RAND Review
Localize the Remedy
Community Efforts Can Ameliorate Poor Quality of Care
Edward Brown, 57, a patient at University Hospital in Newark, N.J., winces as he receives a flu vaccine. New Jersey health officials have urged people to make the influenza vaccination a yearly habit. |
Data and Beliefs
Because quality in most areas of care was uniformly poor, we could not draw firm conclusions about the effects on quality of unique local characteristics, such as income levels, poverty rates, insurance coverage, hospital capacities, or the penetration of health maintenance organizations into the regional health markets. These characteristics might not be decisive factors anyway in determining quality once patients obtain access to care. Previous RAND studies have found no relationship between variations in the rates of medical services used and the clinical appropriateness of those services.
Nevertheless, the design of local quality improvement programs should take into account the needs of the local population. In Miami, where 25 percent of the people live in poverty and where 23 percent of the people under age 65 are uninsured, the quality improvement programs will need to depend on public funding and to have a large outreach component. Conversely, programs in the Boston area, with only 10 percent living in poverty and only 8 percent uninsured, could rely more on the private health care system (see Figure 9).
Some people might be surprised to learn from our community study that performance was not better in areas with outstanding medical institutions compared with other areas. However, we examined the average quality of care delivered to adults within an entire metropolitan area, rather than the unique quality of care received at a specific facility, within a specific health care system, or from a specific doctor. Perceptions of quality in some cities may be driven by beliefs about the performance of benchmark doctors and institutions, whereas the experience of a broad cross-section of patients in those communities may be more variable.
Those who believe that there is no room for improvement in the quality of care delivered within their health care markets should test those beliefs. Objective assessments of quality are essential for identifying priorities for action, galvanizing support for such interventions, and allowing the community at large to benefit from any assessed effectiveness of the interventions. 
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