how good is the quality of health care in the united states?...how good is the quality of u.s....
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How Good Is the Quality of Health Care inthe United States?
MARK A. SCHUSTER, EL IZABETH A. McGLYNN,and ROBERT H. BROOK
Q uality of health care is on the nationalagenda. In September 1996, President Clinton established theAdvisory Commission on Consumer Protection and Quality in
the Health Care Industry, which has released its final report on how todefine, measure, and promote quality of health care (President’s AdvisoryCommission on Consumer Protection and Quality in the Health CareIndustry 1998).
Much of the interest in quality of care has developed in response to thedramatic transformation of the health care system in recent years. Neworganizational structures and reimbursement strategies have created in-centives that may affect quality of care. Although some of the systemsare likely to improve quality, concerns about potentially negative con-sequences have prompted a movement to assure that quality will not besacrificed to control costs.
The concern about quality arises more from fear and anecdote thanfrom facts; there is little systematic evidence about quality of care inthe United States. We have no mandatory national system and few localsystems 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 articleson quality of care in the United States, and we summarize our findings
The Milbank Quarterly, Vol. 83, No. 4, 2005 (pp. 843–95)c© 2005 Milbank Memorial Fund. Published by Blackwell Publishing.
Reprinted from The Milbank Quarterly, Vol. 76, No. 4, 1998 (pp. 517–63). Style andusage are unchanged.
843
844 M.A. Schuster, E.A. McGlynn, and R.H. Brook
in this article. In the absence of a national quality tracking system, webelieve such a summary is the best way to provide an overview of thequality of care delivered in the United States. We provide examplesto illustrate quality in diverse settings, for diverse conditions, and fordiverse demographic groups, and to offer insight into the quality thatexists nationwide.
Methods
Definitions
The Institute of Medicine has defined quality as “the degree to whichhealth services for individuals and populations increase the likelihoodof desired health outcomes and are consistent with current professionalknowledge” (Lohr 1990). Good quality means providing patients withappropriate services in a technically competent manner, with good com-munication, shared decision making, and cultural sensitivity. In practicalterms, poor quality can mean too much care (e.g., providing unnecessarytests, medications, and procedures, with associated risks and side effects),too little care (e.g., not providing an indicated diagnostic test or a life-saving surgical procedure), or the wrong care (e.g., prescribing medicinesthat 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 character-istics, process quality assesses interactions between clinicians and patients,and outcomes offer evidence about changes in patients’ health status. Allthree dimensions can provide valuable information for measuring qual-ity, but the published quality-of-care literature reveals that there is moreexperience 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 skillfullyand whether the right choices are made in diagnosing and treating thepatient. The latter (making the correct choices) is generally measured byassessing 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 andpersonal characteristics, its expected health benefits (e.g., increased life
How Good Is the Quality of U.S. Health Care? 845
expectancy, pain relief, decreased anxiety, improved functional capacity)exceed its expected health risks (e.g., mortality, morbidity, anxiety an-ticipating the intervention, pain caused by the intervention, inaccuratediagnoses) by a wide enough margin to make the intervention or serviceworth doing (Brook et al. 1986). A subset of appropriate care is necessaryor crucial care. Care is considered necessary if there is a reasonable chanceof a nontrivial benefit to the patient and if it would be improper not toprovide the care. In other words, it might be considered ethically unac-ceptable 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 com-plications and wasted resources, and underuse of care, which means thatpeople are not getting care expected to improve their health.
Another way to measure process quality is to determine whether caremeets professional standards. This assessment can be done by creating alist of quality indicators that describe a process of care that should occurfor a particular type of patient or clinical circumstance and then eval-uating whether patients’ care is consistent with the indicators. Qualityindicators are based on standards of care, which are either found in the re-search literature and in statements of professional medical organizationsor determined by an expert panel. Current performance can be com-pared against a physician’s or plan’s own prior performance, against theperformance of other physicians and plans, or with reference to a bench-mark that establishes a goal. Indicators can cover a specific condition(e.g., children with sickle cell disease should be prescribed daily peni-cillin prophylaxis from at least six months of age until at least five yearsof age), or they can cover general aspects of care regardless of condition(e.g., patients prescribed a medication should be asked about medicationallergies).
Literature Review
Our review is based on a search of articles in the National Library ofMedicine’s Medline Plus system (1993 to present) conducted in June1997 and on studies identified from the bibliographies of these arti-cles. We excluded articles published before 1987. We did not aim tobe exhaustive but, rather, to find examples that cover a broad rangeof conditions and settings. We report data only from large or diverse
846 M.A. Schuster, E.A. McGlynn, and R.H. Brook
populations, such as the nation, an entire state, an entire city, or severalhospitals. We do not include data from studies that covered only a singlehospital or clinic.
Categorization
Our review of quality in the United States is divided into three categoriesbased on type of care: preventive (Table 1), acute (Table 2), and chronic(Table 3). We have chosen this categorization because there are differencesin the way these types of care are delivered that could affect quality.Preventive care is typically initiated on a routine basis by the clinicianrather than on an episodic basis by a patient coming to the clinicianwith symptoms, and it is generally not covered as well by insurance.The need for acute care is typically identified by the patient, and thecare is often delivered during a single encounter. Chronic care is morelikely than acute care to be delivered by a clinician who has an ongoingrelationship with the patient, and good chronic care is also more likelyto involve good follow-up. The tables describe the health care servicefor which quality is reported, the sample on which the report is based,the data source for the sample, the findings, and the reference for thefindings. We report on data from 48 articles covering about one-halfmillion people.
Quality of Care in the United States
Perhaps the most striking revelation to emerge from this review is thesurprisingly small amount of systematic knowledge available on thequality of health care delivered in the United States. Even though healthcare is a huge industry that affects the lives of most Americans, wehave only snapshots of information about particular conditions, types ofsurgery, and locations of care.
The dominant finding of our review is that there are large gaps betweenthe care people should receive and the care they do receive. This is truefor all three types of care—preventive, acute, and chronic—whether onegoes for a check-up, a sore throat, or diabetic care. It is true whetherone looks at overuse or underuse. It is true in different types of healthcare facilities and for different types of health insurance. It is true for allage groups, from children to the elderly. And it is true whether one islooking at the whole country or a single city.
How Good Is the Quality of U.S. Health Care? 847
TA
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E1
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atit
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eno
tin
clud
edin
this
part
icul
arst
udy.
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ican
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dem
yof
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iatr
ics
1994
;CD
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.
Chi
ldre
n19
–35
mon
ths
old
in31
,997
hous
ehol
dsfr
oma
nati
onal
lyre
pres
enta
tive
sam
ple
ofth
eU
.S.
Nat
iona
lIm
mun
izat
ion
Surv
ey(N
IS),
1995
74%
rece
ived
allt
heva
ccin
es.(
If3
dose
sof
Hib
are
not
incl
uded
,the
perc
enta
geis
76%
.)
(CD
C19
97)
Infl
uenz
ava
ccin
e(ad
ult)
Ann
ualv
acci
nati
onof
allp
eopl
e≥6
5ye
ars
old
isre
com
men
ded
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
89).
Thi
sre
com
men
dati
onha
ssi
nce
been
reit
erat
ed(U
.S.P
reve
ntiv
eSe
rvic
esTa
skFo
rce
1996
).
App
roxi
mat
ely
8,00
0ad
ults
≥65
year
sol
dfr
oma
sam
ple
ofpe
ople
repr
esen
tati
veof
the
U.S
.civ
ilia
n,no
nins
titu
tion
aliz
edpo
pula
tion
Nat
iona
lHea
lth
Inte
rvie
wSu
rvey
(NH
IS),
1993
52%
rece
ived
annu
alin
flue
nza
vacc
ine.
(CD
C19
95b)
(Con
tinu
ed)
848 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E1—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Pne
umoc
occa
lvac
cine
(adu
lt)
One
-tim
eva
ccin
atio
nfo
ral
lpeo
ple≥6
5ye
ars
old
isre
com
men
ded
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
89).
In19
96,t
here
com
men
dati
onw
asm
odif
ied
tosp
ecif
yon
e-ti
me
vacc
inat
ion
for
all
imm
unoc
ompe
tent
indi
vidu
als≥6
5ye
ars
old
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
96).
Sam
eas
abov
eSa
me
asab
ove
28%
rece
ived
pneu
moc
occa
lva
ccin
e.
(CD
C19
95b)
CA
NC
ER
SCR
EE
NIN
GB
reas
tcan
cer:
clin
ical
brea
stex
amin
atio
n(C
BE
)an
dm
amm
ogra
phy
Rec
omm
enda
tion
sva
ry.I
n19
89,t
heU
SPST
Fre
com
men
ded
anan
nual
CB
Efo
rw
omen
≥40
year
sol
dan
dm
amm
ogra
phy
ever
y1–
2ye
ars
for
wom
en50
–75
year
sol
d(U
.S.P
reve
ntiv
eSe
rvic
esTa
skFo
rce
1989
).In
1996
,it
reco
mm
ende
dm
amm
ogra
phy
ever
y1–
2ye
ars
wit
hor
wit
hout
annu
alC
BE
for
wom
en50
–69
year
sol
d(U
.S.P
reve
ntiv
eSe
rvic
esTa
skFo
rce
1996
).
21,6
01w
omen
≥50
year
sol
dfr
oma
sam
ple
ofpe
ople
repr
esen
tati
veof
the
U.S
.(ex
clud
ing
Ark
ansa
san
dW
yom
ing,
and
incl
udin
gth
eD
istr
ict
ofC
olum
bia)
Beh
avio
ralR
isk
Fact
orSu
rvei
llan
ceSy
stem
,199
2
58%
had
CB
Ein
the
prio
rye
ar;4
6%ha
dm
amm
ogra
phy
inth
epr
ior
year
;40%
had
both
exam
inat
ions
inth
epr
ior
year
.
(CD
C19
93a)
How Good Is the Quality of U.S. Health Care? 849
Cer
vica
lcan
cer:
Pap
anic
olao
u(P
ap)
smea
rW
omen
wit
han
inta
ctut
erus
(hav
ea
cerv
ix)
shou
ldha
vea
Pap
smea
raf
ter
init
iati
onof
sexu
alin
terc
ours
ean
dev
ery
1–3
year
sth
erea
fter
.Som
eor
gani
zati
ons
reco
mm
end
star
ting
Pap
smea
rsfo
ral
lwom
enw
hoha
vere
ache
d18
year
sol
d,re
gard
less
ofse
xual
hist
ory
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
89).
The
sere
com
men
dati
ons
have
sinc
ebe
enre
iter
ated
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
96).
Wom
en≥1
8ye
ars
old
wit
han
inta
ctut
erus
from
asa
mpl
eof
128,
412
peop
lere
pres
enta
tive
ofth
eU
.S.c
ivil
ian,
noni
nsti
tuti
onal
ized
popu
lati
on
NH
IS,1
992
67%
had
aP
apsm
ear
inth
epr
ior
3ye
ars.
(CD
C19
95c)
Col
onca
ncer
:fec
aloc
cult
bloo
dte
stin
g(F
OB
T)
and
sigm
oido
scop
yR
ecom
men
dati
ons
vary
.In
1980
,the
Am
eric
anC
ance
rSo
ciet
yre
com
men
ded
annu
alFO
BT
star
ting
at50
year
sol
d.So
me
othe
ror
gani
zati
ons
mad
esi
mil
arre
com
men
dati
ons.
In19
89,t
heU
SPST
Fdi
dno
tm
ake
reco
mm
enda
tion
s(U
.S.P
reve
ntiv
eSe
rvic
esTa
skFo
rce
1989
),bu
tin
1996
,it
reco
mm
ende
dan
nual
FOB
T,si
gmoi
dosc
opy
(per
iodi
city
unsp
ecif
ied)
,or
both
star
ting
at50
year
sol
d(U
.S.P
reve
ntiv
eSe
rvic
esTa
skFo
rce
1996
).
Adu
lts≥4
0ye
ars
old
from
asa
mpl
eof
128,
412
peop
lere
pres
enta
tive
ofth
eU
.S.c
ivil
ian,
noni
nsti
tuti
onal
ized
popu
lati
on
Sam
eas
abov
e14
%of
men
and
15%
ofw
omen
had
FOB
Tin
the
prio
rye
ar;
44%
ofm
enan
d43
%of
wom
enha
dev
erha
dFO
BT;
11%
ofm
enan
d7%
ofw
omen
had
sigm
oido
scop
yin
the
prio
r3
year
s.
(CD
C19
95c)
(Con
tinu
ed)
850 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E1—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Col
onca
ncer
:FO
BT
and
sigm
oido
scop
ySa
me
asab
ove
250
wom
en40
–65
year
sol
dw
hoha
dno
maj
oril
lnes
ses,
who
rece
ived
prim
ary
care
aton
eof
the
grou
ppr
acti
ces,
and
who
wer
eel
igib
lefo
rpr
even
tive
care
Med
ical
reco
rds
for
pati
ents
from
4gr
oup
prac
tice
sin
Mas
sach
uset
ts,
11/1
/85–
10/3
1/87
51%
–59%
ofw
omen
had
FOB
Tev
ery
2ye
ars
orfl
exib
lesi
gmoi
dosc
opy
ever
y5
year
s.
(Udv
arhe
lyie
tal
.19
91)
CA
RD
IAC
RIS
KFA
CT
OR
SSm
okin
gce
ssat
ion
coun
seli
ngTo
bacc
oce
ssat
ion
coun
seli
ngsh
ould
beof
fere
don
are
gula
rba
sis
toal
lpat
ient
sw
hosm
oke
ciga
rett
es,p
ipes
,or
ciga
rs,a
ndto
thos
ew
hous
esm
okel
ess
toba
cco
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
89).
