'Anemic' Quality Improvement in US Healthcare

Bridget M. Kuehn

October 18, 2016

The quality of outpatient care in the United States improved modestly between 2002 and 2013 in four of nine areas studied but remained steady or worsened in four areas, according to a large observational study published online October 17 in JAMA Internal Medicine.

For more than a decade, a variety of efforts have aimed at improving the quality and value of care in the United States, David M. Levine, MD, from Brigham and Women's Hospital in Boston, Massachusetts, and colleagues write. These efforts have included initiatives to cut use of unnecessary procedures and alternative payment models that reward efficient and effective care. But the fruits of this labor have rarely been assessed on a national scale.

Therefore, Dr Levine and colleagues compared 2002 and 2013 data from the Medical Expenditure Panel Survey, an annual, nationally representative survey of US patients corroborated by data from the patients' clinicians, hospitals, and employers. The authors assessed the change in nine composites of clinical quality compiled from 39 quality measures. Five composites assessed underuse of recommended care, and four assessed overuse of care.

Composite scores improved for recommended medical treatment (from 36% to 42%; P < 0.01), recommended counseling (from 43% to 50%; P < .01), recommended cancer screening (from 73% to 75%; P < .01), and avoidance of inappropriate cancer screening (from 47% to 51%; P = .02). In contrast, composite scores for clinician avoidance of inappropriate medical treatments (from 92% to 89%; P < .01) or refraining from unnecessary antibiotic use (from 50% to 44%; P < .01) worsened.

Meanwhile, recommended use of diagnostic and preventive tests (76%; P = .05), recommended diabetes care (68%; P = .21), and avoidance of needless imaging (90%; P = .64) all held steady.

"Despite more than a decade of efforts, the clinical quality of outpatient care delivered to American adults has not consistently improved," the authors write. "Current deficits in care continue to pose serious hazards to the health of the American public."

Patients, however, reported that their healthcare experiences improved, with an increase in the proportion of patients who rated their healthcare experience an 8, 9, or 10 of 10 (from 72% to 77%; P < .01). In addition, more patients reported "always" having access to care (from 48% to 58%; P < .01) and having good communication from their physician (from 55% to 63%; P < .01).

The authors suggest these improvements may be the result of increasing financial incentives for clinicians to boost "patient experience."

"Our data likely demonstrate that health care systems have responded to these and other incentives and invested to improve patient experience," the authors explain. "Whether other areas of care could be influenced with a similar system of reporting remains to be seen."

The authors note their analysis did not account for the potential effects of the Affordable Care Act, which had not been fully implemented during the study period.

The improvements in quality reported by Dr Levine and colleagues were "anemic," Elizabeth A. McGlynn, PhD, from Kaiser Permanente Research, Pasadena, California, and colleagues write in an invited commentary.

The commentators published a study in 2003 in which they analyzed 439 quality indicators and found US adults were receiving only about half the recommended care for 30 major causes of death or illness. At the time, the "findings caught the public and health professionals by surprise."

They note that differing methods prevent direct comparison between their earlier study and the new one, particularly as Dr Levine and colleagues used a much smaller number of quality indicators.

"Using this limited set of measures, the authors report anemic improvements in quality," Dr McGlynn and colleagues write. "This will likely disappoint many readers. For those actively engaged in efforts to improve quality, the results may not be as surprising."

The commentators note that increasing use and public reporting of quality measures can bring attention to problems but cannot solve them; doing that will require coordinated changes in care delivery systems, they explain.

"Physicians generally know what constitutes best practices and show up every day to do the best for their patients, but reliably and consistently offering those services at the point of care delivery requires a systems approach," Dr McGlynn and colleagues write.

The study authors suggest that the ongoing dominance of fee-for-service payments, which may incentivize inappropriate care, may be contributing to the slow progress. Yet programs designed to mitigate these incentives have little effect on quality, they note.

Payment reform alone is unlikely to improve quality, Dr McGlynn and colleagues emphasize. "We need to find a more effective way to transform the delivery of health care so that physicians and patients can achieve the outcomes that both desire. This will be hard work and will require engagement on the ground and not simply exhortations from those paying the bills."

The authors and commentators have disclosed no relevant financial relationships.

JAMA Intern Med. Published online October 17, 2016. Article full text, Commentary full text

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