A Publication of the
Jacobs Institute of Women's Health
Volume 8, Number 3, October 2000
Understanding and Using Quality Measures
With consumers demanding more health care information, employers clamoring for ways to track services and costs, and policy makers and advocates seeking accountability from health care providers, the need for quality assessment techniques continues to increase. As Jacobs Institute Director Martha Romans put it, "Most Americans get health care through some kind of managed care system, and the importance of assessing quality has never been greater."
At the Jacobs Institute breakfast seminar "Women's Health Quality Measures for Managed Care: What Do They Tell Us, and Do Employers Listen?" in Washington, DC, in June, Carol S. Weisman, PhD, and Jon Gabel addressed some of the many questions quality measurement raises.
Dr. Weisman, professor at the University of Michigan School of Public Health, described the need for quality measures and discussed steps taken to include more and better measures of women's health in the National Committee for Quality Assurance's (NCQA's) Health Plan Employer Data and Information Set (HEDIS). According to the NCQA, about 90% of the nation's managed care organizations use HEDIS to measure performance, making it the "gold standard" for health data collection.
Consumers need information on quality to make informed decisions about health care, health plans need it to set benchmarks for improving care, and researchers need it to identify model plans and programs, said Dr. Weisman. While some claim the information available is underused, Dr. Weisman argues, "There is evidence women do care about the quality of their health care, [but] available quality indicators are limited in scope and focus on reproductive health issues."
Further, "Most available measures focus on screening and not on treatment, providers, information and counseling, follow-up services, or outcomes," said Dr. Weisman. Efforts to broaden the scope of data collected got a boost recently when Dr. Weisman and William Andrews, MD (both members of the Jacobs Institute Board of Governors), as cochairs of the NCQA's Women's Health Measures Advisory Panel, led the development of a HEDIS measure to evaluate menopause counseling and another looking at screening for chlamydia in young women. The panel has also recommended measures on screening for osteoporosis in older women who have had bone fractures, prevention of unintended pregnancy, and improved evaluation measures for prenatal care.
The usefulness of current quality measures is also diminished because measures related to conditions such as heart disease that affect both men and women are not routinely analyzed or reported by gender, so clinicians and consumers alike may miss important gender distinctions. Dr. Weisman noted the Jacobs Institute and the University of Michigan (with funding from the Agency for Healthcare Research and Quality) have embarked on the first effort to analyze consumers' satisfaction with their health plans by gender using data from the Consumer Assessment of Health Plans (CAHPS). Preliminary results from the evaluation of 97,000 adults in 206 health plans suggest women are slightly less satisfied than men with the quality of their health care. The data "suggest small but consistent differences across plans that lead women to rate them lower," said Dr. Weisman.
Dr. Weisman concluded that while she is "a cheerleader for the process, I also recognize we have a long way to go" toward developing appropriate indicators of quality, getting useful quality information out to consumers, and providing evidence on model programs in women's health care.
Jon Gabel, vice president of health systems studies for the American Hospital Association/Health Research and Educational Trust, said his organization surveys employers annually about their perceptions of NCQA accreditation, HEDIS data, and health plan quality in general. Mr. Gabel's data indicate employers do not select health care plans based on quality measures, and he sought to explain why.
Theoretically, access to a good quality health plan has a positive effect on employee morale, productivity, and retention. However, the average employee stays with an institution for only 34 years, so employers don't fully gain the long-term benefits of offering the best available health plans and have "limited loyalty to employees, even in high-paying, high-profile firms," said Mr. Gabel. Moreover, employers - like other consumers -"don't see the relationship between the health plan and quality measures. They don't think of the plan as a person who looks to see you get appropriate care from the appropriate person," said Mr. Gabel.
Both employers and individual consumers place less value on data such as how well a plan's doctors adhere to standard clinical guidelines than they do on personal recommendations from friends and information on access to physicians, waiting times, paperwork, etc. "The bottom line," said Mr. Gabel, "is that NCQA accreditation status and HEDIS data measures are not the meat and potatoes of the ordinary employer."
