Vermont Health Care Quality Dashboard: AHRQ State Snapshots, 2007

There is a plethora of health care quality information published and available on the internet.  The challenge is making sense of it.  For the past five years, the Agency for Healthcare Research and Quality (AHRQ) has published a National Healthcare Quality Report and National Healthcare Disparities Report. These reports measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care.  Because the data is national in scope, dense, and difficult to navigate, the report’s usefulness for guiding state health policy has been limited.  
 
In 2007, AHRQ developed a “State Snapshot” to help State policymakers better understand healthcare quality and disparities specific to their state.  The design is a “performance meter” which provides a quick, high-level overview of the healthcare quality in various settings and types of care.  Each performance meter is based on composite measures of quality which highlight a state’s strengths and weaknesses. 
 
General Findings
In the 2007 State Snapshot, Vermont excels on performance measures in Prevention, Ambulatory Care, Diabetes, Maternal and Child Health, and Respiratory Diseases.  Vermont has shown improvement in Home Health Care Measures.  Nursing home care measures are portrayed as a weaker performing area in Vermont.  However, further analysis is required to determine whether these measures are accurately indicating issues associated with the quality of care in nursing homes or whether characteristics of the patient population, such as severity of illness, contribute to the lower score.  
 
Recommendations
These construct and methodologies behind these performance measures should be examined in more depth to understand whether they truly characterize and summarize the health care delivery system in Vermont.  Over the next couple of years, VPQ will explore these measures further and conduct primary analyses using some of these data sources (Medicare claims for beneficiaries with chronic conditions, data assessing nursing home residents, and data assessing home health care. 
 
Health Care Quality Dashboard Outline [click on a section to jump ahead]

Dashboard dials depicting quality of care measures for Vermont [back to top]
The State Snapshot uses a “performance meter” which provides a quick, high-level view of the overall healthcare quality in various settings and associated with various types of care.  Each performance meter is based on composite measures of quality to highlight a state’s strengths and weaknesses, and for which further research and analysis may identify targeted opportunities for improvement.

For each meter shown, the solid arrow describes results for the most recent data year; the dashed arrow describes the baseline year.  Several data sources comprise these performance meters.  Thus, the most recent year of data available and the baseline year to which it is compared depend on the data source.   
 
Overall Health Care Quality
The overall health care quality in Vermont is rated as average compared to all the States.

 

Types of Care
Likewise, health care quality is rated as average for acute care measures and chronic care measures.  Though still rated as average, the chronic care measures appear to indicate slight improvement.  For preventive measures, Vermont has an above average or “strong” performance rating.
 

Settings of Care
Health care quality for hospital care measures is rated as average compared to all States, and Vermont has an above average or “strong” performance rating on ambulatory care measures. Health care quality for nursing home care measures has a below average or “weak” performance rating.  Health care quality for home health care measures had previously received a below average or “weak” performance rating and has improved to average compared to all States.

 

Care by Clinical Area
Health care quality for cancer measures and heart disease measures are rated as average compared to all States.  Diabetes measures, maternal and child health measures, and respiratory disease measures are described as clinical areas with above average or “strong” performance ratings.

 

About the data behind these summary measures
The AHRQ snapshot performance meters are composite or summary measures that focus on process, outcome, and contextual variables.  They were derived using a compilation of state and national data sources used in the National Healthcare Quality Report.[1]  To account for population characteristics, risk-adjustment techniques are used for many of the measures.  
 
Nursing Home Care Measures: Vermont, 2007 [back to top]
The State Snapshot uses a “performance meter” which provides a quick, high-level view of the overall healthcare quality in various settings and associated with types of care.  Each performance meter is based on composite measures of quality to highlight a state’s strengths and weaknesses, and for which further research and analysis may identify targeted opportunities for improvement.

The nursing home care measures assess the quality of care provided to residents of nursing homes and is the only set of measures in Vermont that has a below average or “weak” performance rating compared to all States.  There are 19 individual measures comprising the performance meter summarizing quality of care for residents in nursing homes.
 
Factors that may influence performance
Understanding the population upon which these measures are based is crucial when making comparisons and drawing conclusions.  Influential factors must be considered to ensure that differences observed in the data reflect actual performance differences, rather than differences in the population, such as age, gender, and severity of illness.  To account for population characteristics, risk-adjustment techniques are used.  It is also important to understand the context of the health care delivery system when looking at performance measures.  Examples of contextual factors include: smoking rates; underlying health of the population (such as rates of obesity and chronic illness); health care coverage (private insurances vs. Medicaid/Medicare); state specifications for Medicaid eligibility; socioeconomic status; and patient care-seeking patterns.  These types of factors can greatly influence performance measures but can be very difficult to include in risk-adjustment due to the limitations of many data sources.
 
Breakdown of this summary measure
Vermont’s performance score on the nursing home care measures was 34.2%; performance scores from the five highest performing states ranged from 65.8% to 69.4%.

Compared to all States, Vermont scored better than average on 2 (of 19) measures, average on 9 (of 19) measures, and below average on 8 (of 19) measures.  The eight measures for which Vermont’s performance is below average are provided in Table 1 below.

 

The nursing home care measure with the greatest disparity from the all-state average is the percentage of short-stay residents with delirium.  The rate in Vermont is 2.8 times higher than the all-state average.  The percentage of Vermont long-stay nursing home residents with pressure sores is 2.4 times higher than the average from all the states, and the percentage of long-stay residents who are more depressed or anxious is 2 times higher than the average of all states.

