We conducted a cross-sectional survey of 210 patients who came to a free medical clinic for health care over an 8-month period. We (1) measured their satisfaction with care, (2) determined the frequency of missed opportunities for providing health education and social work consultation, and (3) assessed whether patient-specific factors drive the frequency of these missed opportunities. Of the 210 patients surveyed, a total of 168 (80.0%) completed the entire survey. The mean satisfaction rating was high (4.6 on a scale of 1 to 5). A significant number of missed opportunities occurred, with only 28% of patients receiving patient education material, and 32% of patients visiting the social worker. No particular patient groups emerged as most susceptible to these missed opportunities. This study shows both the high degree of patient satisfaction at this free clinic and the many opportunities for improving patient education and social services. Adding health education and social work consultation to the patient encounter could improve the health of these patients.

Variation in use of health care is ubiquitous in the United States. It is attributable to exogenous differences in supply of medical resources; to identified and unidentified economic, social, and cultural factors; and to the idiosyncratic beliefs of physicians. It is perpetuated by the parochial character of much clinical practice. Patients in high-intensity areas do not appear to have better health outcomes: Much care is "flat of the curve." A more robust scientific foundation for clinical decisions could help to reduce variations, but major reform of health care financing is probably necessary to achieve substantial improvement in the organization and delivery of care.

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the summer 2004 quarter. It features articles about:

Information technology can support the implementation of clinical research findings in practice settings. Technology can address the quality gap in health care by providing automated decision support to clinicians that integrates guideline knowledge with electronic patient data to present real-time, patient-specific recommendations. However, technical success in implementing decision support systems may not translate directly into system use by clinicians. Successful technology integration into clinical work settings requires explicit attention to the organizational context. We describe the application of a "sociotechnical" approach to integration of ATHENA DSS, a decision support system for the treatment of hypertension, into geographically dispersed primary care clinics. We applied an iterative technical design in response to organizational input and obtained ongoing endorsements of the project by the organization's administrative and clinical leadership. Conscious attention to organizational context at the time of development, deployment, and maintenance of the system was associated with extensive clinician use of the system.

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In early 2003, the Institute of Medicine (IOM) released its report, Priority Areas for National Action: Transforming Health Care Quality. The report listed 20 clinical topics for which "best practices" were strongly supported by clinical evidence. The rates at which these practices have been implemented in the United States has been disappointing low, at a cost of many thousands of lives each year.

To bring data to bear on the quality improvement opportunities articulated in the IOM's 2003 report, the Agency for Healthcare Research and Quality (AHRQ) engaged the Stanford-UCSF Evidence-based Practice Center (EPC) to perform a critical analysis of the existing literature on quality improvement strategies for a selection of the 20 disease and practice priorities noted in the IOM Report. The focus of the commissioned investigations is translating research into practice -- identifying those activities that increase the rate with which practices known to be effective are applied to patient care in real world settings. In other words, the EPC research effort aims to facilitate narrowing the "quality gap" that is in large part responsible for suboptimal health care practices and outcomes. In addition to furthering the IOM's quality agenda, this analysis also has been prepared in support of the National Healthcare Quality Report (NHQR) (also see National Healthcare Disparities Report).

In this, the first volume of Closing the Quality Gap, the authors introduce the series and its goal, while providing methodological and theoretical overviews for the quality improvement (QI) field of study. Subsequent volumes will address the relation of QI strategies to treatment practices for a number of the 20 priority areas identified in the IOM report.

Cardiovascular specialists have been leaders in medicine because of our willingness to study major clinical issues by means of randomized clinical trials. Consequently, the evidence supporting many cardiovascular treatments is substantial, especially when the results of multiple large clinical trials are consistent in showing strong benefits. Cardiovascular professional societies also have been at the forefront in forging consensus among clinical experts and codifying best practice into practice guidelines. It is reasonable to expect that a treatment demonstrated to be effective in clinical trials and strongly endorsed by professional guidelines will be adopted by practicing physicians and consistently used in day-to-day patient care.