Thi
sre
com
men
dati
onha
ssi
nce
been
reit
erat
ed(U
.S.P
reve
ntiv
eSe
rvic
esTa
skFo
rce
1996
).
8,77
8sm
oker
s≥1
8ye
ars
old
from
asa
mpl
eof
43,7
32pe
ople
repr
esen
tati
veof
the
U.S
.civ
ilia
n,no
nins
titu
tion
aliz
edpo
pula
tion
NH
IS,1
991
37%
ofsm
oker
sw
hoha
da
visi
tw
ith
aph
ysic
ian
orot
her
heal
th-c
are
prof
essi
onal
duri
ngth
epr
ior
year
had
been
advi
sed
toqu
itsm
okin
g.
(CD
C19
93b)
How Good Is the Quality of U.S. Health Care? 851
Blo
odch
oles
tero
ltes
ting
In19
88,t
heN
atio
nalH
eart
,Lun
g,an
dB
lood
Inst
itut
ere
com
men
ded
rout
ine
chol
este
rol
scre
enin
gat
leas
tev
ery
5ye
ars
star
ting
at20
year
sol
d.In
1989
,the
USP
STF
reco
mm
ende
dpe
riod
icsc
reen
ing
for
mid
dle-
aged
men
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
89),
and
in19
96,i
tre
com
men
ded
peri
odic
scre
enin
gfo
rm
en35
–65
year
sol
dan
dw
omen
45–6
5ye
ars
old
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
96).
3,70
0ad
ults
≥18
year
sol
dfr
oma
repr
esen
tati
vesa
mpl
eof
the
non–
Afr
ican
Am
eric
anU
.S.
popu
lati
on
Tele
phon
esu
rvey
byth
eN
atio
nalH
eart
,Lu
ng,a
ndB
lood
Inst
itut
e,19
90
65%
ofad
ults
surv
eyed
in19
90ha
dev
erha
da
bloo
dch
oles
tero
lte
st;5
1%ha
dth
ete
stin
the
prio
rye
ar;
and
anad
diti
onal
14%
had
itpr
ior
toth
at.3
5%ha
dne
ver
had
abl
ood
chol
este
rolt
est.
(Sch
ucke
ret
al.
1991
)
Blo
odch
oles
tero
ltes
ting
Sam
eas
abov
eA
dult
s≥2
0ye
ars
old
from
asa
mpl
eof
peop
lere
pres
enta
tive
ofth
eU
.S.(
excl
udin
gW
yom
ing,
Kan
sas,
and
Nev
ada,
and
incl
udin
gth
eD
istr
ict
ofC
olum
bia)
(sam
ple
size
sfo
rin
divi
dual
stat
esra
nge
from
670
to3,
190
peop
le)
CD
C’s
Beh
avio
ral
Ris
kFa
ctor
Surv
eill
ance
Syst
emda
ta,1
991
The
stat
e-sp
ecif
icra
tes
ofad
ults
in19
91w
hoha
dch
oles
tero
lsc
reen
ing
inth
epr
ior
5ye
ars
rang
edfr
om57
%–7
0%.
(CD
C19
93c)
(Con
tinu
ed)
852 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E1—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
GE
NE
RA
LP
RE
VE
NT
IVE
CA
RE
Wel
l-ch
ild
care
The
Am
eric
anA
cade
my
ofP
edia
tric
sre
com
men
dsro
utin
ehi
stor
y,ph
ysic
alex
amin
atio
n,sc
reen
ing
test
s,an
dan
tici
pato
rygu
idan
ceth
roug
hout
chil
dhoo
d(A
mer
ican
Aca
dem
yof
Ped
iatr
ics
1988
).
All
chil
dren
who
had
thei
rse
cond
birt
hday
duri
ngth
efi
rst
half
ofth
est
udy
year
,and
all2
-yea
r-ol
dsw
ith
otit
ism
edia
oras
thm
a,fr
oma
sam
ple
of2,
024
pati
ents
of13
5pr
ovid
ers
Med
ical
reco
rds
from
phys
icia
ns’o
ffic
es,
com
mun
ity
heal
thce
nter
s,an
dho
spit
alou
tpat
ient
faci
liti
essa
mpl
edfr
omM
aryl
and
Med
icai
dcl
aim
sda
ta,1
988
For
each
type
ofcl
inic
alse
ttin
g,th
est
udy
repo
rts
the
aver
age
perc
enta
geof
tech
nica
lqu
alit
yin
dica
tors
for
wel
l-ch
ild
care
that
wer
eno
tm
et.E
ach
aver
age
was
loca
ted
inth
e35
%–6
5%ra
nge.
(Sta
rfie
ldet
al.
1994
)
Wel
l-ad
ultc
are
Pat
ient
ssh
ould
have
prev
enti
vehe
alth
visi
tsev
ery
1–3
year
sw
hen
19–6
4ye
ars
old
and
ever
yye
arw
hen
≥65
year
sol
d(U
.S.
Pre
vent
ive
Serv
ices
Task
Forc
e19
89).
All
adul
tsw
ith
asth
ma,
hype
rten
sion
,and
diab
etes
from
asa
mpl
eof
2,02
4pa
tien
tsof
135
prov
ider
s
Sam
eas
abov
eFo
rea
chty
peof
clin
ical
sett
ing,
the
stud
yre
port
sth
eav
erag
epe
rcen
tage
ofte
chni
cal
qual
ity
indi
cato
rsfo
rw
ell-
adul
tca
reth
atw
ere
not
met
.Eac
hav
erag
ew
aslo
cate
din
the
45%
–55%
rang
e.
(Sta
rfie
ldet
al.
1994
)
a Ifa
desc
ript
ion
inth
efi
rst
colu
mn
has
noci
tati
on,i
tis
cove
red
byth
eci
tati
onin
the
refe
renc
eco
lum
n.bW
eco
ntac
ted
the
auth
ors
ofso
me
ofth
ear
ticl
esto
clar
ify
deta
ils
rela
ted
toth
esa
mpl
ean
dto
the
data
anal
ysis
.
How Good Is the Quality of U.S. Health Care? 853
TA
BL
E2
Exa
mpl
esof
Qua
lity
ofA
cute
Hea
lth
Car
ein
the
Uni
ted
Stat
es
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
AN
TIB
IOT
ICU
SEC
omm
onco
ldA
lmos
tal
lcol
dsar
eca
used
bya
viru
s,fo
rw
hich
anti
biot
ics
are
not
anef
fect
ive
trea
tmen
t.
1,43
9pa
tien
tsw
ith
2,17
1ou
tpat
ient
and
emer
genc
yde
part
men
tvi
sits
for
the
com
mon
cold
(acu
tena
soph
aryn
giti
s)fr
oma
rand
omsa
mpl
eof
50,0
00pa
tien
tsw
ith
atle
ast
1cl
aim
for
care
bya
phys
icia
n,de
ntis
tor
opto
met
rist
Ken
tuck
yM
edic
aid
clai
ms
data
,7/1
/93–
6/30
/94
In60
%of
enco
unte
rsfo
rth
eco
mm
onco
ld,
pati
ents
fill
edpr
escr
ipti
ons
for
anti
biot
ics.
(Mai
nous
etal
.19
96)
Upp
erre
spir
ator
ytr
acti
nfec
tion
Ant
imic
robi
aldr
ugs
dono
tsh
orte
nth
eco
urse
ofvi
ralu
pper
resp
irat
ory
trac
tin
fect
ion
nor
doth
eypr
even
tse
cond
ary
bact
eria
linf
ecti
ons.
Nat
iona
lly
repr
esen
tati
vesa
mpl
eof
3,00
0of
fice
-bas
edph
ysic
ians
Nat
iona
lAm
bula
tory
Med
ical
Car
eSu
rvey
(NA
MC
S),1
992
16%
ofal
lant
imic
robi
aldr
ugpr
escr
ipti
ons
(an
esti
mat
ed17
,922
,000
pres
crip
tion
sna
tion
ally
)w
ere
wri
tten
for
uppe
rre
spir
ator
ytr
act
infe
ctio
nsin
1992
.
(McC
aig
and
Hug
hes
1995
)
(Con
tinu
ed)
854 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E2—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Pha
ryng
itis
,nas
alco
nges
tion
,com
mon
cold
,and
othe
rup
per
resp
irat
ory
trac
tinf
ecti
onSi
nce
mos
tof
thes
eco
ndit
ions
are
vira
l,an
tibi
otic
sha
veno
bene
fit.
Sam
eas
abov
eSa
me
asab
ove
Ove
r70
%of
pati
ents
rece
ived
anti
biot
icpr
escr
ipti
ons
for
phar
yngi
tis
(exc
ludi
ngst
rept
ococ
cal)
,ove
r50
%re
ceiv
edth
emfo
rrh
init
is,a
ndov
er30
%re
ceiv
edth
emfo
ra
nons
peci
fic
uppe
rre
spir
ator
ytr
act
infe
ctio
n,co
ugh,
orco
ld.
(Dow
ella
ndSc
hwar
tz19
97)
RE
SPIR
AT
OR
YIL
LNE
SSP
neum
onia
:hos
pita
lcar
eC
are
for
pneu
mon
ia1,
408
pati
ents
hosp
ital
ized
wit
hpn
eum
onia
from
ana
tion
ally
repr
esen
tati
vesa
mpl
eof
7,15
6pa
tien
tsho
spit
aliz
edw
ith
any
of5
cond
itio
ns(c
onge
stiv
ehe
art
fail
ure,
acut
em
yoca
rdia
linf
arct
ion,
pneu
mon
ia,s
trok
e,hi
pfr
actu
re)(
Dra
per
etal
.19
90)
Med
ical
reco
rds
for
Med
icar
epa
tien
tsfr
om29
7ho
spit
als
in5
stat
es(C
alif
orni
a,Fl
orid
a,In
dian
a,P
enns
ylva
nia,
Texa
s),7
/1/8
5–6/
30/8
6
52%
–90%
ofpa
tien
tsw
ith
pneu
mon
iare
ceiv
edap
prop
riat
eco
mpo
nent
sof
care
(e.g
.,do
cum
enta
tion
ofto
bacc
ous
e/no
nuse
and
low
er-e
xtre
mit
yed
ema;
bloo
dpr
essu
rere
adin
gs;
oxyg
enth
erap
yor
intu
bati
onfo
rhy
poxi
cpa
tien
ts).
(Kah
net
al.1
990)
How Good Is the Quality of U.S. Health Care? 855
Pne
umon
iaH
ospi
tala
dmis
sion
sfo
rpn
eum
onia
are
cons
ider
edap
prop
riat
ew
hen,
for
exam
ple,
apa
tien
tfa
ils
toim
prov
ew
ith
outp
atie
ntor
alm
edic
atio
nor
has
apl
eura
leff
usio
nor
anem
pyem
a.
445
hosp
ital
adm
issi
ons
ofch
ildr
en<
18ye
ars
old
adm
itte
dw
ith
pneu
mon
ia
Med
ical
reco
rds
for
pati
ents
from
12ho
spit
als
in5
com
mun
itie
sin
Bos
ton
and
near
bysu
burb
s,7/
1/85
–6/3
0/86
9.4%
ofad
mis
sion
sw
ere
inap
prop
riat
e.(P
ayne
etal
.199
5)
Bro
nchi
tis/
asth
ma
Hos
pita
ladm
issi
ons
for
bron
chit
is/a
sthm
aar
eco
nsid
ered
appr
opri
ate
whe
n,fo
rex
ampl
e,a
pati
ent
has
fail
edto
impr
ove
wit
hou
tpat
ient
ther
apy
orha
sa
pneu
mot
hora
x.
1,03
8ho
spit
alad
mis
sion
sof
chil
dren
<18
year
sol
dad
mit
ted
wit
hbr
onch
itis
/ast
hma
Sam
eas
abov
e4.
4%of
adm
issi
ons
wer
ein
appr
opri
ate.
(Pay
neet
al.1
995)
OT
ITIS
ME
DIA
Trea
tmen
t46
4ch
ildr
en≤3
year
sol
ddi
agno
sed
wit
hot
itis
med
iafr
oma
sam
ple
of2,
024
pati
ents
of13
5pr
ovid
ers
Med
ical
reco
rds
from
phys
icia
ns’o
ffic
es,
com
mun
ity
heal
thce
nter
s,an
dho
spit
alou
tpat
ient
faci
liti
essa
mpl
edfr
omM
aryl
and
Med
icai
dcl
aim
sda
ta,
1988
For
each
type
ofcl
inic
alse
ttin
g,th
est
udy
repo
rts
the
aver
age
perc
enta
geof
tech
nica
lqua
lity
indi
cato
rsfo
rot
itis
med
iath
atw
ere
not
met
.E
ach
aver
age
was
loca
ted
inth
e10
%–4
0%ra
nge.
(Sta
rfie
ldet
al.
1994
) (Con
tinu
ed)
856 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E2—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Use
ofty
mpa
nost
omy
tube
sIn
dica
tion
sfo
rty
mpa
nost
omy
tube
plac
emen
tin
clud
ere
frac
tory
mid
dle
ear
infe
ctio
nan
dch
roni
cm
asto
idit
is.
