Quality of Care in Episodes of Respiratory Illness Among Medicaid Patients in New Mexico

As part of ambulatory-care review, the New Mexico Experimental Medical Care Review Organization (EMCRO) developed medical guidelines for the use of injections and informed physicians about them through written communications and personal visits. After their adoption, the EMCRO denied payment for Medicaid claims not meeting the guidelines. To study the effect of these activities, the authors compared quality of care in entire episodes of respiratory infections before and after guidelines were promulgated. Quality as judged by minimal criteria for antibiotic use improved. Percentages of episodes with appropriate therapy rose from 36% to 42% for streptococcal sore throat, from 42% to 81% for bronchitis, and from 36% to 51% for acute upper respiratory infection. Quality improved most among physicians with the poorest records initially; outliers still gave inadequate care. Assessment of episodes of care derived from claims data thus appears to be a feasible and nonintrusive mechanism for detecting deficiencies in quality and evaluating quality-assurance activities.