Three Polio; four Diphtheria, Tetanus, Pertussis; one Measles, Mumps, Rubella; and three Haemophilus influenzae type b (Hib) by 18 months old. (Three to four doses of Hib are recommended, depending on formulation; three Hepatitis B virus vaccines [HBV] are also recommended but were not included in this particular study.) (American Academy of Pediatrics [AAP], 1994; Centers for Disease Control and Prevention [CDC], 1995a).

Children 19–35 months old in 31,997 households from a nationally representative sample of the United States (U.S.).

National Immunization Survey (NIS), 1995.

74% received all the vaccines. (If three doses of Hib are not included, the percentage is 76%.)

CDC, 1997

Annual vaccination of all people≥65 years old is recommended (U.S. Preventive Services Task Force [USPSTF], 1989). This recommendation has since been reiterated (USPSTF, 1996).

Approximately 8,000 adults ≥65 years old from a sample of people representative of the U.S. civilian, noninstitutionalized population.

National Health Interview Survey (NHIS), 1993.

52% received annual influenza vaccine.

CDC, 1995b

Same as above.

From a sample of 7,997 randomly selected patients ≥20 years old who had visited a clinic during the

Mailed surveys with phone follow-up of patients who visited one of 44 clinics from August 1, to

72% of people≥65 years had an influenza vaccine in the prior year.

Kottke et al., 1997

study period, 6,830 (85%) completed surveys.

September 9, 1994, in the Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies.

One-time vaccination for all people≥65 years old is recommended (USPSTF, 1989). In 1996, the recommendation was modified to specify one-time vaccination for all immunocompetent individuals≥65 years old (USPSTF, 1996).

Approximately 8,000 adults ≥65 years old from a sample of people representative of the U.S. civilian, noninstitutionalized population.

NHIS, 1993

28% received pneumococcal vaccine.

CDC, 1995b

Same as above.

From a sample of 7,997 randomly selected patients ≥20 years old who had visited a clinic during the study period, 6,830 (85%) completed surveys.

Mailed surveys with phone follow-up of patients who visited one of 44 clinics from August 1, to September 9, 1994, in the Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies.

36% of people≥65 years old had ever had a pneumococcal vaccine.

Kottke et al., 1997

Recommendations vary. In 1989, the USPSTF recommended an annual clinical breast exam (CBE) for women≥40 years old and mammography every 1–2 years for women 50–75 years old (USPSTF, 1989).

21,601 women≥50 years old from a sample of people representative of the U.S. population (excluding Arkansas and Wyoming,

Behavioral Risk Factor Surveillance System, 1992.

58% had clinical breast exam in the prior year; 46% had mammography in the prior year; 40% had both examinations in the

CDC, 1993a

In 1996, it recommended mammography every 1–2 years with or without annual clinical breast exam for women 50–69 years old (USPSTF, 1996).

and including the District of Columbia).

prior year.

Same as above.

From a sample of 7,997 randomly selected patients ≥20 years old who had visited a clinic during the study period, 6,830 (85%) completed surveys.

Mailed surveys with phone follow-up of patients who visited one of 44 clinics from August 1, to September 9, 1994, in the Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies.

72% of women≥50 years old had a breast examination in the prior two years; 68% of women 50 years or older had a mammogram in the prior two years.

Kottke et al., 1997

Same as above.

221 women>50 years old.

Interview survey of women in farm households randomly sampled from six southern Minnesota counties, 1992.

38% of women had not received a mammogram in the prior 18 months.

Stoner et al., 1998

Women with an intact uterus (having a cervix) should have a Papanicolaou (Pap) smear after initiation of sexual intercourse and every 1–3 years thereafter. Some organizations recommend starting Pap smears for all women who have reached 18 years old, regardless of sexual history (USPSTF, 1989). These recommendations

Women≥18 years old with an intact uterus from a sample of 128,412 people representative of the U.S. civilian, noninstitutionalized population.

NHIS, 1992.

67% had a Pap smear in the prior 3 years.

CDC, 1996

have since been reiterated (USPSTF, 1996).

Same as above.

From a sample of 7,997 randomly selected patients ≥20 years old who had visited a clinic during the study period, 6,830 (85%) completed surveys.

Mailed surveys with phone follow-up of patients who visited one of 44 clinics from August 1, to September 9, 1994, in the Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies.

84% of women had a Pap smear in the prior two years.

Kottke et al., 1997

Recommendations vary. In 1980, the American Cancer Society recommended annual fecal occult blood testing (FOBT) starting at 50 years old. Some other organizations made similar recommendations. In 1989, the USPSTF did not make recommendations (USPSTF, 1989), but in 1996, it recommended annual FOBT, sigmoidoscopy (periodicity unspecified), or both starting at 50 years old (USPSTF, 1996).

Adults≥40 years old from a sample of 128,412 people representative of the U.S. civilian, noninstitutionalized population.

NHIS, 1992

14% of men and 15% of women had FOBT in the prior year; 44% of men and 43% of women had ever had FOBT; 11% of men and 7% of women had proctosigmoidoscopy in the prior 3 years.

CDC, 1996

Same as above.

250 women 40–65 years old who had no major illnesses, who received primary care at one of the group practices, and who were eligible for preventive care.

Medical records for patients from four group practices in Massachusetts, November 1, 1985, to October 31, 1987.

51%–59% of women had FOBT every 2 years or flexible sigmoidoscopy every 5 years.

Udvarhelyi et al., 1991

The USPSTF recommends a complete history of tobacco use as well as tobacco cessation counseling on a regular basis (USPSTF, 1989, 1996). The Agency for Health Care Policy and Research (AHCPR) recommends that primary care physicians identify patients’ smoking status and counsel smokers at every visit (AHCPR, 1996).

