CEO SUMMARY: This research project involved 13,000 patients and a detailed review of medical records. The startling conclusion: the health system provides proper diagnosis and treatment only 55% of the time! Because of the study’s depth, it provides a compelling argument that the nation’s providers have plenty of room for improvement. This bodes well for diagnostic testing and its role in high-quality care.
HEALTHCARE QUALITY ADVOCATES got a big boost on June 26, 2003, when the New England Journal of Medicine (NEJM) published results of a two-year study that found patients get proper diagnosis and treatment only 55% of the time.
Perceptive pathologists and lab managers will immediately recognize that these findings will motivate the nation’s healthcare system to pay closer attention to the proper use of laboratory testing. A 45% rate of failure to properly diagnose and treat patients will not be tolerated by consumers, employers (who pay healthcare bills), insurers, and government-funded health programs.
The study was conducted by RAND Health and funded by a $6.5 million grant from the Robert Wood Johnson Foundation. The study piggy-backed on the work of the Community Quality Index (CQI) study and was designed to “assess the extent to which the recommended processes of medical care—one dimension of quality—are delivered to a representative sample of the United States population for a broad spectrum of conditions.”
This RAND study has high credibility because it is the most comprehensive effort ever undertaken to assess the adequacy of healthcare. Telephone inter- views were conducted with 13,275 people living in six regions of the United States. Physical healthcare records were obtained and examined for 6,712 of these individuals.
Key findings were two. First, participants received 54.9% of recommended care. This performance ratio was similar across the areas of preventive care, acute care, and care for chronic conditions.
Second, underuse was a greater problem than overuse. Whereas 46.3% of participants did not receive recommended care, 11.3% of participants received care that “was not recommended and was potentially harmful.”
Criteria For Evaluation
As quality indicators, RAND researchers selected 30 clinical areas involved in about half the reasons people seek healthcare. Within each clinical area, specific standards of quality were based on national guidelines and medical literature and approved by panels of leading physicians. Medical care delivered to the study’s participants was evaluated against these parameters.
“Our study—based on reviews of medical records and interviews with nearly 7,000 adults in 12 metropolitan areas—found that the average adult received only about eight of the 16 medical services he or she needed over two years,” stated Elizabeth A. McGlynn, Ph.D., lead study author and Associate Director of RAND Health. “Everyone in the study was at risk of failing to get needed services or at risk of getting unneeded and even possibly harmful medical services.”
Appalling Rate Of Failure
In their conclusion, the study’s authors wrote about the failure to provide recommended healthcare, stating “…the gap between what we know works and what is actually done is substantial enough to warrant attention. These deficits, which pose serious threats to the health and well-being of the U.S. public, persist despite initiatives by both the federal government and private healthcare delivery systems to improve care.”
McGlynn observed that “even people who had health insurance and access to healthcare services failed to receive some elements of good care. This suggests that just being able to get in the door to see a doctor is no guarantee that you’ll receive the care you need.”
These are powerful statements. From the Six Sigma perspective, which uses events-per-million to evaluate work processes, this means that 460,000 times out of one million, care-givers fail to provide the recognized standard of care. By another measure, 113,000 times out of one million, care-givers actually give the patient care services which are not recommended and are potentially harmful!
In the NEJM, the authors of the study made two recommendations, both with sweeping consequences. Their first recommendation is that “a key component of any solution, however, is the routine availability of information on performance at all levels.” They specifically reference “automating the entry of key data for clinical decision making and for the measurement and reporting of quality.” The goal is to make routine the availability of information on healthcare performance at all levels.
The second recommendation is the establishment of “a national base line for performance.” This would make it possible “to assess the effect of policy changes and to evaluate large-scale national, regional, state, or local efforts to improve [healthcare] quality.”
Blame for the current situation is attributed to several factors. One, there is an absence of an accountability system for hospitals and physicians. Two, physicians lack awareness of current recommended guidelines for care. Three, insurance companies, which pay the bills, have little financial incentive to address the problem.
THE DARK REPORT predicts this RAND study on healthcare quality will be used to bolster the efforts of employers, payers, and government health pro- grams to push providers to improve the quality of care. The national media may have given only passing publicity to this story by the national media, but buyers of healthcare paid close attention.
Ramifications For Labs
Pathologists and laboratory managers, should study the ramifications of the RAND study from several strategic perspectives. First, how will measuring the quality of healthcare services affect existing laboratory operations and work processes? Labs will probably find themselves tracking non-traditional measures of quality.
Second, will the laboratory be ready to support those clinicians who take active steps to review current recommended standards of care for the types of health problems they treat? Laboratory testing plays a key role in early detection, diagnosis, prognosis, and patient monitoring. It is reason- able to expect some physicians will want a closer clinical relationship with their laboratory as they take active steps to improve quality in their clinics and group practices.
Third, does the laboratory have a strategic plan which meets the needs of clinicians for electronic dissemination of laboratory test data? Because laboratory test data is the preponderance of information in most patient’s health file, labs will be under pressure to raise their capabilities in this area.
It is a remarkable conclusion that almost half the adults in this country do not get recommended care—and that almost 12% get care which is not recommended and is potentially harmful! That finding certainly disarms providers who question the need to measure quality, rank provider performance, and make this information available to the public.
Pathologists and laboratory administrators who understand the implications of this trend can take early steps to pre- pare their laboratory staff for this new emphasis on measured quality. Overall, this trend should increase the value of laboratory services to clinicians.
CMS Reacts Swiftly To RAND Study Findings
PROVIDER ACCOUNTABILITY is another way to describe the objective of measuring provider performance and making those measurements public. That seems to be exactly where Medicare is headed.
Just days after publication of the RAND Health study on healthcare quality, Medicare officials responded. Barbara Paul, Director of Quality Measurement and Health Assessment for the Centers for Medicare and Medicaid Services (CMS) noted that the failure of the healthcare system to provide recommended care almost 50% of the time is “a dramatic portrayal of the challenge we have regarding quality today.”
Paul also observed that CMS, by Labor Day, will post on its Web site results of a pilot project where hospitals report their performance on ten quality indicators for three disease conditions. This project was started in December 2002 and has the support of several hospital and healthcare trade associations.
CMS intends to measure indicators of quality on physician and hospital performance, and make them available to the public. THE DARK REPORT expects the findings of this new RAND Health study will accelerate that process.