Every day, millions of Americans

receive high-quality health care that

helps to maintain or restore their health

and ability to function. However, far

too many do not. Quality problems are

reflected in a wide variation in the use

of health care services, underuse of

some services, overuse of other services,

and misuse of services, including an

unacceptable level of errors.

A central goal of health care quality

improvement is to maintain what is

good about the existing health care

system while focusing on the areas that

need improvement. Improving the

quality of care and reducing medical

errors are priority areas for the Agency

for Healthcare Research and Quality

(AHRQ). AHRQ is working to develop

and test measures of quality, identify

the best ways to collect, compare, and

communicate data on quality, and

widely disseminate information about

the most effective strategies for

improving the quality of care.

Evidence of Quality Problems

Several types of quality problems in

health care have been documented

through peer-reviewed research. These

include:

• Variation in services. There

continues to be a pattern of wide

variation in health care practice,

including regional variations and

small-area variations. This is a clear

indicator that health care practice

has not kept pace with the evolving

science of health care to ensure

evidence-based practice in the

United States.

• Underuse of services. Millions of

people do not receive necessary care

and suffer needless complications

that add to costs and reduce

productivity. Each year, an

estimated 18,000 people die because

they do not receive effective

interventions. For example, a study

of Medicare patients who had

suffered heart attacks found that

only 21 percent of eligible patients

received beta blockers. The

mortality rate among patients who

received beta blockers was 43

percent lower than it was among

nonrecipients. Another AHRQfunded study examined the use of

beta blockers before heart bypass

surgery and found that patients who

received beta blocker therapy before

surgery had lower rates of death and

fewer complications both during

and after surgery than patients who

did not receive this therapy. 

• Overuse of services. Each year,

millions of Americans receive health

www.ahrq.gov

AHRQ is the lead Federal agency charged with 

supporting research designed to improve the

quality of health care, reduce its cost, address

patient safety and medical errors, and 

broaden access to essential services. AHRQ

sponsors and conducts research that provides

evidence-based information on health care 

outcomes; quality; and cost, use, and access.

The information helps health care 

decisionmakers—patients and clinicians, health

system leaders, and policymakers—make more

informed decisions and improve the quality of

health care services.

Improving Health

Care Quality

Agency for Healthcare Research and Quality • 2101 East Jefferson Street • Rockville, MD 20852

F ACT SHEET

U.S. Department of Health 

and Human Services

Public Health Service
care services that are unnecessary,

increase costs, and may even

endanger their health. Research has

shown that this occurs across all

populations. For example, an

analysis of hysterectomies

performed on women in seven

health plans found that one in six

operations was inappropriate. A

study examining the use of

antibiotics for treating ear infections

in children on Medicaid found that

expensive antibiotics were used far

more often than indicated. According to the findings, if only

half the prescriptions written in

1992 for more expensive antibiotics

had been written for amoxicillin, a

less expensive but equally effective

antibiotic, Colorado’s Medicaid

program would have saved nearly

$400,000 that year.

•Misuse of services.Too many

Americans are injured during the

course of their treatment, and some

die prematurely as a result. For

example, a study of injuries to

patients treated in hospitals in New

YorkState found that 3.7 percent

experienced adverse events; 13.6

percent of these events led to death,

and 2.6 percent led to permanent

disability. About one-fourth of these

adverse events resulted from

negligence. A national study found

that over a 10-year period (1983-

1993), deaths due to medication

errors rose more than two-fold, with

7,391 deaths attributed to

medication errors in 1993 alone.

•Disparities in quality. Although

quality problems affect all

populations, they may be most

marked for members of ethnic and

racial minority populations. Researchers at the University of

Alabama at Birmingham examined

the use of thrombolysis (“clot

busters”) for patients who had

experienced a heart attack and

found that while this evidencebased life-saving treatment was

underused for all, black Medicare

beneficiaries were significantly less

likely than whites to receive this

treatment.

Findings from Recent Research

on Health Care Quality

AHRQ and its predecessor agencies—

the Agency for Health Care Research

and Quality and the National Center

for Health Services Research and Health Care Technology Assessment—

have been conducting and supporting research on quality for more than two

decades. Following are some examples

of findings from recent AHRQsupported research on quality and

quality improvement. • Atrial fibrillation. Thousands of Medicare patients with atrial

fibrillation can benefit from a new

2 www.ahrq.gov

2.8%

3.4%

with without

beta blockers

30-day mortality

Outcomes of beta blocker use

before bypass surgery

Ferguson, Coombs, and Peterson. Preoperative 

b-blocker use and mortality and morbidity

following CABG surgery in North America.