6,42
9ch
ildr
en<
16ye
ars
old
wit
hre
curr
ent
acut
eot
itis
med
iaan
d/or
pers
iste
ntot
itis
med
iaw
ith
effu
sion
who
wer
ein
sure
din
heal
thpl
ans
requ
irin
gpr
ecer
tifi
cati
onby
aut
iliz
atio
nre
view
firm
Inte
rvie
ws
wit
hph
ysic
ians
’of
fice
staf
fat
otol
aryn
golo
gypr
acti
ces
from
49st
ates
and
the
Dis
tric
tof
Col
umbi
a,1/
1/90
–7/3
0/91
;ad
diti
onal
inte
rvie
ws
wer
eco
nduc
ted
wit
hot
olar
yngo
logi
sts
tode
term
ine
the
exis
tenc
eof
exte
nuat
ing
clin
ical
circ
umst
ance
s
41%
oftu
bein
sert
ions
wer
eap
prop
riat
e,32
%eq
uivo
cal,
and
27%
inap
prop
riat
e.If
exte
nuat
ing
clin
ical
circ
umst
ance
sw
ere
take
nin
toac
coun
t,42
%of
tube
inse
rtio
nsw
ere
appr
opri
ate,
35%
equi
voca
l,an
d23
%in
appr
opri
ate.
(Kle
inm
anet
al.
1994
)
HIP
FRA
CT
UR
ES
Hip
frac
ture
:hos
pita
lcar
eC
are
for
hip
frac
ture
1,40
4pa
tien
tsho
spit
aliz
edw
ith
hip
frac
ture
from
ana
tion
ally
repr
esen
tati
vesa
mpl
eof
7,15
6pa
tien
tsho
spit
aliz
edw
ith
any
of5
cond
itio
ns(c
onge
stiv
ehe
art
fail
ure,
acut
em
yoca
rdia
linf
arct
ion,
pneu
mon
ia,s
trok
e,hi
pfr
actu
re)(
Dra
per
etal
.19
90)
Med
ical
reco
rds
for
Med
icar
epa
tien
tsfr
om29
7ho
spit
als
in5
stat
es(C
alif
orni
a,Fl
orid
a,In
dian
a,P
enns
ylva
nia,
Texa
s),7
/1/8
5–6/
30/8
6
67%
–94%
ofpa
tien
tsw
ith
hip
frac
ture
rece
ived
appr
opri
ate
com
pone
nts
ofca
re(e
.g.,
docu
men
tati
onof
men
tal
stat
usan
dpe
dalo
rle
gpu
lse;
seru
mpo
tass
ium
leve
l;el
ectr
ocar
diog
ram
).
(Kah
net
al.1
990)
How Good Is the Quality of U.S. Health Care? 857
PR
EN
ATA
LC
AR
EM
edic
alhi
stor
y9,
924
wom
enw
hoha
dli
vebi
rths
in19
88fr
oma
nati
onal
lyre
pres
enta
tive
sam
ple
ofth
eU
.S.(
excl
udin
gSo
uth
Dak
ota
and
Mon
tana
,and
incl
udin
gth
eD
istr
ict
ofC
olum
bia)
Nat
iona
lMat
erna
land
Infa
ntH
ealt
hSu
rvey
(NM
IHS)
,198
8
80%
wer
eas
ked
abou
the
alth
hist
ory
duri
ngth
efi
rst
orse
cond
visi
t.
(Kog
anet
al.1
994)
Phy
sica
lexa
min
atio
nSa
me
asab
ove
Sam
eas
abov
e98
%ha
dth
eir
wei
ght
and
heig
htm
easu
red,
96%
had
bloo
dpr
essu
rem
easu
red,
and
86%
rece
ived
aph
ysic
alor
pelv
icex
amin
atio
ndu
ring
the
firs
tor
seco
ndvi
sit.
(Kog
anet
al.1
994)
Lab
orat
ory
test
s(he
mog
lobi
nbl
ood
test
and
urin
etes
t)Sa
me
asab
ove
Sam
eas
abov
e79
%re
ceiv
edbl
ood
test
san
d93
%re
ceiv
edur
inal
ysis
duri
ngth
efi
rst
orse
cond
visi
t.
(Kog
anet
al.1
994)
Med
ical
hist
ory,
phys
ical
exam
inat
ion,
and
labo
rato
ryte
sts
Sam
eas
abov
eSa
me
asab
ove
56%
rece
ived
allo
fthe
eval
uati
ons
list
edab
ove
duri
ngth
efi
rst
orse
cond
visi
t.
(Kog
anet
al.1
994)
(Con
tinu
ed)
858 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E2—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Cou
nsel
ing
abou
tnut
riti
onan
dw
eigh
tgai
n Sam
eas
abov
eSa
me
asab
ove
97%
wer
eco
unse
led
abou
tvi
tam
ins,
93%
wer
eco
unse
led
abou
tdi
et,
and
72%
wer
eco
unse
led
abou
tpr
oper
wei
ght
gain
duri
ngpr
egna
ncy,
duri
ngat
leas
ton
epr
enat
alvi
sit.
(Kog
anet
al.1
994)
Cou
nsel
ing
abou
talc
ohol
,tob
acco
,and
illi
citd
rugs
Sam
eas
abov
eSa
me
asab
ove
68%
wer
eco
unse
led
tore
duce
orel
imin
ate
alco
holc
onsu
mpt
ion,
69%
tore
duce
orel
imin
ate
smok
ing,
and
65%
tost
opus
eof
ille
gald
rugs
,dur
ing
atle
ast
one
pren
atal
visi
t.
(Kog
anet
al.1
994)
Cou
nsel
ing
abou
tbre
astf
eedi
ngSa
me
asab
ove
Sam
eas
abov
e53
%w
ere
coun
sele
dab
out
brea
stfe
edin
gdu
ring
atle
ast
one
pren
atal
visi
t.
(Kog
anet
al.1
994)
Cou
nsel
ing
abou
tnut
riti
on,w
eigh
tgai
n,al
coho
l,to
bacc
o,il
lici
tdru
gs,a
ndbr
east
feed
ing
Sam
eas
abov
eSa
me
asab
ove
32%
rece
ived
allo
fthe
coun
seli
ngli
sted
abov
edu
ring
atle
ast
one
pren
atal
visi
t.
(Kog
anet
al.1
994)
How Good Is the Quality of U.S. Health Care? 859
Rou
tine
pren
atal
scre
enin
gte
sts
(i.e
.,te
sts
tosc
reen
for
anem
ia,
asym
ptom
atic
bact
eriu
ria,
syph
ilis
,gon
orrh
ea,h
epat
itis
B,
rube
lla
imm
unit
y,an
dR
hfa
ctor
and
anti
body
)
Ran
dom
sam
ple
of58
6w
omen
who
had
ali
vebi
rth
from
24,1
70bi
rths
that
occu
rred
duri
ngth
est
udy
peri
od
Med
ical
reco
rds
for
pati
ents
from
6H
MO
sin
6st
ates
(Ari
zona
,Cal
ifor
nia,
Col
orad
o,M
assa
chus
etts
,M
inne
sota
,Ore
gon)
,8/
1/89
–7/3
1/90
Am
ong
6H
MO
s,w
omen
rece
ived
64%
–95%
(ave
rage
82%
)of7
reco
mm
ende
dro
utin
epr
enat
alsc
reen
ing
test
s.
(Mur
ata
etal
.199
4)
Oth
erro
utin
epre
nata
lcar
e(i
.e.,
firs
tpr
enat
alvi
sit
duri
ngfi
rst
trim
este
r,ac
cura
tede
term
inat
ion
ofge
stat
iona
lage
,sc
reen
ing
for
inhe
rite
ddi
sord
ers,
mea
sure
men
tof
sym
phys
is-f
unda
lhei
ght,
and
bloo
dpr
essu
rem
easu
rem
ent)
Sam
eas
abov
eSa
me
asab
ove
Am
ong
6H
MO
s,w
omen
rece
ived
78%
–87%
(ave
rage
84%
)of5
proc
esse
sof
rout
ine
pren
atal
care
.
(Mur
ata
etal
.199
4)
Car
efor
com
plic
atio
nsof
preg
nanc
y(e
.g.,
diag
nost
ican
dtr
eatm
ent
inte
rven
tion
saf
ter
abno
rmal
scre
enin
gte
stre
sult
s,an
dca
reto
mit
igat
eef
fect
sof
preg
nanc
y-in
duce
dhy
pert
ensi
onan
dge
stat
iona
ldia
bete
s)
Sam
eas
abov
eSa
me
asab
ove
Am
ong
6H
MO
s,w
omen
rece
ived
54%
–77%
(ave
rage
70%
)of
proc
esse
sof
care
for
com
plic
atio
nsof
preg
nanc
y.
(Mur
ata
etal
.199
4)
Scre
enin
gan
dfo
llow
-up
for
prot
einu
ria
(pro
tein
inur
ine)
Uri
neis
chec
ked
for
prot
ein
toev
alua
tefo
rth
epr
esen
ceof
pree
clam
psia
,ase
riou
sco
mpl
icat
ion
ofpr
egna
ncy.
Inpa
tien
tre
cord
sfo
r2,
336
wom
enfr
oma
sam
ple
of2,
878
birt
hsin
1985
;pr
enat
alca
rere
cord
sfo
r82
3of
thes
ew
omen
Med
ical
reco
rds
for
pati
ents
sam
pled
from
Med
icai
dcl
aim
sfi
les
for
wom
enan
dch
ildr
enen
roll
edin
Aid
toFa
mil
ies
wit
hD
epen
dent
Chi
ldre
n
Test
ing
was
prov
ided
at75
%–8
3%of
visi
ts.
Foll
ow-u
pw
aspe
rfor
med
for
41%
–65%
ofpa
tien
tsw
ith
prot
einu
ria.
(Car
eyet
al.1
991)
(Con
tinu
ed)
860 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E2—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Scre
enin
gan
dfo
llow
-up
for
prot
einu
ria
(pro
tein
inur
ine)
(con
tinu
ed)
(AFD
C)i
n2
com
mun
itie
sin
Cal
ifor
nia
and
2co
mm
unit
ies
inM
isso
uri,
1985
Rec
ordi
ngof
gest
atio
nala
geSa
me
asab
ove
Sam
eas
abov
eG
esta
tion
alag
ew
asre
cord
edat
78%
–95%
ofvi
sits
.
(Car
eyet
al.1
991)
Ass
essm
ento
ffet
alhe
artt
ones
afte
r18
wee
ksof
gest
atio
nSa
me
asab
ove
Sam
eas
abov
eFe
talh
eart
tone
sw
ere
asse
ssed
at81
%–9
3%of
visi
ts.
(Car
eyet
al.1
991)
Fol
low
-up
for
low
hem
atoc
rit
Low
hem
atoc
rit
indi
cate
san
emia
.Sa
me
asab
ove
Sam
eas
abov
eFo
llow
-up
was
perf
orm
edfo
r32
%–5
1%of
pati
ents
wit
hlo
whe
mat
ocri
t.
(Car
eyet
al.1
991)
Fol
low
-up
for
high
bloo
dpr
essu
reSa
me
asab
ove
Sam
eas
abov
eFo
llow
-up
was
perf
orm
edfo
r31
%–5
3%of
pati
ents
wit
hhi
ghbl
ood
pres
sure
.
(Car
eyet
al.1
991)
a Ifa
desc
ript
ion
inth
efi
rst
colu
mn
has
noci
tati
on,i
tis
cove
red
byth
eci
tati
onin
the
refe
renc
eco
lum
n.bW
eco
ntac
ted
the
auth
ors
ofso
me
ofth
ear
ticl
esto
clar
ify
deta
ils
rela
ted
toth
esa
mpl
ean
dto
the
data
anal
ysis
.
How Good Is the Quality of U.S. Health Care? 861
TA
BL
E3
Exa
mpl
esof
Qua
lity
ofC
hron
icH
ealt
hC
are
inth
eU
nite
dSt
ates
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
AST
HM
AA
dult
asth
ma
Adu
lts≥1
8ye
ars
old
ina
grou
pof
393
adul
tsan
dch
ildr
endi
agno
sed
wit
has
thm
a,fr
oma
sam
ple
of2,
024
pati
ents
of13
5pr
ovid
ers
Med
ical
reco
rds
from
phys
icia
ns’o
ffic
es,
com
mun
ity
heal
thce
nter
s,an
dho
spit
alou
tpat
ient
faci
liti
essa
mpl
edfr
omM
aryl
and
Med
icai
dcl
aim
sda
ta,1
988
For
each
type
ofcl
inic
alse
ttin
g,th
est
udy
repo
rts
the
aver
age
perc
enta
geof
tech
nica
lqua
lity
indi
cato
rsfo
rad
ult
asth
ma
that
wer
eno
tm
et.E
ach
ofth
eav
erag
esw
aslo
cate
din
the
40%
–45%
rang
e.B
etw
een
5%an
d35
%of
care
was
inap
prop
riat
e.
(Sta
rfie
ldet
al.
1994
)
Chi
ldho
odas
thm
aC
hild
ren
<18
year
sol
din
agr
oup
of39
3ad
ults
and
chil
dren
diag
nose
dw
ith
asth
ma,
from
asa
mpl
eof
2,02
4pa
tien
tsof
135
prov
ider
s
Sam
eas
abov
eFo
rea
chty
peof
clin
ical
sett
ing,
the
stud
yre
port
sth
eav
erag
epe
rcen
tage
ofte
chni
calq
uali
tyin
dica
tors
for
chil
dhoo
das
thm
ath
atw
ere
not
met
.E
ach
ofth
eav
erag
esw
aslo
cate
din
the
30%
–40%
rang
e.B
etw
een
0%an
d20
%of
care
was
inap
prop
riat
e.
(Sta
rfie
ldet
al.
1994
)
(Con
tinu
ed)
862 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
DIA
BE
TE
SM
ELL
ITU
SD
ilat
edey
eexa
min
atio
nto
scre
enfo
rre
tino
path
yA
nnua
ldil
ated
eye
exam
inat
ion
star
ting
atti
me
ofdi
agno
sis
ofno
n-in
suli
n-de
pend
ent
diab
etes
mel
litu
s(N
IDD
M)a
nd5
year
saf
ter
diag
nosi
sof
insu
lin-
depe
nden
tdi
abet
esm
elli
tus
(ID
DM
).
