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Reliability

Opportunities for improvement in the quality of U.S. health care are well documented. Preventable medical errors in hospitals result in tens of thousands of deaths per year (Kohn, 2000); preventable medication errors occur at least 1.5 million times per year (Aspden et al., 2006); and, on average, adults receive only 55 percent of recommended care (McGlynn et al., 2003). A policy improves the reliability of the health care system when it increases the likelihood that recommended care will always be delivered safely to all patients.

Measuring Reliability
Percentage of Recommended Care Received by U.S. Adults
Reliability of Care for Population Subcategories
Types of Reliability: Underuse and Overuse
Types of Reliability: Patient Safety
References
Measuring ReliabilitySave to My Compare

Reliability is measured as the number of times that a recommended health care process is performed divided by the number of opportunities to perform the process. Here are some examples:

  • A specific measure of one aspect of a care process—for example, mammograms for women age 50 and older.
  • Aggregated measures reflecting treatment of one condition or type of care—for example, the proportion of diabetic patients who receive needed care for their diabetes.
  • The proportion of patients who receive all indicated care for all of their medical needs.

Reliability is measured at multiple levels:

  • Geographic areas: the nation, regional and state comparisons, and metropolitan areas.
  • Population subgroups: age, gender, income, education, race, insurance status, and health status.
  • Care settings: hospitals, nursing homes, medical groups, etc.
  • Types of care/functions: preventive, acute, or chronic care; screening, diagnosis, treatment, or follow-up.
  • Mode of care: encounters with providers, medication, immunization, physical examination, lab test/imaging, surgery, history, and counseling.
  • Condition: hypertension, asthma, hip fracture, etc.
Percentage of Recommended Care Received by U.S. AdultsSave to My Compare

In a recent study that produced the first national report on quality of care, RAND assessed the extent to which recommended care was provided to a representative sample of the U.S. population for a broad range of conditions in 12 metropolitan areas. Key findings include the following:

  • Overall, adults received about half of recommended care.
  • Quality of care was similar in all of the metropolitan areas studied.
  • Quality varied across conditions, and across communities for the same condition.
  • No community had consistently the best or worst quality of care.
  • All sociodemographic groups were at risk for poor care.

See Figure 1.

Figure 1. Overall Reliability of the U.S. Health System: Percentage of Recommended Care Delivered

Figure 1. Overall Reliability of the U.S. Health System: Percentage of Recommended Care Delivered SOURCE: Asch et al., 2006; McGlynn et al., 2003; Kerr et al., 2004. Click to Zoom
Reliability of Care for Population SubcategoriesSave to My Compare

Study findings regarding overall quality of care were echoed in findings regarding quality of care for subgroups of the population (see Figure 2).

All population subgroups are at risk for poor health care. All groups received between 50 and 60 percent of recommended care.

The gap between the care that each patient receives and the recommended care that he or she should receive is far larger than the differences between population subgroups.

Figure 2. Reliability of Care for Population Subcategories: Sex, Age, Race, Education, and Income

Figure 2. Reliability of Care for Population Subcategories: Sex, Age, Race, Education, and Income SOURCE: Asch et al., 2006. Click to Zoom
Types of Reliability: Underuse and OveruseSave to My Compare

Multiple RAND studies conducted in the 1980s and early 1990s examined the appropriateness of the use of various medical and surgical procedures. Generally, a procedure was considered to be appropriate if the patient's expected health benefits exceeded the expected health risks by a substantial margin.

The main conclusion from this body of work was that on average one–third or more of common surgical procedures performed in the United States were provided for reasons that were not supported by clinical research and may have been harmful to patients (see, for example, Anderson, 1993; Bernstein, 1993; Chassin, 1987; Gray, 1990; Hilborne, 1993; Kleinman, 1994; Leape, 1993; Winslow, 1988). The rates of inappropriate use ranged from a low of 2 percent for coronary artery bypass graft surgery (CABG) and cataract removal to a high of 32 percent for carotid endarterectomy. The rates of equivocal use also varied dramatically, ranging from 7 percent for CABG to 38 percent for percutaneous transluminal coronary angioplasty.

RAND's more recent national assessment of quality of care found that underuse of care was more common than overuse (see Figure 3).

