NEWS

U.S. Falls Short of Top-Notch Health Care, Report Says

James Schultz

America’s health care system is far from achieving its potential to be among the world’s best, according to the authors of a report issued in January by the Institute of Medicine (IOM).



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In its recent report, the Institute of Medicine identified 20 areas in which sustained effort could "transform the entire health care system."

 
"We have extraordinary knowledge and capacity to deliver the best care in the world, but we repeatedly fail to translate that knowledge and capacity into clinical practice," the authors wrote in "Priority Areas for National Action: Transforming Health Care Quality." "Although the health care workforce is trying hard to deliver the best care, those efforts are doomed to failure with today’s outmoded and poorly designed systems."

The report noted that the inability to provide top-notch care is the result of "disjointed health care delivery systems that are unable to put these treatments into practice." Additional complications that degrade care delivery are increased cost pressures, reduced physician time with patients, the sheer and accelerating accumulation of medical knowledge, competing standards, and the inability of many providers to communicate regularly and consistently with the communities they serve.

"Health care professionals need to be persuaded to bring better care across the board," said George Isham, M.D., medical director and chief health officer for HealthPartners Inc. in Bloomington, Minn., and chair of the IOM report committee. "They need to be given incentives for doing so. As metrics are developed, there will be better rewards for improving performance. [Now] there are in many cases gaps between the wonderful therapies that have been developed and what people are actually getting."

Addressing those shortcomings is especially urgent, according to the IOM, because chronic disease is now the leading cause of illness, disability, and death in the United States, accounting for the majority of health care expenditures. In 2000, direct costs associated with chronic illness totaled $510 billion, a figure that may double to $1.07 trillion by 2020. In the year 2000, the report noted, nearly half the American population, or some 125 million people, suffered from at least one chronic illness, with 60 million afflicted with two.

Areas of Improvement

The report identifies 20 priority areas in which sustained effort could, according to the report, "transform the entire health care system." These include familiar treatment areas, such as cancer screening, and pain control in advanced cancer, heart disease, stroke, asthma, diabetes, and hypertension. Less apparent but essential priorities should include such matters as depression, immunization, frailty associated with old age, care coordination, tobacco-dependence treatment, and the emerging issue of obesity.

Five of the included conditions—heart disease, cancer, stroke, heart disease, and diabetes—account for roughly 1.5 million deaths annually and represent 63% of total annual deaths in the United States. The IOM report asserted that if a redesigned system of care led to even a small reduction in mortality of 5%, nearly 75,000 premature deaths could be averted.

"Earlier IOM reports have demonstrated major variations in quality. This report is another piece of the puzzle," said Greg Pawlson, M.D., executive vice president of the National Committee for Quality and a member of the IOM report committee. "There are systems that just aren’t working effectively. Even using existing technologies and procedures, we can do better."

Two Cancer-Specific Areas

The report focuses on two primary areas of cancer prevention and treatment: screening and pain management. The report encourages the creation of enhanced programs designed to prevent colorectal and cervical cancer, and it encourages offering appropriate screenings and timely follow-up to more people. The IOM report suggested that systems-based interventions implemented for these two cancers could serve as models for other cancers where an evidence base is documented for screening, or could be used once one has been established.

"Health care is complicated," said Karen Bodenhorn, R.N., chief executive officer and president of the Center for Health Improvement in Sacramento, Calif. "People are busy. There are medical crises. Systems need to be in place so that providers are prompted to check on screenings, whether they’ve been ordered and what the results are."

The report notes outcomes of a 5-year demonstration project targeting low-income members of minority groups who received their health care through the Los Angles County Department of Health Services. Systems interventions included physician education to heighten awareness of screening guidelines; patient education regarding risk factors for cervical cancer; policy interventions, such as written protocols to ensure follow-up of abnormal results; and expanded capacity—increased clinic hours and same-day appointments for referrals. During the study period, patients were three times more likely to receive screenings compared with the baseline year.

Pain management for cancer should also be a priority, according to the IOM. Severe pain affects 20% to 50% of patients at the time of diagnosis and during subsequent treatment, as well as 55% to 95% of those in the advanced stages of disease. The report pointed out that, because less than 10% of cancer patients near death have pain that requires sedation to overcome, at least 90% of patients can be comfortable through most of their illness. Yet, despite proven guidelines for pain relief, such as the World Health Organization’s three-step analgesic ladder, which gradually adjusts the potency of medication as the patient’s level of pain increases, pain continues to be undertreated.

"We don’t necessarily need new pain medications," said the National Committee for Quality’s Pawlson. "We know we can do better using existing approaches to pain. Sometimes it’s a matter of not being aggressive enough in simply asking patients if they’re in pain."

To achieve measurable results, the IOM report suggested developing standardized measures that can be compared and continuously improved. Any subsequent assessments, the authors insist, must include measures of the degree to which the system has been transformed and of the clinical impact on patient care. As changes are implemented, the list of priority areas should be reviewed and updated, ideally in 3 but in no more than 5 years. Other priorities may need to be added as the result of new data on impact or the development of new treatment interventions. Likewise, if strategies for improvement are effective, some areas may be removed.

Oversight

The federal Agency for Healthcare Research and Quality, within the Department of Health and Human Services and in collaboration with other private and public entities, could oversee progress by annually reviewing and reporting on measured results and disseminating information on improvement efforts. As part of that process, mechanisms would be developed to solicit public input, review and revise the priority framework, criteria and candidate list; assess current priorities and new candidates against criteria; decide on an updated priority list; establish a process to determine plans for implementation; and revise and continue measures in place.

"There are a lot of opportunities for improvements," said report chair Isham. "We’re encouraged that improvements can be made. I’m optimistic, across the board. With substantial effort, these gaps can be closed."



             
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