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Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

Chapter: Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee

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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Page 249
Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Page 250
Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Page 259
Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Page 260
Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Page 272
Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Appendix A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee Millions of Americans receive high-quality health care in the United States. Our capacity to provide the most sophisticated and effective care is unrivaled, and there is no evidence that any other system achieves better quality. Yet there is abundant evidence that serious and extensive quality problems exist throughout the U.S. health care system, resulting in harm to many Americans. Opportunities for improvement exist in all areas of clinical practice, across the continuum of care. As a result of overuse, underuse, and misuse of health care services, our society pays a substantial price. The opportunity costs of poor quality include years of life lost or spent with major or minor impairments, pain and suffering, disability costs, and lost productivity. In many areas, especially those involving overuse and misuse of health care services, that improving quality is also likely to lower health care costs. BACKGROUND The Quality of Health Care in America (QHCA) Project, a part of the Insti- tute of Medicine’s Special IOM Initiative on Quality, was established in June 1998 and charged with developing a strategy to produce a significant improve- ment in quality over the coming decade. The Committee on the Quality of Health Care in America, chaired by Will- iam C. Richardson, Ph.D., was responsible for this 2-year project. Four advisory groups were established to assist the QHCA Committee in carrying out its charge. To provide a broad base of expertise, these advisory 225

226 CROSSING THE QUALITY CHASM groups consisted of both committee members and other distinguished leaders within the health care arena. Each advisory group was chaired by a member(s) of the QHCA Committee. One of these four groups, the Technical Advisory Panel on the State of Quality, chaired by Mark Chassin, M.D., was asked to review and synthesize literature on the state of quality in the health care industry. Other members of this panel included: Arnold Epstein, M.D., M.A.; Brent James, M.D.; James P. Logerfo, M.D.; Harold Luft, Ph.D.; R. Heather Palmer, M.B., B.Ch.; Kenneth B. Wells, M.D. This appendix presents the panel’s findings. REVIEW OF THE LITERATURE In developing its approach to this effort, the State of Quality Panel reviewed an earlier synthesis of the literature on quality that was carried out by investiga- tors at the RAND Corporation (Schuster et al., 1998). This earlier review covered papers that, for the most part, were published between 1993 and mid-1997. To extend that earlier work, the IOM commissioned an updated synthesis from the investigators at RAND. This update covered the literature included in the earlier review with the addition of (1) papers published between July 1997 and August 1998, and (2) selected publications identified by members of the State of Quality Panel. A draft of this commissioned paper was reviewed by the State of Quality Panel at its November 1998 meeting, and subsequently revised in accordance with the panel’s suggestions. The final version, provided at the end of this appen- dix, was completed in January 1999. DISCUSSION OF FINDINGS A synthesis of findings from the literature on the quality of health care provides abundant evidence of poor quality. There are examples of exemplary care, but the quality of care is not consistent. Thus, the average American cannot assume that he or she will receive the best care modern medicine has to offer. There are many examples of overuse, underuse, and misuse of health care services. Overuse refers to the provision of health services for which the potential risks outweigh the potential benefits. Underuse indicates that a health care ser- vice for which the potential benefits outweigh the potential risks was not pro- vided. Misuse occurs when otherwise appropriate care is provided, but in a man- ner that does or could lead to avoidable complications. Overuse of health care services is common. Examples include the following: • performance of major surgery (e.g., hysterectomy, coronary artery bypass graft) without appropriate reasons; • provision of antibiotics for the common cold and other viral upper respi- ratory tract infections for which they are ineffective;

APPENDIX A 227 • insertion of tubes in children’s eardrums in the absence of clinically ap- propriate indications; and • performance of chiropractic spinal manipulation for certain back condi- tions for which there is no evidence of benefit. Lack of insurance is a major contributing factor to underuse. Even with comprehensive insurance coverage, however, much of the population fails to receive recommended preventive services, and many patients do not receive the full range of clinically indicated services for acute and chronic conditions. Ex- amples include the following: • Cardiac care In a study of 3,737 Medicare patients with a diagnosis of heart attack who were eligible for treatment with beta blockers, only 21 percent were found to have received beta blockers within 90 days of discharge. The adjusted mortality rate for patients with treatment was 43 percent below that of patients without treatment (Soumerai et al., 1997). • Pneumococcal vaccine In 1989, the U.S. Preventive Services Task Force recommended that people 65 years and older receive a one-time vaccination for pneumonia, and in 1996, this recommendation was modified to apply to all immunocompetent people aged 65 and older. Yet studies of the proportion of elderly who had been vaccinated produced estimates in the range of only 28 to 36 percent (CDC, 1995; Kottke et al., 1997). • Acute care for pneumonia Two studies of hospitalized patients with pneu- monia found serious shortcomings in the proportion of patients receiving appro- priate components of care (Kahn et al., 1990; Meehan et al., 1997). In recent years, increased attention has been focused on misuse. Studies of misuse are particularly challenging because actual or potential adverse events often go undocumented and unreported. But studies of preventable deaths and adverse drug events point to frequent and sometimes serious errors. For example, one study of over 4,000 hospitalized patients found that there were 19 prevent- able or potential adverse drug events per 1,000 patient days in intensive care units and 10 preventable or potential adverse drug events per 1,000 patient days in general care units (Cullen et al., 1997). LEVEL OF HARM CAUSED BY POOR QUALITY The existing literature does not allow a comprehensive estimate of the bur- den of harm due to poor quality. The literature on health care quality covers only a portion of the full range of quality concerns. For the most part, published studies focus on individuals who come into contact with the health care system. From a population perspective, the opportunity cost of poor quality must also

228 CROSSING THE QUALITY CHASM include the health benefits lost as a result of limited access due to financial or other barriers and poor patient adherence to therapeutic advice. These opportu- nity costs include years of life lost or spent with major or minor impairments, pain and suffering, disability costs, and lost productivity. The literature also does not reveal how frequently the various types of qual- ity problems occur. For example, some kinds of overuse problems may have a greater likelihood of being documented than some types of misuse or underuse problems because the data necessary to document overuse are more likely to reside in administrative datasets or medical records. From the available literature, it is also not possible to produce estimates of the costs of eliminating certain types of quality problems or the benefits likely to be derived. But there is no doubt that major improvements are possible in many clinical areas and health care settings, across the full continuum of care. NEED FOR FURTHER WORK The panel’s work represents a modest effort to review the state of health care quality. Specifically, the literature review was commissioned for this study lim- ited in the following ways: • It focused only on publications in leading peer-reviewed journals. Other sources of information, such as the data and analyses of Medicare Peer Review Organizations (PROs) or analyses using malpractice data, were not included. The Medicare PRO program is a particularly promising source of information on quality because the PROs have been conducting quality review projects involv- ing physicians, hospitals, and health plans for over 10 years. • The review did not focus in depth on specific clinical areas. An intensive review by clinical area would provide a more complete picture of the full spec- trum of quality problems and their frequency of occurrence. • The review did not include the many publications based on reports of patient experience or satisfaction. • The review did not include the body of studies reporting the impact of quality improvement activities. Thus it permits only anecdotal observations on the effectiveness of various of attempts to improve quality. • Although the publications included in the review appeared in peer-re- viewed journals, the panel made no attempt to assess the scientific rigor of the methodologies employed. Despite the above limitations, the panel believes that more in-depth reviews would not change its general conclusions that there are many areas in which quality of care can be improved. At the same time, additional research might be helpful for several reasons:

APPENDIX A 229 • A fuller understanding of quality problems would be useful in identifying specific areas in which those problems are greatest, as well as the most promising opportunities for improvement. • Condition-specific analyses would provide better estimates of the poten- tial benefits foregone as a result of poor quality and the best strategies for im- provement. • Additional work focused in particular clinical areas might also be helpful in raising awareness of practitioners and others who are skeptical about the existence of quality problems in their areas of expertise. Condition-specific analy- ses of quality that employ rigorous and valid measures could help build stronger support for quality improvement initiatives. • Additional reviews of the literature should be conducted to identify fac- tors that contribute to poor quality and effective strategies for improvement. For example, review of the literature on quality substantiates that for certain complex procedures, higher volume leads to better outcomes. But we do not know whether this result is attributable to the greater skill of an experienced surgeon, the greater standardization of processes in high-volume settings, or some other factor. Abun- dant evidence exists that quality can be improved, and there is much to be learned from the review of various improvement strategies about the roles of patients, clinicians, and systems and the use of various types of incentives. • Additional conceptual work, literature and data analysis, and develop- ment of measures are needed to improve capacities for quality-of-care assessment in certain key areas of medicine. An example is quality assessment in the areas of mental health, substance abuse, and neurologic disorders, and quality assessment for special populations, such as the frail elderly, poor children, and ethnic minorities. REFERENCES Centers for Disease Control and Prevention. 1995. Influenza and Pneurnococcal Vaccination Cover- age Levels among Persons Aged > 65 Years—United States, January–December 1995. Mor- bidity and Mortality Weekly Report 46:176–82. Cullen D.J., et al. 1997. Preventable Adverse Drug Events in Hospitalized Patients: a Comparative Study of Intensive Care and General Care Units. Critical Care Medicine 8:1289–97. 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 Sys- tem. Journal of the American Medical Association 264:1969–73. Kottke, T.E., L.I. Solberg, ML. Brekke, et al. 1995, Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries: Patterns of Use and Outcomes. Circulation 92:2841–7. Meehan, T.P., M.J. Fine, H.M. Krumholz, et al. 1997. Quality of Care, Process and Outcomes in Elderly Patients with Pneumonia. Journal of the American Medical Association 278:2080–4 Schuster, Mark A., Elizabeth A. McGlynn, and Robert H. Brook. 1998. “How Good Is the Quality of Health Care in the United States?” 1998. 76 (4) Milbank Quarterly 517–563. Soumerai, S.B., T.D. McLaughlin, E. Hertzmark, G. Thibault, and L. Goldman. 1997. Adverse Outcomes of Underuse of Beta-Blockers in Elderly Survivors of Acute Myocardial Infarction. Journal of the American Medical Association 277:115–21.

The Quality of Health Care in the United States: A Review of Articles Since 1987 Mark A. Schuster, M.D., Ph.D.;1 Elizabeth A. McGlynn, Ph.D.;2 Cung B. Pham, B.A.;3 Myles D. Spar, M.D.;4 and Robert H. Brook, M.D., Sc.D.5 Submitted January 1999 Quality of health care is on the national agenda. In September 1996, Presi- dent Clinton established the Advisory Commission on Consumer Protection and Quality in the Health Care Industry, which has released its final report on how to define, measure, and promote quality of health care (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). Much of the interest in quality of care has developed in response to the dramatic transformation of the health care system in recent years. New organiza- tional structures and reimbursement strategies have created incentives that may affect quality of care. Although some of the systems are likely to improve quality, concerns about potentially negative consequences have prompted a movement to assure that quality will not be sacrificed to control costs. The concern about quality arises more from fear and anecdote than from facts; there is little systematic evidence about quality of care in the United States. The nation has no mandatory national system and few local systems to track the quality of care delivered to the American people. More information is available on the quality of airlines, restaurants, cars, and VCRs than on the quality of health care. In 1997, the National Coalition on Health Care (NCHC) commissioned us to review the academic literature for articles that provide evidence of the quality of care in the United States (Schuster et al., 1998). The Institute of Medicine’s Authors’ affiliations: 1Health Sciences, RAND; Department of Pediatrics, UCLA 2Health Sci- ences, RAND 3Department of Pediatrics, UCLA 4HSR&D Field Program, Sepulveda Veterans Administration Medical Center; and 5Health Sciences, RAND; Department of Medicine, UCLA. 231

232 CROSSING THE QUALITY CHASM Technical Advisory Panel on the State of Quality commissioned an update to include studies published between January 1997 and July 1998. In this report, we summarize our findings from both the original study and the update. In the absence of a national quality tracking system, we believe such a summary is the best way to provide an overview of the quality of care delivered in the United States. We provide examples to illustrate quality in diverse settings, for diverse conditions, and for diverse demographic groups, and to offer insight into the quality that exists nationwide. DEFINING QUALITY The Institute of Medicine has defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr, 1990). Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cul- tural sensitivity. Quality can be evaluated based on structure, process, and outcomes (Donabedian, 1980). Structural quality evaluates health system capacities, pro- cess quality assesses interactions between clinicians and patients, and outcomes offer evidence about changes in patients’ health status. The best process mea- sures are those for which there is research evidence that better processes lead to better outcomes. For example, controlling blood pressure reduces mortality from stroke and heart disease; performing routine mammography identifies breast can- cer at an earlier stage so that a cure is more likely; prescribing inhaled corticoster- oids reduces the likelihood and severity of asthma flare-ups. Similarly, the best outcome measures are those which are tied to processes of care, in other words, those over which the health care system has influence. For example, the survival rate for pancreatic cancer would not be a good outcome measure because we do not yet have treatments that meaningfully affect survival. By contrast, pain level in patients with pancreatic cancer is a reasonable outcome measure. All three dimensions can provide valuable information for measuring qual- ity, but most of the quality-of-care literature focuses on measuring processes of care. Two measurement approaches dominate in the literature: (a) assessing appropriateness of care and (b) adherence to professional standards. (a) An intervention or service (e.g., a lab test, procedure, medication) is considered appropriate if, for individuals with particular clinical and personal characteristics, its expected health benefits (e.g., increased life expectancy, pain relief, decreased anxiety, improved functional capacity) exceed its expected health risks (e.g., mortality, morbidity, anxiety anticipating the intervention, pain caused by the intervention, inaccurate diagnoses) by a wide enough margin to make the intervention or service worth doing (Brook et al., 1986). A subset of appropriate

APPENDIX A 233 care is necessary or crucial care. Care is considered necessary if there is a reason- able chance of a nontrivial benefit to the patient and if it would be improper not to provide the care—in other words, if it might be considered ethically unaccept- able not to provide this care (Kahan et al., 1994; Laouri et al., 1997). (b) Another way to measure process quality is to determine whether care meets or adheres to professional standards. This assessment can be done by creating a list of quality indicators that describe a process of care that should occur for a particular type of patient or clinical circumstance and by evaluating whether patients’ care is consistent with the indicators. Quality indicators are based on standards of care, which are either found in the research literature and in statements of professional medical organizations or determined by an expert panel. Current performance can be compared against a physician’s or a plan’s own prior performance, against the performance of other physicians and plans, or with reference to a benchmark that establishes a goal. Indicators can cover a specific condition (e.g., children with sickle cell disease should be prescribed daily penicillin prophylaxis starting by no later than six months of age, until at least five years of age), or they can cover general aspects of care regardless of condition (e.g., patients prescribed a medication should be asked about medica- tion allergies). HOW WE CONDUCTED OUR LITERATURE SEARCHES This report draws on two searches of the scientific literature. The original NCHC report was based on a search for quality-of-care articles from the MEDLINE PLUS database (1993 to present) conducted in June 1997 and on relevant studies identified from the bibliographies of these articles. This database incorporates both the National Library of Medicine (NLM)’s MEDLINE data- base and the Health Planning and Administration’s HEALTH database. The NCHC report excluded articles published before 1987. In conducting our litera- ture search, we did not aim to be exhaustive, but rather to find examples that encompass a broad range of conditions and settings. (The inclusion criteria are described in the next section.) For this update, we conducted a systematic search of articles published be- tween January 1, 1997, and July 31, 1998, using the NLM’s Medical Subject Headings (MeSH) to search for appropriate articles. This system is designed so that each MeSH term corresponds to a single concept appearing in the biomedical literature. Trained NLM indexers assign relevant MeSH terms to each database entry (usually about 10–12 per entry) (NLM, 1997a). The more than 17,000 MeSH terms are organized in a tree format, with multiple hierarchical layers of subheadings (NLM, 1997b)(Our search terms appear at the end of the report). We conducted our search on August 24, 1998, and obtained 2,402 entries. Two authors reviewed each entry and its abstract to determine whether the study had potential for inclusion in our summary tables. Based on this initial screening,

