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John M. Eisenberg, M.D., M.B.A., Administrator, AHCPR
Before the House Subcommittee on Health and the Environment, October 28, 1997
Mr. Chairman, thank you for giving me the opportunity to address the Subcommittee on the very
timely and important issue of health care quality. As you know, this issue has been of great
concern in the health care system as we continue to witness dramatic changes in the structure and
delivery of care. Today, I would like to provide you with my perspective on quality, not only as
the Administrator of the Agency for Health Care Policy and Research (AHCPR), but as someone
who has only recently left a career in clinical medicine for Government service.
My perspective on the quality of health care is also shaped by my experiences as the Chair of
Medicine at Georgetown University, Chair of the Physician Payment Review Commission (PPRC), and as a professor of medicine.
What is Quality?
At its most basic level, quality is doing the right thing, at the right time, in the right way, for the
right person. The challenge clinicians face every day is knowing what the right thing is, when
the right time is, and what is the right way.
Most health professionals see quality as having three dimensions: structure, process, and
outcome. Structure represents the basic characteristics of physicians, hospitals, other
professionals and other facilities. It describes whether there are well-educated health
professionals, appropriate hospitals, nursing homes, and clinics, as well as well-maintained
medical records and good mechanisms for communication between clinicians. Structure is the
framework in which we practice, and although the education of professionals and the facilities in
which we practice is among the best in the world, let us never take them for granted. I was a
medical educator for 20 years, and believe that Wordsworth had it right when he said, "The child
is father to the man."
If the structure is solid, we can concern ourselves with the process of medical care. Concern for
process suggests that quality is determined not just by having the right people and facilities
available, but also means the right things must get done in the right way. You are familiar with
many of these process indicators. They include questions like did children get immunized? Was
the correct drug given in the correct dose? How long did the patient stay in the hospital?
The third dimension, outcome, reflects the end result of care. Did people get better? Was
disease or disability reduced? Was it reduced as much as it could have been, given what we
know is scientifically possible? This is an area of increasing interest, but one in which what we
don't know is striking. We need to be able to measure the outcomes of care so that we know
which types of care really help patients and so that we can look to instances of poor outcome for
opportunities for improvement.
I have felt for years that we need to ensure that we are protecting the quality of the health care
provided to this Nation's citizens by developing science-based, reliable quality measurement and
improvement tools. It is this area to which I devoted my own research and it is for this reason
that I enthusiastically accepted the opportunity to lead AHCPR.
Simply put, we measure quality by looking at whether health care is effective, accountable, safe,
fair, and accessible. All five elements are important, but as one involved in clinical care, I want
to emphasize our accountability for providing safe and effective clinical services. Once
individuals have access to health care and are treated fairly, what is the quality of care to which
they have access?
The context of our discussion about quality is that our country has a market-oriented health care
system. Whether publicly or privately financed, a basic element of market-oriented health care is
the opportunity for informed choices by purchasers, by patients and by those acting on their
behalf. As one expert has said, "Information plus choice equals power." Therefore, an essential
part of health care quality improvement is to empower with information the ultimate consumer of
health care, the patient, the subscriber, the enrollee, the insured life, the beneficiary, the member—or whatever you choose to call the people for whom we provide medical care.
Last year, AHCPR, in conjunction with Kaiser Family Foundation, conducted a nationally
representative survey on Americans' need for and use of information regarding quality of health care. The survey found that 42 percent of Americans surveyed say that quality of care is their
biggest concern in choosing a health plan, yet 61 percent have not seen information comparing
the quality of health plans, doctors, or hospitals.
We need an infrastructure in place that will provide consumers with information on health care
quality. This information should include outcomes of treatments, patient assessments, and other
Today I would like to concentrate on the clinical aspects of quality once someone has gained
access to care.
