Fact Sheet
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).
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Evidence of Problems / Recent Research /
Making Quality Count / Future Research / More Information
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.
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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.
Select for Figure 1 (2 KB).
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.
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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.
|
New Severity Measure for Hospitalized Pneumonia Patients
Hospitalized pneumonia patients who have abnormal vital signs, mental confusion, or
problems with eating or drinking in the 24 hours prior to discharge are more likely than
other pneumonia patients not to be able to resume normal activities on discharge. Also,
they face a greater chance of readmission or death.
AHRQ-supported researchers at Mount Sinai School of Medicine developed a simple
severity-of-illness measure that can be used by clinicians to judge whether it is safe for
a patient to be discharged from the hospital. The measure uses information from the
five vital signs that are checked several times a day in hospitalized patients
(temperature, heart rate, blood pressure, respiratory rate, and oxygen levels in the
blood), as well as assessment of the patient's mental status and ability to eat and drink.
Patients in this study who were discharged with two or more unstable factors had a
five-fold greater risk of readmission or death. Using this instrument, the researchers
found that one in five of the patients they studied had been discharged "medically
unstable." |
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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).
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Future Research
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.
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More Information
To find out more about AHRQ-funded
research on health care quality, visit our
Web site at http://www.ahrq.gov/qual/qualix.htm or contact:
Katherine Crosson, M.P.H., C.H.E.S.
Phone: (301) 427-1328
E-mail: Katherine.Crosson@ahrq.hhs.gov
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AHRQ Publication No. 02-P032
Current as of September 2002
Internet Citation:
Improving Health Care Quality. Fact Sheet. AHRQ Publication No. 02-P032, September 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/qualfact.htm
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