U.S. Health Care Quality Falls Short On Crucial Measures

The Commonwealth Fund today released a new chartbook that is a first-of-its kind portrait of the state of health care quality in the United States. Based on over 150 published studies and reports of quality of care, the chartbook contains a series of 54 charts and accompanying analysis that documents serious gaps on many crucial health quality dimensions. Quality of Health Care in the United States: A Chartbook, by Sheila Leatherman, Adjunct Professor, University of North Carolina School of Public Health and Douglas McCarthy, Research Associate, Argus Insights, aims to provide an authoritative, comprehensive, and useful resource for policymakers, providers, and the public about quality of care. It also includes a unique section on successful examples of collaborative projects that have led to improvement.

"Quality will not improve by itself. In fact, the task will be even more challenging in the future because of the increasing complexity of care, with new tests, procedures, and treatments, including drugs. In addition, the aging U.S. population will use more health care services," said Karen Davis, president of The Commonwealth Fund. "Health care leaders and policymakers need to develop policies and processes that support quality improvement. This report provides a starting point for action." "We have created an overall picture of quality through many snapshots of data, hoping that this common understanding will lead to policy action and the implementation of specific programs we know are effective for improving performance," said Leatherman. "Quality problems are not just isolated incidents that affect a few people. This report proves that this is a pervasive problem that affects all of us." The report organizes the information in six chapters that follow the general framework recommended by the President's Commission on Consumer Protection and Quality in Health Care and the Institute of Medicine (IOM). Highlights from each section include: Effectiveness The IOM defines effectiveness as "providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit."

• Childhood immunizations - Over one-quarter (27%) of young children age 19 to 35 months were not fully up-to-date on all recommended doses of five key vaccines nationally in 2000. Immunization rates range from a low of 64 percent in Texas to a high of 83% in Iowa and North Carolina.
• Breast cancer screening - The rate of women age 50 and over receiving a mammogram in the past two years more than doubled from 1987 (27%) to 1998 (69%). However, rates are still lower than they should be.
• Overuse of antibiotic for sore throat - Widespread over-prescribing has led to the emergence of antibiotic-resistant bacteria. Although the rate of use of antibiotics to treat adults with sore throats has declined, from 77% in 1989 to 57% in 1999, rates are still higher than where they appropriately should be-between 11 and 33 percent-if clinical guidelines were followed.
• Beta-blocker medication to prevent recurrent heart attack - Only three-quarters of Medicare heart attack patients received beta-blocker medication when indicated to prevent recurrent heart attacks. Rates ranged from a low of 47 percent in Mississippi to 93 percent in Massachusetts and the District of Columbia.

Patient Safety Preventable medical mistakes, whether due to a mistake with medication, missed or delayed diagnosis, or surgical error, are a serious problem. Based on credible estimates, medical mistakes rank among the leading causes of death in the U.S., exceeding deaths from motor vehicle accidents, breast cancer, or AIDS.

• Increase in medication mistakes - From 1987 to 1995, rates of medication-prescribing mistakes with the potential for adverse outcomes more than tripled in proportion to hospital admissions (from 2.4 to 8.4 per 100). This data, from a teaching hospital, may be representative of a wider trend suggesting that medication mistakes are increasing along with the intensity of therapy.
• Unsafe or inappropriate prescribing for the elderly - Six studies during the past decade show that between 14 and 24 percent of elderly patients were prescribed medications that could potentially cause harm in or have questionable effectiveness for the elderly.

Access and Timeliness This section encompasses the ability of patients to get needed care and minimizing unnecessary delays in getting care.

• Effect of being uninsured on access to primary care - Uninsured working-age adults were up to three times more likely (27%) to report not seeing a physician when needed and not receiving recommended preventive services due to cost than those with public or private insurance coverage (8%) during 1997-1998. Those who were uninsured for less than one year were also more likely to report difficulty obtaining access to primary care (22%).
• Effect of regular source of health care on access to preventive care - Adults with a regular source of care were two to five times more likely to receive preventive care-such as mammograms, pap tests, and colorectal cancer screening-than those without a regular health care provider in 1998.
• Timely initiation of prenatal care - The percentage of women receiving prenatal care has improved over the past two decades, reaching 83 percent in 1999. However, while rates for women who are members of racial and ethnic minority groups have improved, due at least in part to Medicaid expansions in recent years, they are still below rates for white women (74% for African American and Hispanic women, and 70% for Native American women vs. 88% for white women).

Focus on the Patient Quality of health care has two major dimensions: the technical proficiency with which it is delivered and the subjective experience of patients, including the degree to which patients and doctors work together to agree on the best decisions for the patient's care.

