Volume 1: No. 3, July 2004

COMMENTARY
Prevention Health Care Quality in America: Findings From the First National Healthcare Quality and Disparities Reports

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	Navigate This Article • Introduction • Findings • Conclusions • Author Information • References • Tables

Ed Kelley, PhD, Ernie Moy, MD, MPH, Beth Kosiak, PhD, Dwight McNeill, PhD, Chunliu Zhan, MD, PhD, Dan Stryer, MD, Carolyn Clancy, MD

Suggested citation for this article: Kelley E, Moy E, Kosiak B, McNeill D, Zhan C, Stryer D, et al. Prevention health care quality in America: findings from the first National Healthcare Quality and Disparities Reports. Prev Chronic Dis [serial online] 2004 Jul [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
jul/04_0031.htm.

Introduction

The Agency for Healthcare Research and Quality (AHRQ) released in December 2003 the first National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) on behalf of the U.S. Department of Health and Human Services (1,2). In this commentary, we summarize the main findings of the reports on preventive care for both primary prevention of disease and secondary prevention of increasing acuity of existing disease and discuss the implications for quality measurement and improvement efforts.

Federal partners within the U.S. health care system have recently focused on increasing the use of preventive care services. Tommy G. Thompson, Secretary of Health and Human Services, issued a challenge in April 2003 at the launch of the Steps to a HealthierUS national initiative:

"Approximately 95% of the $1.4 trillion that we spend as a nation on health goes to direct medical services, while approximately 5% is allocated to preventing disease and promoting health. This approach is equivalent to waiting for your car to break down before you take it in for maintenance. By changing the way we view our health, the Steps initiative helps move us from a disease care system to a true health care system." (3)

Good quality preventive care holds the promise of greatly reducing the nation’s health care costs and overall burden of disease. Numerous studies and reports have examined the general quality of preventive care services in the United States (4-7). Others have explored the performance of the U.S. health care system in delivering specific preventive care services such as immunizations (8,9), cancer screening (10-12), and cholesterol and blood pressure screening (13-15).

The NHQR and NHDR provide the first national baseline views of the quality of health care services and of differences in how at-risk groups in America use the services. The reports provide one of the broadest examinations to date of prevention health care quality for the nation and among key priority populations, measuring quality of care across a range of dimensions, including the degree to which care is safe, patient centered, timely, and effectively delivered. They track more than 50 primary and secondary prevention quality-of-care measures in five clinical areas, including cancer, diabetes, heart disease, maternal and child health, and respiratory disease.

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Findings of the NHQR and NHDR

Table 1 summarizes the major conclusions of the two reports: the promise of high-quality health care is not a given, gaps in quality are particularly acute for certain racial, ethnic, and socioeconomic groups, and improvement is possible.

NHQR findings

In some areas, however, prevention health care quality has improved. For example, the incidence rate of new cases of cervical and colorectal cancers detected at an advanced stage has been declining for decades. The percentage of institutionalized adults (persons in long-term care or nursing homes) who have ever received pneumococcal vaccination, while still low at 33% (1999), has improved from 25% (1997). More than 73% of children aged 19 to 35 months have all their recommended vaccinations. And 83% of women obtain prenatal care in their first trimester.

NHDR findings

• People of lower SES and some minorities are less likely to have colorectal and breast cancer screening.
• People of lower SES and Hispanics are less likely to have blood pressure and cholesterol screening in addition to counseling and treatment for some cardiac risk factors.
• People of lower SES and blacks are less likely to have recommended childhood immunizations before the age of four years.
• Children of lower SES and some minority children are less likely to have dental care.
• Lower-SES, black, and Hispanic adults are less likely to have recommended immunizations for influenza and pneumococcal disease.

Preventive care for specific diseases

NHQR and NHDR findings for cancer, diabetes, and heart disease are presented below.

Figure. Cancer screening rates, 1998–2000, National Healthcare Quality Report. Data not available for colorectal screening rates for 1999. Data from National Health Interview Survey, 2000 (19).

Diabetes
High quality of care for diabetes requires that people with diabetes receive the tests, exams, and treatments that can help them and their providers manage their condition. Table 2 shows variability in the rate of delivery of services across the five process measures of care, ranging from a low of 54.8% for influenza immunization to a high of 94.3% for a lipid profile test. Of particular note is that only 23% of people with diabetes get all recommended secondary preventive services.

Heart disease
The reports track performance in screening for high blood pressure and high cholesterol and in delivering smoking cessation counseling.

Cholesterol screening. Cholesterol screening rates have increased in the last two decades. According to 1998 NHIS data, 67% of adults had their cholesterol checked within the previous five years and more than 80% of adults aged 45 or older had their cholesterol checked (21).

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Conclusions and Implications

The NHQR and NHDR are two of the most comprehensive national assessments of preventive care quality in the United States. They show that the U.S. health care system is missing numerous opportunities to provide evidence-based preventive care and that usage rates for a number of preventive care services are not improving. Significant progress is needed in areas such as colorectal cancer screening, delivery of the full complement of diabetes secondary preventive services, and cessation counseling for smokers, particularly when they are admitted to the hospital for heart attacks.

The purpose of the reports, according to the Congressional mandate that created them, is to document the state of health care quality for the nation. The reports do not address the determinants of health care quality, nor do they prescribe how quality of care could be improved or suggest a national agenda for improving quality. Many public and private entities address these important research, policy, and quality-improvement questions.

