Exhaustive research documents the fact that today, in America, there is no guarantee that any individual will receive high-quality care for any particular health problem. The health care industry is plagued with overutilization of services, underutilization of services, and errors in health care practice.
These quality problems are not new, nor are they unique to any particular type of arrangements through which health care is financed and delivered. The term "managed care" denotes a wide spectrum of health care arrangements, including health maintenance organizations, preferred provider organizations, and point-of-service arrangements. Both the best and the worst health care our system has to offer can be found in managed care plans, as it can in traditional fee-for-service (or indemnity) arrangements (Miller and Luft, 1997).
Key indicators of the quality problems we face include:
Despite this growing body of evidence, the American health care industry still does not have the ability to systematically measure and report on the quality of health care that is delivered to patients. What is known, however, indicates that there are substantial areas for improvement in the quality of care.
The lack of comprehensive information on the quality of American health care is unacceptable in an industry that accounts for more than $1 trillion in annual expenditures and comprises nearly one-seventh of the U.S. economy.
These problems with the quality of American health care present a clear and compelling argument for national action. Recent advances in the science of medicine, the measurement of quality, and the public and private commitment to accountability in the health care industry provide the Nation with a tremendous opportunity to improve the quality of health care in the United States. To achieve this necessary progress, we will need a national commitment to quality improvement, beginning with leadership from the highest levels of government, industry, labor, and the health care professions.
There are a variety of types of error that occur in the delivery of health services, including missed diagnoses, errors in the interpretation of laboratory or imaging studies, medication administration or prescribing errors, surgical errors, and errors in the care furnished by doctors, nurses, and other health care professionals.
Another study found that antibiotics, cardio-vascular agents, gastrointestinal agents, and narcotics were the most common medications involved in errors (Lesar, Lomaestro, and Polh, 1997). A study that examined the preventability of adverse reactions to medications found that about 28 percent were preventable overall and 42 percent of the life-threatening events were preventable (Bates et al., 1995). Studies of medication errors have evaluated the processes by which errors occur. One such study in pediatrics found lower rates of error associated with verbal orders (2.6 per 1,000) compared with handwritten or computer-entered orders (8.5 and 6.3 per 1,000, respectively) (West et al., 1994).
Preventable deaths represent another view into the prevalence of errors in practice. An assessment of deaths from stroke, pneumonia, or heart attack in 12 hospitals indicated that 14 percent could have been prevented if adequate diagnosis and treatment had been provided (Dubois and Brook, 1988). An evaluation of fetal and maternal outcomes following emergency cesarean section found that 60 percent of the infant deaths (5 infants out of 20 that had fetal heart tones) could have been prevented with earlier diagnoses and by performing cesarean sections (Morris et al., 1996).
Among adults, the two key immunizations are influenza vaccines, recommended annually for those over age 65 and for those with selected chronic health problems, and pneumococcal vaccines, recommended once for persons over age 65 and for those at increased risk of serious complications from pneumonia. A nationally representative survey of adults age 65 and older conducted in 1993 found that only 52 percent had received an annual influenza vaccine and only 28 percent had received a pneumococcal vaccine (CDC, 1995a).
Another type of preventive service is routine screening of persons without symptoms to detect the presence of disease at an early stage. Studies have found room for improvement in screening rates. For instance, a nationally representative sample of women age 50 and older found that 45 percent had a mammography in the previous year (CDC, 1993a). A survey of women age 18 and older found that 67 percent had received a pap smear in the previous 3 years (CDC, 1995b). Finally, a national study of persons 40 and older found that just 14 percent of men and 27 percent of women had received a fecal occult blood test to screen for colorectal cancer in the past year (CDC, 1995b). More recent data from National Committee for Quality Assurance show that managed care plan enrollees obtained screening services at higher rates than these national averages (NCQA, 1997).
