Who Is at Geatest Risk for Receiving Poor-Quality Health Care?

Department of Medicine , University of California, Irvine, Irvine, California, United States
New England Journal of Medicine (Impact Factor: 55.87). 03/2006; 354(11):1147-56. DOI: 10.1056/NEJMsa044464
Source: PubMed


American adults frequently do not receive recommended health care. The extent to which the quality of health care varies among sociodemographic groups is unknown.
We used data from medical records and telephone interviews of a random sample of people living in 12 communities to assess the quality of care received by those who had made at least one visit to a health care provider during the previous two years. We constructed aggregate scores from 439 indicators of the quality of care for 30 chronic and acute conditions and for disease prevention. We estimated the rates at which members of different sociodemographic subgroups received recommended care, with adjustment for the number of chronic and acute conditions, use of health care services, and other sociodemographic characteristics.
Overall, participants received 54.9 percent of recommended care. Even after adjustment, there was only moderate variation in quality-of-care scores among sociodemographic subgroups. Women had higher overall scores than men (56.6 percent vs. 52.3 percent, P<0.001), and participants below the age of 31 years had higher scores than those over the age of 64 years (57.5 percent vs. 52.1 percent, P<0.001). Blacks (57.6 percent) and Hispanics (57.5 percent) had slightly higher scores than whites (54.1 percent, P<0.001 for both comparisons). Those with annual household incomes over 50,000 dollars had higher scores than those with incomes of less than 15,000 dollars (56.6 percent vs. 53.1 percent, P<0.001).
The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care.

Download full-text


Available from: Claude Messan Setodji, Jul 24, 2014
    • "Nevertheless, health professionals fail to use research evidence, resulting in a gap between evidence-based recommendations and the health care that patients receive. This also results in unwarranted variation in practice and negatively affects quality of care and patient safety (Asch et al., 2006; Flottorp, Jamtvedt, Gibis, & McKee, "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Even though health professionals have a positive attitude toward evidence-based practice (EBP), they have limited skills when it comes to implementation of EBP. A postprofessional program in EPB has been offered at Bergen University College since 2004. To date, there is limited knowledge of how the graduates of the program implement and make use of the EBP principles in their working environment in different healthcare settings. Aim: The aim of the study was to explore the facilitators and strategies to successful implementation of the steps of EBP as experienced by health professionals who had completed a postgraduate program in EBP. Methods: Grounded theory was used in gathering and analyzing data from single and focus group interviews of 20 health professionals who had attended a postprofessional program in EBP. Inclusion criteria also required current clinical practice. Results: This study identified a specific set of activities used by health professionals when implementing EBP within their service organization. Creating an interest and understanding of EBP amongst their colleagues appeared to be a challenge, which they addressed by using the generated grounded theory of "tailoring principles." The dominant condition of this theory was management involvement. Linking evidence to action: This study highlighted the importance of middle-range managers' coordinating and supporting role as a decisive component in the process of implementing EBP to clinical settings in Norway. Moreover, the dynamic complex process of "tailoring principles" also showed how the production of a clinical protocol became an outcome of implementation effectiveness as well as input for further intervention effectiveness. Tailoring the principle of EBP to the organizational and cultural context facilitated the implementation of EBP.
    No preview · Article · Jan 2016 · Worldviews on Evidence-Based Nursing
    • "Quality of care concerns have been published in the media in western industrialized countries for decades [1] [2] [3] [4]. In addition, studies have shown remarkable variability in quality of care across health care providers [5] [6] [7] [8] [9]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Hospitals report cards have been put in place within the past few years to increase the amount of publicly reported quality information in Germany. Objective The aim of this study was to assess the potential of German hospital report cards to improve quality of care. Methods First, a systematic Internet search aimed at identifying available report cards was conducted. Second, cross-sectional data (August/September 2013) were analyzed with respect to awareness, comprehension, and impact of report cards by using descriptive analysis and binary multivariate logistic regression models. Results Hospital report cards (N = 62) have become broadly available. However, awareness remains low, about one third (35.6%) of all respondents (N = 2,027) were aware of German hospital report card. Regarding comprehensibility, in 60.7% of all experiments (N = 6,081), respondents selected the hospital with the lowest risk-adjusted mortality; significant differences could be determined between the report cards (p<.001) with scores ranging from 27.5% to 77.2%. Binary multivariate logistic regression analysis revealed different significant respondent-related predictors on each report card. Finally, an impact on hospital choice making was determined. Conclusions To increase the potential of hospital report cards, health policy makers should promote the availability of report cards. In addition, the comprehensibility of German hospital report cards cannot be regarded as satisfying and should be enhanced in the future.
    No preview · Article · Dec 2014 · Health Policy
  • Source
    • "Some harm is caused by healthcare professional error arising from factors such as poor system and equipment design, and high workload [4,5]. Other harm results from deviations from guidelines and policies; only between 50 and 70% of patients receive recommended care [6,7]. Interventions to change professional behavior have modest and variable effects [8]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: There is evidence of unsafe care in healthcare systems globally. Interventions to implement recommended practice often have modest and variable effects. Ideally, selecting and adapting interventions according to local contexts should enhance effects. However, the means by which this can happen is seldom systematic, based on theory, or made transparent. This work aimed to demonstrate the applicability, feasibility, and acceptability of a theoretical domains framework implementation (TDFI) approach for co-designing patient safety interventions. We worked with three hospitals to support the implementation of evidence-based guidance to reduce the risk of feeding into misplaced nasogastric feeding tubes. Our stepped process, informed by the TDF and key principles from implementation literature, entailed: involving stakeholders; identifying target behaviors; identifying local factors (barriers and levers) affecting behavior change using a TDF-based questionnaire; working with stakeholders to generate specific local strategies to address key barriers; and supporting stakeholders to implement strategies. Exit interviews and audit data collection were undertaken to assess the feasibility and acceptability of this approach. Following audit and discussion, implementation teams for each Trust identified the process of checking the positioning of nasogastric tubes prior to feeding as the key behavior to target. Questionnaire results indicated differences in key barriers between organizations. Focus groups generated innovative, generalizable, and adaptable strategies for overcoming barriers, such as awareness events, screensavers, equipment modifications, and interactive learning resources. Exit interviews identified themes relating to the benefits, challenges, and sustainability of this approach. Time trend audit data were collected for 301 patients over an 18-month period for one Trust, suggesting clinically significant improved use of pH and documentation of practice following the intervention. The TDF is a feasible and acceptable framework to guide the implementation of patient safety interventions. The stepped TDFI approach engages healthcare professionals and facilitates contextualization in identifying the target behavior, eliciting local barriers, and selecting strategies to address those barriers. This approach may be of use to implementation teams and policy makers, although our promising findings confirm the need for a more rigorous evaluation; a balanced block evaluation is currently underway.
    Full-text · Article · Oct 2013 · Implementation Science
Show more