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AHRQ State Snapshots Audio Conference Transcript

Moderator:  Margie Shofer
April 28, 2008
1:00 PM ET

On April 28, 2008, Jeff Brady and Rosanna Coffey gave an audio conference presentation entitled 2007 State Snapshots: State-Based Information from the National Healthcare Quality Report. This is the transcript of the event's presentation. 

Operator: Good day, ladies and gentlemen, and welcome to the AHRQ State Snapshots audio conference. At this time, all participants are in a listen-only mode. Later, we will conduct a question-and-answer session and instructions will follow at that time. If anyone should require assistance during the conference, please press star, then zero on your touchtone telephone. As a reminder, this conference call is being recorded.

I would now like to introduce your host for today's conference, Ms. Margie Shofer, from the Agency for Healthcare Research and Quality. Please proceed.

Margie Shofer: Hello, everyone. I'm Margie Shofer in the Office of Communications and Knowledge Transfer at the Agency for Healthcare Research and Quality. We're delighted to be hosting this audio conference on the State Snapshots tool, and hope you find it useful.

This audio conference is the first of three featuring AHRQ tools shared at workshops we held this past December and January. We see these audio conferences as a first step in what we hope to be a series of follow-on technical assistance opportunities. So, if after hearing more about the snapshots today you're interested in further assistance from AHRQ and using them, please let us know.

So, today we will be showcasing the updated version of the AHRQ State Snapshots tool, which was released on March 26 of this year. The tool allows you to see how you compare to other states in the nation as a whole across many quality indicators. The latest version of this tool uses updated data, includes several new features which we will be sharing with you today.

We're hosting this audio conference in response to the interest in the State Snapshots tool expressed by the participants from both workshops. We know that some of you attended one of the workshops, whereas others may have had less time to interact with the tool. As such, we'll spend some time reviewing the basics of the tool, but then we'll jump into a discussion of some recent modifications to the tool, as well as some specific questions that surfaced during the workshop.

We would appreciate your active participation in this call, as the primary purpose is to address any questions you might about the tool, collect your suggestions for future tool enhancements or modifications, and learn how you envision using the tool and for what purposes.

And, again, related to this last point, we really hope you'll tell us more about the types of technical assistance that you might need in order to make full or better use of the State Snapshots tool. That's really a big aim of ours.

The presentation today will be given by Drs. Jeff Brady and Rosanna Coffey. Jeff Brady is the Acting Director of the U.S. National Healthcare Reports here at AHRQ. He is an M.D. with a background in primary care and also preventive medicine and public health, and he oversees the National Healthcare Quality and Disparities Reports and all derivative products, which include the State Snapshots.

Rosanna Coffey is Vice President of Thomson-Reuters Healthcare, formerly Thomson Healthcare, which was formerly MedStat. Rosanna and her team support the work of the National Healthcare Quality and Disparities Reports and have developed a number of derivative products including the design of the State Snapshots. She is a Ph.D. economist with 30 years of health services research experience.

The presentation is going to start today with a brief overview and then pause about halfway through for some quick clarifying questions. The second half of the presentation will focus on the specific questions raised by state participants at the recent workshop. And then the operator is going to open the audio conference up to your questions, ideas and suggestions.

So, without further ado, I am going to hand this over to Jeff.

Jeff Brady: Good afternoon, everybody. There is a slide presentation that I'm going to work through, and I'll actually refer to the page numbers of that presentation as I talk, so you can sort of follow along. In the middle of that presentation I'll be turning it over to Dr. Coffey, and we'll let you know where we are at that point as well.

As Margie mentioned, this follows the two state workshops that are provided, at which the State Snapshots was described in more detail there. So, we're hoping to go beyond that and provide some more information and have a more in-depth discussion about how we can hopefully improve the tool for you all, which you really represent a key audience and key users of the report.

So, I'm now on the second slide, slide No. 2, where I'll just quickly talk about the plan for today. I'm going to briefly overview the larger effort on which the State Snapshots is based, and that larger effort is the National Heatlhcare Quality Report and Disparities Report. So, a brief overview of that.

Then I'll turn it over to Dr. Coffey, where she will go more in-depth into the State Snapshots tool itself, and focus in particular on some new features that we've added in 2007. Again, that was released last month, in March.

And then as was already mentioned, we'll have some general questions. And then there's a section of the presentation just to help guide us where we really are looking for input from you all on the phone.