Another type of preventive care is characterized by counseling or other interventions to prevent behaviors that are known risk factors for the development of serious chronic conditions. Smoking causes 19 percent of deaths annually (McGinnis and Foege, 1993), and advice from a practitioner to quit smoking has been demonstrated to be an effective intervention (USPSTF, 1996). Yet a survey of smokers age 18 and older indicated that 37 percent had been advised to quit smoking in the past year by a health professional (CDC, 1993b), again with significantly higher rates of such advice among smokers in managed care plans (NCQA, 1997).
Acute care. A leading indicator of the quality of acute care is the proportion of pregnant women initiating prenatal care in the first trimester. In 1992, about 78 percent of women nationally initiated prenatal care in the first trimester (PHS, 1995). The rate was 85 percent among women enrolled in managed care plans reporting HEDIS data (NCQA, 1997).
Care for heart attacks provides another important example of underuse of potentially effective care:
Chronic care. Assessing quality of care for chronic conditions tends to be complex because multiple processes are required, stratification by severity may be necessary, the need for clinical detail from health records is greater, and the settings of care are varied. However, failure to receive high-quality care for chronic conditions may have the greatest potential consequences for the health and functioning of the population.
Chronic illness has replaced infectious diseases as the number one source of death in the world. Approaches for treating chronic conditions are growing, from high-tech treatments such as coronary artery bypass graft surgery or angioplasty to low-tech solutions such as home care and assistive devices. Yet knowledge about the quality of care for chronic illness or the efficacy of many treatments for producing desirable outcomes is in its infancy. For example, hip fractures and strokes -- the two most common disabling conditions in older people -- often result in profound functional losses. Among hip fracture patients, between 55 percent and 75 percent lose their ability to perform basic activities of daily living. Among stroke survivors, about 40 percent have moderate functional impairments 6 months later and 10 to 15 percent remain severely disabled. Despite such impacts, the effectiveness of different rehabilitation options for restoring function and preventing long-term nursing home placement is largely unknown (Kramer et al., 1997).
In other cases, knowledge of the most efficacious treatment of chronic conditions does exist, yet treatment approaches are unevenly applied. Care for persons with diabetes provides an example. In 1989, 49 percent of people with diabetes in the United States had received a dilated eye examination in the past year and 66 percent had received one in the past 2 years (Brechner et al., 1993). A study of Medicare patients in Alabama, Iowa, and Maryland reported that 46 percent had an eye examination and 16 percent had received a glycosylated hemoglobin test, a marker for glucose control in diabetes (Weiner et al., 1995).
Similar findings have been demonstrated for mental health conditions. One study found that only 20 percent to 30 percent of general medicine patients with depression were prescribed antidepressant medications; among those prescribed medication, 30 percent received a subtherapeutic dose (Wells et al., 1994). A recent consensus panel on the undertreatment of depression concluded that "there is overwhelming evidence that individuals with depression are being seriously undertreated" (Hirschfeld et al., 1997).
Another significant area of overuse of health services lies in the use of medications. Treatment of respiratory infections (common cold, influenza, sore throat, sinus infections, bronchitis, and pneumonia) is the most common reason for Americans visiting a physician, representing about 10 percent of all visits among adults and 13 percent of visits for children (NCHS, 1994a; NCHS, 1994b). The cause of many upper respiratory infections is a virus, and antibiotics are not an effective treatment for viral illnesses. Yet several studies have reported high rates (30 to 70 percent) of inappropriate prescription of antibiotics for viral infections (Mainous et al., 1996; McCaig and Hughes, 1995; Dowell and Schwartz, 1997). Another study found that unnecessary prescriptions for nonsteroidal anti-inflammatory drugs were written in 42 percent of visits; this pattern of overprescribing can increase risk for hospitalization and death from gastrointestinal bleeding and perforation (Tamblyn et al., 1997).
The appropriateness of hospitalization has been examined in several different studies:
The first evidence of small-area variation in the rates of common surgical procedures was published in the early 1970's (Wennberg and Gittelsohn, 1973). A 1981 study of 123 medical and surgical procedures performed on Medicare beneficiaries in 13 metropolitan areas in the United States found threefold or greater differences for 54 percent of the procedures. A review of the literature in 1987 demonstrated variations at every level (e.g., regional, State, hospital area) and for a variety of utilization dimensions (e.g., length of stay, discharge rates, surgical procedure rates) (Paul-Shaheen et al., 1987).