2,39
2ad
ults
≥18
year
sol
dw
ith
IDD
M(1
24pa
tien
ts),
NID
DM
trea
ted
wit
hin
suli
n(9
22pa
tien
ts),
and
NID
DM
not
trea
ted
wit
hin
suli
n(1
,346
pati
ents
)fro
ma
sam
ple
of84
,572
peop
lere
pres
enta
tive
ofth
eU
.S.
civi
lian
,no
nins
titu
tion
aliz
edpo
pula
tion
Nat
iona
lHea
lth
Inte
rvie
wSu
rvey
,198
949
%ha
da
dila
ted
eye
exam
inat
ion
inth
epr
ior
year
;66%
had
anex
amin
atio
nin
the
prio
r2
year
s;61
%an
d57
%of
pati
ents
athi
ghri
skof
visi
onlo
ssbe
caus
eof
ahi
stor
yof
reti
nopa
thy
orof
long
dura
tion
ofdi
abet
es,
resp
ecti
vely
,had
anex
amin
atio
nin
the
prio
rye
ar.
(Bre
chne
ret
al.
1993
)
Any
eyee
xam
inat
ion
(inc
ludi
ngno
ndil
ated
)to
scre
enfo
rre
tino
path
yD
ilat
edey
eex
amin
atio
nis
reco
mm
ende
d,as
desc
ribe
dab
ove,
but
any
eye
exam
inat
ion
isal
sore
port
edto
dete
rmin
ew
heth
erth
ere
was
any
effo
rtto
asse
ssfo
rre
tino
path
y.
Sam
eas
abov
eSa
me
asab
ove
61%
had
aney
eex
amin
atio
nin
the
prio
rye
ar;7
9%ha
dan
exam
inat
ion
inth
epr
ior
2ye
ars.
(Bre
chne
ret
al.
1993
)
How Good Is the Quality of U.S. Health Care? 863
Eye
exam
byop
htha
lmol
ogis
tD
ilat
edey
eex
amin
atio
nis
reco
mm
ende
d,as
desc
ribe
dab
ove,
but
anex
amin
atio
nby
anop
htha
lmol
ogis
tse
rves
asa
prox
yfo
ra
dila
ted
eye
exam
inat
ion.
97,3
88M
edic
are
pati
ents
≥65
year
sol
ddi
agno
sed
wit
hdi
abet
esm
elli
tus
All
Med
icar
ecl
aim
sda
ta(P
arts
Aan
dB
)fro
m3
stat
es(A
laba
ma,
Iow
a,M
aryl
and)
,sub
mit
ted
from
7/1/
90–6
/30/
91
54%
did
not
have
anex
amin
atio
nby
anop
htha
lmol
ogis
tdu
ring
the
prio
rye
ar.
(Wei
ner
etal
.199
5)
Hem
oglo
bin
A1C
Hem
oglo
bin
A1C
(or
glyc
osyl
ated
hem
oglo
bin)
isa
bloo
dte
stth
atre
flec
tsth
em
etab
olic
cont
rolo
fdi
abet
es.T
hete
stsh
ould
bepe
rfor
med
atle
ast
once
aye
arfo
rdi
abet
ics.
Sam
eas
abov
eSa
me
asab
ove
84%
did
not
rece
ive
ahe
mog
lobi
nA
1Cte
stdu
ring
the
prio
rye
ar.
(Wei
ner
etal
.199
5)
Cho
lest
erol
scre
enin
gIt
isre
com
men
ded
that
tota
lch
oles
tero
lsho
uld
bem
easu
red
atle
ast
once
aye
arfo
rdi
abet
ics.
97,3
88M
edic
are
pati
ents
≥65
year
sol
ddi
agno
sed
wit
hdi
abet
esm
elli
tus
All
Med
icar
ecl
aim
sda
ta(P
arts
Aan
dB
)fro
m3
stat
es(A
laba
ma,
Iow
a,M
aryl
and)
,sub
mit
ted
from
7/1/
90–6
/30/
91
45%
did
not
rece
ive
bloo
dch
oles
tero
lscr
eeni
ngdu
ring
the
prio
rye
ar.
(Wei
ner
etal
.199
5)
Dia
bete
smel
litu
s36
8ad
ults
≥18
year
sol
ddi
agno
sed
wit
hdi
abet
es,
from
asa
mpl
eof
2,02
4pa
tien
tsof
135
prov
ider
s
Med
ical
reco
rds
from
phys
icia
nof
fice
s,co
mm
unit
yhe
alth
cent
ers,
and
hosp
ital
outp
atie
ntfa
cili
ties
sam
pled
from
Mar
ylan
dM
edic
aid
clai
ms
data
,198
8
For
each
clin
ical
sett
ing,
the
stud
yre
port
sth
eav
erag
epe
rcen
tage
ofte
chni
cal
qual
ity
indi
cato
rsfo
rdi
abet
esth
atw
ere
not
met
.E
ach
aver
age
was
loca
ted
inth
e40
%–6
0%ra
nge.
(Sta
rfie
ldet
al.1
994)
(Con
tinu
ed)
864 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
HY
PE
RT
EN
SIO
NTr
eatm
entf
orhy
pert
ensi
onH
yper
tens
ion
(or
high
bloo
dpr
essu
re)i
sa
lead
ing
risk
fact
orfo
rco
rona
ryhe
art
dise
ase,
cong
esti
vehe
art
fail
ure,
stro
ke,r
uptu
red
aort
ican
eury
sm,r
enal
dise
ase,
and
reti
nopa
thy,
all
ofw
hich
cont
ribu
teto
high
mor
bidi
tyan
dm
orta
lity
(U.S
.Pre
vent
ive
Serv
ices
Task
Forc
e19
89).
Thi
sw
asre
iter
ated
in19
96(U
.S.
Pre
vent
ive
Serv
ices
Task
Forc
e19
96).
246
pati
ents
>30
year
sol
dw
ith
chro
nic
unco
mpl
icat
edhy
pert
ensi
on
Med
ical
reco
rds
for
pati
ents
from
4gr
oup
prac
tice
sin
Mas
sach
uset
ts,
11/1
/85–
10/3
1/87
41%
–54%
ofpa
tien
tsha
dth
eir
hype
rten
sion
cont
roll
ed(m
ean
bloo
dpr
essu
re<
150/
90).
(Udv
arhe
lyie
tal
.19
91)
Trea
tmen
tfor
hype
rten
sion
Sam
eas
abov
eN
atio
nall
yre
pres
enta
tive
sam
ple
ofU
.S.a
dult
sw
ith
hype
rten
sion
(sam
ple
size
not
avai
labl
e)
Nat
iona
lHea
lth
and
Nut
riti
onE
xam
inat
ion
Surv
eyII
I,19
88–9
1
55%
ofpe
ople
wit
hhy
pert
ensi
onha
dbl
ood
pres
sure
unde
rco
ntro
l(bl
ood
pres
sure
<16
0/95
onon
eoc
casi
onan
dre
port
edcu
rren
tly
taki
ngan
tihy
pert
ensi
vem
edic
atio
ns);
21%
whe
nus
ing
stri
ctcr
iter
ia(b
lood
pres
sure
<14
0/90
and
repo
rted
curr
entl
yta
king
anti
hype
rten
sive
med
icat
ions
).
(Joi
ntN
atio
nal
Com
mit
tee
onD
etec
tion
1993
)
How Good Is the Quality of U.S. Health Care? 865
Trea
tmen
tfor
hype
rten
sion
Sam
eas
abov
e8,
697
adul
ts≥1
8ye
ars
old
diag
nose
dw
ith
hype
rten
sion
from
asa
mpl
eof
36,6
10pe
ople
repr
esen
tati
veof
the
U.S
.
NH
IS,1
990
89%
ofad
ults
wit
hhy
pert
ensi
onre
ceiv
edad
vice
from
aph
ysic
ian
abou
tco
ntro
llin
ghy
pert
ensi
on(i
.e.,
taki
ngan
tihy
pert
ensi
vem
edic
atio
n,de
crea
sing
salt
inta
ke,l
osin
gw
eigh
t,or
exer
cisi
ng);
80%
repo
rted
taki
ngat
leas
ton
eac
tion
toco
ntro
lhy
pert
ensi
on.
(CD
C19
94b)
Trea
tmen
tfor
hype
rten
sion
Sam
eas
abov
e59
3ad
ults
≥18
year
sol
ddi
agno
sed
wit
hhy
pert
ensi
on,
from
asa
mpl
eof
2,02
4pa
tien
tsof
135
prov
ider
s
Med
ical
reco
rds
from
phys
icia
nof
fice
s,co
mm
unit
yhe
alth
cent
ers,
and
hosp
ital
outp
atie
ntfa
cili
ties
sam
pled
from
Mar
ylan
dM
edic
aid
clai
ms
data
,198
8
For
each
type
ofcl
inic
alse
ttin
g,th
est
udy
repo
rts
the
aver
age
perc
enta
geof
tech
nica
lqua
lity
indi
cato
rsfo
rhy
pert
ensi
onth
atw
ere
not
met
.Eac
hav
erag
ew
aslo
cate
din
the
40%
–55%
rang
e.
(Sta
rfie
ldet
al.1
994)
DE
PR
ESS
ION
Dep
ress
ion:
trea
tmen
tT
here
isno
evid
ence
that
min
ortr
anqu
iliz
ers
are
effe
ctiv
efo
rde
pres
sion
,but
ther
eis
evid
ence
that
anti
depr
essa
ntm
edic
atio
nsar
eef
fect
ive
for
depr
essi
on.
634
pati
ents
wit
hcu
rren
tde
pres
sive
diso
rder
orde
pres
sive
sym
ptom
sfr
oma
sam
ple
of22
,399
adul
tpa
tien
tsw
hovi
site
d1
larg
eH
MO
and
seve
ral
mul
tisp
ecia
lty,
mix
ed-g
roup
prac
tice
sin
each
city
duri
ngth
est
udy
peri
od
Med
ical
Out
com
esSt
udy
in3
citi
es(B
osto
n,C
hica
go,L
osA
ngel
es);
ques
tion
nair
esco
mpl
eted
2/86
–10/
86;p
hone
inte
rvie
ws
com
plet
ed5/
86–1
2/86
19%
ofpa
tien
tsw
ere
trea
ted
wit
hm
inor
tran
quil
izer
s;12
%w
ere
trea
ted
wit
han
tide
pres
sant
med
icat
ions
;11%
wer
etr
eate
dw
ith
aco
mbi
nati
onof
min
ortr
anqu
iliz
ers
and
anti
depr
essa
ntm
edic
atio
ns;5
9%re
ceiv
edne
ithe
r.
(Wel
lset
al.
1994
a)
(Con
tinu
ed)
866 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Dep
ress
ion:
trea
tmen
tSa
me
asab
ove
1,19
8pa
tien
tsho
spit
aliz
edw
ith
depr
essi
on,
repr
esen
tati
veof
all
Med
icar
eel
derl
ypa
tien
tsho
spit
aliz
edin
gene
ral
med
ical
hosp
ital
sw
ith
adi
scha
rge
diag
nosi
sof
depr
essi
on
Med
ical
reco
rds
for
Med
icar
epa
tien
tsfr
om29
7ho
spit
als
in5
stat
es(C
alif
orni
a,Fl
orid
a,In
dian
a,P
enns
ylva
nia,
Texa
s),7
/1/8
5-6/
30/8
6
33%
ofpa
tien
tsdi
scha
rged
wit
han
tide
pres
sant
sha
ddo
ses
belo
wre
com
men
ded
leve
l.
(Wel
lset
al.1
994b
)
Dep
ress
ion:
adm
issi
onA
ppro
pria
tere
ason
sfo
rad
mis
sion
incl
ude
depr
essi
on,m
edic
alco
ndit
ion
mer
itin
gac
ute
care
,com
orbi
dm
ajor
psyc
hiat
ric
diso
rder
,or
med
ical
reas
ons
prec
ludi
ngou
tpat
ient
care
for
depr
essi
on.
Sam
eas
abov
eSa
me
asab
ove
93%
wer
ead
mit
ted
for
clea
rly
orpo
ssib
lyap
prop
riat
ere
ason
s,an
d7%
wer
ead
mit
ted
for
inap
prop
riat
ere
ason
s.
(Wel
lset
al.1
993)
How Good Is the Quality of U.S. Health Care? 867
Dep
ress
ion:
adm
issi
onas
sess
men
tSa
me
asab
ove
Sam
eas
abov
eA
spa
rtof
adm
issi
onas
sess
men
t,23
%of
pati
ents
did
not
have
adeq
uate
psyc
holo
gica
las
sess
men
t,26
%di
dno
tha
veco
gnit
ive
asse
ssm
ent,
50%
did
not
have
asse
ssm
ent
ofps
ycho
sis,
19%
did
not
have
docu
men
tati
onof
psyc
hiat
ric
hist
ory,
47%
did
not
docu
men
tw
heth
erpa
tien
tha
da
hist
ory
ofsu
icid
eat
tem
pts
orid
eati
on,2
4%di
dno
tha
vedo
cum
enta
tion
ofpr
ior
orcu
rren
tm
edic
atio
nus
e,an
d45
%di
dno
tha
vedo
cum
enta
tion
that
hear
tso
unds
wer
eex
amin
ed.
Mea
nnu
mbe
rof
com
pone
nts
ofne
urol
ogic
exam
inat
ion
(ass
essm
ents
ofpu
pils
,dee
pte
ndon
refl
exes
and
gait
)pe
rfor
med
was
1.4.
