U.S. physicians follow recommended best practices for diagnosis and treatment about 55% of the time, a study conducted by researchers at Rand has found, the Wall Street Journal reports. The two-year, $6.5 million study -- published in today's issue of the New England Journal of Medicine -- examined screening, diagnosis, treatment and follow-up care for 30 conditions based on a set of 439 recommendations (Pereira, Wall Street Journal, 6/26). Researchers conducted random telephone interviews and reviewed the medical records of about 7,000 U.S. adults in 12 metropolitan areas and found that adults did not receive recommended care about 46% of the time. Of that percentage, patients received care that was "potentially harmful" about 11% of the time, researchers found (Rand release, 6/25). Those figures varied little among acute, chronic and preventive care, USA Today reports (Rubin, USA Today, 6/26). However, health care quality "differed markedly by disease," the Washington Post reports. The highest percentages of recommended care delivery were reported for cataracts at 79%, breast cancer at 76% and prenatal care at 73%. The lowest percentages of recommended care were reported for peptic ulcer at 33%, hip fracture at 23% and alcohol dependence at 11%. In addition, the study found that medication prescription followed guidelines for treatment 69% of the time; immunizations, 66% of the time; physical exams, 63%; and lab work, 62%. Physicians asked "key questions" about medical history 43% of the time, according to the Post (Brown, Washington Post, 6/26). Other study findings include:
- 40% of heart patients who were appropriate candidates for aspirin therapy were not prescribed the drug;
- 35% of people with high blood pressure were not properly diagnosed or given the right amounts of drugs;
- 75% of people with diabetes did not receive required testing to determine medication effectiveness;
- 64% of elderly patients had received or were offered a pneumonia vaccine; and
- 38% of those interviewed had been surveyed for colorectal cancer.
Researchers said that health care providers' varying usage rates for treatment guidelines could stem from an "absence of an accountability system," a lack of awareness among health care providers about best practices and limited financial incentives for insurers to pay for recommended care, the Journal
reports (Wall Street Journal
Elizabeth McGlynn, primary author of the study, said, "The implications are that everybody is at risk. It's important for people not to be complacent about the quality of care they receive" (Marks, Christian Science Monitor, 6/26). Dr. Donald Berwick, head of the Institute for Healthcare Improvement, said the study should not be "an indictment of physicians or nurses. They are simply working in a care system that is incapable of supporting excellence, a system we have designed for failure" (Washington Post, 6/26). Dr. James Martin, president of the American Academy of Family Physicians, said the high number of best practices might be daunting for providers, adding that research has found that if providers followed all recommended steps, an average exam would last 90 minutes instead of 15 to 20 (McConnaughey, AP/Las Vegas Sun, 6/25).
Editorial Calls for Reforms
Because the records reviewed for the study may have poorly documented, "it would not be appropriate to interpret the findings of this study as showing that a typical adult in the United States has a 50-50 chance of receiving adequate care," according to an accompanying commentary written by Dr. Earl Steinberg, adjunct professor of medicine and public policy at Johns Hopkins University. However, the study indicates that "the quality of the care delivered in the United States is considerably lower than it should be," Steinberg writes. Steinberg recommends that quality of health care provided by doctors and hospitals be reported routinely; providers make greater use of information technology; providers encourage patients to take a more active role in care; and the system address the problem that financial incentives "often discourage quality improvement" (Steinberg, New England Journal of Medicine, 6/26).
McGlynn today comments on the Rand study in a Los Angeles Times opinion piece. In addition, ABCNews' "World News Tonight" yesterday reported on the study. The segment includes comments from Berwick, McGlynn, and Dr. John Pronovost, associate professor of anesthesiology and critical care and health policy at Johns Hopkins School of Medicine (McKenzie, "World News Tonight," ABCNews, 6/25). The full transcript of the segment is available online. The full segment is available online in RealPlayer.