1. Hand, Mary M. MSPH, RN
  2. Chesley, Francis D. Jr MD
  3. Ho, Karen K. MHS
  4. Clancy, Carolyn M. MD

Article Content

THE 2005 National Healthcare Quality Report (NHQR)1 and National Healthcare Disparities Report (NHDR)2 from the Agency for Healthcare Research and Quality (AHRQ) present the third annual opportunity to measure healthcare quality in the United States and track changes over time. These congressionally mandated reports were first released in 2003 to provide annual data on the "vital signs" of the nation's healthcare quality and disparities. Nurses in a variety of professional settings can use the information in the reports to validate, modify, and design policy, clinical practice, and quality improvement initiatives in support of the progress and challenges highlighted in the reports.



The background, purpose, conceptual framework, design, and the scope of developing annual reports to the nation on trends in healthcare quality and disparities have been described previously.3 Briefly, the Healthcare Research and Quality Act of 1999 (Public Law 106-129) mandated that AHRQ, an agency of the Department of Health and Human Services (HHS), produce annual reports on healthcare quality and disparities in the United States.


The 2003 National Healthcare Quality and Disparities Reports, as the inaugural reports, established the framework for the subsequent annual reports. The 2003 NHQR is an overview of the quality of US healthcare. Its companion, the 2003 NHDR, shows gaps in both healthcare quality and access to healthcare based on racial, ethnic, and socioeconomic status for priority populations (racial and ethnic minorities, low-income groups, women, children, elderly, residents of rural areas, and individuals with special healthcare needs). Measures of healthcare access are unique to the NHDR report and encompass 2 dimensions of access-facilitators and barriers to care, and healthcare utilization. Both reports measure quality and disparities in 4 key areas of healthcare:


* Effectiveness,


* Patient safety,


* Timeliness, and


* Patient-centeredness.



The 2004 reports marked the first publication of data on the rate of healthcare quality improvement and disparities in healthcare for the entire nation, initiating an ongoing goal of the reports to track progress in improving healthcare quality and eliminating disparities.4



Building on previous reports, the 2005 NHQR employs new databases and measures to provide a more comprehensive assessment of healthcare quality. It includes 179 performance measures assembled across the 4 dimensions of quality mentioned above. This year's report begins annual tracking of 46 core report measures that were selected by an interagency HHS work group from the full NHQR measures set as representing the most important and scientifically sound measures of quality. Also included are 4 new composite measures that summarize data from a collection of individual measures. Composite measures were created for heart attack, heart failure, pneumonia, patient-centered care, and overall healthcare quality improvement.1


The 2005 NHQR report includes the following.


* Highlights: summarizing the main themes from the report.


* Data sources and methods.


* Healthcare effectiveness: examining the quality of healthcare in the general US population focusing on 9 clinical condition/care setting areas and representative core measures.


* Patient safety: tracking measures of patient safety, including hospital-acquired infections, injuries or adverse events due to medical care, and medication safety.


* Timeliness: examining the delivery of time-sensitive clinical care and patient perceptions of the timeliness and accessibility of their care.


* Patient-centeredness: tracking patients' experiences with care and their perspectives on it, for both routine and emergency services.


* Two online appendixes with data tables and measure specifications available at:




The NHDR is an overview of disparities in healthcare among racial, ethnic, and socioeconomic groups in the general US population and tracks progress in eliminating disparities. The 2005 NHDR for the first time presents data to track trends across the measure set and begins to examine whether the nation is making progress toward eliminating healthcare disparities.


The 2005 NHDR includes


* highlights: summarizing key themes from the 2005 report


* data sources and methods: including those used in the 2005 report and key changes from the previous report;


* disparities in quality of healthcare in the general US population: using the same measures as the NHQR and the 4 components of effectiveness, patient safety, timeliness, and patient-centeredness;


* disparities in access to healthcare in the general US population: covering barriers to and facilitators of healthcare and healthcare utilization;


* disparities in quality of, and access to, healthcare among AHRQ's priority populations; and


* 4 online appendixes available at:




Overall the 2005 National Healthcare Quality and Disparities Reports show that the quality of healthcare for Americans continues to improve at a modest pace, and healthcare disparities are narrowing overall for minorities. However, for Hispanics, disparities have widened in both quality of care and access to care.5


NHQR findings

The NHQR reports that overall quality of care in the United States improved at a rate of 2.8%, the same increase shown in the previous year's report.3 Of 44 core quality measures, 23 showed significant improvement, 2 showed worsening, and 19 were unchanged.1,6


The 2005 NHQR identifies 4 themes that are extensions of the 2003 and 2004 reports' themes, enhancing our understanding of the trends in healthcare quality:


* Healthcare quality continues to improve at a modest pace across most measures.


