U.S. report finds sluggish increases in quality of care

For the first time, an HHS agency's annual report explores ways of figuring out the cost efficiency of health care.

By Kevin B. O’Reilly — Posted April 28, 2008

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The pace of health care quality improvement appears to be slowing, according to the Agency for Healthcare Research and Quality's fifth annual report compiling federal and state data on more than 200 quality metrics.

A composite measure of health care quality improved at a 2.3% average annualized rate between 1994 and 2005, with the rate falling to 1.5% from 2000 to 2005. And in a first stab at examining the cost efficiency of the American health care system, AHRQ noted that costs, as estimated by the Centers for Medicare & Medicaid Services, jumped 6.7% from 1994 to 2005.

AHRQ, part of the U.S. Dept. of Health and Human Services, said in its March report that cost and quality cannot be reliably compared because "expenditures are comprehensively measured, but quality is not." Still, experts said, the new report represents another high-profile effort to link cost and quality.

In addition to comparing overall rates of quality improvement and costs, AHRQ's "National Healthcare Quality Report" examines progress versus expenses for conditions such as heart disease, cancer and diabetes mellitus. Other efficiency metrics include trend data on the number and cost of potentially preventable hospitalizations and hospital costs per patient admission.

"This is just an introductory look" at efficiency, said Jeffrey Brady, MD, MPH, AHRQ acting director of national health care reports. "This is a very challenging area to get at, but also a very important area. Wasting resources on care that's not the right care at the right time for the right patient is definitely an issue, and we need to look at how can we measure and characterize that."

Quality experts interviewed for this story said there is little reason to expect any meaningful correlation between cost and quality because the current reimbursement system is geared toward volume, procedures and testing over chronic disease management and primary care.

Improving quality won't necessarily cut costs, said Bruce Bagley, MD. "If we actually implemented all of the diabetes measures, we'd see increases in care," said Dr. Bagley, American Academy of Family Physicians medical director for quality improvement. "You may see some cost increases early on as care that wasn't happening before starts to get provided."

Last year, the American Medical Association adopted policy in favor of "ongoing investigation and cost-effectiveness analysis of nonclinical health system spending, to reduce costs that do not add value to patient care." The AMA also said "value-based decision-making" should be promoted at all levels as one of several broad strategies aimed at addressing rising health care costs.

Quality improving, but slowly

The AHRQ report gauges quality of care by using measures such as the number of women 40 or older who received mammograms in the previous two years. In addition to sluggish quality changes, measures of patient safety showed only a 1% annual rate of improvement from 2000 to 2005.

Meanwhile, a companion AHRQ report on disparities found that while some gaps were reduced or even eliminated, most metrics of racial and ethnic minorities' access to quality care have stayed the same or worsened.

"The simple take-home point is that opportunities abound for improving both health care quality and disparities," said AHRQ's Dr. Brady, a preventive medicine specialist.

Physician experts' reactions to the new figures were mixed.

David B. Nash, MD, said the mammoth quality report is sobering. "The rate of improvement has been very low," said Dr. Nash, chair of the health policy department at Jefferson Medical College in Philadelphia and editor of the American Journal of Medical Quality. "It's been almost nine years since the IOM report ["To Err is Human"] came out. We should be doing a lot better."

But the AAFP's Dr. Bagley said the health care system is still headed in the right direction.

"It's discouraging that the rate of improvement has slowed," Dr. Bagley said. "The good news is that we're still improving, but if you're waiting for some kind of dramatic click of the switch and everything's going to be wonderful -- well, it's not going to be that way."

The apparent slowing in quality improvement is unsurprising, said Vincenza Snow, MD, the American College of Physicians' director of clinical programs and quality of care.

"There's only so much you can achieve by trying harder," Dr. Snow said. "To get the bigger changes, we'll need a much larger, coordinated, systems approach and change the way practice is reimbursed and move to actually giving people the time to provide quality care."

James M. Levett, MD, said the move to adopt quality systems that prevail in other industries is just starting to pick up speed in health care.

"I don't think you can measure quality with a simple metric," said Dr. Levett, chair-elect of the American Society for Quality's health care division. "There's a lot of stuff happening that may not be reflected by these metrics that I'd argue five years from now will be extremely important and shift things in a very positive direction."

Notable successes

While the overall picture of national progress on quality improvement and reducing racial and ethnic health care disparities is mixed, AHRQ's reports did highlight some areas where the health system is making progress.

For example, the percentage of heart attack patients who received smoking cessation counseling jumped from 42.7% in 2000-01 to 90.9% in 2005. Forty-eight states exceeded 80% on this measure in 2005. Also, the overall rate of potentially avoidable hospitalizations fell 8% between 2000 and 2004.

Though the rate of change appears frustratingly slow, experts said the new report does not mean that quality-improvement efforts are for naught.

"We need to just take this report at face value and keep moving," Dr. Bagley said. "If we started to see a trend going in the other direction, with quality getting worse, then we'd be very concerned. But as more and more people are starting to measure their performance and get feedback -- that's what's going to drive change."

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AHRQ looks at costs and quality

Care for some of the most serious conditions continued to improve each year from 2001 to 2004. Costs also rose during that period. Average annualized change:

Care Cost increase Quality improvement
Overall 7.6% 1.9%
Heart disease 12.9% 5.6%
Cancer 9.0% 3.6%
Diabetes mellitus 3.7% 0.6%

Source: U.S. Agency for Healthcare Research and Quality, "National Healthcare Quality Report, 2007" and "National Healthcare Disparities Report, 2007"

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Location, location, location

Different health care settings saw different rates of quality improvement.

Settings Average annualized
improvement, 1994-2005
Hospital 2.9%
Home health 2.8%
Ambulatory care 1.7%
Long-term care 0.8%

Source: U.S. Agency for Healthcare Research and Quality, "National Healthcare Quality Report, 2007" and "National Healthcare Disparities Report, 2007"

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Not all improvements are equal

The relative rate of disparities for minorities continues, in both quality and access. A relative rate of 10.0, for example, means a 10 times greater likelihood for that racial or ethnic group than for whites.

Group Measure Relative rate 2005 2007
Blacks New AIDS cases per 100,000 people 10.4 10.0
Hispanics New AIDS cases per 100,000 people 3.7 3.5
Blacks Hospital admissions for pediatric asthma per 100,000 people 4.0 3.8
Asians Adults older than 65 who never received pneumococcal vaccination 1.5 1.5
American Indians/Alaska Natives Women not receiving first-trimester prenatal care 2.1 2.1
American Indians/Alaska Natives Adults reporting poor communication with health professionals 1.8 1.8

Source: U.S. Agency for Healthcare Research and Quality, "National Healthcare Quality Report, 2007" and "National Healthcare Disparities Report, 2007"

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External links

"National Healthcare Quality Report" and "National Healthcare Disparities Report," Agency for Healthcare Research and Quality, 2007 (link)

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