Monday, March 20, 2006

NEJM article on who is at greatest risk of poor quality health care

The March 16, 2006 issue of NEJM published an article reporting the results of applying RAND's Quality Indicators ( some 439 of them) for 30 medical conditions based on telephone interviews followed by review of medical records for those participants who gave permission.

The quality indicators were chosen by a nine member multispeciality "expert panel" using the RAND-UCLA modified Delphi method. The degree to which physicians "comply" with these opinions of what is good care is the measure of quality.

One could haggle with how to measure quality in this type study but nevetheless some of results will give ammunition for health policy wonks of almost any persuasion.

Those who believe a single payer (government) system is best will have to gloss over the authors' sentence that says:

" In the United Kingdom,with universal coverage, a study using our methods found that the overall proportion of recommended health care that was received was similar to what we have reported"

and what they report in this article is that the " problems with quality of care are indeed widespread and systemic and require a system wide approach."

You have to wonder what approach they would recommended as they seem to say both the single payer and the current U.S. set up give equally unacceptable results.

Surprisingly they found that :
"..Blacks had higher scores than whites for the quality of heath care".

This differs markedly from what many other studies have shown.

They also found that
"...health insurance status was largely unrelated to the quality of care".

So is all this concern about the large number of uninsured people misdirected?

This is not outcome data. We have no idea from this study what effect these alleged non-compliances have on the health outcomes. This is process data collected by a method prone to bias ( telephone interviews),using a huge list of quality indicators some of which are evidence based and some expert based. If the medical record did not document a given medical act it is counted as it it did not occur. Further, we are not told in the article what sort of infractions occured and how serious they may be. It is like being told there were 17,242 crimes in a given state over a given time period and we are left in the dark as what types of crimes were documented and how many in each category.

I'll bet we will see a flurry of letters to the editor attacking various aspects of this article.

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