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Series Overview – Jun. 23, 2011

Closing the Quality Gap: Revisiting the State of the Science -- Series Overview

Background

In 2004, the Agency for Healthcare Research and Quality (AHRQ) launched a collection of evidence reports to bring data to bear on quality improvement opportunities identified by an Institute of Medicine study, Priority Areas for National Action: Transforming Health Care Quality.1 The 2004–2007 AHRQ collection—Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies—summarized the evidence on quality improvement strategies related to chronic conditions (diabetes, asthma, and hypertension), practice areas (prevention of health care–acquired infections and antibiotic prescribing behavior) and cross-cutting priorities (care coordination).2-8

A new series of reports, Closing the Quality Gap: Revisiting the State of the Science (hereafter, CQG series), continues the focus on improving the quality of health care through critical assessment of relevant evidence for selected settings, interventions, and clinical conditions. As before, this series aims to assemble the evidence about effective strategies to close the “quality gap”—the difference between what is expected to work well for patients based on known evidence and what actually happens in day-to-day clinical practice across populations of patients. For every patient who receives optimal care, the evidence suggests that on average another patient does not.9,10 This series not only expands the topic terrain beyond that covered in the initial collection but also marshals the knowledge of eight Evidence-based Practice Centers (EPCs), with the goal of applying and advancing the state of the science for improving the health care system for the benefit of all patients.

The table of contents is provided to facilitate navigation through the rest of the document.

Table of Contents

Topic Selection and Scope Development

Topics for the new CQG series, reflecting identified quality improvement issues, were solicited from the various portfolios at AHRQ. Among the topics that were nominated, the following considerations factored into selection for inclusion in the series: the ability to focus and clarify the topic area; the topic’s relevance to quality improvement and a systems approach; the extent to which it is amenable to systematic review; its low likelihood for duplication and/or overlap with other known or ongoing work; its relevance and potential impact in terms of improving care; and the fit of the set of topics as a whole as a reflection of AHRQ portfolios.

Eight topics comprise the new CQG series, which will apply the methodology and framework from the first series.

   

Eight EPCs will further develop these topics, prepare separate protocols for the evidence reviews, and then systematically review the literature—all these steps are consistent with the methodology outlined in the AHRQ Methods Guide for Effectiveness and Comparative Effectiveness Reviews.11 These evidence reviews will be developed under common principles reflected in the Key Questions (KQs) for the new CQG series and in the organizing framework outlined below. A subsequent summary report will be developed to highlight commonalities and challenges seen across the spectrum of evidence reports.

For both the previous and forthcoming CQG series, the reports target multiple audiences and associated uses. For example, policymakers may be interested in the research evidence in order to prioritize quality improvement strategies and choose how best to close the quality gaps within their purview. Research funders may be most interested in the gaps in the evidence base for quality improvement so that they can set funding priorities to fill these gaps. Administrators at the helm of health care–delivery organizations may have similar interests to policymakers in terms of identifying what works and what does not within a particular topic area. Meanwhile, clinicians and patients may find these reports useful as an introduction to the broad spectrum of approaches to improving quality of care and as a guide to those quality improvement activities that may fall within their control. All readers of these reports may expect a deeper understanding of the nature and extent of quality gaps, as well as the systemic changes necessary to close them.

Ultimately, the overarching hope for the new CQG series remains the same as that of the earlier collection: “. . . to become an essential source of accessible and critical analyses of the evidence supporting techniques for implementing state-of-the-art best practices (related to each topic), while stimulating ideas for ongoing quality improvement activity nationally, in individual health systems, and among individual caregivers” (p. 3).6 In addition, the new CQG series will culminate in a synthetic report on lessons learned that cut across the topics, with the goal of describing the state of the science of quality improvement and the implications for each of the targeted audiences.

 

Principles

The work of the Institute of Medicine National Priorities Committee that catalyzed the earlier CQG series included development of specific criteria to vet and ultimately report on topics where actionable improvement could be anticipated in the near future with evidence-backed action.1 Each EPC team will consider all scope options in light of specific prioritization criteria that were described by the earlier Institute of Medicine Committee and that have been extended based on additional considerations relevant to the current health care–delivery system:

  • Impact: What opportunities exist for a sizable improvement in health and well-being (the quality gap)? What are the economic implications?
  • Improvability: What strategies might be expected to reduce quality gaps and improve the value of care delivered?
  • Inclusivity: What is the relevance of the topic to patients, conditions, or settings that are underrepresented in research?

Adding to these considerations, the EPC teams will consider the “sweet spot” for their topic where an evidence review has a reasonable expectation of netting useful information for specified stakeholders who have the power to act upon the information gleaned in an effort to close the identified quality gap. With this aim in mind, they will also identify likely audiences for their topic report.

Key Questions for the CQG Series

Figure 1 summarizes the sequence of KQs for the series, which will provide guidance about the scope of the topic, the composition of the Technical Expert Panel, analysis, and reporting:

Key Question 1

What is the quality gap (or gaps) targeted by this review, and how might each gap be approached to lead to improvements?

Key Question 2

  1. Who are the likely stakeholders who could act upon the gap, and what evidence will they need?
  2. What are the likely level(s) for implementation of results from the topic report?

Consider macro-level (e.g., public policymaking, markets, or organizational policymaking) and micro-level (e.g., clinician, patient) audiences and their potential leverage in using the evidence.