* Improvement is variable, with notable areas of high performance.


* Quality is improving, but more remains to be done to achieve optimal quality.


* Sustained rates of quality improvement are possible.1



Of the 4 dimensions of healthcare quality, patient safety and a subset of the effectiveness dimension related to several clinical conditions and care settings show the most improvement.1 In the area of patient safety, defined as freedom from accidental injury due to medical care or medical errors,7 5 core measures improved at an average rate of 10.2%. All but one of the core measures relate to inpatient hospital issues, including adverse events associated with central venous catheters, iatrogenic pneumothorax, and hospital-acquired septicemia in intensive care unit patients.1


The measures of clinical conditions, care settings, and populations with the most improvement overall were quality measures for diabetes, heart disease, respiratory conditions, nursing home care, and maternal and child healthcare, which showed an overall rate of change of 5.4%.1 Hospital treatment for the elderly, specifically in care for a heart attack and for pneumonia, together shows a combined rate of improvement that was almost 4 times the rate for all the other measures (9.2% vs 2.5%).1 Specifically in the area of heart attack care, inpatient mortality for elderly patients dropped by 30% between 1994 and 2002, owing to greater rates of treatment with evidence-based therapies such as [beta]-blockers, aspirin, and ACE inhibitors.6 Recommended care for patients with pneumonia improved significantly, reflecting timely and appropriate receipt of antibiotic therapy in the hospital as well as influenza and pneumonia vaccines. The overall pneumonia composite measure for provision of recommended care for Medicare patients with pneumonia improved significantly, from 54% of the time in 2002 to 59% in 2003. These areas with the greatest improvement in quality of care were ones in which there has been significant focus and coordinated efforts to deliver "best practice" treatments, such as through the work of the Centers for Medicare & Medicaid's 53 Quality Improvement Organizations. Some of the areas in which hospitals are now reporting publicly on their performance are areas with substantial improvements.1


While many measures show significant improvement, the nation is far from meeting the HHS Healthy People 2010 Objectives.8 For example, although the number of age-adjusted breast cancer deaths per 100,000 population decreased significantly from 26.6 in 1999 to 25.6 in 2002, the Healthy People 2010 target of 22.3 will not be met at the present rate. Also, while the proportion with hypertension under control increased significantly from 23% in 1988-1994 to 29% in 1999-2002, the Healthy People 2010 target of 50% will not be met for 20 years.


Many other measures are slow to change and present significant challenges to quality improvement. For example, the overall rate of late-stage breast cancer has not changed over the past 10 years, and over a third of smokers hospitalized with a heart attack report that their doctor did not advise them to quit smoking, a rate that has not changed over the last 3 years. While improvements in quality are encouraging in a number of areas, a sizable percentage of the measures (43%) showed no significant change.1


NHDR findings

The key findings of the 2005 NHDR are as follows:


* More racial disparities in quality of care were narrowing than were widening.


* Most racial disparities in access to care were narrowing (affecting blacks, Asians, and American Indians/Alaska Natives).


* Many of the largest disparities in measures of quality and access were observed for low-income people, regardless of race or ethnicity with some signs of improvement.


* However, for Hispanics, the majority of disparities for both quality and access were growing wider.5


Figures 1 and 2 summarize these trends in disparities and key findings.2

Figure 1 - Click to enlarge in new windowFigure 1. Quality measures for selected groups in comparison with reference group.
Figure 2 - Click to enlarge in new windowFigure 2. Access measures for selected groups in comparison with reference group.

Specific examples of areas reflecting these key findings, related to changes in disparities over time from the 2005 NHDR, include the following:


* Rates of late-stage breast cancer decreased more rapidly from 1992 to 2002 among black women (169 to 161 per 100,000 women) than among white women (152 to 151 per 100,000).


* Treatment of heart failure improved more rapidly from 2002 to 2003 among American Indian Medicare beneficiaries (69% to 74%) than among white Medicare beneficiaries (73% to 74%).


