Quality Of Health Care For Americans Research Articles

The Long Wait For Medical Excellence

In October 1997 the book Demanding Medical Excellence: Doctors and Accountability in the Information Age provided a pathbreaking examination of the quality of American health care. It documented rampant medical error and the absence of evidence-based practice, highlighted the potential of electronic health records (EHRs), endorsed what is now known as value purchasing, and showed how patients could exert more control over their care. Although the book suggested that transformational change was imminent, sixteen years later little has changed in some areas (medical error), while in others (evidence-based medicine and population health) change is only now gaining momentum. The exception is technology, where incentives boosted EHR use and the Internet has made a vast array of information available to patients. Paradigm shifts are traumatic, and only recently has intense financial pressure made greater clinical accountability seem less painful than retaining the tradition of untrammeled autonomy. In hearing rooms and hospital hallways, the policy conversation is changing. This shift, though an unavoidable source of anxiety, nonetheless promises a genuine renewal of American medicine.

Editorial

FigureAs part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign, the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) recently published its list of “Five Things Physicians and Patients Should Question.” The goals of the campaign were to promote awareness of the overuse of tests and treatments and to improve the overall quality of American healthcare. The AAO-HNSF Patient Safety and Quality Improvement Committee was charged with leading an unbiased and equitable process to arrive at five conditions. The committee reviewed 20 initial items for consideration and then refined the list based on the amount of supporting clinical evidence and the frequency of use of the test, procedure, or treatment. Three of the final five items address diseases of the ear. 1. Don't order a computed tomography (CT) scan of the head/brain for sudden hearing loss. The support for this item comes from a recent AAO-HNSF Clinical Practice Guideline (Otolaryngol Head Neck Surg 2012;146[suppl 3]:S1-35).Figure: Michael E. McCormick, MDThe role of imaging in a patient with sudden sensorineural hearing loss (SSNHL) is to identify pathology that may be causing acute symptoms. SSNHL typically results from an abnormality of the cochlea, cochleovestibular nerve (CN VIII), or brainstem. While we are unable to accurately image the inside of the cochlea with current modalities, more central etiologies, such as the CN VIII and brainstem, are best evaluated by magnetic resonance imaging.Figure: Rahul K. Shah, MDTherefore, a routine CT scan of the head/brain adds no diagnostic yield to the workup of these patients in most clinical situations. Furthermore, CT scans expose the patient to potentially harmful radiation and intravenous contrast (Expert Opin Drug Metab Toxicol 2009;5[4]:403-416; Arch Intern Med 2009;169[22]:2078-2086). 2. Don't prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea. Ototopical antibiotic drops are typically 100 to 1,000 times more concentrated than oral preparations and do not need to undergo systemic metabolism and biodistribution (Drugs 1999;58[3]:509-531). As a consequence, topical preparations often can treat bacteria that oral antibiotics cannot. Using antibiotic eardrops instead of oral agents can also help prevent the development and spread of resistant bacteria (Pediatr Infect Dis J 2001;20[1]:102-103) and avoids the systemic side effects associated with oral therapy, such as vomiting, diarrhea, and rash.Figure. David: W. Roberson, MD3. Don't prescribe oral antibiotics for uncomplicated acute external otitis. Similar to the first recommendation, this item is supported by evidence from an AAO-HNSF Clinical Practice Guideline (Otolaryngol Head Neck Surg 2006;134[suppl 4]:S4-S23). The item applies primarily to healthy patients without complications or extension beyond the ear canal. In addition to the benefits of curbing overuse of oral antibiotics, there are multiple nonantibiotic preparations that are efficacious. Awareness of and general adherence to these simple recommendations by our health professional colleagues could potentially save an immeasurable amount of resources while improving the quality and perhaps outcomes of care in the United States.

