FACT SHEET
Improving Health
Care Quality
A g e n c y f o r H e a l t h c a re R e s e a rc h a n d Q u a l i t y • 2 1 0 1 E a s t J e ff e r s o n S t re e t • R o c k v i l l e , M D 2 0 8 5 2
Every day, millions of Americans variation in health care practice,
receive high-quality health care that including regional variations and
helps to maintain or restore their health small-area variations. This is a clear
and ability to function. However, far indicator that health care practice
too many do not. Quality problems are has not kept pace with the evolving
reflected in a wide variation in the use science of health care to ensure
of health care services, underuse of evidence-based practice in the
www.ahrq.gov some services, overuse of other services, United States.
and misuse of services, including an • Underuse of services. Millions of
AHRQ is the lead Federal agency charged with
unacceptable level of errors. people do not receive necessary care
supporting research designed to improve the
A central goal of health care quality and suffer needless complications
quality of health care, reduce its cost, address that add to costs and reduce
improvement is to maintain what is
patient safety and medical errors, and good about the existing health care productivity. Each year, an
broaden access to essential services. AHRQ system while focusing on the areas that estimated 18,000 people die because
need improvement. Improving the they do not receive effective
sponsors and conducts research that provides
quality of care and reducing medical interventions. For example, a study
evidence-based information on health care of Medicare patients who had
errors are priority areas for the Agency
outcomes; quality; and cost, use, and access. for Healthcare Research and Quality suffered heart attacks found that
The information helps health care (AHRQ). AHRQ is working to develop only 21 percent of eligible patients
decisionmakers—patients and clinicians, health and test measures of quality, identify received beta blockers. The
the best ways to collect, compare, and mortality rate among patients who
system leaders, and policymakers—make more
communicate data on quality, and received beta blockers was 43
informed decisions and improve the quality of percent lower than it was among
widely disseminate information about
health care services. the most effective strategies for nonrecipients. Another AHRQ-
improving the quality of care. funded study examined the use of
beta blockers before heart bypass
surgery and found that patients who
Evidence of Quality Problems received beta blocker therapy before
Several types of quality problems in surgery had lower rates of death and
health care have been documented fewer complications both during
through peer-reviewed research. These and after surgery than patients who
include: did not receive this therapy.
U.S. Department of Health • Variation in services. There • Overuse of services. Each year,
and Human Services continues to be a pattern of wide millions of Americans receive health
Public Health Service
example, a study of injuries to
Outcomes of beta blocker use patients treated in hospitals in New
before bypass surgery York State found that 3.7 percent
experienced adverse events; 13.6
3.4% percent of these events led to death,
2.8% and 2.6 percent led to permanent
disability. About one-fourth of these
adverse events resulted from
negligence. A national study found
that over a 10-year period (1983-
1993), deaths due to medication
errors rose more than two-fold, with
7,391 deaths attributed to
medication errors in 1993 alone.
30-day mortality
with without • Disparities in quality. Although
beta blockers quality problems affect all
populations, they may be most
Ferguson, Coombs, and Peterson. Preoperative
b-blocker use and mortality and morbidity marked for members of ethnic and
following CABG surgery in North America. racial minority populations.
JAMA, 287(17):2221-7, May 2002 Researchers at the University of
Alabama at Birmingham examined
care services that are unnecessary, the use of thrombolysis (“clot
increase costs, and may even busters”) for patients who had
endanger their health. Research has experienced a heart attack and
shown that this occurs across all found that while this evidence-
populations. For example, an based life-saving treatment was
analysis of hysterectomies underused for all, black Medicare
performed on women in seven beneficiaries were significantly less
health plans found that one in six likely than whites to receive this
operations was inappropriate. A treatment.
study examining the use of
antibiotics for treating ear infections Findings from Recent Research
in children on Medicaid found that on Health Care Quality
expensive antibiotics were used far AHRQ and its predecessor agencies—
more often than indicated. the Agency for Health Care Research
According to the findings, if only and Quality and the National Center
half the prescriptions written in for Health Services Research and
1992 for more expensive antibiotics Health Care Technology Assessment—
had been written for amoxicillin, a have been conducting and supporting
less expensive but equally effective research on quality for more than two
antibiotic, Colorado’s Medicaid decades. Following are some examples
program would have saved nearly of findings from recent AHRQ-
$400,000 that year. supported research on quality and
• Misuse of services. Too many quality improvement.
