According to the report, published in tomorrow's Journal of the American Medical Association, the proportion of Medicare patients receiving appropriate care increased from 70 percent in the 1998-to-1999 period, to 73 percent for 2000 to 2001. The relative rankings among different states were about the same, and there were some variations depending on the state and the particular measurement in question.
"It's a significant rise. It's real. It's not just sampling error. But, gee, we do have a long way to go," says Dr. Stephen Jencks, lead author of the study and director of the quality improvement group at the U.S. Centers for Medicare and Medicaid Services (CMS) in Baltimore.
"Things are going in the right direction," agrees Dr. Randolph Peto, medical director for quality improvement at MassPRO in Waltham, Mass. MassPRO is the quality improvement organization in Massachusetts that works under contract from CMS.
"This is one of the few national studies that can provide this amount of quality improvement information, and since the Medicare population is one of biggest patient groups out there, this is important information," he says.
Medicare is the national health-care program available for people age 65 or older, younger people with disabilities and people with permanent kidney failure requiring dialysis or transplant.
The new study is a follow-up to an initial report released in 2000 that weighed in on 24 indicators of quality of care during 1998 and 1999. Those earlier indicators measured delivery of various services known to prevent or treat heart attack, heart failure, stroke, pneumonia, breast cancer and diabetes.
The current study looked at 22 indicators, including whether a mammogram was given every two years; for heart attack victims, whether aspirin was given within 24 hours of hospital admission; and, for pneumonia, whether antibiotics were administered within eight hours of the patient's arrival at a hospital. Information was gleaned primarily from bills but also from health-care consumers themselves.
What accounts for the improvements? Jencks points to changes implemented since the last report card two years ago. "On a number of issues, there has been a substantial national consciousness-raising, particularly among the physician community," he says. "Pneumococcal vaccine and beta blockers have been particular targets."
Quality improvement organizations such as MassPRO, which are under contract to work with hospitals and physicians to raise levels of service, may also have played a role, Jencks says.
In both the initial report and the current follow-up report, northern states and states that are less populous showed better performance.
However, some areas of care, such as dilated retinal eye exams to prevent blindness in people with diabetes, showed no improvement. "There may be some kind of glass ceiling going on," Peto says. "That certainly is a question of why aren't we making more movement."
The current study reflected mostly fee-for-service Medicare, as opposed to managed care. Peto says that a comparison of the two programs is forthcoming and may help fee-for-service adopt measures that have been successful with the managed care program.
Jencks says these reports will be appearing regularly.