So, moving to slide 3 now, the reports, the National Healthcare Quality Report and Disparities Report really have a particular place within the Agency for Healthcare Research and Quality that represents not completely the mission of the agency, but a large part of it.

The mission of AHRQ is to improve the efficiency, effectiveness, quality, safety and equity of healthcare, and these topics are all addressed in varying levels of detail in both of the reports. We feel at AHRQ that not only the agency itself, but the reports have a particular niche which can be described in a few different ways. One is to develop knowledge through a search. Another big part of our efforts at AHRQ is to disseminate the evidence that is produced not only at AHRQ but elsewhere.

And then where the reports play a key role is in measuring quality. There are some other measurement activities at AHRQ which many of you are well aware. The scope of the reports themselves is quite broad, and it's really quality of healthcare at the national level.

And then, finally, and this is an important point, because this is the sort of aspect of our niche and the reports niche out of which the State Snapshots grew. We ultimately hope with all of these efforts that we are facilitating change.

So, moving on to slide 4, the reports were released in early March. Both reports released on the same day, and these were the fifth year that AHRQ has produced the reports, and those are available online. The website is later in the presentation.

Moving on to slide No. 5, there are various measures types in the Quality and Disparities Report. These are just some high level ways in which those are grouped, by setting of care, different places where care is delivered, and then as well by stages of care.

And then moving on to slide 6, you can see in a little more detail some of the content that's included in the reports. This is a representation of the tables of contents for each report, and you can see how the content compares for the Quality Report and the Disparities Report, with the Disparities Report picking up these extra additional topics of "Access to Healthcare" and "Priority Populations" as a way to organize information about healthcare disparities.

And then the final point I want to make on slide No. 7 is that the reports themselves and as well the State Snapshots tool are based on really a multitude of data sources. And this is one way of considering or grouping those different data sources. We have information that comes out of provider and facility sample surveys, and you can see examples of those. Many of those come from our sister agency, the CDC, National Center for Healthcare Statistics, and then you can see the specific surveys. For example, the National Ambulatory Medical Care Survey is one.

Other types of data sources are surveillance and vital statistics information. Again, our sister agency, CDC, supplies a lot of that. But there are others in the form of NIH and the cancer data that comes from SEER.

Another big group is Population Sample Surveys. This is where much of the AHRQ data sort of falls in the form of the Medical Expenditure Panel Survey that AHRQ manages, as well as the CAP Survey. But in addition, some other examples of data sources.

And then finally organizational data systems and in particular some of note are the healthcare -- the HCUP Project, and then our other -- another sister agency, CMS, provides quite a bit of data that falls into this category.

So, with that, I'm going to make sure we save enough time for questions. But before that, I'm going to turn it over to Dr. Coffey for sort of an overview of the State Snapshots tool.

Rosanna Coffey: All right. Thank you, Jeff. This is Rosanna Coffey. On slide 8, you can see, we're going to start talking now about the State Snapshots. We're going to give you a quick overview of this.

If you're at your computer and you want to take a tour through the Snapshots while I'm talking, the URL is at the top of this slide. It's http://statesnapshots.ahrq.gov.

So, the State Snapshots are really developed for people like you, state policymakers, so that you could look at all of the information on healthcare quality that's been assembled in the Quality Report and the Disparities Report. It's a state-by-state view, and you will find in there summary performance measures. And for every one of these summary measures, which is a different dimension of healthcare, you can click on usually a meter and you'll find the individual measures that lie behind the summary measure.

There are also focus areas, clinical issues, that are particular focus areas. And this year we've added some information about the context of your state environment in which the results on quality occur. And, as always, we have detailed methods and some interpretation guides.

So, if you're in the website and you can get to the State Selection Map, which is a link on the homepage, and you see a map like this one that I have on the screenshot, just click on a state you're interested in and it will take you to some of the measures. And you'll be able to follow along in this left-hand menu for the areas that I'm going to talk about.

So, on slide 9, before we actually go into those left menu items, I thought I'd give you a little bit of an idea about how the snapshots have already been used. And for those of you at the workshop, you heard about Arkansas Center for Health Improvement. They really took the opportunity of the State Snapshots to get a view of their state. They pulled together stakeholders and all united behind the view that things were as bad as they thought they were for their particular state. And this information allowed them to jumpstart quality improvement. In fact, their Employee Benefits Division used the metrics and some of the analyses out of the State Snapshots to look at their own data for state government employees in Arkansas.