(Wel
lset
al.1
993)
(Con
tinu
ed)
868 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Dep
ress
ion:
diag
nosi
sand
trea
tmen
t 64pa
tien
tsw
ith
maj
orde
pres
sion
from
asa
mpl
eof
2,59
2co
nsec
utiv
epr
imar
yca
repa
tien
ts18
–65
year
sol
dw
hoat
tend
edon
eof
the
stud
ycl
inic
s
Pat
ient
surv
eys
and
inte
rvie
ws,
phys
icia
nsu
rvey
s,an
dco
mpu
teri
zed
phar
mac
yre
cord
sfr
om3
prim
ary
care
clin
ics
ofG
roup
Hea
lth
Coo
pera
tive
ofP
uget
Soun
din
Was
hing
ton
Am
ong
pati
ents
wit
hm
ajor
depr
essi
onw
hore
ceiv
edan
tide
pres
sant
med
icat
ions
,78%
rece
ived
dosa
ges
wit
hin
the
reco
mm
ende
dra
nges
.
(Sim
onan
dV
onK
orff
1995
)
ME
NTA
L/A
DD
ICT
IVE
DIS
OR
DE
RM
enta
lor
addi
citv
edis
orde
rP
eopl
ew
ith
men
talo
rad
dict
ive
diso
rder
from
asa
mpl
eof
20,2
91ad
ults
≥18
year
sol
d
Nat
iona
lIns
titu
teof
Men
tal
Hea
lth’
sE
pide
mio
logi
cC
atch
men
tA
rea
stud
yin
terv
iew
s,19
80–8
5
29%
ofpe
ople
wit
han
ym
enta
lor
addi
ctiv
edi
sord
erre
ceiv
edso
me
prof
essi
onal
orvo
lunt
ary
men
talh
ealt
hse
rvic
edu
ring
the
prio
r12
mon
ths,
asdi
d32
%of
peop
lew
ith
any
diso
rder
exce
ptsu
bsta
nce
use,
37%
ofpe
ople
wit
han
ym
enta
ldi
sord
erw
ith
com
orbi
dsu
bsta
nce
use,
24%
ofpe
ople
wit
hsu
bsta
nce
use
(e.g
.,al
coho
l),6
4%of
peop
lew
ith
schi
zoph
reni
a,46
%of
peop
lew
ith
any
(Reg
ier
etal
.199
3)
How Good Is the Quality of U.S. Health Care? 869
affe
ctiv
edi
sord
er(e
.g.,
depr
essi
on),
33%
ofpe
ople
wit
han
yan
xiet
ydi
sord
er(e
.g.,
obse
ssiv
e-co
mpu
lsiv
e),7
0%of
peop
lew
ith
som
atiz
atio
n,31
%of
peop
lew
ith
anti
soci
alpe
rson
alit
ydi
sord
er,a
nd17
%of
peop
lew
ith
seve
reco
gnit
ive
impa
irm
ent.
HY
STE
RE
CT
OM
YH
yste
rect
omy
Hys
tere
ctom
yis
the
surg
ical
rem
oval
ofth
eut
erus
.64
2w
omen
≥20
year
sol
dw
houn
derw
ent
none
mer
genc
y,no
nonc
olog
ichy
ster
ecto
mie
s
Med
ical
reco
rds
for
pati
ents
from
7m
anag
edca
reor
gani
zati
ons,
8/1/
89–7
/31/
90
16%
ofhy
ster
ecto
mie
sw
ere
inap
prop
riat
e,25
%w
ere
equi
voca
l,an
d58
%w
ere
appr
opri
ate.
(Ber
nste
inet
al.
1993
b)
BR
EA
STC
AN
CE
RB
reas
tcan
cer:
trea
tmen
t19
9w
omen
50–6
9ye
ars
old
and
175
wom
en≥7
0ye
ars
old,
wit
had
enoc
arci
nom
aof
the
brea
st,r
ecei
ving
prim
ary
canc
erm
anag
agem
ent
ata
part
icip
atin
gho
spit
al
Med
ical
reco
rds
from
7ho
spit
als
inso
uthe
rnC
alif
orni
a,fo
rw
omen
wit
hbr
east
canc
erdi
agno
sed
in19
80–8
2
67%
ofw
omen
≥70
year
sol
dre
ceiv
edap
prop
riat
etr
eatm
ent,
com
pare
dw
ith
83%
ofw
omen
50–6
9ye
ars
old.
Whe
nco
ntro
llin
gfo
rco
mor
bidi
ty,h
ospi
tal,
and
canc
erst
age,
adi
ffer
ence
inap
prop
riat
enes
sre
late
dto
age
pers
iste
d.
(Gre
enfi
eld
etal
.19
87) (C
onti
nued
)
870 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
CA
RD
IAC
DIS
EA
SEC
oron
ary
arte
rydi
seas
e:co
rona
ryan
giog
raph
yC
oron
ary
angi
ogra
phy
isa
met
hod
for
eval
uati
ngco
rona
ryar
tery
anat
omy
tode
term
ine
whe
ther
apa
tien
tis
aca
ndid
ate
for
coro
nary
arte
ryby
pass
graf
tsu
rger
yor
perc
utan
eous
tran
slum
inal
coro
nary
angi
opla
sty.
352
pati
ents
who
met
expl
icit
lyde
fine
dcr
iter
iafo
rne
cess
ity
ofco
rona
ryan
giog
raph
y,fr
omam
ong
1,35
0po
siti
veex
erci
sest
ress
test
sin
ara
ndom
lyse
lect
edsa
mpl
eof
5,85
0st
ress
test
s
Med
ical
reco
rds
from
4te
achi
ngho
spit
als
(3pu
blic
,1pr
ivat
e)in
Los
Ang
eles
,and
pati
ent
tele
phon
ein
terv
iew
s(w
ith
243
ofth
e35
2pa
tien
ts),
1/1/
90–6
/30/
91
43%
ofpa
tien
tsre
ceiv
edco
rona
ryan
giog
raph
yw
ithi
n3
mon
ths
ofth
epo
siti
veex
erci
sest
ress
test
;56
%re
ceiv
edco
rona
ryan
giog
raph
yw
ithi
n12
mon
ths
ofth
epo
siti
vete
st.
(Lao
urie
tal
.199
7)
Cor
onar
yar
tery
dise
ase:
coro
nary
angi
ogra
phy
Sam
eas
abov
eR
ando
msa
mpl
eof
1,33
5pa
tien
tsw
hoha
dco
rona
ryan
giog
raph
y
Med
ical
reco
rds
from
15no
nfed
eral
hosp
ital
spr
ovid
ing
coro
nary
angi
ogra
phy
inN
ewY
ork,
sele
cted
thro
ugh
ast
rati
fied
rand
omsa
mpl
e(f
orlo
cati
on,v
olum
eof
coro
nary
angi
ogra
phy,
and
auth
oriz
atio
nto
perf
orm
coro
nary
arte
ryby
pass
graf
tsu
rger
y),1
990
4%of
coro
nary
angi
ogra
phie
sw
ere
inap
prop
riat
e,20
%w
ere
equi
voca
l,an
d76
%w
ere
appr
opri
ate.
(Ber
nste
inet
al.
1993
a)
How Good Is the Quality of U.S. Health Care? 871
Cor
onar
yar
tery
dise
ase:
coro
nary
angi
ogra
phy
Sam
eas
abov
eR
ando
msa
mpl
eof
1,67
7ca
ses
ofco
rona
ryan
giog
raph
y
Med
icar
eph
ysic
ian
clai
ms
data
and
med
ical
reco
rds
from
3si
tes
sele
cted
from
13si
tes
in8
stat
es(A
rizo
na,C
alif
orni
a,C
olor
ado,
Iow
a,M
assa
chus
etts
,Mon
tana
,P
enns
ylva
nia,
Sout
hC
arol
ina)
,198
1
17%
ofco
rona
ryan
giog
raph
ies
wer
ein
appr
opri
ate,
9%w
ere
equi
voca
l,an
d74
%w
ere
appr
opri
ate.
(Cha
ssin
etal
.198
7)
Cor
onar
yar
tery
dise
ase:
coro
nary
arte
ryby
pass
graf
t(C
AB
G)
InC
AB
Gsu
rger
y,da
mag
edbl
ood
vess
els
supp
lyin
gth
ehe
art
are
repl
aced
wit
hve
ssel
sfr
omel
sew
here
inth
ebo
dy.
Stra
tifi
ed,r
ando
msa
mpl
eof
386
pati
ents
who
unde
rwen
tC
AB
Gsu
rger
yin
the
3ho
spit
als
Med
ical
reco
rds
from
3ho
spit
als
(exc
ludi
ngV
eter
ans
Adm
inis
trat
ion
orgo
vern
men
talh
ospi
tals
and
spec
ialt
yho
spit
als)
sele
cted
thro
ugh
ast
rati
fied
rand
omsa
mpl
e(f
orsi
zean
dte
achi
ngst
atus
)in
aw
este
rnst
ate
aspa
rtof
the
Nat
iona
lIn
stit
utes
ofH
ealt
hC
onse
nsus
Dev
elop
men
tP
rogr
am,1
979,
1980
,and
1982
14%
ofC
AB
Gsu
rger
ies
wer
ein
appr
opri
ate,
30%
wer
eeq
uivo
cal,
and
56%
wer
eap
prop
riat
e.
(Win
slow
etal
.19
88) (C
onti
nued
)
872 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Cor
onar
yar
tery
dise
ase:
CA
BG
Sam
eas
abov
eR
ando
msa
mpl
eof
1,15
6pa
tien
tsw
hoha
dis
olat
edC
AB
Gsu
rger
y
Med
ical
reco
rds
for
pati
ents
from
12A
cade
mic
Med
ical
Cen
ter
Con
sort
ium
hosp
ital
sin
10st
ates
(Cal
ifor
nia,
Iow
a,Lo
uisi
ana,
Mar
ylan
d,M
assa
chus
etts
,Min
neso
ta,
New
Ham
pshi
re,N
ewY
ork,
Nor
thC
arol
ina,
Pen
nsyl
vani
a),1
990
1.6%
ofC
AB
Gsu
rger
ies
wer
ein
appr
opri
ate,
7%w
ere
equi
voca
l,an
d92
%w
ere
appr
opri
ate.
(Lea
peet
al.1
996)
Cor
onar
yar
tery
dise
ase:
CA
BG
Sam
eas
abov
eR
ando
msa
mpl
eof
1,33
8pa
tien
tsw
hoha
dis
olat
edC
AB
Gsu
rger
y
Med
ical
reco
rds
from
15no
nfed
eral
hosp
ital
spr
ovid
ing
CA
BG
proc
edur
ein
New
Yor
k,se
lect
edth
roug
ha
stra
tifi
edra
ndom
sam
ple
(for
loca
tion
and
volu
me
ofC
AB
Gop
erat
ions
),19
90
2.4%
ofC
AB
Gsu
rger
ies
wer
ein
appr
opri
ate,
7%w
ere
equi
voca
l,an
d91
%w
ere
appr
opri
ate.
(Lea
peet
al.1
993)
Cor
onar
yar
tery
dise
ase:
perc
utan
eous
tran
slum
inal
coro
nary
angi
opla
sty
(PT
CA
)P
TC
Aus
esa
min
iatu
reba
lloo
nca
thet
erto
decr
ease
sten
osis
(blo
ckag
e)in
bloo
dve
ssel
ssu
pply
ing
the
hear
t.
Ran
dom
sam
ple
of1,
306
pati
ents
who
had
PT
CA
Med
ical
reco
rds
from
15no
nfed
eral
hosp
ital
spr
ovid
ing
PT
CA
inN
ewY
ork,
sele
cted
thro
ugh
ast
rati
fied
rand
omsa
mpl
e(f
orlo
cati
onan
dvo
lum
eof
PT
CA
),19
90
4%of
PT
CA
sw
ere
inap
prop
riat
e,38
%w
ere
equi
voca
l,an
d58
%w
ere
appr
opri
ate.
(Hil
born
eet
al.
1993
)
How Good Is the Quality of U.S. Health Care? 873
Hea
rtat
tack
:tre
atm
entw
ith
aspi
rin
Asp
irin
isan
effe
ctiv
e,in
expe
nsiv
e,an
dsa
fetr
eatm
ent
for
ahe
art
atta
ck.A
spir
inth
erap
yre
duce
ssh
ort-
term
mor
tali
tyin
pati
ents
wit
hsu
spec
ted
hear
tat
tack
by23
%.A
spir
insh
ould
not
begi
ven
topa
tien
tsw
ith
cert
ain
cond
itio
ns(e
.g.,
hem
orrh
agic
stro
ke,
gast
roin
test
inal
blee
ding
).
7,91
7M
edic
are
pati
ents
≥65
year
sol
d,ho
spit
aliz
edw
ith
hear
tat
tack
who
wer
e“i
deal
”ca
ndid
ates
for
trea
tmen
tw
ith
aspi
rin
wit
hno
poss
ible
cont
rain
dica
tion
sto
aspi
rin
ther
apy
Med
ical
reco
rds
for
Med
icar
ebe
nefi
ciar
ies
who
wer
eho
spit
aliz
edin
4st
ates
(Ala
bam
a,C
onne
ctic
ut,
Iow
a,W
isco
nsin
),as
part
ofth
eC
oope
rati
veC
ardi
ovas
cula
rP
roje
ctP
ilot
,6/1
/92–
2/28
/93
64%
rece
ived
aspi
rin
wit
hin
the
firs
t2
days
ofho
spit
aliz
atio
n.
(Kru
mho
lzet
al.
