TABLE 2.
Examples of Quality of Acute Health Care in the United States
| Health Care Servicea | Sample Description | Data Source | Quality of Care | Referencea |
|---|---|---|---|---|
| ANTIBIOTIC USE | ||||
| Common cold | ||||
| Almost all colds are caused by a virus, for which antibiotics are not an effective treatment. | 1,439 patients with 2,171 outpatient and emergency department visits for the common cold (acute nasopharyngitis) from a random sample of 50,000 patients with at least 1 claim for care by a physician, dentist or optometrist | Kentucky Medicaid claims data, 7/1/93–6/30/94 | In 60% of encounters for the common cold, patients filled prescriptions for antibiotics. | (Mainous et al. 1996) |
| Upper respiratory tract infection | ||||
| Antimicrobial drugs do not shorten the course of viral upper respiratory tract infection nor do they prevent secondary bacterial infections. | Nationally representative sample of 3,000 office-based physicians | National Ambulatory Medical Care Survey (NAMCS), 1992 | 16% of all antimicrobial drug prescriptions (an estimated 17,922,000 prescriptions nationally) were written for upper respiratory tract infections in 1992. | (McCaig and Hughes 1995) |
| Pharyngitis, nasal congestion, common cold, and other upper respiratory tract infection | ||||
| Since most of these conditions are viral, antibiotics have no benefit. | Same as above | Same as above | Over 70% of patients received antibiotic prescriptions for pharyngitis (excluding streptococcal), over 50% received them for rhinitis, and over 30% received them for a nonspecific upper respiratory tract infection, cough, or cold. | (Dowell and Schwartz 1997) |
| RESPIRATORY ILLNESS | ||||
| Pneumonia: hospital care | ||||
| Care for pneumonia | 1,408 patients hospitalized with pneumonia from a nationally representative sample of 7,156 patients hospitalized with any of 5 conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al. 1990) | Medical records for Medicare patients from 297 hospitals in 5 states (California, Florida, Indiana, Pennsylvania, Texas), 7/1/85–6/30/86 | 52%–90% of patients with pneumonia received appropriate components of care (e.g., documentation of tobacco use/nonuse and lower-extremity edema; blood pressure readings; oxygen therapy or intubation for hypoxic patients). | (Kahn et al. 1990) |
| Pneumonia | ||||
| Hospital admissions for pneumonia are considered appropriate when, for example, a patient fails to improve with outpatient oral medication or has a pleural effusion or an empyema. | 445 hospital admissions of children <18 years old admitted with pneumonia | Medical records for patients from 12 hospitals in 5 communities in Boston and nearby suburbs, 7/1/85–6/30/86 | 9.4% of admissions were inappropriate. | (Payne et al. 1995) |
| Bronchitis/asthma | ||||
| Hospital admissions for bronchitis/asthma are considered appropriate when, for example, a patient has failed to improve with outpatient therapy or has a pneumothorax. | 1,038 hospital admissions of children <18 years old admitted with bronchitis/asthma | Same as above | 4.4% of admissions were inappropriate. | (Payne et al. 1995) |
| OTITIS MEDIA | ||||
| Treatment | ||||
| 464 children ≤3 years old diagnosed with otitis media from a sample of 2,024 patients of 135 providers | Medical records from physicians’ offices, community health centers, and hospital outpatient facilities sampled from Maryland Medicaid claims data, 1988 | For each type of clinical setting, the study reports the average percentage of technical quality indicators for otitis media that were not met. Each average was located in the 10%–40% range. | (Starfield et al. 1994) | |
| Use of tympanostomy tubes | ||||
| Indications for tympanostomy tube placement include refractory middle ear infection and chronic mastoiditis. | 6,429 children <16 years old with recurrent acute otitis media and/or persistent otitis media with effusion who were insured in health plans requiring precertification by a utilization review firm | Interviews with physicians’ office staff at otolaryngology practices from 49 states and the District of Columbia, 1/1/90–7/30/91; additional interviews were conducted with otolaryngologists to determine the existence of extenuating clinical circumstances | 41% of tube insertions were appropriate, 32% equivocal, and 27% inappropriate. If extenuating clinical circumstances were taken into account, 42% of tube insertions were appropriate, 35% equivocal, and 23% inappropriate. | (Kleinman et al. 1994) |
| HIP FRACTURES | ||||
| Hip fracture: hospital are | ||||
| Care for hip fracture | 1,404 patients hospitalized with hip fracture from a nationally representative sample of 7,156 patients hospitalized with any of 5 conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al. 1990) | Medical records for Medicare patients from 297 hospitals in 5 states (California, Florida, Indiana, Pennsylvania, Texas), 7/1/85–6/30/86 | 67%–94% of patients with hip fracture received appropriate components of care (e.g., documentation of mental status and pedal or leg pulse; serum potassium level; electrocardiogram). | (Kahn et al. 1990) |
