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2021 National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Dec.
The foundation of quality healthcare is doing the right thing at the right time in the right way for the right person and having the best results possible. Quality healthcare often means striking the right balance when providing healthcare services by avoiding overuse (e.g., unnecessary tests), underuse (e.g., missed blood pressure screening), or misuse (e.g., prescribing of drugs with harmful interactions). 1
The COVID-19 pandemic has affected almost all aspects of the way people live and work, especially with regard to healthcare and quality of healthcare people have received during the pandemic. More data are needed to fully understand how healthcare quality has been affected but one area with evidence of a decrease in quality of care is preventive healthcare. For instance, cancer screening is integral to cancer control and prevention. Due to the COVID-19 outbreak, many screenings have either been canceled or postponed, leaving a vast number of patients without access to recommended healthcare services. This disruption to cancer screening services may have a significant impact on patients, healthcare practitioners, and health systems. 2
The quality of healthcare can be measured, monitored, and improved over time. By specifying clearly, based on current science, which services should be provided to patients who have or are at risk for certain conditions and finding out whether those services are being correctly provided at the right time, we can track the performance of our medical care system. Experts in a field can propose a measure of performance, then test, adopt, and implement it.
Measures of healthcare quality tracked in the National Healthcare Quality and Disparities Report (NHQDR) encompass a broad array of services (prevention, acute treatment, and chronic disease management) and settings (doctors’ offices, emergency departments [EDs], dialysis centers, hospitals, nursing homes, hospices, and home health). Most NHQDR quality measures quantify processes that make up high-quality healthcare or outcomes related to receipt of high-quality healthcare. A few structural measures are included, such as the availability of health information technologies and workforce diversity.
Surveys of patients, patients’ families, caregivers, and providers; Administrative data from healthcare facilities; Abstracts of clinical charts; Registry data; and Vital statistics.Most data are reported annually and are generally available through 2016, 2017, or 2018.
As defined by the landmark Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century, “equity” in health caregiving is based on the idea that “all individuals rightly expect to be treated fairly by social institutions, including health care organizations.” In addition, applying an “equity” approach ensures that quality care is available to all and that the quality of care provided does not differ by race, ethnicity, or other personal characteristics unrelated to a patient’s reason for seeking care. 3
Due in part to unfair policies, practices, and conditions, the quality of healthcare has varied based on race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, and residence location. As specified in the Healthcare Research and Quality Act, this report focuses on disparities related to race, ethnicity, socioeconomic status, and geographic location. Through the examination of disparities in care, policymakers, researchers, providers, and public health practitioners can better understand the relationship between quality and equity in care.
Major updates made to three data sources since 2018—specifically the Medical Expenditure Panel Survey (MEPS), Healthcare Cost and Utilization Project (HCUP), and National Health Interview Survey (NHIS)—have had an outsized impact on the information available for presentation as part of the 2021 NHQDR. Trend data are currently not available for almost half of the core measures. Therefore, the 2021 NHQDR does not include a summary figure showing all trend measures or all changes in disparities. The report does include summary trend and change in disparities figures for some populations and results for individual measures.
The National Academy of Medicine, formerly Institute of Medicine (IOM), identifies patient centeredness as a core component of quality healthcare. 3 Patient centeredness is defined as:
[H]ealth care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care. 4
Patient centeredness “encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient.” Error! Bookmark not defined. In addition, translation and interpretation services, as well as auxiliary aids and services, facilitate communication between individuals and providers and are often a legal requirement. xii The patient- or person-centered approach includes viewing the individual as a unique person, rather than focusing strictly on the diagnosis or chronic condition, and building a therapeutic alliance based on the person’s and provider’s perspectives.
Person-centered care is supported by good communication between individuals and providers so that individuals’ needs and wants are understood and addressed and individuals understand and participate in their own care. This approach to care has been shown to improve health and healthcare. 5 , 6 , 7 , 8 Examples of person-centered care are ensuring that individuals’ feedback on their preferences, desired outcomes, and experiences of care is integrated into care delivery and enabling people to effectively manage their own care and services.