Clinicians want to do the right thing. Physicians and other health care professionals need better
scientific information on which treatments are most appropriate for which patients and at what
point during the course of their care. What I am emphasizing is building the evidence base for
clinical practice. I can not overstate the importance of this evidence base. It gives health care
professionals the information they need to make effective, timely diagnoses and to provide
appropriate treatment. The famous medical sociologist Renee Fox has said that there are two
levels of uncertainty in medical practice—not knowing what the facts are about what is best, and
not knowing whether anyone knows. Health professionals need to know what works to provide
quality health care, and their patients deserve no less.
The ever-changing, ever-growing medical literature is making it difficult for busy physicians and
other health care professionals to keep up with the latest scientific evidence. For example, it is
estimated that if a physician were to read two peer-reviewed journal articles each night, at the
end of the year, he would be 800 articles behind in his reading. While it is good to have a large body
of information, we need to provide this information in a useful format.
Having a readily accessible evidence base for treatment also will help improve the
communication between patients and their doctors. Together physicians and their patients can
use this information to find the most effective, appropriate, and least burdensome treatment. I
have often worked with patients to find sources of information that will provide them with
scientifically valid information about their conditions and treatments. This sharing of
information and communication is the foundation of a good doctor-patient relationship.
In my role as the head of a federal health agency, I see the importance of providing a sound
evidence base for clinical practice in order to assure and improve its quality. This is invaluable
to a health care system that is faced with the critical issue of what care is appropriate. Medical
practice varies widely in this country. You may have seen that the Washington Post recently ran a front page article on the variation of predeath care in the United States. The study, part of Dr.
John Wennberg's 1998 Dartmouth Atlas, shows that the amount of care that Americans receive in their final months of life varies according to the part of the country they live in. For
example, Dr. Wennberg found that people on the east coast are more than twice as likely to die
in the hospital as are people on the west coast. Such variation compels us to study what care is
appropriate, how much is enough, and what is fair.
Let me qualify that variation is not inherently bad. In some cases, variation is caused by
geographical, epidemiological, or cultural preferences. For example, we expect to have a higher
rate of skin cancer in the South, and therefore more treatment for skin cancer. We need more
research on and knowledge about health care outcomes to understand whether variation in
medical practice should be celebrated or eliminated.
Variation also may point to areas of uncertainty or inconsistencies in how health care is delivered
in this country. What those inconsistencies mean is a subject for further research and data
collection, and point to the need for better information on what works, when and for whom.
We know, for example, that there is a 20- to 80-percent variation in immunization rates among the
managed care organizations reported to the National Committee for Quality Assurance (NCQA)
for its recently released 1997 Quality Compass. This report details rankings of managed care organizations along a wide variety of indicators including immunization, mammography, and
Information for Improved Choice
An important component of variation is personal preference. Patients and their clinicians must
weigh personal preferences when making health care decisions. For example, research has
indicated that some patients with laryngeal cancer would rather risk living fewer years than
undergo a procedure that would cause them to lose their voices. For them, the issue is not the
length of their lives but the quality of their lives. That is a decision about outcomes that patients
make reflecting their own priorities, their own values, their own choices.
Although individual preferences are important, we know that there are some essential issues of
quality that are common to all patient encounters. We know that certain drugs and certain
immunizations should be given in certain clinical circumstances. Our challenge is to provide
consumers with information on quality that will help them make decisions about the care they
receive according to their individual needs and desires.
These decisions about the clinical services that will serve patients' needs represent one level of
choice that requires valid information. When we decide on a health plan and a clinician or
hospital we deserve the kind of information we can get when choosing a car, a home, and most
other products and services that we use our limited resources to buy.
The Kaiser/AHCPR survey I mentioned earlier found that a large majority of Americans (nearly 90 percent in every case) felt that quality information—such as how a plan cares for its members who
have health problems, ease of getting care, and success in treating or managing disease—was
"very important" when choosing a health plan.
With the growing complexity of the marketplace, the demand for this kind of information is
growing. We cannot leave the other health care stakeholders out of the mix. We must also
ensure that health plans, purchasers, large corporate purchasers, and small
businesses also have the information they need to make good decisions.
