Quality of Care

The United States outspends other comparable countries on health care, yet the quality of care often falls short. Americans fail to receive about half of recommended health services, ultimately leading to both higher costs and increased risk of mortality. At the same time, overuse, misuse, and variation in the use of health care services contribute to poor health outcomes. Federal programs such as Medicare, hospital systems, and other interested parties have tried to deploy quality improvement programs, though these are specific to certain diseases and populations, and there is only modest evidence that they have been effective. Improving quality of care across the U.S. health care system remains a challenge.

In work spanning decades, RAND Health Care has been at the vanguard of measuring the quality of health care. Our researchers helped establish the scientific basis for assessing quality of care across multiple settings, including developing ways to reliably assess the quality (including appropriateness of care), safety, patient-centeredness, and overall value of care. RAND continues to explore multiple aspects of quality measurement such as by surveying patients about their experiences of care, identifying ways to help care be more centered on patients’ individual needs, and exploring opportunities to improve patient safety.

Highlights

Keeping Clinical Quality Measures Relevant

The Medicare Star Ratings program provides actionable information to Medicare beneficiaries about the quality of Medicare Advantage (MA) and Part D plans. Beneficiaries can use the ratings, updated annually before each Open Enrollment period, to compare plan performance on quality of care and other dimensions. RAND researchers support Medicare with ongoing analyses to calculate the Star Ratings and continually improve the methods used. Such analyses help uncover issues before any potential adjustments to the ratings are implemented or confirm that adjustments are working as intended. For instance, RAND helped CMS understand whether its Categorical Adjustment Index (CAI) helped address measurement bias within the Star Ratings. The CAI helped ensure that the Star Ratings do not undervalue the performance of MA contracts that enroll higher percentages of people with greater social risk. Without this adjustment, MA plans could have an incentive to avoid these types of patients.

Assessing Patients' Experiences of Care

The measurement of patient care experiences has emerged as a crucial dimension of health care quality—one that can only be captured from the patients themselves. Funded by AHRQ and CMS, the CAHPS® family of surveys captures patient-reported experiences of care in Medicare, Medicaid, and large private health insurance plans as well as experiences with providers and facilities, such as hospices and hospitals. Recent studies have revealed declines in patient experience scores for hospital care since the start of the COVID-19 pandemic. Another study examined CAHPS Hospice Survey results from more than 650,000 family caregivers of patients who died in more than 3,000 hospices across the United States. Caregivers reported substantially worse care in for-profit hospices than not-for profit hospices, differences that persisted even after taking into account factors such as hospice location, size, and number of years in operation. However, not all for-profit hospices performed poorly, and the high performers could serve as models for those with lower care ratings. Data from survey results from the CAHPS Clinician and Group survey have been used in research to evaluate interventions, disparities in patient experience, and associations of patient experience with factors such as organizational climate, physician empathy, and medication adherence.

Making Care More Patient-Centered

A core dimension of health care quality is the degree to which care is respectful of and responsive to individual patient preferences, needs, and values. Patient-reported measures are critical for assessing outcomes and guiding quality improvement efforts. They can also be used to incorporate patient voices in some medical contexts, such as palliative care. RAND developed the RAND/PPMD Patient Centeredness Method to get patients involved in developing clinical guidelines. Building on the previously developed ExpertLens™, this online modified-Delphi approach allows caregivers and patients to use their first-hand experience with treatment—for example, with Duchenne Muscular Dystrophy care—to have a say in what works—or doesn’t—as they receive care. Other RAND researchers have used a group decisionmaking approach called deliberative democracy to engage community members who have lived experience with maternal mortality and severe maternal morbidity to help identify priorities to address these problems.

Establishing Opportunities for Patient Safety Improvement

More than two decades ago, the Institute of Medicine identified patient safety as one of the most pressing problems facing the U.S. health care system and proposed a comprehensive approach to reducing medical errors. RAND then conducted pioneering analysis that assessed subsequent progress in patient safety improvement, primarily in hospitals, and developed a widely used toolkit to help hospitals implement patient safety improvement initiatives. A later analysis brought together an international panel to conduct a comprehensive evidence-based assessment of patient safety strategies, which recommended that 22 patient safety practices should be "encouraged" for adoption based on the strength of evidence for their effectiveness.

Recent work has continued to assess the effects of patient safety policies and practices. Clinicians in hospitals interviewed about patient-safety issues during the COVID-19 pandemic reported that limited access to care and declines in care delivery led to an increase in adverse patient safety events such as misdiagnoses, infections, and falls. Other work regarding infection control in long-term care found that the pandemic exacerbated known problems with care quality, staff retention, and resident autonomy and well-being. Analysis of a Medicare program that withholds payment to hospitals in the event of hospital-acquired infections (HAIs) found that the program reduced HAIs. A review of the many available patient-safety tools concluded that tool use and impact varied widely. Voluntary incident reporting may also miss safety events among minoritized hospital patients. Diagnostic safety, a common cause of preventable harm in outpatient and hospital settings, is the focus of an ongoing project encouraging and evaluating use of new resources to support health care organizations in diagnostic excellence.

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