• Perceptions of health care quality - Little more than half (53%) of the American public thinks that the quality of health care in the U.S. is good or excellent. Nearly three of five (57%) of U.S. physicians say that their ability to provide quality health care has gotten worse in the past 5 years.
• Public perceptions of the health care system - While a majority of people said that hospitals (72%) and their own physician (84%) were doing a good job, fewer had confidence in the leaders of medicine (44%) and think health insurers are doing a good job (39%). Three of five Americans (59%) think managed care harms quality.
• Satisfaction with nursing home care - Over one-third (37%) of people with substantial nursing home experience expressed dissatisfaction with the care that they, a family member, or a friend received in the last three years.

Disparities in Health Care A substantial body of research has demonstrated that minority Americans are worse off than whites on a wide variety of indicators of health care access and quality that determine health outcomes. Research has also found that women sometimes receive less treatment than men.

• Racial/ethnic disparity in preventive care - Blacks and Hispanics were less likely than whites to receive some preventive care services. Compared to whites (69%), the flu shot vaccination rate in adults 65 and over was 18 percentage points lower for African Americans (51% vs. 69%) and 13 points lower for Hispanics (56% vs. 69%). This finding is striking because Medicare covers this preventive service equally for all elderly beneficiaries.
• Racial disparity in use of invasive heart procedures - Black patients with coronary artery disease were less likely than white patients to receive procedures that restore blood flow to the heart muscle. Seventy percent of white patients with severe disease received either angioplasty or bypass surgery, compared with 56% of black patients with severe disease. In the study, differences in patients' insurance status did not account for the difference in treatment. Blacks were 18% more likely than whites to have died after five years, suggesting that they were undertreated.
• Pain management - Among cancer patients visiting 54 outpatient clinics, 59 percent of minority patients and 38 percent of white patients had inadequate pain management based on an assessment of their pain severity and the medication prescribed to treat it (if any).

Capacity to Improve This section describes interventions that have been shown to improve care, indicating that the U.S. health care system does have the capacity to improve.

• Improving immunization rates - Patients who received reminders about upcoming or overdue immunizations were two-and-a-half times more likely to be vaccinated, or up-to-date on their vaccinations, than those who did not. With the effectiveness of patient reminders clearly demonstrated, wider dissemination is called for. Advanced automated billing systems and immunization registries are making reminder systems increasingly feasible and affordable for more physicians. It is estimated that reminders cost $7 to $63 per child vaccinated; the question is who should pay for them.
• Improving diabetes management - The quality of diabetes care among Medicare patients improved when six managed health care plans in Arizona collaborated with the state's Medicare Peer Review Organization on quality improvement. After one year, the proportion of patients with their blood sugar under control rose from 40 percent of patients to 62 percent.
• Preventing serious medication mistakes - Medication mistakes that caused patient injury or had the potential to cause injury (and were not intercepted before reaching the patient) were reduced by 86 percent (from 7.6 per 1,000 patient days to 1.1 per 1,000 patient days) by a computerized physician order entry system at a teaching hospital.

"It is encouraging that the chartbook points to significant improvements in care in the past 10 years, indicating that change is possible," said Anne-Marie Audet, M.D., vice president at the Fund. "But in fact there are only a few examples where quality has reached the level we should expect. This means that quality of care is not what it should be for those who need it the most, children and adults with chronic diseases, the elderly and frail individuals most at risk from the consequences of poor care." What are the next steps to improve quality? Quality problems can't be cured by simply spending more money. The U.S. already spends more on health care per capita and as a proportion of GDP than any other nation. New approaches, based on better diagnosis of the problems of quality, and implementation of effective corrective strategies, will be needed. The authors outline ways to move forward:

• Enhancing knowledge - Evidence-based guidelines must be incorporated in daily practice to help physicians determine the best course of treatment. Systematic reviews of the literature, guidelines, and computerized practice prompts need to be routinely implemented.
• Making information on quality available - More comprehensive and systematic reporting on quality performance at all levels of the health care system-national, state, health plan, and individual provider-are needed.
• Improving quality through coverage - Improving rates of health insurance coverage is a prerequisite to improving access and quality of care. Rewarding quality - Attempts to exploit consumer market forces have had only a marginal effect to date and the need to implement incentives-either financial or non-financial-is increasingly recognized. For example, payment should be linked to the quality of the care, when feasible.

"Quality will only improve with the concerted efforts of physicians and other clinicians, patients, insurers, policymakers, and health system leaders all working toward the same goal," said Stephen C. Schoenbaum, M.D., senior vice president at the Fund.