Quality of Outpatient Care Has Not Improved in Past Decade

The quality of outpatient care for adults has not improved during the past decade, and in some important areas has worsened, according to a new study published in JAMA Internal Medicine by David M. Levine, MD, of Brigham & Women’s Hospital in Boston, and colleagues.

The authors examined changes in the quality of care and patient experience from 2002 to 2013 using the Medical Expenditure Panel Survey (MEPS), a nationally representative annual survey of noninstitutionalized US civilians. Sample sizes were between 20,679 and 26,509 per year during a period in which federal, state, and local quality improvement initiatives aimed to improve the quality of patient care in the United States.

“Evaluation of care quality performance may enable policy makers, clinicians, and health system leaders to target key areas for attention and improvement,” the authors explained.

The study measured 46 indicators of the quality of outpatient care, using data from the MEPS of data from individuals, clinicians, hospitals, pharmacies, and employers. The investigators used 9 clinical quality composites that included 5 “underuse” composites (eg, recommended cancer screenings) and 4 “overuse” composites (eg, avoidance of imaging) based on 39 quality measures; an overall patient experience rating; and 2 patient experience composites (physician communication and access) based on 6 measures.

Four quality composites improved: recommended medical treatment (from 36% to 42%), recommended counseling (from 43% to 50%), recommended cancer screening (from 73% to 75%), and avoidance of inappropriate cancer screening (from 47% to 51%). For example, avoidance of inappropriate cervical cancer screening in women older than 65 years improved. However, avoidance of inappropriate colorectal cancer screening in those older than 75 years worsened.

Two clinical composites worsened: avoidance of inappropriate medical treatments (from 92% to 89%) and avoidance of inappropriate antibiotic use (from 50% to 44%). Avoidance of inappropriate medications in older adults, opioids for back pain, and nonsteroidal anti-inflammatory drugs in hypertension, heart failure, or kidney disease worsened.

Three quality measures were unchanged: recommended diagnostic and preventive testing (76%), recommended diabetes care (68%), and inappropriate imaging avoidance (90%).

The proportion of participants who rated their care highly improved for overall care (from 72% to 77%), physician communication (from 55% to 63%), and access to care (from 48% to 58%).

“Although there were areas of improvement, including provision of recommended medical treatments, recommended counseling, and avoidance of inappropriate cancer screening, there were also areas of decline, including avoidance of inappropriate antibiotic prescribing and avoidance of inappropriate medical treatments,” the researchers wrote.

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, the investigators wrote.

“Ongoing national efforts to measure and improve the quality of outpatient care should continue, with a renewed focus on identifying and disseminating successful improvement strategies,” they concluded.