Contextual Information on Vermont Nursing Homes
There are currently 40 federally licensed nursing homes in Vermont ranging in size from 21 beds to 177 beds.  The majority of the nursing homes are for-profit organizations (73%).  Services provided (beyond basic nursing home services) vary.  Nine facilities have Certified Special Care Units providing specialized Alzheimer’s and/or Dementia care.[2]    
 
Most measures in the AHRQ Snapshots, including the nursing home care measures, exclude facilities that do not have more than 30 residents in the denominator.  Several Vermont nursing homes do not meet this criterion for several measures.  AHRQ’s nursing home care measures are risk-adjusted but there may be influential population characteristics which impact performance that are not currently accounted for in the risk-adjustment.  For example, Vermont Department of Disabilities, Aging, and Independent Living coordinate several programs that provide services and support for older Vermonters to remain as independent as possible and to be active and contributing members of their community.  Additionally, there are eleven not-for-profit Visiting Nurse Associations and home care agencies in Vermont that provide a range of services and specialized care in the home for individuals with acute and long-term illnesses.  
 
Thus, because of Vermont’s home-and-community-based services, nursing home residents may differ from the national profile.  Vermont nursing home residents tend to be older with 48.5% of residents aged 85 years and older versus 42.3% nationally.  Additionally, Vermont nursing home residents may be more severely impaired than nationally.  For example, Vermont nursing home residents are less likely to participate in their assessment (18% less likely to participate themselves and 34% less likely to have family participate).  Vermont nursing home residents are also more likely to be admitted directly from home after utilizing home health services (2.4 times) or from an assisted living/group home (1.8 times).  Residents in Vermont nursing homes are 67% more likely to have an assessment of “little or no activity”.  One possible explanation for these factors is that home-based and community-based supports and services effectively delay the need for admission to nursing homes.  
 
Because Vermont nursing home residents tend to be older and possibly more severely impaired than nationally, the AHRQ measures shown in Table 1 may be inflated and not representative of overall nursing home care in Vermont.
 
Data behind the nursing home measures
The nursing home care performance meter consists of 19 individual measures from The Centers for Medicare and Medicaid’s Nursing Home Minimum Data Set (MDS).  The data includes all residents in Medicare or Medicaid certified nursing and long-term care facilities.  The MDS is a standardized, primary screening and assessment tool of health status; it measures physical, medical, psychological, and social functioning of nursing home residents.  Baseline data for these measures is calendar year 2002 and most recent year for which data are available is calendar year 2006.  The 2008 National Healthcare Quality Report was recently published.  An updated 2008 State Snapshots report is expected later this summer.

Additionally, over the next couple of years, VPQ will both examine the 2008 State Snapshots and conduct primary analyses with the Nursing Home MDS data set that underlies these measures to better understand how these measures are influenced by contextual landscape of Vermont and identify areas for improving the quality of care.
 
Home Health Care Measures: Vermont, 2007 [back to top]
The State Snapshot uses a “performance meter” which provides a quick, high-level view of overall healthcare quality in various settings and associated with various types of care.  Each performance meter is based on composite measures of quality which highlight a state’s strengths and weaknesses, and for which further research and analysis may identify targeted opportunities for improvement.

The rating in Vermont for this quality metric for Home Health Care is average compared to all States, and has demonstrated improvement since 2005.  This set of measures on home health care is composed of 10 measures to assess the quality of care for recipients of specialized nursing care or therapy at home.
 
Factors that may influence performance
Understanding the population upon which these measures are based is crucial when making comparisons and drawing conclusions.  Influential factors must be considered to ensure that differences observed in the data reflect actual performance differences, rather than differences in the population, such as age, gender, and severity of illness.  To account for differences in population characteristics, risk-adjustment techniques are used.  
 
It is also important to also understand the context of the health care delivery system when looking at performance measures.  These types of factors can greatly influence performance measures but can be very difficult to include in risk-adjustment due to the limitations of many data sources.  Examples of these contextual factors include: smoking rates; underlying health of the population (such as rates of obesity and chronic illness); health care coverage (private insurances vs. Medicaid/Medicare); socioeconomic status; and patient care-seeking patterns.  
      
Breakdown of this summary measure
Vermont’s performance score on the home health care measures was 50%; performance scores from the five highest performing states ranged from 80% to 95%.  
 
Compared to all states, Vermont scored better than average on 1 (of 10) measures, average on 8 (of 10) measures, and below average on 1 (of 10) measures.  Within Vermont, from 2005 to 2006, there has been improvement on 7 of the measures. 
 


Contextual Information on Home Health Care in Vermont
There are 11 not-for-profit home health agencies in Vermont.[3]  Home health provides skilled nursing services, individualized specialty care, and assistance with personal care and activities of daily living for people of all ages with acute and long term illnesses.
 
AHRQ’s home health care measures are risk-adjusted but there may be influential population characteristics or contextual factors which impact performance that is not currently accounted for in the risk-adjustment.  Examples of these characteristics include: 

Further analyses of these factors and the Medicaid’s Home Health Outcome and Assessment Information Set (OASIS) data are needed in order to fully understand the impact they may have on Vermont’s home health quality measures.
 
Data behind the home health measures
The home health care performance meter consists of 10 individual measures from The Centers for Medicare and Medicaid’s Home Health Outcome and Assessment Information Set (OASIS).  The data set contains elements that represent core items of a comprehensive assessment for an adult receiving specialized nursing care or therapy at home.  Baseline data for these measures is calendar year 2005 and most recent year for which data are available is calendar year 2006.  The 2008 National Healthcare Quality Report was recently published.  An updated 2008 State Snapshots report is expected later this summer.
 
Additionally, over the next couple of years, VPQ will both examine the 2008 State Snapshots and conduct primary analyses with the OASIS data set that underlies these measures to better understand how these measures are influenced by contextual landscape of Vermont and identify areas for improving the quality of care.

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