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Quality of Care

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Everyone should be concerned about health care quality

Problems in the U.S. health care system include underuse, overuse, and misuse of health care services. These problems occur in small and large communities alike, in all parts of the country, and with about equal frequency in managed care and traditional fee-for-service systems of care. Overall quality of care is the problem, not managed care, according to a recent report by the Institute of Medicine's National Roundtable on Health Care Quality. The report, supported in part by the Agency for Health Care Policy and Research (contract 290-95-2006), warns that current efforts to improve U.S. health care will not succeed without a major, systematic effort to overhaul the delivery of health care services, education and training of clinicians, and assessment and improvement of care quality.

The report cites underuse, such as missed immunizations or missed opportunities to detect and treat diseases such as hypertension or depression; overuse, such as prescribing an antibiotic for a viral infection like a cold; and misuse, such as avoidable complications of surgery or adverse drug events. For instance, medication-related injuries occur at the rate of about 2,000 per year in each large teaching hospital; about 28 percent of these injuries are preventable. As noted in the report, underuse is not confined to managed care plans. Between 40 percent and 60 percent of patients in selected HMO and fee-for-service populations do not receive needed care or services known to be effective for specific conditions.

At present, quality improvement efforts are sporadic at best and usually are limited to single, large hospitals. Fee-for-service plans encourage overuse; capitation payments encourage underuse. No current payment system systematically rewards excellence in quality. The Roundtable concludes that everyone has a stake in improving health care quality, and they recommend that health care professionals take the lead and play an active role in quality improvement.

Details are in "The urgent need to improve health care quality," by Mark R. Chassin, M.D., M.P.P., M.P.H., Robert W. Galvin, and the National Roundtable on Health Care Quality, in the Journal of the American Medical Association 280(11), pp. 1000-1005, 1998.

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