Key Question 3

  1. From an initial exploration of the potential literature, what is the state of the science for the topic area and gap?
  2. What populations, interventions, comparators, outcomes, timing, and setting (“PICOTS”) are relevant to the topic?
  3. How has the topic been studied in terms of concepts (e.g., logic models, relevant theories), methods (e.g., primary data-collection and study designs available), and context sensitivity?

Figure 1: Analytic Sequence of Key Questions for the CQG Series for Topic Scope Development

This figure illustrates the flow and relationship of series key questions for scope development of each of the topics in the “Closing the Quality Gap” series. Starting with the boxes on the left is Key Question 1, The Quality Gap, which is addressed by three elements: (1) Information/Data, achieved through measuring, (2) Incentives, or influencing, and (3) Infrastructure & Processes for improving. Key Question 1 flows to Key Question 2, Target Audience(s) at two levels of implementation: Macro, which includes Policy/Market and Organization, and Micro, which includes the Clinician and the Patient. Key Question 2 flows into the final Key Question 3 at the right of the figure, titled Evidence Available. This is addressed by the State of the Science which incorporates Concepts, Content—including PICOTS, Methods, and Context-sensitivity.

Each topic for the new CQG series is broad and requires choices among numerous scope options. The purpose of the KQs for the series is to help each EPC develop a full range of possibilities and then select a reasonable set of KQs for a given topic. As specified in Figure 1, the theoretical ways to address a quality gap are built upon a quote by Victor Fuchs in which he conceptualizes the “3 I’s”: Real reform “. . . requires changes in the organization and delivery of care that provide physicians with the information, infrastructure, and incentives they need to improve quality and control costs”.12  These leverage points for improvement are applicable beyond the physician and include other clinicians, systems managers, and patients themselves. As a result, the following three general approaches are hypothesized to address quality gaps (KQ 1):

  • Measuring quality: gathering information/data on quality.
  • Influencing quality: creating incentives for better quality.
  • Improving quality: implementing changes to infrastructure, processes, and other elements of the health care–delivery system. (Often, interventions in this category are aimed at changing clinician or organizational behavior at a local level.)

For each topic, these approaches may be matched to the applicable target audience(s) (KQ 2) at the level(s) of implementation expected, as described in Figure 1. Further, the review of literature about each topic will build from the state of the science (KQ 3) available on the specific strategies to implement the general approach.

Organizing Framework for the Closing the Quality Gap Series

An overarching organizational framework (Figure 2) for all of the topics was developed to serve as a tool to specify all of the potentially relevant areas (the boxes in Figure 2) for a topic and then to assist in making decisions about a practical scope that will limit the number of areas covered. This framework is also intended to convey the relationships among the topics and to support drawing cross-cutting lessons for quality improvement science, which will be outlined in the summary report.

Figure 2: CQG Series Analytic Framework To Summarize Applicable Areas for Each Topic

This figure illustrates how the elements of scope for each topic relate to one another, and provides a common framework across all topic areas in the series. On the far left the first element asks if the “Topic emphasis [is to] close the quality gap?” This question is addressed by three elements: Information, Incentives, and Infrastructure/Delivery System. These three elements are directed at target audience(s). The target audiences can be at the macro level, which includes policy and delivery organization, or micro, which includes the clinician and the patient.

References

  1. Institute of Medicine Committee on Identifying Priority Areas for Quality Improvement. Adams K and Corrigan J, eds. Priority areas for national action: transforming health care quality. Washington, DC: National Academies Press; 2003.
  2. Bravata DM, Sundaram V, Lewis R, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 5—Asthma Care. Technical Review No. 9 (Prepared by Stanford University–UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality, January 2007. AHRQ Publication No. 04(07)-0051-5.
  3. McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7—Care Coordination. Technical Review No. 9 (Prepared by Stanford University–UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality, June 2007. AHRQ Publication No. 04(07)-0051-7.
  4. Ranji SR, Shetty K, Posley KA, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 6—Prevention of Healthcare-Associated Infections. Technical Review No. 9 (Prepared by Stanford University–UCSF Evidence-based Practice Center under Contract No. 290-02-0017). i Rockville, MD: Agency for Healthcare Research and Quality, January 2007. AHRQ Publication No. 04(07)-0051-6.
  5. Ranji SR, Steinman MA, Shojania KG, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 4—Antibiotic Prescribing Behavior. Technical Review No. 9 (Prepared by Stanford University–UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality, January 2006. AHRQ Publication No. 04(06)-0051-4.
  6. Shojania KG, McDonald KM, Wachter R, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 1—Series Overview and Methodology. Technical Review No. 9 (Prepared by Stanford University–UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality, August 2004. AHRQ Publication No. 04-0051-1.
  7. Shojania KG, Ranji SR, Shaw LK, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 2—Diabetes Mellitus Care. Technical Review 9. (Prepared by Stanford University–UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality, September 2004. AHRQ Publication No. 04-0051-2.
  8. Walsh J, McDonald KM, Shojania KG, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 3—Hypertension Care. Technical Review No. 9. (Prepared by Stanford University–UCSF Evidence-based Practice Center under Contract No. 290-02-0017). Rockville, MD: Agency for Healthcare Research and Quality, January 2005. AHRQ Publication No. 04-0051-3.
  9. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-45.
  10. Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med 2007;357:1515-23.
  11. Agency for Healthcare Research and Quality. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and Quality, March 2011. AHRQ Publication No. 10(11)-EHC063-EF. Chapters available at: www.effectivehealthcare.ahrq.gov/methodsguide.cfm.
  12. Fuchs VR. The proposed government health insurance company—no substitute for real reform. N Engl J Med 2009;360:2273-5.
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