Quality of medical care delivered to Medicare beneficiaries - A profile atstate and national levels

Context Despite condition-specific and managed care-specific reports, no sy stematic program has been developed for monitoring the quality of medical c are provided to Medicare beneficiaries. Objective To create a monitoring system for a range of measures of clinical performance that supports quality improvement and provides repeated, relia ble estimates at the national and state levels for fee-for-service (FFS) Me dicare beneficiaries. Design, setting, and Participants National study of repeated, cross-section al observational data collected in 1997-1999 on all Medicare FFS beneficiar ies or on a representative sample of beneficiaries with a particular condit ion. Data were collected using medical record abstraction for inpatient car e, analysis of Medicare claims for some ambulatory services, and surveys fo r immunization rates. Separate samples were drawn for each topic for each s tate. Main Outcome Measures Beneficiary patients' receipt of 24 process-of-care m easures related to primary prevention, secondary prevention, or treatment o f 6 medical conditions (acute myocardial infarction, breast cancer, diabete s mellitus, heart failure, pneumonia, and stroke) for which there is strong scientific evidence and professional consensus that the process of care ei ther directly improves outcomes or is a necessary step in a chain of care t hat does so. Results Across all states for all measures, the percentage of patients rece iving appropriate care in the median state ranged from a high of 95% (avoid ance of sublingual nifedipine for patients with acute stroke) to a low of 1 1% (patients with pneumonia screened for pneumococcal immunization status b efore discharge). The median performance on an indicator is 69% (patients d ischarged with heart-failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). Some states (particularly less populous states and those in the N ortheast) consistently ranked high in relative performance while others (pa rticularly more populous states and those in the Southeast) consistently ra nked low. Conclusions It is possible to assemble information on a diverse set of clin ical performance measures that represent performance on the range of servic es in a health insurance program. These findings indicate substantial oppor tunities to improve the care delivered to Medicare beneficiaries and urgent ly invite a partnership among practitioners, hospitals, health plans, and p urchasers to achieve that improvement.