Localize the Remedy

Community Efforts Can Ameliorate Poor Quality of Care

By Elizabeth A. McGlynn

Elizabeth McGlynn is associate director of RAND Health and director of the Center for Research on Quality in Health Care, a RAND Health program.

More than a year ago, we at the RAND Corporation reported that adults in the United States receive about 55 percent of the health care recommended for the leading causes of death and disability. To address this problem, we have called for the widespread adoption of electronic clinical information systems to improve care delivery and to increase accountability in the health system nationwide.

Because health care is delivered locally, the improvement strategies must be tailored to community needs. To begin, communities must develop an understanding about how well care is delivered in each community and about what solutions are possible to the problems that are identified.

Thanks to a grant from The Robert Wood Johnson Foundation, we were able to examine the quality of care delivered over a two-year period in a dozen randomly selected U.S. metropolitan areas, each with populations above 200,000 (see Figure 1). No metropolitan area consistently had the best or worst performance in every category of care. However, the quality of care varied substantially by type of medical condition.

Most people in America do not believe that quality of care is a problem for them. Many think that the care delivered by their doctor, or in their community, is better than the care delivered in the nation as a whole. Our latest study found that such an assumption could be dangerous.

Highlights of the study are as follows:

• The overall performance was strikingly similar in all 12 communities studied. Overall quality ranged from 59 percent of recommended care delivered in Seattle to 51 percent in Little Rock and Orange County (see Figure 2). We found the same basic level of performance for chronic, acute, and preventive care.
• Quality of care varied widely by type of care, even within communities. Figure 3 shows that Little Rock had the highest score in preventing chronic disease (80 percent of recommended care delivered) but the lowest score in substance abuse counseling (32 percent delivered). As for chronic conditions, Figure 4 shows that Newark scored among the highest in treating hypertension (69 percent of recommended care delivered) but the lowest in treating depression (47 percent delivered). Likewise, Figure 5 shows that Cleveland and Syracuse tied for the best in treating cardiac conditions (70 percent of recommended care delivered) but were also among the worst in treating diabetes (44 percent delivered).
• Regarding preventive care in general, Figure 6 shows that all communities did a better job of immunizing patients and of preventing chronic disease through screening tests (such as measuring blood pressure) than they did delivering other types of preventive care (such as substance abuse counseling or prevention of sexually transmitted diseases and HIV).
• For an array of chronic conditions (from hypertension and cardiac conditions to depression, pulmonary problems, and diabetes), the quality of care once again varied both across conditions and across communities (see Figure 7).
• Quality of care for hypertension was consistently among the best for chronic conditions. Residents of Cleveland and Newark received 69 percent of the recommended care for hypertension, with residents of Phoenix, Seattle, and Syracuse close behind at 68 percent.
• Quality of care for depression and for pulmonary problems (asthma and chronic obstructive pulmonary disease) was lower than for hypertension and cardiac conditions. In 9 of the 12 communities, quality of care for diabetes was the lowest of all.

This kind of information, specific to local markets, is essential for setting priorities about how to allocate public and private resources most effectively. The information also brings the problems close enough to home to motivate action. Equipped with this kind of information, communities can target their resources toward areas such as immunizations, screenings for chronic diseases, educational prevention of chronic diseases, employer-based efforts, collaborations among universities and hospitals, or public safety initiatives.