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Quality of health care is on the national agenda. In September 1996, President Clinton established the Advisory
Commission on Consumer Protection and Quality in the Health Care Industry, which has released its final report on how to define, measure, and promote quality of health care (President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry 1998).
Much of the interest in quality of care has developed in response to the dramatic transformation of the health care system in recent years. New organizational structures and reimbursement strategies have created incentives that may affect quality of care. Although some of the systems are likely to improve quality, concerns about potentially negative consequences have prompted a movement to assure that quality will not be sacrificed to control costs.
The concern about quality arises more from fear and anecdote than from facts; there is little systematic evidence about quality of care in the United States. We have no mandatory national system and few local systems to track the quality of care delivered to the American people. More information is available on the quality of airlines, restaurants, cars, and VCRs than on the quality of health care.
We have conducted a review of the academic literature for articles on quality of care in the United States, and we summarize our findings in this article. In the absence of a national quality tracking system, we believe such a summary is the best way to provide an overview of the quality of care delivered in the United States. We provide examples to illustrate quality in diverse settings, for diverse conditions, and for diverse demographic groups, and to offer insight into the quality that exists nationwide.
Methods
Definitions
The Institute of Medicine has defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr 1990).
Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cultural sensitivity. In practical terms, poor quality can mean too much care (e.g., providing unnecessary tests, medications, and procedures, with associated risks and side effects), too little care (e.g., not providing an indicated diagnostic test or a lifesaving surgical procedure), or the wrong care (e.g., prescribing medicines that should not be given together, using poor surgical technique).
Quality can be evaluated based on structure, process, and outcomes (Donabedian 1980). Structural quality evaluates health system characteristics, process quality assesses interactions between clinicians and patients, and outcomes offer evidence about changes in patients’ health status. All three dimensions can provide valuable information for measuring quality, but the published quality-of-care literature reveals that there is more experience with measuring processes of care.
Two particular techniques, which measure a type of process quality called “technical process quality,” dominate the literature.
Technical process quality refers to whether care is provided skillfully and whether the right choices are made in diagnosing and treating the patient. The latter (making the correct choices) is generally measured by assessing appropriateness or adherence to professional standards.
An intervention or service (e.g., a lab test, procedure, medication) is considered appropriate if, for individuals with particular clinical and personal characteristics, its expected health benefits (e.g., increased life expectancy, pain relief, decreased anxiety, improved functional capacity) exceed its expected health risks (e.g., mortality, morbidity, anxiety anticipating the intervention, pain caused by the intervention, inaccurate diagnoses) by a wide enough margin to make the intervention or service worth doing (Brook et al. 1986). A subset of appropriate care is necessary or crucial care. Care is considered necessary if there is a reasonable chance of a nontrivial benefit to the patient and if it would be improper not to provide the care. In other words, it might be considered ethically unacceptable not to provide this care (Kahan et al. 1994; Laouri et al. 1997). Appropriateness criteria and necessity criteria can be used, respectively, to measure overuse of care, which is a problem because of treatment complications and wasted resources, and underuse of care, which means that people are not getting care expected to improve their health.
Another way to measure process quality is to determine whether care meets professional standards. This assessment can be done by creating a list of quality indicators that describe a process of care that should occur for a particular type of patient or clinical circumstance and then evaluating whether patients’ care is consistent with the indicators. Quality indicators are based on standards of care, which are either found in the research literature and in statements of professional medical organizations or determined by an expert panel. Current performance can be compared against a physician's or plan's own prior performance, against the performance of other physicians and plans, or with reference to a benchmark that establishes a goal. Indicators can cover a specific condition (e.g., children with sickle cell disease should be prescribed daily penicillin prophylaxis from at least six months of age until at least five years of age), or they can cover general aspects of care regardless of condition (e.g., patients prescribed a medication should be asked about medication allergies).
Literature Review
Our review is based on a search of articles in the National Library of Medicine's Medline Plus system (1993 to present) conducted in June 1997 and on studies identified from the bibliographies of these articles. We excluded articles published before 1987. We did not aim to be exhaustive but, rather, to find examples that cover a broad range of conditions and settings. We report data only from large or diverse populations, such as the nation, an entire state, an entire city, or several hospitals. We do not include data from studies that covered only a single hospital or clinic.
Categorization
Our review of quality in the United States is divided into three categories based on type of care: preventive (Table 1), acute (Table 2), and chronic (Table 3). We have chosen this categorization because there are differences in the way these types of care are delivered that could affect quality. Preventive care is typically initiated on a routine basis by the clinician rather than on an episodic basis by a patient coming to the clinician with symptoms, and it is generally not covered as well by insurance. The need for acute care is typically identified by the patient, and the care is often delivered during a single encounter. Chronic care is more likely than acute care to be delivered by a clinician who has an ongoing relationship with the patient, and good chronic care is also more likely to involve good follow-up. The tables describe the health care service for which quality is reported, the sample on which the report is based, the data source for the sample, the findings, and the reference for the findings. We report on data from 48 articles covering about one-half million people.
Mark A Schuster, Elizabeth A McGlynn, and Robert H Brook