234 CROSSING THE QUALITY CHASM we retrieved more than 200 articles. Each was reviewed by two authors to deter- mine whether the article was eligible for inclusion in this report. Some articles identified in the literature search were not available from the library by the completion date of the report. Because we did not find any studies of misuse in our update search, we conducted a supplemental search using key words such as “adverse,” “event#,” and “preventable” that produced additional relevant articles. In addition, several studies were recommended by members of the Institute of Medicine’s Technical Advisory Panel on the State of Quality. Criteria for Including Studies We include only data from large or diverse U.S. populations—for example, the nation, an entire state, an entire city, or several hospitals. Studies from mul- tiple offices of a single managed care organization are also considered eligible, but we do not include data from studies that cover only a single hospital or clinic. Although such studies are informative and the cumulative weight of their find- ings compelling, they are especially subject to concerns that they provide evi- dence of isolated problems rather than insight into the quality of care delivered more broadly. We include baseline data from quality improvement interventions as well as data for comparison/control/nonintervention groups from such interventions. We report baseline rather than follow-up data because the former are more likely to be representative of the quality of care provided around the country. Quality measurement conducted after a specific intervention shows the potential for in- terventions to improve quality, but until such interventions are commonplace, these post-intervention results are unlikely to represent what is taking place in most parts of the country. In addition, even the post-intervention results from such studies virtually always show room for further improvement. We report results only from studies for which we can identify a standard of good quality and exclude those for which there is no standard. For example, some studies show variations in practices that may reflect variations in quality. How- ever, the studies cannot determine which hospital or clinic or group of physicians is providing better or worse quality care. Types of Studies Not Included There are several ways to measure quality of care that are not represented among the studies listed in our summary tables. Although these approaches are valuable components of the quality-of-care toolbox, they have not been used in a way that provides an overview of quality in the United States. Studies often compare outcomes across multiple institutions to show which have better and which have worse outcomes, but the studies do not always present

APPENDIX A 235 a standard against which to compare outcomes. As a consequence, we do not know if the institution with the best outcomes is not nearly as good as it should be, or if the institution with the worst outcomes is nonetheless doing quite well. We only know how they compare with each other. If the outcomes are not risk-adjusted, it can be even more difficult to interpret them. This does not mean that studies cannot use outcomes to shed light on variations in quality. For ex- ample, prescription of beta blockers after a heart attack is a frequently used measure of quality. One study found that only about one in five eligible patients with a heart attack received beta blockers within 90 days of hospital discharge and also that those who received the treatment were much less likely to die than those who did not (Soumerai et al., 1997). Another study showed that poorer quality of care for children with asthma was associated with more hospitaliza- tions (Homer et al., 1996). We found a similar limitation with using satisfaction ratings, which some consider a type of outcome. We do not report on levels of satisfaction because it is difficult to determine what is an acceptable level of satisfaction. There is generally no standard to which to compare the results, and we do not know whether the institution with the best satisfaction ratings could and should be doing much better. Studies of access to care are not typically classified as quality-of-care stud- ies, but a person who is unable to obtain health care could hardly be said to be receiving good quality care. Access studies are beyond the scope of this report. However, we need to keep in mind that quality-of-care studies often measure quality only for people who have interacted with the health care system and so tend to overstate quality of care received by the population as a whole (Franks et al., 1993a, 1993b; Lurie et al., 1984, 1986; Sorlie et al., 1994). In general, structural measures have not been consistently shown to relate either to process quality or outcomes, but there are exceptions. For example, volume of care provided (in other words, the number of procedures performed or the number of patients cared for) by an institution or clinician has often been found to relate to quality (Hannan et al., 1989, 1995; Kelly and Hellinger, 1986; Kitahata et al., 1996; Luft et al., 1979; Phibbs et al., 1996; Riley and Lubitz, 1985; Stone et al., 1992). Another type of study does not provide direct evidence of quality of health care but is useful for identifying reasons for poor quality. Studies in which physi- cians report what they generally do or what they would do for a particular scenario can be informative, especially when physicians report practices that indicate poor quality. Although these studies do not describe care provided to individual patients, they can indicate a need for further education or other efforts to improve clinical practices. Finally, we note that our search mechanism almost certainly missed articles with relevant data. Many studies not intended as quality-of-care studies provide

236 CROSSING THE QUALITY CHASM data that shed light on quality of care. Some of these were identified through our search, but it is likely that many others were not. PROFILE OF QUALITY OF CARE IN THE UNITED STATES We divided our review of quality in the United States into three categories: underuse (Table A-1), overuse (Table A-2), and misuse (Table A-3). Underuse indicates that a health care service for which the potential benefits outweigh the potential risks (i.e., necessary care) is not provided. Overuse indicates the re- verse—a health care service is provided when the potential risks outweigh the potential benefits (i.e., inappropriate care). Misuse occurs when otherwise appro- priate care is provided in a way that leads to or could lead to avoidable complica- tions. Examples of misuse include when an antibiotic appropriate to the patient’s infection is prescribed despite the fact that the patient has a documented allergy to the antibiotic, or when two drugs, each of which is appropriate for a patient’s condition, are prescribed despite contraindications to prescribing them together. An incorrect dose or dosing schedule is also considered misuse. In each summary table, we list (and sometimes describe) the health care service for which quality is reported, the sample on which the report is based, the data source for the sample, the findings, and the reference. The tables report data from 73 articles. Perhaps the most striking revelation to emerge from this review is the sur- prisingly small amount of systematic knowledge available on the quality of health care delivered in the United States. Even though health care is a huge industry that affects the lives of most Americans, we have only snapshots of information about particular conditions, types of surgery, and locations of care. Gaps Between Ideal Care and Actual Care The dominant finding of our review is that there are large gaps between the care people should receive and the care they do receive. This is true for preven- tive, acute, and chronic care, whether one goes for a checkup, a sore throat, or diabetic care. It is true whether one looks at overuse, underuse, or misuse. It is true in different types of health care facilities and for different types of health insurance. It is true for all age groups, from children to the elderly. And it is true whether one is looking at the whole country or a single city. A few examples emphasize this point. An annual influenza vaccine is recom- mended as a preventive measure for all adults 65 years or older, a group at especially high risk for complications and death from influenza (U.S. Preventive Services Task Force, 1989, 1996). However, in 1993, only 52 percent of people in this age group in the United States received the vaccine; among people who had been to the doctor at least once that year, the percentage was slightly higher at 56 percent (Centers for Disease Control and Prevention, 1995b).

APPENDIX A 237 A major issue in acute care is the overuse of antibiotics, which has led to the development of strains of bacteria that are resistant to available antibiotics (Cen- ters for Disease Control and Prevention, 1994a). Antibiotics are almost never an appropriate treatment for people with a common cold because almost all colds are caused by a virus, for which antibiotics are not effective. However, in a study of Medicaid beneficiaries diagnosed with a cold in Kentucky during a one-year period from 1993 to 1994, 60 percent filled a prescription for an antibiotic (Mainous et al., 1996). In a national study of patient visits in 1992, 51 percent of adult patients and 44 percent of patients younger than 18 years old diagnosed with a common cold were treated with antibiotics (Gonzales et al., 1997; Nyquist et al., 1998). Other types of medications are also not always used in the most appropriate manner. Among hospitalized elderly patients with depression who were dis- charged on antidepressant medication, 33 percent were on a dose below the recommended level (Wells et al., 1994b). In a study of 634 patients with depres- sion or depressive symptoms in Boston, Chicago, and Los Angeles, 19 percent were treated with minor tranquilizers and no antidepressants (Wells et al., 1994a), despite the lack of evidence that tranquilizers work for depression and the risk that they will cause side effects or addiction (Depression Guideline Panel, 1993). Patients with chronic conditions, for which certain routine examinations and tests are crucial in order to prevent complications, do not all get the care they need. Diabetes mellitus causes several complications that are less likely to occur with good care. One of these complications is an eye condition called diabetic retinopathy, which is the leading cause of new blindness among persons aged 20 to 74 in the United States. It is recommended that patients with insulin-dependent diabetes mellitus have an annual dilated eye examination (the clinician uses drops to enlarge the pupil to see behind it more easily) starting five years after diagnosis and that patients with non-insulin-dependent diabetes mellitus have the exam annually starting at the time of diagnosis. In a national study in 1989, only 49 percent of adults with either type of diabetes had undergone a dilated eye exami- nation in the past year (66 percent in the past two years), and 61 percent had undergone any type of eye exam in the past year (79 percent in the past two years). Twenty percent of diabetics had no eye exam in the past two years. Among diabetics who were at particularly high risk for vision loss because they already had retinopathy or because they had had diabetes for a long time, 61 percent and 57 percent, respectively, had a dilated examination in the past year (Brechner et al., 1993). Sometimes surgery is performed on people who do not need it. A study of seven managed care organizations revealed that about 16 percent of hysterecto- mies performed during a one-year period from 1989 to 1990 were carried out for inappropriate reasons. An additional 25 percent were done for reasons of uncer- tain clinical benefit (Bernstein et al., 1993b). There are also examples of patients who need surgery but do not receive it. In a study of four hospitals, 43 percent of

238 CROSSING THE QUALITY CHASM patients with a positive exercise stress test demonstrating the need for coronary angiography had received it within 3 months; 56 percent had received it within 12 months (Laouri et al., 1997). Adverse events are injuries caused by medical management of a disease rather than by the disease itself. A review in New York State in 1984 found that 1.0 percent of hospitalizations had an adverse event due to negligence (Brennan et al., 1991). A study of two Boston hospitals found an adjusted rate of prevent- able adverse drug events of 1.8 per 100 non-obstetric hospital admissions; 20 percent of these events were life-threatening (Bates et al., 1995). Not all studies have found such poor quality. In a study of patients from 10 academic medical centers who had cataract surgery, 2 percent had the surgery for inappropriate reasons (Tobacman et al., 1996). In a study of patients in New York State who underwent coronary artery bypass graft surgery, 1.6 percent had sur- gery for inappropriate reasons (Leape et al., 1996). Nonetheless, the majority of studies described in the tables show much room for improving quality. How Managed Care Affects Quality Many have been quick to conclude that managed care is responsible for much of the poor quality care found in the U.S. health care system. However, studies published in the research literature neither clearly confirmed nor refuted this conclusion. Some studies find that managed care organizations provide better care than fee-for-service; some find that fee-for-service provides better care; still others find that the care is about the same (Miller and Luft, 1993, 1994). Results vary depending on the setting, the type of care assessed, and the methodology. Examining how managed care affects quality is complicated by the research approach, which has generally lumped together managed care organizations with- out distinguishing them by type (e.g., group- and staff-model health maintenance organizations, independent practice associations, preferred provider organiza- tions, point-of-service plans) or by features (e.g., comprehensiveness of the ben- efits package, nonprofit versus for-profit status). For purposes of examining qual- ity, it would be more useful to assess the effect of specific characteristics of managed care organizations. For example, including immunizations in a benefits package may have a larger impact on immunization rates than whether the care is offered by a managed care organization or a fee-for-service provider. A final important constraint on examining managed care’s affect on quality is the pace of change in this industry. Indeed, managed care is changing so rapidly (Landon et al., 1998) that most currently available studies are already out of date. We do not have a quality measurement system that enables timely assess- ment of the rapid changes occurring in the health care marketplace. Even the most widely used systems (e.g., the Health Plan Employer Data and Information Set, described below) are far from universal and do not include both managed care and fee-for-service.

APPENDIX A 239 Trends in Quality-of-Care Assessment Because the Technical Advisory Panel specifically requested an update on studies published in 1997–1998, we examined these studies as a group. There are several notable findings. First, few of these later studies reported on overuse of care. By contrast, our original review produced many examples of overuse. These early studies were based principally on the UCLA/RAND appropriateness method (Brook, 1994), which was one of the key methods used for quality assessment in the late 1980s and early 1990s. We do not know why the number of appropriate- ness studies has declined in recent years. Perhaps the many studies published throughout the prior decade convinced researchers that a great deal of inappropri- ate care is being provided, and they saw no need to make the same point over and over again. Or perhaps researchers now prefer other types of research questions and methodologies. Most of the recent studies provided examples of underuse. The findings are similar to those in the original review. For most types of care that researchers choose to study, we find that although many people do receive high quality care, many others do not. For example, a national study found that smoking status of adult patients was known by about two-thirds of primary care physicians after seeing their adult patients (Thorndike et al., 1998). Most preventive screening tests in the various studies were performed on more than half of the studied population but far from all. Blood pressure screening was particularly high (88 percent at last visit in one study [Kottke et al., 1997]), and in at least one study, cholesterol screening was high as well (84 percent) (Davis et al., 1998). Papani- colaou tests also appear to be provided to a large percentage of eligible women (Kottke et al., 1997). Quality continues to vary for acute care as well. The vast majority of hospitalized patients with pneumonia had timely oxygenation mea- surements (89 percent), but a lower percentage received blood cultures before antibiotics (57 percent) (Meehan et al., 1997). Most of the studies of underuse were in chronic care. Mental health care falls below standards, with 70 percent of schizophrenics in one study receiving poor symptom management, and 79 percent of those experiencing medication side effects receiving poor management of them (Young et al., 1998). Cardiac care was the major area in which quality-of-care studies were conducted over the past decade, and the care patterns documented in the earlier studies continue among the recent ones. Excellent clinical research has shown repeatedly that certain medications should and should not be used for people with myocardial infarctions or unstable angina, yet several quality-of-care studies show that many patients are still not getting proper treatments (e.g., Berger et al., 1998; Krumholz et al., 1998; Simpson et al., 1997; Soumerai et al., 1998). As mentioned above, one study with particularly striking results found that only 21 percent of eligible patients with a heart attack received beta blockers within 90 days of hospital discharge (Soumerai et al., 1997). Although patients with cardiovascular dis-

240 CROSSING THE QUALITY CHASM ease—a subset of the population that unambiguously needs cholesterol testing— had very high rates of cholesterol testing (96 percent), a much lower percentage of these patients received comprehensive treatment when their tests were abnor- mal (McBride et al., 1998). Other Sources of Information About Quality of Care In this paper, we have described reports of quality that have appeared in the research literature. There are also some systems that measure quality in select sectors of the United States, most notably the National Committee for Quality Assurance’s (NCQA) Health Plan Employer Data and Information Set (HEDIS). HEDIS is a performance measurement tool designed to help purchasers and consumers evaluate managed care plans and to hold plans accountable for the quality of their services. In 1996, more than 330 plans—over half the U.S. plans representing more than three-quarters of all commercial managed care enroll- ees—were reporting HEDIS measures on their commercial enrollees. Average adherence rates for select indicators made publicly available by NCQA fell pri- marily in the 60 to 70 percent range, with the extremes at 38 percent for diabetic eye exams (past year) and 84 percent for initiation of prenatal care in the first trimester (Thompson et al., 1998). Thus, HEDIS’s findings are consistent with those of the studies we have reported. Whether assessing quality as part of a research study or as part of a marketplace tool, the evidence repeatedly shows that quality falls short of standards. CONCLUSIONS There is good reason to be proud of the U.S. health care system, and evi- dence from international studies does not show consistent superiority elsewhere in the world (Gray et al., 1990; Pilpel et al., 1992; McGlynn et al., 1994; Froehlich et al., 1997; Meijler et al., 1997; Tamblyn et al., 1997; Wong et al., 1997). The United States is responsible for many important advances in health care technol- ogy, and state-of-the-art care is available in both large and small communities throughout the country. However, just because outstanding care is available does not mean that it is always provided or that everyone has access to such care. Most people in the studies reported here did receive excellent care. What is notable is that many did not. The quality of health care provided in the United States varies among hospi- tals, cities, and states. Whether the care is preventive, acute, or chronic, it fre- quently does not meet professional standards. We can do much better. The solu- tion is not simply a matter of spending more money on health care. A large part of our quality problem is the amount of inappropriate care provided in this country. Eliminating such nonbeneficial and potentially harmful care would generate large savings in human and financial costs. However, there are also many examples of