Medicaid Patients' Access to Subspecialty Ambulatory Care in Connecticut

The overall quality of American health care and medical education is negatively affected by disparities in patients' access to care.1 Many internal medicine residency programs provide primary care to patients with Medicaid. We hypothesized that Medicaid patients lack full access to ambulatory subspecialty care (SC), which necessarily affects the educational experiences of residents who provide their primary care. Clinic attending physicians (chiefs) at all 17 residency teaching clinics in Connecticut responded to an e-mail questionnaire asking about the frequency of Medicaid patients' timely access to ambulatory and (when needed) procedural SC (table). TABLE Responses of Connecticut Teaching Clinic Chiefs to Their Experience in Obtaining Subspecialty Care for Medicaid Patients Zero to 18 subspecialities were “never, rarely or sometimes” available for patients in Connecticut's 17 teaching clinics. Care was more available when centers had training programs in SCs (odds ratio, 3.5; 95% confidence interval, 2.0–5.8). Seventy-seven percent answered that SC was less accessible than for their privately insured patients. Connecticut is an affluent state, yet access to SC was described as “never, rare, or sometimes” in 36% of SC centers. The American Medical Association's code of ethics states that “each physician has an obligation to share in providing care to the indigent.”2 The government requires hospitals “to ensure that Medicaid beneficiaries have full access to all of its available services.”3 If many Medicaid patients cannot access essential services, then it 5 explain mediocre outcomes in underserved groups.1 While this study should be expanded and verified, our findings should concern physicians and health care policymakers. This survey was conducted at teaching clinics where trainees might assimilate practice disparities. They observe firsthand the inconsistent application of ethical concepts we expect them to master (ie, “society has an obligation to make access to an adequate level of healthcare available to all its members regardless of ability to pay.”4) and realities “on the ground.” They might conclude either that there are not enough subspecialists (possible, but unlikely for most disciplines in Connecticut) or that ethical obligations are insufficient for some physicians in our state to care for this segment of the population. With health care reform, Medicaid beneficiaries are projected to increase by 15 million,5 only exacerbating this problem. There are potential solutions. We propose that hospitals and their physicians should proactively create equally shared coverage for essential services, as the public health code proposes.3 Additionally, hospitals and state licensure boards could require participation as a condition of privileges. Lastly, regulatory bodies (eg, departments of public health, Joint Commission, and Center for Medicaid Services) could audit the community service assurance of hospitals.3 To the extent that we physicians are advocates for patients and the health of our society, we might object collectively to this status quo and participate locally, to contribute our time, and politically, to create a more just system.2,4 Perhaps most importantly, we owe it to our trainees to “not look the other way.” At a minimum, we can “name” injustices that they observe and explore reasons for and solutions to such problems. As teachers, we can demonstrate through modeling of persistent patient advocacy that more often than not, vital services can be obtained if we persevere. And we can work with our hospital leaders to politely confront injustices, appealing to the humanity and beneficence of our colleagues, to install local solutions.

The Veterans Health Administration: A Domestic Model for a National Health Care System?

Health care in the United States is once again emerging as a key issue in national debates leading up to the 2008 presidential election. The discussions reflect, in part, growing public unease about the current health care system, fueled by rising health care costs,1 concerns about the quality of American health care, and the growing number of Americans without health insurance (approaching 45 million).2 These concerns are further ignited by recent reports that put the American health care system in perspective vis-a-vis the rest of the world. For instance, the World Health Organization ranked the US health care system at number 37 among 191 nations.3 The Commonwealth Fund recently ranked the US health care system next to last compared with United Kingdom, Canada, New Zealand, and Australia.4 Even among insured patients, the quality and equity of health care delivered in the United States has been a subject of debate.5 Public concern about the US health care system is starting to show up in public satisfaction ratings. Although most Americans receive medical care locally, patient surveys demonstrate low satisfaction rates with health care quality or access.6

The National Agenda for Quality Palliative Care: The National Consensus Project and the National Quality Forum

The release in 2007 of the National Quality Forum (NQF) preferred practices is a significant advance in the field of palliative care. These NQF preferred practices build on the clinical practice guidelines for palliative care developed by the National Consensus Project (NCP). The NQF is dedicated to improving the quality of American health care, and their focus on palliative care recognizes its growing place within the broader scope of health care. This article reviews the work of both the NCP and NQF and presents the domains and preferred practices that should guide quality improvement efforts in hospice and palliative care.

