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January 15, 2003

Medicare Quality ImprovementBad Apples or Bad Systems?

Author Affiliations

Author Affiliation: Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, Md.

JAMA. 2003;289(3):354-356. doi:10.1001/jama.289.3.354

The Quality Improvement Group at the Centers for Medicare and Medicaid Services leads the quality improvement organizations (QIOs, formerly the PROs [peer review organizations], PSROs [professional standards review organizations], EMCROs [experimental medical care review organizations], etc),1 and according to the results of a study by Jencks and colleagues2 in this issue of THE JOURNAL, their leadership is effective. No other US organization measures quality at the hospital level. The QIO program uses 24 quality indicators that have strong evidence to support them. Jencks et al report that between 1999 and 2001, the proportion of Medicare patients receiving appropriate care improved from 70% to 73% on average, although this rate varied widely across states and by indicator.2 Their analysis is valid, robust, understandable, and correct. For the 1999-2002 QIO contract cycle, Centers for Medicare & Medicaid Services required all QIOs to improve quality in 5 clinical areas (acute myocardial infarction, heart failure, pneumonia, surgical infection, and outpatient diabetes), not just to passively review charts.3 The QIO quality indicators address some aspects of suboptimal quality, but others remain.

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