1995
)
Hea
rtat
tack
:tre
atm
entw
ith
aspi
rin
Sam
eas
abov
e5,
490
Med
icar
epa
tien
ts≥6
5ye
ars
old,
hosp
ital
ized
wit
hhe
art
atta
ckw
how
ere
aliv
eat
disc
harg
ean
dw
hoha
dno
cont
rain
dica
tion
sto
aspi
rin
ther
apy
Som
eas
abov
e76
%w
ere
disc
harg
edw
ith
inst
ruct
ions
tota
keas
piri
n.P
atie
nts
who
wer
epr
escr
ibed
aspi
rin
atdi
scha
rge
had
a6-
mon
thm
orta
lity
rate
of8.
4%,
com
pare
dw
ith
17%
for
pati
ents
not
pres
crib
edas
piri
n.
(Kru
mho
lzet
al.
1996
) (Con
tinu
ed)
874 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Hea
rtat
tack
:tre
atm
entw
ith
aspi
rin
Sam
eas
abov
e7,
486
pati
ents
who
wer
e“i
deal
”ca
ndid
ates
for
trea
tmen
tw
ith
aspi
rin
duri
ngin
itia
lho
spit
aliz
atio
nfr
oma
sam
ple
of16
,124
Med
icar
epa
tien
tsho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck;5
,841
pati
ents
who
wer
eal
ive
atdi
scha
rge
and
who
wer
e“i
deal
”ca
ndid
ates
for
trea
tmen
tw
ith
aspi
rin
prio
rto
orat
tim
eof
disc
harg
e,fr
omth
esa
me
sam
ple
Sam
eas
abov
e83
%re
ceiv
edas
piri
ndu
ring
hosp
ital
izat
ion;
77%
rece
ived
aspi
rin
prio
rto
orat
tim
eof
disc
harg
e.
(Ell
erbe
cket
al.
1995
)
Hea
rtat
tack
:tre
atm
entw
ith
aspi
rin
Sam
eas
abov
e18
7pa
tien
tsw
ith
conf
irm
edhe
art
atta
ckw
how
ere
aliv
eat
disc
harg
ean
dw
hoha
dno
cont
rain
dica
tion
sto
aspi
rin
ther
apy
from
asa
mpl
eof
300
Med
icar
epa
tien
ts≥6
5ye
ars
old
hosp
ital
ized
wit
ha
prin
cipa
ldia
gnos
isof
hear
tat
tack
Med
icar
em
orta
lity
data
issu
edby
the
Hea
lth
Car
eF
inan
cing
Adm
inis
trat
ion
(HC
FA)a
ndm
edic
alre
cord
sfo
rM
edic
are
pati
ents
from
6ho
spit
als
inC
onne
ctic
ut,a
spa
rtof
the
Med
icar
eH
ospi
tal
Info
rmat
ion
Pro
ject
,10
/1/8
8–9/
30/9
1
73%
rece
ived
aspi
rin
atti
me
ofdi
scha
rge.
(Mee
han
etal
.199
5)
How Good Is the Quality of U.S. Health Care? 875
Hea
rtat
tack
:tre
atm
entw
ith
thro
mbo
lyti
csT
hrom
boly
tics
are
med
icat
ions
that
brea
kdo
wn
som
eof
the
acut
ebl
ocka
gein
the
bloo
dve
ssel
sth
atca
uses
ahe
art
atta
ck,t
here
byre
duci
ngin
farc
tsi
zean
dli
mit
ing
left
vent
ricu
lar
dysf
unct
ion.
Thr
ombo
lyti
csha
vebe
ensh
own
tore
duce
post
-AM
Im
orta
lity
byas
muc
has
25%
,tho
ugh
they
shou
ldno
tbe
give
nto
pati
ents
wit
hce
rtai
nco
ndit
ions
(e.g
.,re
cent
hem
orrh
agic
stro
ke)
1,10
5pa
tien
tsw
how
ere
“ide
al”
cand
idat
esfo
rtr
eatm
ent
wit
hth
rom
boly
tic
agen
tsfr
oma
sam
ple
of16
,124
Med
icar
epa
tien
tsho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck.
Med
ical
reco
rds
for
Med
icar
ebe
nefi
ciar
ies
who
wer
eho
spit
aliz
edin
4st
ates
(Ala
bam
a,C
onne
ctic
ut,
Iow
a,W
isco
nsin
),as
part
ofth
eC
oope
rati
veC
ardi
ovas
cula
rP
roje
ctP
ilot
,6/1
/92–
2/28
/93
70%
rece
ived
thro
mbo
lyti
csdu
ring
hosp
ital
izat
ion.
(Ell
erbe
cket
al.
1995
)
Hea
rtat
tack
:tre
atm
entw
ith
thro
mbo
lyti
csSa
me
asab
ove
68pa
tien
tsw
ith
conf
irm
edhe
art
atta
ckw
hoha
dno
cont
rain
dica
tion
sto
thro
mbo
lyti
cth
erap
yan
dw
hoha
del
ectr
ocar
diog
raph
icin
dica
tion
sfo
rth
rom
boly
tic
ther
apy
from
asa
mpl
eof
300
Med
icar
epa
tien
ts≥6
5ye
ars
old
hosp
ital
ized
wit
ha
prin
cipa
ldia
gnos
isof
hear
tat
tack
Med
icar
em
orta
lity
data
issu
edby
HC
FAan
dm
edic
alre
cord
sfo
rM
edic
are
pati
ents
from
6ho
spit
als
inC
onne
ctic
ut,a
spa
rtof
the
Med
icar
eH
ospi
tal
Info
rmat
ion
Pro
ject
,10
/1/8
8–9/
30/9
1
43%
rece
ived
thro
mbo
lyti
csdu
ring
hosp
ital
izat
ion.
(Mee
han
etal
.199
5)
(Con
tinu
ed)
876 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Hea
rtat
tack
:tre
atm
entw
ith
hepa
rin
Hep
arin
isbe
nefi
cial
topa
tien
tsw
ith
hear
tat
tack
thou
ghhe
pari
nsh
ould
not
begi
ven
topa
tien
tsw
ith
cert
ain
cond
itio
ns(e
.g.,
blee
ding
diso
rder
s,st
roke
).
9,85
7pa
tien
tsw
how
ere
“ide
al”
cand
idat
esfo
rtr
eatm
ent
wit
hhe
pari
nfr
oma
sam
ple
of16
,124
Med
icar
epa
tien
tsho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck
Med
ical
reco
rds
for
Med
icar
ebe
nefi
ciar
ies
who
wer
eho
spit
aliz
edin
4st
ates
(Ala
bam
a,C
onne
ctic
ut,
Iow
a,W
isco
nsin
),as
part
ofth
eC
oope
rati
veC
ardi
ovas
cula
rP
roje
ctP
ilot
,6/1
/92–
2/28
/93
69%
rece
ived
hepa
rin
duri
ngho
spit
aliz
atio
n.(E
ller
beck
etal
.19
95)
Hea
rtat
tack
:tre
atm
entw
ith
intr
aven
ousn
itro
glyc
erin
Intr
aven
ous
nitr
ogly
ceri
nis
bene
fici
alto
pati
ents
wit
hhe
art
atta
ckw
hoha
vepe
rsis
tent
ches
tpa
in,
alth
ough
intr
aven
ous
nitr
ogly
ceri
nsh
ould
not
begi
ven
topa
tien
tsw
ith
cert
ain
cond
itio
ns(e
.g.,
shoc
kor
hypo
tens
ion
onad
mis
sion
).
1,75
4pa
tien
tsw
how
ere
“ide
al”
cand
idat
esfo
rtr
eatm
ent
wit
hin
trav
enou
sni
trog
lyce
rin
from
asa
mpl
eof
16,1
24M
edic
are
pati
ents
hosp
ital
ized
wit
ha
prin
cipa
ldia
gnos
isof
hear
tat
tack
Sam
eas
abov
e74
%re
ceiv
edin
trav
enou
sni
trog
lyce
rin
duri
ngho
spit
aliz
atio
n.
(Ell
erbe
cket
al.
1995
)
Hea
rtat
tack
:avo
idan
ceof
calc
ium
chan
nelb
lock
ersf
orpa
tien
tsw
ith
aco
ntra
indi
cati
onC
alci
umch
anne
lblo
cker
ssh
ould
not
begi
ven
topa
tien
tsw
ith
cert
ain
cond
itio
ns(e
.g.,
low
left
vent
ricu
lar
ejec
tion
frac
tion
,evi
denc
eof
shoc
kor
pulm
onar
yed
ema
duri
ngho
spit
aliz
atio
n).
785
pati
ents
wit
hcl
ear
cont
rain
dica
tion
toca
lciu
mch
anne
lblo
cker
sfr
oma
sam
ple
of16
,124
Med
icar
epa
tien
tsho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck
Sam
eas
abov
e21
%w
how
ere
inel
igib
lefo
rca
lciu
mch
anne
lblo
cker
sre
ceiv
edth
em.
(Ell
erbe
cket
al.
1995
)
How Good Is the Quality of U.S. Health Care? 877
Hea
rtat
tack
:sm
okin
gce
ssat
ion
advi
cefo
rsm
oker
sSm
oker
sw
ith
coro
nary
arte
rydi
seas
ew
host
opsm
okin
gha
vea
bett
erpr
ogno
sis
than
thos
ew
hoke
epsm
okin
g;at
the
tim
eof
hear
tat
tack
,th
ese
smok
ers
are
mos
tsu
scep
tibl
eto
advi
ceab
out
cess
atio
nof
smok
ing.
1,69
1sm
oker
sw
how
ere
“ide
al”
cand
idat
esfo
rsm
okin
gce
ssat
ion
advi
cefr
oma
sam
ple
of16
,124
Med
icar
epa
tien
tsho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck
Sam
eas
abov
e28
%re
ceiv
edsm
okin
gce
ssat
ion
advi
cepr
ior
toor
atti
me
ofdi
scha
rge.
(Ell
erbe
cket
al.
1995
)
Hea
rtat
tack
:tre
atm
entw
ith
angi
oten
sin-
conv
erti
ngen
zym
e(A
CE
)in
hibi
tors
AC
Ein
hibi
tors
can
redu
cepo
st-A
MI
mor
tali
tyin
pati
ents
wit
hle
ftve
ntri
cula
rdy
sfun
ctio
n,al
thou
ghA
CE
inhi
bito
rssh
ould
not
begi
ven
topa
tien
tsw
ith
cert
ain
cond
itio
ns(e
.g.,
aort
icst
enos
is).
1,47
3pa
tien
tsw
how
ere
“ide
al”
cand
idat
esfo
rtr
eatm
ent
wit
hA
CE
inhi
bito
rsfr
oma
sam
ple
of16
,124
Med
icar
epa
tien
tsho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck
Sam
eas
abov
e59
%re
ceiv
edA
CE
inhi
bito
rspr
ior
toor
atti
me
ofdi
scha
rge.
(Ell
erbe
cket
al.
1995
)
Hea
rtat
tack
:bet
abl
ocke
rth
erap
yB
eta
bloc
ker
ther
apy
can
redu
cepo
st-A
MI
mor
tali
tyby
asm
uch
as25
%,
alth
ough
beta
bloc
kers
shou
ldno
tbe
give
nto
pati
ents
wit
hce
rtai
nco
ndit
ions
(e.g
.,lo
wle
ftve
ntri
cula
rej
ecti
onfr
acti
on,p
ulm
onar
yed
ema)
.
2,97
6pa
tien
tsw
how
ere
“ide
al”
cand
idat
esfo
rtr
eatm
ent
wit
hbe
tabl
ocke
rsfr
oma
sam
ple
of16
,124
Med
icar
epa
tien
tsho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck
Sam
eas
abov
e45
%re
ceiv
edbe
tabl
ocke
rspr
ior
toor
atti
me
ofdi
scha
rge.
(Ell
erbe
cket
al.
1995
)
(Con
tinu
ed)
878 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Hea
rtat
tack
:bet
abl
ocke
rth
erap
ySa
me
asab
ove
3,73
7M
edic
are
pati
ents
≥65
year
sol
dw
ith
prin
cipa
ldi
agno
sis
ofhe
art
atta
ckw
how
ere
elig
ible
for
trea
tmen
tw
ith
beta
bloc
kers
,fro
ma
stat
ewid
eco
hort
of5,
332
peop
lew
hoha
dsu
rviv
eda
hear
tat
tack
for
atle
ast
30da
ysan
dw
hoha
dpr
escr
ipti
ondr
ugco
vera
ge
New
Jers
eyM
edic
are
hosp
ital
adm
issi
ons
and
enro
llm
ent
data
,198
6–92
;New
Jers
eyM
edic
aid
drug
util
izat
ion
and
enro
llm
ent
file
s,19
86–9
1;N
ewJe
rsey
Pro
gram
ofP
harm
acy
Ass
ista
nce
for
the
Age
dan
dD
isab
led
drug
util
izat
ion
data
,198
6–91
21%
rece
ived
beta
bloc
kers
wit
hin
90da
ysof
disc
harg
e;ad
just
edm
orta
lity
rate
for
pati
ents
wit
htr
eatm
ent
was
43%
less
than
that
ofpa
tien
tsw
itho
uttr
eatm
ent.
(Sou
mer
aiet
al.