On a positive note, Mr. Gabel said NCQA-accredited plans tend to be slightly less expensive than other plans, probably because NCQA-accredited plans also tend to be larger and have more purchasing power.
Dorothy Tucker, an NCQA staff member attending the seminar, pointed out that newer measures added to HEDIS, such as the menopause counseling measure, reflected a new wave of consumer interest, expectations, and empowerment. The organization has focused on developing a more "sophisticated" set of measures it hopes will better inform employers and employees selecting health plans, said Ms. Tucker.
In response to issues raised by other audience members, both Dr. Weisman and Mr. Gabel called for more consumer education about quality measurement. Dr. Weisman hopes individuals will understand the increasing importance of surveys to gather data and be willing to take part in them. Mr. Gabel emphasized many consumers equate "quality" with logistic issues such as the number of doctors in a plan, while researchers strive to evaluate more concrete performance measures.NIH's Pinn Receives Mahoney Outstanding Service Award
Vivian W. Pinn, MD, director of the Office of Research on Women's Health at the National Institutes of Health, received the Margaret E. Mahoney Award for Outstanding Service September 21 for her work in advancing the quality of health care for women everywhere.
Edward N. Brandt, MD, former assistant secretary of health of the U.S. Department of Health and Human Services and senior program advisor to The Commonwealth Fund, presented the award to Dr. Pinn at a dinner during the Margaret E. Mahoney Symposium on Quality Health Care for Women in the United States and the United Kingdom. For 2000, The Commonwealth Fund and the Jacobs Institute combined The Commonwealth Fund's annual Mahoney Symposium with the two organizations' second annual joint conference on women's health.
Since her appointment in 1991, Dr. Pinn has led the Office of Research on Women's Health to achieve its ambitious mandate to broaden and strengthen research in the area of women's health. Dr. Pinn has established policies aimed at eliminating gaps in knowledge resulting from women's exclusion from many medical research studies.
Established in 1994, the Margaret E. Mahoney Award bears the name of a leader in the field of health care philanthropy. Each year, the award recognizes an individual whose work has fostered the field of health policy and health services and contributed to a better understanding of the complex issues involved.
U.S. and U.K. health care leaders took part in the two-day symposium in Washington, DC. Through a series of panel discussions, the group tackled the issues of establishing quality measurements for women's primary health care, empowering patients to make informed health decisions, improving health care access for minority women, and increasing efforts to identify and prevent domestic violence. The proceedings of the symposium will be published in Women's Health Issues in early 2001.
October 26-27, Annual Update on Women's Health Research, tenth annual Scientific Advisory Meeting of the Society for Women's Health Research, Washington, DC, will focus on recent research on sex differences in drug use and abuse, sexually transmitted infections, and pain. For more information, visit the group's web site at www.womens-health.org or e-mail [email protected]November 10, "Smoke Gets in Your Eyes, Heart, Ovaries - A Symposium on Tobacco and Women's Health," the annual symposium of the Women's Health Research Group, Baltimore, MD, includes Maryland State Senator Barbara Hoffman, and Dr. Michele Bloch of the National Cancer Institute's Tobacco Control Research Branch, among other speakers. For more information, call 410-706-2866 or visit http://medschool.umaryland.edu/womenshealth.
November 12 - 16, Eliminating Health Disparities, American Public Health Association Annual Meeting, Boston, MA, features Scott Harshbarger, President, CEO, Common Cause, as guest speaker. For more information, call 202-777-2742 or visit the group's web site at www.apha.org.Making the Grade on Women's Health: A National and State-by-State Report Card, from the National Women's Law Center (www.nwlc.org), FOCUS on Health and Leadership for Women (http://cceb.med.upenn.edu/focus), and The Lewin Group (www.lewin.com), can be obtained through any of those organizations' web sites or ordered by phone (NWLC: 202-588-5180; FOCUS: 215-573-8897; Lewin Group: 415-538-2800).
