e State's position among other States mean?
- What goals should be set for quality improvement?
While all the questions that a quality improvement committee might raise will not be answerable from data in the NHQR, it is a valuable source for identifying readily available and consensus-based measures for locating national averages, for deriving other benchmarks, and for selecting achievable targets for improvement. This module shows how to do these things from a State viewpoint. Module 2 presented a minimum set of measures from the NHQR that can be used for assessing diabetes quality within the State. Module 3 uses that measure set to describe two steps:
Step 1: Identifying appropriate metrics and comparisons
Step 2: Interpreting the State's position among other States
While the specific questions that State leaders ask about the quality of health care in the State will determine the comparisons to be made, below is a general guide to thinking about and using the data in the NHQR to create information for State quality improvement programs.
Step 1: Identifying Appropriate Metrics and Comparisons
Benchmark Metrics for States
The NHQR provides a national set of estimates and some State estimates that can be used as benchmarks for quality improvement. A benchmark is an external marker for assessing how one entity, for example a State, compares. The benchmark can represent the best performer or the average performer. How the State fares depends on what the benchmark is.
Several types of metrics or benchmarks can be used for assessing a State. From more to less stringent, they include:
- The theoretic limit of aiming for 100-percent achievement (or 0-percent occurrence for avoidable events), which is an ideal but often impractical goal.
- A best-in-class estimate of the top State or top tier of States (the top 10 percent of States is used in this Resource Guide), which shows what has been achieved.
- A national consensus-based goal, such as Healthy People 2010, set by a consensus of experts; such goals may be set more or less stringently than other benchmarks.
- A national average over all States, which shows the norm of practice nationwide but, being an average estimate, will represent a weaker goal than the best-in-class estimate.
- A regional average, which a State can use to compare itself to other States that are more likely to face similar environments, but as a goal it will be less aggressive than the best-in-class goal.
- An individual State rate, which itself can be used as a baseline against which to evaluate State-level interventions and progress over time within the State or to offer as a norm for local provider comparisons.
Most of these benchmarks can be found in or derived from the NHQR. The best-in-class estimate is not reported in the NHQR, nor is the regional norm based on BRFSS data. Both, however, can be derived from data in the NHQR. Detail on how the best-in-class estimate and other benchmarks are derived is given in Appendix D.
These benchmarks for each of the diabetes care-related measures in the NHQR are reported in Table D.1 in Appendix D. These benchmarks for four measures—HbA1c test, eye exam, foot exam, and flu vaccinations—are graphically displayed in Figure 3.1.
For HbA1c testing, for example, Figure 3.1 shows a range of benchmark values. Though the theoretic limit may be difficult to achieve for many valid reasons, the best-in-class estimate has been achieved by some States. The national average is often used to assess a State's performance. However, Figure 3.1 makes it clear that the national average is not a very difficult level to achieve; about half of the States are above and about half are below that average. The same is true for regional estimates that take into account the practice patterns in different regions of the country.
For the eye and foot exam process measures in Figure 3.1, the best-in-class average is above the national Healthy People 2010 goal, which itself still exceeded the national average in 2001. The influenza vaccinations for adults with diabetes have the lowest rates 