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A Profile at State and National Levels

Stephen F. Jencks, MD, MPH; Timothy Cuerdon, PhD; Dale R. Burwen, MD, MPH; Barbara Fleming, MD, PhD; Peter M. Houck, MD; Annette E. Kussmaul, MD, MPH; David S. Nilasena, MD, MSPH, MS; Diana L. Ordin, MD, MPH; David R. Arday, MD, MPH

JAMA. 2000;284:1670-1676.

Context  Despite condition-specific and managed care–specific reports, no systematic program has been developed for monitoring the quality of medical care provided to Medicare beneficiaries.

Objective  To create a monitoring system for a range of measures of clinical performance that supports quality improvement and provides repeated, reliable estimates at the national and state levels for fee-for-service (FFS) Medicare beneficiaries.

Design, Setting, and Participants  National study of repeated, cross-sectional observational data collected in 1997-1999 on all Medicare FFS beneficiaries or on a representative sample of beneficiaries with a particular condition. Data were collected using medical record abstraction for inpatient care, analysis of Medicare claims for some ambulatory services, and surveys for immunization rates. Separate samples were drawn for each topic for each state.

Main Outcome Measures  Beneficiary patients' receipt of 24 process-of-care measures related to primary prevention, secondary prevention, or treatment of 6 medical conditions (acute myocardial infarction, breast cancer, diabetes mellitus, heart failure, pneumonia, and stroke) for which there is strong scientific evidence and professional consensus that the process of care either directly improves outcomes or is a necessary step in a chain of care that does so.

Results  Across all states for all measures, the percentage of patients receiving appropriate care in the median state ranged from a high of 95% (avoidance of sublingual nifedipine for patients with acute stroke) to a low of 11% (patients with pneumonia screened for pneumococcal immunization status before discharge). The median performance on an indicator is 69% (patients discharged with heart failure diagnosis who received angiotensin-converting enzyme inhibitors; diabetic patients having an eye examination in the last 2 years). Some states (particularly less populous states and those in the Northeast) consistently ranked high in relative performance while others (particularly more populous states and those in the Southeast) consistently ranked low.

Conclusions  It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement.

Author Affiliations: Health Care Financing Administration, Baltimore, Md.

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