With increasing reports of dangerous deficiencies in the quality of health care, the nation's largest health care foundation today announced a $300-million commitment to improve quality in regions across the United States.

Underscoring the scope of the problem, the Robert Wood Johnson Foundation (RWJF) also released new research showing that the quality of care people receive can vary dramatically depending on their race and where they live.

The $300-million commitment to improve health care in 14 communities, that together cover 11 percent of the U.S. population, is the largest effort of its kind ever undertaken by a U.S. philanthropy. Known as Aligning Forces for Quality, the community-focused program will lift the overall quality of health care, reduce racial and ethnic disparities and provide models for national reform.

“Across America, there are serious gaps between the health care that people should receive and the care they actually receive,” said Risa Lavizzo-Mourey, M.D., M.B.A., president and CEO of the Robert Wood Johnson Foundation. “Despite having the most expensive health care system in the world, patients are subject to too many mistakes, too much miscommunication and too much inequity. As a result, too many Americans aren't receiving the care they need and deserve. This unprecedented commitment of resources, expertise and training will turn proven practices for improving quality into real results in communities across America.”

The new research, conducted by the Dartmouth Atlas Project at the Dartmouth Institute for Health Policy and Clinical Practice for the Aligning Forces for Quality initiative, analyzes Medicare claims to illustrate staggering variations in health care quality across the country. Researchers examined five different measures of care at the state level and in the 14 Aligning Forces for Quality communities.

Most strikingly, researchers found significant differences by race and by region in whether patients lost a leg to amputation, a complication of peripheral vascular disease and diabetes.

African Americans lost legs to amputations at a rate nearly five times that of whites—4.17 per 1,000 African-American Medicare beneficiaries, compared to 0.88 per 1,000 white Medicare beneficiaries. In Louisiana, the state with the highest rate of amputations, 1.66 of every 1,000 beneficiaries lost a leg to amputation in 2003-2005, compared to the national average of 1.14. Utah fared best—0.50 per 1,000 beneficiaries.

The report also demonstrates significant differences in whether people get basic recommended care—such as women getting regular mammography tests or patients with diabetes getting essential blood tests.

• One in three women insured by Medicare are not getting recommended mammograms. Overall, the study shows 64 percent of the white women got mammograms, compared to 57 percent of African-American women. In Mississippi, 57 percent of female patients aged 65-69 got mammograms in 2004-2005, compared to the national average of 64 percent. Maine fared best with 74 percent—a 17-point gap between the high and low states.
  
• About one in seven patients with diabetes are not getting crucial blood tests. About 85 percent of white patients with diabetes got the blood sugar control tests, compared to 79 percent for African Americans. In Alaska, 71 percent of patients with diabetes got an important test for blood sugar control every year, compared to the national average of 84 percent. Vermont fared best with 91 percent receiving the test annually—a 20-point gap between the high and low states.

“These findings underscore the importance of the local health care system as the focus for efforts to improve care,” said Elliott Fisher, M.D., M.P.H., director of the Center for Health Policy Research at Dartmouth and one of the report's co-authors. “In most regions, blacks are less likely to receive recommended care than whites, but the differences across regions are generally much larger than the differences within regions. And in some regions of the country, African Americans receive care equal to that of whites—but the care for everyone is well below the national average. These findings point to the critical importance of local efforts that bring together stakeholders to improve quality and reduce disparities everywhere.”

Aligning Forces for Quality will concentrate its resources in 14 communities across the country:

• Cincinnati, Ohio
• Cleveland, Ohio
• Detroit, Mich.
• Humboldt County, Calif.
• Kansas City, Mo.
• Maine
• Memphis, Tenn.
• Minnesota
• Seattle, Wash.
• South Central Pennsylvania
• Western Michigan
• Western New York
• Willamette Valley, Ore.
• Wisconsin

They were selected as part of a highly competitive process to find communities that were positioned to make fundamental and cutting-edge changes to rebuild their health care systems.