8,778 smokers≥18 years old from a sample of 43,732 people representative of the U.S. civilian, noninstitutionalized population.

NHIS, 1991.

37% of smokers who had a visit with a physician or other health care professional during the prior year had been advised to quit smoking.

CDC, 1993b

Same as above.

From a sample of 7,997 randomly selected patients ≥20 years old who had visited a clinic during the study period, 6,830 (85%) completed surveys.

Mailed surveys with phone follow-up of patients who visited one of 44 clinics from August 1, to September 9, 1994, in the Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies.

53% of smokers were asked their smoking status. 47% of smokers were advised to quit.

Kottke et al., 1997

Same as above.

A nationally representative sample of 3,254 physicians representing 145,716 adult patient ambulatory care visits.

National Ambulatory Medical Care Survey (NAMCS), 1991–1995.

Physicians knew the patient’s smoking status at 66% of all patient visits. (The percentage for primary care physicians ranged from about 61% to

Thorndike et al., 1998

67%, depending on the year.) Smoking counseling was provided at 22% of visits of known smokers. (The percentage for primary care physicians ranged from 20% to 38%.)

In 1988, the National Heart, Lung, and Blood Institute recommended routine cholesterol screening at least every 5 years starting at 20 years old. In 1989, the USPSTF recommended periodic screening for middle-aged men (USPSTF, 1989), and in 1996, it recommended periodic screening for men 35–65 years old and women 45–65 years old. Treatment includes dietary therapy, physical activity, or lipid-lowering medications depending on the patient (National Cholesterol Education Program [NCEP], 1993).

3,700 adults≥18 years old from a representative sample of the non-African American U.S. population.

Telephone survey by the National Heart, Lung, and Blood Institute, 1990.

65% of adults had ever had a blood cholesterol test; 51% had the test in the prior year; and an additional 14% had it prior to that. 35% had never had a blood cholesterol test.

Schucker et al., 1991

Same as above.

Adults≥20 years old from a sample of people representative of the U.S. population (excluding Wyoming, Kansas, and

CDC’s Behavioral Risk Factor Surveillance System, 1991.

The state-specific rates of adults who had cholesterol screening in the prior 5 years ranged from 57% to 70%.

CDC, 1993c

Nevada, and including the District of Columbia) (sample sizes for individual states range from 670 to 3,190 people).

Same as above.

From a sample of 7,997 randomly selected patients ≥20 years old who had visited a clinic during the study period, 6,830 (85%) completed surveys.

Mailed surveys with phone follow-up of patients who visited one of 44 clinics from August 1, to September 9, 1994, in the Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies.

68% had had their cholesterol measured during the prior 5 years.

Kottke et al., 1997

Same as above.

1,004 people 40–64 years old from a sample that had been enrolled continuously for at least 5 years and had at least one outpatient visit during the study period.

Medical records from three sites of a managed care plan (South Florida; Jacksonville, Florida; and Atlanta, Georgia), January 1, 1988, to December 31, 1993.

84% were screened for elevated cholesterol levels at least once during the 6-year period. 86% with a diagnosis of hypercholesterolemia were treated with diet therapy, cholesterol-lowering drugs, or both.

Davis et al., 1998

In 1989, the USPSTF recommended blood pressure measurements for normotensive patients≥21 years old every 2 years if their last diastolic and systolic blood pressures were below 85 mm Hg and 140 mm Hg, respectively, and annually if their last diastolic was 85–89 mm Hg (USPSTF, 1989). In 1996, these recommendations were modified to specify apparently normotensive patients (USPSTF, 1996).

From a sample of 7,997 randomly selected patients ≥20 years old who had visited a clinic during the study period, 6,830 (85%) completed surveys.

Mailed surveys with phone follow-up of patients who visited one of 44 clinics from August 1, to September 9, 1994, in the Minneapolis-St. Paul metropolitan area with contracts with one of two managed care companies.

88% had blood pressure measured at the most recent visit.

Kottke et al., 1997

The AAP recommends routine history, physical examination, screening tests, and anticipatory guidance throughout childhood (AAP, 1988).

All children who had their second birthday during the first half of the study year, and all 2-year-olds with otitis media or asthma, from a sample of 2,024 patients of 135 providers.

Medical records from physicians’ offices, community health centers, and hospital outpatient facilities sampled from Maryland Medicaid claims data, 1988.

For each type of clinical setting, the study reports the average percentage of technical quality indicators for well-child care that were not met. Each average fell in the 35%–65% range.

Starfield et al., 1994

Patients should have preventive health visits every 1–3 years when 19–64 years old and every year when≥65 years old (USPSTF, 1989).

All adults with asthma, hypertension, and diabetes from a sample of 2,024 patients of 135 providers.

Same as above.

For each type of clinical setting, the study reports the average percentage of technical quality indicators for well-adult care that were not met. Each average fell in the 45%–55% range.

Starfield et al., 1994

Includes documentation of tobacco use/ nonuse and lower-extremity edema; blood pressure readings; oxygen therapy or intubation for hypoxic patients.

1,408 patients hospitalized with pneumonia from a nationally representative sample of 7,156 patients hospitalized with any of five conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990).

Medical records for Medicare patients from 297 hospitals in five states (California, Florida, Indiana, Pennsylvania, Texas), July 1, 1985, to June 30, 1986.

52%–90% of patients with pneumonia received appropriate components of care.

