More evidence about how the nation's elderly do not receive high-quality medical care is provided by two new reports published yesterday in the Journal of the American Medical Association.
Specifically, one report noted that the level at which Medicare beneficiaries receive six recommended preventive-medicine services is well below national goals, while the second indicated that hypertension control in elderly patients is "suboptimal."
According to the first report's author, Hoangmai Pham, M.D., a senior health researcher at the Center for Studying Health System Change in Washington, the fact that quality targets are not being met is an old story. She said that the real news generated by her report is how often doctors who are in solo or two-physician practices and are more dependent on Medicaidrevenue fail to deliver routine preventive care.
"The news is the variation," Pham said. "We know from other studies that quality is less than ideal in the U.S. healthcare system."
Pham collected data from the Community Tracking Study Physician Survey on 3,660 physicians caring for 24,581 Medicare beneficiaries in 2001. She found that board-certified physicians in practices with three or more doctors with access to healthcare information technology were more likely to offer eye exams for diabetic patients, hemoglobin A1c testing for monitoring glucose levels, mammograms, colon cancer screening and flu and pneumonia vaccinations.
According to the report, there is an expectation that 100% of the appropriate Medicare beneficiaries will receive an eye exam, hemoglobin A1c monitoring, mammogram and flu vaccination. The overall observed rates, however, were 47.9%, 55.9%, 46.7% and 46.5%, respectively.
Patients visiting a practice where Medicaid accounted for 5% or less of total revenue received more preventive care than those going to doctors where Medicaid accounted for 16% or more of practice revenue. For hemoglobin A1c monitoring, the rates were 61.2% and 48.4%; for mammograms, the rates were 52.1% and 38.9%; and for flu vaccines, they were 50.2% and 39.2%
"Practice structure and practice resources really matter in the delivery of quality care," she said. "The more resources in a practice, the higher the chances the patient will receive quality care."
The variation was not the result of solo practitioners being too busy addressing more immediate concerns to administer preventive care, Pham said, because beneficiary data were adjusted for comorbidities. "I'm sure it's not perfect, but it's a good start for zeroing in on practice," she said. "I also think it's entirely valid to say one physician can't do everything for a particular patient in the time they're allotted."
Pham said that solo physicians serving a low-income patient population may also face financial barriers that limit their ability to hire support staff or invest in information technology. "You don't want to give physicians a pass, but you must also recognize that they are not working in a vacuum," she said.
Because her findings were so consistent across the board, Pham said it was her suspicion that if she looked at 10 other preventive medical services, "we'd see the same thing."
One of the services Pham did not measure was hypertension control, which was targeted by the Institute of Medicine's 2003 report, Priority Areas for National Action: Transforming Health Care Quality, as key to preventing coronary artery disease, congestive heart failure, stroke and other potentially fatal conditions. Previous JAMA studies have indicated that controlling hypertension can avoid 68,000 preventable deaths annually.
According to the other JAMA report released yesterday, people ages 80 and older are particularly at risk.
Donald Lloyd-Jones, M.D., an assistant professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago, analyzed data on 5,296 persons enrolled in the National Heart, Lung and Blood Institute's Framingham Heart Study.
Lloyd-Jones found that the rates for controlled hypertension for patients under 60 years old, ages 60 to 79, and 80 and older were, respectively 38%, 36% and 38% for men and 38%, 28% and 23% in women.
"Control rates among older women are abysmal," Lloyd-Jones said, adding that concerns about mixing multiple prescriptions and prescription costs in general could be leading doctors to avoid treating hypertension aggressively in older patients. Nevertheless, he said these concerns can be managed and should not prevent treatment that can improve quality of life.
"Those concerns are real, but are over-emphasized," Lloyd-Jones said. "We have a lot to gain if we identify these patients with hypertension and take steps toward controlling it. The risk reduction with treatment can be dramatic and clearly outweighs the potential side effects, which can be reduced with good medical management."
View the study abstracts at the JAMA Web site.