* Access to a usual source of care increased slightly from 1999 to 2003 for Hispanics (77% to 78%) and whites (88% to 90%), with Hispanics less likely to have access to a usual source of care.3



Despite the evidence of narrowing of disparities, there are still many opportunities for improvement. Table 1 presents an overview of disparities in quality that are getting worse rather than better. All the groups shown had at least 1 area in which they received worse care than whites and for which the difference was getting worse. Hispanics had many more measures that fell in this category than other groups. Some disparities in quality of care were unique to specific groups, such as higher rates of black children versus white children with admissions for asthma. Other disparities in quality of care were noteworthy for multiple groups, including vaccinations, services for persons with diabetes, smoking cessation, hospital treatment of heart attack, problems with timeliness, and problems with patient-provider communication.2

Table 1 - Click to enlarge in new windowTable 1. Measures that are

The 2005 NHDR also found that only Hispanics and the poor face worsening disparities in access to care. For the poor, disparities in 4 of the 6 core report measures of access were getting worse. For Hispanics, all disparities in access were getting worse except being uninsured all year.2



Promoting high-quality healthcare and eliminating healthcare disparities are fundamental to the nurse's role.9 Nurses often confront healthcare quality and disparity issues in the diverse settings and levels (eg, local, regional, state, and national) in which they practice. The NHQR and NHDR provide a focus and potential resource for improving healthcare quality and eliminating disparities wherever nurses work.


In describing the current status of healthcare nationally, nurses can find healthcare quality and disparities information for their clinical setting or population of interest. The reports are now able to provide trend data that can be tracked and used by practitioners and policymakers to drive quality improvement efforts for relevant clinical conditions and in patient care settings, especially in public health, home health, and long-term care.3 For example, in the hospital setting, nurses who have the opportunity to influence charting or health information technology documentation can help define areas for improvement and quality improvement projects. The data can be used for making more informed decisions about policies and processes of care within institutions, communities, and regions. Facilities and networks can compare their performance with their state and the nation, including areas where they excel and where improvement is warranted. Using the data in the 2005 NHDR, nurses can address disparities through community-based projects and use the NHDR findings as benchmarks against which to compare their progress as indicated by local data.3,4


State health departments can do regional and national comparisons, using the new State Snapshot Web tool, which was released in January 2006 and is based on the 2005 NHQR and NHDR. It provides quick and easy access to many measures and tables from each state's perspective and displays summary performance meters showing the level of the quality for different types of care (prevention, acute, and chronic) and settings of care (hospital, ambulatory, nursing home, and home health) for each state.


To help nurses operationalize the potential applications of the reports, AHRQ sponsors Quality Tools, a Web-based clearinghouse providing practical tools for assessing, measuring, promoting, and improving the quality of healthcare in the United States (see Information on nursing research at AHRQ can be found on the Nursing Research page, which can be accessed on the lower right side of the AHRQ Web site at:



The NHQR and NHDR provide relevant data for the nursing community to monitor healthcare delivery, track data, identify areas where improvement is most needed, and participate in state and local quality improvement efforts through AHRQ's online tools for states. Nurses are needed to participate in initiatives that can close quality and disparities gaps.




1. 2005 National Healthcare Quality Report. US Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md. AHRQ Publication No. 06-0018. December 2005. Available at: Accessed June 2, 2006. [Context Link]


2. 2005 National Healthcare Disparities Report. US Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Md. AHRQ Publication No. 06-0017. December 2005. Available at: Accessed June 2, 2006. [Context Link]


3. Poker A, Hubbard H, Collins Sharp BA. The first national reports on United States healthcare quality and disparities. J Nurs Care Qual. 2004;19:316-324. [Context Link]


4. Poker A, Farquhar M, Dayton E. Using the national healthcare quality and disparities reports for executive decision making. Nurse Leader. 2005:1-3. [Context Link]


5. AHRQ Releases 2005 National Healthcare Quality and Disparities Reports. Press Release January 9, 2006. Available at: Accessed August 17, 2006. [Context Link]


6. AHRQ Newscast Week of January 9, 2006. Available at: Accessed August 17, 2006. [Context Link]


7. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. [Context Link]


8. US Department of Health and Human Services. Healthy People 2010. Washington, DC: Government Printing Office; 2000. Available at: Accessed May 31, 2006. [Context Link]


9. Committee on the Work Environment for Nurses and Patient Safety Board on Health Care Services. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: Institute of Medicine of the National Academies, The National Academies Press; 2004. [Context Link]

Section Description


This commentary on patient safety in nursing practice comes from the Agency for Healthcare Research and Quality.