APPENDIX A 241 people who receive either too little or technically poor care; fixing these prob- lems may increase expenditures. Some people might conclude that quality is good enough based on the evi- dence we have presented in this report—in other words, that the standards used in the various studies are too high. We would disagree with such a conclusion. Clinicians and health plans that are motivated to improve the quality of care they deliver can use information on quality to focus their improvement efforts. For example, a group of all cardiothoracic surgeons practicing in Maine, New Hampshire, and Vermont, using continuous quality improvement and other tech- niques to improve their practices, reduced their combined mortality rates by 24 percent (O’Connor et al., 1996). Government action also has the potential to spur improvement. In New York State (NYS), risk-adjusted mortality for coronary artery bypass graft (CABG) surgery decreased 41 percent from 4.17 percent in 1989 (when the NYS Department of Health began disseminating information regarding the outcomes of CABG surgery) to 2.45 percent in 1992 (Hannan et al., 1994). Between 1987 (before the NYS reporting program began) and 1992, unad- justed 30-day mortality rates following CABG declined by 33 percent in NYS Medicare patients, compared with a 19 percent decline nationwide, giving NYS the lowest statewide risk-adjusted CABG mortality rate in the country (Peterson et al., 1998). If quality-of-care information is made available regularly and in an interpret- able form, consumers and large purchasers can use it to make informed decisions when choosing among clinicians and plans, which will, in turn, give providers an added incentive to improve quality. Policy makers can also use information about quality of care to determine the impact of public and private changes in the health care marketplace. We are currently experiencing a dramatic shift in the organiza- tion and financing of health services delivery in the United States. The private sector has been the driving force behind this transformation, but the public sector is beginning to use its market power as well. Incentives to move Medicaid and Medicare beneficiaries into managed care represent one of many examples of public sector change. Although quality assessment organizations, accreditation organizations, and government agencies are currently doing work to measure quality of care, most of this activity has begun during the past decade. The rapid development of the field is encouraging, but it is confined to organizations that cover specific sections of the country or restrict themselves to certain segments of the health care market- place. Their work, as well as the findings of individual studies such as those listed in Tables A-1 to A-3, provides some evidence of the situation throughout the country. But changes in the U.S. health care delivery system are occurring more rapidly than evaluations of them can be performed. Much of the information concerning the relation between the organization of the health care system and quality of care is already outdated. At present, the United States has only a

242 CROSSING THE QUALITY CHASM patchwork of systems that measure quality, with little uniformity, breadth, or ability to produce rapid results. Furthermore, these systems do not yet assess most providers of health care in the United States. There is no system that pro- vides a comprehensive assessment of quality of care for the nation—including how quality varies by population subgroups (e.g., gender, age, race/ethnicity, income, region of country, size of community) and how quality is changing over time. Efforts such as HEDIS could eventually lead to development of a compre- hensive, national quality assessment system, but such a system may not develop rapidly unless there is an organized effort to ensure that it does. The United States cannot afford to let this situation continue. A systematic strategy for routine monitoring and reporting on quality, as well as the informa- tion systems needed to support such activities, will be essential if we are to preserve the best of the American health care system while striving to improve the efficiency with which high-quality services are provided. This strategy could be organized by the federal government, the private sector, or a public–private partnership. It could involve coordination among all three. But in any case, the strategy will need to cover the aspects of quality that patients, purchasers, and providers care about; it will need to collect data in a way that is manageable, reasonable, and affordable; and it will need to produce infor- mation in a format that is useful for making a variety of decisions. The United States is capable of implementing a quality measurement system that can provide the multiple participants in the health care system with the information they need to ensure delivery of high-quality care. In light of the changes that the health care system has been experiencing, a strategy to measure and consequently to improve quality is needed now. ACKNOWLEDGMENTS Partial funding was provided by the National Coalition on Health Care and the Institute of Medicine. We are indebted to Allison L. Diamant, M.D., M.S.P.H., Mark Chassin, M.D., M.P.P., M.P.H., Janet Corrigan, Ph.D., Molla Donaldson, D.Ph., Rachel Spilka, Ph.D., and Joseph H. Triebwasser, M.D., for comments on drafts of this paper. We are also indebted to James Tebow, Ph.D., Lauren N. Nguyen, M.P.H., Yuko Sano, A.B., Sinaroth Sor, M.D., and Myra Wong, A.B., for document and research assistance. REFERENCES Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. Qual- ity First: Better Health Care for All Americans. Final Report to the President of the United States. Washington, D.C. Agency for Health Care Policy and Research. 1994. Acute Low Back Problems in Adults. Clinical Practice Guideline #14.

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APPENDIX A 245 Hannan, E.L. H. Kilburn, M. Racz, E. Shields, and M.R. Chassin. 1994. Improving the Outcomes of Coronary Artery Bypass Surgery in New York State. Journal of the American Medical Asso- ciation 271:761–6. Hannan, E.L., J.F. O’Donnell, H. Kilburn, Jr., H.R. Bernard, A. Yazici. 1989. Investigation of the Relationship between Volume and Mortality for Surgical Procedures Performed in New York State Hospitals. Journal of the American Medical Association 262:503–10. Hannan, E.L., A.L. Siu, D. Kumar, H. Kilburn, Jr., M.R. Chassin. 1995. The Decline in Coronary Artery Bypass Graft Surgery Mortality in New York State: The Role of Surgeon Volume. Journal of the American Medical Association 273:209–13. 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. Journal of the American Medical Association. 269:761–5. Hillner, B.E., M.K. McDonald, L. Penberthy, et al. 1997. Measuring Standards of Care for Early Breast Cancer in an Insured Population. Journal of Clinical Oncology 15:1401–8. Homer, C.J., P. Szilagyi, L. Rodewald, et al. 1996. Does Quality of Care Affect Rates of Hospitaliza- tion for Childhood Asthma? Pediatrics 98:18–23. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. 1993. The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Archives of Internal Medicine 153:154–83. Kahan, J.P., S.J. Bernstein, L.L. Leape, et al. 1994. Measuring the Necessity of Medical Procedures. Medical Care 32:357–65. 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 Sys- tem. Journal of the American Medical Association 264:1969–73. Kelly, J.V., F.J. Hellinger. 1986. Physician and Hospital Factors Associated with Mortality of Surgi- cal Patients. Medical Care 24:785–800. Kitahata, M.M., T.D. Koepsell, R.A. Deyo, C.L. Maxwell, W.T. Dodge, and E.H. Wagner. 1996. Physicians’ Experience with the Acquired Immunodeficiency Syndrome as a Factor in Pa- tients’ Survival. New England Journal of Medicine 334:701–6. 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. Journal of the American Medical Association 271:1250–5. Klinkman, M.S., D.W. Gorenflo, and T.S. Ritsema. 1997. The Effects of Insurance Coverage on the Quality of Prenatal Care. Archives of Family Medicine 6:557–66. Kogan, M.D., G.R. Alexander, M. Kotelchuck, D.A. Nagey, and B.W. Jack. 1994. Comparing Moth- ers’ Reports on the Content of Prenatal Care Received with Recommended National Guidelines for Care. Public Health Reports 109:637–46. Kottke, T.E., L.I. Solberg, M.L. Brekke, et al. 1997. Delivery Rates for Preventive Services in 44 Midwestern Clinics. Mayo Clinic Proceedings 72: 515–23. Krumholz, H.M., M.J. Radford, E.F. Ellerbeck, et al. 1995. Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries: Patterns of Use and Outcomes. Cir- culation 92:2841–7. ———. 1996. Aspirin for Secondary Prevention after Acute Myocardial Infarction in the Elderly: Prescribed Use and Outcomes. Annals of Internal Medicine 124:292–8. Krumholz, H.M., D.M. Philbin, Y. Wang, et al. 1998. Trends in the Quality of Care with Medicare Beneficiaries Admitted to the Hospital with Unstable Angina. Journal of the American College of Cardiology 31: 957–63. Landon, B.E., I.B. Wilson, and P.D. Cleary. 1998. A Conceptual Model of the Effects of Health Care Organizations on the Quality of Medical Care. Journal of the American Medical Association 279:1377–82.

246 CROSSING THE QUALITY CHASM Laouri, M., R.L. Kravitz, S.J. Bernstein, et al. 1997. Underuse of Coronary Angiography: Applica- tion of a Clinical Method. International Journal for Quality in Health Care 9:5–22. Lazovich D., E. White, D.B. Thomas, R.E. Moe. 1991. Underutilization of Breast-Conserving Sur- gery and Radiation Therapy Among Women With Stage I or II Breast Cancer. Journal of the American Medical Association 266:3433–8. Leape, L.L., T.A. Brennan, N. Laird, et al., 1991. The Nature of Adverse Events in Hospitalized Patients: Results of the Harvard Medical Practice Study II. New England Journal of Medicine 324:377–84. Leape, L.L., L.H. Hilbome, R.E. Park, et al. 1993. The Appropriateness of Use of Coronary Artery Bypass Graft Surgery in New York State. Journal of the American Medical Association 269:753–60. Leape, L.L., L.L. Hilbome, J.S. Schwartz, et al. 1996. The Appropriateness of Coronary Artery Bypass Graft Surgery in Academic Medical Centers. Annals of Internal Medicine 125:8–18. Legorreta. A.P., J. Christian-Herman, R.D. O’Connor, et al. 1998. Compliance with National Asthma Management Guidelines and Specialty Care: A Health Maintenance Organization Experience. Archives of Internal Medicine 158: 457–64. Lieu, T.A., J.C. Mohle-Boetani, G.T. Ray, L.M. Ackerson, D.L. Walton. 1998. Neonatal Group B Streptococcal Infection in a Managed Care Population. Obstetrics and Gynecology 92: 21–7. Liu, Z., K.L. Shilkret, L. Finelli. 1998. Initial Drug Regimens for the Treatment of Tuberculosis: Evaluation of Physician Prescribing Practices in New Jersey. Chest 113:1446-51. Lohr, K.N. Ed. 1990. Medicare: A Strategy for Quality Assurance. Washington D.C.: National Academy Press. Luft, H.S., J.P. Bunker, A.C. Enthoven. 1979. Should Operations Be Regionalized? The Empirical Relation between Surgical Volume and Mortality. New England Journal of Medicine 301:1364– 9. Lurie, N., N.B. Ward, M.F. Shapiro, R.H. Brook. 1984. Termination of Medical Benefits: Does it Affect Health? New England Journal of Medicine 311:480–4. Lurie, N., N.B. Ward, M.F. Shapiro, et al. 1986. Termination of Medical Benefits: A Follow-Up Study One Year Later. New England Journal of Medicine 314:1266–8. Mainous, A.G., W.J.-Hueston, and J.R. Clark. 1996. Antibiotics and Upper Respiratory Infection: Do Some Folks Think There Is a Cure for the Common Cold? Journal of Family Practice 42:357–61. McBride, P.M., H.G. Schrott, M.B. Plane, G. Underbakke, R.L. Brown. 1998. Primary Care Practice Adherence to National Cholesterol Education Program Guidelines for Patients with Coronary Heart Disease. Archives of Internal Medicine 158:1238–44. McCaig, L.F., and J.M. Hughes. 1995. Trends in Antimicrobial Drug Prescribing among Office- Based Physicians in the United States. Journal of the American Medical Association 273:214– 9. 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. Journal of the American Medical Association 272:934–40. Meehan, T.P., J. Hennen, M.J. Radford, M.K. Petrillo, P. Elstein, and D.J. Ballard. 1995. Process and Outcome of Care for Acute Myocardial Infarction among Medicare Beneficiaries in Connecti- cut: A Quality Improvement Demonstration Project. Annals of Internal Medicine 122:928–36. Meehan, T.P., M.J. Fine, H.M. Krumholz, et al. 1997. Quality of Care, Process and Outcomes in Elderly Patients with Pneumonia. Journal of the American Medical Association 278:2080–4 Meijler, A.P., H. Rigter, S.J. Bernstein, et al. 1997. The Appropriateness of Intention to Treat Deci- sions for Invasive Therapy in Coronary Artery Disease in the Netherlands. Heart 77:219–24. Miller, R.H., and H.S. Luft. 1993. Managed Care: Past Evidence and Potential Trends. Frontiers of Health Services Management 9:3–37.

APPENDIX A 247 ———. 1994. Managed Care Plan Performance since 1980: A Literature Analysis. Journal of the American Medical Association 271:1512–9. Murata, P.J., E.A. McGlynn, A.L. Siu, et al. 1994. Quality Measures for Prenatal Care: A Compari- son of Care in Six Health Care Plans. Archives of Family Medicine 3:41–9. NIH Consensus Conference Treatment of Early-Stage Breast Cancer. 1991. Journal of the American Medical Association 265:391–5. National Library of Medicine. 1997a. Medical subject headings, Annotated Alphabetic List, 1998. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Library of Medicine; Washington, D.C. ———. 1997b. Medical Subject Headings, Tree Structures, 1998. Bethesda, Md.: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Library of Medicine; Washington, D.C. Nyquist, A., R. Gonzales, J.F. Steiner, and M.A. Sande. 1998. Antibiotic Prescribing for Children With Colds, Upper Respiratory Tract Infections, and Bronchitis. Journal of the American Medi- cal Association 279:875–7. O’Connor, G.T., S.K. Plume, E.M. Olmstead, et al. 1996. A Regional Intervention to Improve the Hospital Mortality Associated With Coronary Artery Bypass Graft Surgery. Journal of the American Medical Association 275:841–6. Payne, S.M., C. Donahue, P. Rappo, et al. 1995. Variations in Pediatric Pneumonia and Bronchitis/ Asthma Admission Rates. Is Appropriateness a Factor? Archives of Pediatrics and Adolescent Medicine 149:162–9. Peterson, E.D., E.R. DeLong, J.G. Jollis, L.H. Muhlbaier, and D.B. Mark. 1998. The Effects of New York’s Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly. Journal of the American College of Cardiology 32:993–9. Phibbs, C.S., J.M. Bronstein, E. Buxton, and R.H. Phibbs. 1996. The Effects of Patient Volume and Level of Care at the Hospital of Birth on Neonatal Mortality. Journal of the American Medical Association 276:1054–9. Pilpel, D., G.M. Fraser, J. Kosecoff, S. Weitzman, and R.H. Brook. 1992. Regional Differences in Appropriateness of Cholecystectomy in a Prepaid Health Insurance System. Public Health Review 20:61–74. Retchin, S.M., and J. Preston. 1991. Effects of Cost Containment on the Care of Elderly Diabetics. Archives of Internal Medicine 151:2244–8. Regier, D.A., W.E. Narrow, D.S. Rae, R.W. Maderscheid, B.Z. Locke, and F.K. Goodwin. 1993. The de facto US Mental and Addictive Disorders Service System. Archives of General Psychiatry 50:85–94. Riley, G., J. Lubitz. 1985. Outcomes of Surgery among the Medicare Aged: Surgical Volume and Mortality. Health Care Financing Review 7:37–47. Schucker, B., J.T. Wittes, N.C. Santanello, et al. 1991. Change in Cholesterol Awareness and Action. Archives of Internal Medicine 151:666–73. Schuster, M.A., E.A. McGlynn, R.H. Brook. 1998. How Good Is the Quality of Health Care in the United States? Milbank Quarterly 76:517–63. Shekelle, P.G., I. Coulter, E.L. Hurwitz, et al. 1998. Congruence Between Decisions to Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America. Annals of Internal Medicine 129:9–17. Simon, G.E., and M. VonKorff. 1995. Recognition, Management, and Outcomes of Depression in Primary Care. Archives of Family Medicine 4:99–105. Simpson, R.J. Jr., R.R. Weiser. S. Naylor, C.A. Sueta, A.K. Metts. 1997. Improving Care for Un- stable Angina Patients in a Multiple Hospital Project Sponsored by a Federally Designated Quality Improvement Organization. American Journal of Cardiology. 80(8B):80H–4H.