Maine has taken a different approach in using the State Snapshot. They tacked onto the information technology and wanted the same look and feel for their own project on hospital transparency. And they asked AHRQ for the information program -- or the technology program behind the Snapshots, and AHRQ provided those -- asked us to provide those, which we did. And then they decided they would like us to help them develop. So, we went off into a slightly different direction. We had different kinds of methodological problems, but was very exciting and fun working with Maine on this particular application on the State Snapshot.

And the last two items here are newspaper articles that came out after this most recent release of the Snapshots. One in Florida on discussing why Florida 's hospital rates were so much lower than the norm. And that was interesting to hear people around -- to read about people around the states viewing their own measures. And also the AP wire service looked at the big huge decline in physical restraints used in nursing homes, and did a piece on that.

Slide 10 is the first sort of layout of all of the information in the State Snapshots. This meter is a tool that we use visually for all of this different dimension. So, the dimensions here, the types of care, the settings of care, and the care by clinical area each have one of these meters. And the meter is a relative kind of performance. It tells about your state compared to the nation, or compared to the region, and it gives you a previous and a baseline, dash line, and a solid line current information.

On slide 11, I have laid out a little bit more information about what's behind each meter. We have detailed information and the methods that you can go to read all of this. But to give you an overview, to develop one of these meters, we take a subset of the NHQR measures. So, if we're doing the hospital setting, we'll take all of the hospital measures. We'll classify each state's performance on each of those hospital measures.

First, we'll calculate the all state or the regional average, and then we'll determine if a state is statistically better than average, average, or worse than average compared to that group. And for every measure in the subset, we'll give the state a score. If that measure is better than average, it gets one point; if it's average it gets a half a point; and if it's worse than average, it gets no points. You sum up those points and divide by the number of measures.

So, in effect, when you have a needle that's way over in the very strong range, that says that all or nearly all of your measures are above average. If that needle is in the very weak range, it says that all or nearly all of your measures are below average. So, that's the concept.

Slide 12, now it talks about the individual measures. So, if you click on any meter, you'll be taken directly to a list of measures that are behind that meter. And in addition, we have some other layouts of individual measures. The first one listed there, there are five strongest and five weakest measures for each state compared to all states reporting. And we also have a state ranking table. I'm going to show you those two.

The last one I'm not going to show to you, but you need to know about it. Because if you want to have something done differently, you want to look at different measures and combine them together, or you want to do a totally separate analysis with some of your own data, you need to know that all the measures for all the states are in a big huge, humungous table that you could give to an analyst and have them -- tell them where it is and they can download the information and analyze it themselves in whatever way they want to analyze it.

Slide 13 is just a screenshot for California. We selected to do the screenshot. It's the five strongest and five weakest measures. You've got a short name, you've got the longer names. It's much more descriptive, and it tells you which direction that measure is better, whether it's the highest measure is the best or the lowest measure is the best.

The next slide 14 looks at the ranking on selected measures that go across the states, and here we have the short name, long name, and again this time we have the all state average, the state rate that you're looking at -- in this case, it's California -- and then the rank of that state on that measure.

This was something that was put together in our first snapshot to get some media attention. Okay.

Slide 15, now we're turning to some of the clinical information. And while most of the clinical areas that we have information on are these meters, this particular one goes into more depth.

So, we have process of care measures that are in a meter format. We have outcomes of care measures, which are bar charts of avoidable hospitalization. And we have disparities by income and race and ethnicity that come out of the Disparities Report with some additional analysis. And we have some cost savings for state government employees. So, I'm going to jump to the latter two and show you the screen shots on those.

This map for California, this is an old map, actually. We didn't have the updates in the State Snapshots website at the time we prepared these slides. So, when you click on that, you're going to see a different configuration of color. But let me explain what these are.

These represent the gap between the high and low income groups in different states compared to the gap for all states. So, if your state is red, it's saying that your gap between high and low income for HbA1c testing is worse than the gap between high and low income across U.S. in general.

And if you're green, you're better, you have a narrower gap, and if you're yellow, it's at the average of the whole U.S. The white states are those for which we don't have data or the data were insufficient.

Okay. Then on slide 17, we're looking at a configuration where we try to estimate for state government employees the share of the state's health expenditures that go -- on state government employees that go towards diabetes care. And this compares to the region as well as to all states. And those red circles that I have here on the screen shots are where we have estimated expenses of dollars that are spent.

