JAMA Study Shows Gains Closing Quality Gap For Seniors
QIO Efforts to Promote Better Clinical Practices Pay Off

Washington, D.C.— A study published in the January 15 issue of the Journal of the American Medical Association shows broad progress in closing the quality gap in the treatment of chronic conditions and serious illnesses affecting millions of seniors. Eliminating the quality gap—the difference between what medical experts say should be standard practice and the care actually provided to seniors—is a major goal of Medicare Quality Improvement Organizations (QIOs).

The study, Improvement in the Quality of Care Delivered to Medicare Beneficiaries: 1998-99 to 2000-2001, reports performance on 22 clinical quality indicators—such as administration of aspirin after heart attack, regular blood sugar testing for diabetes, or mammogram screening for breast cancer—and compares 2001 national and state-level data to 1998 baseline data published in JAMA in November 2000.

The JAMA study published January 15 shows improvement on 20 out of 22 quality indicators between 1998-1999 and 2000-2001. Clinical research has shown that high performance on these indicators is closely associated with lower mortality and more rapid recovery from serious illnesses, as well as more successful management of chronic conditions.

"Longer lives and better quality of life. That’s what high performance on the indicators means for seniors," said David Schulke, executive vice president of the American Health Quality Association, which represents QIOs nationwide. "Thousands of older Americans are walking around today because doctors and hospitals have improved the quality of treatment with the help of QIOs. This study is important because it shows that significant results can be achieved over a short period of time. But major gaps remain. There’s a long way to go, but we expect the emerging focus on public reporting of quality performance should boost improvement rates."

QIOs have been working under contract to the Centers for Medicare and Medicaid Services since 1998 on national projects to help providers and physicians adopt recommended practices and develop systems of care to improve the quality of treatment for heart attacks, heart failure, stroke, pneumonia, diabetes, and breast cancer, as well as prevention of pneumonia and flu. National QIO projects evolved from a number of successful local efforts conducted by QIOs in the early 1990s. In their current contract cycle (2002-2005), QIOs have a broader assignment: they will also work collaboratively with nursing homes and home health agencies.

Strong Gains In Treatment for Heart Attack, Diabetes, Pneumonia

The JAMA study shows significant increases in the use of many recommended treatments for heart attack, pneumonia, and diabetes, as well as notable progress in adult immunizations. For example, the administration of beta blockers at discharge for heart attack patients increased from 72% in 1998-1999 to 79% in 2000-2001 in the median state—7% absolute improvement. Other areas showing strong improvement, weighted to reflect the number of Medicare beneficiaries in each state, include:

The study also examines how these improvements helped close the quality gap in critical treatment areas. For example, for the median state, prescription of the correct antibiotic for pneumonia patients went from 79% (a quality gap of 21%) in 1998-1999 to 85% (a quality gap of 15%) in 2000-2001. This 6 point absolute improvement represents a 32% closing of the quality gap, expressed in the study as "relative improvement." Areas showing strong gains nationally in relative improvement include:

Average relative improvement nationally for quality indicators of outpatient care (diabetes, mammography, flu and pneumonia vaccination) was 19.9% combined; average relative improvement for inpatient care (heart attack, stroke, heart failure, immunization screening, and pneumonia) was 11.9% combined.

In addition to areas of success, the JAMA study pinpoints areas where providers and QIOs have had little national impact, such as the use of ACE inhibitors to treat heart failure or the use of smoking cessation counseling.

The study shows continued wide differences in quality of care from state to state following a pattern revealed in the 1998 baseline study—with better performance concentrated in northern and less populous states. State rankings remained largely stable over time. There was a trend towards less variation among states, as should occur with increased adherence to science-based practices.

In response to these findings, QIOs will be conducting intensive training sessions around the country over the next three years to help medical professionals learn what system changes have succeeded and why. "QIO collaboratives will use the data from this study to highlight what system changes have been effective in raising the quality of care for seniors, show how to rapidly replicate these successes, and provide support for implementation," said Schulke.

QIO Impact Noted

Although the JAMA study was not designed to measure the impact of QIO work, it notes that progress on closing the quality gap reported in the article is consistent with the goals of the Medicare QIO program. AHQA Executive VP David Schulke points out that QIOs serve as facilitators, or catalysts for improvement. "Doctors and hospital staff do the day-to-day work to implement improvements," he said. "They deserve most of the credit."

Data for the JAMA study was collected by abstraction centers, surveys, and claims analysis under direction of the Medicare Quality Improvement Program, headed by Dr. Stephen Jencks, co-author of the study. The article notes that, "The QIO program has created the performance measurement system that allows us to track progress on these topics and has dramatically heightened national awareness of the opportunity for improvement."

As hospitals move towards voluntarily reporting their performance data to the public, QIOs will play a central supporting role in the development of capacity to collect and report quality performance data. QIOs will also assist hospitals and physicians in using performance data to identify opportunities for improvement, and provide technical assistance to facilitate change.