248 CROSSING THE QUALITY CHASM Sorlie, P.D., N.J. Johnson, E. Backlund, D.D. Bradham. 1994. Mortality in the Uninsured Compared with that in Persons with Public and Private Insurance. Archives of Internal Medicine 154:2409– 16. Soumerai, S.B., T.D. McLaughlin, E. Hertzmark, G. Thibault, and L. Goldman. 1997. Adverse Outcomes of Underuse of Beta-Blockers in Elderly Survivors of Acute Myocardial Infarction. Journal of the American Medical Association 277:115–21. Soumerai, S.B., T.J. McLauglin, J.H. Gurwitz, et al. 1998. Effect of Local Medical Opinion Leaders on Quality of Care for Acute Myocardial Infarction: A Randomized Controlled Trial. Journal of the American Medical Association 279:1358–63. Starfield, B., N.R. Powe, J.R. Weiner, et al. 1994. Costs vs Quality in Different Types of Primary Care Settings. Journal of the American Medical Association 272:1903–8. Stone, V., G. Seage, T. Hertz, and A. Epstein. 1992. The Relation between Hospital Experience and Mortality for Patients with AIDS. Journal of the American Medical Association 268:2655–61. Stoner, T.J., B. Dowd, W. P.Carr, G. Maldonado, T.R. Church, J. Mandel. 1998. Do Vouchers Improve Breast Cancer Screening Rates? Results from a Randomized Trial. Health Services Research. 33:11–28. Summary of the Second Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). 1993. Journal of the American Medical Association 626: 3015–23. Tamblyn, R., L. Berkson, W.D. Dauphinee, et al. 1997. Unnecessary Prescribing of NSAIDs and the Management of NSAID-Related Gastropathy in Medical Practice. Annals of Internal Medicine 127:429–38. Thamer, M., N.F. Ray, S.C. Henderson, et al. 1998. Influence of the NIH Consensus Conference on Helicobacter Pylori on Physician Prescribing Among a Medicaid Population. Medical Care 36:646–60. Thompson, J.W., J. Bost, F. Ahmed, C.E. Ingalls and C. Sennett. 1998. The NCQA’s Quality Com- pass: Evaluating Managed Care in the United States. Health Affairs 17:152–8. Thorndike, AX, N.A. Rigotti, R.S. Stafford, and D.E. Singer. 1998. National Patterns in the Treat- ment of Smokers by Physicians. Journal of the American Medical Association 279:604–8. 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. Ophthal- mology 103:207–15. Udvarhelyi, I.S., K. Jennison, R.S. Phillips, and A.M. Epstein. 1991. Comparison of the Quality of Ambulatory Care for Fee-for-Service and Prepaid Patients. Annals of Internal Medicine 115:394–400. U.S. Preventive Services Task Force. 1989. Guide to Clinical Preventive Services. Baltimore: Will- iam & Wilkins. ———. 1996. Guide to Clinical Preventive Services. Baltimore: William & Wilkins. Weiner, J.P., S.T. Parente, D.W. Garnick, J. Fowles, A.G. Lawthers, and H. Palmer. 1995. Variation in Office-Based Quality: A Claims-Based Profile of Care Provided to Medicare Patients with Diabetes. Journal of the American Medical Association 273:1503–8. Wells, K.B., R.D. Hays, M.A. Burnam, et al. 1989. Detection of Depressive Disorder for Patients Receiving Prepaid or Fee-for-Service Care: Results from the Medical Outcomes Study. Journal of the American Medical Association 262:3298–302. Wells, K., W. Katon, B. Rogers, and P. Camp. 1994a. Use of Minor Tranquilizers and Antidepres- sant Medications by Depressed Outpatients: Results from the Medical Outcomes Study. Ameri- can Journal of Psychiatry 151:694–700. Wells, K.B., G. Norquist, B. Benjamin, W. Rogers, K. Kahn, and R. Brook. 1994b. 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.

APPENDIX A 249 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 150:1799–805. Winslow, C.M., J.B. Kosecoff, M. Chassin, D.E. Kanouse, and R.H. Brook. 1988. The Appropriate- ness of Performing Coronary Artery Bypass Surgery. Journal of the American Medical Asso- ciation 260:505–9. Wong, J.H., J.M. Findlay, and M.E. Suarez-Almazor. 1997. Regional Performance of Carotid Endar- terectomy: Appropriateness, Outcomes, and Risk Factors for Complications. Stroke 28:891–8. Young, A.S., G. Sullivan, M.A. Bumam, R.H. Brook. 1998. Measuring the Quality of Outpatient Treatment for Schizophrenia. Archives of General Psychiatry 55:611–7.

TABLE A-1 Examples of Quality of Health Care in the United States—Underuse: Did Patients Receive the Care They 250 Should Have Received? Health Care Servicea Sample Description Data Source Quality of Care Referenceb PREVENTIVE CARE Immunizations Childhood Vaccines Three Polio; four Diphtheria, Tetanus, Children 19–35 months old National Immunization 74% received all the CDC, 1997 Pertussis; one Measles, Mumps, Rubella; in 31,997 households from Survey (NIS), 1995. vaccines. (If three doses of and three Haemophilus influenzae type b a nationally representative Hib are not included, the (Hib) by 18 months old. (Three to four sample of the United States percentage is 76%.) doses of Hib are recommended, depending (U.S.). on formulation; three Hepatitis B virus vaccines [HBV] are also recommended but were not included in this particular study.) (American Academy of Pediatrics [AAP], 1994; Centers for Disease Control and Prevention [CDC], 1995a). Influenza Vaccine Annual vaccination of all people ≥ 65 Approximately 8,000 adults National Health Interview 52% received annual CDC, 1995b years old is recommended (U.S. Preventive ≥ 65 years old from a Survey (NHIS), 1993. influenza vaccine. Services Task Force [USPSTF], 1989). sample of people This recommendation has since been representative of the U.S. reiterated (USPSTF,1996). civilian, noninstitutionalized population. Same as above. From a sample of 7,997 Mailed surveys with phone 72% of people ≥ 65 years Kottke randomly selected patients follow-up of patients who had an influenza vaccine in et al., 1997 ≥ 20 years old who had visited one of 44 clinics the prior year. visited a clinic during the from August 1, to

study period, 6,830 (85%) September 9, 1994, in the completed surveys. Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies. Pneumococcal Vaccine One-time vaccination for all people ≥ 65 Approximately 8,000 adults NHIS, 1993 28% received CDC, 1995b years old is recommended (USPSTF, ≥ 65 years old from a pneumococcal vaccine. 1989). In 1996, the recommendation was sample of people modified to specify one-time vaccination representative of the U.S. for all immunocompetent individuals ≥ 65 civilian, noninstitutionalized years old (USPSTF, 1996). population. Same as above. From a sample of 7,997 Mailed surveys with phone 36% of people ≥ 65 years Kottke randomly selected patients follow-up of patients who old had ever had a et al., 1997 ≥ 20 years old who had visited one of 44 clinics pneumococcal vaccine. visited a clinic during the from August 1, to study period, 6,830 (85%) September 9, 1994, in the completed surveys. Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies. Cancer Screening Breast Cancer Screening Recommendations vary. In 1989, the 21,601 women ≥ 50 years Behavioral Risk Factor 58% had clinical breast CDC, 1993a USPSTF recommended an annual clinical old from a sample of people Surveillance System, 1992. exam in the prior year; breast exam (CBE) for women ≥ 40 years representative of the U.S. 46% had mammography in old and mammography every 1–2 years for population (excluding the prior year; 40% had women 50–75 years old (USPSTF, 1989). Arkansas and Wyoming, both examinations in the continues 251

TABLE A-1 Continued 252 Health Care Servicea Sample Description Data Source Quality of Care Referenceb In 1996, it recommended mammography and including the District prior year. every 1–2 years with or without annual of Columbia). clinical breast exam for women 50–69 years old (USPSTF, 1996). Same as above. From a sample of 7,997 Mailed surveys with phone 72% of women ≥ 50 years Kottke randomly selected patients follow-up of patients who old had a breast et al., 1997 ≥ 20 years old who had visited one of 44 clinics examination in the prior visited a clinic during the from August 1, to two years; 68% of women study period, 6,830 (85%) September 9, 1994, in the 50 years or older had a completed surveys. Minneapolis-St. Paul mammogram in the prior metropolitan area with two years. contracts with one of two managed care companies. Same as above. 221 women > 50 years old. Interview survey of women 38% of women had not Stoner et al., in farm households received a mammogram in 1998 randomly sampled from six the prior 18 months. southern Minnesota counties, 1992. Cervical Cancer Screening Women with an intact uterus (having a Women ≥ 18 years old with NHIS, 1992. 67% had a Pap smear in CDC, 1996 cervix) should have a Papanicolaou (Pap) an intact uterus from a the prior 3 years. smear after initiation of sexual intercourse sample of 128,412 people and every 1–3 years thereafter. Some representative of the U.S. organizations recommend starting Pap civilian, noninstitutionalized smears for all women who have reached population. 18 years old, regardless of sexual history (USPSTF, 1989). These recommendations

have since been reiterated (USPSTF, 1996). Same as above. From a sample of 7,997 Mailed surveys with phone 84% of women had a Pap Kottke randomly selected patients follow-up of patients who smear in the prior two et al., 1997 ≥ 20 years old who had visited one of 44 clinics years. visited a clinic during the from August 1, to study period, 6,830 (85%) September 9, 1994, in the completed surveys. Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies. Colon Cancer Screening Recommendations vary. In 1980, the Adults ≥ 40 years old from NHIS, 1992 14% of men and 15% of CDC, 1996 American Cancer Society recommended a sample of 128,412 people women had FOBT in the annual fecal occult blood testing (FOBT) representative of the U.S. prior year; 44% of men and starting at 50 years old. Some other civilian, noninstitutionalized 43% of women had ever organizations made similar population. had FOBT; 11% of men recommendations. In 1989, the USPSTF and 7% of women had did not make recommendations (USPSTF, proctosigmoidoscopy in the 1989), but in 1996, it recommended annual prior 3 years. FOBT, sigmoidoscopy (periodicity unspecified), or both starting at 50 years old (USPSTF, 1996). Same as above. 250 women 40–65 years Medical records for 51%–59% of women had Udvarhelyi old who had no major patients from four group FOBT every 2 years or et al., 1991 illnesses, who received practices in Massachusetts, flexible sigmoidoscopy primary care at one of the November 1, 1985, to every 5 years. group practices, and who October 31, 1987. were eligible for preventive care. continues 253

TABLE A-1 Continued 254 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Cardiac Risk Factors Smoking Counseling The USPSTF recommends a complete 8,778 smokers ≥ 18 years NHIS, 1991. 37% of smokers who had a CDC, 1993b history of tobacco use as well as tobacco old from a sample of visit with a physician or cessation counseling on a regular basis 43,732 people other health care (USPSTF, 1989, 1996). The Agency for representative of the U.S. professional during the Health Care Policy and Research (AHCPR) civilian, noninstitutionalized prior year had been advised recommends that primary care physicians population. to quit smoking. identify patients’ smoking status and counsel smokers at every visit (AHCPR, 1996). Same as above. From a sample of 7,997 Mailed surveys with phone 53% of smokers were asked Kottke randomly selected patients follow-up of patients who their smoking status. 47% et al., 1997 ≥ 20 years old who had visited one of 44 clinics of smokers were advised to visited a clinic during the from August 1, to quit. study period, 6,830 (85%) September 9, 1994, in the completed surveys. Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies. Same as above. A nationally representative National Ambulatory Physicians knew the Thorndike sample of 3,254 physicians Medical Care Survey patient’s smoking status at et al., 1998 representing 145,716 adult (NAMCS), 1991–1995. 66% of all patient visits. patient ambulatory care (The percentage for visits. primary care physicians ranged from about 61% to

67%, depending on the year.) Smoking counseling was provided at 22% of visits of known smokers. (The percentage for primary care physicians ranged from 20% to 38%.) Blood Cholesterol Screening In 1988, the National Heart, Lung, and 3,700 adults ≥ 18 years old Telephone survey by the 65% of adults had ever had Schucker Blood Institute recommended routine from a representative National Heart, Lung, and a blood cholesterol test; et al., 1991 cholesterol screening at least every 5 years sample of the non-African Blood Institute, 1990. 51% had the test in the starting at 20 years old. In 1989, the American U.S. population. prior year; and an USPSTF recommended periodic screening additional 14% had it prior for middle-aged men (USPSTF, 1989), and to that. 35% had never had in 1996, it recommended periodic a blood cholesterol test. screening for men 35–65 years old and women 45–65 years old. Treatment includes dietary therapy, physical activity, or lipid-lowering medications depending on the patient (National Cholesterol Education Program [NCEP], 1993). Same as above. Adults ≥ 20 years old from CDC’s Behavioral Risk The state-specific rates of CDC, 1993c a sample of people Factor Surveillance System, adults who had cholesterol representative of the U.S. 1991. screening in the prior 5 population (excluding years ranged from 57% to Wyoming, Kansas, and 70%. continues 255

TABLE A-1 Continued 256 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Nevada, and including the District of Columbia) (sample sizes for individual states range from 670 to 3,190 people). Same as above. From a sample of 7,997 Mailed surveys with phone 68% had had their Kottke randomly selected patients follow-up of patients who cholesterol measured during et al., 1997 ≥ 20 years old who had visited one of 44 clinics the prior 5 years. visited a clinic during the from August 1, to study period, 6,830 (85%) September 9, 1994, in the completed surveys. Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies. Blood Cholesterol Screening and Treatment Same as above. 1,004 people 40–64 years Medical records from three 84% were screened for Davis et al., old from a sample that had sites of a managed care elevated cholesterol levels 1998 been enrolled continuously plan (South Florida; at least once during the for at least 5 years and had Jacksonville, Florida; and 6-year period. 86% with a at least one outpatient visit Atlanta, Georgia), January diagnosis of during the study period. 1, 1988, to December 31, hypercholesterolemia were 1993. treated with diet therapy, cholesterol-lowering drugs, or both.

Blood Pressure Screening In 1989, the USPSTF recommended blood From a sample of 7,997 Mailed surveys with phone 88% had blood pressure Kottke pressure measurements for normotensive randomly selected patients follow-up of patients who measured at the most et al., 1997 patients ≥ 21 years old every 2 years if ≥ 20 years old who had visited one of 44 clinics recent visit. their last diastolic and systolic blood visited a clinic during the from August 1, to pressures were below 85 mm Hg and 140 study period, 6,830 (85%) September 9, 1994, in the mm Hg, respectively, and annually if their completed surveys. Minneapolis-St. Paul last diastolic was 85–89 mm Hg (USPSTF, metropolitan area with 1989). In 1996, these recommendations contracts with one of two were modified to specify apparently managed care companies. normotensive patients (USPSTF, 1996). General Preventive Care Well-Child Care The AAP recommends routine history, All children who had their Medical records from For each type of clinical Starfield physical examination, screening tests, and second birthday during the physicians’ offices, setting, the study reports et al., 1994 anticipatory guidance throughout first half of the study year, community health centers, the average percentage of childhood (AAP, 1988). and all 2-year-olds with and hospital outpatient technical quality indicators otitis media or asthma, from facilities sampled from for well-child care that a sample of 2,024 patients Maryland Medicaid claims were not met. Each average of 135 providers. data, 1988. fell in the 35%–65% range. Well-Adult Care Patients should have preventive health All adults with asthma, Same as above. For each type of clinical Starfield visits every 1–3 years when 19–64 years hypertension, and diabetes setting, the study reports et al., 1994 old and every year when ≥ 65 years old from a sample of 2,024 the average percentage of (USPSTF, 1989). patients of 135 providers. technical quality indicators for well-adult care that were not met. Each average fell in the 45%–55% range. continues 257

TABLE A-1 Continued 258 Health Care Servicea Sample Description Data Source Quality of Care Referenceb ACUTE CARE Pneumonia Pneumonia: Hospital Care Includes documentation of tobacco use/ 1,408 patients hospitalized Medical records for 52%–90% of patients with Kahn et al., nonuse and lower-extremity edema; blood with pneumonia from a Medicare patients from 297 pneumonia received 1990 pressure readings; oxygen therapy or nationally representative hospitals in five states appropriate components of intubation for hypoxic patients. sample of 7,156 patients (California, Florida, care. hospitalized with any of Indiana, Pennsylvania, five conditions (congestive Texas), July 1, 1985, to heart failure, acute June 30, 1986. myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990). Includes various components of 1,343 patients ≥ 65 years National Medicare claims 89% had oxygenation Meehan pneumonia care consistent with prevailing old hospitalized with data and medical records, assessment within 24 hours et al., 1997 standards of care. pneumonia. October 1, 1994, to of hospital arrival, 76% September 30, 1995 received antibiotics within 8 hours of arrival, 69% had blood cultures within 24 hours of arrival, and 57% had blood cultures collected before initial antibiotic administration.