Language barriers. Racial and ethnic concordance between individuals and providers. Effects of disabilities on individuals’ healthcare experiences. Providers’ cultural competency. Accommodations for low health literacy.Person-centered decision making (when physicians consider the needs and circumstances of an individual) for planning an individual’s care has been shown to improve healthcare outcomes. 10
Person-centered approaches to care have been shown to improve individuals’ health status. These approaches rely on building a relationship between the individual and the provider, improving communication, fostering a positive atmosphere, and encouraging individuals to actively participate in interactions with their provider. 11
Person-centered care can reduce the chance of misdiagnosis due to poor communication. 12 A small but significant absolute risk reduction of mortality from coronary artery disease, Improved control of diabetes and hyperlipidemia, Better adherence to antihypertensive medication, Bereavement adjustment in caregivers of cancer patients, and Higher self-efficacy of adherence to HIV medications. 13Poor communication, lack of collaboration, and lack of support for self-care are associated with suffering and waste in healthcare. 14
Person-centeredness has been shown to reduce overuse of medical care. 15Improved communication methods can lower barriers to discussion about medication costs with individuals. 16
Improved communication between individuals and providers during medical decision making can reduce costs. 17
Data for these measures can be found at https://datatools.ahrq.gov/nhqdr.
Adults who reported that home health care providers talked about pain in the last 2 months of care.Family caregivers who received the right amount of emotional and spiritual support from the hospice care team.
Adult hospital patients who sometimes or never had good communication about medications they received in the hospital.
More than half of the Person-Centered Care measures showed significant improvement, with measures of communication between individuals and providers showing the greatest improvement.
More than 50 million adults in the United States have chronic daily pain. Best practices for pain management emphasize person-centered care in the diagnosis and treatment of pain. 18 However, individuals can be reluctant to discuss pain with their providers. 19 It is imperative for providers to openly discuss, actively monitor, and accurately assess pain with those in their care, as collaborative and effective interventions can improve individuals’ pain. 20 Pain assessment and pain management are also requirements for accrediting home health organizations. 21
Adults who reported that home health care providers talk ed about pain in the last 2 months of care, 2012–2019. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories are not (more. )
From 2012 to 2019, overall, the percentage of adults who reported that home health care providers talked about pain in the last 2 months of care increased from 87.5% to 90.0% (Figure 1).
The 2015 achievable benchmark was 91.3%. At the current rate of increase, overall, the benchmark could be achieved in 3 years.
The top 10% of states that contributed to the achievable benchmark were Alabama, Missouri, New Mexico, North Dakota, Oklahoma, West Virginia, and Wisconsin. One territory, Guam, was not included in the benchmark but was in the benchmark range.
Hospice care increasingly relies on unpaid caregivers in home and other community settings, a difficult role for people who may not be formally trained, as “responsibilities must be managed while simultaneously witnessing and coping with the impending death of a loved one.” 22 However, quality of care can decline as caregivers’ anxiety and depression increase. 23 Addressing the emotional and spiritual well-being of family caregivers is therefore an essential part of effective hospice care for both the caregiver and the patient.
Family caregivers who received the right amount of emotional and spiritual support from the hospice care team, 2015–2019. Note: The benchmark calculation takes the average of the top 10% of states with statistically reliable data. U.S. territories (more. )
From 2015 to 2019, overall, the percentage of family caregivers who received the right amount of emotional and spiritual support from the hospice care team increased from 88.8% to 90.0% (Figure 2).
The 2015 achievable benchmark was 90.9%. At the current rate of increase, overall, the benchmark could be achieved in 3 years.
The top 10% of states that contributed to the achievable benchmark were Arkansas, Idaho, Kentucky, North Carolina, and West Virginia.
