Closing the Quality Gap:
A Critical Analysis of
Quality Improvement Strategies
Preface
The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based Practice Centers (EPCs), sponsors the development of evidence reports and technology assessments to assist public- and private-sector organizations in their efforts to improve the quality of health care in the United States. The reports and assessments provide organizations with comprehensive, science-based information on common, costly medical conditions and new health care technologies. The EPCs systematically review the relevant scientific literature on topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to developing their reports and assessments.
To bring the broadest range of experts into the development of evidence reports and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter into collaborations with other medical and research organizations. The EPCs work with these partner organizations to ensure that the evidence reports and technology assessments they produce will become building blocks for health care quality improvement projects throughout the Nation. The reports undergo peer review prior to their release.
AHRQ expects that the EPC evidence reports and technology assessments will inform individual health plans, providers, and purchasers as well as the health care system as a whole by providing important information to help improve health care quality.
Structured Abstract
Objective:
Hypertension affects more than 50 million people in the United States alone. Despite clear evidence regarding the beneficial effects of quality treatment for high blood pressure, many millions of diagnosed and undiagnosed hypertensives are not receiving the optimal standard of care. The difference in patient outcomes achieved with present hypertension treatment methods and those thought to be possible using best practice treatment methods is known as a quality gap, and such gaps are at least partly responsible for the loss of thousands of lives each year. This review was organized to bring a systematic assessment of different quality improvement (QI) strategies and their effects to the process of identifying and managing hypertension.Search Strategy and Inclusion Criteria: Investigators searched the MEDLINE® database, the Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) registry, article bibliographies, and relevant journals for experimental evaluations of QI interventions aimed at improving hypertension screening and management of non-pregnant adults with primary hypertension. The reviewers included randomized or quasi-randomized controlled trials, controlled before–after studies, and interrupted time series in which at least one reported outcome measure included changes in blood pressure, or provider or patient adherence to a recommended process of care.
Data Collection and Analysis: Relevant data were abstracted independently by two reviewers. Each QI intervention was classified into one or more of the following components: provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self-management, patient reminders, audit and feedback, organizational change, or financial incentives. Certain categories were further subdivided into major subtypes (e.g., professional meetings for provider education and disease management for organizational change). The researchers also evaluated the impact of clinical information systems as a mediator for interventions of all types. They compared the different QI strategies in terms of the median effects achieved for blood pressure control and for a generalized measure of provider or patient adherence.
Main Results: Sixty-three articles reporting a total of 82 comparisons met the inclusion criteria. Studies of hypertension identification were found to be too heterogeneous for quantitative analysis. The majority of screening studies were clinic-based (with a few offered at work sites), and the most common strategies involved patient and/or provider reminders. These generally showed positive results; several studies found that patients were more likely to know their blood pressure or attend clinic visits after receiving reminders. Across all studies with a variety of strategies, the median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 4.5 mmHg (interquartile range: 1.5, 11.0) and 2.1 mmHg (interquartile range: -0.2, 5.0), respectively. The median increase in the proportion of patients in the target SBP range and target DBP range was 16.2 percent (interquartile range: 10.3, 32.2), and 6.0 percent (interquartile range: 1.5, 17.5), respectively. Studies that focused on improving provider adherence showed a range of median reduction of 1.3 percent to a median improvement of 3.3 percent across all QI strategies. Overall, patient adherence showed a median improvement of 2.8 percent (interquartile range: 1.9, 3.0).
Conclusion: The findings of this review suggest that QI strategies appear, in general, to be associated with the improved identification and control of hypertension. It is not possible to
discern with complete confidence which specific QI strategies have the greatest effects, since most of the studies included more than one QI strategy. All of the assessed strategies may be beneficial under some circumstances, and in varying combinations. There may be other useful strategies that have not been studied in trials meeting the inclusion criteria for evidence-based review; it is not possible to draw conclusions about these strategies.
Summary
Introduction
In early 2003, the Institute of Medicine (IOM) released its report, Priority Areas for National Action: Transforming Health Care Quality. The report listed 20 clinical topics for which "best practices" were strongly supported by clinical evidence. The report—along with other literature—clearly documents the disappointingly low rates at which these practices have been implemented in the United States, at an annual cost of many thousands of lives.
To bring data to bear on the quality improvement opportunities articulated in the IOM’s 2003 report, the Agency for Healthcare Research and Quality (AHRQ) engaged the Stanford-UCSF Evidence-based Practice Center (EPC) to perform a critical analysis of the existing literature on quality improvement strategies for a selection of the 20 disease and practice priorities noted in the IOM Report. Rather than concentrating on the specific clinical practices that appear to improve health outcomes, the focus of this review is on translating research into practice—identifying those activities that increase the rate at which practices regarded as effective are applied to patient care in real world settings. In other words, the authors aim to narrow the "quality gap" that is in large part responsible for suboptimal health care practices and outcomes.
This report focuses on the clinical problem of hypertension. It, like the other reports in the series, aims to help readers assess whether the evidence suggests that a quality improvement strategy would work in their specific practice or with their specific patient population. The question of whether these may be crosscutting practices—that is, the manner in which those that have been studied for specific conditions such as hypertension might be applicable to others, such as asthma—remains to be seen. We will further address these practices in subsequent volumes, as we review the evidence for many of the other conditions highlighted in the 2003 IOM report.
We defined the quality gap as the difference between health care processes or outcomes observed in practice, and those potentially obtainable on the basis of current professional knowledge. We defined a quality improvement (QI) strategy as an intervention aimed at reducing the quality gap for a group of patients representative of those encountered in routine practice. Finally, a quality improvement target is an outcome, process, or structure that the QI strategy aims to influence, with the goal of reducing the quality gap. Examples of targets relevant to this volume include outcomes such as reductions in blood pressure, or processes such as improved provider adherence with medication choices in patients with hypertension. Nine types of QI strategies were considered; they are shown (with examples) in Table 1.
1
Table 1. Taxonomy of QI strategies with examples of substrategies QI strategy
Examples
Provider reminder systems
• Reminders in charts for providers
• Computer-based reminders for providers
• Computer-based decision support
Facilitated relay of clinical data to providers
• Transmission of clinical data from outpatient specialty clinic to primary care provider by means other than medical record, e.g., phone call or fax
Audit and feedback
• Feedback of performance to individual providers
• Quality indicators and reports
• National/state quality report cards
• Publicly released performance data
• Benchmarking – provision of outcomes data from top performers for comparison with provider’s own data
Provider education
• Workshops and conferences
• Educational outreach visits (e.g., academic detailing)
• Distribution of educational materials
Patient education
• Classes
• Parent and family education
• Patient pamphlets
• Intensive education strategies promoting self-management of chronic conditions
Promotion of self-management
• Materials and devices to promote self-management
Patient reminder systems
• Postcards or calls to patients
Organizational change
• Case Management, Disease Management
• Total Quality Management, Cycles of Quality Improvement
• Multidisciplinary teams
• Change from paper to computer-based records
• Increased staffing
• Skill mix changes
Financial incentives, regulation, and policy
Provider Directed:
• Financial incentives based on achievement of performance goals
• Alternative reimbursement systems (e.g., fee-for-service, capitated payments)
• Licensure requirements
Patient Directed:
• Co-payments for certain visit types
• Health insurance premiums, user fees
Health System Directed:
• Initiatives by accreditation bodies (e.g., residency work hour limits)
• Changes in reimbursement schemes (e.g., capitation, prospective payment, salaried providers)
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