[Show abstract][Hide abstract] ABSTRACT: Context
Despite condition-specific and managed care–specific reports,
no systematic program has been developed for monitoring the quality of medical
care provided to Medicare beneficiaries.Objective
To create a monitoring system for a range of measures of clinical performance
that supports quality improvement and provides repeated, reliable estimates
at the national and state levels for fee-for-service (FFS) Medicare beneficiaries.Design, Setting, and Participants
National study of repeated, cross-sectional observational data collected
in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample
of beneficiaries with a particular condition. Data were collected using medical
record abstraction for inpatient care, analysis of Medicare claims for some
ambulatory services, and surveys for immunization rates. Separate samples
were drawn for each topic for each state.Main Outcome Measures
Beneficiary patients' receipt of 24 process-of-care measures related
to primary prevention, secondary prevention, or treatment of 6 medical conditions
(acute myocardial infarction, breast cancer, diabetes mellitus, heart failure,
pneumonia, and stroke) for which there is strong scientific evidence and professional
consensus that the process of care either directly improves outcomes or is
a necessary step in a chain of care that does so.Results
Across all states for all measures, the percentage of patients receiving
appropriate care in the median state ranged from a high of 95% (avoidance
of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients
with pneumonia screened for pneumococcal immunization status before discharge).
The median performance on an indicator is 69% (patients discharged with heart
failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic
patients having an eye examination in the last 2 years). Some states (particularly
less populous states and those in the Northeast) consistently ranked high
in relative performance while others (particularly more populous states and
those in the Southeast) consistently ranked low.Conclusions
It is possible to assemble information on a diverse set of clinical
performance measures that represent performance on the range of services in
a health insurance program. These findings indicate substantial opportunities
to improve the care delivered to Medicare beneficiaries and urgently invite
a partnership among practitioners, hospitals, health plans, and purchasers
to achieve that improvement.
Figures in this Article
As concern grows that attempts to control the cost of health care will
crowd out quality, evidence has also emerged that quality of care is and has
been far more uneven than previously recognized. The public health report
entitled Healthy People 20101
showed wide gaps between public health performance goals and actual achievements
on many measures, including some delivered by the fee-for-service (FFS) health
care system. Reviews, most notably by Schuster et al,2
showed that there were major gaps in acute, chronic, and preventive care almost
everywhere that studies have been done. More recently, a report from the Institute
of Medicine showed serious problems of harm to patients from medical errors.3 This kind of evidence was reflected in the recommendation
of a recent presidential commission that quality of health care should become
a major national priority.4 Despite condition-specific
and managed care–specific reports, there has been no systematic program
for monitoring the quality of medical care provided to FFS Medicare beneficiaries.
Except for the clinical measures of the Health Plan Employer Data and
Information Set (HEDIS)5 and the Diabetes Quality
Improvement Project (DQIP)6 there is no clinical
quality measure set in general national use. About 4 years ago, the Health
Care Financing Administration (HCFA) began to implement a program to measure
and track the quality of the care for which Medicare pays. Simultaneously,
HCFA committed to using its peer review organization (PRO) contractors to
systematically promote improved performance on the quality measures tracked
under this program using a voluntary, collaborative, and nonpunitive educational
This article describes the 24 initial measures used in this program
and reports the baseline values measured in 1997-1999. The Medicare measurement
system we developed includes most of the HEDIS clinical measures, but it addresses
more conditions, measures more elements of care, and measures the care delivered
to the 85% of Medicare beneficiaries who are covered under FFS. The sampling
frame provides state-level results to target PRO activities, evaluate PRO
and HCFA effectiveness in improving care, and create a national picture of
care under Medicare FFS.
Even though purchasers and beneficiaries are primarily interested in
outcomes, we focused on measuring processes of care critical to outcomes rather
than on measuring outcomes themselves. Five reasons drove this choice: (1)
in comparison to outcomes of care, there is more consensus on appropriate
processes of care and the target rates (nearly 100%); (2) measuring processes
of care generally does not require the risk adjustment that has been so controversial
in comparisons of outcomes; (3) it is easier for providers, practitioners,
and plans to identify and fix the reasons why critical processes of care were
not carried out than to determine why outcomes are not optimal; (4) many important
outcomes take years; and (5) because significant, achievable improvements
in outcomes are generally much smaller in relative terms than improvements
in processes, unrealistic sample sizes are necessary to measure significant
improvements in outcomes. While we report only process measures here, HCFA
intends to track outcomes, risk-adjusted when possible, at the national level
for the targeted conditions.
JAMA The Journal of the American Medical Association 10/2000; 284(13):1670-1676. DOI:10.1001/jama.284.13.1670 · 35.29 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives. To study clinical practice and attitudes in hypertension care amongst general practitioners (GPs) and hospital internal medicine specialists.
Design. Mailed case report questionnaires.
Subjects. Ninety GPs and 69 internal medicine specialists at randomly selected primary health care centres and hospital outpatient departments.
Main outcome measures. Case-bound treatment preferences, treatment goals and return visit planning, and views on factors influencing practice.
Results. The participation rate was 84% and 70%, for GPs and internal medicine specialists, respectively. GPs more often proposed nonpharmacological therapy (P < 0.05), solely and as a complementary treatment, and prescribed more calcium antagonists (P < 0.001), whilst internal medicine specialists prescribed more ACE inhibitors (P < 0.001). Personal experience guides practice more than national consensus and economy, more so with increasing time since specialization.
Conclusions. GPs and internal medicine specialists in Sweden report a hypertension practice closely related to each others' and to the intentions of national guidelines.
Journal of Internal Medicine 04/1995; 237(5):473 - 478. DOI:10.1111/j.1365-2796.1995.tb00872.x · 6.06 Impact Factor
Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. The impact factor represents a rough estimation of the journal's impact factor and does not reflect the actual current impact factor. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.