Otitis Media Otitis Media: Treatment Includes various components of otitis 464 children ≥ 3 years old Medical records from For each type of clinical Starfield media care consistent with prevailing diagnosed with otitis media physicians’ offices, setting, the study reports et al., 1994 standards of care. from a sample of 2,024 community health centers, the average percentage of patients of 135 providers. and hospital outpatient technical quality indicators facilities sampled from for otitis media that were Maryland Medicaid claims not met. Each average fell data, 1988. in the 10%–40% range. Hip Fractures Hip Fracture: Hospital Care Includes documentation of mental status 1,404 patients hospitalized Medical records for 67%–94% of patients with Kahn et al., and pedal or leg pulse, serum potassium with hip fracture from a Medicare patients from 297 hip fracture received 1990 level, electrocardiogram. nationally representative hospitals in five states appropriate components of sample of 7,156 patients (California, Florida, care. hospitalized with any of Indiana, Pennsylvania, five conditions (congestive Texas), July 1, 1985, to heart failure, acute June 30, 1986. myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990). Urinary Tract Infections Urinary Tract Infections: Diagnosis The provision of a urine culture in 535 episodes of UTI from Medicaid claims from 52% received a urine Bronstein diagnosing a urinary tract infection (UTI) 465 children who received Alabama, July 1, 1989, to culture. et al., 1997 is consistent with prevailing standards of ambulatory care for UTIs June 30, 1993. care. out of a sample of 147,356 children < 8 years old with continues 259

TABLE A-1 Continued 260 Health Care Servicea Sample Description Data Source Quality of Care Referenceb continuous Medicaid coverage (exclusive of children with Medicaid because of Supplemental Security Income) for all 12 months of 1992. Pregnancy and Delivery Prenatal Care: Medical History, Physical Examination, and Laboratory Tests Includes various components of prenatal 9,924 women who had live National Maternal and 80% were asked about Kogan et al., care consistent with prevailing standards births in 1988 from a Infant Health Survey health history during the 1994 of care. nationally representative (NMIHS), 1988. first or second visit. 98% sample of the U.S. had their weight and height population (excluding South measured, 96% had blood Dakota and Montana, and pressure measured, and including the District of 86% received a physical or Columbia). pelvic examination during the first or second visit. 79% received blood tests and 93% received urinalysis during the first or second visit. 56% received all of the evaluations listed above during the first or second visit.

Prenatal Care: Counseling About Nutrition, Weight Gain, Substance Use, and Breastfeeding Includes various components of prenatal Same as above. Same as above. 97% were counseled about Kogan et al., care consistent with prevailing standards vitamins, 93% were 1994 of care. counseled about diet, and 72% were counseled about proper weight gain during pregnancy during at least one prenatal visit. 68% were counseled to reduce or eliminate alcohol consumption, 69% to reduce or eliminate smoking, and 65% to stop use of illegal drugs during at least one prenatal visit. 53% were counseled about breastfeeding during at least one prenatal visit. 32% received all of the counseling listed above during at least one prenatal visit. Prenatal Care: Screening Tests Includes tests to screen for anemia, Random sample of 586 Medical records for Among six HMOs, women Murata asymptomatic bacteriuria, syphilis, women who had a live birth patients from six HMOs in received 64%–95% et al., 1994 gonorrhea, hepatitis B, rubella immunity, from 24,170 births that six states (Arizona, (average 82%) of seven and Rh factor and antibody. occurred during the study California, Colorado, recommended routine period. Massachusetts, Minnesota, prenatal screening tests. Oregon), August 1, 1989, to July 31, 1990. continues 261

TABLE A-1 Continued 262 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Prenatal Care: Other Routine Prenatal Care Includes first prenatal visit during first Same as above. Same as above. Among six HMOs, women Murata trimester, accurate determination of received 78%–87% et al., 1994 gestational age, screening for inherited (average 84%) of five disorders, measurement of symphysis- processes of routine fundal height, and blood pressure prenatal care. measurement. Prenatal Care: Pregnancy Complications Includes diagnostic and treatment Same as above. Same as above. Among six HMOs, women Murata interventions after abnormal screening test received 54%–77% et al., 1994 results, and care to mitigate effects of of care for complications pregnancy-induced hypertension and of pregnancy. gestational diabetes. Prenatal Care: Proteinuria Urine is checked for protein to evaluate Inpatient records for 2,336 Medical records for Testing was provided at Carey et al., for the presence of preeclampsia, a serious women from a sample of patients sampled from 75%–83% of visits. 1991 complication of pregnancy. 2,878 births in 1985; Medicaid claims files for Follow-up was performed prenatal care records for women and children for 41%–65% of patients 823 of these women. enrolled in Aid to Families with proteinuria. with Dependent Children (AFDC) in two communities in California and two communities in Missouri, 1985.

Prenatal Care: Recording of Gestational Age Includes a component of prenatal care Same as above. Same as above. Gestational age was Carey et al., consistent with prevailing standards of recorded at 78%–95% of 1991 care. visits. Prenatal Care: Assessment of Fetal Heart Tones after 18 Weeks of Gestation Includes a component of prenatal care Same as above. Same as above. Fetal heart tones were Carey et al., consistent with prevailing standards of assessed at 81%–93% of 1991 care. visits. Prenatal Care: Follow-up for Low Hematocrit Low hematocrit indicates anemia. Same as above. Same as above. Follow-up was performed Carey et al., for 32%–51% of patients 1991 with low hematocrit. Prenatal Care: Follow-up for High Blood Pressure Includes a component of prenatal care Same as above. Same as above. Follow-up was performed Carey et al., consistent with prevailing standards of for 31%–53% of patients 1991 care. with high blood pressure. Prenatal Care: Physical Examination Includes various components of prenatal 267 women receiving Medical records from seven 99% had blood pressure Klinkman care consistent with prevailing standards routine, low-risk prenatal private and hospital-based assessed at each visit. 93% et al., 1997 of care. care were randomly prenatal care sites in had fundal height assessed selected, with stratification Washtenaw County, at each visit after 20 weeks by insurance type Michigan, for women gestation. (Medicaid, health receiving care between maintenance organization, January 1, 1991, and fee-for-service). December 31, 1992. continues 263

TABLE A-1 Continued 264 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Prenatal Care: Laboratory Screening Tests Includes various components of prenatal Same as above. Same as above. Patients received an Klinkman care consistent with prevailing standards average of 81%–83% et al., 1997 of care. (depending on insurance type) of recommended laboratory screening tests. Delivery: Neonatal Group B Streptococcal (GBS) Disease The American College of Obstetricians and 81 women with ROM ≥ 18 Medical records from two 88% received an antibiotic Lieu et al., Gynecologists recommends intrapartum hours from among all HMO hospitals (in which effective against GBS, 37% 1998 antibiotics for women with rupture of women with deliveries protocols similar to ACOG received antibiotics within membranes (ROM) for 18 hours or more during the study period. guidelines had been 20 hours of ROM (median to prevent neonatal Group B Streptococcal adopted) in San Francisco duration of ROM was 31 (GBS) infection (ACOG, 1993, 1996). and Oakland, California, hours). for women who delivered from January to June 1995. CHRONIC CARE Asthma Adult Asthma Care Includes various components of asthma Adults ≥ 18 years old in a Medical records from For each type of clinical Starfield care consistent with prevailing standards group of 393 adults and physicians’ offices, setting, the study reports et al., 1994 of care. children diagnosed with community health centers, the average percentage of asthma, from a sample of and hospital outpatient technical quality indicators 2,024 patients of 135 facilities sampled from for adult asthma that were providers. Maryland Medicaid claims not met. Each of the data, 1988. averages was located in the 40%–45% range. Between 5% and 35% of care was inappropriate.

Childhood Asthma Care Includes various components of asthma Children < 18 years old in Same as above. For each type of clinical Starfield care consistent with prevailing standards a group of 393 adults and setting, the study reports et al., 1994 of care. children diagnosed with the average percentage of asthma, from a sample of technical quality indicators 2,024 patients of 135 for childhood asthma that providers. were not met. Each of the averages was located in the 30%–40% range. Between 0% and 20% of care was inappropriate. Asthma Care Includes various components of asthma 5,580 patients ≥ 14 years Survey of patients from 72% of patients with severe Legorreta care consistent with prevailing standards old who were prescribed multiple sites of a health asthma had a steroid et al., 1998 of care. asthma medications. maintenance organization inhaler, 26% of patients in California, 1996. needing daily medications had a peak flow meter at home, and 42% were advised about self- management tools. Diabetes Mellitus Diabetes Mellitus: Dilated Eye Examination Annual dilated eye examination to screen 2,392 adults ≥ 18 years old NHIS, 1989. 49% had a dilated eye Brechner for retinopathy starting at time of with IDDM (124 patients), examination in the prior et al., 1993 diagnosis of non-insulin-dependent NIDDM treated with insulin year; 66% had an diabetes mellitus (NIDDM) and 5 years (922 patients), and NIDDM examination in the prior 2 after diagnosis of insulin-dependent not treated with insulin years; 61% and 57% of diabetes mellitus (IDDM). (1,346 patients) from a patients at high risk of sample of 84,572 people vision loss because of a continues 265

TABLE A-1 Continued 266 Health Care Servicea Sample Description Data Source Quality of Care Referenceb representative of the U.S. history of retinopathy or of civilian, noninstitutionalized long duration of diabetes, population. respectively, had an examination in the prior year. Diabetes Mellitus: Any Eye Examination Dilated eye examination is recommended, Same as above. Same as above. 61% had an eye Brechner as described above, but any eye examination in the prior et al., 1993 examination is also reported to determine year; 79% had an whether there was any effort to assess for examination in the prior retinopathy. 2 years. Diabetes Mellitus: Eye Exam by Ophthalmologist Dilated eye examination is recommended, 97,388 Medicare patients All Medicare claims data 54% did not have an Weiner as described above, but an examination by ≥ 65 years old diagnosed (Parts A and B) from three examination by an et al., 1995 an ophthalmologist serves as a proxy for a with diabetes mellitus. states (Alabama, Iowa, ophthalmologist during the dilated eye examination. Maryland), submitted from prior year. July 1, 1990, to June 30, 1991. Diabetes Mellitus: Physical Examination Includes various components of diabetes 292 patients ≥ 65 years old National Medicare 92%–96% had their weight Retchin and care consistent with prevailing standards with diabetes mellitus. Competition Evaluation, recorded at least once after Preston, of care. with medical records from diagnosis. 70% (for both 1991 8 HMOs and 113 fee-for- HMO and FFS providers) service providers for had a peripheral vascular patients drawn from examination. 94%–96% had

enrollment lists of patients blood pressure recorded at with start-up dates between least annually. 30%–48% January 1983, and May had a funduscopic 1984; records were examination or referral to abstracted from the start-up an ophthalmologist within date to March 31, 1986. 2 years of diagnosis. 58%– 63% had tonometry performed. Diabetes Mellitus: Hemoglobin A1C 97,388 Medicare patients All Medicare claims data 84% did not receive a Weiner Hemoglobin A1C (or glycosylated ≥ 65 years old diagnosed (Parts A and B) from three hemoglobin A1C test et al., 1995 hemoglobin) is a blood test that reflects with diabetes mellitus. states (Alabama, Iowa, during the prior year. the metabolic control of diabetes. The test Maryland), submitted from should be performed at least once a year July 1, 1990, to June 30, for diabetics. 1991. Diabetes Mellitus: Cholesterol Screening Same as above. Same as above. 45% did not receive blood Weiner It is recommended that total cholesterol be cholesterol screening et al., 1995 measured at least once a year for diabetics. during the prior year Diabetes Mellitus: Laboratory Studies and Follow-ups Includes various components of diabetes 292 patients ≥ 65 years old National Medicare 74%–89% had urinalysis Retchin and care consistent with prevailing standards with diabetes mellitus. Competition Evaluation, performed. 75%–95% had Preston, of care. with medical records from creatinine or serum urea 1991 8 HMOs and 113 fee-for- nitrogen determined at least service providers for annually after diagnosis. patients drawn from 82%–83% had an enrollment lists of patients electrocardiogram with start-up dates between performed within 6 months January 1983, and May of diagnosis. 91%–95% had 1984; records were at least one repeated blood continues 267

TABLE A-1 Continued 268 Health Care Servicea Sample Description Data Source Quality of Care Referenceb abstracted from the start-up glucose within 12 months date to March 31, 1986. of diagnosis. 84%–90% who were not taking insulin had blood glucose recorded at least every 12 months. 74% (for both HMO and FFS providers) who were taking insulin had blood glucose recorded at least every 6 months. Diabetes Mellitus: Influenza Vaccine Includes diabetes care consistent with Same as above. Same as above. 19%–62% received an Retchin and prevailing standards of care. influenza vaccination. Preston, 1991 Diabetes Mellitus Includes various components of diabetes 368 adults ≥ 18 years old Medical records from For each clinical setting, Starfield care consistent with prevailing standards diagnosed with diabetes, physician offices, the study reports the et al., 1994 of care. from a sample of 2,024 community health centers, average percentage of patients of 135 providers. and hospital outpatient technical quality indicators facilities sampled from for diabetes that were not Maryland Medicaid claims met. Each average was data, 1988. located in the 40%–60% range.

Peptic Ulcer Disease Peptic Ulcer Disease: Treatment People with H. pylori peptic ulcer disease About 3,571 Medicaid Computerized inpatient, 11% of patients received Thamer (PUD) should be prescribed antimicrobial beneficiaries ≥ 18 years old outpatient, and antimicrobials within five et al., 1998 therapy for the infection, as strongly who received care for PUD pharmaceutical claims files days of a PUD encounter. recommended by the National Institutes of and who were not receiving of the Pennsylvania Health Consensus Development nonsteroidal Medicaid Program, March Conference in February 1994. antiinflammatory drugs. 1994, to February 1996. Hypertension Hypertension: Treatment Hypertension (high blood pressure) is a 246 patients > 30 years old Medical records for 41%–54% of patients had Udvarhelyi leading risk factor for coronary heart with chronic uncomplicated patients from four group their hypertension et al., 1991 disease, congestive heart failure, stroke, hypertension. practices in Massachusetts, controlled (mean blood ruptured aortic aneurysm, renal disease, November 1, 1985, to pressure < 150/90). and retinopathy, all of which contribute to October 31, 1987. high morbidity and mortality (U.S. Preventive Services Task Force, 1989). This was reiterated in 1996 (U.S. Preventive Services Task Force, 1996). Same as above. Nationally representative National Health and 55% of people with Joint sample of U.S. adults with Nutrition Examination hypertension had blood National hypertension (sample size Survey III, 1988–1991. pressure under control Committee not available). (blood pressure < 160/95 on on one occasion and Detection, reported currently taking 1993 antihypertensive medications); 21% when using strict criteria (blood pressure < 140/90 and reported currently taking antihypertensive medications). continues 269

TABLE A-1 Continued 270 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Same as above. 8,697 adults ≥ 18 years old NHIS, 1990. 89% of adults with CDC, 1994b diagnosed with hypertension received hypertension from a sample advice from a physician of 36,610 people about controlling representative of the U.S. hypertension (i.e., taking population. antihypertensive medication, decreasing salt intake, losing weight, or exercising); 80% reported taking at least one action to control hypertension. Same as above. 593 adults ≥ 18 years old Medical records from For each type of clinical Starfield diagnosed with physician offices, setting, the study reports et al., 1994 hypertension, from a community health centers, the average percentage of sample of 2,024 patients of and hospital outpatient technical quality indicators 135 providers. facilities sampled from for hypertension that were Maryland Medicaid claims not met. Each average fell data, 1988. in the 40%–55% range. Mental Health Depression: Detection Includes diagnostic criteria consistent with 650 patients with current Medical Outcomes Study in 44%–51% of depressed Wells et al., prevailing standards of care. depressive disorder from a three cities (Boston, patients who visited general 1989 sample of 22,462 adult Chicago, Los Angeles); medical clinicians had their patients who visited one questionnaires completed depression detected during large HMO; several February to October 1986; the visit. 78%–94% of

multispecialty, mixed-group phone interviews completed depressed patients who practices; single-specialist May to December 1986. visited mental health small group practices; or specialists had their solo practice providers in depression detected during each city during the study the visit. period. Depression: Treatment Includes various components of depression Same as above. Same as above. 50%–58% of depressed Wells et al., care consistent with prevailing standards patients who visited general 1989 of care. medical clinicians received appropriate care (the depression was detected, and they were counseled or referred to a mental health specialist or another clinician was noted to be providing the majority of the patient’s care). 83%– 93% of depressed patients who visited mental health specialists received appropriate care. Depression: Admission Assessment Includes various components of depression 1,198 patients hospitalized Medical records for As part of admission Wells et al., care consistent with prevailing standards with depression, Medicare patients from 297 assessment, 23% of patients 1993 of care. representative of all hospitals in five states did not have adequate Medicare elderly patients (California, Florida, psychological assessment, hospitalized in general Indiana, Pennsylvania, 26% did not have cognitive medical hospitals with a Texas), July 1, 1985, to assessment, 50% did not discharge diagnosis of June 30, 1986. have assessment of continues 271