This particular information and also the next slide, which is slide 18, comes out of work that was done for AHRQ using a return on investment calculator on diabetes. It was developed by the Lewin Group, and these estimates are new estimates this year because they have revised their calculator, somewhat lower than they were before. And you will -- if you go to the Excess Cost of Diabetes on the left-hand menu under "Focus on Diabetes," and scroll down. I can't do it here with this screen shot, but you can. You'll see all of the caveats about whether you like really experience these savings and what they mean.

Okay. And slide 19, this is just a summary of the new features of the State Snapshots. We have now, because of state -- what were they -- they were state work groups that Academy of Health put together to evaluate the Snapshots. They said, "Gee, can't we have all of these meters in one place? So, we've done a dashboard and that's on the left-hand menu pretty close to the top. And so you'll be able to see, once you understand what this meter is, you can read this. You'll see everything in one place.

We've also added two clinical sort of state performance goals. One comes out of Healthy People 2010, and the other out of Clinical Preventive Services Task Force. And then finally these contextual dials. I'm going to show you the dashboard. Here's the slide 20 is sort of a little bit of a snippet of the dashboard.

Slide 21 is the focus on Healthy People 2010. And this is just in a table format, so you can look and see your information compared to those targets, both for the most recent year in the baseline.

And then on slide 22, we have the Clinical Preventive Services measures, and a state's performance on just those measures. This one we did do in a meter format the same kind of methodology that I talked about before.

And then slide 23 shows the state contextual factors, and these are simply -- usually percents. We look at demographics, health status and resources in the state, and the needle is your state's values, whatever state you're looking at. And each range is the range across all the states. So, it gives you a sense of where you lie compared to all the other states. And it's important to understand that states have different kinds of circumstances and populations and resources, and that does certainly affect what we'd expect to see in quality of healthcare.

So, that is a quick overview. We could open the lines now and take any quick clarifying questions before we go into some specific questions that we've had.

Operator: Thank you. Ladies and gentlemen, if you have a question at this time, please press the 1 key on your touchtone telephone. If your question has been answered or if you wish to remove yourself from the queue, please press the pound key.

Rosanna Coffey: Okay. I see a question from Tom Dyeson, Washington State.

Tim Dyeson: Yes. This is Tim Dyeson from Washington State.

Rosanna Coffey: Yes, sorry, Tim.

Tim Dyeson: How are you separating out state government employees?

Rosanna Coffey: On the diabetes, it's only on that diabetes focus, where we're looking at the lives and expenses. We got state government employees out of a -- I have to go back and look at the actual source on that, but we've got it from a standard national source. Is that what you mean?

Tim Dyeson: Well, I would have been more likely the one to complete for the State of Washington, so I'm just trying to figure out if -- did I give you that or not?

Rosanna Coffey: No, we didn't actually go to states for this information. It is -- you would have provided it through the some association of budget officers. Are you familiar with that?

Tim Dyeson: Yes. Yes.

Rosanna Coffey: I'm sorry I don't have all the details at my fingertips, but that's where it came from.

Tim Dyeson: That's right, okay.

Rosanna Coffey: And then that goes into this calculator that I was talking about that the Lewin Group developed.

Tim Dyeson: Okay, gotcha. Thank you.

Operator: Again, if you have a question at this time, please press the 1 key on your touchtone telephone.

Rosanna Coffey: Okay, I don't see anymore questions.

Operator: There are no further questions at this time.

Jeff Brady: Rosanna, I'll pick up, I guess, there?

Rosanna Coffey: Yes, please. Thanks, Jeff.

Jeff Brady: Sure. So, just to orient folks, we're on slide 25 now. So, again, there will be an opportunity for additional questions at the end. This was mainly just for clarifying questions as was asked.

One thing we'd like to do a major, I guess, objective or goal of this talk is to kind of take the discussion beyond what happened in the state workshops at the end of last year, beginning of this year. And so with that, again on slide 25, we want to talk a little bit about answering this question for you and also getting your input and feedback about how we envision it being used. But it's simply just a question, can the State Snapshots help states set priorities, and sort of a subordinate point to that, which measures are most important?

The next point that we want to touch on is whether or not the Snapshots can be redesigned. Some of the particular points that we've heard raised from various users are things such as whether or not it's possible to let users define their own state group for which to compare themselves.

I think hopefully most of you picked up when Rosanna was talking, but at present or maybe hopefully even from your own use of the site, at present the only comparisons that we really provide are to the national average, and then also to states within the region that a particular state is.

Another point -- but, again, the point there is whether or not other comparisons are possible both technically within the site and then I guess what other comparisons would be appropriate to include.