Regional variation is quite apparent in the use of inpatient hospital services. In 1994, for example, overall hospital discharge rates were 49 percent higher in the Northeast than in the West and lengths of stay were 40 percent higher (Graves and Gillum, 1997). These variations also are apparent among specific conditions. Rates of hospital discharges for diabetes mellitus were 85 percent higher in the South than in the West and discharges for pneumonia were 76 percent higher in the South than in the West. Discharge rates for psychoses were 160 percent higher in the Northeast than in the West and 107 percent higher for asthma (Karuza et al., 1995).
Utilization rates also have been shown to vary within States and regions. A study of hysterectomy rates in Massachusetts between 1982 and 1989 found a fivefold variation (Haas et al., 1993). Hospitalization rates among children with asthma also varied, with children in Boston having a 3.8 percent risk of hospitalization compared with a 2.3 percent rate for children in New Haven, Connecticut. Researchers even found variations in utilization within Los Angeles County (Carlisle et al., 1995).
Variation in utilization is not limited to hospitals. A recent study of the use of hormone replacement therapy (HRT) found that HRT was prescribed in 13.7 percent of visits by women age 40 and older in the West compared to 3.9 percent of visits by women in the Northeast (Stafford et al., 1997). Women living in metropolitan areas were more likely to receive HRT than those residing in nonmetropolitan areas. A study of diabetes care among Medicare beneficiaries in three States found more than a twofold variation in care (Weiner et al., 1995).
Variations also have been demonstrated among individual practitioners. A study of the intensity of treatment provided by psychiatrists and psychologists found that the average time in face-to-face treatment per patient per month varied 244 percent among psychiatrists and 128 percent among psychologists nationally (Knesper et al., 1989). Cesarean section rates were shown to vary from 19.1 percent to 42.3 percent in a study of affluent women cared for by obstetricians practicing at a single community hospital (Goyert et al., 1989). A study of physician differences in the management of low back pain in a single managed care organization found variation in the frequency of prescribing pain medication and bed rest resulting in cost differentials of 79 percent between the high- and low-use groups (Von Korff et al., 1994).
Every year brings advances in the interventions available to screen for diseases, prevent diseases from developing, make diagnoses, treat conditions, and monitor the progress of disease. For example:
While these innovations in medicine have significantly, and positively, affected the health of the population, they also pose a challenge for health care practitioners to keep their skills up-to-date. Just reading about advances (as compared to active training in or experience with new techniques) is a daunting task. For instance, according to an analysis of MEDLINE entries, the number of citations reporting on randomized controlled trials has increased from an average of 509 annually between 1975 and 1980 to 8,636 annually from 1993 through 1997 (McGlynn, 1998). Although no practitioner needs to follow advances across all areas of medicine and surgery, rapid expansion of knowledge is occurring even within specific areas. Randomized controlled trials published on coronary artery disease increased from about 6 per year between 1975 and 1980 to 149 per year between 1993 and 1997. For diabetes, the growth was from about 6 per year to about 176 per year in the same time periods. For asthma, citations increased from 13 to 200 annually. And, while there were no randomized trials reported in the literature on laser surgery between 1980 and 1985, about 30 were published per year between 1993 and 1997.
Randomized trials represent only one type of study report that practitioners are expected to track. Large observational studies also contribute new insights into the science of medicine. Considerable attention is being paid to methods for making information more readily available to practitioners, such as through the Internet and information systems within health plans. Meta-analysis, a technique that summarizes findings across multiple studies, is another mechanism that may assist practitioners in understanding the "bottom line" message from the literature. Only one citation classified as a meta-analysis appeared between 1985 and 1990, compared with 416 annually between 1993 and 1997.
