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.
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%).
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).
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.