The other point is about data and whether or not that can be provided by payer type. This is something that we already do to some extent for some measures, where the data support it. In the National Healthcare Quality and Disparities Report, some of this is pulled into the print reports already, but more information is available on the data tables appendices for each of those reports. But, again, back to the point of this discussion is whether or not some of that could be incorporated into the State Snapshots' website.

And the last discussion, to some extent, is an example of how that happens in that case for state employees as a particular subgroup. Some others, I think that are of interest, are groups such as the Medicaid group, Medicare group, and others.

And then the final, I guess, example that we've included here in terms of discussions that we've heard about redesigning the site are about whether or not the data would support substate geography. So, I think the best example of this is for folks that attended the workshop -- attended one of the workshops, the H Cut Mapping tool really does substate, provide the information in smaller geographic units than states.

Currently within the National Healthcare Quality and Disparities Reports and related derivative products, we don't go to a smaller geographic unit beyond states. However, there are some examples where we've worked with other parts of AHRQ and others outside of AHRQ to drill down beyond that on some specific projects.

And then moving on to the last point on slide 25 in terms of some questions that we've received, one in particular is about severity adjustments and whether or not those could be made for state environments, and the context of this question was the specific example of long-term care and patient acuity, and to what extent, number one, does the site and data available within the site control for that -- for patient acuity? And then, number two, what's available if folks wanted to go beyond that to examine that?

So, again, our point with this part of the audio teleconference is to hopefully stimulate some thinking in preparation for the discussion that we'll have in a few minutes. But before that, I want to go ahead and turn to slide 26 and explore just in a little bit more detail this idea of the Snapshots and setting priorities, and whether or not that's a function of -- and an objective of the site for users. The simple answer to that is, yes, definitely, that's what's envisioned. And, as you can imagine, if you've spent any time on the site, it's sort of set up to provide that answer and help states to set priorities.

In particular, thinking back to one of the new features where we provide the dashboard of basically all of the performance meters for the different summary measures, that's a quick way for users to get an overview of the landscape and hopefully to identify both areas of high performance and low performance in a particular state.

And then beyond that, the steps that we envision users might take, the second item underneath the dashboard view there is sort of to do the sniff test, and really ask yourself do these findings that we present in the snapshots confirm what you may already know about healthcare in your state? In most cases, that is the case where often you're looking at the exact same data that is populating the site. And so there is consistency there. But, if not, certainly we want to hear about that, or if there are alternative data sources that you use more heavily and we'd like to know about how they may or may not coincide with what we have on the site.

The second bullet about examining measures behind the meters to determine what exactly is being measured. The site is built in this way so that users can drill down. Once you have the broad overview of how performance is in your state, then, really, you can go down to the measure level to see which measures are driving either high or low performance. Because, really, the detailed view is what often in almost all cases is needed to really plan any sort of response or action.

And then the other point is our -- simply as it says here, are there some measure that are particularly problematic? And, again, always sort of looping back to ask the question is this consistent with what you know about your particular state?

And then, finally, we envision definitely that the State Snapshots are a place or at least a group of information around which other groups can talk and really vent their results. And just some very simple ways that happens is they -- the user is responsible for maybe a broader scope of healthcare, contact subject matter experts in particular areas to discuss their awareness or lack thereof of a particular quality performance.

And then more in a policy question, are the current priorities that are set supported by the data that's presented in the site? Are there some that may be surprising or new ones that are suggested by the site?

And then, finally, this is really a tool for action, so what are the next steps that your state might take with this awareness?

And, again, an important thing that we like to achieve with this audio teleconference and conversation is to hear how this works in your state, is our vision of how this tool might help state healthcare policymakers function. Is it accurate? Is this actually playing out the way we hope that it is in your state?

With that, I think Rosanna, you're going to cover slide 27?

Rosanna Coffey: I am. I'm going to cover the next few slides about the redesign of the Snapshot. Before I do that, this is for Tim Dyeson. We did look up your question to get a more accurate answer for you. It's the Bureau of Labor Statistics 2004 Quarterly Census of Employment and Wages, and that's where that came from, Tim.

Okay, the Snapshot redesign. One of the questions we have was, could you design your own group of states that you want to compare to? We find this is a question that rural states, in particular, would like the ability to compare themselves to other states that are as sparsely populated or has the same topology as they have. And so we gave some thought to this, allowing you to just draw any group of states that you want to draw complicates the design of the website considerably. And just to be able to give you the ability to do it in the fly is something that we'd have to evaluate the feasibility and cost of, and AHRQ would need to decide whether to spend that kind of money on complete redesign of the website to do that. So, that's a question.

