July / August 2008
Progress Slows in Improving Patient Safety for All Populations
Ever since the Institute of Medicine reported that up to 98,000 Americans die each year as the result of medical errors (2000) and observed that our healthcare system suffers from a "chasm" between consistent, high-quality care that is based on the best scientific knowledge available and the care many actually receive (2001), there has been renewed vigor in reducing variation and improving healthcare for all Americans. A particular emphasis has been placed on improving patient safety and reducing medical errors, with dozens of multi-stakeholder initiatives aimed at protecting patients from harm.
The Agency for Healthcare Research and Quality (AHRQ) has been documenting steady, but modest, improvement in the quality of American healthcare. Two new reports published by the Agency indicate that, unfortunately, the rate of quality improvement appears to be slowing. Data that would provide a comprehensive national assessment of patient safety remain incomplete; nevertheless, the rate of improvement in quality measures that represent patient safety is modest, at best.
The pace of improvements in patient safety is based on measures of healthcare quality, including the protection of patients from medical errors. The fifth annual National Healthcare Quality Report (www.ahrq.gov/qual/nhqr07/nhqr07.pdf) and National Healthcare Disparities Report (www.ahrq.gov/qual/nhdr07/nhdr07.pdf) also examined healthcare quality more broadly and found that some areas of healthcare made important gains, but overall quality improved by an average of just 1.5% per year between 2000 and 2005. That modest rate represents a decline compared with the 2.3% average annual rate over the longer period from 1994 to 2005.
Disturbingly, measures of patient safety (which are also factored into the overall rate) showed an average annual improvement of only 1%. That rate reflected such measures as how many Medicare surgery patients had not received antibiotics to prevent infection at the right time, what portion of elderly patients had been given potentially harmful prescription drugs, and how many patients developed post-surgery complications.
These results are worrisome not simply because they exist, but because they exist despite the ongoing efforts around the country to improve patient safety. Efforts to improve quality are working, but the gains are not occurring widely enough or quickly enough. Until these trends accelerate, we will continue to miss vital opportunities to save lives.
Minority Patients at Highest Risk
AHRQ's quality and disparities analyses draw on more than three dozen databases to measure quality and disparities in five areas: the effectiveness of care, patient safety, timeliness of care, patient centeredness, and the efficiency of care.
The National Healthcare Quality Report tracks quality measures for the healthcare system overall. Its companion, the National Healthcare Disparities Report, summarizes differences in healthcare quality and access experienced by various racial, ethnic, and income groups, as well as other priority populations including children, women, individuals with special healthcare needs, residents of rural areas, and the elderly. The two reports are published together because healthcare quality and disparities are related issues, and it is important to track overall healthcare quality improvement simultaneously with the disparities that exist for many throughout our healthcare system.
The 2007 reports do show some notable gains. For instance, using measures such as what portion of heart attack patients received recommended tests, medications, or counseling to quit smoking, the report found an average 5.6% annual improvement rate from 2000 to 2005. Disparities in childhood vaccines have also been reduced for Blacks, Asians, and Hispanics.
But the evidence is clear that patient safety is not improving as fast as it should. This is particularly true for vulnerable populations. For instance, in 2005, Black surgical patients continued to have significantly higher rates than White patients for postoperative complications (7.51% compared with 4.48%), and the proportion of appropriately timed antibiotics provided to Medicare surgery patients was significantly lower for Hispanics (69.8%) and Asians (70.8%) than for Whites (75.2%).
Although patient safety is one of the six Institute of Medicine aims for the healthcare system, the landmark report on patient safety, To Err Is Human, does not mention race or ethnicity when discussing the problem of patient safety. A recent review of the literature found that only 9 of 323 articles on pediatric patient safety (3.1%) included race or ethnicity in the analysis.
It is clear that variations in quality, including patient safety according to race, age, income, insurance status, and geography undercut improvement efforts. These disparities are reflected in a variety of measures and settings. For instance, insurance status has a significant impact on quality. Consider, for instance, that the proportion of women with private insurance received mammograms at a much greater rate (74%) in the past two years than uninsured women (38%). This is the sort of healthcare disparity that should, and can, be addressed.
Measuring quality in healthcare is complex, and, as these reports demonstrate, sustaining quality improvement is difficult. While we are seeing improvements, they are small compared to the quality chasm that exists. While all of the factors that contribute to medication errors or avoidable surgical complications are not always clear, patient safety is an area that many Americans understand, and they expect action from the healthcare community. In order to more rapidly close the chasm between the knowledge we do have about health and the safety and quality of healthcare that is actually delivered, a renewed commitment to quality improvement is necessary. We hope that the National Healthcare Quality Report and National Healthcare Disparities Report will provide the impetus for that renewed commitment.
Jeffrey Brady is lead staff at the Agency for Healthcare Research and Quality for the National Healthcare Quality Report. He may be contacted at firstname.lastname@example.org.
Karen Ho is lead staff at the Agency for Healthcare Research and Quality for the National Healthcare Disparities Report. She may be contacted at email@example.com.
Carolyn Clancy is director of the Agency for Healthcare Research and Quality. She is a general internist and holds an academic appointment at George Washington University School of Medicine in Washington, D.C. She may be contacted at firstname.lastname@example.org.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.