How Good Is the Quality of Health Care in the United States?

How Good Is the Quality of Health Care in the United States?

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Description: Researchers have found deficits in health care quality for more than four decades. Attempts to develop a more comprehensive method for measuring quality of care for the population, use this method to estimate the quality of care nationally, by community, by population characteristics, translate findings into information accessible to different audiences, and calibrate the likely effects of quality deficits on the health and well being of the American public.

 
Author: Elizabeth A. McGlynn, Ph.D. (Fellow) | Visits: 2298 | Page Views: 2303
Domain:  Medicine Category: Practice Mngmnt Subcategory: Quality 
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Contents:
How Good Is the Quality of Care in the United States?

Elizabeth A. McGlynn, Ph.D. March 24, 2006

What Do We Know About Quality?
� Researchers have found deficits in quality for more than
four decades � Morehead (1962): 57% of hospital care optimal � Payne (1970): 41% of ambulatory care acceptable � Schuster, McGlynn, Brook (1998 review): 50%-70% of recommended care received � But, most people do not believe there is a quality problem � Little information on quality routinely available � Information is poorly presented � Bad care doesn't always produce bad results

McGlynnDrew-2 03/24/06

What Did We Set Out to Do?
� Develop a more comprehensive method for
measuring quality of care for the population: QA Tools

� Use this method to estimate the quality of care
nationally, by community, by population characteristics different audiences

� Translate findings into information accessible to � Calibrate the likely effects of quality deficits on the
health and well being of the American public

McGlynnDrew-3 03/24/06

QA Tools: Developing a Comprehensive Measure of Technical Quality
� Selected 30 clinical areas representing about half
of reasons people seek care

McGlynnDrew-4 03/24/06

QA Tools Clinical Areas
� � � � � � � � � � � � � � � � Alcohol dependence Asthma Atrial fibrillation Breast cancer Benign prostatic hyperplasia Cataracts Chronic lung disease Colorectal cancer Congestive heart failure Coronary artery disease Depression Diabetes mellitus Dyspepsia/peptic ulcer Family planning Headache Hip fracture � � � � � � � � � � � � � � � Hyperlipidemia Hypertension Hysterectomy Low back pain Menopause management Orthopedic conditions Osteoarthritis Pain & palliative care for cancer Pneumonia Prenatal care & delivery Preventive care Prostate cancer Sexually transmitted diseases Stroke Urinary tract infection

McGlynnDrew-5 03/24/06

QA Tools: Developing a Comprehensive Measure of Technical Quality
� Selected 30 clinical areas representing about half
of reasons people seek care

� Developed specific standards, or indicators, within
each clinical area based on literature reviews

McGlynnDrew-6 03/24/06

Sample Standards (Chronic Care)
� (Asthma) Patients presenting to the physician's office
or ER with an FEV1 or PEF < 70% of baseline should be treated with beta2-agonists before discharge.

� (Benign prostatic hyperplasia) Patients diagnosed with
BPH who report symptoms of moderate prostatism should have treatment options discussed or offered within one month of the note of symptoms.

� (Hyperlipidemia) Patients with pre-existing coronary

disease with an LDL > 130mg/dl should begin diet or drug therapy within 3 months.

McGlynnDrew-7 03/24/06

QA Tools: Developing a Comprehensive Measure of Technical Quality
� Selected 30 clinical areas representing about half
of reasons people seek care

� Developed specific standards, or indicators, within
each clinical area based on literature reviews

� Convened 45 experts, each nominated by specialty
societies to evaluate proposed standards

McGlynnDrew-8 03/24/06

QA Tools: Developing a Comprehensive Measure of Technical Quality
� Selected 30 clinical areas representing about half
of reasons people seek care � Developed specific standards, or indicators, within each clinical area based on literature reviews � Convened 45 experts, each nominated by specialty societies to evaluate proposed standards � Developed computer-assisted medical record abstraction software to collect necessary data

McGlynnDrew-9 03/24/06

Example: Data Needed to Evaluate Adherence to Standards
Type 2 diabetics who have failed dietary therapy should receive oral hypoglycemic therapy.