TABLE A-1 Continued 272 Health Care Servicea Sample Description Data Source Quality of Care Referenceb depression. psychosis, 19% did not have documentation of psychiatric history, 47% did not have documentation of whether patient had a history of suicide attempts or ideation, 24% did not have documentation of prior or current medication use, and 45% did not have documentation that heart sounds were examined. Mean number of components of neurologic examination (assessment of pupils, deep tendon reflexes, and gait) performed was 1.4. Mental/Addictive Disorder Includes diagnostic criteria and treatment People with mental or National Institute of Mental 29% of people with any Regier et al., consistent with prevailing standards of addictive disorder from a Health’s Epidemiologic mental or addictive 1993 care. sample of 20,291 adults Catchment Area study disorder received some ≥ 18 years old. interviews, 1980–1985. professional or voluntary mental health service during the prior 12 months, as did 32% of people with any disorder except

substance use, 37% of people with any mental disorder with comorbid substance use, 24% of people with substance use (e.g., alcohol), 64% of people with schizophrenia, 46% of people with any affective disorder (e.g., depression), 33% of people with any anxiety disorder (e.g., obsessive-compulsive), 70% of people with somatization, 31% of people with antisocial personality disorder, and 17% of people with severe cognitive impairment. Schizophrenia: Treatment Includes various components of 224 patients from a random Patient interviews and 70% of patients with Young schizophrenia care consistent with sample of patients 18–65 medical records from a significant psychotic et al., 1998 prevailing standards of care. years old with schizophrenia Veterans Affairs Medical symptoms received poor or schizoaffective disorder Center clinic and a management of their who had been treated at the community mental health symptoms, and 79% of clinic for >3 months, had center clinic during a patients with significant been hospitalized < 21 days 3-month period in early medication side effects during the prior 3 months, 1996. (akathisia, parkinsonism, and had >1 visit with a tardive dyskinesia) received psychiatrist during the poor management of the sampling period. side effects. 35% of patients with severe continues 273

TABLE A-1 Continued 274 Health Care Servicea Sample Description Data Source Quality of Care Referenceb disability were not receiving case management. 57% of patients in close contact with family members had no communication between the clinic and the family. Cancer Breast Cancer: Diagnosis Patients with breast cancer have better 5,766 newly diagnosed Data submitted to American The average rate across Hand et al., outcomes if diagnosis is made at an early patients with histologically Cancer Society, Illinois hospitals of patients 1991 stage. confirmed breast cancer. Division, Chicago, by 99 diagnosed with cancer at a hospitals out of 104 Illinois late stage (IIb through IV) hospitals with active cancer was 18%. registries, 1988. Breast Cancer: Diagnosis Patients with breast cancer have better 2,958 newly diagnosed Same as above. The average rate across Hand et al., outcomes if hormone receptor levels in patients with histologically hospitals of patients who 1991 tumor tissue are determined. confirmed Stage II–IV did not have a hormone breast cancer. receptor test was 11%. Diagnosis should be made with fine needle 918 insured women ≤ 64 Data collected by Virginia 92% had initial biopsy Hillner aspiration, cytology, limited incisional years old with local/ Cancer Registry from 50 prior to total mastectomy. et al., 1997 biopsy, or definitive wide local excision. regional invasive breast hospitals that represented cancer Stage I or II. 85% of Virginia hospital beds, and claims data from

Trigon Blue Cross Blue Shield of Virginia, 1989– 1991. Breast Cancer: Treatment Includes various components of breast 199 women 50–69 years old Medical records from seven 67% of women ≥ 70 years Greenfield cancer treatment consistent with prevailing and 175 women ≥ 70 years hospitals in southern old received appropriate et al., 1987 standards of care. old with adenocarcinoma of California, for women with treatment, compared with the breast receiving primary breast cancer diagnosed in 83% of women 50–69 years cancer management at a 1980, to 1982. old. After controlling for participating hospital. comorbidity, hospital, and cancer stage, a difference in appropriateness related to age persisted. Breast conservation, defined as excision of 8,095 women with a first Data from the Seattle-Puget 34% had breast-conserving Lazovich the tumor and surrounding tissue, with primary breast cancer, Sound cancer registry, surgery. et al., 1991 axillary dissection, followed by radiation Stage I or II. which covers cancer cases therapy, was preferable to mastectomy for in 13 western Washington the majority of women with Stage I or II counties and is part of the breast cancer, as supported by clinical Surveillance, Epidemiology, trials and a 1990 NIH Consensus and End Results (SEER) Conference (NIH Consensus Conference, program of the National 1991). Cancer Institute, 1983– 1989. Same as above. 2,657 women with complete Same as above. 85% received radiation records out of 2,731 women therapy. with a first primary breast cancer, Stage I or II, who underwent breast-conserving surgery. continues 275

TABLE A-1 Continued 276 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Same as above. 4,311 newly diagnosed Data submitted to American The average rate across Hand et al., patients with histologically Cancer Society, Illinois hospitals of patients who 1991 confirmed Stage I–II breast Division, Chicago, by 99 did not receive radiotherapy cancer. hospitals out of 104 Illinois after partial mastectomy hospitals with active cancer was 48%. registries, 1988. Same as above. 918 insured women ≤ 64 Data collected by Virginia 86% received local breast Hillner years old with local/regional Cancer Registry from 50 radiation following et al., 1997 invasive breast cancer Stage hospitals that represented lumpectomy. I or II. 85% of Virginia hospital beds and claims data from Trigon Blue Cross Blue Shield of Virginia, 1989– 1991. Patients with breast cancer have better 2,248 newly diagnosed Data submitted to American The average rate across Hand et al., outcomes if adjuvant therapy is given to patients with histologically Cancer Society, Illinois hospitals of patients who 1991 patients with Stage II neoplasms. confirmed Stage II breast Division, Chicago, by 99 did not receive adjuvant cancer. out of 104 Illinois hospitals therapy was 44%. with active cancer registries, 1988. Premenopausal, node-positive women with 918 insured women ≤ 64 Data collected by Virginia 83% of premenopausal Hillner local/regional breast cancer should receive years old with local/ Cancer Registry from 50 women with at least one et al., 1997 adjuvant chemotherapy. regional invasive breast hospitals that represented positive axillary node cancer Stage I or II. 85% of Virginia hospital received adjuvant beds, and claims data from chemotherapy.

Trigon Blue Cross Blue Shield of Virginia, 1989, to 1991. Patients with breast cancer have better 4,311 newly diagnosed Data submitted to American The average rate across Hand et al., outcomes if axillary lymph node dissection patients with histologically Cancer Society, Illinois hospitals of patients who 1991 is done as part of the surgical treatment confirmed Stage I-II breast Division, Chicago, by 99 did not have a lymph node with Stage I and II neoplasms. cancer hospitals out of 104 Illinois dissection was 9%. hospitals with active cancer registries, 1988 Same as above. 918 insured women ≤ 64 Data collected by Virginia 88% underwent axillary Hillner years old with local/ Cancer Registry from 50 node dissection. et al., 1997 regional invasive breast hospitals that represented cancer Stage I or II. 85% of Virginia hospital beds, and claims data from Trigon Blue Cross Blue Shield of Virginia, 1989– 91. Women with early stage breast carcinoma 1,292 women who Medical records, patient 84%–86% received Guadagnoli (TNM Stages I and II) who undergo underwent breast-conserving surveys, and physician radiation therapy after et al., 1998 breast-conserving surgery should then surgery from a sample of surveys for patients from breast-conserving surgery. receive radiation therapy. 2,575 women with early- 18 Massachusetts hospitals stage breast carcinoma, from a stratified random excluding patients for whom sample of 20, from national recommendations September 1993, to were not likely to apply. September 1995, and from 30 Minnesota hospitals, from January 1993, to December 1993. continues 277

TABLE A-1 Continued 278 Health Care Servicea Sample Description Data Source Quality of Care Referenceb For early-stage breast carcinoma (TNM 2,559 women who had Same as above. 81%–94% underwent Guadagnoli Stages I and II), axillary lymph node axillary lymph node axillary lymph node et al., 1998 dissection should be performed. dissection from a sample of dissection. 2,575 women with early- stage breast carcinoma, excluding patients for whom national recommendations were not likely to apply. For early-stage breast carcinoma (TNM 228 premenopausal women Same as above. 94%–97% received Guadagnoli Stages I and II), premenopausal women with positive lymph nodes chemotherapy. et al., 1998 with positive lymph nodes should receive from a sample of 2,575 chemotherapy. women with early-stage breast carcinoma, excluding patients for whom national recommendations were not likely to apply. For early-stage breast carcinoma (TNM 168 postmenopausal women Same as above. 59%–63% received Guadagnoli Stages I and II), postmenopausal women with positive lymph nodes hormonal therapy. et al., 1998 with positive lymph nodes and positive and positive estrogen estrogen receptor status should receive receptor status from a hormonal therapy. sample of 2,575 women with early-stage breast carcinoma, excluding patients for whom national recommendations were not likely to apply.

Breast Cancer: Follow-up Annual mammography is appropriate for 918 insured women ≤ 64 Data collected by Virginia 79% of women had a Hillner women who have had local/regional breast years old with local/regional Cancer Registry from 50 mammogram within the et al., 1997 cancer. invasive breast cancer Stage hospitals that represented first 18 months I or II. 85% of Virginia hospital postoperatively. beds, and claims data from Trigon Blue Cross Blue Shield of Virginia, 1989– 1991. Cardiovascular Disease Cardiovascular Disease: Blood Cholesterol Testing Clinical trials have shown a 30%–50% 603 patients 27–70 years Physician survey, patient 96% had total cholesterol McBride reduction in morbidity and mortality rates old with CVD. survey, and medical records levels, 67% had LDL et al., 1998 with management of cholesterol levels for from 159 physicians in 45 values, 90% had patients with cardiovascular disease primary care practices in triglyceride levels, and (CVD). The Adult Treatment Panel and around four midwestern 75% had HDL levels (ATP-II) of the National Cholesterol cities: Eau Claire, recorded in the past 5 Education Program recommended Wisconsin; Iowa City, years. 72% with LDL management of cholesterol in patients with Iowa; Madison, Wisconsin; > 130 mg/dL had received CVD with goals of LDL level < 100 Minneapolis, Minnesota; diet counseling, and 42% mg/dL and triglyceride level < 200 mg/dL August 1993, to February had received cholesterol- (NCEP, 1993). 1995. lowering medication; 58% with LDL 100–130 mg/dL had received diet counseling, and 42% had received cholesterol- lowering medication. continues 279

TABLE A-1 Continued 280 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Coronary Artery Disease: Coronary Angiography Coronary angiography is a method for 352 patients who met Medical records from four 43% of patients received Laouri et al., evaluating coronary artery anatomy to explicitly defined criteria teaching hospitals (three coronary angiography 1997 determine whether a patient is a candidate for necessity of coronary public, one private) in Los within 3 months of the for coronary artery bypass graft surgery or angiography, from among Angeles, California and positive exercise stress test; percutaneous transluminal coronary 1,350 positive exercise patient telephone interviews 56% received coronary angioplasty. stress tests in a randomly (with 243 of the 352 angiography within 12 selected sample of 5,850 patients), January 1, 1990, months of the positive test. stress tests. to June 30, 1991. Myocardial Infarction (MI): Treatment with Aspirin Aspirin is an effective, inexpensive, and 7,917 Medicare patients ≥ Medical records for 64% received aspirin Krumholz safe treatment for a heart attack. Aspirin 65 years old hospitalized Medicare beneficiaries who within the first 2 days of et al., 1995 therapy reduces short-term mortality in with heart attack who were were hospitalized in four hospitalization. patients with suspected heart attack by “ideal” candidates for states (Alabama, 23%. Aspirin should not be given to treatment with aspirin, with Connecticut, Iowa, patients with certain conditions (e.g., no possible contraindications Wisconsin), as part of the hemorrhagic stroke, gastrointestinal to aspirin therapy. Cooperative Cardiovascular bleeding). Project Pilot, June 1, 1992, to February 28, 1993. Same as above. 5,490 Medicare patients ≥ Same as above. 76% were discharged with Krumholz 65 years old hospitalized instructions to take aspirin. et al., 1996 with heart attack who were Patients who were alive at discharge and who prescribed aspirin at had no contraindications to discharge had a 6-month aspirin therapy. mortality rate of 8.4%, compared with 17% for

patients not prescribed aspirin. Same as above. 7,486 patients who were Same as above. 83% received aspirin Ellerbeck “ideal” candidates for during hospitalization; 77% et al., 1995 treatment with aspirin received aspirin prior to or during initial hospitalization at time of discharge. from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack; 5,841 patients who were alive at discharge and who were “ideal” candidates for treatment with aspirin prior to or at time of discharge, from the same sample. Same as above. 187 patients with confirmed Medicare mortality data 73% received aspirin at Meehan heart attack who were alive issued by the Health Care time of discharge. et al., 1995 at discharge and who had Financing Administration no contraindications to (HCFA) and medical aspirin therapy from a records for Medicare sample of 300 Medicare patients from six hospitals patients ≥ 65 years old in Connecticut, as part of hospitalized with a principal the Medicare Hospital diagnosis of heart attack. Information Project, October 1, 1988, to September 30, 1991. continues 281

TABLE A-1 Continued 282 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Same as above. Subset of 2,938 patients Medical records from 16 The median percentage of Soumerai with admitting diagnosis of Minnesota hospitals for eligible patients ≥ 65 years et al., 1998 MI. patients admitted August 1, old receiving aspirin in the 1995, to April 30, 1996. first 48 hours of hospitalization was 77%. Unstable Angina: Treatment with Aspirin Same as above. 384 patients who were Medical records and 72% received aspirin on Krumholz “ideal” candidates for administrative data for admission (66% in 1993– et al., 1998 treatment with aspirin on patients with Medicare 1994 and 82% in 1995). admission and 321 who from three Connecticut 65% were prescribed were “ideal” candidates for hospitals, 1993–1995. aspirin at discharge (66% aspirin at discharge, from a in 1993–1994 and 79% in sample of 450 patients ≥ 65 1995). years old hospitalized with unstable angina. Unstable Angina: Treatment with Aspirin Same as above. 735 patients who were Medical records of 76% received aspirin Simpson “ideal” candidates for Medicare beneficiaries during their hospital stay. et al., 1997 treatment with aspirin discharged from 16 67% were prescribed during hospitalization and hospitals in North Carolina aspirin at discharge. 531 who were “ideal” between October 1, 1993, candidates for aspirin at and September 30, 1994. discharge, from a sample of 882 patients ≥ 65 years old with unstable angina.

