Research Brief

A presidential commission has recommended strategies for defining, measuring, and promoting quality. The private sector is eager to use information about quality to help employees make better choices among clinicians and health plans, a trend known as "value-based purchasing."

Is the quality of U.S. health care adequate? Is it getting better, worse, or staying the same?

Surprisingly, the answer to these questions is, "We don't really know." Drs. Mark Schuster, Elizabeth McGlynn, and Robert Brook, national experts on quality of care, observe that "more information is available on the quality of airlines, restaurants, cars, and VCRs than on the quality of health care." However, their review of nearly 50 studies published over the past decade suggests that quality varies substantially across physicians, hospitals, geographical locations, types of care, and age groups. These studies provide no evidence that managed care has perceptibly improved or worsened quality.

What Is Quality and How Is It Measured?

Quality of care can be defined on two dimensions:

  • The technical aspects of care: Whether people get only those services that are skillfully provided and are likely to improve their health status.
  • The art of care: Whether doctors communicate treatment choices to patients accurately and appropriately, take patients' preferences into account, and treat them in a culturally appropriate and respectful manner.

In practical terms, poor quality can mean too much care (e.g., unnecessary surgery), too little care (e.g., not providing an indicated diagnostic test), or the wrong care (e.g., an excessively high dose of a medication).

Assessments of quality usually ask whether the right choices are made in diagnosing and treating the patient. One way to answer this question is to determine whether the care given is appropriate—that is, the expected health benefits exceed expected risks. Care that it would be considered unethical not to provide is necessary care.

Criteria for judging appropriateness and necessity can be used to measure both overuse and underuse. These criteria, or quality indicators, are usually based on a combination of scientific evidence found in the research literature and the judgments of panels of experts.

What Do We Know About Quality of Care in the United States?

Schuster, McGlynn, and Brook reviewed studies of the quality of care published in the leading professional journals over the past decade. They divided their review into preventive (e.g., cancer screening), acute (e.g., ear infection), and chronic (e.g., diabetes) care because some people may value information about, for example, the quality of preventive care more than information about the quality of acute care. The 48 articles from which they report data cover services delivered to one-half million people for a broad range of conditions and settings.

The authors present these data in a series of tables describing the health care service, the group of patients included in the study, the source of the data used, and the findings about quality. In the absence of a national quality-tracking system, the authors argue, these snapshots are the best way to provide an overview of the quality of care across the nation. The table below provides highlights of their review.

The Gap Between Recommended Care and Care Received

The best evidence suggests that people receive only half the preventive care recommended. People with acute or chronic conditions receive about two-thirds of the care they need. About one-fifth to one-third of both acute and chronic care is unnecessary. These findings are consistent with results of quality measurement by HEDIS, a performance-measurement system designed to assist purchasers and consumers in choosing among managed-care plans. In 1997, about one-third of U.S. managed-care plans voluntarily and publicly reported HEDIS measures on their commercial enrollees.

What conclusion emerges from this literature survey?

There are large gaps between the care people should receive and the care they do receive. This is true

  • for all types of care—preventive, acute, and chronic
  • in different types of health care facilities
  • for different types of health insurance
  • for all age groups
  • across the whole country and in individual locations.

Emphasizing that the studies reviewed include different populations, time periods, and methods, the authors offer some simple averages as a rough summary of their findings.

The gap between recommended care and care received is not merely a matter of academic concern. The gap can translate into lives lost. For example, the findings of a representative national study clearly showed that hospitalized patients who received lower-quality care—that is, did not receive services that they needed—are more likely to die.

Managed Care Is Not the Problem—or, So Far, the Solution

Many observers have blamed managed care, with its emphasis on cost containment, for much of the poor care found in the U.S. health care system. Empirical studies do not confirm this assertion. Managed care has not substantially improved or worsened quality over that available in the fee-for-service system.

Problems with quality predate managed care. Indeed, the findings from the review of the current literature are consistent with quality assessments under fee-for-service arrangements, analyzed as part of RAND's Health Insurance Experiment as long ago as the 1970s, before the words managed care received national attention.

Quality Matters

SOURCE: Kahn et al., 1990.

A national study documented the percentage of hospital patients with common conditions who will die, depending on whether they receive good or poor care. In this case, differences in quality translate into 5–8 extra deaths per 100 patients hospitalized.

Where Do We Go from Here?

A disturbing national picture emerges from these discrete snapshots. The quality of care people receive often depends on which physician or hospital they choose, or in which city or state they receive care. Even the best care often falls short of professional standards.

Just spending more money will not solve the problem. Indeed, a major part of the problem is overuse, which is wasteful and potentially harmful to health. On the one hand, eliminating such care has the potential to save money without harming health. On the other hand, many people receive either too little or technically poor care. Fixing these problems may increase expenditures and would improve health.

