medicare beneficiaries in each Florida zip code. FMQA then showed this data to hundreds of providers throughout the state. By attending community health fairs and training church leaders on how parishioners can recognize and manage the diabetes, FMQA also closed the gaps between African Americans and non-African Americans for biennial eye exams, from 7.9% to 5.5%, and for biennial lipid profiles, from 19.2% to 14.1%. Quality Insights of Delaware has raised mammography awareness through a coalition of African-American leaders called Mature African Americans for Mammography (MAAM). Working with MAAM, the QIO has invited community members to educational meetings and asked them to share information with family, friends, and others. The MAAM Coalition reached as many as 3,000 women, resulting in about 350 new mammography screenings. Quality Insights’ work has helped increase the number of Delaware’s African American women receiving mammograms from 40% to 45% between 1998-2000. While we commend the workgroup for including both the existing CMS preventive and inpatient care measures, we are concerned that the selected inpatient measures are not relevant to measuring health care disparities. We offer the following recommendations to deal with issues of concern: RECOMMENDATION #1: AHRQ should define a subset of inpatient measures that reflects healthcare disparities. QIO research and medical literature has identified that health care disparities are most prevalent among preventive services and care for chronic diseases—such as percentage of individuals that receive a mammography, immunizations, and screening for diabetes. In contrast, the inpatient quality of care measures selected by the workgroup for acute myocardial infarction, heart failure, and pneumonia reflect standard procedures of care in hospitals, which are delivered to all patients regardless of race or ethnicity. As QIOs have demonstrated in work with hospitals, the identified inpatient measures effectively ascertain the variation in care among hospitals. But these measures would fail to demonstrate meaningful differences in care provided to minority populations as compared to whites. In a soon to be released manuscript by CMS and CHQ, indicators for pneumonia, acute myocardial infarction, and congestive heart failure had small or non-existent differences in rates among various disadvantaged populations defined by race and ethnicity. In fact, the authors found that the administration of ACE Inhibitors among African Americans hospitalized with CHF actually was 1.9% greater than the rate of administration among all beneficiaries combined. On the contrary, authors identified significant disparities across virtually every minority population among the outpatient indicators of care selected by the workgroup—adult immunization, breast cancer screening, and diabetes management. It is critical to understand whether disadvantaged populations receive an equitable quality of care when compared to whites. However, it is unlikely the NHDR inpatient measures would provide indisputable evidence that such disparities exist. These results suggest that the list of NHDR measures should be further refined to reflect healthcare issues that define disparities among disadvantaged populations. RECOMMENDATION #2: AHRQ must develop a consistent means of aligning databases for use in the NHDR as the proposed data sources contain figures on populations with non-standardized definitions collected at varying time intervals. The data sources proposed by the workgroup use a variety of methods to collect and classify race and ethnicity. These differences will pose significant problems for the aggregated reporting of various health care disparities. Consensus does not exist regarding the appropriate classification scheme for race and ethnicity. Recently, the NQF recommended that federal policies should specifically promote the standardized classification and collection of race and ethnicity data in healthcare settings. This will continue to be a major challenge to effective disparities research and reporting and remains a priority for policymakers. Thank you for the opportunity to offer these comments. Direct questions to Dave Adler, AHQA Public Affairs Associate, 202-331-5790 or dadler@ahqa.org; or Dawn Fitzgerald, Center for Healthcare Quality Chief Operating Officer, 901-682-0381 or dfitzgerald@tnqio.sdps.org. Sincerely, David G. Schulke Executive Vice President American Health Quality Association Dawn Fitzgerald Chief Operating Officer, Programs Center for Healthcare Quality Medicare’s Quality Improvement Support Contractor for Underserved Populations