Who? What? Where? Resources for Women's Health and Aging, from the Alliance for Aging Research and the National Institution on Aging (supported by a grant from the Lilly Centre for Womens Health, Eli Lilly and Company), includes brief, patient-oriented overviews of common concerns for women about aging paired with contact information for appropriate nonprofit, government, and other organizations. Topics range from skin changes to cancer to widowhood. For a free copy, call the Alliance at 202-293-2856 or write them at 2021 K Street, NW, Suite 305, Washington, DC 20006.
Health Issues Specific to Incarcerated Women and The Health of Homeless Women, two new research briefs from the Women's and Children's Health Policy Center, can be downloaded from the organization's web site at www.med.jhu.edu/wchpc/pub/pubs.html or purchased by calling the National Maternal and Child Health Clearinghouse at 888-434-4624. Both publications describe the characteristics of these specific populations and potential roles for state and community public health programs in addressing their health needs.
For a free sample copy of the new Journal of Immigrant & Refugee Services, e-mail [email protected] or write to The Haworth Press, Inc., Sample Copy Department - Box Comp, 10 Alice Street, Binghamton, NY 13904-1580.
We are currently accepting applications for the 2001 Jacobs Institute/Ortho-McNeil Pharmaceutical Scholar award. Research that considers the changing health care environment, the unmet need for primary and preventive health services, the historic lack of research on women's health, and the importance of social, cultural, legal, economic, and behavioral factors influencing the financing and delivery of health care to women is eligible. The award is a one-year, $30,000 grant. The application deadline is October 15, 2000. For more information, please contact the Jacobs Institute at 202-863-4990 or click here.Jacobs Institute Partners with AHRQ on Women and Heart Disease
The Agency for Healthcare Research and Quality (AHRQ) and the Jacobs Institute of Women's Health recently established a public-private sector steering committee to study the prevention, diagnosis, and treatment of heart disease in women. The steering committee met June 21 at AHRQ headquarters in Rockville, MD, with the goals of identifying the state of the art and current trends in research, public education, and clinical practice, as well as setting an agenda for further work.
The committee concluded that poor implementation of existing clinical guidelines for risk management, diagnosis, and treatment of cardiovascular disease is part of the problem. Both women and their physicians often fail to recognize the prevalence and seriousness of cardiovascular disease in women. The committee recommended the following measures be taken to improve the cardiovascular health of women:
To further these goals, the committee asked AHRQ to commission an evidence report summarizing existing research on women and heart disease and identifying any areas in which clinical practices for men and women should differ. It also recommended AHRQ support research on compliance with guidelines in managed care settings and hold a research conference to determine why doctors' adherence to clinical guidelines is so poor for female patients. In addition, the group supported gender-stratified analysis of existing quality measures (such as those contained in the Health Plan Employer Data and Information Set [HEDIS]) that assess the care of women with heart disease.
Thanks to a grant from Wyeth-Ayerst, the Jacobs Institute mailed its Guidelines for Counseling Women on the Management of Menopause free of charge to over 185,000 health practitioners. The counseling guidelines are designed for use by health plans and clinicians in conjunction with the National Committee for Quality Assurances (NCQAs) HEDIS® Management of Menopause measure. Members of 14 major health and medical associations, including doctors, nurse practitioners, and nurse midwives, received the publication.
The 28-page publication includes a pocket guide with key suggestions for clinicians, common symptoms, risk factors, and interventions for coronary heart disease and osteoporosis. Single copies cost $7.50 plus shipping; Jacobs Institute members receive a 20% discount. To order, call 202-863-4990 or go to the order form.
The Jacobs Institute welcomes two new members to its Board of Governors: W. Allen Schaffer, MD, and Lynne S. Wilcox, MD, MPH. Dr. Schaffer currently serves as the chief medical officer and senior vice president of Medical Strategy and Health Policy for CIGNA HealthCare in Hartford, CT. He is also an assistant clinical professor at the University of Connecticut School of Medicine. Dr. Schaffer served on the Board of Directors for the National Committee on Quality Assurance (NCQA) from 1994 to 1995. He has cowritten several articles and other publications on such topics as quality measurement for health plans, medical advertising, and other health care policy issues.