Same as above. 2,392 patients who were Medical records from acute 87% received aspirin Berger “ideal” candidates for care hospitals in Maryland during their stay. 77% et al., 1998 aspirin during and the District of received aspirin at hospitalization and 1,387 Columbia in Medicare’s discharge. who were “ideal” National Claims History candidates for aspirin at File sampled during discharge, from a sample of January 1994, to July 1995. 4,300 patients with MI. MI: Treatment with Thrombolytics Thrombolytics are medications that break 1,105 patients who were Medical records for 70% received thrombolytics Ellerbeck down some of the acute blockage in the “ideal” candidates for Medicare beneficiaries who during hospitalization. et al., 1995 blood vessels that causes a heart attack, treatment with thrombolytic were hospitalized in four thereby reducing infarct size and limiting agents from a sample of states (Alabama, left ventricular dysfunction. Thrombolytics 16,124 Medicare patients Connecticut, Iowa, have been shown to reduce post-MI hospitalized with a principal Wisconsin), as part of the mortality by as much as 25%, though they diagnosis of heart attack. Cooperative Cardiovascular should not be given to patients with certain Project Pilot, June 1, 1992, conditions (e.g., recent hemorrhagic to February 28, 1993. stroke). Same as above. 68 patients with confirmed Medicare mortality data 43% received thrombolytics Meehan heart attack who had no issued by HCFA and during hospitalization et al., 1995 contraindications to medical records for thrombolytic therapy, and Medicare patients from 6 who had electrocardio- hospitals in Connecticut, as graphic indications for part of the Medicare thrombolytic therapy, from Hospital Information a sample of 300 Medicare Project, October 1, 1988, to patients ≥ 65 years old September 30, 1991. continues 283

TABLE A-1 Continued 284 Health Care Servicea Sample Description Data Source Quality of Care Referenceb hospitalized with a principal diagnosis of heart attack. Same as above. 245 patients who were Medical records from acute 60% received thrombolytics Berger “ideal” candidates for care hospitals in Maryland within 1 hour after arrival. et al., 1998 thrombolytics in the first and the District of hour of arrival from a Columbia in Medicare’s sample of 4,300 patients National Claims History with MI. File sampled during January 1994, to July 1995. Same as above. Subset of 2,938 patients Medical records from 16 The median percentage of Soumerai with admitting diagnosis of Minnesota hospitals for eligible patients ≥ 65 years et al., 1998 MI. patients admitted August 1, old receiving thrombolytics 1995, to April 30, 1996. in the first 48 hours of hospitalization was 55%. MI: Reperfusion (Thrombolysis/Percutaneous Transluminal Coronary Angioplasty [PTCA]) PTCA uses a miniature balloon catheter to 398 patients who were Medical records from acute 64% received reperfusion Berger decrease stenosis (blockage) in blood considered “ideal” care hospitals in Maryland therapy (thrombolysis/ et al., 1998 vessels supplying the heart. (Thrombolysis candidates for reperfusion and the District of PTCA) within 12 hours of is described above.) from a sample of 4,300 Columbia in Medicare’s arrival at hospital. patients with MI. National Claims History File sampled during January 1994, to June 1995.

MI: Treatment with Heparin Heparin is beneficial to patients with heart 9,857 patients who were Medical records for 69% received heparin Ellerbeck attack, though heparin should not be given “ideal” candidates for Medicare beneficiaries who during hospitalization. et al., 1995 to patients with certain conditions (e.g., treatment with heparin from were hospitalized in four bleeding disorders, stroke). a sample of 16,124 states (Alabama, Medicare patients Connecticut, Iowa, hospitalized with a principal Wisconsin), as part of the diagnosis of heart attack. Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993. Unstable Angina: Treatment with Heparin Same as above. 369 patients who were Medical records and 24% received intravenous Krumholz “ideal” candidates for administrative data for heparin (20% in 1993 to et al., 1998 treatment with heparin, patients with Medicare from 1994 and 32% in 1995). from a sample of 450 three Connecticut hospitals, Of those receiving heparin, patients ≥ 65 years old 1993–1995. 51% had a therapeutic hospitalized with unstable activated partial angina. thromboplastin time (PTT) within 24 hours. Same as above. 91 patients who were Medical records of 63% received heparin Simpson considered “ideal” Medicare beneficiaries administered intravenously. et al., 1997 candidates for heparin discharged from 16 intravenously administered, hospitals in North Carolina from a sample of 882 between October 1, 1993, patients ≥ 65 years old with and September 30, 1994. unstable angina. continues 285

TABLE A-1 Continued 286 Health Care Servicea Sample Description Data Source Quality of Care Referenceb MI: Treatment with Intravenous Nitroglycerin Intravenous nitroglycerin is beneficial to 1,754 patients who were Medical records for 74% received intravenous Ellerbeck patients with heart attack who have “ideal” candidates for Medicare beneficiaries who nitroglycerin during et al., 1995 persistent chest pain, although intravenous treatment with intravenous were hospitalized in four hospitalization. nitroglycerin should not be given to nitroglycerin from a sample states (Alabama, patients with certain conditions (e.g., shock of 16,124 Medicare patients Connecticut, Iowa, or hypotension on admission). hospitalized with a principal Wisconsin), as part of diagnosis of heart attack. Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993. MI: Smoking Cessation Advice Smokers with coronary artery disease who 1,691 smokers who were Same as above. 28% received smoking Ellerbeck stop smoking have a better prognosis than “ideal” candidates for cessation advice prior to or et al., 1995 those who keep smoking; at the time of smoking cessation advice at time of discharge. heart attack, these smokers are most from a sample of 16,124 susceptible to advice about cessation of Medicare patients smoking. hospitalized with a principal diagnosis of heart attack. Same as above. 551 patients who were Medical records from acute 41% received smoking Berger smokers from a sample of care hospitals in Maryland cessation advice. et al., 1998 4,300 patients with MI. and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to July 1995.

Unstable Angina: Smoking Cessation Advice Same as above. 133 patients who were Medical records of 23% received smoking Simpson identified as smokers, from Medicare beneficiaries cessation counseling. et al., 1997 a sample of 882 patients ≥ discharged from 16 65 years old with unstable hospitals in North Carolina angina. between October 1, 1993, and September 30, 1994. MI: Treatment with Angiotensin-Converting Enzyme (ACE) Inhibitors ACE inhibitors can reduce post-MI 1,473 patients who were Medical records for 59% received ACE Ellerbeck mortality in patients with left ventricular “ideal” candidates for Medicare beneficiaries who inhibitors prior to or at et al., 1995 dysfunction, although ACE inhibitors treatment with ACE were hospitalized in four time of discharge. should not be given to patients with inhibitors from a sample of states (Alabama, certain conditions (e.g., aortic stenosis). 16,124 Medicare patients Connecticut, Iowa, hospitalized with a principal Wisconsin), as part of diagnosis of heart attack. Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993. Same as above. 407 patients who were Medical records from acute 65% received ACE Berger considered “ideal” care hospitals in Maryland inhibitors for low ejection et al., 1998 candidates for ACE and the District of fraction (EF). inhibitors from a sample of Columbia in Medicare’s 4,300 patients with MI. National Claims History File sampled during January 1994, to July 1995. Unstable Angina: Treatment with ACE Inhibitors Same as above. 177 patients who were Medical records of 39% received an ACE Simpson considered “ideal” Medicare beneficiaries inhibitor during et al., 1997 candidates for an ACE discharged from 16 hospitalization. 42% continues 287

TABLE A-1 Continued 288 Health Care Servicea Sample Description Data Source Quality of Care Referenceb inhibitor during hospitals in North Carolina received an ACE inhibitor hospitalization and 127 who between October 1, 1993, at discharge. were “ideal” candidates for and September 30, 1994. an ACE inhibitor at discharge, from a sample of 882 patients ≥ 65 years old with unstable angina. MI: Treatment with Beta Blockers Beta blocker therapy can reduce post-MI 2,976 patients who were Medical records for 45% received beta blockers Ellerbeck mortality by as much as 25%, although “ideal” candidates for Medicare beneficiaries who prior to or at time of et al., 1995 beta blockers should not be given to treatment with beta were hospitalized in four discharge. patients with certain conditions (e.g., low blockers from a sample of states (Alabama, left ventricular ejection fraction, 16,124 Medicare patients Connecticut, Iowa, pulmonary edema). hospitalized with a principal Wisconsin), as part of diagnosis of heart attack. Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993. Same as above. 3,737 Medicare patients ≥ New Jersey Medicare 21% received beta blockers Soumerai 65 years old with principal hospital admissions and within 90 days of discharge; et al., 1997 diagnosis of heart attack enrollment data, 1986– adjusted mortality rate for who were eligible for 1992; New Jersey Medicaid patients with treatment was treatment with beta drug utilization and 43% lower than that of blockers, from a statewide enrollment files, 1986– patients without treatment. cohort of 5,332 people who 1991; New Jersey Program had survived a heart attack of Pharmacy Assistance for for at least 30 days and the Aged and Disabled drug

who had prescription drug utilization data, 1986–1991. coverage. Same as above. 104 patients with confirmed Medicare mortality data 41% received beta blockers Meehan heart attack who were alive issued by HCFA and at time of discharge. et al., 1995 at discharge and who had medical records for no contraindications to beta Medicare patients from 6 blockers from a sample of hospitals in Connecticut, as 300 Medicare patients ≥ 65 part of the Medicare years old hospitalized with Hospital Information a principal diagnosis of Project, October 1, 1988, to heart attack. September 30, 1991. MI: Treatment with Beta Blockers Same as above. Subset of 2,938 patients Medical records from 16 The median percentage of Soumerai with admitting diagnosis of Minnesota hospitals for eligible patients receiving et al., 1998 MI. patients admitted August 1, beta blockers in the first 48 1995, to April 30, 1996. hours of hospitalization was 78%. Same as above. 302 patients who were Medical records from acute 60% received beta blockers Berger considered “ideal” care hospitals in Maryland at discharge. et al., 1998 candidates for beta blockers and the District of at discharge from a sample Columbia in Medicare’s of 4,300 patients with MI. National Claims History File sampled during January 1994, to July 1995. Unstable Angina: Treatment with Beta Blockers Same as above. 815 patients who were Medical records of 45% received beta blockers Simpson “ideal” candidates for beta Medicare beneficiaries during hospitalization. et al., 1997 continues 289

TABLE A-1 Continued 290 Health Care Servicea Sample Description Data Source Quality of Care Referenceb blockers during discharged from sixteen 38% received beta blockers hospitalization and 589 who hospitals in North Carolina at discharge. were “ideal” candidates for between October 1, 1993, beta blockers at discharge, and September 30, 1994. from a sample of 882 patients ≥ 65 years old with unstable angina. MI: Hospital Care Includes documentation of examination of 1,437 patients hospitalized Medical records for 64%–68% of patients with Kahn et al., jugular veins and alcoholism/smoking with acute myocardial Medicare patients from 297 acute myocardial infarction 1990 habits. infarction from a nationally hospitals in five states received appropriate representative sample of (California, Florida, components of care. 7,156 patients hospitalized Indiana, Pennsylvania, with any of five conditions Texas), July 1, 1985, to (congestive heart failure, June 30, 1986. acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990). Unstable Angina: Low-Cholesterol Diet Includes care for unstable angina 637 discharged patients Medical records of 38% were prescribed a Simpson consistent with prevailing standards of who were “ideal” Medicare beneficiaries low-cholesterol diet at et al., 1997 care. candidates for a low- discharged from 16 discharge. cholesterol diet, from a hospitals in North Carolina sample of 882 patients ≥ and Septemeber 30, 1994. 65 years old with unstable angina.

Unstable Angina: Lipid-Lowering Drugs Includes care for unstable angina 637 patients who were Same as above. 16% received lipid- Simpson consistent with prevailing standards of “ideal” candidates for a lowering drugs at et al., 1997 care. lipid-lowering drug at discharge. discharge, from a sample of 882 patients ≥ 65 years old with unstable angina. Congestive Heart Failure: Hospital Care Includes documentation of past surgery 1,465 patients hospitalized Same as above. 66%–97% of patients with Kahn et al., and lung examination, blood pressure with congestive heart congestive heart failure 1990 readings, electrocardiogram, serum failure from a nationally received appropriate potassium level, oxygen therapy or representative sample of components of care. intubation for hypoxic patients. 7,156 patients hospitalized with any of five conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990). Stroke: Hospital Care Includes documentation of previous stroke 1,442 patients hospitalized Same as above. 38%–94% of patients with Kahn et al., and gag reflex, blood pressure readings, with stroke from a stroke received appropriate 1990 electrocardiogram, serum potassium level. sample of 7,156 patients components of care. hospitalized with any of five conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990). 291 aIf a description in the first column has no citation, it is covered by the citation in the reference column. bWe contacted the authors of some of the articles to clarify details related to the sample and to the data analysis.

TABLE A-2 Examples of Quality of Acute Health Care in the United States—Overuse: Did Patients Receive Inappropriate 292 Care? Health Care Servicea Sample Description Data Source Quality of Care Referenceb Antibiotic Use Common Cold Almost all colds are caused by a virus, for 1,439 patients with 2,171 Kentucky Medicaid claims In 60% of encounters for Mainous which antibiotics are not an effective outpatient and emergency data, July 1, 1993, to June the common cold, patients et al., 1996 treatment. department visits for the 30, 1994. filled prescriptions for common cold (acute antibiotics. nasopharyngitis) from a random sample of 50,000 patients with at least one claim for care by a physician, dentist, or optometrist. Same as above. Patients ≥ 18 years old with National Ambulatory 51% of patients diagnosed Gonzales a diagnosis of the common Medical Care Survey with a cold were treated et al., 1997 cold, exclusive of adults (NAMCS), 1992. with antibiotics. with underlying lung disease, from a nationally representative sample of 1,529 physicians representing 28,787 adult patient ambulatory care visits.

Same as above. Children ≤ 18 years Same as above. Antibiotics were prescribed Nyquist diagnosed with common at 44% of visits of patients et al., 1998 colds from a total of 531 with common colds pediatric office visits with a primary diagnosis of cold, upper respiratory tract infection (URI), or bronchitis, exclusive of children with underlying lung disease, from a sample representative of the U.S. population. Upper Respiratory Tract Infection Antimicrobial drugs do not shorten the Physicians who participated Same as above. 16% of all antimicrobial McCaig and course of viral URI, nor do they prevent from a nationally drug prescriptions (an Hughes, secondary bacterial infections. representative sample of estimated 17,922,000 1995 3,000 office-based prescriptions nationally) physicians. were written for upper respiratory tract infections in 1992. Same as above. Patients ≥ 18 years old with Same as above. 52% of patients diagnosed Gonzales a diagnosis of URI, with a URI were treated et al., 1997 exclusive of adults with with antibiotics. underlying lung disease, from a nationally representative sample of 1,529 physicians representing 28,787 adult patient ambulatory care visits. continues 293

TABLE A-2 Continued 294 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Same as above. Children ≤ 18 years Same as above. Antibiotics were prescribed Nyquist diagnosed with URIs from at 46% of visits of patients et al., 1998 a total of 531 pediatric with URIs. office visits with a primary diagnosis of cold, URI, or bronchitis, exclusive of children with underlying lung disease, from a sample representative of the U.S. population. Pharyngitis, Nasal Congestion, Common Cold, and Other Upper Respiratory Tract Infections Since most of these conditions are viral, Physicians who participated Same as above. Over 70% of patients Dowell and antibiotics have no benefit. from a nationally received antibiotic Schwartz, representative sample of prescriptions for pharyngitis 1997 3,000 office-based (excluding streptococcal), physicians. over 50% received them for rhinitis, and over 30% received them for a nonspecific URI, cough, or cold.

