Americans have a slightly better than 50-50 chance their medical
problems will be addressed in an optimal way when they visit a
doctor's office or enter a hospital, according to a new survey.
The failure to do the right thing -- or, more precisely, all the
right things -- extends across the spectrum of activities physicians
are expected to perform.
Recommended "best practices" were followed about two-thirds of
the time in diagnostic testing, prescribing drugs for acute and
chronic illnesses, and monitoring patients' long-term health. In the
area of counseling and health education, there was a 1-in-5 chance
patients would get everything experts say they should.
The quality of treatment differed markedly by disease, with the
best performances seen in breast cancer, certain forms of heart
disease and low back pain. For pneumonia, bladder infections,
diabetes and peptic ulcers, however, fewer than half of the
recommended best practices were followed. Most of the time, the
problem was that physicians and nurses did not do or ask enough. But
with some conditions, such as migraine headaches, patients were
overtreated.
The study, being published today in the New England Journal of
Medicine, sketches a dark and disturbing portrait of American health
care. It adds to the rapidly growing body of research showing a huge
gap between what is known by medical scientists and what is done by
medical practitioners.
"Everyone is at risk of failing to get care that they need to
live a longer and healthier life," said Elizabeth A. McGlynn, a
researcher at Rand, a consulting company in California, who headed
the study. "It is time to stop having a debate whether we have a
problem, and start having a talk about how we can solve the
problem."
Although many studies have shown that it takes a long time --
often more than a decade -- for the majority of clinicians to adopt
practices of proven worth, several experts not involved with the
Rand survey were nevertheless surprised by the low level of
performance it found.
"The bad news is just how bad the results are. The good news is
that there is a lot of work going on in this area," said Carolyn M.
Clancy, head of the Agency for Healthcare Research and Quality in
the Department of Health and Human Services.
"If auto repair defect rates were the same as this, we wouldn't
be alive today," said Donald M. Berwick, a pediatrician who heads
the Institute for Healthcare Improvement, a nonprofit organization
in Boston. "This is something that the public ought to be very
concerned about. We ought to set a national agenda for dramatic
improvement of care."
The study built on a previous survey that asked 20,000 randomly
chosen adults in 12 metropolitan areas where and how they received
medical care. In this study, they were asked to name their
physicians and consent to the release of their medical records for
the previous two years. A brief medical history was also taken over
the phone. Ultimately, copies of hospital charts and clinic notes
from about 40 percent of the people surveyed were sent to Rand
researchers.
Twenty nurses then reviewed the records, looking for evidence
that specific interventions were done -- or, in some cases, avoided
-- in people with particular medical histories, conditions,
symptoms, findings on physical exam, habits or laboratory results.
The recommended interventions were chosen by experts, based on
strong evidence of value or harm found in scientific studies. In the
case of some conditions, there were many -- 37 for coronary artery
disease, 27 for high blood pressure, 25 for asthma. In others there
were few -- 5 for alcohol dependence, 5 for pneumonia, 3 for
arthritis. In all, there were 439 on the list.
The percentage of the time that patients got the recommended
treatment for a selection of conditions was: cataracts, 79 percent;
breast cancer, 76 percent; prenatal care, 73 percent; low back pain,
69 percent; coronary artery disease, 68 percent; hypertension, 65
percent; congestive heart failure; 64 percent; depression, 58
percent.
Performance was worse in treatment of diabetes, in which patients
got 45 percent of recommended care; peptic ulcer, 33 percent; hip
fracture, 23 percent; alcohol dependence, 11 percent.
The researchers also looked at performance based on general type
of intervention. Medication choices followed recommended practices
69 percent of the time; immunizations, 66 percent; physical
examination, 63 percent; and lab testing, 62 percent. However,
physicians asked key questions while getting the medical history for
the patient 43 percent of the time. Adequate counseling and teaching
were done 18 percent of the time.
Some of the oversights found in the survey involve recommended
practices with major effects on mortality that have been known for
years. For example, 61 percent of people with heart attacks
(myocardial infarction) received aspirin, which reduces the risk of
death by 15 percent. This has been well established since 1988.
Among people with the abnormal heart rhythm called atrial
fibrillation, the study found that 57 percent of those younger than
65, and 43 percent of those older than 65, were prescribed the
anticoagulant warfarin. A study published in 1990 showed that giving
the drug to people with that condition lowered the annual risk of
stroke from 3 percent to 0.4 percent.
Several experts said that blame for poor performance should fall
not primarily on practitioners.
"I don't think that this study should be read as an indictment of
physicians or nurses. They are simply working in a care system that
is incapable of supporting excellence, a system we have designed for
failure," Berwick said.
Among the many urgent changes that are needed, he said, is much
better use of information technology to track what has been done for
patients, remind physicians what needs to be done, provide
information about best practices in real time, and measure clinician
performance on a regular schedule.