But we do have another approach, which wouldn't be just defining states on the fly, but you could perhaps specify some types of comparisons that you would like to have and we could build those into the state snapshots, and that would not be a big, expensive deal.

For example, I've listed some here. Suppose you want to compare your state to other low population density states. So, that might be one type of comparison we could build. Another might be the high poverty states. Another might be our states that are magnets for tertiary care, where they have big, huge academic centers and they draw people from all over the country for care. Some states -- you wanted to compare yourself with another state like that.

And you may have other ideas, so we would really like to have two things from you when we open this for comment. One is what are -- can you come up with sort of the characteristics that you'd like to give to compare your state to and help us define those. And the other question is, do you think this is a valuable tool or not? Because AHRQ needs to make the decision about whether to go into this with additional resources.

The next redesign question was about reporting by payer. In this case it's a question of whether the data are available by payer within the state, and we're 100% sure of it only for the HCUP data, the Healthcare Cost and Utilization Project, which is the discharge records that have been put together by AHRQ for many, many states, I think up to 30 or 40 states now.

So, that's one place where we have indicators by -- you have a record -- information on the discharge records that this is a Medicaid, Medicare, private insurance, uninsured, or some other categories. And that would be a feasible way to look at those.

But the HCUP measures are very small proportion of the measures that are in the Quality and Disparities Report. And so in order to beyond those, we need to assess two things: Which of the data sources are all payer, and then for those we'd have to recalculate rates by payer and examine cell sizes to make sure that we're not identifying organizations or individuals.

And, also, which -- some of these measures are clearly payer-specific. There are Medicare and Medicaid measures, and to be able to combine any of those we'd have to see whether they have enough measures. In other words, are they collecting the same types of measures and if it's one or two measures, we probably wouldn't do a kind of meter for that.

But, again, this is an area where we'd like to have your comments on the value of this when we open it for discussion.

And then the last redesign issue that I have here is whether we can report by substate geography. And then, again, it really depends on the detail and the data sources. HCUP has zip code level data, but, again, it may identify hospitals and we cannot do that with HCUP.

I have heard that the Behavioral Risk Factor Surveillance Survey may report by county in the future, so that would allow some county level statistic, perhaps.

But in general we need to assess confidentiality issues, and also whether there are meaningful groups of counties in each state that could be combined, because we might be able to get around some of the confidentiality issues if we can group them. Like in Kentucky, if we did the Appalachian counties together, or the counties that have difficult or poor health status in the state.

But it would be a pretty major undertaking to do this, so definitely AHRQ wants to hear your comments on the value of this kind of substate analysis, where we're looking at groups of counties, most likely.

And with that, Jeff, I'm going to turn it back to you for the last question that we had.

Jeff Brady: Okay. Just to let folks know, we're on slide 30 now, and this picks up on what was mentioned previously about a specific request, some discussions that we were having with a user of the site, and their interest in explaining to some extent their performance in long-term care. And more specifically they're wondering whether not patient acuity was -- to what extent it could be responsible or explain their level of performance.

And actually what we found, to quickly summarize the experience in this particular case, was that this is something that required really a level of detail that would -- that is currently, for sure, beyond what's included in the State Snapshots and to some extent might always be something that's beyond.

But nevertheless, I think we are open to considering maybe what parts, if there are particular elements of severity that could easily be summarized and incorporated into analyses that could be pulled into the snapshots.

But, really, this is just provided as an example of the kinds of questions that we get, and we try to field and consider whether or not it's something that we could not only help a user with, but also potentially help other users with if it's a common request that we're getting.

And then just a few points in general about severity and what it is in the Snapshots currently. As you all most likely know, many of the measures that are included in the Snapshots and also the reports as well, do incorporate severity adjustment. One example of that is HRQ Hospital Quality Measures. The quality indicators have built into the measures themselves some adjustments for severity. In many cases the underlying data for other data sources or the methods are just not available to adjust for severity.

And so it's not to say, again, I just want to make the point that although in long-term care, this is a question that we got specifically where the data was not necessarily adjusted. For many other measures it is. In most cases where there are not adjustments, there are definitely good reasons for that. And in those cases really you need specialized data and research methods that would extend beyond the scope of the State Snapshots tool.

With that, I think we want to stop on our prepared sort of overview of the Snapshots. And so I think we want to ask the moderator to open it up. So, Denise, if you would, I guess we're going to take questions now and feedback.