Bronchitis Most cases of bronchitis are caused by a Patients ≥ 18 years old with Same as above. 66% of patients diagnosed Gonzales virus, for which antibiotics are not an a diagnosis of bronchitis, with bronchitis were treated et al., 1997 effective treatment. exclusive of adults with with antibiotics. underlying lung disease, from a nationally representative sample of 1,529 physicians representing 28,787 adult patient ambulatory care visits. Same as above. Children ≤ 18 years Same as above. Antibiotics were prescribed Nyquist diagnosed with bronchitis at 75% of visits of patients et al., 1998 from a total of 531 pediatric with bronchitis. office visits with a primary diagnosis of cold, URI, or bronchitis, exclusive of children with underlying lung disease, from a sample representative of the U.S. population. Respiratory Illness Pneumonia Hospital admissions for pneumonia are 445 hospital admissions of Medical records for patients 9.4% of admissions were Payne et al., considered appropriate when, for example, children < 18 years old from 12 hospitals in five inappropriate. 1995 a patient fails to improve with outpatient admitted with pneumonia. communities in Boston and oral medication or has a pleural effusion nearby suburbs, July 1, or an empyema. 1985, to June 30, 1986. continues 295

TABLE A-2 Continued 296 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Bronchitis/Asthma Hospital admissions for bronchitis/asthma 1,038 hospital admissions Same as above. 4.4% of admissions were Payne et al., are considered appropriate when, for of children < 18 years old inappropriate. 1995 example, a patient has failed to improve admitted with bronchitis/ with outpatient therapy or has a asthma. pneumothorax. Otitis Media Use of Tympanostomy Tubes Indications for tympanostomy tube 6,429 children < 16 years Interviews with physicians’ 41% of tube insertions were Kleinman placement include refractory middle ear old with recurrent acute office staff at appropriate, 32% equivocal, et al., 1994 infection and chronic mastoiditis. otitis media and/or otolaryngology practices and 27% inappropriate. If persistent otitis media with from 49 states and the extenuating clinical effusion who were insured District of Columbia, circumstances were taken in health plans requiring January 1, 1990, to July 30, into account, 42% of tube precertification by a 1991; additional interviews insertions were appropriate, utilization review firm. were conducted with 35% equivocal, and 23% otolaryngologists to inappropriate. determine the existence of extenuating clinical circumstances.

Depression Depression: Treatment There is no evidence that minor 634 patients with current Medical Outcomes Study 19% of patients were Wells et al., tranquilizers are effective for depression, depressive disorder or (MOS) in three cities treated with minor 1994a but there is evidence that antidepressant depressive symptoms from (Boston, Chicago, Los tranquilizers; 12% were medications are effective for depression. a sample of 22,399 adult Angeles); questionnaires treated with antidepressant patients who visited one completed February to medications; 11% were large HMO or several October 1986; phone treated with a combination multispecialty, mixed-group interviews completed May of minor tranquilizers and practices in each city during to December 1986. antidepressant medications; the study period. 59% received neither. Depression: Admission Appropriate reasons for admission include 1,198 patients hospitalized Medical records for 93% were admitted for Wells et al., depression, medical condition meriting with depression, Medicare patients from 297 clearly or possibly 1993 acute care, comorbid major psychiatric representative of all hospitals in five states appropriate reasons, and 7% disorder, or medical reasons precluding Medicare elderly patients (California, Florida, were admitted for outpatient care for depression. hospitalized in general Indiana, Pennsylvania, inappropriate reasons. medical hospitals with a Texas), July 1, 1985, to discharge diagnosis of June 30, 1986. depression. Hysterectomy Hysterectomy Hysterectomy is the surgical removal of 642 women ≥ 20 years old Medical records for patients 16% of hysterectomies were Bernstein the uterus. who underwent from seven managed care inappropriate, 25% were et al., 1993b nonemergency, organizations, August 1, equivocal, and 58% were nononcologic 1989, to July 31, 1990. appropriate. hysterectomies. continues 297

TABLE A-2 Continued 298 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Cardiovascular Disease Coronary Artery Disease: Coronary Angiography Coronary angiography is a method for Random sample of 1,335 Medical records from 15 4% of coronary Bernstein evaluating coronary artery anatomy to patients who had coronary nonfederal hospitals angiographies were et al., 1993a determine whether a patient is a candidate angiography. providing coronary inappropriate, 20% were for coronary artery bypass graft surgery or angiography in New York equivocal, and 76% were percutaneous transluminal coronary State, selected through a appropriate. angioplasty. stratified random sample (for location, volume of coronary angiography, and authorization to perform coronary artery bypass graft surgery), 1990. Same as above. Random sample of 1,677 Medicare physician claims 17% of coronary Chassin cases of coronary from three sites selected inappropriate, 9% were et al., 1987 angiography. from 13 sites in eight states equivocal, and 74% were (Arizona, California, appropriate. Colorado, Iowa, Massachusetts, Montana, Pennsylvania, South Carolina), 1981.

Coronary Artery Disease: Coronary Artery Bypass Graft (CABG) In CABG surgery, damaged blood vessels Stratified random sample of Medical records from three 14% of CABG surgeries Winslow supplying the heart are replaced with 386 patients who underwent hospitals (excluding were inappropriate, 30% et al., 1988 vessels from elsewhere in the body. CABG surgery in the three Veterans Administration, were equivocal, and 56% hospitals. other governmental, and were appropriate. specialty hospitals) selected through a stratified random sample (for size and teaching status) in a western state as part of the National Institutes of Health Consensus Development Program, 1979, 1980, and 1982 Same as above. Random sample of 1,156 Medical records for patients 1.6% of CABG surgeries Leape et al., patients who had isolated from 12 Academic Medical were inappropriate, 7% 1996 CABG surgery. Center Consortium hospitals were equivocal, and 92% in 10 states (California, were appropriate. Iowa, Louisiana, Maryland, Massachusetts, Minnesota, New Hampshire, New York, North Carolina, Pennsylvania), 1990. Same as above. Random sample of 1,338 Medical records from 15 2.4% of CABG surgeries Leape et al., patients who had isolated nonfederal hospitals were inappropriate, 7% 1993 CABG surgery. providing CABG procedure were equivocal, and 91% in New York State, selected were appropriate. through a stratified random sample (for location and volume of CABG operations), 1990. continues 299

TABLE A-2 Continued 300 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Coronary Artery Disease: Percutaneous Transluminal Coronary Angioplasty (PTCA) PTCA uses a miniature balloon catheter to Random sample of 1,306 Medical records from 15 4% of PTCAs were Hilborne decrease stenosis (blockage) in blood patients who had PTCA. nonfederal hospitals inappropriate, 38% were et al., 1993 vessels supplying the heart. providing PTCA in New equivocal, and 58% were York State, selected appropriate. through a stratified random sample (for location and volume of PTCA), 1990. Myocardial Infarction (MI): Permanent Cardiac Pacemaker Pacemakers help regularize abnormal heart Medicare patients who Medical records from six 20% of pacemaker Greenspan rates and rhythms. underwent a total of 382 university teaching implantations were et al., 1988 pacemaker implantations. hospitals, 11 university- inappropriate, 36% were affiliated hospitals, and 13 equivocal, and 44% were community hospitals in appropriate. Philadelphia County, January 1, to June 30, 1983. MI: Treatment with Lidocaine Lidocaine prophylaxis used to prevent Subset of 2,938 patients Medical records from The median percentage of Soumerai ventricular fibrillation in patients treated with admitting diagnosis of sixteen Minnesota hospitals patients ineligible for et al., 1998 for probable MI has been shown to MI. for patients admitted lidocaine who received it in increase mortality. August 1, 1995, to April the first 48 hours of 30, 1996. hospitalization was 12%.

MI: Avoidance of Calcium Channel Blockers for Patients with a Contraindication Calcium channel blockers should not be 785 patients with clear Medical records for 21% of those for whom Ellerbeck given to patients with certain conditions contraindication to calcium Medicare beneficiaries who calcium channel blockers et al., 1995 (e.g., low left ventricular ejection fraction, channel blockers from a were hospitalized in four were contraindicated evidence of shock, or pulmonary edema sample of 16,124 Medicare states (Alabama, received them. during hospitalization). patients hospitalized with a Connecticut, Iowa, principal diagnosis of heart Wisconsin), as part of the attack. Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993. Same as above. 220 patients with a Medical records from acute 18% of those for whom Berger contraindication for calcium care hospitals in Maryland calcium blockers were et al., 1998 channel blockers (i.e., a left and the District of contraindicated received ventricular ejection fraction Columbia in Medicare’s them. < 40% ) from a sample of National Claims History 4,300 patients with MI. File sampled during January 1994, to July 1995. Unstable Angina: Avoidance of Calcium Channel Blockers for Patients with a Contraindication Same as above. 218 patients with Medical records of 62% of those for whom Simpson contraindications for Medicare beneficiaries calcium blockers were et al., 1997 calcium channel blocking discharged from 16 contraindicated received drugs, from a sample of hospitals in North Carolina them. 882 patients ≥ 65 years old between October 1, 1993, with unstable angina. and September 30, 1994. continues 301

TABLE A-2 Continued 302 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Carotid Arteries Carotid Endarterectomy Carotid endarterectomy is a procedure that Random sample of 1,302 Medicare physician claims 32% of carotid Chassin opens up stenotic (blocked) carotid arteries cases of carotid data and medical records endarterectomies were et al., 1987 (which supply blood to the brain). endarterectomy. from three sites selected inappropriate, 32% were from thirteen sites in eight equivocal, and 35% were states (Arizona, California, appropriate. Colorado, Iowa, Massachusetts, Montana, Pennsylvania, South Carolina), 1981. Gastrointestinal Disease Upper Gastrointestinal Tract Endoscopy Endoscopy enables visualization of the Random sample of 1,585 Same as above. 17% of upper Chassin gastrointestinal tract, and permits biopsy cases of upper gastrointestinal tract et al., 1987 and brush cytologic examination. gastrointestinal tract endoscopies were endoscopy. inappropriate, 11% were equivocal, and 72% were appropriate. Cataracts Cataract Surgery Cataract surgery is a commonly performed 1,020 patients who Medical records for patients 2% of cataract surgeries Tobacman surgery in adults ≥ 65 years old. Cataract underwent a total of 1,139 from 10 academic medical were inappropriate, 7% et al. 1996 surgery should not be performed on people cataract surgeries. centers, 1990. were equivocal, and 91% with certain conditions (e.g., macular were appropriate. degeneration or diabetic retinopathy).

Low Back Pain Chiropractic Spinal Manipulation AHCPR has concluded that spinal A random sample of 10 Medical records of patients Initiation of spinal Shekelle manipulation hastens recovery from acute patients per office (920 from 92 chiropractic offices manipulation was et al., 1998 low back pain not caused by such patients) who sought in or near Miami, Florida; inappropriate in 20%–40% conditions as fracture, tumor, infection, chiropractic care for low Minneapolis-St. Paul, of cases, uncertain in 20%– and cauda equina syndrome (AHCPR, back pain for the first time Minnesota; Portland, 30% of cases, and 1994). during the study period. Oregon; and San Diego, appropriate in 40%–54% of California; who sought care cases (depending on city). for the first time between January 1, 1985, and December 31, 1991. aIf a description in the first column has no citation, it is covered by the citation in the reference column. bWe contacted the authors of some of the articles to clarify details related to the sample and to the data analysis. 303

TABLE A-3 Examples of Quality of Health Care in the United States Misuse: Did Patients Receive Appropriate Care in a 304 Manner That Could Have Caused Harm? Health Care Servicea Sample Description Data Source Quality of Care Referenceb Preventable Deaths Evaluation of preventable deaths A death is considered preventable when 182 patients who died in Medical records for patients 14% of deaths resulted from Dubois and the patient received poor care, and the hospitals from stroke, from 12 hospitals, 1985. inadequate diagnosis or Brook, 1988 poor care probably resulted in the patient’s pneumonia, or heart attack. treatment and could have death. been prevented. Adverse Events Adverse Events An adverse event is an injury that is caused by medical management rather than the underlying disease and that prolongs hospitalization, produces a disability at discharge, or both. 30,121 medical records 51 randomly selected acute There were 1,133 adverse Brennan from a weighted sample of care, nonpsychiatric events and 280 negligent et al., 1991 31,429 records of hospitals in New York events during 1984 hospitalized patients from a State, 1984. admissions, representing a population of 2,671,863 3.7% statewide incidence nonpsychiatric discharged rate of adverse events, and patients. a 1.0% statewide incidence rate of adverse events due to negligence.

Same as above. 30,121 medical records 51 randomly selected acute 17% of adverse events Leape et al., from a weighted sample of care, nonpsychiatric resulting from operations 1991 31,429 records of hospitals in New York and 37% of other adverse hospitalized patients from a State, 1984. events were due to population of 2,671,863 negligence; 47% of nonpsychiatric discharged physician errors leading to patients. adverse events were due to negligence. Adverse Drug Events Same as above. 4,031 adult nonobstetric Medical records and reports There were 1.8 preventable Bates et al., admissions to a stratified of hospital staff for 2 adverse drugs events 1995 random sample of 11 tertiary care hospitals in (ADEs) per 100 admissions medical and surgical units Boston, February to July (adjusted rate), of which in two hospitals. 1993. 20% were life threatening, 43% were serious, and 37% were significant. There were an additional 5.5 potential ADEs per 100 admissions (adjusted rate). Same as above. 4,031 patients admitted to Case-investigation reports There were 19 preventable Cullen 5 intensive care units (3 (including staff interviews, or potential ADEs per 1000 et al., 1997 medical, 2 surgical) and 6 medical record review, etc.) patient days in the ICUs. general care units (4 for patients admitted There were 10 preventable medical, 2 surgical) between February and July or potential ADEs per 1000 selected from a stratified 1993. patient days in general care random sample of units in units. Rates adjusted for 2 tertiary care hospitals in number of medications per Boston. patient showed no significant differences for the two settings. continues 305

TABLE A-3 Continued 306 Health Care Servicea Sample Description Data Source Quality of Care Referenceb Mental Health Depression: Treatment Includes treatment consistent with 1,198 patients hospitalized Medical records for 33% of patients discharged Wells et al., prevailing standards of care. with depression, Medicare patients from with antidepressants had 1994b representative of all 297 hospitals in five states doses below recommended Medicare elderly patients (California, Florida, level. hospitalized in general Indiana, Pennsylvania, medical hospitals with a Texas), July 1, 1985, to discharge diagnosis of June 30, 1986. depression. Includes treatment consistent with 64 patients with major Patient surveys and Among patients with major Simon and prevailing standards of care. depression from a sample interviews, physician depression who received VonKorff, of 2,592 consecutive surveys, and computerized antidepressant medications, 1995 primary care patients 18–65 pharmacy records from 3 78% received dosages years old who attended one primary care clinics of within the recommended of the study clinics. Group Health Cooperative ranges. of Puget Sound in Washington.

Tuberculosis Tuberculosis: Treatment People infected with tuberculosis (TB) in 1,230 culture-positive TB Data from the Tuberculosis 36% of patients were not Liu et al., areas with ≥ 4% isoniazid resistance patients, 98% of whom Control Program, New initially treated with four 1998 should be treated with a four-drug were in counties for which Jersey Department of or more drugs. regimen. a four-drug regimen is Health and Senior Services, recommended. 1994 to 1995. aIf a description in the first column has no citation, it is covered by the citation in the reference column. bWe contacted the authors of some of the articles to clarify details related to the sample and to the data analysis. 307

308 CROSSING THE QUALITY CHASM APPENDIX: Search Strategy for January 1997–July 1998 MEDLINE PLUS Search Medical Subject Heading Boolean Search Type (MeSH) Search Term Tree Numbera Operator Subject Quality of health care N4.761 or Subject Guideline adherence N4.761.337 or Explode exact Outcome and process assessment, N4.761.761.559 subject b health care Subject Professional review organization N4.761.673 or Subject Quality indicators, health care N4.761.789 and Language English and Date 1997, 1998 NOTE: As Boolean operators, “or” means that articles with one search term and/or another search term are included, and “and” means that articles must have both search terms (or strings of search terms) to be included. For this search, articles with any of the Medical Subject Headings (MeSH) were included, and only articles in English and from 1997 or 1998 were included. aTree Number is a National Library of Medicine alphanumerical code for indexing MeSH terms. bThe “Explode” search function includes the MeSH category as well as all the subcategorical branches connected to it. It is equivalent to typing out the MeSH term and each of its subcategorical branches separately. The subcategories included when exploding “Outcome and Process Assess- ment, Health Care” are: Outcome Assessment, Treatment Outcome, Medical Futility, Treatment Failure, and Process Assessment.

Next: Appendix B Redesigning Health Care with Insights from the Science of Complex Adaptive Systems »
Crossing the Quality Chasm: A New Health System for the 21st Century Get This Book
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Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project

Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America.

Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers:

  • A set of performance expectations for the 21st century health care system.
  • A set of 10 new rules to guide patient-clinician relationships.
  • A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality.
  • Key steps to promote evidence-based practice and strengthen clinical information systems.

Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

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