People at Risk of Receiving Poor Health Care in All Parts of the United States

A RAND Corporation study that is the second installment of the largest and most comprehensive examination ever conducted of health care quality in the United States finds that people in all parts of the country are at risk for receiving poor health care.

The new analysis from the Community Quality Index (CQI) study by RAND Health is the first comprehensive community-based assessment of health care quality in the United States. It was published today in the journal Health Affairs.

The study reports on a comprehensive examination of how effectively health care is delivered in these 12 metropolitan areas: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich; Little Rock, Ark.; Miami; Newark, N.J.; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y.

Although the economic and health resource profiles of these communities are very different, there were few consistent differences in the quality of care received by people in the communities. The study found that, on average:

• People in the 12 communities studied received only 50 to 60 percent of recommended health care.
• There were very few significant variations in the quality of preventive, acute and chronic care across communities nationwide.
• No single community consistently had the highest or lowest performance for all selected chronic conditions.
• Quality of health care varied substantially across conditions. In almost all communities, the poorest care was for diabetes.

The 12 communities in the CQI are representative of metropolitan areas with populations of 200,000 or more. The study was based on interviews with nearly 7,000 adults in these communities and a review of all of their medical records. It assessed 439 clinical indicators of quality for 30 acute and chronic conditions such as urinary tract infections, diabetes, asthma, high blood pressure and heart disease—along with preventive care. For quality of care ratings in the individual communities, refer to this table (PDF).

A previous report from the CQI study focused on the quality of care delivered nationally, but provided no information about whether the problems observed were consistent across communities or based on exceptionally poor performance in a few communities.

The new analysis demonstrates that poor quality exists throughout the United States health care system and is not relegated to certain pockets of the country.

“What we now know is that it really doesn’t matter where you live—only about 50 percent of the time are you getting the recommended care,” said lead study author Eve A. Kerr, MD, MPH of the Veterans Affairs Ann Arbor Health Care System and the University of Michigan. “The lack of community level variation in overall quality should serve as a wakeup call to all communities to examine their own quality of care and determine how they can do a better job.”

Elizabeth A. McGlynn, Ph.D., Associate Director of RAND Health and a co-author of the study, noted that while low levels of quality were reported previously for the nation, many people may have concluded that quality was better in their own community than in the nation as a whole.

“Even if you are minutes away from the best hospital in your community, you are still at risk for poor care,” McGlynn said. “We hope this study stimulates a dialogue among patients, doctors, employers, hospitals, and insurers in these 12 communities, and in other communities we did not study, about the best local solutions to these serious deficits.”

Researchers noted that some people may be surprised that performance was not better in areas with outstanding medical institutions. The analysis examined average care for adults from an entire metropolitan area, rather than care received from a specific facility, health care system or doctor.

Although no one community fared significantly better than the others on the quality of preventive, acute and chronic care, there were some differences. Among the findings:

• All the communities demonstrated important deficits in the provision of basic care. People living in Little Rock received 51 percent of indicated care, compared with 59 percent among those living in Seattle.
• Residents in all communities were more likely to receive services to prevent chronic disease through screening (for example, measuring blood pressure) and immunizations than they were to receive other dimensions of preventive care, such as services to prevent sexually transmitted diseases and HIV, or substance abuse counseling.
• Quality of care for hypertension was among the best for the chronic conditions—residents in Cleveland received about 70 percent of indicated care.
• Quality of care for cardiac conditions (coronary artery disease, congestive heart failure and atrial fibrillation) was generally lower than care for hypertension, ranging from 52 percent in Indianapolis and Newark to 70 percent in Cleveland and Syracuse.
• Care for depression ranged from 47 percent in Newark to 63 percent in Seattle.

Collaborating on the study were: Kerr; 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); and Joan Keesey. B.A. (RAND).

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.

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