Concept Eligibility Type 2 diabetics

How to Identify the Data Element � History of diabetes � Visit where problem is diabetes � Type 2 specified or type not specified

Failed dietary therapy

� Note in medical record or 2 elevated HbA1c (>8.5) and not on oral hypoglycemics � Match to list of eligible drugs � Date failure date � Note in medical record
McGlynnDrew-10 03/24/06

Scoring On oral hypoglycemics Refused treatment

What Did We Set Out to Do?
� Develop a more comprehensive method for
measuring quality of care for the population: QA Tools � Use this method to estimate the quality of care nationally, by community, by population characteristics � Translate findings into information accessible to different audiences � Calibrate the likely effects of quality deficits on the health and well being of the American public

McGlynnDrew-11 03/24/06

Where Was the Study Done?


SEATTLE

LANSING



SYRACUSE � BOSTON


CLEVELAND � � NEWARK INDIANAPOLIS


ORANGE COUNTY




PHOENIX

LITTLE ROCK


GREENVILLE




MIAMI

McGlynnDrew-12 03/24/06

Data Sources
� Telephone interviews (demographics, health
history, some process measures)

� Medical records from all providers (i.e., physicians,
facilities) for the two years preceding the date of the telephone interview

McGlynnDrew-13 03/24/06

Participants Differ from the General Population
Characteristic Age (years) Female (%) Education (years) Nonwhite (%) Participants 45.5 59.6 13.7 18.6 Nation 33.1 50.9 13.0 24.9

McGlynnDrew-14 03/24/06

Constructing Quality Scores
Score = # of times recommended care was given # of opportunities to deliver recommended care

McGlynnDrew-15 03/24/06

What Did We Set Out to Do?
� Develop a more comprehensive method for
measuring quality of care for the population: QA Tools � Use this method to estimate the quality of care nationally, by community, by population characteristics � Translate findings into information accessible to different audiences � Calibrate the likely effects of quality deficits on the health and well being of the American public

McGlynnDrew-16 03/24/06

Overall, About Half of Recommended Care Is Received

Care that meets quality standards

McGlynn et al, 2003
McGlynnDrew-17 03/24/06

There Is Substantial Room for Improvement Across All Types of Care
Chronic

Preventive

Acute

0
McGlynn et al., 2003

20

40

60

80

100

% of standards passed
McGlynnDrew-18 03/24/06

Quality of Care for Cardiopulmonary Problems Varies Widely
Coronary artery disease Hypertension Heart failure Stroke Chronic lung disease Asthma High cholesterol Pneumonia Atrial fibrillation 0
McGlynn et al., 2003

20

40

60

80

100

% of standards passed
McGlynnDrew-19 03/24/06

Significant Variation Exists in Management of Adults' General Medical Problems
Cataracts Low back pain Depression Osteoarthritis BPH Headache Diabetes Ulcers Alcohol dependence 0
McGlynn et al., 2003

20

40

60

80

100

% of quality standards passed
McGlynnDrew-20 03/24/06

And You Aren't Safe Anywhere...
Boston Cleveland Greenville Indianapolis Lansing Little Rock Miami Newark Orange Co Phoenix Seattle Syracuse
30 Kerr et al., 2004 40 50 60 70 80 90 100

Overall

% of recommended care received
McGlynnDrew-21 03/24/06

And You Aren't Safe Anywhere...
Boston Cleveland Greenville Indianapolis Lansing Little Rock Miami Newark Orange Co Phoenix Seattle Syracuse
30 Kerr et al., 2004 40 50 60 70 80 90 100

Overall Preventive

% of recommended care received
McGlynnDrew-22 03/24/06

And You Aren't Safe Anywhere...
Boston Cleveland Greenville Indianapolis Lansing Little Rock Miami Newark Orange Co Phoenix Seattle Syracuse
30 Kerr et al., 2004 40 50 60 70 80 90 100