Essential to improving quality of care is measuring it and providing that information, routinely and in an interpretable form, to clinicians, health plans, consumers, and policymakers.

  • Clinicians and plans can use such information to improve the care they provide.
  • Consumers and large purchasers can use it to guide choices about clinicians and plans.
  • Policymakers can use information about quality to alter the health care marketplace and ensure that it performs better.

We have the tools to measure quality. Over the past decade, RAND has developed more than 1,000 criteria that form a comprehensive set of measures of the quality of care delivered to men, women, and children. We have developed mechanisms to obtain this information from both patient surveys and medical records. We have also developed measures of health status and patient satisfaction that can be used to assess the effects of changes in health care policy.

The United States urgently needs a strategy for routine monitoring and reporting on quality, including a plan to develop the information systems needed to support those activities. Such a strategy could be organized by the federal government, by the private sector, or by a public-private partnership—or it could involve all three.

The quality problem is too pressing to be ignored. As Brook puts it: "Americans tolerate more variation in the performance of their health care system than they would ever put up with in the performance of an airline, a computer company, or even the manufacture of their breakfast cereal. We have to change that. We must make quality and cost equal partners and produce health systems that will truly benefit the patients and communities of the 21st century."

Highlights from the Review of Recent Quality Assessments Drawn from Nationally Representative Studies

Recommended Health Care Service Quality of Care Reference
Preventive Care
Routine childhood vaccines 74% of children received all recommended vaccines CDC, 1997
Annual influenza vaccine for all people over 65 52% received annual influenza vaccine CDC, 1995a
Pap smear every 1–3 years for women over 18 67% had Pap smear in prior 3 years CDC, 1995b
Acute Care
Antimicrobial drugs not appropriate for viral upper-respiratory-tract infection 16% of all antimicrobial drug prescriptions in 1992 were written for upper-respiratory-tract infections McCaig and Hughes, 1995
Care for hip fracture 67%–94% of patients with hip fracture received appropriate components of care Kahn et al., 1990
Routine prenatal screening tests Across 6 HMOs, women received 64%–95% of 7 recommended tests Murata et al., 1994
Chronic Care
Dilated-eye examination to screen for diabetic retinopathy Less than two-thirds of patients at high risk had recommended eye exam in past year Brechner et al., 1993
Beta-blocker therapy can reduce post–heart attack mortality by as much as 24% 45% of heart attack patients received beta blockers before or at time of discharge Ellerbeck et al., 1995
Persons on antidepressants should be given adequate doses 33% of depressed patients discharged from a hospital with antidepressants had doses below recommended level Wells et al., 1994


  • Brechner, R.J., C.C. Cowie, L.J. Howie, W.H. Herman, J.C. Will, and M.I. Harris. 1993. "Ophthalmic Examination Among Adults with Diagnosed Diabetes Mellitus." JAMA 270:1714–1718.
  • CDC (Centers for Disease Control and Prevention). 1995a. "Influenza and Pneumococcal Vaccination Coverage Levels Among Persons Aged >65 Years—United States, 1973–1993." Morbidity and Mortality Weekly Report (MMWR) 44:506–515.
  • CDC. 1995b. "Trends in Cancer Screening—United States, 1987 and 1992." MMWR 45:57–61.
  • CDC. 1997. "National, State, and Urban Area Vaccination Coverage Levels Among Children Aged 19–35 Months—United States, January–December 1995." MMWR 46:17–82.
  • Ellerbeck, E.G., S.F. Jencks, M.J. Radford, et al. 1995. "Quality of Care for Medicare Patients with Acute Myocardial Infarction: A Four-State Pilot Study from the Cooperative Cardiovascular Project." JAMA 273:1509–1514.
  • Kahn, K.L., W.H. Rogers, L.V. Rubenstein, et al. 1990. "Measuring Quality of Care with Explicit Process Criteria Before and After Implementation of the DRG-Based Prospective Payment System." JAMA 64:1969–1973.
  • McCaig, L.F., and J.M. Hughes. 1995. "Trends in Antimicrobial Drug Prescribing Among Office-Based Physicians in the United States." JAMA 273:214–219.
  • Murata, P.J., E.A. McGlynn, A.L. Siu, et al. 1994. "Quality Measures for Prenatal Care: A Comparison of Care in Six Health Care Plans." Archives of Family Medicine 3(1):41–49.
  • Wells, K.B., G. Norquist, B. Benjamin, W. Rogers, K. Kahn, and R. Brook. 1994. "Quality of Antidepressant Medications Prescribed at Discharge to Depressed Elderly Patients in General Medical Hospitals Before and After Prospective Payment System." General Hospital Psychiatry 16:4–15.