And then while we're waiting for questions, we actually did receive one question in advance, and I'm going to go over that very briefly, and hopefully that will even stimulate some further feedback and discussion from you all who are participating.

This question actually was from one of the participants, Diane Feeney from the Maryland State Department of Mental Health and Hygiene. We appreciate the question, first of all. Thank you. And then I want to just touch on it briefly and then, if necessary, give Diane an opportunity to make sure we've understood the question correctly.

But it was a question that specifically related to data that's included also on the Hospital Compare Site, so the CMS data. There were a few kind of points embedded in this question. One was related to data currency, if you will.

And I want to make the point by way of answering this question first is to say that the most current data that's in the State Snapshots for that source is from 2005. And that's information that you can find fairly easily on the site when you drill down to the measure level. You can see in a fairly clear table that not only do we show the baseline year, but the most recent data year.

But Diane's question related to, I think, some analysis that they performed after looking at the State Snapshots site to look at more recent data and sort of do some trending based on that. And I think her observation was that the all-state average had actually declined to some extent. And I believe, Diane, you said in your question that Maryland 's average had actually improved. And certainly that's definitely possible. You've done exactly what we have hoped users will do and, again, gone beyond the data that's included in the State Snapshots site to look in particular areas.

Let me stop there first and just ask, Diane, are you on the phone now still?

Operator: Ms. Feeney, if you're on the line, please hit the 1 key. Your line is open.

Diane Feeney: Thank you. I think you've characterized my question well. The issue was that people working currently particularly with those heart attack measures believe that they're topped off in terms of hospital performance. And that what I saw, though, in terms of a trend for the all state, from the 2005 data period to the current period was performance had actually gone down on four heart attack measures, which is not I guess the current thinking amongst people who are sort of focused on this hospital measurement world.

Jeff Brady: Right, right. So, turning to the second part of your question about sort of why we thought the observation that you made of declining all state average, it would really be speculation on our part. But just a few points to mention that, of course, for any measure there will be variation, and that's something we try to characterize not only in the State Snapshots site, but with the reports overall, whether it's variation at the national level, variation among caparisons to state -- among states, or with different priority populations.

But I think your observation that, yes, these are often measures that are pointed to, to say that they are topping off and sort of reaching not complete maximal performance, if you will, but definitely pushing up against that ceiling.

And, again, it would be speculation on our part, but I think it's possible that it makes the case that actually even for these types of measures for which there has been a longer history of focus and lots of effort, there's a long history of measurement in those particular areas. But even for those, it requires constant vigilance and sort of renewed dedication to sort of across-the-board quality focus. Again, that's -- in terms of explaining the why, it's not something we always get to in the reports or even in the snapshots, but that's sort of where we end up on this point, I guess. But we would open it up for other responses to that.

But I think your question makes a good point about how we hope folks use the State Snapshots site. So, thanks again for the question.

Diane Feeney: Thank you.

Operator: Again, if you have a question or comment at this time, please press the 1 key on your touchtone telephone. Our first question comes from Jonathan Teague of OFHPD.

Mary Trent: Actually, this is Mary Trent. Same office. We'd like to underscore the value of doing substate level geographic analyses for California. In particular it's important because we have a very large, diverse state, and because a lot of our health and healthcare planning is done at the county level. So, substate level analyses would make the data much more actionable and useful to policymakers.

The second is more of a question. Could you say more about adapting the Snapshots methodology for facility level reporting?

Rosanna Coffey: Sure. This is Rosanna Coffey. I'll take the second part of that, and thank you for your comment about the substate level analyses. Adapting the technology, this was work at the main quality forum, and we had originally provided to them the programs that we use for the State Snapshots, how we got to the meters, the particular software we used, how the measures were developed, and so on, and the programs that were used to develop those. And when we provided those to Maine, it was very early in their planning, and that was the point where they were knowing that they wanted to do analyses at the hospital level. And so we thought that this methodology could be transferred to the hospital level and, in fact, when we started working with them on it, we were still thinking we were going to use these meter kind of layouts. It turned out that we had issues of small cell sizes and small numbers of hospitals in Maine. And so we had to come up with a different kind of methodology.

I don't know whether there's anyone on the line from Maine, but there is a data test site. If anyone is on the line from Maine, would you push 1 on your phone? There is a beta test site -- okay, Diane Williams. Diane, are you familiar with the beta test site and whether it could be provided to other states at this point?