Overall Preventive Acute

% of recommended care received
McGlynnDrew-23 03/24/06

And You Aren't Safe Anywhere...
Boston Cleveland Greenville Indianapolis Lansing Little Rock Miami Newark Orange Co Phoenix Seattle Syracuse
30 Kerr et al., 2004 40 50 60 70 80 90 100

Overall Preventive Acute Chronic

% of recommended care received
McGlynnDrew-24 03/24/06

No One Is Immune From Quality Deficits
Gender

Male Female White Black Hispanic Other

Race

Age

18-30 31-64 65+

0

20

40

60

80

100
McGlynnDrew-25 03/24/06

% of recommended care delivered

Money Doesn't Buy Quality

Income

>$50K $15-50K $15K Medicare > None $15-50K>$15K >$50 > $15K M>F Chronic F>M 31-64>18-30 B>W Preventive F>M 18-30 > 31-64> 65+ B>W, H>W

McGlynnDrew-27 03/24/06

But This Defies the Conventional Wisdom
Other Stuff

Health Status

Access

Care Processes

Health Outcomes

McGlynnDrew-28 03/24/06

What Did We Set Out to Do?
� Develop a more comprehensive method for
measuring quality of care for the population: QA Tools � Use this method to estimate the quality of care nationally, by community, by population characteristics � Translate findings into information accessible to different audiences � Calibrate the likely effects of quality deficits on the health and well being of the American public

McGlynnDrew-29 03/24/06

Does It Matter If Standards Are Met?
Condition Diabetes What We Found Preventable Complications/ Deaths (Annual) 2,600 blind; 29,000 kidney failure 68,000 deaths 37,000 deaths 10,000 deaths 9,600 deaths
McGlynnDrew-30 03/24/06

Blood sugar not measured for 40%; 24% uncontrolled Hypertension Blood pressure uncontrolled in 58% Heart attacks 39-55% did not receive needed medications Pneumonia 36% no vaccine Colon cancer 62% not screened

Does It Matter If Standards Are Met?
Condition Diabetes What We Found Preventable Complications/ Deaths (Annual) 2,600 blind; 29,000 kidney failure 68,000 deaths 37,000 deaths 10,000 deaths 9,600 deaths
McGlynnDrew-31 03/24/06

Blood sugar not measured for 40%; 24% uncontrolled Hypertension Blood pressure uncontrolled in 58% Heart attacks 39-55% did not receive needed medications Pneumonia 36% no vaccine Colon cancer 62% not screened

Does It Matter If Standards Are Met?
Condition Diabetes What We Found Preventable Complications/ Deaths (Annual) 2,600 blind; 29,000 kidney failure 68,000 deaths 37,000 deaths 10,000 deaths 9,600 deaths
McGlynnDrew-32 03/24/06

Blood sugar not measured for 40%; 24% uncontrolled Hypertension Blood pressure uncontrolled in 58% Heart attacks 39-55% did not receive needed medications Pneumonia 36% no vaccine Colon cancer 62% not screened

Does It Matter If Standards Are Met?
Condition Diabetes What We Found Preventable Complications/ Deaths (Annual) 2,600 blind; 29,000 kidney failure 68,000 deaths 37,000 deaths 10,000 deaths 9,600 deaths
McGlynnDrew-33 03/24/06

Blood sugar not measured for 40%; 24% uncontrolled Hypertension Blood pressure uncontrolled in 58% Heart attacks 39-55% did not receive needed medications Pneumonia 36% no vaccine Colon cancer 62% not screened

What's Needed to Move the Nation Forward?
� Increased public awareness of problem � Information on performance that is easy to access
and understand � Widespread adoption of information systems technologies � Alignment of financial incentives � Tools and skill building for patients and health professionals

McGlynnDrew-34 03/24/06

Care Delivered in the VA More Frequently Meets Quality Standards

Care that meets quality standards

Asch et al, 2004
McGlynnDrew-35 03/24/06

Greatest Differences Found in Metrics & Conditions Included in VA System
VA Metrics & Incentives Different Metrics for VA Conditions No VA Measure 0 20 40 60 80 100 US VA

% of recommended care delivered

Asch et al., 2004
McGlynnDrew-36 03/24/06

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