Angiotensin-converting enzyme (ACE) inhibitors have followed this pathway of building evidence and professional consensus. Many randomized clinical trials have clearly shown that ACE inhibitors reduce mortality and morbidity rates among patients with heart failure and left ventricular systolic dysfunction. Pooled data from 5 large trials showed the odds of death of patients randomized to ACE inhibitors were reduced by 26% compared with placebo, translating into roughly 6 fewer deaths per 100 patients treated. The economic outcomes also are favorable because much of the cost of prescribing ACE inhibitors for heart failure is recouped by the reduced need for hospital admissions. Consequently, the use of ACE inhibitors for heart failure is quite cost-effective. The American College of Cardiology/American Heart Association Guidelines Committee has weighed the evidence and given ACE inhibitors for treatment of heart failure a Class I recommendation. Indeed, use of ACE inhibitors is so well accepted that it is part of the quality-of-care clinical performance measure for heart failure. There is little, if any, controversy that ACE inhibitors should be generally prescribed for patients with heart failure due to systolic dysfunction.

Use of ACE inhibitors increased progressively for heart failure through the early 1990s, but growth in use has stalled more recently, and a substantial number of patients with heart failure still do not receive ACE inhibitors. The data reported by Masoudi and associates in this issue of Circulation show a stubborn, persistent gap between ideal practice and actual use of ACE inhibitors for heart failure. These investigators found that between 1998 and 2001, only 68% of patients 65 years of age and older with heart failure, systolic dysfunction, and no contraindications to treatment received an ACE inhibitor. This percentage rose only to 76% of patients when either ACE inhibitor or angiotensin receptor blocker (ARB) use was counted. The percentage of patients receiving ACE inhibitors or ARBs was below 80% in all but 3 of the 55 subgroups examined by Masoudi and associates. The investigators found little explanation for this persistent and vexing gap between actual and ideal performance, inasmuch as the only strong predictor of ACE inhibitor use versus nonuse was the presence of preexisting renal dysfunction. The latest national report card on this important aspect of heart failure treatment shows a "D+" for ACE inhibitor use (68%), rising only to a "C" (76%) if extra credit is given for ARB use. Should we accept these grades?

Closing the Gap

Perhaps the most optimistic interpretation of the data reported by Masoudi and associates is that evidence from clinical trials, by itself, will only go so far in changing clinical practice. Evidence may be necessary to alter the knowledge and attitudes of physicians about treatment, but this may not be sufficient to change their management consistently. To close the gap between actual and ideal performance, additional, specific measures are probably needed. A variety of active interventions have been shown to improve use of evidence-based therapies. Masoudi and associates did not report any data on use of measures within the hospitals or physician practices that might improve quality of care, so there may be an opportunity to adopt such measures more widely. Reminder systems for physicians, either simple chart-based measures or more sophisticated computerized approaches, can be quite effective in improving use of medications when physicians agree that the medication is effective. Critical pathways, care maps, and other structured approaches to quality improvement also may work well within hospitals to increase adherence to evidence-based practice guidelines. Reorganization of care by use of heart failure care teams or nurse facilitators may be even more effective, but these approaches require a much greater commitment of resources. Nevertheless, multidisciplinary approaches are particularly attractive in the care of patients with chronic diseases such as heart failure, because management of multiple factors, including adherence to diet and medication recommendations, is needed for successful outcomes. The structure of our medical care system also may contribute to the gap between actual and ideal clinical management; paying for innovative practice improvement programs has been difficult because they are not readily reimbursed in the fee-for-service model (although they may be well suited to prepaid integrated healthcare systems).

We have paid a lot of attention to translation of novel therapies from the basic laboratory to proof of efficacy in clinical trials, yet we've not paid enough attention to the final steps of learning how to best deliver consistent, high-quality care. With more attention to the nitty-gritty details of practice improvement, the grade for ACE inhibitor use in patients with heart failure could (and should) be raised to an "A" on the next report card.

Purchasers of health care are not holding the healthcare system accountable for quality and cost. Employers need to: Offer their employees a wide range of choices in health coverage. Earmark for employees' purchase a fixed dollar amount for health care set at or below the price of the low-priced plan. Insist that carriers and providers report the quality of care delivered.

This issue of CHP/PCOR's quarterly newsletter covers news and developments from the spring 2004 quarter.

It features articles about: our new core faculty member Paul Wise, a children's health policy researcher who joins us from Boston University; a survey of patient safety culture now getting underway at hospitals nationwide; CHP/PCOR acting director Doug Owens' research findings on the cost-effectiveness of potential HIV vaccines; a wrap-up of the second annual Health Care Quality and Outcomes Research Conference, where CHP/PCOR faculty and trainees attended and presented research; and new CHP/PCOR assistant director Vandana Sundaram.