Americans are injured during the • Atrial fibrillation. Thousands of
course of their treatment, and some Medicare patients with atrial
die prematurely as a result. For fibrillation can benefit from a new
2 www.ahrq.gov
HIV patients and their doctors.
AHRQ-supported research demonstrates overuse of preoperative Half of all HIV-infected people in
testing the United States—especially blacks,
A recent study by AHRQ-funded researchers found no differences in outcomes Hispanics, injection drug users, and
between patients who did and did not undergo routine preoperative testing before people with low education—never
cataract surgery. Cataract surgery is the most common operation among the elderly in talk about end-of-life care with their
the United States. In 1996, Medicare beneficiaries had about 1.5 million cataract doctors. Such discussions could
operations. Routine medical testing before cataract surgery is estimated to cost improve physicians’ understanding
Medicare $150 million each year. of the care their patients do and do
not want when they are very ill and
Cataract surgery is usually an outpatient procedure, and rates of illness and death close to death.
associated with the procedure are very low. This large randomized study involved
nearly 20,000 elective cataract operations in 18,189 patients at nine surgical centers. Making Quality Count
The overall rate of complications, both during and after surgery, was the same for both
Following are examples of AHRQ-
groups (31.3 per 1,000 operations). The researchers conclude that routine
supported research now in progress that
preoperative testing confers no benefit on patients having cataract surgery
focuses on improving health care
quality:
quality improvement tool developed by the large and growing U.S. • Bringing evidence-based medicine
with support from AHRQ. Hispanic population could have to the hospital bedside.
Researchers found that their new important consequences for Researchers at the University of
CHADS2 method for predicting Medicaid because the resulting Iowa are carrying out a 3-year
risk of stroke in patients with atrial excess disability could increase long- randomized study at 12 hospitals in
fibrillation is more accurate than term custodial costs. Iowa, Missouri, and Illinois to
existing methods. CHADS2 may be • End-of-life discussions. Findings evaluate the effectiveness and cost-
especially helpful for identifying from this AHRQ study can be used effectiveness of implementing an
low-risk patients who, by taking to improve end-of-life care and evidence-based acute pain
aspirin, can avoid the office visits, promote more effective use of health management guideline for
expense, and side effects associated care resources by encouraging hospitalized elderly hip fracture
with warfarin, which carries a risk of discussions between terminally ill patients. The intervention targets
bleeding.
• Underuse of hip replacement
surgery in Hispanic patients. Even New severity measure for hospitalized pneumonia patients
when they have insurance, elderly Hospitalized pneumonia patients who have abnormal vital signs, mental confusion, or
Hispanics undergo far fewer hip problems with eating or drinking in the 24 hours prior to discharge are more likely than
replacement operations than elderly other pneumonia patients not to be able to resume normal activities on discharge. Also,
non-Hispanic whites. This study of they face a greater chance of readmission or death.
Hispanics aged 65 or older in Texas,
New Mexico, Arizona, and Illinois AHRQ-supported researchers at Mount Sinai School of Medicine developed a simple
found that they were less than one- severity-of-illness measure that can be used by clinicians to judge whether it is safe for
third as likely as non-Hispanic a patient to be discharged from the hospital. The measure uses information from the
whites of the same age to undergo five vital signs that are checked several times a day in hospitalized patients
total hip replacement, an operation (temperature, heart rate, blood pressure, respiratory rate, and oxygen levels in the
that can alleviate pain and improve blood), as well as assessment of the patient’s mental status and ability to eat and drink.
physical function and quality of life Patients in this study who were discharged with two or more unstable factors had a
in patients with severe osteoarthritis. five-fold greater risk of readmission or death. Using this instrument, the researchers
According to the researchers, found that one in five of the patients they studied had been discharged “medically
underuse of hip replacement surgery unstable.”
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both nurses and prescribing 500,000 mammograms from 91
physicians and includes training, facilities and 279 radiologists. The
computerized learning modules, the goal is to identify reasons for
use of opinion leaders, the use of variability in the interpretation of
feedback and reminder cards, and mammograms and determine how
system interventions for modifying the quality of mammography can be
chart forms and institutional policy. improved.
