Evaluating the state of quality-improvement science through evidence synthesis: insights from the closing the quality gap series.
BACKGROUND
The Closing the Quality Gap series from the Agency for Healthcare Research and Quality summarizes evidence for eight high-priority health care topics: outcomes used in disability research, bundled payment programs, public reporting initiatives, health care disparities, palliative care, the patient-centered medical home, prevention of health care-associated infections, and medication adherence.


OBJECTIVE
To distill evidence from this series and provide insight into the "state of the science" of quality improvement (QI).


METHODS
We provided common guidance for topic development and qualitatively synthesized evidence from the series topic reports to identify cross-topic themes, challenges, and evidence gaps as related to QI practice and science.


RESULTS
Among topics that examined effectiveness of QI interventions, we found improvement in some outcomes but not others. Implementation context and potential harms from QI activities were not widely evaluated or reported, although market factors appeared important for incentive-based QI strategies. Patient-focused and systems-focused strategies were generally more effective than clinician-focused strategies, although the latter approach improved clinician adherence to infection prevention strategies. Audit and feedback appeared better for targeting professionals and organizations, but not patients. Topic reviewers observed heterogeneity in outcomes used for QI evaluations, weaknesses in study design, and incomplete reporting.


CONCLUSIONS
Synthesizing evidence across topics provided insight into the state of the QI field for practitioners and researchers. To facilitate future evidence synthesis, consensus is needed around a smaller set of outcomes for use in QI evaluations and a framework and lexicon to describe QI interventions more broadly, in alignment with needs of decision makers responsible for improving quality.
Senior Scholar and Executive Director of the Center for Health Policy/Center for Primary Care and Outcomes Research at Stanford University in CA. kathryn.mcdonald@stanford.edu.
Kathryn M
KM
McDonald
Project Coordinator at the Center for Health Policy/Center for Primary Care and Outcomes Research at Stanford University in CA. emschultz@stanford.edu.
Ellen M
EM
Schultz
Medical Officer at the Center for Outcomes and Evidence of the Agency for Healthcare Research and Quality in Rockville, MD. christine.chang@ahrq.hhs.gov.
Christine
C
Chang
D003695:Delivery of Health Care / Q000592:standards*; D006302:Health Services Research; D006801:Humans; D017063:Outcome Assessment, Health Care; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D012107:Research Design