Improving Health Care Quality
Quality problems are reflected today in the wide variation in use of health care services, the underuse and overuse of some services, and misuse of others. Improving the quality of health care and reducing medical errors are priorities for the Agency for Healthcare Research and Quality (AHRQ).
Every day, millions of Americans receive high-quality health care that helps to maintain or restore their health and ability to function. However, far too many do not. Quality problems are reflected in a wide variation in the use of health care services, underuse of some services, overuse of other services, and misuse of services, including an unacceptable level of errors.
A central goal of health care quality improvement is to maintain what is good about the existing health care system while focusing on the areas that need improvement. Improving the quality of care and reducing medical errors are priority areas for the Agency for Healthcare Research and Quality (AHRQ).
AHRQ is working to develop and test measures of quality, identify the best ways to collect, compare, and communicate data on quality, and widely disseminate information about the most effective strategies for improving the quality of care.
Evidence of Quality Problems
Several types of quality problems in health care have been documented through peer-reviewed research.
Variation in services. There continues to be a pattern of wide variation in health care practice, including regional variations and small-area variations. This is a clear indicator that health care practice has not kept pace with the evolving science of health care to ensure evidence-based practice in the United States.
Underuse of services. Millions of people do not receive necessary care and suffer needless complications that add to costs and reduce productivity. Each year, an estimated 18,000 people die because they do not receive effective interventions. For example, a study of Medicare patients who had suffered heart attacks found that only 21 percent of eligible patients received beta blockers. The mortality rate among patients who received beta blockers was 43 percent lower than it was among nonrecipients.
Another AHRQ-funded study examined the use of beta blockers before heart bypass surgery and found that patients who received beta blocker therapy before surgery had lower rates of death and fewer complications both during and after surgery than patients who did not receive this therapy.
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Overuse of services. Each year, millions of Americans receive health care services that are unnecessary, increase costs, and may even endanger their health. Research has shown that this occurs across all populations.
For example, an analysis of hysterectomies performed on women in seven health plans found that one in six operations was inappropriate. A study examining the use of antibiotics for treating ear infections in children on Medicaid found that expensive antibiotics were used far more often than indicated.
According to the findings, if only half the prescriptions written in 1992 for more expensive antibiotics had been written for amoxicillin, a less expensive but equally effective antibiotic, Colorado's Medicaid program would have saved nearly $400,000 that year.
AHRQ-Supported Research Demonstrates Overuse of Preoperative Testing
A recent study by AHRQ-funded researchers found no differences in outcomes between patients who did and did not undergo routine preoperative testing before cataract surgery. Cataract surgery is the most common operation among the elderly in the United States. In 1996, Medicare beneficiaries had about 1.5 million cataract operations. Routine medical testing before cataract surgery is estimated to cost Medicare $150 million each year.
Cataract surgery is usually an outpatient procedure, and rates of illness and death associated with the procedure are very low. This large randomized study involved nearly 20,000 elective cataract operations in 18,189 patients at nine surgical centers. The overall rate of complications, both during and after surgery, was the same for both groups (31.3 per 1,000 operations). The researchers conclude that routine preoperative testing confers no benefit on patients having cataract surgery.
Misuse of services. Too many Americans are injured during the course of their treatment, and some die prematurely as a result.
For example, a study of injuries to patients treated in hospitals in New York State found that 3.7 percent experienced adverse events; 13.6 percent of these events led to death, and 2.6 percent led to permanent disability. About one-fourth of these adverse events resulted from negligence. A national study found that over a 10-year period (1983-93), deaths due to medication errors rose more than two-fold, with 7,391 deaths attributed to medication errors in 1993 alone.
Disparities in quality. Although quality problems affect all populations, they may be most marked for members of ethnic and racial minority populations. Researchers at the University of Alabama at Birmingham examined the use of thrombolysis ("clot busters") for patients who had experienced a heart attack and found that while this evidence-based life-saving treatment was underused for all, black Medicare beneficiaries were significantly less likely than whites to receive this treatment.
Findings from Recent Research on Health Care Quality
AHRQ and its predecessor agencies—the Agency for Health Care Research and Quality and the National Center for Health Services Research and Health Care Technology Assessment—have been conducting and supporting research on quality for more than two decades.
Following are some examples of findings from recent AHRQ-supported research on quality and quality improvement.
Atrial fibrillation. Thousands of Medicare patients with atrial fibrillation can benefit from a new quality improvement tool developed with support from AHRQ. Researchers found that their new CHADS2 method for predicting risk of stroke in patients with atrial fibrillation is more accurate than existing methods. CHADS2 may be especially helpful for identifying low-risk patients who, by taking aspirin, can avoid the office visits, expense, and side effects associated with warfarin, which carries a risk of bleeding.
Underuse of hip replacement surgery in Hispanic patients. Even when they have insurance, elderly Hispanics undergo far fewer hip replacement operations than elderly non-Hispanic whites. This study of Hispanics aged 65 or older in Texas, New Mexico, Arizona, and Illinois found that they were less than one-third as likely as non-Hispanic whites of the same age to undergo total hip replacement, an operation that can alleviate pain and improve physical function and quality of life in patients with severe osteoarthritis. According to the researchers, underuse of hip replacement surgery by the large and growing U.S. Hispanic population could have important consequences for Medicaid because the resulting excess disability could increase long-term custodial costs.
