Localize the Remedy

Community Efforts Can Ameliorate Poor Quality of Care

Underuse and Overuse

Nationwide, we found that underuse of care was a greater problem than overuse. Patients failed to receive recommended care about 46 percent of the time, compared with only 11 percent of the time when patients did receive care that was not recommended and was potentially harmful (see Figure 8). The quality deficits pose serious threats to the health of the American public and translate into thousands of preventable complications and deaths per year. For example:

• Only 24 percent of diabetics had their average blood sugar levels measured regularly to assess whether treatment was effective. Poor control of blood sugar can lead to kidney failure, blindness, and amputation of limbs.
• Patients with hypertension received less than 65 percent of recommended care, and nearly 60 percent of the patients did not have their blood pressure well controlled. Poor blood pressure control is associated with increased risk for heart disease, stroke, and death. In fact, poor blood pressure control contributes to more than 68,000 preventable deaths annually.
• Only 45 percent of heart attack patients received beta blockers, and only 61 percent received aspirin — medications that could reduce the risk of death by more than 20 percent, contributing to an estimated 37,000 preventable deaths per year.
• Only 64 percent of elderly Americans were vaccinated against pneumonia. Nearly 10,000 deaths from pneumonia could be prevented annually through proper vaccinations.
• Just 38 percent of adults were screened for colorectal cancer. Routine tests and appropriate follow-up could prevent 9,600 deaths a year.

AP/WIDE WORLD PHOTOS/JIM BRYANT   Cecile Crowdery, 77, works out at the Olympic Athletic Club in Seattle, Wash. She was one of 74,171 women aged 50 to 79 who participated in a government-funded study that found that women who had engaged in the equivalent of about 1.5 to 2.5 hours a week of moderate-intensity exercise had an 18 percent reduced risk of breast cancer.

Computers and Communities

The first step in improving care is to ensure the routine availability of information on health care performance. Computerized information systems, such as those already in use by the U.S. Veterans Administration, automate the entry and retrieval of key data for this purpose. The information systems support clinical decisionmaking, quality measurement, and reporting. Installing these kinds of systems at health care facilities nationwide will require a major investment in health information systems.

Information is essential, but it is not enough. Once the information is available, teams of health professionals — doctors, nurses, and health educators — need to use the information collaboratively and quickly to identify the best course of care for each patient. In many cases, the teams also need to be able to explain the additional information — and the treatment options — clearly to patients so that they can choose the treatments that are right for them.

On a larger scale, communities need to evaluate their local quality of care and to decide which local quality initiatives to pursue. Regional health plans, medical groups, and public health clinics often share patients. Therefore, those who work within each component of community care have an incentive to examine where the improvements need to be made to enhance the overall performance.

As part of this local evaluation, communities can also choose to come together and to tackle some problems at the regional or state level. For example, 43 medical groups and hospitals in Minnesota are collaborating to accelerate the adoption of best clinical practices, resulting in uniform practice guidelines for all six Minnesota health plans. In New York State, the collective monitoring and public reporting of mortality rates after coronary artery bypass graft surgery have successfully contributed to a decline in operative mortality.

Community-based solutions do not lie entirely within the health care system. Large employers could also provide leadership. In one community, the county health department developed an outreach program for retired public employees, inviting them to return to their former places of work for influenza and pneumococcal vaccines.

Public health departments could work jointly with local health insurers to offer additional services, such as community-based smoking cessation programs that could target all residents, regardless of insurance status. As yet another option, public and community health centers could offer screening and counseling programs for HIV, tuberculosis, and other infectious diseases.

Community-based education and outreach efforts could, in turn, activate patients to demand improved quality across many dimensions of care and to identify their own requirements of care. For example, several community-based organizations have developed guidelines to help patients assess whether they are receiving the care they need for selected health problems.

Perhaps most important, patients must take responsibility for their own care. They should consult with trusted sources to learn what kinds of preventive care or curative treatment they need. Patients should seek information from their physicians, from health care agencies that specialize in their personal conditions or diseases (such as the American Diabetes Association), and from organizations that set the standards for provision of preventive care (such as the U.S. Preventive Services Task Force).

Patients could then work with their physicians to ensure that they receive recommended care. Patients should not assume that their physicians will remember all that needs to be done. Patients can help their physicians provide good care by being active advocates for it.