Figure 3. Types of Reliability: Underuse and Overuse

Figure 3. Types of Reliability: Underuse and Overuse SOURCE: McGlynn et al., 2003. Click to Zoom
Types of Reliability: Patient SafetySave to My Compare

The Institute of Medicine report To Err is Human: Building a Safer Health System introduced many Americans to the fact that medical errors kill thousands of people every year (IOM, 2000). The Agency for Healthcare Research and Quality tracks adverse events (injuries caused by medical care) that are reported and publishes an annual accounting. Figure 4 shows two types of adverse health events that indicate problems with the reliability of health care delivery:

  • Adverse health events that can follow surgery, including postoperative pneumonia, urinary tract infection, or a blood clot. A composite indicator shows that these events occur in about 7 percent of surgeries.
  • Adverse drug events in hospitals related to frequently used medications. They were relatively common in 2005, ranging from about 7 percent of Medicare patients receiving warfarin to 13 percent of Medicare patients receiving intravenous heparin.

Figure 4. Types of Reliability: Patient Safety

Figure 4. Types of Reliability: Patient Safety SOURCE: Analysis of Agency for Healthcare Research and Quality, 2008. Click to Zoom
ReferencesSave to My Compare

Anderson GM, Grumbach K, Luft HS, Roos LL, Mustard C, Brook R, "Use of Coronary Artery Bypass Surgery in the United States and Canada: Influence of Age and Income," Journal of the American Medical Association, Vol. 269, No. 13, April 7 1993, pp. 1661–1666.

Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA, "Who is at Greatest Risk for Receiving Poor–Quality Health Care?" New England Journal of Medicine, Vol. 354, No. 11, March 16 2006, pp. 1147–1156.

Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds., Preventing Medication Errors, Washington, D.C.: Institute of Medicine of the National Academies, National Academies Press, 2006.

Bernstein SJ, McGlynn EA, Siu AL, Roth CP, Sherwood MJ, Keesey JW, Kosecoff J, Hicks NR, Brook RH, "The Appropriateness of Hysterectomy: A Comparison of Care in Seven Health Plans," Journal of the American Medical Association, Vol. 269, No. 18, May 12 1993, pp. 2398–2402.

Chassin MR, Kosecoff J, Solomon DH, Brook RH, "How Coronary Angiography Is Used: Clinical Determinants of Appropriateness," Journal of the American Medical Association, Vol. 258, No. 18, November 13, 1987, pp. 2543–2547.

Gray D, Hampton JR, Bernstein SJ, Kosecoff J, Brook RH, "Clinical Practice: Audit of Coronary Angiography and Bypass Surgery," Lancet, Vol. 335, No. 8701, June 2 1990, pp. 1317–1320.

Hilborne LH, Leape LL, Bernstein SJ, Park RE, Fiske ME, Kamberg CJ, Roth CP, Brook RH, "The Appropriateness of Use of Percutaneous Transluminal Coronary Angioplasty in New York State," Journal of the American Medical Association, Vol. 269, No. 6, February 10, 1993, pp. 761–765 .

Kerr EA, McGlynn EA, Adams J, Keesey J, Asch SM, "Profiling the Quality of Care in Twelve Communities: Results from the CQI Study," Health Affairs, Vol. 23, No. 3, May/June 2004, pp. 247–256.

Kleinman LC, Kosecoff J, Dubois RW, Brook RH, "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger Than 16 Years in the United States," Journal of the American Medical Association, Vol. 271, No. 16, April 27, 1994, pp. 1250–1255.

Kohn LT, Corrigan JM, Donaldson MA, eds., To Err Is Human: Building a Safer Health System, Washington, D.C.: Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press, 2000.

Leape LL, Hilborne LH, Park RE, Bernstein SJ, Kamber CJ, Sherwood M, Brook RH, "The Appropriateness of Use of Coronary Artery Bypass Graft Surgery in New York State," Journal of the American Medical Association, Vol. 269, No. 6, February 10, 1993, pp. 753–760.

McGlynn EA, Asch AM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA, "The Quality of Health Care Delivered to Adults in the United States," New England Journal of Medicine, Vol. 348, No. 26, June 26, 2003, pp. 2635–2645.

Winslow CM, Solomon DH, Chassin MR, Kosecoff J, Merrick NJ, Brook RH, "The Appropriateness of Carotid Endarterectomy," New England Journal of Medicine, Vol. 318, No. 12, March 24 1988, pp. 721–727 .

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