In communities as diverse as Miami, Boston and Indianapolis, people receive only 50 percent to 60 percent of recommended medical care.

The study, funded by the Robert Wood Johnson Foundation, used data on more than 6,500 participants from 12 U.S. cities who had participated in a large national study involving 60 metropolitan areas. Researchers from RAND Health, the University of Michigan, and the University of California, Los Angeles, focused on the quality of overall care as well as preventive care, care for chronic disease, and acute care.

The publication detailing the study, "Profiling the Quality of Care in Twelve Communities: Results from the CQI Study," was published in the May/June 2004 issue of Health Affairs. Elizabeth McGlynn, Ph.D., associate director, RAND Health, is the principal investigator of the entire CQI study. RWJF spoke about this publication with lead author Eve A. Kerr, M.D., M.P.H., a research scientist from the Ann Arbor Veterans Affairs Center for Practice Management and Outcomes Research and an associate professor at the University of Michigan.

Q: In general, did your findings agree with those of similar studies?

A: We found that, on average, people received only 50 percent to 60 percent of recommended care. The important fact here is that it didn't matter where those people lived.

In many instances, our findings are consistent with what others have seen. Take diabetes, for example. We do know there's been improvement in diabetes care, but that has been for select populations. Other studies have also focused on a smaller number of measures, so when we look at a large number of measures in diabetes and look across populations—not just people in one area or who are part of one health plan—we're finding larger deficits.

This is the largest national study of global quality of health care that we know about. We studied nearly 7,000 adults. We looked at receipt of services for 30 acute and chronic conditions and for preventive care. We looked at preventive care, chronic care and acute care, as well as many dimensions of health care delivery.

Q: How did you define "quality" in this study?

A: The extent to which health care is being provided consistent with current knowledge and recommendations.

Q: Did you find any startling differences among the 12 cities in terms of overall care?

A: The differences across communities were small. If you looked at overall quality of care, residents in Seattle received closer to 60 percent of services, whereas those in Little Rock got closer to 50. There were some differences, but more similarities than differences.

Q: What about preventive care?

A: Overall, there were few differences in preventive care across communities—about 50-60 percent of recommended preventive care was received. But different dimensions of preventive care were delivered at different rates. For example, the receipt of sexually transmitted disease prevention services was much lower, and cardiac chronic preventive care was higher, and everything else fell in between. Some of that makes sense because certain preventive measures, such as checking someone's blood pressure, are easier to do than, say, screening and counseling for substance abuse.

Q: In the area of chronic-disease care, diabetes seemed to fare poorly. This seemed to hold even in cities with world-class hospitals. Why?

A: Diabetes is a great example because the condition requires clinicians to do so many different things to treat it appropriately. It also requires patients to understand their health care and be involved and responsible for a lot of things.

This is the area where we really see a need for fundamental redesign of the health care system. Patients with chronic conditions need many things to be done to ensure a good outcome. For example, they may need frequent blood tests, adequate medication intensification, and education so that they can manage aspects of their conditions themselves. Our health care system isn't designed to make sure all the things that need to happen are happening. This should be a wake-up call for us to think about the way we're delivering health care.

Q: Because you didn't collect data from people who had not been to a health care provider at all in the previous two years, could we actually be talking about a much larger deficit than the one you found?

A: We studied patients who have had access to the system. We need to be concerned about access, and access is important but it's not enough. This work shows that even people who have had access to the health care system are still not getting recommended services.

Q: How might communities work on solving this problem?

A: I think the key words are activation and collaboration. The first step is to try to understand what's going on in a community. We've shown that it's possible to begin to do that. For collaboration: This is an opportunity for communities to think about how different aspects of the community can work together—the health care system, employers and so on—to help patients to be informed consumers and understand their health care needs and how to interact with the system. There are communities doing this to one degree or another. For example, why should you only be able to get immunizations from your doctor's office? A company should want to get all its employees immunized, and a community should too, and it could save everybody money in the end.

In addition, I hope we're training doctors who want to work with patients to help make them activated consumers of health care. As a doctor myself, that's how I like to work with patients: making sure they have their questions answered, responding to their needs, and trying to make sure they have the information they need to take care of their own health. I may only have 20 minutes three times a year with someone, but a patient lives with his or her health conditions all day, every day.

Q: What are the next steps?

A: Our next paper will look at who is getting care and who isn't in each of these communities. We'll be looking at individual characteristics.