Intergrating Quality into Utah's Health System Reform

• The Problem: Why Health Reforms Should Focus on Quality

Health care spending is out of control, and this is why Utah policymakers and business leaders are finally ready to consider broad health system reforms.  The U.S. spends more by far on health care than any other industrialized country (health spending consumes 16% of the GDP in 2005)—yet it ranks 37th in overall health.  In its 2001 report, Crossing the Quality Chasm, the Institute of Medicine concluded that “between the health care we have and the care we could have lies not just a gap, but a chasm.” By measures like those from the Commonwealth Fund, the U.S. ranks lowest among all industrialized countries in terms of quality of care (Davis).

According to the Institute of Medicine, 44,000 to 98,000 people die in hospitals each year due to preventable injuries.  The lower estimate (which was based on published research conducted in Utah & Colorado) establishes preventable injuries in hospitals as at least the 8th leading cause of death in the U.S.  In fact, these hospital-related injuries are believed to cause more deaths per year than automobile accidents (43,458), breast cancer (42,297), or AIDS (16,516). 

However, poor quality health care in the United States, or in Utah, is not caused by spending too little.  In fact, states with the highest per beneficiary Medicare spending tend to be the states with the lowest overall quality ranking.  How could this be? Researchers have documented what common sense could have foretold: the negative relationship between spending and quality may be driven by the use of intensive, costly care that crowds out the use of more effective care (Baicker, 2004).  In other words, American medical care systems often fail to do those things that have proven value and, conversely, often do things that are not useful.  Care delivery in America is also compartmentalized and disjointed.  Effective information sharing and process coordination and basic continuity of care are rarely evident as patients move from one provider to the next, especially across institutions or settings of care.  Quality improvement efforts are also often short-sighted, uncoordinated, and sometimes self-limiting due to the lack of continuity in the system.  As a result of all of these design failures, American health care “gets it right” only about 55% of the time.

How does Utah measure up? According to one ranking of states by the Commonwealth Fund (CMWF), about average on overall health system performance (24th), but surprisingly in the bottom tier (48th) on standard measures of quality.  However, the Agency for Health Resources and Quality ranks Utah among states with strong performance in health care quality.  No matter what measure is used, all states can do better.  Quality improvement must become a shared objective for all of us.

For all its limitations, the CMWF is helpful in identifying areas in need of improvement in Utah’s health care delivery systems (Utah’s rank shown in parenthesis): 

• Percent of adults age 50+ who receive recommended screenings (35);
• preventive care for diabetes (31);
• Well child visits (42);
• Percent of surgical patients who receive appropriate timing of antibiotics (45);
• Percent of adults with a usual source of care (46);
• Percent of Medicare patients whose provider listens, explains, shows respect, and spends enough time with them (50).

Source: Commonwealth Fund Scorecard on Health System Performance, 2007

In addition to producing inconsistency in care delivery and missed opportunities, common health care system design flaws lead to failures in patient safety.  A study conducted by the Utah Department of Health (and other organizations) found that in 2001, 18 adverse events occurred for every 100 hospital admissions and an estimated 407 iatrogenic adverse events (deaths or permanent injury caused by medical care) occurred that year in hospitals.  Fatal iatrogenic medical injuries could be the 4th- to7th leading cause of death in Utah (Xu, 2003). 

Data on rates of iatrogenic injuries in other settings of care are currently lacking; however, it is very likely that the rates are similar or perhaps even higher.  Like other self-reporting systems, Utah’s mandatory sentinel event (a serious injury or fatality caused by the care delivery process) reporting system for hospitals and ambulatory surgery centers underestimates predicted sentinel health care-related events in Utah by an order of magnitude.  Failure to recognize errors when they occur, failure to associate errors with injuries, lack of understanding of the reporting requirements, and fear of punishment are all possible causes for this underreporting.  It is clear that before we can sustain fundamental improvements in patient safety, we must become more consistent in measuring patient safety performance in Utah’s hospitals.