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POLICY/QUALITY: Sliding Down the Back Side of the Health Care Quality Curve: Who’s at Greatest Risk?, by Brian Smedley

The recent RAND study that suggested that there were few or no differences in the quality of treament of minorities when they got into the US health system has not been taken lying down by those who believe that there are great differences, and that ignoring them to look at the bigger picture, as the RAND researchers suggested, is not the way to go. Brian Smedley, the research director at The Opportunity Agenda wrote this opinion piece criticizing the RAND study for THCB:

Ask anyone who’s worked in, received treatment in, or studied American hospitals and health care systems, and you’ll find broad agreement:  U.S. health care systems are beset by quality problems.  Information systems don’t "talk" well with one another, medical errors remain all too common, and many patients don’t receive the types of treatments and services that they should.

 

Recently, a new study expands on these problems, finding that treatment is mediocre at best for all patients, regardless of race, ethnicity, gender, or income.  This study, published March 16 by physician Steven Asch and colleagues in the New England Journal of Medicine, finds that, on average, patients receive a little more than half of the care recommended by a set of "gold standard" guidelines.  And even though few patients are well-served, women and minorities were found to fare better than whites and men in receiving recommended care.

 

This finding wouldn’t be so shocking to most Americans, who tend to believe that health care is fair for all groups, even if less-than-stellar.  Many Americans tolerate (and therefore tacitly accept) that fact that minorities are more likely to be uninsured or underinsured, or to live in communities that lack high-quality primary and specialty care, access-related problems which have profound implications for quality of health care. But once patients are in the health care system, we believe, race or ethnicity doesn’t matter.

 

This view, however, squarely contradicts what the vast majority of research studies have found for decades – that some patients, most notably African Americans, Latinos, those who don’t speak English well, and in some cases, women – receive a lower quality of health care than their counterparts, even when they have similar health insurance and are treated for the same health conditions in the same hospitals. This applies across the gamut of health care, ranging from basic services such as screening and immunization, to primary care, to more expensive, high-tech, specialty procedures.

 

These are the conclusions of literally hundreds of studies published in peer-reviewed journals over the last two decades.  And while a few studies, such as the Asch study, find that disparities are diminishing or that all groups receive equal (albeit poor) treatment, their findings must be considered relative to the massive volume of evidence to the contrary.   Even the U.S. Department of Health and Human Services’ National Healthcare Disparities Report, released in January and which represents the most comprehensive survey of its kind, finds that, despite some areas of improvement, racial and ethnic healthcare disparities persist, and are worsening in some areas.   For example, the NHDR found that Latino patients with diabetes are receiving poorer quality care today than they were even a few years ago.   

 

Importantly, the Asch study confirms that quality problems abound.  But the authors’ conclusion – that "quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care" – unfortunately presents a false choice.  Policymakers are not confronted with the question of whether to prioritize efforts to reduce inequality, or efforts to improve overall quality. Rather, these problems are inextricably linked.  The persistence of healthcare disparities is a clear warning that systemic problems plague our health systems. Moreover, many of the same interventions that will reduce disparities – such as promoting the broader use of evidence-based guidelines and public reporting of hospital quality scores by patient race, ethnicity, and primary language – will help to improve quality for all patients.

Progressive health care advocates should seize upon health care disparities as a key political issue and an argument for stepped-up quality improvement efforts. Unequal health care is not only wrong, it’s one of many signals that American health care is reeling from systemic problems that hamper the best efforts of hard-working physicians, nurses, administrators, and others to provide the best quality care.  Our concern and focus should be on raising the quality of care for everyone, with particular attention to those who are least well served.

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ware double fleece hangjack danielsjack danielsMarcMatthew Holt Recent comment authors
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ware double fleece hang
Guest

An impressive share! I have just forwarded this onto a colleague who had been conducting a
little research on this. And he actually ordered me breakfast due to the fact
that I stumbled upon it for him… lol. So allow me to
reword this…. Thank YOU for the meal!! But yeah, thanks for
spending the time to discuss this topic here on your site.

jack daniels
Guest
jack daniels

Most of the RAND criteria they are using for quality judgment is only their opinion. Only a few of their recommendations are endorsed wholesale by all the medical organizations and researchers.