There also has been an explosion in the availability of practice guidelines, which increasingly are viewed as mechanisms for communicating information about best practices. Between 1975 and 1980, about 1 publication annually was classified as a practice guideline, compared to 454 annually between 1993 and 1997. Initial resistance among practitioners to guidelines has given way to active participation in constructing such guidelines (Hoyt, 1997). The Directory of Clinical Practice Guidelines, published by the American Medical Association (AMA), currently lists 1,700 clinical practice guidelines. A survey of physician medical groups and independent practice associations found that 87 percent were developing or implementing guidelines to accomplish either cost containment or quality improvement goals (Fang et al., 1996).
The proliferation of guidelines and concerns about the scientific basis for guidelines in general led the AMA to create the Clinical Practice Guidelines Recognition Program, which will identify evidence-based guidelines meeting a set of criteria developed by a partnership among the AMA, national medical specialty societies, the Agency for Health Care Policy and Research (AHCPR), the American Hospital Association, and the Joint Commission on Accreditation of Healthcare Organizations. In addition, the AHCPR, the AMA, and the American Association of Health Plans are working jointly to develop a comprehensive, Internet-based source of clinical practice guidelines. The initiative, known as the National Guideline Clearinghouse (NGC), will make available a full range of current guidance on treatments for specific medical conditions. The NGC will make full-text clinical practice guidelines, abstracts, summaries, and comparisons available to every physician, health plan, provider, purchaser, and consumer with access to the Internet. It is anticipated that the NGC will be launched on the Internet in the fall of 1998.
While the "science" of health care advances, increasing attention is being paid to the "art" of health care as reflected in patient evaluations of their experiences with care. While there is a growing emphasis in health care on patient-provider partnership efforts, patients and their health care providers do not always agree on the importance of different elements of care. One study found differences between doctors and their patients on the importance of 73 of 125 elements of care (Laine et al., 1996). Patients ranked provision of information as the second most important aspect of care (behind clinical skill), whereas physicians ranked information sixth. Communication can affect health outcomes. A review of 21 studies found that in 16 a positive relationship between good doctor-patient communication and health outcomes was documented (Stewart, 1995). Outcomes that were positively influenced included emotional health, symptom resolution, function, clinical outcomes, and pain control.
Poor communication can lead to patient failure to adhere to recommended treatment regimens. A study in five urban teaching hospitals in the Northeast found that dissatisfaction with discharge instructions was a key factor that resulted in 12 percent of patients not filling their prescriptions (Thomas et al., 1996). A study conducted in Canada found that 20 percent of hospitalized patients reported that they were not told about important side effects of medications they were taking and 20 percent of patients undergoing tests indicated that results were not explained (Charles et al., 1994).
In summary, we know enough from the results of studies of variability, overutilization, underutilization, and errors to draw some conclusions about the level of quality. We know that there is a gap between best practices and actual practices. We know that even highly trained health professionals make mistakes from time to time. And we know that the likelihood that any one of us will get the best care possible varies considerably.
Another method for improving care is structured encounter forms that serve to prompt practitioners to provide certain processes during single or multiple encounters. Prenatal care forms are one example. A randomized trial involving pediatric house staff found that the group using a structured form that included key developmental milestones had greater adherence to standards of developmental screening than the group without the form. Parent satisfaction also was higher (Zenni and Robinson, 1996).
Feedback to practitioners about their performance relative to expectations is another method that has been used to improve quality. New York State's Cardiac Reporting System is one of the best known examples of successful public feedback of results. Risk-adjusted mortality rates following coronary artery bypass graft surgery are published for individual hospitals and physicians in the State. Between 1989 and 1992, a 41 percent decrease in risk-adjusted mortality in the State was documented (Hannan et al., 1994). Private feedback to practitioners about performance is more common. For example, a combined strategies trial using an evidence-based protocol, an opinion leader, CME rounds, and feedback demonstrated a reduction in the use of superficial cultures to evaluate sepsis in neonates from 50.5 percent to 6.9 percent (Paes et al., 1994).
Reminder systems have been used to help both patients and practitioners increase adherence to preventive service recommendations. A study of patient-directed methods for improving mammography rates compared three strategies: (1) mailed birthday card reminders; (2) a personalized letter from the medical director with educational materials enclosed; and (3) phone calls that included reminders, counseling, and appointment scheduling. Although overall rates of adherence were small, the most effective strategy was phone calls (28 percent), followed by birthday reminders (15 percent), and then mailed materials (9 percent) (Davis et al., 1997).
