RAND Study Shows That Chronically Ill Patients Have Better Outcomes When They Receive Higher Quality Outpatient Medical Care
January 31, 2007
The quality of outpatient medical care received by people with chronic health problems has a direct impact on the quality of their daily lives, according to a study by researchers from the RAND Corporation and UCLA that is among the first to link better outpatient care to improved health outcomes among non-elderly patients.
Researchers found that patients whose care more closely followed prescribed treatment guidelines were more likely to maintain good health and had better health-related quality of life, according to a study appearing in the February edition of the journal Health Services Research.
“Our findings show that the quality of medical care can have a noticeable impact on the daily lives of patients,” said lead author Dr. Katherine Kahn, a UCLA physician and researcher at RAND, a nonprofit research organization. “Examining the quality of health care is not simply an academic exercise.”
The RAND Health project team studied 963 adults from three western states who suffered from heart disease, asthma, emphysema or diabetes, evaluating the care they received over a 30-month period against 120 measures of medical care developed from previous studies and by panels of medical experts.
Since all of the patients in the project had serious illnesses, their health, on average, declined during the 2.5 year period of the study. But those who received better-quality medical care experienced the smallest decline in health, delaying some of the effects of aging, Kahn said.
For example, the decrease in quality of life among patients who received poorer quality care was comparable to changing, across 2.5 years, from being able to function comfortably after mild exertion to functioning comfortably only at rest. In contrast, patients who received better quality care were more likely to preserve their function continuing, for example, to manage activities involving exertion.
Even patients who received moderately better care were observed to have significantly improved quality of life and function. Receiving care near the top of the measured scale allowed patients to avoid the decline in health experienced over the study period among patients who received poor quality care, according to the study.
Researchers say they were able to demonstrate their results by creating a novel way of judging care based on a more detailed picture of how patient complexity and burden of illness influence the way patients are treated.
Studies of the quality of medical care have been confounded by the fact that the sickest patients usually receive the largest amount of medical care, according to John Adams, a RAND researcher and co-author of the study. But because their burden of disease is so large, these same patients are usually those most likely to become sicker or die over the course of a study.
Researchers from RAND developed a way to account for the issue by looking not only at the severity of a patient's primary disease, but by also examining the number and severity of patients' other diseases.
In studying how care influences outcomes, researchers accounted for the unique ways in which doctors and other clinicians tailor individual patient care to the patients' dynamic medical needs. Consideration of the ways clinicians alter care in response to patients' complex and changing needs allowed researchers to more accurately assess the effect of quality medical care on patient outcomes.
The RAND researchers found that the sickest patients are the ones who are most likely to receive recommended medical care. While this is good news for sicker patients, the findings suggest doctors may be doing too little preventive care for chronically but stably ill patients without acute needs, according to researchers.
“This suggests that doctors do not pay enough attention to the patients until they have an acute decompensation,” Kahn said. “It looks like there is a missed opportunity to provide medical care to a group of patients with chronic illnesses who have not yet experienced a major decline in their health.”
Researchers say the study demonstrates that measuring the quality of medical care is important to patients and health care providers, as well as insurance companies, employers and other groups that that pay for health care.
Future studies should focus on identifying patient, clinician, and organizational factors that increase the chance of patients receiving high-quality medical care, Kahn said.
Support for the research was provided by the U.S. Agency for Healthcare Research and Quality, the American Association of Health Plans and the Robert Wood Johnson Foundation.
Other authors of the study are: Drs. Diana T. Tisnado, Honghu Liu, Ashlee Hu and Carol M. Mangione, all of the David Geffen School of Medicine at UCLA; Drs. John L. Adams and Cheryl L. Damberg of RAND; Ronald D. Hays of RAND and UCLA; and Wen-Pin Chen of the University of California, Irvine.
RAND Health, a division of the RAND Corporation, is the nation's largest independent health policy research program, with a broad research portfolio that focuses on quality, costs and delivery, among other topics.