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Through the Quality Kaleidoscope: Reflections on the Science and Practice of Improving Health Care Quality: Closing the Quality Gap: Revisiting the State of the Science [Internet].


Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Feb. Report No.: 13-EHC041-EF.
AHRQ Methods for Effective Health Care.



The United States devotes significant resources to health care, yet quality is often lacking. In 2004, the Agency for Healthcare Research and Quality launched a collection of evidence reports on quality improvement (QI) opportunities and strategies related to chronic conditions, practice areas, and cross-cutting priorities. This new Closing the Quality Gap series expands the topics examined and marshals the knowledge of eight Evidence-based Practice Centers (EPCs) to synthesize lessons learned and to advance the state of QI science.


The eight topics are: effectiveness of bundled payment programs, effectiveness of the patient-centered medical home, QI strategies to address health disparities, effectiveness of medication adherence interventions, effectiveness of public reporting, prevention of healthcare-associated infections, QI measurement of outcomes for people with disabilities, and health care and palliative care for patients with advanced and serious illness.


Each EPC conducted a systematic review of the peer-reviewed literature. Topic search strategies are available in the individual topic reports. This methods report relies on the final topic reports to highlight common lessons, identify implications for future systematic reviews of complex QI topics, and recommend next steps to advance the QI field.


The series collectively assessed the evidence across quality levers and various populations, interventions, outcomes, settings, and contexts. Various approaches were taken to analyze the evidence in meaningful ways for key audiences. The challenges across reports informed approaches for future reviews, including use of logic models, approaches to defining and searching for complex health care interventions, assessment of individual study quality and strength of evidence, meaningful synthesis, and methods for synthesis. Directions for future QI research include the role of systematic review to advance the field, consistent measurement, consistent and complete reporting, a focus on health, understanding of context, and development of a common lexicon for QI intervention.


In their innovative review of these complex topics, EPCs faced several common challenges, including difficulty in synthesizing the evidence due to heterogeneity in choice of outcomes measures; limited ability to draw conclusions due to weaknesses in study design and incomplete reporting; and difficulty applying traditional systematic review methods to the multifaceted, context-dependent, systems-level interventions typical of the QI field. Future research will be strengthened by consistent use of a core set of outcomes measures, more robust study designs, more complete reporting of intervention characteristics and contextual factors, and development of additional systematic review methods specific to the QI field.

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