Kahn et al., 1990

Includes various components of pneumonia care consistent with prevailing standards of care.

1,343 patients≥65 years old hospitalized with pneumonia.

National Medicare claims data and medical records, October 1, 1994, to September 30, 1995

89% had oxygenation assessment within 24 hours of hospital arrival, 76% received antibiotics within 8 hours of arrival, 69% had blood cultures within 24 hours of arrival, and 57% had blood cultures collected before initial antibiotic administration.

Meehan et al., 1997

Includes various components of otitis media care consistent with prevailing standards of care.

464 children≥3 years old diagnosed with otitis media from a sample of 2,024 patients of 135 providers.

Medical records from physicians’ offices, community health centers, and hospital outpatient facilities sampled from Maryland Medicaid claims data, 1988.

For each type of clinical setting, the study reports the average percentage of technical quality indicators for otitis media that were not met. Each average fell in the 10%–40% range.

Starfield et al., 1994

Includes documentation of mental status and pedal or leg pulse, serum potassium level, electrocardiogram.

1,404 patients hospitalized with hip fracture from a nationally representative sample of 7,156 patients hospitalized with any of five conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990).

Medical records for Medicare patients from 297 hospitals in five states (California, Florida, Indiana, Pennsylvania, Texas), July 1, 1985, to June 30, 1986.

67%–94% of patients with hip fracture received appropriate components of care.

Kahn et al., 1990

The provision of a urine culture in diagnosing a urinary tract infection (UTI) is consistent with prevailing standards of care.

535 episodes of UTI from 465 children who received ambulatory care for UTIs out of a sample of 147,356 children<8 years old with

Medicaid claims from Alabama, July 1, 1989, to June 30, 1993.

52% received a urine culture.

Bronstein et al., 1997

continuous Medicaid coverage (exclusive of children with Medicaid because of Supplemental Security Income) for all 12 months of 1992.

Includes various components of prenatal care consistent with prevailing standards of care.

9,924 women who had live births in 1988 from a nationally representative sample of the U.S. population (excluding South Dakota and Montana, and including the District of Columbia).

National Maternal and Infant Health Survey (NMIHS), 1988.

80% were asked about health history during the first or second visit. 98% had their weight and height measured, 96% had blood pressure measured, and 86% received a physical or pelvic examination during the first or second visit. 79% received blood tests and 93% received urinalysis during the first or second visit. 56% received all of the evaluations listed above during the first or second visit.

Kogan et al., 1994

Includes various components of prenatal care consistent with prevailing standards of care.

Same as above.

Same as above.

97% were counseled about vitamins, 93% were counseled about diet, and 72% were counseled about proper weight gain during pregnancy during at least one prenatal visit. 68% were counseled to reduce or eliminate alcohol consumption, 69% to reduce or eliminate smoking, and 65% to stop use of illegal drugs during at least one prenatal visit. 53% were counseled about breastfeeding during at least one prenatal visit. 32% received all of the counseling listed above during at least one prenatal visit.

Kogan et al., 1994

Includes tests to screen for anemia, asymptomatic bacteriuria, syphilis, gonorrhea, hepatitis B, rubella immunity, and Rh factor and antibody.

Random sample of 586 women who had a live birth from 24,170 births that occurred during the study period.

Medical records for patients from six HMOs in six states (Arizona, California, Colorado, Massachusetts, Minnesota, Oregon), August 1, 1989, to July 31, 1990.

Among six HMOs, women received 64%–95% (average 82%) of seven recommended routine prenatal screening tests.

Murata et al., 1994

Includes first prenatal visit during first trimester, accurate determination of gestational age, screening for inherited disorders, measurement of symphysis-fundal height, and blood pressure measurement.

Same as above.

Same as above.

Among six HMOs, women received 78%–87% (average 84%) of five processes of routine prenatal care.

Murata et al., 1994

Includes diagnostic and treatment interventions after abnormal screening test results, and care to mitigate effects of pregnancy-induced hypertension and gestational diabetes.

Same as above.

Same as above.

Among six HMOs, women received 54%–77% of care for complications of pregnancy.

Murata et al., 1994

Urine is checked for protein to evaluate for the presence of preeclampsia, a serious complication of pregnancy.

Inpatient records for 2,336 women from a sample of 2,878 births in 1985; prenatal care records for 823 of these women.

Medical records for patients sampled from Medicaid claims files for women and children enrolled in Aid to Families with Dependent Children (AFDC) in two communities in California and two communities in Missouri, 1985.

Testing was provided at 75%–83% of visits. Follow-up was performed for 41%–65% of patients with proteinuria.

Carey et al., 1991

Includes a component of prenatal care consistent with prevailing standards of care.

Same as above.

Same as above.

Gestational age was recorded at 78%–95% of visits.

Carey et al., 1991

Includes a component of prenatal care consistent with prevailing standards of care.

Same as above.

Same as above.

Fetal heart tones were assessed at 81%–93% of visits.

Carey et al., 1991

Low hematocrit indicates anemia.

Same as above.

Same as above.

Follow-up was performed for 32%–51% of patients with low hematocrit.

Carey et al., 1991

Includes a component of prenatal care consistent with prevailing standards of care.

Same as above.

Same as above.

Follow-up was performed for 31%–53% of patients with high blood pressure.

Carey et al., 1991

Includes various components of prenatal care consistent with prevailing standards of care.

267 women receiving routine, low-risk prenatal care were randomly selected, with stratification by insurance type (Medicaid, health maintenance organization, fee-for-service).

Medical records from seven private and hospital-based prenatal care sites in Washtenaw County, Michigan, for women receiving care between January 1, 1991, and December 31, 1992.

