Efforts to improve outpatient care quality fall short

The quality of outpatient care for U.S. adults has not significantly improved, according to findings published in JAMA Internal Medicine.

This poses “serious hazards to the health of the American public,” according to David M. Levine, MD, MA, from the division of general internal medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, and colleagues.

They noted that research nearly 15 years ago found that adults received about half of recommended health services.

“Since then, there have been local, regional, and national efforts to improve the quality of health care, including expanded quality measurement and public reporting programs; increased adoption of pay-for-performance; increased adoption of value-based purchasing by private and public payers; broad encouragement of electronic health record use; improved coverage for recommended services; and expansion of patient-centered medical homes,” Levine and colleagues wrote. “In recent years, these efforts have been complemented by an increasing focus on overuse through programs such as the American Board of Internal Medicine Foundation’s Choosing Wisely initiative and increasing attention to patient-reported outcomes.”

They conducted an analysis of quality measures from the Medical Expenditure Panel Survey (MEPS) between 2002 and 2013 to evaluate the success of inpatient quality improvement efforts. The survey covered U.S. adults aged 18 years and older, and ranged from 20,679 to 26,509 participants each year.

Levine and colleagues specifically assessed nine clinical quality composites, which were based on 39 quality measures. They comprised five underuse composites, such as recommended treatments, and four overuse composites, such as avoiding inappropriate imaging. In addition, the researchers measured overall patient experience, physician communication and physician access.

Results showed that four quality measures improved, while two declined and three stayed the same.

Avoiding inappropriate cancer screening (47% to 51%; P = .02), recommended cancer screening (73% to 75%; P < .01), recommended counseling (43% to 50%; P < .01) and recommended medical treatment (36% to 42%; P < .01) all improved.

Avoiding inappropriate medical treatments (92% to 89%) and inappropriate antibiotic use (50% to 44%) both declined (P < .01).

Recommended diabetes care (68%), recommended diagnostic and preventive testing (76%), and avoiding inappropriate imaging (90%) stayed the same.

The researchers also reported that overall patient experience (72% to 77%), access to care (48% to 58%) and physician communication (55% to 63%) improved (P < .01).

“Despite more than a decade of efforts to improve the quality of health care in the United States, the quality of outpatient care delivered to adults has not consistently improved,” Levine and colleagues concluded. “There have been improvements in patient experience. Current deficits in care continue to pose serious hazards to the health of the American public in the form of missed care opportunities as well as waste and potential harm from overuse. Ongoing national efforts to measure and improve the quality of outpatient care should continue, with a renewed focus on identifying and disseminating successful improvement strategies.”

In an accompanying editorial, Elizabeth A. McGlynn, PhD, from Kaiser Permanente Research, and colleagues wrote that the “anemic” quality improvements are likely “to disappoint many readers.”

“Much of the work in quality improvement has focused on approaches that are driven by payers and policy makers,” they wrote. “These have included measurement and public reporting, payment incentives, investments in electronic medical records, and developing virtual systems of care in select areas. None of these approaches by itself is likely to fundamentally alter the level of quality delivered throughout the nation.”

The authors wrote that health care providers must work with patients to significantly change care quality, but that these approaches need resources, time and energy that doctors do not have.

“We need to find a more effective way to transform the delivery of health care so that physicians and patients can achieve the outcomes that both desire,” McGlynn and colleagues concluded. “This will be hard work and will require engagement on the ground and not simply exhortations from those paying the bills.” – by Chelsea Frajerman Pardes

Disclosures: The authors report no relevant financial disclosures.

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