“Doctors, nurses and hospitals—everyone in health care—want to deliver high-quality care,” said Bruce Siegel, M.D., M.P.H., research professor in the Department of Health Policy at The George Washington University School of Public Health and Health Services and the newly named director of the Aligning Forces for Quality national program office. “The fragmented nature of our health care markets and delivery systems often prevents key players from working together. By teaming up those who get care, give care and pay for care, we will help these communities achieve lasting change.”

Aligning Forces for Quality was originally launched by RWJF in 2006. In the first phase, the communities began efforts to improve health care for patients with chronic illness in outpatient settings, such as doctors' offices and clinics. With this expansion, Aligning Forces for Quality community teams will now strive to improve care for all patients across all settings by:

• Helping physicians improve the quality of care for patients.
• Giving people information that helps them be better partners with their doctors in managing their own health and make informed choices about their health care.
• Improving care inside hospitals, with a special focus on the central role that nursing plays.
• Reducing inequality in care for patients of different races and ethnicities.

RWJF has for years worked to develop strategies and tools to improve health care quality. These efforts include funding for the development of quality measures; early pay-for-performance experiments; a new model for providing chronic care; and programs to improve cardiac care, nursing and eliminate racial disparities, or to target specific diseases such as asthma, diabetes and depression. Aligning Forces for Quality will bring the proven practices developed in these and other efforts to bear in the 14 communities.

With the expansion of its Aligning Forces for Quality initiative, the Foundation will also make available new content on the Quality/Equality section of its main web site, www.rwjf.org. The Quality/Equality Program Area features an expansive library of new interventions, tools, resources and related videos to help providers and others improve the quality of care in their communities. These Promising Practices have been developed based on the findings and lessons learned from RWJF-supported programs to improve health care quality in a variety of settings.

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The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. By helping Americans lead healthier lives and get the care they need, the Foundation expects to make a difference in our lifetime.

Statements by Experts and Organizations Regarding the National Launch of Aligning Forces for Quality

Donald Berwick, M.D., M.P.P., F.R.C.P.
President and CEO of the Institute for Healthcare Improvement
“The Foundation has for years championed the efforts of reformers and innovators to improve health care quality. This is a bold commitment to turn lessons learned at a national level into useful tools and practical know-how that will bring real results in communities.”

Janet Corrigan, Ph.D., M.B.A.
President and CEO of the National Quality Forum
“Aligning Forces for Quality is a sterling example of how the quality movement is moving beyond rhetoric and working to spark real change on the ground in communities.”

James King, M.D.
President
American Academy of Family Physicians
"Family physicians are located in every county in the United States, and each day we see first hand the impact individuals and organizations can have when they work together to tackle a community's health care needs. That's why we support the Robert Wood Johnson Foundations Aligning Forces for Quality initiative—an effort that is bringing all critical stakeholders together around common objectives for the ultimate goal of improved patient care."

Debra L. Ness
President of the National Partnership for Women & Families
“Aligning Forces for Quality recognizes that health care is ultimately about the patients. Its programs will help people get the information they need to be better partners with their doctors in managing their own health and making sound decisions about where they get their health care.”

Margaret E. O'Kane, M.S.
President of the National Committee for Quality Assurance
“Aligning Forces for Quality represents a significant step forward in the national drive to improve the quality of care. Far too often, quality is left out of the health reform equation. Aligning Forces for Quality is an important recognition that we must address the quality and cost of care if we want to expand coverage.”

Andrew Webber
President and CEO of the National Business Coalition on Health
“Aligning Forces for Quality puts measuring and reporting of physician performance right where it needs to be—at the heart of health care improvement. This is essential if we want better value and better results.”

John E. Wennberg, M.D., M.P.H.
Peggy Y. Thomson Professor (Chair) in the Evaluative Clinical Sciences, Founder and Director Emeritus of The Dartmouth Institute for Health Policy and Clinical Practice and its Dartmouth Atlas Project
"These data provide demonstrable evidence of the unacceptably uneven nature of health care and health disparities in America. We must work to close these gaps and improve the quality of care for everyone. The community-based approach that Aligning Forces for Quality will yield important lessons for health reform everywhere.”