IOM quality study targets 20 priority areas

The revolutionary report is the latest from the Institute of Medicine aimed at improving patient care.

By Andis Robeznieks, amednews staff. Feb. 17, 2003.

Narrowing the gap between what is common practice and what is recognized as the best medical practice is the goal behind an Institute of Medicine study identifying 20 key areas where quality improvement could "transform" health care delivery.

To establish the 20 target areas, a study committee judged the disabling, mortality and economic impact particular medical conditions have on patients, families and communities.

Transforming the U.S. health care system
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The committee also evaluated a condition's "improvability" (likelihood the gap between current and best practices could be closed), and its inclusiveness in regard to age, gender, socioeconomic status and ethnicity.

"The key thing is that it's a terrific set of starting points to improve quality of care in this country," said committee Chair George J. Isham, MD, medical director of Bloomington, Minn.-based HealthPartners Inc.

"It's not about finding new solutions for heart disease," he said. "It's about taking what we already know about heart disease and delivering it to the people with heart disease."

Unlike other medical reports that create a stir and then gather dust on bookshelves, Dr. Isham said that "Priority Areas for National Action: Transforming Health Care Quality" has the potential for "revolutionizing health care delivery."

Auspicious origins

He described how "Transforming Health Care Quality" follows in the footsteps of the IOM reports "To Err is Human: Building a Safer Health System" and "Crossing the Quality Chasm: A New Health System for the 21st Century" and how the priority areas originated from a list of recommendations contained in that second landmark report.

"The plan that was laid out in the previous report was quite bold," he said. "And this report fits into that -- in both scope and ambition."

Feedback regarding the report has been overwhelmingly positive, Dr. Isham said, but there has been some complaints that AIDS treatment was not listed as a targeted area.

"We considered hundreds and hundreds of conditions, each of which is important to the people who have them," he explained. "We did specifically look at AIDS, but -- by going through this process -- these were the 20 that emerged."

By targeting better coordination of care and self-management of care, Dr. Isham added, the results could be better treatment for AIDS and thousands of other conditions not specifically listed.

The report also highlighted the broad-spectrum impact major depression has on the nation's health and noted how improving delivery of treatment for depression could have many ripple effects.

"I think there is increased attention to the important role depression plays in mortality and morbidity, and the tremendous prevalence of this condition," Dr. Isham said.

He noted how the World Health Organization recently stated that depression "contributes to more medical disability than any other single medical condition" in the United States.

Good starting points

Gordon Schiff, MD, director of clinical quality research at Chicago's John H. Stroger Jr. Hospital of Cook County, gave the latest IOM report lukewarm support.

Dr. Schiff, whose critique of "Crossing the Quality Chasm" appeared in Public Health Reports, said "Transforming Health Care Quality" hasn't had much of an impact.

Nevertheless, he added that its writers chose reasonable and broad targets, and he agreed that they were good starting points for getting the issue of quality improvement moving forward. "What I have seen is somewhat lacking in specificity of exactly who should do what, when, where and how to fund [it]."

Dr. Schiff added that it's "not always as easy to implement the changes in reality as on paper," and noted how even apparently obvious quality improvements -- such as The Leapfrog Group's call for computer prescription order entry -- can be difficult to complete.

Dr. Isham said some of these concerns are being addressed, and that funding for a "summit meeting" to follow up on the report's recommendations already has been secured by the IOM. The meeting, most likely convened this fall, would discuss strategies for hitting the targets mentioned in the report.

ADDITIONAL INFORMATION:

Transforming the U.S. health care system

Medical responses to these 20 target areas, chosen for their "impact, improvablity, and inclusiveness" are viewed as starting points to improve quality for all patients.

Asthma: Use anti-inflammatories; treat persistent mild cases better.
Care coordination: Collaborate on care for 60 million Americans with multiple chronic conditions.
Children with special health care needs: Recognize that those with chronic physical, developmental, behavioral or emotional conditions need more care.
Diabetes: Prevent progression.
End of life with advanced organ system failure: Minimize symptoms; reduce exacerbation rates.
Evidence-based cancer screening: Reduce death rates for several forms of cancer.
Frailty associated with old age: Prevent falls and pressure ulcers; maximize function.
Hypertension: Educate the nearly one-third of the people who have it and don't know it.
Immunization: Target nursing home residents, low-rate populations.
Ischemic heart disease: Prevent disease; reduce recurrence of attacks.
Major depression: Reach the more than 50% who are misdiagnosed.
Medication management: Use technology to prevent errors.
Nosocomial infections: Use CDC guidelines to save 40,000 lives a year.
Obesity: Focus on treating the nation's most preventable cause of premature death and disability.
Pain control for advanced cancer: Cooperate across care settings; educate public about opioids.
Pregnancy and childbirth: Raise the number of those getting first-trimester care.
Self-management/health literacy: Boost health-managing skills.
Severe and persistent mental illness: Raise public-sector care quality.
Stroke: Integrate care across disciplines; begin rehabilitation as soon as possible.
Tobacco-dependence treatment in adults: Use layered interventions.