The First National Report Card on Quality of Care

For Release

June 25, 2003

Fact Sheet:

How Good Is the Quality of Health Care in America?

Overall, adults receive only half of recommended care. This is the key finding from the largest and most comprehensive examination of health care quality ever conducted in the United States. The study was conducted by RAND Health with funding from The Robert Wood Johnson Foundation.

The Community Quality Index Study assessed the extent to which recommended care was provided to a representative sample of the U.S. population for a broad range of conditions. The research team used random telephone surveys to interview more than 13,000 adults in 12 metropolitan areas regarding their health care experiences. About 6,700 provided written consent for researchers to review their medical records and use the information to evaluate performance on 439 clinical indicators of quality for preventive care and for 30 chronic and acute conditions such as diabetes, asthma, high blood pressure, heart disease, pneumonia, and low back pain.

This study differs from previous assessments of quality because it evaluated more health problems simultaneously, examined quality across the nation rather than in one geographic area, included people with all types of insurance, and included those who were healthy as well as those who were ill.

The quality indicators used in the study were derived from RAND's Quality Assessment (QA) Tool system. To create the system, RAND staff selected 30 clinical areas representing about half of the reasons that people seek care. They developed specific standards or quality indicators within each clinical area, based on a review of national guidelines and the medical literature. Panels of leading physicians from multiple specialties approved the proposed quality indicators.

The indicators allowed the research team to examine quality from the perspective of what is being done (type of care), why it is being done (function), how it is being delivered (mode), and the nature of the quality problem (underuse or overuse). The researchers developed computer-assisted medical record abstraction software to collect the necessary data.

Key Findings. Overall, participants in the study received 55 percent of recommended care. The level of performance was similar for chronic, acute, and preventive care and across the functions of medicine—screening, diagnosis, treatment, and follow-up.

Underuse of care was a greater problem than overuse. For example, patients failed to receive recommended care about 46 percent of the time, compared with 11 percent of the time when they received care that was not recommended and potentially harmful.

Quality varied substantially by condition. For example, people with cataracts received about 79 percent of recommended care, whereas those with alcohol dependence received about 11 percent.

Poor Quality Matters. These deficits in care pose serious threats to the health of the American public and likely translate into thousands of preventable complications and deaths per year. For example:

  • People with diabetes received only 45 percent of the care they need. For example, fewer than half 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 got 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 screening 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.

What's Needed to Improve Care? This study provides the best estimates ever available about the quality of care in the United States. The study reveals substantial gaps between agreed upon standards of care and the care actually provided. These deficits persist despite initiatives by both the federal government and private health care delivery systems to improve care.

The first step in improving care will be routine availability of information on health care performance at all levels. What's needed are information systems that can produce the necessary measures of care routinely as part of the process of delivering care. Achieving this will require a major overhaul of our current health information systems, with a focus on automating the entry and retrieval of key data to support clinical decisionmaking and to measure and report on quality.

Information is essential, but it isn't enough. We need to create teams of health professionals—doctors, nurses, health educators—who work together to give each individual the care needed. Those teams must have tools to help them quickly identify the best set of services for each patient and be able to explain the choices clearly so that patients can decide the right treatment.

What Can Patients Do? Patients need to take responsibility for their own care. They should seek information from trusted sources such as the American Diabetes Association, the American Heart Association, or the Agency for Healthcare Research and Quality to learn what kind of preventive care or treatment they should be receiving; then they should work with their physicians to ensure that they get recommended care. Patients should not assume that their physicians will remember all that needs to be done. They can help their physicians provide good care by being active advocates for it.


McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The Quality of Health Care Delivered to Adults in the United States, New England Journal of Medicine, Vol. 348, No. 26, June 26, 2003, pp. 2635-2645.

For more information, view the news release.

A complete list of the quality indicators is available in the study's Appendix A, “The Quality of Health Care Delivered to Adults in the United States,“ as a PDF; a description of the literature on which they are based can be found at

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