Is medical care lacking but equal?
Who Is at Greatest Risk for Receiving Poor-Quality Health Care?
By Steven M. Asch, M.D., M.P.H., Eve A. Kerr, M.D., M.P.H., Joan Keesey, B.A., John L. Adams, Ph.D., Claude M. Setodji, Ph.D., Shaista Malik, M.D., M.P.H., and Elizabeth A. McGlynn, Ph.D.
The New England Journal of Medicine
March 16, 2006
We have previously reported that Americans receive about half of recommended health care and that there is remarkably little geographic variation in this rate. The present study demonstrates that the differences among population subgroups in the quality of health care, even when they are statistically significant, are small in relation to the gap between actual and optimal performance. These results underscore the profound and systemic nature of the quality-of-care problem.
We found that health insurance status was largely unrelated to the quality of care among those with at least minimal access to care. Although having insurance increases the ease of access to the health care system, it is not sufficient to ensure appropriate use of services or content of care. Indeed, within systems where access to care is more equitable, disparities in quality due to race or ethnic group or to other characteristics are often reduced or even reversed, but substantial gaps between observed and optimal quality remain.
To make substantial improvements in the quality of health care available to all patients, we must focus on large-scale, system-wide changes. Our previous study of the quality of care delivered in the Veterans Affairs health system illustrates some of the potential for improvement. In that system, with one of the country’s most mature electronic medical-record systems, decision-support tools at the point of care, automated order entry, routine measurement of and reporting on quality, and financial incentives for performance, we found that participants received 67 percent of recommended care, a considerably better rate than the 55 percent observed in the current study.
We have previously shown substantial deficits in the quality of care nationally and in metropolitan areas with very different market profiles. In this study, we have now shown that individual characteristics that often have a protective effect do not shield most people from deficits in the quality of care. As the Institute of Medicine has concluded, problems with the quality of care are indeed widespread and systemic and require a system-wide approach.
http://content.nejm.org/cgi/content/full/354/11/1147
Working Paper (technical appendix to “Who Is at Greatest Risk for Receiving Poor-Quality Health Care?”): http://www.rand.org/pubs/working_papers/2006/RAND_WR174-1.pdf
And…
Medical Care Lacking but Equal
By Rob Stein
The Washington Post
March 16, 2006
Blacks and Hispanics tend to receive slightly better day-to-day medical care than whites when they see a doctor, a large and surprising study has found, sparking new debate about the impact of race on health in America.
The study, the most comprehensive examination of the quality of primary care in the United States, found no significant differences among patients from different ethnic groups or incomes once they get to see a doctor, but a slight trend toward better care for blacks and Hispanics.
The researchers stressed, however, that other disparities in health care do exist. Poor people and minorities, for example, are less likely to see a doctor in the first place and they receive far less expensive care. In addition, the minor variations among racial groups found in the study are swamped by the low level of care everyone gets, they said.
“The obsession with racial disparities is a distraction from what we really need to do, which is improve health care for everyone,” said Sally Satel, who studies health care at the American Enterprise Institute, a conservative think tank. “This shows us that, if anything, minority groups actually have even somewhat better outcomes.”
http://www.washingtonpost.com/wp-dyn/content/article/2006/03/15/AR2006031502120.html
Comment: By Don McCanne, M.D.
To understand what was measured in this study, you should glance at the technical appendix at the link above. Some of the quality indicators listed are clearly high priority items and most of those do have a very high mean score for compliance. Some items are low priority, and it would be unreasonable to expect them to be included in every medical record for the given clinical event. Some are controversial and should not be included as arbitrary measures of quality. Many others may be addressed during the clinical interaction but might be included in the record only if the clinician were compulsive about detailed charting even though the item is of only nominal significance.
If you were to go through the list and weight the relative importance and effectiveness of each quality indicator, the scores would be much higher than the 55 percent reported. Nevertheless, we can do better, and we should attempt to do so.
A major concern about this study is that the overestimation of quality impairment was used to demonstrate that the lack of insurance or the presence of unfavorable sociodemographic factors had little bearing on these quality parameters. Thus, Sally Satel of AEI makes the outrageous statement that “minority groups actually have even somewhat better outcomes.” In fact, their broad sweep of what they define as recommended care was so broad, and so bluntly focused, that it obliterated well documented differences in access and outcomes.
Innumerable studies have proven that health disparities and the lack of insurance maim and kill people. This study should not deter us in the least from continuing our fight for health care justice.