Tom Leith
Guest
Tom Leith

> As far as delivering an aspirin…
This is quite simply, insulting.
t

Marc
Guest

Well, I guess I have to disagree, and maybe even get in the last word or two. As far as delivering an aspirin to a heart attack patient. What if that patient had a low platelet count, or was on blood thinners? Would it have been a good idea to give him aspirin, or even necessary? I’m also not so sure that giving a pneumonia vaccine to someone with pneumonia would be very effective, although I am not a doctor. And just how is it that you characterize medical uncertainty? Nobody is trying to reduce quality of care to a… Read more »

Tom Leith
Guest
Tom Leith

> And reports, such as the NEJM report, that tries to > define quality, by relating it simply to receiving > the recommended treatment are even more meaningless. No, not meaningless. If we were in (say) a three-sigma world with respect to healthcare you would have a fair point. But we’re not. We are not even in a two-sigma world. In the world we are in, we can’t reliably deliver the recommended aspirin to heart attack patients when they come into the ED. We can’t seem to deliver discharge instructions — minimal patient education — to people whose health is… Read more »

Marc
Guest

Tom, I should have clarified physical condition as being athletic condition, but hopefully you knew what I meant.

Marc
Guest

Thanks Tom, but don’t feel too sorry for me. It’s not as bad as you think, at least not yet? 🙂 While I would much prefer not to be sick, I consider it a blessing in disquise, which I do try to indicate in my blog. It has given me a much different outlook on life, which I think many would benefit from. Also if we met, you would never know I was sick, plus, and although I don’t know you, there is high probability that I am in much better physical condition than you. Anywaze, enough of that. Let’s… Read more »

Tom Leith
Guest
Tom Leith

I am sorry to hear about your cancer. It seems to me you use the terms outcome and quality a little inconsistently. As for what you said about measurement, all I can do is refer you back to the fourth paragraph of your first post in this thread. Even if you meant to say you don’t think the quality of treatment can be fairly measured, I would still object. Patient satisfaction is an important part of quality; important enough to completely overwhelm a particular clinical outcome. It is true that some patients will find the benefit/burden ratio of the recommended… Read more »

Marc
Guest

Boy Tom, you love using those big words that I have to keep looking up. Interloqutor! If you were talking about me, I didn’t really say outcomes couldn’t be measured, I said they couldn’t be quantified with any accuracy without taking into account how severely injured a person is, or how far along the diseased has progressed in any given person. That is what cannot be measured or quantified. I should add that my opinions are based on my own experience. When I was diagnosed with NHL, over 4 years ago, my doctors were ready to give me the recommended… Read more »

Tom Leith
Guest
Tom Leith

> Tom you said that if nothing was known about > outcomes data, that going to a doctor would be > worthless. I did not say that. What I said was: If you don’t think outcomes can be fairly measured, then all medicine is a spin of the wheel and it is irrational to seek the advice of a doctor because there is no basis for your belief that you might walk out in better shape than you when you went in. Contrast the meaning of what I said with what I think you misread me to mean: If there… Read more »

jack daniels
Guest
jack daniels

I read the study again, and some of the “quality” criteria in there is a joke.
One of the criteria that doctors were penalized on was whether or not they asked about seat belt usage.
I’m sorry but thats not the doctors job. Alot of the stuff in their “quality” criteria list is very shady to say the least

jack daniels
Guest
jack daniels

Marc and Tom are both right to some extent, but neither is right exclusively. Health care outcomes CAN BE measured and standardized, provided that sufficient inclusion and exclusion criteria exist. Take for example the thrombolytic drug TPA. TPA has been proven beyond any doubt to have a positive effect in treating acute stroke, but ONLY for those patients that meet a laundry list of inclusion and exclusion criteria. Whether TPA is effective in the aggregate for people with stroke who dont meet those criteria is just guessing. Some docs say yes, others say no. Thats why ER docs, who have… Read more »

Marc
Guest

Well, I might consider my statement polemical, but certainly not a canard! Have you ever heard the statement doctors practice medicine. Certainly the recommended treatment may increase the odds of a good outcome, but only in the average person with an average severity of disease or injury. Oh if we were all only average, how simple things would be. And medicine is anything but irrational, but neither is it necessarily “rational” for lack of a better term. There is no one absolute right answer, and that is the reason we go to doctors. It is their training and expertise that… Read more »

Tom Leith
Guest
Tom Leith

OK, for you quality means I walk out of the hospital, or doctors office, in better shape than I went in. Fair enough. The authors of the NEJM report take as a given that following recommendations increases the odds of a good outcome on your definition. You are making the Cookbook Medicine criticism, which is thoroughly discussed elsewhere. I think it is a strawman argument, and a polemical canard. If you don’t think outcomes can be fairly measured, then all medicine is a spin of the wheel and it is irrational to seek the advice of a doctor because there… Read more »

Marc
Guest

The way I see it, there is a difference between the quality of care one receives, and whether one receives what others, unfamiliar with a case, have determined to be the recommended care. Everyone of us is different, and it is the doctors job to determine what the appropriate treatment should be in any particular situation, and it may not be the recommended treatment. I have read the NEJM report, and was not impressed. It did not indicated the outcomes of those who were treated. Did those who receive the recommended treatment have better health outcomes than those that received… Read more »