The goals are to determine whether • Racial and ethnic variation in
a multidimensional organizational medical interactions. In this 5-year
intervention alters nurse and program, researchers at the Baylor
physician behaviors and whether College of Medicine and the
institutional barriers to change are Houston VA are developing and
reduced. testing interventions to improve
• Evidence-based reminders in doctor-patient communication
home health care. These researchers patterns to reduce racial and ethnic
are comparing the effectiveness of disparities in use and outcomes.
two alternative information-based Both clinicians and patients are
strategies intended to improve participating in the project, which
provider performance and promote also includes an information
adherence to evidence-based dissemination component to
guidelines among home health care translate research findings into
nurses. The study employs a practice as rapidly as possible.
randomized design that assigns • Otitis media: Parent education to
nurses to one of two treatment avoid antibiotic use. Acute otitis
groups or a control group (usual media (AOM) continues to be a
care). Nurses in the basic major child health problem. The
intervention group receive “just in average child experiences 2.6 AOM
time” e-mail reminders highlighting episodes per year in the first 2 years
six condition-specific practices they of life. The overuse of antibiotics for
should follow for patients with AOM has led to the emergence of
either heart failure or cancer pain. multi-drug resistant pathogens, even
Nurses in the augmented though research has shown that 80
intervention group receive the same to 90 percent of children with
e-mail reminders along with AOM will recover without
additional information and antibiotics. This randomized
consulting services from an expert controlled trial is evaluating the
peer. safety, efficacy, cost to parent, and
• Understanding variability in acceptability of an intervention
community mammography. This consisting of parent education,
community-based, multicenter nonantibiotic symptomatic therapy,
observational study involves a and careful followup of children
unique collaboration among three with mild AOM. The goal is to
geographically distinct breast cancer establish the safety of withholding
surveillance programs in the States antibiotics from children with mild
of Washington, New Hampshire, AOM and change parents’
and Colorado. The investigators are expectations about universal
collecting breast cancer outcomes antibiotic treatment of AOM.
and interpretive data on more than
www.ahrq.gov 4
Hospital volume and surgical mortality
20%
16%
15.1%
11.6%
Adjusted mortality
8%
4%
Pancreatic Esophagectomy Mitral valve
resection replacement
Highest-volume hospitals
Lowest-volume hospitals
Source: Adapted from Birkmeyer, Siewers, Finlayson, et al. Hospital volume and surgical
mortality in the United States. NEJM 346(15):1128-37, 2002.
• Benefits of regionalizing surgery hospitals. Indeed, they found that
for Medicare patients. In this elderly patients undergoing
ongoing study, researchers at treatment for any one of 14 high-
Dartmouth Medical School are risk cardiovascular or cancer
using Medicare data and data from operations were more likely to
AHRQ’s National Inpatient Sample survive if they were treated in high-
(NIS) to investigate the potential volume hospitals.
benefits of regionalizing patients
who have certain high-risk Future Research
procedures. For example, in the Priorities for future research on quality
April 11, 2002 issue of the New and quality improvement—particularly
England Journal of Medicine, they the overuse, underuse, and misuse of
reported a 12 percentage point health care services—include:
difference in survival for patients
being treated for cancer of the • Identify which financial and
pancreas at high- and low-volume organizational factors promote
hospitals. Only 4 percent of patients quality and how different payment
treated at the highest volume methods, financial incentives, and
hospitals died, compared with 16 organizational factors affect the
percent at the lowest volume behavior of health care
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organizations, providers, purchasers, • Identify and address factors that
and patients. promote adoption of promising
• Design and implement new care quality improvement strategies (e.g.,
processes that enable patients to act patient self-management) by all who
as co-managers of their health care, would benefit.
particularly for chronic illnesses.
More Information
• Identify telecommunications
applications that will enhance To find out more about AHRQ-funded
patients’ access to information and research on health care quality, visit our
patient-provider communication. Web site at www.AHRQ.gov or contact
Katherine Crosson, M.P.H., C.H.E.S,
• Identify effective information
at 301-594-6856 or via e-mail to
technology tools and systems that
kcrosson@ahrq.gov.
alert providers in real-time to the
critical information they need to
provide safer, high quality care.
• Implement and evaluate strategies to
improve quality of care for people
with disabilities.
www.ahrq.gov
AHRQ Pub. No. 02-P032
September 2002
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