Dr. Wilcox is a captain in the U.S. Public Health Service Commissioned Corps and director of the Division of Reproductive Health, National Center for Chronic Disease Prevention and Promotion, at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. In her current position at the CDC, she has testified before Congress on maternal health issues, served on the NCQA's Women's Health Measurement Advisory Panel, and acted as liaison to the Board of Directors of the Association of Maternal and Child Health Programs. She has traveled around the world representing the CDC on women's health issues and has cowritten numerous published works on a range of women's health considerations.
Domestic Violence Prevention Paper Wins Gibbs Award
The 2000 Charles E. Gibbs Leadership Award went to Ilene Hyman, PhD, and her coauthors for their paper, "Primary Prevention of Violence Against Women." Ms. Hyman and Sepali Guruge, MSc; Donna E. Stewart, MD, DPsych; and Farah Ahmad, MBBS, MPH, conducted a review of literature published on intervention programs to prevent violence against women. The programs included educational initiatives, attempts at early identification of abuse, efforts to empower women, providing resources for victims of abuse, and efforts to change laws related to violence against women.
The review identified promising interventions and made several policy recommendations to the Ontario Ministry of Health Women's Health Council, which commissioned the report. The recommendations ranged from general efforts to increase awareness of available resources and improve community involvement to specific suggestions for health practitioner education, routine screening, and safety. The article will be published in the November/December issue of Women's Health Issues, the journal of the Jacobs Institute. The $1,000 Leadership Prize has been awarded annually to the best submission on a given topic; for 2000, the topic was "Putting Prevention into Practice."
Beginning with articles published in the 2001 (volume 11) January/February issue of Women's Health Issues, the Gibbs Leadership Prize will go to the best manuscript published in the journal each year. The journal's Editorial Board will award the first Leadership Prize under this new arrangement in 2002. For more information, click here.
The Editorial Board also invites submissions for an upcoming theme issue on screening and treatment for mental health problems in pregnant women and nursing mothers. The deadline for submissions is March 30, 2001.
Generally, manuscripts should be 750-2000 words long with an abstract of fewer than 100 words. For complete author instructions, click here.How We Got Here
The third in a series on the people and events that shaped the Jacobs Institute's first 10 years.
From the beginning, Women's Health Issues (WHI), the journal of the Jacobs Institute of Women's Health, has emphasized the relationship between social and medical sciences as they pertain to women's health care. Its commitment to addressing issues of interest to "health professionals, social scientists, policy makers, and others concerned with the complex and diverse facets of health care delivery to women," as stated in its "Aims and Scope," distinguishes it from the many journals already in circulation.
First published in 1990, WHI was among the Jacobs Institute's earliest efforts, demonstrating the Institute's commitment to its goals and serving as a benefit to members and supporters. Since then, WHI has grown from a quarterly to a bimonthly publication and has given rise to several supplements, such as the Women's Health Data Book. The Institute has been sought out as a sponsor for important conferences because of WHI's ability to provide organized publication of the proceedings after the event.
Over the years, WHI has published research reports and conference presentations on ethics, managed care, adolescent health, exercise, domestic violence, and numerous other issues under the able editorial leadership of Warren H. Pearse, MD. Its editorial board has included Drs. Barbara Bartman, Chloe Bird, Robert Cefalo, Jennifer Downey, Rosanne Harrigan, Arden Larsen, Bert Peterson, Vicki Seltzer, and Nada Stotland, as well as Dr. Carol Weisman, who also currently serves as associate editor. Elsevier Science, Inc., publishes the journal, which is included in Index Medicus, among other international databases. It remains the only journal devoted to women's health issues at the medical/social interface.New Members
Welcome to the following new members of the Jacobs Institute, who joined between May 13 and August 18, 2000. For more information on membership, call the Jacobs Institute at 202-863-4990 or click here.
Peter C. C. Mann, MD