American Adults Often Fail to Get Recommended Care, Posing 'Serious Threats' to Health

A new RAND Health study that is the largest and most comprehensive examination ever conducted of health care quality in the United States found that adults fail to receive recommended health care nearly half the time.

Researchers noted that the deficiencies in care they found pose “serious threats to the health of the American public” that could contribute to thousands of preventable deaths in the United States each year.

The researchers said their findings shatter the widely held perception that health care quality is not a problem in the United States. In reality, the study found that many people are not receiving appropriate treatment. According to the researchers, these findings are the best estimates ever provided of the seriousness of the quality problem in the United States.

The study—which examined preventive care as well as the management of 30 common health problems such as diabetes, asthma, high blood pressure and heart disease—is to be published Thursday (June 26) in the New England Journal of Medicine.

“Most of us take health care quality for granted,” said lead study author Elizabeth A. McGlynn, Ph.D., Associate Director of RAND Health. “This study shows that we can't. There is a tremendous gap between what we know works and what patients are actually getting. Virtually everyone in this country is at risk for poor care.”

The study used a unique methodology that involved both random telephone surveys and reviews of patients' medical records. Nearly 7,000 adults in 12 metropolitan areas were interviewed about selected health care experiences. In addition, those interviewed gave written consent for researchers to review their medical records and use the information to evaluate performance on 439 detailed clinical indicators of care for 30 acute and chronic conditions, as well as preventive care.

“For the nation to make serious progress on quality, we must have routinely available, at every level in the health care system, the type of information produced for this study,” noted David Lawrence, M.D., retired Chairman and CEO of Kaiser Foundation Health Plan and Hospitals. “The methods developed at RAND represent the gold standard for future assessments of health care quality.”

Most other studies have assessed a single condition, focused on a small number of indicators of quality, looked at care in one geographic area, or assessed people with a single type of insurance coverage. This study looks at how health care across the nation is being provided and cuts across all geographic areas, insurance types and a wide range of conditions.

Quality varied substantially according to medical condition, ranging from 79 percent of recommended care for cataracts among older people to 11 percent of recommended care for people with alcohol dependence. Among the key findings:

• People with diabetes received only 45 percent of the care they need. For example, less than one-quarter of diabetics had their blood sugar levels measured regularly. Poor control of blood sugar can lead to kidney failure, blindness and amputation of limbs.
• People with coronary artery disease received 68 percent of recommended care, but just 45 percent of heart attack patients received medications that could reduce their risk of death by more that 20 percent.
• Patients with pneumonia received just 39 percent of recommended care. In fact, fewer than two-thirds of elderly Americans were vaccinated against pneumonia. Nearly 10,000 deaths from pneumonia could be prevented annually through proper vaccinations.
• Patients with colorectal cancer received 54 percent of recommended care, but just 38 percent of adults were screened for colorectal cancer. Routine tests and appropriate follow-up could prevent 9,600 deaths a year.
• Patients with high blood pressure received less than 65 percent of recommended care. 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.

Similar levels of deficiencies were found across preventive, acute, and chronic care. Underuse of care was greater than overuse. Patients failed to receive recommended care approximately 46 percent of the time, compared with 11 percent of the time when they received care that was not recommended and potentially harmful. Overall, patients received 55 percent of recommended care.

“Even people who had health insurance and access to health care services failed to receive some elements of good care,” McGlynn said. “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.”

McGlynn and her colleagues noted that these deficiencies appeared despite concerted efforts in recent years by both the federal government and the private sector to improve health care delivery. The researchers said that key to any future progress will be the routine availability of information on health care performance at all levels.

“Making such information available will require a major overhaul of our current health information systems, with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality,” the researchers wrote.

Collaborating on the study were: McGlynn; Steven M. Asch, M.D., M.P.H. (RAND, Veterans Affairs Greater Los Angeles Health Care System, University of California Los Angeles); John Adams, Ph.D. (RAND); Joan Keesey. B.A. (RAND); Jennifer Hicks, Ph.D. (RAND); Alison DeCristofaro, M.P.H. (RAND); and Eve A. Kerr, M.D., M.P.H. (Veterans Affairs Ann Arbor Health Care System, University of Michigan).

The study was funded by The Robert Wood Johnson Foundation (RWJF). Established in 1972, RWJF is the nation's largest philanthropy devoted exclusively to health and health care. Drs. Asch and Kerr were supported by the Veterans Affairs Health Services Research and Development program.

About RAND Health
RAND Health is the nation's largest independent health-policy research organization, with a broad research portfolio that focuses on medical quality, health-care costs and delivery of health care, among other topics.