As with health care practitioners, consumer education strategies alone do not appear to be effective. For example, a randomized trial of a patient education program designed to reduce emergency room use for persons with asthma found no difference between the control and intervention groups in the first year following the intervention (Shields et al., 1990). A study of methods for improving influenza vaccination rates among the elderly combined community-based education with making the shots available for free. The educational intervention alone improved rates from about 41 percent to 54 percent; the addition of free shots increased rates from 41 percent to 64 percent (hospital-based) and 69 percent (physician-based) (Ives et al., 1994).
One starting point for quality improvement programs may be to examine the factors contributing to errors in processes or outcomes of care. For example, an assessment of factors contributing to errors in an intensive care unit found that human error was a factor in 55 percent of incidents and that violations of practice standards were a factor in 28 percent (Buckley et al., 1997). Both direct observation and monitoring systems were used to detect errors. A prospective observational study of the causes of adverse events in the hospital found that about 18 percent of patients experienced an adverse event and that 38 percent of these were caused by an individual, 16 percent were the result of systems factors, and 10 percent were due to administrative decisions (Andrews et al., 1997).
A related approach is to examine the processes by which certain interventions are provided, particularly those that require several steps to accomplish a goal. For example, staff in a health maintenance organization (HMO) examined the processes by which complete blood counts, mammograms, and surgical consultations were ordered and provided across nine clinics in the system. Variations in both the intent and successful implementation of steps in each of these interventions were noted; enhanced information systems were identified as one potential solution to some of the problems identified (Banks et al., 1995).
System redesign has been used frequently to improve the use of preventive services, particularly by reducing missed opportunities to provide the intervention. For example, to improve rates of mammography, medical assistants and licensed practical nurses were trained to determine if a woman visiting the clinic was due for a mammogram and, if so, were allowed to offer and order the test. The proportion of visits in which women were up-to-date on mammography screening increased in the intervention clinic from 68 percent to 77 percent compared with a 1 percentage point increase in one control clinic and a 2 percentage point decline in another control clinic (McCarthy et al., 1997).
Large-scale systems redesign has been shown to be effective in improving adherence to preventive service recommendations. For example, at Group Health of Puget Sound, a combination of strategies has demonstrated effectiveness. Eighty-nine percent of enrolled children have complete immunizations, the proportion of smokers has declined from 25 percent to 17 percent, bicycle helmet use among children has increased from 4 percent to 48 percent, and head injuries for this group decreased 67 percent (Thompson et al., 1995).
Quality improvement programs are designed around a team model, and the effective functioning of the team is likely to be critical to the success of the enterprise. A study of quality management teams in Veterans Administration hospitals found that commitment to total quality management by the facility and practitioners along with the number of teams involved in active quality improvement projects explained a substantial portion of the variation in quality improvement realized across the hospitals (Lammers et al., 1996). Inappropriate prescribing of medications for elderly outpatient veterans on multiple drug regimens was significantly reduced by adding a clinical pharmacist to the treatment team (28 percent decline in the intervention groups vs. 5 percent in the control group at 12 months) (Hanlon et al., 1996).
What is needed to move forward? Significant advances have been made in the methods of quality measurement so that it is possible to assess the quality of care for diverse conditions in a variety of settings. We need to implement such measurement activities systematically, and on a broad national scale. This will require investment in people, methods, and data systems. We also need to find mechanisms for making the lessons of quality improvement available to all participants in the health care industry. The quality of services can be improved, but doing so requires an understanding of the extent of the gap between standards and actual practice, the likely causes of the gap, effective tools for closing the gap, and a cultural change that values engaging in ongoing quality improvement.
To accomplish these vitally important aims, the United States needs a national commitment to the measurement, improvement, and maintenance of high-quality health care for all its citizens. The body of this report lays out a series of steps that must be taken by all sectors -- public and private -- to achieve the goal of a quality health care system for all Americans.
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