The clinical quality of outpatient care for adults in the United States did not improve consistently from 2002 to 2013, despite numerous local, regional, and national efforts to make it better, according to a report published online Oct. 17 in JAMA Internal Medicine.

“Current deficits in care continue to pose serious hazards to the health of the American public in the form of missed care opportunities as well as waste and potential harm from overuse,” said David M. Levine, MD, of Brigham and Women’s Hospital and Harvard Medical School, Boston, and his associates.

Since a 2003 report showing that American adults received about half of the recommended health care services, many programs have sought to make improvements by expanding quality measurements and public reporting, increasing pay for performance, increasing value-based purchasing by payers, increasing the use of electronic medical records, improving coverage for recommended services, and expanding patient-centered medical homes.

Yet few data are available by which to gauge whether these efforts have been effective, the investigators noted (JAMA Intern Med. 2016 Oct 17; doi:10.1001/jamainternmed.2016.6217 ).

They analyzed data from a nationally representative annual outpatient survey to determine whether 46 indicators of care quality changed from 2002 to 2013. Sample sizes ranged from 20,679 to 26,509 adults per year, and that information was supplemented by responses from the patients’ clinicians, pharmacies, and employers.

Overall, rates of recommended treatment delivery showed an “anemic” improvement from 36% to 42%, with a few areas showing marked improvement while others showed little improvement or actual declines.

For example, rates of recommended medications for heart failure increased from 41% to 65%; rates for recommended statin therapy for stroke patients increased from 34% to 57%; and rates of recommended smoking-cessation counseling increased from 49% to 61%. However, rates of inappropriate antibiotic prescribing and inappropriate medications in the elderly both worsened.

Recommended colorectal cancer screening improved from 48% to 63%; but recommended breast cancer screening declined from 81% to 77%, and recommended cervical cancer screening declined from 90% to 86%.

Inappropriate cervical cancer screening in the elderly improved, but inappropriate colorectal cancer screening in the elderly worsened.

Of greatest concern, approximately half of elderly adults underwent inappropriate cancer screening when it was unlikely to prolong life. And approximately half of adults who saw a clinician for a viral illness received inappropriate antibiotics. In addition, approximately 15% who consulted a clinician for back pain received an inappropriate lumbar radiograph.

“These areas represent prime targets for efforts to improve the value of care delivered by eliminating services that have a neutral or negative impact on health,” Dr. Levine and his associates said.

The investigators emphasized that these data do not reflect changes resulting from the Affordable Care Act, which was implemented in late 2013. The ACA has encouraged many organizational changes, renewed the focus on primary care, and expanded health insurance coverage to 30 million more people. All of these changes are expected to improve overall health care quality, the study authors noted. But it is not yet known whether these changes will have their intended effect.

This study was supported in part by the National Institutes of Health and the Ryoichi Sasakawa Fellowship Fund. Dr. Levine and his associates reported having no relevant financial disclosures.


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