1997
)
Hea
rtat
tack
:bet
abl
ocke
rth
erap
ySa
me
asab
ove
104
pati
ents
wit
hco
nfir
med
hear
tat
tack
who
wer
eal
ive
atdi
scha
rge
and
who
had
noco
ntra
indi
cati
ons
tobe
tabl
ocke
rsfr
oma
sam
ple
of30
0M
edic
are
pati
ents
≥65
year
sol
dho
spit
aliz
edw
ith
apr
inci
pald
iagn
osis
ofhe
art
atta
ck
Med
icar
em
orta
lity
data
issu
edby
HC
FAan
dm
edic
alre
cord
sfo
rM
edic
are
pati
ents
from
6ho
spit
als
inC
onne
ctic
ut,a
spa
rtof
the
Med
icar
eH
ospi
tal
Info
rmat
ion
Pro
ject
,10
/1/8
8–9/
30/9
1
41%
rece
ived
beta
bloc
kers
atti
me
ofdi
scha
rge.
(Mee
han
etal
.199
5)
Hea
rtat
tack
:per
man
entc
ardi
acpa
cem
aker
Pac
emak
ers
help
regu
lari
zeab
norm
alhe
art
rate
san
drh
ythm
s.
Med
icar
epa
tien
tsw
houn
derw
ent
ato
talo
f382
pace
mak
erim
plan
tati
ons
Med
ical
reco
rds
from
6un
iver
sity
teac
hing
hosp
ital
s,11
univ
ersi
ty-a
ffil
iate
dho
spit
als,
and
13co
mm
unit
yho
spit
als
inP
hila
delp
hia
Cou
nty,
1/1/
83–6
/30/
83
20%
ofpa
cem
aker
impl
anta
tion
sw
ere
inap
prop
riat
e,36
%w
ere
equi
voca
l,an
d44
%w
ere
appr
opri
ate.
(Gre
ensp
anet
al.
1988
)
How Good Is the Quality of U.S. Health Care? 879
Hea
rtat
tack
:hos
pita
lcar
eC
are
for
hear
tat
tack
1,43
7pa
tien
tsho
spit
aliz
edw
ith
acut
em
yoca
rdia
lin
farc
tion
from
ana
tion
ally
repr
esen
tati
vesa
mpl
eof
7,15
6pa
tien
tsho
spit
aliz
edw
ith
any
of5
cond
itio
ns(c
onge
stiv
ehe
art
fail
ure,
acut
em
yoca
rdia
linf
arct
ion,
pneu
mon
ia,s
trok
e,hi
pfr
actu
re)(
Dra
per
etal
.19
90)
Med
ical
reco
rds
for
Med
icar
epa
tien
tsfr
om29
7ho
spit
als
in5
stat
es(C
alif
orni
a,Fl
orid
a,In
dian
a,P
enns
ylva
nia,
Texa
s),7
/1/8
5–6/
30/8
6
64%
–68%
ofpa
tien
tsw
ith
acut
em
yoca
rdia
lin
farc
tion
rece
ived
appr
opri
ate
com
pone
nts
ofca
re(e
.g.,
docu
men
tati
onof
exam
inat
ion
ofju
gula
rve
ins
and
alco
holi
smor
smok
ing
habi
ts).
(Kah
net
al.1
990)
Con
gest
iveh
eart
fail
ure:
hosp
ital
care
Car
efo
rco
nges
tive
hear
tfa
ilur
e1,
465
pati
ents
hosp
ital
ized
wit
hco
nges
tive
hear
tfa
ilur
efr
oma
nati
onal
lyre
pres
enta
tive
sam
ple
of7,
156
pati
ents
hosp
ital
ized
wit
han
yof
5co
ndit
ions
(con
gest
ive
hear
tfa
ilur
e,ac
ute
myo
card
iali
nfar
ctio
n,pn
eum
onia
,str
oke,
hip
frac
ture
)(D
rape
ret
al.
1990
)
Sam
eas
abov
e66
%–9
7%of
pati
ents
wit
hco
nges
tive
hear
tfa
ilur
ere
ceiv
edap
prop
riat
eco
mpo
nent
sof
care
(e.g
.,do
cum
enta
tion
ofpa
stsu
rger
yan
dlu
ngex
amin
atio
non
day
2;bl
ood
pres
sure
read
ings
;el
ectr
ocar
diog
ram
;ser
umpo
tass
ium
leve
l;ox
ygen
ther
apy
orin
tuba
tion
for
hypo
xic
pati
ents
).
(Kah
net
al.1
990)
(Con
tinu
ed)
880 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Stro
ke:h
ospi
talc
are
Car
efo
rst
roke
1,44
2pa
tien
tsho
spit
aliz
edw
ith
stro
kefr
oma
nati
onal
lyre
pres
enta
tive
sam
ple
of7,
156
pati
ents
hosp
ital
ized
wit
han
yof
5co
ndit
ions
(con
gest
ive
hear
tfa
ilur
e,ac
ute
myo
card
ial
infa
rcti
on,p
neum
onia
,st
roke
,hip
frac
ture
)(D
rape
ret
al.1
990)
Sam
eas
abov
e38
%–9
4%of
pati
ents
wit
hst
roke
rece
ived
appr
opri
ate
com
pone
nts
ofca
re(e
.g.,
docu
men
tati
onof
prev
ious
stro
kean
dga
gre
flex
;blo
odpr
essu
rere
adin
gs;
elec
troc
ardi
ogra
m;s
erum
pota
ssiu
mle
vel)
.
(Kah
net
al.1
990)
CA
RO
TID
AR
TE
RIE
SC
arot
iden
dart
erec
tom
yC
arot
iden
dart
erec
tom
yis
apr
oced
ure
that
open
sup
sten
otic
(blo
cked
)car
otid
arte
ries
(whi
chsu
pply
bloo
dto
the
brai
n).
Ran
dom
sam
ple
of1,
302
case
sof
caro
tid
enda
rter
ecto
my
Med
icar
eph
ysic
ian
clai
ms
data
and
med
ical
reco
rds
from
3si
tes
sele
cted
from
13si
tes
in8
stat
es(A
rizo
na,
Cal
ifor
nia,
Col
orad
o,Io
wa,
Mas
sach
uset
ts,M
onta
na,
Pen
nsyl
vani
a,So
uth
Car
olin
a),1
981
32%
ofca
roti
den
dart
erec
tom
ies
wer
ein
appr
opri
ate,
32%
wer
eeq
uivo
cal,
and
35%
wer
eap
prop
riat
e.
(Cha
ssin
etal
.198
7)
GA
STR
OIN
TE
STIN
AL
DIS
EA
SEU
pper
gast
roin
test
inal
trac
tend
osco
pyE
ndos
copy
enab
les
visu
aliz
atio
nof
the
gast
roin
test
inal
trac
t,an
dpe
rmit
sbi
opsy
and
brus
hcy
tolo
gic
exam
inat
ion.
Ran
dom
sam
ple
of1,
585
case
sof
uppe
rga
stro
inte
stin
altr
act
endo
scop
y
Sam
eas
abov
e17
%of
uppe
rga
stro
inte
stin
altr
act
endo
scop
ies
wer
ein
appr
opri
ate,
11%
wer
eeq
uivo
cal,
and
72%
wer
eap
prop
riat
e.
(Cha
ssin
etal
.198
7)
How Good Is the Quality of U.S. Health Care? 881
CA
TAR
AC
TS
Cat
arac
tsur
gery
Cat
arac
tsu
rger
yis
aco
mm
only
perf
orm
edsu
rger
yin
adul
ts≥6
5ye
ars
old.
Cat
arac
tsu
rger
ysh
ould
not
bepe
rfor
med
inpe
ople
wit
hce
rtai
nco
ndit
ions
(e.g
.,m
acul
arde
gene
rati
onor
diab
etic
reti
nopa
thy)
.
1,02
0pa
tien
tsw
houn
derw
ent
ato
talo
f1,1
39ca
tara
ctsu
rger
ies
Med
ical
reco
rds
for
pati
ents
from
10ac
adem
icm
edic
alce
nter
s,19
90
2%of
cata
ract
surg
erie
sw
ere
inap
prop
riat
e,7%
wer
eeq
uivo
cal,
and
91%
wer
eap
prop
riat
e.
(Tob
acm
anet
al.
1996
)
HIV
/AID
SR
elat
ion
betw
een
hosp
ital
expe
rien
cean
dm
orta
lity
from
AID
S30
0pa
tien
tsdi
agno
sed
wit
hac
quir
edim
mun
odef
icie
ncy
synd
rom
e(A
IDS)
Cas
ere
cord
sof
the
Mas
sach
uset
tsA
IDS
Surv
eill
ance
Pro
gram
and
bill
ing
reco
rds
from
40ho
spit
als,
med
ical
reco
rds
for
pati
ents
from
22of
the
40ho
spit
als,
and
data
tape
sfr
omth
eM
assa
chus
etts
Rat
eSe
ttin
gC
omm
issi
on,
1/1/
87–1
2/31
/88
Pat
ient
sin
low
-exp
erie
nce
hosp
ital
sw
ere
2.16
tim
esm
ore
like
lyto
die
(2.9
2w
hen
cont
roll
ing
for
char
acte
rist
ics
pote
ntia
lly
asso
ciat
edw
ith
mor
tali
ty)
duri
ngan
AID
Sad
mis
sion
,com
pare
dw
ith
thos
ein
high
-exp
erie
nce
hosp
ital
s.
(Con
tinu
ed)
882 M.A. Schuster, E.A. McGlynn, and R.H. Brook
TA
BL
E3—
Con
tinu
ed
Hea
lth
Car
eSe
rvic
eaSa
mpl
eD
escr
ipti
onD
ata
Sour
ceQ
uali
tyof
Car
eR
efer
ence
b
Rel
atio
nbe
twee
nph
ysic
ian
expe
rien
cean
dm
orta
lity
from
AID
S12
5pr
imar
yca
reph
ysic
ians
’cli
nica
lex
peri
ence
str
eati
ng40
3ad
ult
mal
epa
tien
tsw
ith
AID
S
Gro
upH
ealt
hH
IV/A
IDS
Surv
eill
ance
Dat
abas
e,G
roup
Hea
lth’
sU
tili
zati
onM
anag
emen
t/C
ost
Man
agem
ent
Info
rmat
ion
Syst
em,a
ndph
ysic
ian
pers
onne
lrec
ords
,19
84–9
4
Pat
ient
sof
phys
icia
nsw
ith
the
leas
tex
peri
ence
surv
ived
14m
onth
saf
ter
AID
Sdi
agno
sis
com
pare
dw
ith
26m
onth
sfo
rpa
tien
tsof
phys
icia
nsw
ith
the
mos
tex
peri
ence
.
(Kit
ahat
aet
al.
1996
)
NE
ON
ATA
LM
OR
TALI
TY
Rel
atio
nbe
twee
nph
ysic
ian
expe
rien
cean
dne
onat
alm
orta
lity
53,2
29bi
rths
clas
sifi
edas
like
lyne
onat
alin
tens
ive
care
unit
(NIC
U)
adm
issi
ons
from
asa
mpl
eof
473,
209
birt
hs(s
ingl
eton
son
ly)i
n19
90
Cal
ifor
nia
birt
hce
rtif
icat
ean
din
fant
deat
hfi
lefo
ral
lno
nfed
eral
hosp
ital
s,C
alif
orni
aO
ffic
eof
Stat
ewid
eH
ealt
hP
lann
ing
and
Dev
elop
men
t(O
SHP
D)d
isch
arge
abst
ract
s,C
alif
orni
aP
erin
atal
Dis
patc
hC
ente
rs’n
eona
talt
rans
port
data
,and
OSH
PD
hosp
ital
data
,199
0
Infa
nts
born
inho
spit
als
wit
han
aver
age
NIC
Uce
nsus
≥20
pati
ents
per
day
had
low
erri
sk-a
djus
ted
mor
tali
tyth
anth
ose
born
inho
spit
als
wit
hout
anN
ICU
(odd
sra
tio
=0.
74;
conf
iden
cein
terv
al=
0.58
–0.9
5;P
=.0
2).
(Phi
bbs
etal
.199
6)
How Good Is the Quality of U.S. Health Care? 883
PR
EV
EN
TAB
LED
EA
TH
SE
valu
atio
nof
prev
enta
bled
eath
s18
2pa
tien
tsw
hodi
edin
hosp
ital
sfr
omst
roke
,pn
eum
onia
,or
hear
tat
tack
Med
ical
reco
rds
for
pati
ents
from
12ho
spit
als,
1985
14%
ofde
aths
resu
lted
from
inad
equa
tedi
agno
sis
ortr
eatm
ent
and
coul
dha
vebe
enpr
even
ted.
(Dub
ois
and
Bro
ok19
88)
AD
VE
RSE
EV
EN
TS
Adv
erse
even
tsA
nad
vers
eev
ent
isan
inju
ryth
atis
caus
edby
med
ical
man
agem
ent
rath
erth
anth
eun
derl
ying
dise
ase
and
that
prol
ongs
hosp
ital
izat
ion,
prod
uces
adi
sabi
lity
atdi
scha
rge,
orbo
th.
30,1
21m
edic
alre
cord
sfr
oma
wei
ghte
dsa
mpl
eof
31,4
29re
cord
sof
hosp
ital
ized
pati
ents
from
apo
pula
tion
of2,
671,
863
nonp
sych
iatr
icdi
scha
rged
pati
ents
51ra
ndom
lyse
lect
edac
ute
care
,non
psyc
hiat
ric
hosp
ital
sin
New
Yor
k,19
84
The
rew
ere
1,13
3ad
vers
eev
ents
and
280
negl
igen
tev
ents
duri
ng19
84ad
mis
sion
s,re
pres
enti
nga
3.7%
stat
ewid
ein
cide
nce
rate
ofad
vers
eev
ents
,and
a1.
0%st
atew
ide
inci
denc
era
teof
adve
rse
even
tsdu
eto
negl
igen
ce.
