A study last week exposing serious deficiencies in basic healthcare delivery bolstered the federal government's budding campaign to hold providers accountable for accepted indicators of care quality, a top Medicare official said.
The study by the Rand Corp. in the June 26 New England Journal of Medicine, which found that U.S. adults fail to receive recommended care nearly half the time, is "a dramatic portrayal of the challenge we have regarding quality today," said Barbara Paul, director of quality measurement and health assessment at the Centers for Medicare and Medicaid Services.
The Rand study of 30 common health problems kept track of 439 clinical indicators of care for conditions such as asthma, colorectal cancer, diabetes, heart disease and pneumonia.
A CMS-backed pilot project, in which hospitals are reporting their performance on 10 quality indicators for three disease conditions, was launched in December 2002; results will be posted on the CMS Web site after Labor Day, Paul said. The experiment in gathering and compiling quality statistics has the support of the American Hospital Association, the Federation of American Hospitals and other healthcare trade groups and encompasses hospitals in three states and other facilities around the country that volunteered for the pilot (Dec. 16, 2002, p. 8).
By measuring indicators of quality and reporting them to the public, the CMS will stimulate clinicians and hospitals into improving their adherence to clinical protocols that recommend what to do for acute and chronic conditions, Paul said. "The systems that are in place to support clinicians in making good decisions are woefully inadequate," said Paul, a physician. "The amount of information to process day in and day out is enormous, and we need systems in place to help us."
Researchers in the Rand study said the widespread evidence of deficiencies could contribute to thousands of preventable deaths each year, and it shatters the widely held perception that healthcare quality is not a problem. The lack of recommended care persisted despite concerted efforts in recent years by both the federal government and the private sector to improve healthcare delivery, said lead researcher Elizabeth McGlynn.
"Even people who had health insurance and access to healthcare services failed to receive some elements of good care," McGlynn said. "This suggests that just being able to get in the door to see a doctor is no guarantee that you'll receive the care you need."
Paul said the report was not about bad doctors or bad hospitals, but about the dearth of detail that providers have at their fingertips when making care decisions or keeping track of what should be done for a patient. The published consequences of inadequate information, she said, should make providers realize the need to increase their information system capability.
The call for better information technology covered not only individual care decisions but also analysis of care across populations.
The key to any future progress will be the routine availability of information on healthcare performance at all levels, the Rand researchers said. "Making such information available will require a major overhaul of our current health-information systems, with a focus on automating the entry and retrieval of key data for clinical decisionmaking and for the measurement and reporting of quality."
But providers also will have to look for creative ways to re-establish physician-patient bonds that aid in the continuity of care, said Nancy Foster, the AHA's senior director of policy. "We hear from the public that many have health plans change so often that they no longer have a relationship with a primary-care physician," Foster said. "We need to reinvent the way we reach out to them."
The comprehensive study of 6,712 adults in 12 metropolitan areas involved random telephone surveys and reviews of patients' medical records with their consent. Among the findings, patients with pneumonia received the accepted medical mix of tests and interventions only 39% of the time. For people with diabetes, the rate of adherence was 45%; for patients with colorectal cancer, it was 54%.
Preventive measures fared even worse. Patients with coronary artery disease received 68% of recommended care, but only 45% of heart-attack patients received medications that could reduce their risk of death by more than 20%, the study said. Similarly, only 25% of diabetes patients had their blood-sugar levels measured regularly; poor control of blood sugar can lead to kidney failure, blindness and amputation of limbs.