Quality of Medical Care Gets Better, Not Worse, When Patients Have More Chronic Illnesses

Contrary to popular belief, patients with multiple chronic illnesses do not receive worse quality of care, according to a RAND Corporation study issued today.

The study is the first large scale assessment of quality of care in patients with multiple chronic conditions. It had been widely assumed that quality would get worse as the number of chronic conditions went up because there was simply too much for busy clinicians to do. The new RAND Health study, published in the June 14 edition of the New England Journal of Medicine, refutes this notion.

Researchers examined three different groups of patients to determine whether they received recommended medical care for a variety of common chronic illnesses including diabetes, heart failure, depression, high blood pressure and heart disease.

They found the likelihood that patients received recommended care increased by about 2 percent with each additional chronic illness. The effect appeared to level off when patients had more than five illnesses, but researchers say there were too few patients with more than five problems to have confidence in those findings.

"The importance of our findings is that they indicate that quality of care measurement systems can be constructed in a way that does not create disincentives for doctors to care for patients who have multiple medical problems," said senior author Dr. Paul Shekelle of the Greater Los Angeles VA Healthcare System and RAND, a nonprofit research organization.

"Measures of the quality of medical care increasingly are being used to evaluate physicians and hospitals, both to promote transparency of care, to create competition based upon quality, and as part of pay-for-performance schemes," Shekelle said. "There is a very real worry that quality measures could create financial and other incentives for doctors to avoid caring for complex patients. Our findings indicate that this does not need to be the case."

Researchers say their findings may be partly explained by the fact most people with multiple health problems visit the doctor more often — increasing the chance they will be offered recommended medical care. In addition, some of the patients studied made more visits to medical specialists, who may do a better job of providing appropriate care for chronic conditions in their specialty.

But the study also found that patients with multiple illnesses who visited only primary care doctors received better quality care than patients with fewer illnesses. Researchers say the finding demonstrates that primary care doctors can provide higher quality care to patients with complex medical problems as well as those with more limited health conditions.

Co-author Dr. Neil Wenger of the David Geffen School of Medicine at UCLA and RAND cautioned "the quality measurement sets used in this study were both clinically detailed and patient centered. These findings may not be true when using more simplistic measures of quality."

Researchers say the overall findings are particularly striking given similar results were found from three different patient groups using two different sets of quality indicators.

The 7,680 patients in the study originally were enrolled in the Community Quality Index study, the Assessing Care of Vulnerable Elders study or the Veterans Health Administration project. Each of those studies gathered detailed information about participants between 1996 and 2000.

While quality measures usually are developed for patients with one condition, many patients have multiple medical problems of varying severity. About 65 percent of Medicare recipients have more than one medical condition and nearly 20 percent have four or more illnesses.

Support for the study was provided by RAND and the United Kingdom National Primary Care Research and Development Centre.

Other authors of the study are: Dr. Takahiro Higashi of Kyoto University in Japan; John L. Adams and Elizabeth A. McGlynn of RAND; Dr. Constance Fung and Dr. Steven M. Asch of RAND and the Greater Los Angeles VA Healthcare System; Dr. Martin Roland and David Reeves of the National Primary Care Research and Development Centre, Manchester, England; and Dr. Eve A. Kerr of the Veterans Affairs Ann Arbor Health Care System and the University of Michigan.

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