Inpatients often receive medications during their hospital stay. For example, 80% of ED visits involve drug therapy. 24 Good communication between the individual and the healthcare provider decreases the risk of medication-related adverse events 25 and has also been shown to increase adherence to prescription medications. 26 , 27 Therefore, effectively discussing medications is a key component of communication between individuals and providers.
Adult hospital patients who sometimes or never had good communication about medications they received in the hospital, 2009–2019 (lower rates are better). Note: The benchmark calculation takes the average of the top 10% of states with statistically (more. )
From 2009 to 2019, overall, the percentage of adult hospital patients who sometimes or never had good communication about medications they received in the hospital decreased from 12.7% to 10.8% (Figure 3).
The 2015 achievable benchmark was 7.8%. At the current rate of increase, overall, the benchmark could not be achieved for 15 years.
The top 10% of states that contributed to the achievable benchmark were Alabama, Alaska, Colorado, Kansas, Mississippi, South Dakota, Utah, and Wyoming. One territory, the Virgin Islands, was not included in the benchmark but its percentage was in the benchmark range.
Through its Consumer Assessment of Healthcare Providers and Systems (CAHPS ® ) program, the Agency for Healthcare Research and Quality (AHRQ) has been dedicated to advancing scientific knowledge, measurement, and improvement of person-centered care since 1995. The CAHPS surveys assess healthcare quality by asking patients to report on
their experiences with care. Survey findings are used to monitor and drive improvements in experience with care and better inform consumers about healthcare providers in their area. Users of CAHPS surveys include the Centers for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance, Department of Veterans Affairs, and Department of Defense.
The HHS Office of Minority Health has developed Think Cultural Health, a website featuring information, resources, and continuing education opportunities related to culturally and linguistically appropriate services (CLAS) and the National CLAS Standards for healthcare professionals.
The HHS Office for Civil Rights (OCR) Medical School Curriculum Initiative educates future healthcare practitioners about OCR’s civil rights authorities to prevent and address racial and ethnic health disparities. Since 2009, OCR has presented the medical school curriculum to approximately 8,500 medical school, nursing, and allied health students, including professional school and undergraduate students. As part of this initiative, OCR takes part in the Association of American Medical Colleges’ Summer Health Professionals Education Program (SHPEP). Through the SHPEP, OCR has provided training to nearly 1,000 premedical and predental college students at a dozen universities every summer since 2014.
Currently, SHPEP trainings consist of two modules. The first module, launched in 2014, addresses compliance with Title VI of the Civil Rights Act of 1964, which prohibits recipients from discriminating on the basis of race, color, or national origin. It also covers Title IX of the Education Amendments of 1972 and Section 1557 of the Affordable Care Act (Section 1557), which prohibit harassment and discrimination on the basis of sex (including pregnancy, sexual orientation, and gender identity) in education and health programs or activities funded by HHS. In 2020, OCR added a second module on effective communication requirements for individuals who are deaf or hard of hearing, pursuant to Section 1557, Section 504 of the Rehabilitation Act of 1973, and the Americans With Disabilities Act.
The Administration for Community Living (ACL) and CMS administer the National Center on Advancing Person-Centered Practices and Systems (NCAPPS) to help states, tribes, and territories apply person-centered thinking, planning, and practice. NCAPPS provides technical assistance, learning collaboratives, public monthly webinars, and a resource clearinghouse dedicated to improving education about and implementation of person-centered principles.
The Veterans Health Administration (VHA) Office of Patient Centered Care & Cultural Transformation is transforming from the traditional model of healthcare to a personalized, proactive, patient-driven model through the Whole Health program.
An individual’s experience is also affected by health literacy levels. AHRQ has produced a toolkit called the SHARE approach, which involves a five-step process for shared decision making and tools to help individuals and providers ensure clear understanding and communication with one another.