Quality Measurement and Improvement
Certainly a key element in quality health care is to ensure that the three elements are in place—that
the structure of the system is strong and that clinicians are able to know what to do and are able
to do it with skill and expertise. We also need to measure how well we do in the structure and
process of care, to measure the outcomes we achieve, and to identify areas where there is an
opportunity for improvement. We need to develop more and better measures that accurately
measure quality. We also need to communicate the results in useful, understandable formats that
help improve health care decisionmaking. And, it is critically important that this information is
available in the public domain.
We have been successful in doing this in the automobile industry. For instance, if I am buying a
car, I know that I can find data on the safety, efficiency, and reliability of different car models.
This data is based on accepted measurements, such as crash tests, service records, and fuel
Like the automobile industry, we must make it the goal for our health care system to provide
similar information on the quality of health care services. To that end, we must strive to develop
accepted measures and instruments used to gauge and improve the quality of health care services.
I am not suggesting that all providers and plans in every clinical setting and every region in this
country be evaluated using the exact same measures. Measures and instruments should not be
one-size-fits-all, but should reflect the diversity of needs and uses. What I am advocating is a
"department store" of accepted quality measures, all based on science and validated for reliability
and usefulness, where users of measures can pick the set that fits their need, whether that need is
to compare health plans or providers, or to conduct a hospital quality improvement project.
The Public Role
As a physician who has had experience providing care in a Veterans Affairs hospital and has
cared for Medicare beneficiaries, I have had the opportunity to gain insight into the public role in
providing and paying for care. Our responsibility for quality includes Government's role as
purchaser and provider, but goes beyond this level to serve to help the health care market work as
effectively as possible for all Americans.
In my view, it is the responsibility of Government, in partnership with the private sector, to
ensure that the science of performance measurement matures in a way that promotes effective,
efficient, and reliable measurement and reporting. Government's contribution in this partnership
plays out in four critical areas.
One, the Government supports and conducts the basic research underpinning the science of
quality measurement and quality improvement. Resting on the strong foundation of outstanding
biologic research by our colleagues such as those at the National Institutes of Health, AHCPR supports health services research about the effectiveness and outcomes of medical care that serves as an essential building block for quality
measurement. This research provides the evidence needed about what works and doesn't work
in health care practice, and hence what can be measured and improved.
Two, the Government can put science into practice by supporting the development and
testing of measurement tools and instruments.
A third and unique Government contribution is that the research, measures, and tools
developed by us and our partners are in the public domain available for all to use. There were
many times during my years of practice and as Chief of Medicine at Georgetown that I wished
that we had access to a toolbox of quality measures that would have enabled us to measure
quality and patient outcomes better.
Last, but by no means least, the fourth major role of Government is the implementation of
quality measures within Government health programs. The Government is the largest purchaser
of health care in the Nation, accounting for more than 43 percent of health care dollars, and is
entrusted with the care of many of this Nation's most vulnerable citizens. It is our responsibility
to ensure that we are providing the highest quality care to our beneficiaries and that taxpayer
dollars are being used to buy services based on quality and value. How do we hope to achieve
these goals? By developing, testing, and using science-based measures and using the results to
improve quality either through consumer choice strategies or quality improvement projects.
Mr Chairman, while quality of care is difficult to define, we are making progress in that
direction. We know that consumers, physicians, and the health care system as a whole need
information on what works and what doesn't work in health care. This information is critical,
and as I have seen through my career, essential to improving the quality of care provided in this nation.
Goldstein, A. "Dying Patients' Care Varies Widely by Place, Study Says." Washington Post, October 15, 1997, p. A01.
Wennberg, JE. The Dartmouth Atlas of Health Care. The Center of Evaluative Clinical Sciences, Dartmouth Medical School. Chicago: American Hospital Publishing, 1998.
1997 Quality Compass. Database on CD-ROM available from the National Committee for Quality Assurance, NCQA Publications Center, P.O. Box 533, Annapolis Junction, MD 20701-0533 or phone 1-800-839-6487. Quality Compass Web page: http://www.ncqa.org/tabid/177/Default.aspx