| PRENATAL CARE | ||||
| Medical history | ||||
| 9,924 women who had live births in 1988 from a nationally representative sample of the U.S. (excluding South Dakota and Montana, and including the District of Columbia) | National Maternal and Infant Health Survey (NMIHS), 1988 | 80% were asked about health history during the first or second visit. | (Kogan et al. 1994) | |
| Physical examination | ||||
| Same as above | Same as above | 98% had their weight and height measured, 96% had blood pressure measured, and 86% received a physical or pelvic examination during the first or second visit. | (Kogan et al. 1994) | |
| Laboratory tests (hemoglobin blood test and urine test) | ||||
| Same as above | Same as above | 79% received blood tests and 93% received urinalysis during the first or second visit. | (Kogan et al. 1994) | |
| Medical history, physical examination, and laboratory tests | ||||
| Same as above | Same as above | 56% received all of the evaluations listed above during the first or second visit. | (Kogan et al. 1994) | |
| Counseling about nutrition and weight gain | ||||
| Same as above | Same as above | 97% were counseled about vitamins, 93% were counseled about diet, and 72% were counseled about proper weight gain during pregnancy, during at least one prenatal visit. | (Kogan et al. 1994) | |
| Counseling about alcohol, tobacco, and illicit drugs | ||||
| Same as above | Same as above | 68% were counseled to reduce or eliminate alcohol consumption, 69% to reduce or eliminate smoking, and 65% to stop use of illegal drugs, during at least one prenatal visit. | (Kogan et al. 1994) | |
| Counseling about breastfeeding | ||||
| Same as above | Same as above | 53% were counseled about breastfeeding during at least one prenatal visit. | (Kogan et al. 1994) | |
| Counseling about nutrition, weight gain, alcohol, tobacco, illicit drugs, and breastfeeding | ||||
| Same as above | Same as above | 32% received all of the counseling listed above during at least one prenatal visit. | (Kogan et al. 1994) | |
| Routine prenatal screening tests | ||||
| (i.e., tests to screen for anemia, asymptomatic bacteriuria, syphilis, gonorrhea, hepatitis B, rubella immunity, and Rh factor and antibody) | Random sample of 586 women who had a live birth from 24,170 births that occurred during the study period | Medical records for patients from 6 HMOs in 6 states (Arizona, California, Colorado, Massachusetts, Minnesota, Oregon), 8/1/89–7/31/90 | Among 6 HMOs, women received 64%–95% (average 82%) of 7 recommended routine prenatal screening tests. | (Murata et al. 1994) |
| Other routine prenatal care | ||||
| (i.e., first prenatal visit during first trimester, accurate determination of gestational age, screening for inherited disorders, measurement of symphysis-fundal height, and blood pressure measurement) | Same as above | Same as above | Among 6 HMOs, women received 78%–87% (average 84%) of 5 processes of routine prenatal care. | (Murata et al. 1994) |
| Care for complications of pregnancy | ||||
| (e.g., diagnostic and treatment interventions after abnormal screening test results, and care to mitigate effects of pregnancy-induced hypertension and gestational diabetes) | Same as above | Same as above | Among 6 HMOs, women received 54%–77% (average 70%) of processes of care for complications of pregnancy. | (Murata et al. 1994) |
| Screening and follow-up for proteinuria (protein in urine) | ||||
| Urine is checked for protein to evaluate for the presence of preeclampsia, a serious complication of pregnancy. | Inpatient records for 2,336 women from a sample of 2,878 births in 1985; prenatal care records for 823 of these women | Medical records for patients sampled from Medicaid claims files for women and children enrolled in Aid to Families with Dependent Children (AFDC) in 2 communities in California and 2 communities in Missouri, 1985 | Testing was provided at 75%–83% of visits. Follow-up was performed for 41%–65% of patients with proteinuria. | (Carey et al. 1991) |
| Recording of gestational age | ||||
| Same as above | Same as above | Gestational age was recorded at 78%–95% of visits. | (Carey et al. 1991) | |
| Assessment of fetal heart tones after 18 weeks of gestation | ||||
| Same as above | Same as above | Fetal heart tones were assessed at 81%–93% of visits. | (Carey et al. 1991) | |
| Follow-up for low hematocrit | ||||
| Low hematocrit indicates anemia. | Same as above | Same as above | Follow-up was performed for 32%–51% of patients with low hematocrit. | (Carey et al. 1991) |
| Follow-up for high blood pressure | ||||
| Same as above | Same as above | Follow-up was performed for 31%–53% of patients with high blood pressure. | (Carey et al. 1991) | |
a
If a description in the first column has no citation, it is covered by the citation in the reference column.
b
We contacted the authors of some of the articles to clarify details related to the sample and to the data analysis.