JAMA, 287(17):2221-7, May 2002
quality improvement tool developed

with support from AHRQ.

Researchers found that their new

CHADS2 method for predicting

risk of stroke in patients with atrial

fibrillation is more accurate than

existing methods. CHADS2 may be

especially helpful for identifying

low-risk patients who, by taking

aspirin, can avoid the office visits,

expense, and side effects associated

with warfarin, which carries a risk of

bleeding.

• Underuse of hip replacement

surgery in Hispanic patients. Even

when they have insurance, elderly

Hispanics undergo far fewer hip

replacement operations than elderly

non-Hispanic whites. This study of

Hispanics aged 65 or older in Texas,

New Mexico, Arizona, and Illinois

found that they were less than onethird as likely as non-Hispanic

whites of the same age to undergo

total hip replacement, an operation

that can alleviate pain and improve

physical function and quality of life

in patients with severe osteoarthritis.

According to the researchers,

underuse of hip replacement surgery

by the large and growing U.S.

Hispanic population could have

important consequences for

Medicaid because the resulting

excess disability could increase longterm custodial costs. 

• End-of-life discussions. Findings

from this AHRQ study can be used

to improve end-of-life care and

promote more effective use of health

care resources by encouraging

discussions between terminally ill

HIV patients and their doctors.

Half of all HIV-infected people in

the United States—especially blacks,

Hispanics, injection drug users, and

people with low education—never

talk about end-of-life care with their

doctors. Such discussions could

improve physicians’ understanding

of the care their patients do and do

not want when they are very ill and

close to death.

Making Quality Count

Following are examples of AHRQsupported research now in progress that

focuses on improving health care

quality:

• Bringing evidence-based medicine

to the hospital bedside.

Researchers at the University of

Iowa are carrying out a 3-year

randomized study at 12 hospitals in

Iowa, Missouri, and Illinois to

evaluate the effectiveness and costeffectiveness of implementing an

evidence-based acute pain

management guideline for

hospitalized elderly hip fracture

patients. The intervention targets

3

AHRQ-supported research demonstrates overuse of preoperative 

testing

A recent study by AHRQ-funded researchers found no differences in outcomes

between patients who did and did not undergo routine preoperative testing before

cataract surgery. Cataract surgery is the most common operation among the elderly in

the United States. In 1996, Medicare beneficiaries had about 1.5 million cataract

operations. Routine medical testing before cataract surgery is estimated to cost

Medicare $150 million each year. 

Cataract surgery is usually an outpatient procedure, and rates of illness and death

associated with the procedure are very low. This large randomized study involved

nearly 20,000 elective cataract operations in 18,189 patients at nine surgical centers.

The overall rate of complications, both during and after surgery, was the same for both

groups (31.3 per 1,000 operations). The researchers conclude that routine

preoperative testing confers no benefit on patients having cataract surgery

New severity measure for hospitalized pneumonia patients

Hospitalized pneumonia patients who have abnormal vital signs, mental confusion, or

problems with eating or drinking in the 24 hours prior to discharge are more likely than

other pneumonia patients not to be able to resume normal activities on discharge. Also,

they face a greater chance of readmission or death. 

AHRQ-supported researchers at Mount Sinai School of Medicine developed a simple

severity-of-illness measure that can be used by clinicians to judge whether it is safe for

a patient to be discharged from the hospital. The measure uses information from the

five vital signs that are checked several times a day in hospitalized patients

(temperature, heart rate, blood pressure, respiratory rate, and oxygen levels in the

blood), as well as assessment of the patient’s mental status and ability to eat and drink. 

Patients in this study who were discharged with two or more unstable factors had a

five-fold greater risk of readmission or death. Using this instrument, the researchers

found that one in five of the patients they studied had been discharged “medically

unstable.”
both nurses and prescribing

physicians and includes training,

computerized learning modules, the

use of opinion leaders, the use of

feedback and reminder cards, and

system interventions for modifying

chart forms and institutional policy.

The goals are to determine whether

a multidimensional organizational

intervention alters nurse and

physician behaviors and whether

institutional barriers to change are reduced. 