Improving the quality of health care: who will lead?

National interest in the quality of American health care increased dramatically in 1999. The press, the Institute of Medicine, legislators, physicians, and hospitals joined in a vigorous policy discussion. But a similar debate occurred in 1988, following reports from four public agencies that detailed their concerns about health care quality. In the intervening decade, research has not documented much improvement. In this paper we outline the quality problems in U.S. health care, review some of their most prominent causes, consider the biggest obstacles to bringing about major improvement, and discuss the vital role of leadership in achieving this goal.

New Rules: Regulation, Markets, and the Quality of American Health Care.

Editor-In-Chief: Scott Gibbs; Editors: Micaela Sullivan-Fowler and Nigel W. Rowe. Pp. 320. Mosby-Year Book, St. Louis, Mo., 1996. Price $24.95.

New Rules: Regulation, Markets, and the Quality of American Health Care

Troyen A. Brennan, MD, JD, is the leading medicolegal scholar at Harvard Medical School and School of Public Health. Donald M. Berwick, MD, president and chief executive officer of the Institute for Healthcare Improvement, probably is the leading figure in the movement for quality improvement (QI) in health care. Both maintain active clinical practices. From two such collaborators, one has high hopes for a book on emerging challenges in health regulation. To a very large extent, this book fulfills the promise. It is intelligent and extraordinarily well informed. The style is variable, perhaps reflecting the dual authorship: sometimes the reading is engaging; at other times the parade of statutes, regulations, and holdings becomes extremely dry. One misses more sustained argument against opposing views; the approach here is unlikely to convince a reader who did not start out sympathetic to it. And inevitably in a work dealing with recent developments, some

New Rules: Regulation, Markets, and the Quality of American Health Care

Troyen A Brennan, Donald M Berwick Jossey-Bass, £28.25, pp 404 ISBN 0 7879 0149 0 Non-American readers will learn more from New Rules than they may want to know about the detailed history of regulation in the United States. But at times that history is fascinating, and the lessons that are drawn by Brennan and Berwick are undoubtedly relevant to us in Britain, as our accreditation systems begin to mimic those across the Atlantic, and the calls for regulation increase in the wake of any avoidable scandal. It seems a pity that non-American experience gets no mention. Among the pioneers of audit, Florence Nightingale deserves recognition. More seriously, the omission of the British-based development …

Book Review New Rules: Regulation, markets, and the quality of American health care By Troyen A. Brennan and Donald M. Berwick. 404 pp. San Francisco, Jossey–Bass, 1996. $36.95. 0-7879-0149-0

Book Review New Rules: Regulation, markets, and the quality of American health care By Troyen A. Brennan and Donald M. Berwick. 404 pp. San Francisco, Jossey–Bass, 1996. $36.95. 0-7879-0149-0

THE ASSAULT ON TEACHING HOSPITALS

The quality of American health care—unarguably the best in the world—is under siege. Republicans released budget plans last week that would cut subsidies to teaching hospitals that train doctors and perform clinical research. Meanwhile, the private market, whose reform Congress bungled last year, has been doing the same. The two-pronged assault is alarming. American physicians provide innovative, technically advanced care whose quality can be traced in part to generous subsidies for basic research that Congress has provided through the National Institutes for Health (NIH). The NIH estimates that the Senate budget plan could reduce these subsidies for non-AIDS research over the next seven years by as much as 25%; the cut is deeper if inflation is taken into account. The proposed NIH cuts are easily identified and will be subject to public scrutiny. Two other threats are harder to spot. The Federal Government, when reimbursing hospitals for treating Medicare patients, pays an average of 30% extra if treatment is provided in a teaching hospital. The extra payments cover costs associated with training doctors and translating basic research into clinical practice ... Under the GOP budgets, these payments could fall between 30 and 60%. The other dagger aimed at teaching hospitals comes from the private sector. Private insurers have also paid more for patients treated in teaching hospitals. That practice is ending. Wielding new-found market power, health maintenance organizations and other managed-care groups are driving down hospital rates. They refuse to pay for training or research that does not directly benefit their enrollees.