(Bre
nnan
etal
.199
1)
Adv
erse
drug
even
tsSa
me
asab
ove
4,03
1ad
ult
adm
issi
ons
toa
stra
tifi
edra
ndom
sam
ple
of11
med
ical
and
surg
ical
unit
sin
two
hosp
ital
s.
Med
ical
reco
rds
and
repo
rts
ofho
spit
alst
afff
or2
tert
iary
care
hosp
ital
sin
Bos
ton,
2/93
–7/9
3
The
rew
ere
1.8
prev
enta
ble
adve
rse
drug
sev
ents
(AD
Es)
per
100
adm
issi
ons
(adj
uste
dra
te),
ofw
hich
20%
wer
eli
feth
reat
enin
g,43
%w
ere
seri
ous,
and
37%
wer
esi
gnif
ican
t.T
here
wer
ean
addi
tion
al5.
5po
tent
ialA
DE
spe
r10
0ad
mis
sion
s(a
djus
ted
rate
).
(Bat
eset
al.1
995)
a Ifa
desc
ript
ion
inth
efi
rst
colu
mn
has
noci
tati
on,i
tis
cove
red
byth
eci
tati
onin
the
refe
renc
eco
lum
n.bW
eco
ntac
ted
the
auth
ors
ofso
me
ofth
ear
ticl
esto
clar
ify
deta
ils
rela
ted
toth
esa
mpl
ean
dto
the
data
anal
ysis
.
884 M.A. Schuster, E.A. McGlynn, and R.H. Brook
It is difficult to provide a numerical summary of the findings pre-sented in these tables, but we offer some simple averages as a roughsummary. However, we must emphasize that these studies cover differ-ent populations, time periods, and methodologies, and so the averagesonly give a ballpark idea of the quality of care people are receiving.
For acute and chronic care studies, data are mostly reported as thepercentage of people who received recommended care (care that shouldhave been delivered was delivered) or contraindicated care (care thatshould not have been delivered was delivered). For the few studies thatreported the percentage of people who did not receive recommended care(care that should have been delivered was not delivered), we subtractthe value from 100 percent to convert to the percentage who receivedrecommended care. We also omit a few studies from the averaging processbecause they did not report a percentage of people receiving good or badcare. (Some studies, for example, showed an association between care of aparticular condition delivered by more experienced clinicians and betterclinical outcomes for the condition.) Finally, when there is a range ofvalues for a single item, we use the value that indicates highest quality.
A simple average of the findings of the preventive care studies showsthat about 50 percent of people received recommended care. (None ofthe studies reported a percentage of people receiving contraindicatedpreventive care.) An average of 70 percent of patients received recom-mended acute care, and 30 percent received contraindicated acute care.For chronic conditions, 60 percent received recommended care and 20percent received contraindicated care. These values do not indicate exactlevels of quality in the United States, but they do provide a quantitativesense of how much could be done in all areas to identify and eliminateoveruse and underuse of care. To provide more precise percentages, wewould need to take into account the methodologies of the studies, thesample sizes, the prevalence of conditions, and the impact each type ofcare has in promoting health.
A few examples emphasize this point. An annual influenza vaccine isrecommended as a preventive measure for all adults 65 years or older, agroup at especially high risk for complications and death from influenza(U.S. Preventive Services Task Force 1989, 1996). However, in 1993,52 percent of people in this age group in the United States receivedthe vaccine; among people who had been to the doctor at least oncethat year, the percentage was slightly higher at 56 percent (Centers forDisease Control and Prevention [CDC] 1995b).
How Good Is the Quality of U.S. Health Care? 885
A major issue in acute care is the overuse of antibiotics, which has ledto the development of strains of bacteria that are resistant to availableantibiotics (Begley 1994; Centers for Disease Control and Prevention1994a). Antibiotics are almost never an appropriate treatment for peoplewith a common cold because almost all colds are caused by a virus, forwhich antibiotics are not effective. However, in a study of Medicaidbeneficiaries diagnosed with a cold in Kentucky during a one-year periodfrom 1993 to 1994, 60 percent filled a prescription for an antibiotic(Mainous et al. 1996).
Other types of medications are also not always used in the most ap-propriate manner. Among hospitalized elderly patients with depressionwho were discharged on antidepressant medication, 33 percent were ona dose below the recommended level (Wells et al. 1994b). In a studyof 634 patients with depression or depressive symptoms in Boston,Chicago, and Los Angeles, 19 percent were treated with minor tran-quilizers and no antidepressants (Wells et al. 1994a), despite the lackof evidence that tranquilizers work for depression and the risk thatthey will cause side effects or addiction (Depression Guideline Panel1993).
Patients with chronic conditions, for which certain routine examina-tions and tests are crucial in order to prevent complications, do not allget the care they need. Diabetes mellitus causes several complicationsthat are less likely to occur with good care. One complication is an eyecondition called diabetic retinopathy, which is the leading cause of newblindness among persons aged 20 to 74 in the United States. It is rec-ommended that patients with insulin-dependent diabetes mellitus havean annual dilated eye examination (the clinician uses drops to enlargethe pupil to see behind it more easily) starting five years after diagnosisand that patients with non-insulin-dependent diabetes mellitus have theexam annually starting at the time of diagnosis. In a national study in1989, 49 percent of adults with either type of diabetes had undergonea dilated eye examination in the past year (66 percent in the past twoyears), and 61 percent had undergone any type of eye exam in the pastyear (79 percent in the past two years). Twenty percent of diabetics hadno eye exam in the past two years. Among diabetics who were at partic-ularly high risk for vision loss because they already had retinopathy orbecause they had had diabetes for a long time, 61 percent and 57 percent,respectively, had a dilated examination in the past year (Brechner et al.1993).
886 M.A. Schuster, E.A. McGlynn, and R.H. Brook
Sometimes surgery is performed on people who do not need it. A studyof seven managed care organizations revealed that about 16 percent ofhysterectomies performed during a one-year period from 1989 to 1990were carried out for inappropriate reasons. An additional 25 percent weredone for reasons of uncertain clinical benefit (Bernstein et al. 1993b).There are also examples of patients who need surgery but do not receiveit. In a study of four hospitals, 43 percent of patients with a positiveexercise stress test demonstrating the need for coronary angiography hadreceived it within 3 months; 56 percent had received it within 12 months(Laouri et al. 1997).
Adverse events are injuries caused by medical management of a diseaserather than by the disease itself. A review in New York State in 1984found that 1.0 percent of hospitalizations had an adverse event due tonegligence (Brennan et al. 1991). A study of two Boston hospitals foundan adjusted rate of preventable adverse drug events of 1.8 per 100 hospitaladmissions; 20 percent of these events were life-threatening (Bates et al.1995).
Not all studies have found such poor quality. In a study of patientswho had cataract surgery, 2 percent had the surgery for inappropriatereasons (Tobacman et al. 1996). In a study of patients who underwentcoronary artery bypass graft (CABG) surgery, 1.6 percent had surgeryfor inappropriate reasons (Leape et al. 1996). Nonetheless, the majorityof studies described in the tables show much room for improvement ofquality.
Many have been quick to conclude that managed care is responsiblefor much of the poor quality that is found in the American health caresystem. Studies published in the research literature have neither clearlyconfirmed nor refuted this conclusion. Some studies find that man-aged care organizations provide better care than fee-for-service (FFS),some find that FFS provides better care, and others find that the care isabout the same (Miller and Luft 1993, 1994). Results vary dependingon the setting, the type of care assessed, and the methodology. This topicis complicated by the research approach, which has generally lumpedtogether managed care organizations without distinguishing them ei-ther by type (e.g., group- and staff-model health maintenance organi-zations, independent practice associations, preferred provider organiza-tions, point-of-service plans) or by features (e.g., comprehensiveness ofthe benefits package, nonprofit versus for-profit status). It would be moreuseful to look at the impact of specific characteristics of managed careorganizations. For example, inclusion of immunizations in the benefits
How Good Is the Quality of U.S. Health Care? 887
package may have a larger impact on immunization rates than whetherthe care is offered by a managed care organization or a fee-for-serviceprovider. Finally, managed care is changing so rapidly (Landon et al.1998) that most currently available studies are already out of date.Our ongoing quality measurement system is not large enough to en-able timely assessment of the rapid changes occurring in the health caremarketplace. Even the most widely used systems (e.g., the Health PlanEmployer Data and Information Set, described below) are far from uni-versal and do not cover both managed care and fee-for-service.
In this article, we have described reports of quality that have appearedin the research literature. There are also some systems that measure qual-ity in select sectors of the United States, most notably the National Com-mittee for Quality Assurance’s (NCQA) Health Plan Employer Data andInformation Set (HEDIS). HEDIS is a performance measurement tooldesigned to assist purchasers and consumers in evaluating managed careplans and to hold plans accountable for the quality of their services.In 1996, more than 330 plans—over half the U.S. plans representingmore than three-quarters of all commercial managed care enrollees—were reporting HEDIS measures on their commercial enrollees. Averageadherence rates for select indicators made publicly available by NCQAfell primarily in the 60 to 70 percent range, with the extremes at 38percent for diabetic eye exams (past year) and 84 percent for initiationof prenatal care in the first trimester (Thompson et al. 1998). Thus,HEDIS’s findings are consistent with those of the studies we have re-ported. Whether assessing quality as part of a research study or as partof a marketplace tool, the evidence repeatedly shows that quality fallsshort of standards.
Although NCQA, other organizations, and government bodies aredoing work to measure quality of care, most of this activity has begunduring the past decade. The rapid development of the field is encour-aging, but it is confined to organizations that cover specific sections ofthe country or restrict themselves to certain segments of the health caremarketplace. Their work, as well as the findings of individual studies,such as those listed in the tables, provide some evidence of the situationthroughout the country. However, there is no system in the United Statesto provide a comprehensive assessment of quality of care for the nation—including how quality varies by population subgroups (e.g., gender, age,race/ethnicity, income, region of country, size of community) and howquality is changing over time. Efforts like HEDIS could eventually leadto development of a more comprehensive, national quality assessment
888 M.A. Schuster, E.A. McGlynn, and R.H. Brook
system, but such a system may not develop rapidly unless there is anorganized effort to ensure that it does.
Conclusions
The quality of health care provided in the United States varies amonghospitals, cities, and states. Whether the care is preventive, acute, orchronic, it frequently does not meet professional standards. We can domuch better. The solution is not simply a matter of spending moremoney on health care. A large part of our quality problem is the amountof inappropriate care provided in this country. Elimination of such non-beneficial and potentially harmful care would lead to a large savings inhuman and financial costs. However, there are also many examples ofpeople who receive either too little or technically poor care; fixing theseproblems may increase expenditures.
Some have assumed that all care delivered in the United States isoutstanding. There is good reason to be proud of our health care system,and the evidence from international studies does not show consistentsuperiority elsewhere in the world (Gray et al. 1990; Pilpel et al. 1992;McGlynn et al. 1994; Froehlich et al. 1997; Meijler et al. 1997; Tamblynet al. 1997; Wong et al. 1997). The United States is responsible for manyimportant advances in health care technology, and state-of-the-art care isavailable in both large and small communities throughout the country.Just because outstanding care is available, however, does not mean thatit is always provided or that everyone has access to such care. Most peoplein the studies reported here did receive excellent care—what is notableis that many also did not.
Some people might conclude that quality is good enough based onthe evidence we have presented in this article—in other words, that thestandards used in the various studies are too high. We would disagreewith such a conclusion.
For those who want to improve our health care system, techniques existto measure and change the delivery of care. Clinicians and health planscan use information on quality to determine where to focus their effortsto provide better care. If this information is made available regularlyand in an interpretable form, consumers and large purchasers can alsouse it to make informed decisions when choosing among clinicians andplans, which will, in turn, give providers an added incentive to improvequality.
How Good Is the Quality of U.S. Health Care? 889
Policy makers can also use information about quality of care to de-termine the impact of public and private changes in the health caremarketplace. We are currently experiencing a dramatic shift in the orga-nization and financing of health services delivery in the United States.The private sector has been the driving force behind this transforma-tion, but the public sector is beginning to use its market power as well.Incentives to move Medicaid and Medicare beneficiaries into managedcare represent one of many examples of public sector reform. Changesare occurring faster than evaluations of these changes can be performed.Much of the information concerning the relation between the organiza-tion of the health care system and the quality of care is already outdated.At present, we have only a patchwork of systems that measure quality,with little uniformity, breadth, or ability to produce rapid results. Fur-thermore, these systems do not yet assess most providers of health carein the United States.
The United States cannot afford to let this situation continue. Asystematic strategy for routine monitoring and reporting on quality, aswell as the information systems needed to support such activities, willbe essential if we are to preserve the best of the American health caresystem while striving to improve the efficiency with which high-qualityservices are provided.
This strategy could be organized by the federal government, the pri-vate sector, or a public-private partnership. It could involve coordinationamong all three. Regardless, the strategy will need to cover the aspects ofquality that patients, purchasers, and providers care about; it will needto collect data in a way that is manageable, reasonable, and affordable;and it will need to produce information in a format that is useful formaking a variety of decisions.
The United States is capable of setting up a quality measurement sys-tem that can provide the multiple participants in the health care systemwith the information they need to ensure delivery of high-quality care.In light of the changes that the health care system has been experienc-ing, a strategy to measure and consequently to improve quality is needednow.
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Acknowledgments: Partial funding was provided by the National Coalition onHealth Care. We are indebted to Allison L. Diamant, MD, MSPH, MollaDonaldson, PhD, Rachel Spilka, PhD, and Joseph H. Triebwasser, MD, forcomments on drafts of this paper. We are also indebted to Lauren N. Nguyen,MPH, Cung B. Pham, Yuko Sano, and Sinaroth Sor, MD, for research assistance.