Despite condition-specific and managed care–specific reports,
no systematic program has been developed for monitoring the quality of medical
care provided to Medicare beneficiaries.
To create a monitoring system for a range of measures of clinical performance
that supports quality improvement and provides repeated, reliable estimates
at the national and state levels for fee-for-service (FFS) Medicare beneficiaries.
Design, Setting, and Participants
National study of repeated, cross-sectional observational data collected
in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample
of beneficiaries with a particular condition. Data were collected using medical
record abstraction for inpatient care, analysis of Medicare claims for some
ambulatory services, and surveys for immunization rates. Separate samples
were drawn for each topic for each state.
Main Outcome Measures
Beneficiary patients' receipt of 24 process-of-care measures related
to primary prevention, secondary prevention, or treatment of 6 medical conditions
(acute myocardial infarction, breast cancer, diabetes mellitus, heart failure,
pneumonia, and stroke) for which there is strong scientific evidence and professional
consensus that the process of care either directly improves outcomes or is
a necessary step in a chain of care that does so.
Across all states for all measures, the percentage of patients receiving
appropriate care in the median state ranged from a high of 95% (avoidance
of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients
with pneumonia screened for pneumococcal immunization status before discharge).
The median performance on an indicator is 69% (patients discharged with heart
failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic
patients having an eye examination in the last 2 years). Some states (particularly
less populous states and those in the Northeast) consistently ranked high
in relative performance while others (particularly more populous states and
those in the Southeast) consistently ranked low.
It is possible to assemble information on a diverse set of clinical
performance measures that represent performance on the range of services in
a health insurance program. These findings indicate substantial opportunities
to improve the care delivered to Medicare beneficiaries and urgently invite
a partnership among practitioners, hospitals, health plans, and purchasers
to achieve that improvement.