The reports contribute to the quality-improvement cycle by providing national information on the state of health care quality, potential benchmarks, and changes that have occurred over time to support a broad community of concerned quality-improvement professionals. Information is critical to helping this broad community understand how gaps and opportunities apply to their own local needs and facilitate their move from data to action. The reports offer more than 525 tables that provide essential information for researchers to analyze the important questions about why performance is the way it is. The reports can help policy makers formulate an agenda for quality by creating understanding about the greatest needs among a wide variety of concerns. Similarly, the reports can serve as a scorecard on the collective performance of all those involved in quality improvement.

In addition to tracking health care quality through the reports, the AHRQ supports quality improvement for the nation by conducting research to determine evidence-based prevention practices, translating research into knowledge, and facilitating the use of knowledge toward the goal of improving the quality of prevention services for all Americans.

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Author Information

The views expressed in this article are those of the authors and do not necessarily reflect those of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Corresponding author: Ed Kelley, PhD, Director, National Healthcare Quality Report, Agency for Healthcare Research and Quality, 540 Gaither Rd, Suite 300, Rockville, MD 20850. Telephone: 301-427-1321. E-mail: ekelley@ahrq.gov.

Author affiliations: Ernie Moy, MD, MPH, Beth Kosiak, PhD, Dwight McNeill, PhD, Chunliu Zhan, MD, PhD, Dan Stryer, MD, Carolyn Clancy, MD, Agency for Healthcare Research and Quality, Rockville, Md.

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References

1. U.S. Department of Health and Human Services. National healthcare quality report. Rockville (MD): Agency for Healthcare Research and Quality; 2003. Available from: URL: http://www.qualitytools.ahrq.gov/qualityreport/ download_report.aspx*.
2. U.S. Department of Health and Human Services. National healthcare disparities report. Rockville (MD): Agency for Healthcare Research and Quality; 2003. Available from: URL: http://www.qualitytools.ahrq.gov/disparitiesreport/ documents/DisparitiesLtr.htm*.
3. U.S. Department of Health and Human Services. Steps to a healthier U.S. Washington (DC): Office of Public Health Promotion; 2001. Available from: URL: http://www.healthierus.gov/steps/steps_brochure.pdf*.
4. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998;280 (11):1000-5.
5. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristotaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348 (26):2635-45.
6. Leatherman S, McCarthy D. Quality of health care in the United States: a chartbook. New York (NY): The Commonwealth Fund; 2003 Apr. 164 p.
7. Janes GR, Blackman DK, Bolen JC, Kamimoto LA, Rhodes L, Caplan LS, et al. Surveillance for use of preventive health-care services by older adults, 1995-1997. MMWR Surveill Summ 1999 Dec 17;48 (8):51-88.
8. Centers for Disease Control and Prevention. National, state and urban area vaccination coverage levels among children aged 19-35 months — United States, January-December 1995. MMWR Morb Mortal Wkly Rep 1997;46 (8):176-82.
9. Kottke TE, Solberg LI, Brekke ML, Cabrera A, Marquez MA. Delivery rates for preventive services in 44 midwestern clinics. Mayo Clin Proc 1997;72 (7):515-23.
10. Hawley ST, Vernon SW, Levin B, Vallejo B. Prevalence of colorectal cancer screening in a large medical organization. Cancer Epidemiol Biomarkers Prev 2004 Feb;13 (2):314-9.
11. Goel MS, Wee CC, McCarthy EP, Davis RB, Ngo-Metzger Q, Phillips RS. Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med 2003 Dec;18 (12):1028-35.
12. Janz NK, Wren PA, Schottenfeld D, Guire KE. Colorectal cancer screening attitudes and behavior: a population-based study. Prev Med 2003 Dec;37 (6 Pt 1):627-34.
13. State-specific cholesterol screening trends — United States, 1991-1999. MMWR Morb Mortal Wkly Rep 2000 Aug 25;49 (33):750-5.
14. Lin T, Chen CH, Chou P. Impact of the high-risk and mass strategies on hypertension control and stroke mortality in primary health care. J Hum Hypertens 2004 Feb;18 (2):97-105.
15. Sheridan S, Pignone M, Donahue K. Screening for high blood pressure: a review of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med 2003 Aug;25 (2):151-8.
16. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997 Jan 8;277 (2):115-21.
17. Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al, editors. SEER Cancer Statistics Review, 1975-2000. Bethesda (MD): National Cancer Institute; 2003. Available from: URL:  http://seer.cancer.gov/csr/1975_2000/*.
18. Centers for Disease Control and Prevention, National Center for Health Statistics. National Hospital Discharge Survey. Hyattsville (MD): The Centers;1998-2000.
19. Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey. Hyattsville (MD): The Centers;2000.
20. Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey (MEPS). Rockville (MD): The Agency:2000.
21. Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey. Hyattsville (MD): The Centers;1998.

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Tables

Table 1. 
General Summary of Health Care in the United States, National Healthcare Quality Report and National Healthcare Disparities Report, Agency for Healthcare Research and Quality, 2003

^a This measure is the percentage of AMI patients that are prescribed beta blockers at discharge.

Table 2. 
Process Measures of Quality Care for Diabetes in Adults Aged 18 and Older, United States, 2000^a

^aData from Medical Expenditure Panel Survey, 2000 (20).

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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.

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