The American healthcare system, often touted as a cutting-edge leader in the world, suddenly finds itself mired in serious questions about the ability of its hospitals and doctors to deliver quality care to millions of Americans - even those with health insurance.
In the largest and most comprehensive study of quality care ever done in the United States, the RAND Corporation has found that nearly half of all Americans don't get the recommended healthcare they should - that which leading experts in their field agree is best - when they go to the doctor or hospital.
• Only 45 percent of heart-attack patients received medications that could reduce their risk of death by more than 20 percent.
• Only 39 percent of patients with what doctors diagnosed as pneumonia received the best recommended kind of care.
• People treated for diabetes received only 45 percent of the care they need.
Those are just some of the findings the researchers concluded pose "serious threats to the health of the American public" and could contribute to thousands of preventable deaths each year.
The study by RAND, one of the world's most respected research institutes, comes on the heels of a series of other reports that found critical shortcomings in the American healthcare system. This includes a report by the Institute for Medicine estimating that as many as 44,000 to 98,000 people die in US hospitals each year as the result of medical errors. The Agency for Healthcare Research and Quality (AHRQ) says more people die from medical errors than from car accidents or breast cancer.
"It's kind of scary. The implications are that everybody is at risk," says Dr. Elizabeth McGlynn, the primary author of the RAND study, which is published in Thursday's New England Journal of Medicine. "It's important for people not to be complacent about the quality of care they receive."
Over the past decade, the issue of improving the quality of healthcare has risen to the top of the agenda for many medical experts. It's become part of the debate about how to keep health costs down and extend coverage to the uninsured.
Around the country, dozens of small experiments are under way aimed at improving care in hospitals and doctors' offices. And the federal government has already launched a successful initiative to reduce medical errors and improve safety in its Veterans Administrations hospitals.
Despite these efforts, the RAND study found that medical errors continue to persist in large numbers across the healthcare system. But the American public has been largely inured to the alarms raised by the experts. Surveys show that, overall, people believe that they get good or excellent care.
"What you have is a real movement among the elite, the professors and scientists, who've discovered that there are very real problems," says Robert Blendon of Harvard's School of Public Health in Boston. "But it's going to be a while before average citizens believe that. They have a lot of trust in their physicians."
The RAND study authors stress that their findings don't necessarily mean doctors are irresponsible or not doing their jobs. Instead, the need is to reform and update the systems through which medical care is delivered.
Currently, many hospitals still operate as they did in the mid-20th century, depending on paper charts and doctors' memories to make decisions about treatment when patients often have multiple physicians for multiple diagnoses. In most cases, it's up to the patient to remember to tell the doctor what medications they're on and what other physicians have said.
"This is about figuring out what are the tools that we need to put in doctors hands to make sure their hard work is more consistently getting the combination of things people most need," says Dr. McGlynn. Those tools include items such as "electronic charts" that any doctor can access to see the patient's whole history and a system for measuring quality and outcomes that can be used by doctors to constantly
assess their treatment. Dr. Don Berwick,
director of the Institute for Healthcare Improvement in Boston, says there has to be a change in the medical culture and how doctors are trained. "We're not trained for teamwork," he says. "Open a medical chart, there's a section for doctors' notes and a section for nurses' notes even though we're dealing with the same patient."
Dr. Carolyn Clancy says it's "humbling" to be told you're not doing as well as you could, particularly for doctors.
"Doctors have been trained to think this is all about their knowledge," says Dr. Clancy, who directs the Agency for AHRQ at the Department of Health and Human Services. "This is not a knowledge problem, this is a systems problem and the good news is that more and more parts of the healthcare system understand this."
Clancy and others also say that patients should take a far more active role in ensuring they're receiving the best care. The agency has put together a list of tips to help patients deal more proactively with their medical-care providers. The American Medical Association had no comment on the report, saying they needed time to study it.