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Selected research from leading health care experts whose findings have a direct bearing on public policies effecting medical progress. Research is chosen based on its quality and relevance by the Medical Progress Today editorial staff.

Selected Research

Who is at greatest risk for receiving poor quality health care?
Steven M. Asch, M.D., M.P.H., New England Journal of Medicine, 3-16-06

This study, from the New England Journal of Medicine paints a picture of American health care that is either reassuring or depressing, depending on how you look at it. On the one hand, it shows that the provision of health care is remarkably uniform across racial, ethnic, and economic strata of American society.

Now for the bad news: Americans receive recommended levels of care a little better than half of the time.

We used data from medical records and telephone interviews of a random sample of people living in 12 communities to assess the quality of care received by those who had made at least one visit to a health care provider during the previous two years. We constructed aggregate scores from 439 indicators of the quality of care for 30 chronic and acute conditions and for disease prevention. We estimated the rates at which members of different sociodemographic subgroups received recommended care, with adjustment for the number of chronic and acute conditions, use of health care services, and other sociodemographic characteristics.

Overall, participants received 54.9 percent of recommended care. Even after adjustment, there was only moderate variation in quality-of-care scores among sociodemographic subgroups. Women had higher overall scores than men…and participants below the age of 31 years had higher scores than those over the age of 64 years… Blacks (57.6 percent) and Hispanics (57.5 percent) had slightly higher scores than whites. Those with annual household incomes over $50,000 had higher scores than those with incomes of less than $15,000 (56.6 percent vs. 53.1 percent.

Conclusions The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care.

The authors conclude that “to make substantial improvements in the quality of health care available to all patients, we must focus on large-scale, system-wide changes,” citing recent information technology improvements at the Veteran’s Administration as one potential model.

The concern with having the government dictate top-down standards of care, however, is that regulations inhibit innovation and experimentation that may lead to improved outcomes. Regina Herzlinger, Manhattan Institute senior fellow and professor at the Harvard Business school, argues that we don’t need more standards—we need more disclosure.

Americans want to know how good their doctors and hospitals are. But the government does not reward good performance — judged by whether patients get better. It rewards only good conformance — for medical providers who follow its recipes. …
Government recipes are delineated primarily through "peer review," not scientific experiments. Although the title implies saintly physicians dispassionately evaluating each other's work, medical "peers" become brass-knuckle fighters when innovators threaten their expertise. The history of medicine is filled with shameful suppressions of important advances. …
Government's appropriate role is to measure outcomes — the real performance of doctors and hospitals. Disclosure was President Franklin Delano Roosevelt's solution. Instead of dictating recipes for hard-hit Depression-era businesses, he created the Securities and Exchange Commission to promulgate audited financial outcomes, measured by generally accepted accounting principles. The resulting transparency is essential to financial markets that reward good firms and penalize laggards. Sunshine is the best disinfectant.


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