Quality eludes U.S. health care Tens of thousands die from errors, misuse of services, study says

December 07, 1997

This article is based on a report on the quality of U.S. health care that was commissioned by the National Coalition on Health Care. The report was prepared by Mark A. Schuster, Elizabeth A. McGlynn and Robert H. Brock of the RAND Corp. WHILE MANY consider the United States to have the finest health care in the world, a large and growing body of evidence indicates that widespread problems exist with the quality of much of America's health care.

Although a trillion dollars is spent on health care in the United States annually, many people receive the wrong kind of care. And millions of Americans are injured, and tens of thousands die unnecessarily because of errors or the overuse, underuse or misuse of services. Moreover, these problems are not being recognized or addressed adequately.

For example, surgery is sometimes performed on people who do not need it. A study of seven managed care organizations showed that about 16 percent of hysterectomies done during a one-year period in 1989-1990 were for inappropriate reasons. An additional 25 percent were performed for reasons of uncertain clinical benefit.

Other patients need surgery but do not receive it. In a study of eight hospitals, 43 percent of patients with a positive exercise stress test demonstrating the need for coronary angiography had received it within three months; 56 percent had received it within 12 months.

Also, preventable and harmful errors are frequently occurring. This is true across the country, across different types of care and providers, and in different settings, including the nation's preeminent health care institutions. These problems long preceded the advent of managed care.

"The issue is critical, and yet we do not have an integrated, national system for assessing or assuring health care quality for America's people," said coalition co-chair Robert D. Ray. "We must find a better way to measure and improve quality. And quality does not consist only - or even mainly - of consumers being able to see the provider of their choice when and where they want to see them. Quality is receiving the right care, in the right setting, at the right time, and too often that is not what is occurring in today's health care system."

Here are some of the findings of the RAND report and other studies that provide a framework for understanding the extent of problems in the United States:

Health care varies widely

* Major gaps in our knowledge base contribute to medical uncertainty. Much of our medical technology has been adopted and widely used without adequate evaluation. The evidence to justify treatment of even the most common medical and surgical conditions is often questionable. This includes such common conditions as prostate cancer and lower back pain, which afflicts millions of people.

* Medical uncertainty leads to enormous regional variations in health care with no evidence that people in regions with access to more care have better outcomes than people in regions with less care.

* The huge variations in the quality of health care are indefensible. Medical literature is replete with studies showing that physicians disagree a high proportion of the time. Often, no one knows who is right. This is not to infer that health professionals are trying to harm people; they are not. They work in flawed systems, and these flaws have to be acknowledged and fixed in a no-fault environment.

Unprofessional standards

* The country has no credible national database on quality, nor a national technology assessment or standard-setting mechanism. This makes it difficult for health professionals to practice as well as they would like or as well as patients would like to see care rendered.

* Without timely and credible information on what works in medical care in different delivery settings, consumers and providers have difficulty knowing what treatments are effective, the benefits and risks of alternative treatments and the providers to go to in each situation. The perception is that patients can obtain this information, but in many cases the information is incomplete, not easily accessible or not available.

Inappropriate care

* Because our quality control assessment and assurance mechanisms are so rudimentary, treatment mistakes and errors are much more common, costly and harmful than generally realized.

* Distressingly high error rates are reported in a wide range of medical practices, with serious, sometimes fatal consequences. For example, autopsy studies show high rates (35 to 40 percent) of missed diagnoses, often resulting in death. Tragedies such as these are not isolated events. The "Harvard Medical Practice Study in the State of New York" has demonstrated this dramatically.

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