Diane Williams: No, I'm sorry. (Inaudible)

Rosanna Coffey: Okay. Well, Josh Cutler is the direct of the Maine Quality Forum, and we could ask him, Mary, if that could be provided to you, so you could at least see what the -- what it looks like and what it feels like. There are -- we had to actually combine measures differently. We did an all or nothing -- not an all or nothing kind of thing, but we summed up the results of cross measures of the same type so that we would have -- we could sum up numerators and use the same denominator. So, it was a different approach.

And we also developed some regression methodology to test the -- whether a particular hospital was above or below the average across a bunch of measures. And that's the methodology. It's also fully documented on their website.

So, if you would get in touch with me, and you can do that by e-mailing me, rosanna, r-o-s-a-n-n-a -- there is no "e" in there. --.coffey@ thomson.com. We also have thomsonreuters.com, but you have to know how to spell Reuters. So, anyway, that's sort of the background on that. I'd be glad to work with you to get you more information.

Are there any more questions?

Operator: Again, if you have a question at this time, please press the 1 key on your touchtone telephone. Our next comment or question comes from the line of Jonathan Teague.

Mary Trent: Nobody spoke up. This is Mary again. Would it be feasible, have you discussed doing some additional contextual analyses? For example, disease prevalence using the BRFSS or NHANES or something like that. And another one would be leading causes of death to alert states to medical problems that might not be picked up in the analysis of the patient data. Have you considered publishing something like Mercer Rates?

Rosanna Coffey: We could add other contextual factors. That's relatively a simple thing to do. The ones that are on there do come out of BRFSS. I'd have to open it up to remember exactly which they are. I'm just doing that just for a second.

The health status measures, overweight, obesity, at risk of heart disease and stroke, and I'm not sure about that reporting for mental health, whether that's on there. But we could add other ones as well. And if you have some ideas about those, ones you think we ought to include, let us know.

Leading cause of death and MRSA rates for the state. We could add any of those, definitely. We just need to find the source and find the information by state, and then put it on here in the same kind of setup.

Mary Trent: Thank you.

Rosanna Coffey: You're welcome.

Jeff Brady: Are there other questions or comments either?

Operator: Again,if you have a comment or question at this time, please press the 1 key on your touchtone telephone.

Jeff Brady: Let me actually pose a question to the group then. One of the things that's not specifically addressed in the slides but it follows some of the discussion that we've had, those at the workshops and elsewhere, and that's whether or not inclusion of particular quality improvement efforts or in some cases promising practices that might be new, whether or not packaging or including at least some examples of that along with the quality performance information, whether or not that would be beneficial to users or not. I wonder if anyone listening now has any thoughts or comments on that point?

Rosanna Coffey: While we're waiting, if you have any questions for any of us, Margie Shofer is going to be collecting all the questions, so we have information at the end of the slide set to send -- for her e-mail address, so you can send any information to her and we will get it. She needs to be included on anything that comes to us anyway.

I'm wondering if anyone has thought about this state group comparison idea that we've been seeing from several states, whether you have a special group of states that you would like to be compared to?

Operator: I'm not showing any further questions or comments at this time.

Margie Shofer: Okay, then, I'm going to conclude the Web conference. I want to thank you all for the questions and your participation in this audio conference. We hope you found it useful. So, on the last slide you'll see that we share where you can find information about the products we discussed today. So, the first bullet you can download the National Healthcare Quality Reports or the Disparities Reports. These reports are pretty long, they're over 200 pages, so we certainly welcome you to download them, but you can also request them, if you want the hard copy. And that number there is the number of our clearing house. You can get one copy for free, if you call that number. You can also download the State Snapshots, and you see that we provided the Web link there for you to download.

And Rosanna mentioned, you can download a summary version of your individual State Snapshots. Now, they're not available yet, but they will be soon, and we will send an e-mail out to alert you when they do become available.

Rosanna Coffey: Margie, I actually forgot to mention that. Thank you.

Margie Shofer: Oh, sure. And if you have any questions or comments about this tool or any other tools that we have at AHRQ, please do not hesitate to contact me. Again, I'm Margie Shofer, and you have my contact information there. For more information about the suite of our Tools developed for State Quality Improvement, or for details about additional follow-up technical assistance, again, that last bullet is where you should go for that type of information.

Thanks again, and this concludes the audio conference. We really look forward to hearing from you. So, please think about how we can help and please let us know. Thank you, everyone.

Operator: Ladies and gentlemen, thank you for your participation in today's conference. This concludes the program. You may now disconnect. Thank you and have a great day.

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