•Evidence-based reminders in

home health care. These researchers

are comparing the effectiveness of

two alternative information-based

strategies intended to improve

provider performance and promote

adherence to evidence-based

guidelines among home health care

nurses. The study employs a

randomized design that assigns

nurses to one of two treatment

groups or a control group (usual

care). Nurses in the basic

intervention group receive “just in

time” e-mail reminders highlighting

six condition-specific practices they

should follow for patients with

either heart failure or cancer pain. Nurses in the augmented

intervention group receive the same

e-mail reminders along with

additional information and

consulting services from an expert

peer. 

•Understanding variability in

community mammography. This

community-based, multicenter

observational study involves a

unique collaboration among three

geographically distinct breast cancer

surveillance programs in the States

of Washington, New Hampshire,

and Colorado. The investigators are

collecting breast cancer outcomes

and interpretive data on more than

500,000 mammograms from 91

facilities and 279 radiologists. The

goal is to identify reasons for variability in the interpretation of

mammograms and determine how

the quality of mammography can be

improved. 

•Racial and ethnic variation in

medical interactions. In this 5-year

program, researchers at the Baylor

College of Medicine and the Houston VA are developing and

testing interventions to improve

doctor-patient communication

patterns to reduce racial and ethnic

disparities in use and outcomes.

Both clinicians and patients are

participating in the project, which

also includes an information

dissemination component to

translate research findings into

practice as rapidly as possible.

•Otitis media: Parent education to

avoid antibiotic use.Acute otitis

media (AOM) continues to be a

major child health problem. The

average child experiences 2.6 AOM

episodes per year in the first 2 years

of life. The overuse of antibiotics for AOM has led to the emergence of

multi-drug resistant pathogens, even

though research has shown that 80

to 90 percent of children with

AOM will recover without

antibiotics. This randomized

controlled trial is evaluating the

safety, efficacy, cost to parent, and

acceptability of an intervention

consisting of parent education,

nonantibiotic symptomatic therapy,

and careful followup of children

with mild AOM. The goal is to

establish the safety of withholding

antibiotics from children with mild AOM and change parents’

expectations about universal

antibiotic treatment of AOM.

www.ahrq.gov4
• Benefits of regionalizing surgery

for Medicare patients. In this

ongoing study, researchers at

Dartmouth Medical School are

using Medicare data and data from

AHRQ’s National Inpatient Sample

(NIS) to investigate the potential

benefits of regionalizing patients

who have certain high-risk

procedures. For example, in the

April 11, 2002 issue of the New

England Journal of Medicine, they

reported a 12 percentage point

difference in survival for patients

being treated for cancer of the

pancreas at high- and low-volume

hospitals. Only 4 percent of patients

treated at the highest volume

hospitals died, compared with 16

percent at the lowest volume

hospitals. Indeed, they found that

elderly patients undergoing

treatment for any one of 14 highrisk cardiovascular or cancer

operations were more likely to

survive if they were treated in highvolume hospitals.

Future Research

Priorities for future research on quality

and quality improvement—particularly

the overuse, underuse, and misuse of

health care services—include:

• Identify which financial and

organizational factors promote

quality and how different payment

methods, financial incentives, and

organizational factors affect the

behavior of health care

5

Lowest-volume hospitals

Highest-volume hospitals

Pancreatic

resection

Esophagectomy Mitral valve

replacement

4%

16%

8%

20%

11.6%

15.1%

Adjusted mortality

Hospital volume and surgical mortality

Source: Adapted from Birkmeyer, Siewers, Finlayson, et al. Hospital volume and surgical

mortality in the United States. NEJM 346(15):1128-37, 2002.
6

organizations, providers, purchasers,

and patients.

• Design and implement new care

processes that enable patients to act

as co-managers of their health care,

particularly for chronic illnesses.

• Identify telecommunications

applications that will enhance

patients’ access to information and

patient-provider communication.

• Identify effective information

technology tools and systems that

alert providers in real-time to the

critical information they need to

provide safer, high quality care.

• Implement and evaluate strategies to

improve quality of care for people

with disabilities.

• Identify and address factors that

promote adoption of promising

quality improvement strategies (e.g.,

patient self-management) by all who

would benefit.

More Information

To find out more about AHRQ-funded

research on health care quality, visit our

Web site at www.AHRQ.gov or contact

Katherine Crosson, M.P.H., C.H.E.S,

at 301-594-6856 or via e-mail to

kcrosson@ahrq.gov.

www.ahrq.gov

AHRQ Pub. No. 02-P032

September 2002