Selected Bibliography of RAND Research on Quality of Care

  • Bernstein, S.J., E.A. McGlynn, A.L. Siu, et al. 1993. "The Appropriateness of Hysterectomy: A Comparison of Care in Seven Health Plans." JAMA 269:2398–2402.
  • Bozzette, S.A., et al. 1998. "The Care of HIV-Infected Adults in the United States." The New England Journal of Medicine 339(26):1897–1904.
  • Brook, R.H. 1997. "Managed Care Is Not the Problem, Quality Is." JAMA 278(19):1612–1614. (Also available as RAND Reprint RP-672, 1998.)
  • Carlisle, D.M., R.B. Valdez, M.F. Shapiro, and R.H. Brook. 1995. "Geographic Variation in Rates of Selected Surgical Procedures Within Los Angeles County." Health Services Research 30 (1, Pt 1):27–42.
  • Chassin, M.R., J. Kosecoff, R.E. Park, et al. 1987. "Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services? A Study of Three Procedures." JAMA 258:2533–2537.
  • Dubois, R.W., and R.H. Brook. 1988. "Preventable Deaths: Who, How Often, and Why?" Annals of Internal Medicine 109:582–589.
  • Froehlich, F., I. Pache, B. Burnand, et al. 1997. "Underutilization of Upper Gastrointestinal Endoscopy." Gastroenterology 112:690–697.
  • Hilborne, L.H., L.L. Leape, S.J. Bernstein, et al. 1993. "The Appropriateness of Use of Percutaneous Transluminal Coronary Angioplasty in New York State." JAMA 269:761–765.
  • Kahan, J.P., S.J. Bernstein, L.L. Leape, et al. 1994. "Measuring the Necessity of Medical Procedures." Medical Care 32:357–365.
  • Kahn, K.L., W.H. Rogers, L.V. Rubenstein, et al. 1990. "Measuring Quality of Care with Explicit Process Criteria Before and After Implementation of the DRG-Based Prospective Payment System." JAMA 64:1969–1973.
  • Kleinman, L.C., J. Kosecoff, R.W. Dubois, and R.H. Brook. 1994. "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger Than 16 Years in the United States." JAMA 271:1250–1255.
  • Laouri, M., R.L. Kravitz, S.J. Bernstein, et al. 1997. "Underuse of Coronary Angiography: Application of a Clinical Method." International Journal for Quality in Health Care 9(1):5–22.
  • McGlynn, E.A. 1998. "The State of Quality: How Good Is Care?" Written testimony prepared for the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, January 28, 1998.
  • McGlynn, E.A., C.D. Naylor, G.M. Anderson, et al. 1994. "Comparison of the Appropriateness of Coronary Angiography and Coronary Artery Bypass Surgery Between Canada and New York State." JAMA 272:934–940.
  • Murata, P.J., E.A. McGlynn, A.L. Siu, et al. 1994. "Quality Measures for Prenatal Care: A Comparison of Care in Six Health Care Plans." Archives of Family Medicine 3(1):41–49.
  • Newhouse, J.P., and the Insurance Experiment Group. 1993. Free for All? Lessons from the RAND Health Insurance Experiment. Cambridge, MA: Harvard University Press.
  • Schuster, M.E., E.A. McGlynn, and R.H. Brook. 1998. "How Good Is the Quality of Health Care in the United States?" Milbank Quarterly 76(4):517–563. (Also available as RAND Reprint RP-751, 1999.)
  • Siu, A.L., F.A. Sonnerberg, E.G. Manning, et al. 1986. "Inappropriate Use of Hospitals in a Randomized Trial of Health Insurance Plans." New England Journal of Medicine 315:1259–1266.
  • Tobacman, J.K., P. Lee, B. Zimmerman, H. Kolder, L. Hilborne, and R.H. Brook. 1996. "Assessment of Appropriateness of Cataract Surgery at Ten Academic Medical Centers in 1990." Ophthalmology 103(2):207–215.
  • Wells, K., W. Katon, B. Rogers, and P. Camp. 1994. "Use of Minor Tranquilizers and Antidepressant Medications by Depressed Outpatients: Results from the Medical Outcomes Study." American Journal of Psychiatry 151:694–700.
  • Wells, K.B., G. Norquist, B. Benjamin, W. Rogers, K. Kahn, and R. Brook. 1994. "Quality of Antidepressant Medications Prescribed at Discharge to Depressed Elderly Patients in General Medical Hospitals Before and After Prospective Payment System." General Hospital Psychiatry 16:4–15.
  • Wells, K.B., W.H. Rogers, L.M. Davis, et al. 1993. "Quality of Care for Hospitalized Depressed Elderly Patients Before and After Implementation of the Medicare Prospective Payment System." American Journal of Psychiatry 150:1799–1805.

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