Number and percentage of all person-centered care measures improving, not changing, or worsening from 2002 to 2019, by setting of care. Key: n = number of measures. Note: For each measure with at least four data points over time, the estimates are realigned (more. )
Core measures listed below are noted as improving (green) or not changing (yellow). More information on how this analysis is conducted is available in the NHQDR Introduction and Methods. More details about the measures shown here are available at the NHQDR website (https://datatools.ahrq.gov/nhqdr).
Hospital Measures. Among the core Person-Centered Care measures, only one speaks to inpatient quality of care. The inpatient quality of care measure improved.
Ambulatory Measures. Among eight measures related to ambulatory care, six were improving over time and two were not changing. These measures include experience of care measures that examine communication between individuals and providers over the course (more. )
Home Health Care Measures. Among nine home health care measures, four improved over time. Five measures showed no statistically significant change.
Hospice Care Measures. Among eight hospice care outcome measures, three improved over time. Five measures showed no statistically significant change.
The Institute of Medicine (IOM) xiv defines patient safety as “freedom from accidental injury due to medical care or medical errors.” 28 In 1999, the IOM published their landmark report, To Err Is Human: Building a Safer Health System, 28 which called for a national effort to reduce medical errors and improve patient safety. Since then, AHRQ has been the federal lead for patient safety research. xv
The IOM report was the impetus for the Patient Safety and Quality Improvement Act of 2005. The Act outlined a patient safety reporting system to provide anonymous and aggregated data about patient safety events, including the creation of AHRQ’s Network of Patient Safety Databases (NPSD) and certification of listed Patient Safety Organizations (PSOs).
In 2015, the National Academy of Medicine built on its initial report on patient safety by publishing Improving Diagnosis in Health Care, which identifies eight major goals for effecting progress on diagnostic error and improving patient safety outcomes. 12 Although improving diagnostic safety and quality was not fully addressed in To Err is Human, the patient safety field has now established consensus that more attention needs to be placed on reducing diagnostic error.
In 2020, AHRQ published an updated synthesis of the scientific evidence for various patient safety practices, Making Healthcare Safer III (https://www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html). This compendium summarizes the evidence for 47 different patient safety practices that address 17 different harm areas, such as healthcare-associated infections, medication management, and diagnostic safety.
More recently, AHRQ released Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine (https://pso.ahrq.gov/sites/default/files/wysiwyg/strategies-to-improve-patient-safety_draft-report.pdf) for public comments in December 2020. This draft report provides an overview of the Patient Safety and Quality Improvement Act of 2005, strategies for reducing medical errors and increasing patient safety, and recommendations for encouraging the use of patient safety strategies.
Reducing preventable hospital admissions and readmissions, Reducing the incidence of adverse healthcare-associated conditions (HACs), and Reducing harm from inappropriate or unnecessary care.To meet these goals, AHRQ supports research and quality improvement programs to reduce healthcare-associated infections (HAIs) and HACs, adverse drug events, and other preventable adverse events. In particular, a common cause of adverse events is gaps in communication either between providers or with patients, their family members, or caregivers.
Communication gaps may occur unintentionally and may result from implicit biases among healthcare providers. 29 Thus, researchers, providers, and policymakers are considering patient safety and person-centered care together to better understand breakdowns in care so that patients experience safer care and better health outcomes.
| Number of deaths in U.S. hospitals due to medical error each year (1999) | 44,000–98,000 28 |
| Age-standardized mortality rate due to adverse effects of medical treatment (2016) | 1.15 per 100,000 population 30 |
| Number of hospital-acquired conditions in U.S. hospitals (2017) | 2,550,000 31 |
| All-payer 30-day readmission rate (2016) | 13.9% of admissions 32 |
Additional hospital inpatient cost due to hospital-acquired conditions (2014) 30 :
| Central line-associated bloodstream infection (CLABSI) | $48,108 |
| Ventilator-associated pneumonia | $47,238 |
| Surgical site infection (SSI) | $28,219 |
| Venous thromboembolism | $17,367 |