End-of-life discussions. Findings from this AHRQ study can be used to improve end-of-life care and promote more effective use of health care resources by encouraging discussions between terminally ill HIV patients and their doctors. Half of all HIV-infected people in the United States—especially blacks, Hispanics, injection drug users, and people with low education—never talk about end-of-life care with their doctors. Such discussions could improve physicians' understanding of the care their patients do and do not want when they are very ill and close to death.
Making Quality Count
Following are examples of AHRQ-supported research now in progress that focuses on improving health care quality.
Bringing evidence-based medicine to the hospital bedside. Researchers at the University of Iowa are carrying out a 3-year randomized study at 12 hospitals in Iowa, Missouri, and Illinois to evaluate the effectiveness and cost-effectiveness of implementing an evidence-based acute pain management guideline for hospitalized elderly hip fracture patients. The intervention targets both nurses and prescribing physicians and includes training, computerized learning modules, the use of opinion leaders, the use of feedback and reminder cards, and system interventions for modifying chart forms and institutional policy. The goals are to determine whether a multidimensional organizational intervention alters nurse and physician behaviors and whether institutional barriers to change are reduced.
Evidence-based reminders in home health care. These researchers are comparing the effectiveness of two alternative information-based strategies intended to improve provider performance and promote adherence to evidence-based guidelines among home health care nurses. The study uses a randomized design that assigns nurses to one of two treatment groups or a control group (usual care).
Nurses in the basic intervention group receive "just in time" E-mail reminders highlighting six condition-specific practices they should follow for patients with either heart failure or cancer pain. Nurses in the augmented intervention group receive the same E-mail reminders along with additional information and consulting services from an expert peer.
Understanding variability in community mammography. This community-based, multicenter observational study involves a unique collaboration among three geographically distinct breast cancer surveillance programs in the States of Washington, New Hampshire, and Colorado. The investigators are collecting breast cancer outcomes and interpretive data on more than 500,000 mammograms from 91 facilities and 279 radiologists. The goal is to identify reasons for variability in the interpretation of mammograms and determine how the quality of mammography can be improved.
Racial and ethnic variation in medical interactions. In this 5-year program, researchers at the Baylor College of Medicine and the Houston VA are developing and testing interventions to improve doctor-patient communication patterns to reduce racial and ethnic disparities in use and outcomes. Both clinicians and patients are participating in the project, which also includes an information dissemination component to translate research findings into practice as rapidly as possible.
Otitis media: Parent education to avoid antibiotic use. Acute otitis media (AOM) continues to be a major child health problem. The average child experiences 2.6 AOM episodes per year in the first 2 years of life. The overuse of antibiotics for AOM has led to the emergence of multi-drug resistant pathogens, even though research has shown that 80 to 90 percent of children with AOM will recover without antibiotics.
This randomized controlled trial is evaluating the safety, efficacy, cost to parent, and acceptability of an intervention consisting of parent education, nonantibiotic symptomatic therapy, and careful followup of children with mild AOM. The goal is to establish the safety of withholding antibiotics from children with mild AOM and change parents' expectations about universal antibiotic treatment of AOM.
Benefits of regionalizing surgery for Medicare patients. In this ongoing study, researchers at Dartmouth Medical School are using Medicare data and data from AHRQ's National Inpatient Sample (NIS) to investigate the potential benefits of regionalizing patients who have certain high-risk procedures.
For example, in the April 11, 2002, issue of the New England Journal of Medicine, they reported a 12 percent difference in survival for patients being treated for cancer of the pancreas at high- and low-volume hospitals. Only 4 percent of patients treated at the highest volume hospitals died, compared with 16 percent at the lowest volume hospitals. Indeed, they found that elderly patients undergoing treatment for any 1 of 14 high-risk cardiovascular or cancer operations were more likely to survive if they were treated in high-volume hospitals.
Select for chart on hospital volume and surgical mortality (Figure 2, 6 KB).
Priorities for future research on quality and quality improvement—particularly the overuse, underuse, and misuse of health care services—include:
- Identify which financial and organizational factors promote quality and how different payment methods, financial incentives, and organizational factors affect the behavior of health care organizations, providers, purchasers, and patients.
- Design and implement new care processes that enable patients to act as co-managers of their health care, particularly for chronic illnesses.
- Identify telecommunications applications that will enhance patients' access to information and patient-provider communication.
- Identify effective information technology tools and systems that alert providers in real-time to the critical information they need to provide safer, high quality care.
- Implement and evaluate strategies to improve quality of care for people with disabilities.
- Identify and address factors that promote adoption of promising quality improvement strategies (e.g., patient self-management) by all who would benefit.
To find out more about AHRQ-funded research on health care quality, visit our Web site at https://www.ahrq.gov/research/findings/factsheets/quality/index.html or contact: