Context Despite widespread concern regarding the quality and safety of health
care, and a Medicare Quality Improvement Organization (QIO) program intended
to improve that care in the United States, there is only limited information
on whether quality is improving.
Objective To track national and state-level changes in performance on 22 quality
indicators for care of Medicare beneficiaries.
Design, Patients, and Setting National observational cross-sectional studies of national and state-level
fee-for-service data for Medicare beneficiaries during 1998-1999 (baseline)
and 2000-2001 (follow-up).
Main Outcome Measures Twenty-two QIO quality indicators abstracted from state-wide random
samples of medical records for inpatient fee-for-service care and from Medicare
beneficiary surveys or Medicare claims for outpatient care. Absolute improvement is defined as the change in performance from baseline
to follow-up (measured in percentage points for all indicators except those
measured in minutes); relative improvement is defined
as the absolute improvement divided by the difference between the baseline
performance and perfect performance (100%).
Results The median state's performance improved from baseline to follow-up on
20 of the 22 indicators. In the median state, the percentage of patients receiving
appropriate care on the median indicator increased from 69.5% to 73.4%, a
12.8% relative improvement. The average relative improvement was 19.9% for
outpatient indicators combined and 11.9% for inpatient indicators combined
(P<.001). For all but one indicator, absolute
improvement was greater in states in which performance was low at baseline
than those in which it was high at baseline (median r =
−0.43; range: 0.12 to −0.93). When states were ranked on each
indicator, the state's average rank was highly stable over time (r = 0.93 for 1998-1999 vs 2000-2001).
Conclusions Care for Medicare fee-for-service plan beneficiaries improved substantially
between 1998-1999 and 2000-2001, but a much larger opportunity remains for
further improvement. Relative rankings among states changed little. The improved
care is consistent with QIO activities over this period, but these cross-sectional
data do not provide conclusive information about the degree to which the improvement
can be attributed to the QIOs' quality improvement efforts.