99% had blood pressure assessed at each visit. 93% had fundal height assessed at each visit after 20 weeks gestation.

Klinkman et al., 1997

Includes various components of prenatal care consistent with prevailing standards of care.

Same as above.

Same as above.

Patients received an average of 81%–83% (depending on insurance type) of recommended laboratory screening tests.

Klinkman et al., 1997

The American College of Obstetricians and Gynecologists recommends intrapartum antibiotics for women with rupture of membranes (ROM) for 18 hours or more to prevent neonatal Group B Streptococcal (GBS) infection (ACOG, 1993, 1996).

81 women with ROM≥18 hours from among all women with deliveries during the study period.

Medical records from two HMO hospitals (in which protocols similar to ACOG guidelines had been adopted) in San Francisco and Oakland, California, for women who delivered from January to June 1995.

88% received an antibiotic effective against GBS, 37% received antibiotics within 20 hours of ROM (median duration of ROM was 31 hours).

Lieu et al., 1998

Includes various components of asthma care consistent with prevailing standards of care.

Adults≥18 years old in a group of 393 adults and children diagnosed with asthma, from a sample of 2,024 patients of 135 providers.

Medical records from physicians’ offices, community health centers, and hospital outpatient facilities sampled from Maryland Medicaid claims data, 1988.

For each type of clinical setting, the study reports the average percentage of technical quality indicators for adult asthma that were not met. Each of the averages was located in the 40%–45% range. Between 5% and 35% of care was inappropriate.

Starfield et al., 1994

Includes various components of asthma care consistent with prevailing standards of care.

Children<18 years old in a group of 393 adults and children diagnosed with asthma, from a sample of 2,024 patients of 135 providers.

Same as above.

For each type of clinical setting, the study reports the average percentage of technical quality indicators for childhood asthma that were not met. Each of the averages was located in the 30%–40% range. Between 0% and 20% of care was inappropriate.

Starfield et al., 1994

Includes various components of asthma care consistent with prevailing standards of care.

5,580 patients≥14 years old who were prescribed asthma medications.

Survey of patients from multiple sites of a health maintenance organization in California, 1996.

72% of patients with severe asthma had a steroid inhaler, 26% of patients needing daily medications had a peak flow meter at home, and 42% were advised about self-management tools.

Legorreta et al., 1998

Annual dilated eye examination to screen for retinopathy starting at time of diagnosis of non-insulin-dependent diabetes mellitus (NIDDM) and 5 years after diagnosis of insulin-dependent diabetes mellitus (IDDM).

2,392 adults≥18 years old with IDDM (124 patients), NIDDM treated with insulin (922 patients), and NIDDM not treated with insulin (1,346 patients) from a sample of 84,572 people

NHIS, 1989.

49% had a dilated eye examination in the prior year; 66% had an examination in the prior 2 years; 61% and 57% of patients at high risk of vision loss because of a

Brechner et al., 1993

representative of the U.S. civilian, noninstitutionalized population.

history of retinopathy or of long duration of diabetes, respectively, had an examination in the prior year.

Dilated eye examination is recommended, as described above, but any eye examination is also reported to determine whether there was any effort to assess for retinopathy.

Same as above.

Same as above.

61% had an eye examination in the prior year; 79% had an examination in the prior 2 years.

Brechner et al., 1993

Dilated eye examination is recommended, as described above, but an examination by an ophthalmologist serves as a proxy for a dilated eye examination.

97,388 Medicare patients ≥ 65 years old diagnosed with diabetes mellitus.

All Medicare claims data (Parts A and B) from three states (Alabama, Iowa, Maryland), submitted from July 1, 1990, to June 30, 1991.

54% did not have an examination by an ophthalmologist during the prior year.

Weiner et al., 1995

Includes various components of diabetes care consistent with prevailing standards of care.

292 patients≥65 years old with diabetes mellitus.

National Medicare Competition Evaluation, with medical records from 8 HMOs and 113 fee-for-service providers for patients drawn from

92%–96% had their weight recorded at least once after diagnosis. 70% (for both HMO and FFS providers) had a peripheral vascular examination. 94%–96% had

Retchin and Preston, 1991

enrollment lists of patients with start-up dates between January 1983, and May 1984; records were abstracted from the start-up date to March 31, 1986.

blood pressure recorded at least annually. 30%–48% had a funduscopic examination or referral to an ophthalmologist within 2 years of diagnosis. 58%– 63% had tonometry performed.

Hemoglobin A1C (or glycosylated hemoglobin) is a blood test that reflects the metabolic control of diabetes. The test should be performed at least once a year for diabetics.

97,388 Medicare patients ≥ 65 years old diagnosed with diabetes mellitus.

All Medicare claims data (Parts A and B) from three states (Alabama, Iowa, Maryland), submitted from July 1, 1990, to June 30, 1991.

84% did not receive a hemoglobin A1C test during the prior year.

Weiner et al., 1995

It is recommended that total cholesterol be measured at least once a year for diabetics.

Same as above.

Same as above.

45% did not receive blood cholesterol screening during the prior year

Weiner et al., 1995

Includes various components of diabetes care consistent with prevailing standards of care.

292 patients≥65 years old with diabetes mellitus.

National Medicare Competition Evaluation, with medical records from 8 HMOs and 113 fee-for-service providers for patients drawn from enrollment lists of patients with start-up dates between January 1983, and May 1984; records were

74%–89% had urinalysis performed. 75%–95% had creatinine or serum urea nitrogen determined at least annually after diagnosis. 82%–83% had an electrocardiogram performed within 6 months of diagnosis. 91%–95% had at least one repeated blood

Retchin and Preston, 1991

abstracted from the start-up date to March 31, 1986.

glucose within 12 months of diagnosis. 84%–90% who were not taking insulin had blood glucose recorded at least every 12 months. 74% (for both HMO and FFS providers) who were taking insulin had blood glucose recorded at least every 6 months.

Includes diabetes care consistent with prevailing standards of care.

Same as above.

Same as above.

19%–62% received an influenza vaccination.

Retchin and Preston, 1991

Includes various components of diabetes care consistent with prevailing standards of care.

368 adults≥18 years old diagnosed with diabetes, from a sample of 2,024 patients of 135 providers.

Medical records from physician offices, community health centers, and hospital outpatient facilities sampled from Maryland Medicaid claims data, 1988.

For each clinical setting, the study reports the average percentage of technical quality indicators for diabetes that were not met. Each average was located in the 40%–60% range.

Starfield et al., 1994

People with H. pylori peptic ulcer disease (PUD) should be prescribed antimicrobial therapy for the infection, as strongly recommended by the National Institutes of Health Consensus Development Conference in February 1994.

About 3,571 Medicaid beneficiaries≥18 years old who received care for PUD and who were not receiving nonsteroidal antiinflammatory drugs.

Computerized inpatient, outpatient, and pharmaceutical claims files of the Pennsylvania Medicaid Program, March 1994, to February 1996.

11% of patients received antimicrobials within five days of a PUD encounter.

Thamer et al., 1998

Hypertension (high blood pressure) is a leading risk factor for coronary heart disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease, and retinopathy, all of which contribute to high morbidity and mortality (U.S. Preventive Services Task Force, 1989). This was reiterated in 1996 (U.S. Preventive Services Task Force, 1996).

246 patients>30 years old with chronic uncomplicated hypertension.

Medical records for patients from four group practices in Massachusetts, November 1, 1985, to October 31, 1987.

41%–54% of patients had their hypertension controlled (mean blood pressure<150/90).

Udvarhelyi et al., 1991

Same as above.

Nationally representative sample of U.S. adults with hypertension (sample size not available).

National Health and Nutrition Examination Survey III, 1988–1991.

55% of people with hypertension had blood pressure under control (blood pressure<160/95 on one occasion and reported currently taking antihypertensive medications); 21% when using strict criteria (blood pressure<140/90 and reported currently taking antihypertensive medications).

Joint National Committee on Detection, 1993

Same as above.

8,697 adults≥18 years old diagnosed with hypertension from a sample of 36,610 people representative of the U.S. population.

NHIS, 1990.

89% of adults with hypertension received advice from a physician about controlling hypertension (i.e., taking antihypertensive medication, decreasing salt intake, losing weight, or exercising); 80% reported taking at least one action to control hypertension.

CDC, 1994b

Same as above.

593 adults≥18 years old diagnosed with hypertension, from a sample of 2,024 patients of 135 providers.

Medical records from physician offices, community health centers, and hospital outpatient facilities sampled from Maryland Medicaid claims data, 1988.

For each type of clinical setting, the study reports the average percentage of technical quality indicators for hypertension that were not met. Each average fell in the 40%–55% range.

Starfield et al., 1994

Includes diagnostic criteria consistent with prevailing standards of care.

650 patients with current depressive disorder from a sample of 22,462 adult patients who visited one large HMO; several

Medical Outcomes Study in three cities (Boston, Chicago, Los Angeles); questionnaires completed February to October 1986;

44%–51% of depressed patients who visited general medical clinicians had their depression detected during the visit. 78%–94% of

Wells et al., 1989

multispecialty, mixed-group practices; single-specialist small group practices; or solo practice providers in each city during the study period.

phone interviews completed May to December 1986.

depressed patients who visited mental health specialists had their depression detected during the visit.

Includes various components of depression care consistent with prevailing standards of care.

Same as above.

Same as above.

50%–58% of depressed patients who visited general medical clinicians received appropriate care (the depression was detected, and they were counseled or referred to a mental health specialist or another clinician was noted to be providing the majority of the patient’s care). 83%– 93% of depressed patients who visited mental health specialists received appropriate care.

Wells et al., 1989

Includes various components of depression care consistent with prevailing standards of care.

1,198 patients hospitalized with depression, representative of all Medicare elderly patients hospitalized in general medical hospitals with a discharge diagnosis of

Medical records for Medicare patients from 297 hospitals in five states (California, Florida, Indiana, Pennsylvania, Texas), July 1, 1985, to June 30, 1986.

As part of admission assessment, 23% of patients did not have adequate psychological assessment, 26% did not have cognitive assessment, 50% did not have assessment of

Wells et al., 1993

depression.

psychosis, 19% did not have documentation of psychiatric history, 47% did not have documentation of whether patient had a history of suicide attempts or ideation, 24% did not have documentation of prior or current medication use, and 45% did not have documentation that heart sounds were examined. Mean number of components of neurologic examination (assessment of pupils, deep tendon reflexes, and gait) performed was 1.4.

Includes diagnostic criteria and treatment consistent with prevailing standards of care.

People with mental or addictive disorder from a sample of 20,291 adults ≥18 years old.

National Institute of Mental Health’s Epidemiologic Catchment Area study interviews, 1980–1985.

29% of people with any mental or addictive disorder received some professional or voluntary mental health service during the prior 12 months, as did 32% of people with any disorder except

Regier et al., 1993

substance use, 37% of people with any mental disorder with comorbid substance use, 24% of people with substance use (e.g., alcohol), 64% of people with schizophrenia, 46% of people with any affective disorder (e.g., depression), 33% of people with any anxiety disorder (e.g., obsessive-compulsive), 70% of people with somatization, 31% of people with antisocial personality disorder, and 17% of people with severe cognitive impairment.

Includes various components of schizophrenia care consistent with prevailing standards of care.

224 patients from a random sample of patients 18–65 years old with schizophrenia or schizoaffective disorder who had been treated at the clinic for>3 months, had been hospitalized<21 days during the prior 3 months, and had>1 visit with a psychiatrist during the sampling period.

Patient interviews and medical records from a Veterans Affairs Medical Center clinic and a community mental health center clinic during a 3-month period in early 1996.

70% of patients with significant psychotic symptoms received poor management of their symptoms, and 79% of patients with significant medication side effects (akathisia, parkinsonism, tardive dyskinesia) received poor management of the side effects. 35% of patients with severe

Young et al., 1998

disability were not receiving case management. 57% of patients in close contact with family members had no communication between the clinic and the family.

Patients with breast cancer have better outcomes if diagnosis is made at an early stage.

5,766 newly diagnosed patients with histologically confirmed breast cancer.

Data submitted to American Cancer Society, Illinois Division, Chicago, by 99 hospitals out of 104 Illinois hospitals with active cancer registries, 1988.

The average rate across hospitals of patients diagnosed with cancer at a late stage (IIb through IV) was 18%.

Hand et al., 1991

Patients with breast cancer have better outcomes if hormone receptor levels in tumor tissue are determined.

2,958 newly diagnosed patients with histologically confirmed Stage II-IV breast cancer.

Same as above.

The average rate across hospitals of patients who did not have a hormone receptor test was 11%.

Hand et al., 1991

Diagnosis should be made with fine needle aspiration, cytology, limited incisional biopsy, or definitive wide local excision.

918 insured women≤64 years old with local/ regional invasive breast cancer Stage I or II.

Data collected by Virginia Cancer Registry from 50 hospitals that represented 85% of Virginia hospital beds, and claims data from

92% had initial biopsy prior to total mastectomy.

Hillner et al., 1997

Trigon Blue Cross Blue Shield of Virginia, 1989– 1991.

Includes various components of breast cancer treatment consistent with prevailing standards of care.

199 women 50–69 years old and 175 women≥70 years old with adenocarcinoma of the breast receiving primary cancer management at a participating hospital.

Medical records from seven hospitals in southern California, for women with breast cancer diagnosed in 1980, to 1982.

67% of women≥70 years old received appropriate treatment, compared with 83% of women 50–69 years old. After controlling for comorbidity, hospital, and cancer stage, a difference in appropriateness related to age persisted.

Greenfield et al., 1987

Breast conservation, defined as excision of the tumor and surrounding tissue, with axillary dissection, followed by radiation therapy, was preferable to mastectomy for the majority of women with Stage I or II breast cancer, as supported by clinical trials and a 1990 NIH Consensus Conference (NIH Consensus Conference, 1991).

8,095 women with a first primary breast cancer, Stage I or II.

Data from the Seattle-Puget Sound cancer registry, which covers cancer cases in 13 western Washington counties and is part of the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute, 1983– 1989.

34% had breast-conserving surgery.

Lazovich et al., 1991

Same as above.

2,657 women with complete records out of 2,731 women with a first primary breast cancer, Stage I or II, who underwent breast-conserving surgery.

Same as above.

85% received radiation therapy.

Same as above.

4,311 newly diagnosed patients with histologically confirmed Stage I-II breast cancer.

Data submitted to American Cancer Society, Illinois Division, Chicago, by 99 hospitals out of 104 Illinois hospitals with active cancer registries, 1988.

The average rate across hospitals of patients who did not receive radiotherapy after partial mastectomy was 48%.

Hand et al., 1991

Same as above.

918 insured women≤64 years old with local/regional invasive breast cancer Stage I or II.

Data collected by Virginia Cancer Registry from 50 hospitals that represented 85% of Virginia hospital beds and claims data from Trigon Blue Cross Blue Shield of Virginia, 1989– 1991.

86% received local breast radiation following lumpectomy.

Hillner et al., 1997

Patients with breast cancer have better outcomes if adjuvant therapy is given to patients with Stage II neoplasms.

2,248 newly diagnosed patients with histologically confirmed Stage II breast cancer.

Data submitted to American Cancer Society, Illinois Division, Chicago, by 99 out of 104 Illinois hospitals with active cancer registries, 1988.

The average rate across hospitals of patients who did not receive adjuvant therapy was 44%.

Hand et al., 1991

Premenopausal, node-positive women with local/regional breast cancer should receive adjuvant chemotherapy.

918 insured women≤64 years old with local/ regional invasive breast cancer Stage I or II.

Data collected by Virginia Cancer Registry from 50 hospitals that represented 85% of Virginia hospital beds, and claims data from

83% of premenopausal women with at least one positive axillary node received adjuvant chemotherapy.

Hillner et al., 1997

Trigon Blue Cross Blue Shield of Virginia, 1989, to 1991.

Patients with breast cancer have better outcomes if axillary lymph node dissection is done as part of the surgical treatment with Stage I and II neoplasms.

4,311 newly diagnosed patients with histologically confirmed Stage I-II breast cancer

Data submitted to American Cancer Society, Illinois Division, Chicago, by 99 hospitals out of 104 Illinois hospitals with active cancer registries, 1988

The average rate across hospitals of patients who did not have a lymph node dissection was 9%.

Hand et al., 1991

Same as above.

918 insured women≤64 years old with local/ regional invasive breast cancer Stage I or II.

Data collected by Virginia Cancer Registry from 50 hospitals that represented 85% of Virginia hospital beds, and claims data from Trigon Blue Cross Blue Shield of Virginia, 1989– 91.

88% underwent axillary node dissection.

Hillner et al., 1997

Women with early stage breast carcinoma (TNM Stages I and II) who undergo breast-conserving surgery should then receive radiation therapy.

1,292 women who underwent breast-conserving surgery from a sample of 2,575 women with early-stage breast carcinoma, excluding patients for whom national recommendations were not likely to apply.

Medical records, patient surveys, and physician surveys for patients from 18 Massachusetts hospitals from a stratified random sample of 20, from September 1993, to September 1995, and from 30 Minnesota hospitals, from January 1993, to December 1993.

84%–86% received radiation therapy after breast-conserving surgery.

Guadagnoli et al., 1998

For early-stage breast carcinoma (TNM Stages I and II), axillary lymph node dissection should be performed.

2,559 women who had axillary lymph node dissection from a sample of 2,575 women with early-stage breast carcinoma, excluding patients for whom national recommendations were not likely to apply.

Same as above.

81%–94% underwent axillary lymph node dissection.

Guadagnoli et al., 1998

For early-stage breast carcinoma (TNM Stages I and II), premenopausal women with positive lymph nodes should receive chemotherapy.

228 premenopausal women with positive lymph nodes from a sample of 2,575 women with early-stage breast carcinoma, excluding patients for whom national recommendations were not likely to apply.

Same as above.

94%–97% received chemotherapy.

Guadagnoli et al., 1998

For early-stage breast carcinoma (TNM Stages I and II), postmenopausal women with positive lymph nodes and positive estrogen receptor status should receive hormonal therapy.

168 postmenopausal women with positive lymph nodes and positive estrogen receptor status from a sample of 2,575 women with early-stage breast carcinoma, excluding patients for whom national recommendations were not likely to apply.

Same as above.

59%–63% received hormonal therapy.

Guadagnoli et al., 1998

Annual mammography is appropriate for women who have had local/regional breast cancer.

918 insured women≤64 years old with local/regional invasive breast cancer Stage I or II.

Data collected by Virginia Cancer Registry from 50 hospitals that represented 85% of Virginia hospital beds, and claims data from Trigon Blue Cross Blue Shield of Virginia, 1989– 1991.

79% of women had a mammogram within the first 18 months postoperatively.

Hillner et al., 1997

Clinical trials have shown a 30%–50% reduction in morbidity and mortality rates with management of cholesterol levels for patients with cardiovascular disease (CVD). The Adult Treatment Panel (ATP-II) of the National Cholesterol Education Program recommended management of cholesterol in patients with CVD with goals of LDL level<100 mg/dL and triglyceride level<200 mg/dL (NCEP, 1993).

603 patients 27–70 years old with CVD.

Physician survey, patient survey, and medical records from 159 physicians in 45 primary care practices in and around four midwestern cities: Eau Claire, Wisconsin; Iowa City, Iowa; Madison, Wisconsin; Minneapolis, Minnesota; August 1993, to February 1995.

96% had total cholesterol levels, 67% had LDL values, 90% had triglyceride levels, and 75% had HDL levels recorded in the past 5 years. 72% with LDL >130 mg/dL had received diet counseling, and 42% had received cholesterol-lowering medication; 58% with LDL 100–130 mg/dL had received diet counseling, and 42% had received cholesterol-lowering medication.

McBride et al., 1998

Coronary angiography is a method for evaluating coronary artery anatomy to determine whether a patient is a candidate for coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty.

352 patients who met explicitly defined criteria for necessity of coronary angiography, from among 1,350 positive exercise stress tests in a randomly selected sample of 5,850 stress tests.

Medical records from four teaching hospitals (three public, one private) in Los Angeles, California and patient telephone interviews (with 243 of the 352 patients), January 1, 1990, to June 30, 1991.

43% of patients received coronary angiography within 3 months of the positive exercise stress test; 56% received coronary angiography within 12 months of the positive test.

Laouri et al., 1997

Aspirin is an effective, inexpensive, and safe treatment for a heart attack. Aspirin therapy reduces short-term mortality in patients with suspected heart attack by 23%. Aspirin should not be given to patients with certain conditions (e.g., hemorrhagic stroke, gastrointestinal bleeding).

7,917 Medicare patients≥ 65 years old hospitalized with heart attack who were “ideal” candidates for treatment with aspirin, with no possible contraindications to aspirin therapy. Medical records for

Medicare beneficiaries who were hospitalized in four states (Alabama, Connecticut, Iowa, Wisconsin), as part of the Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993.

64% received aspirin within the first 2 days of hospitalization.

Krumholz et al., 1995

Same as above.

5,490 Medicare patients≥ 65 years old hospitalized with heart attack who were alive at discharge and who had no contraindications to aspirin therapy.

Same as above.

76% were discharged with instructions to take aspirin. Patients who were prescribed aspirin at discharge had a 6-month mortality rate of 8.4%, compared with 17% for

Krumholz et al., 1996

patients not prescribed aspirin.

Same as above.

7,486 patients who were “ideal” candidates for treatment with aspirin during initial hospitalization from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack; 5,841 patients who were alive at discharge and who were “ideal” candidates for treatment with aspirin prior to or at time of discharge, from the same sample.

Same as above.

83% received aspirin during hospitalization; 77% received aspirin prior to or at time of discharge.

Ellerbeck et al., 1995

Same as above.

187 patients with confirmed heart attack who were alive at discharge and who had no contraindications to aspirin therapy from a sample of 300 Medicare patients≥65 years old hospitalized with a principal diagnosis of heart attack.

Medicare mortality data issued by the Health Care Financing Administration (HCFA) and medical records for Medicare patients from six hospitals in Connecticut, as part of the Medicare Hospital Information Project, October 1, 1988, to September 30, 1991.

73% received aspirin at time of discharge.

Meehan et al., 1995

Same as above.

Subset of 2,938 patients with admitting diagnosis of MI.

Medical records from 16 Minnesota hospitals for patients admitted August 1, 1995, to April 30, 1996.

The median percentage of eligible patients≥65 years old receiving aspirin in the first 48 hours of hospitalization was 77%.

Soumerai et al., 1998

Same as above.

384 patients who were “ideal” candidates for treatment with aspirin on admission and 321 who were “ideal” candidates for aspirin at discharge, from a sample of 450 patients≥65 years old hospitalized with unstable angina.

Medical records and administrative data for patients with Medicare from three Connecticut hospitals, 1993–1995.

72% received aspirin on admission (66% in 1993– 1994 and 82% in 1995). 65% were prescribed aspirin at discharge (66% in 1993–1994 and 79% in 1995).

Krumholz et al., 1998

Same as above.

735 patients who were “ideal” candidates for treatment with aspirin during hospitalization and 531 who were “ideal” candidates for aspirin at discharge, from a sample of 882 patients≥65 years old with unstable angina.

Medical records of Medicare beneficiaries discharged from 16 hospitals in North Carolina between October 1, 1993, and September 30, 1994.

76% received aspirin during their hospital stay. 67% were prescribed aspirin at discharge.

Simpson et al., 1997

Same as above.

2,392 patients who were “ideal” candidates for aspirin during hospitalization and 1,387 who were “ideal” candidates for aspirin at discharge, from a sample of 4,300 patients with MI.

Medical records from acute care hospitals in Maryland and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to July 1995.

87% received aspirin during their stay. 77% received aspirin at discharge.

Berger et al., 1998

Thrombolytics are medications that break down some of the acute blockage in the blood vessels that causes a heart attack, thereby reducing infarct size and limiting left ventricular dysfunction. Thrombolytics have been shown to reduce post-MI mortality by as much as 25%, though they should not be given to patients with certain conditions (e.g., recent hemorrhagic stroke).

1,105 patients who were “ideal” candidates for treatment with thrombolytic agents from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack.

Medical records for Medicare beneficiaries who were hospitalized in four states (Alabama, Connecticut, Iowa, Wisconsin), as part of the Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993.

70% received thrombolytics during hospitalization.

Ellerbeck et al., 1995

Same as above.

68 patients with confirmed heart attack who had no contraindications to thrombolytic therapy, and who had electrocardiographic indications for thrombolytic therapy, from a sample of 300 Medicare patients≥65 years old

Medicare mortality data issued by HCFA and medical records for Medicare patients from 6 hospitals in Connecticut, as part of the Medicare Hospital Information Project, October 1, 1988, to September 30, 1991.

43% received thrombolytics during hospitalization

Meehan et al., 1995

Health Care Service^a

Sample Description

Data Source

Quality of Care

Reference^b

hospitalized with a principal diagnosis of heart attack.

Same as above.

245 patients who were “ideal” candidates for thrombolytics in the first hour of arrival from a sample of 4,300 patients with MI.

Medical records from acute care hospitals in Maryland and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to July 1995.

60% received thrombolytics within 1 hour after arrival.

Berger et al., 1998

Same as above.

Subset of 2,938 patients with admitting diagnosis of MI.

Medical records from 16 Minnesota hospitals for patients admitted August 1, 1995, to April 30, 1996.

The median percentage of eligible patients ≥ 65 years old receiving thrombolytics in the first 48 hours of hospitalization was 55%.

Soumerai et al., 1998

PTCA uses a miniature balloon catheter to decrease stenosis (blockage) in blood vessels supplying the heart. (Thrombolysis is described above.)

398 patients who were considered “ideal” candidates for reperfusion from a sample of 4,300 patients with MI.

Medical records from acute care hospitals in Maryland and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to June 1995.

64% received reperfusion therapy (thrombolysis/ PTCA) within 12 hours of arrival at hospital.

Berger et al., 1998

Heparin is beneficial to patients with heart attack, though heparin should not be given to patients with certain conditions (e.g., bleeding disorders, stroke).

9,857 patients who were “ideal” candidates for treatment with heparin from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack.

Medical records for Medicare beneficiaries who were hospitalized in four states (Alabama, Connecticut, Iowa, Wisconsin), as part of the Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993.

69% received heparin during hospitalization.

Ellerbeck et al., 1995

Same as above.

369 patients who were “ideal” candidates for treatment with heparin, from a sample of 450 patients ≥ 65 years old hospitalized with unstable angina.

Medical records and administrative data for patients with Medicare from three Connecticut hospitals, 1993–1995.

24% received intravenous heparin (20% in 1993 to 1994 and 32% in 1995). Of those receiving heparin, 51% had a therapeutic activated partial thromboplastin time (PTT) within 24 hours.

Krumholz et al., 1998

Same as above.

91 patients who were considered “ideal” candidates for heparin intravenously administered, from a sample of 882 patients ≥ 65 years old with unstable angina.

Medical records of Medicare beneficiaries discharged from 16 hospitals in North Carolina between October 1, 1993, and September 30, 1994.

63% received heparin administered intravenously.

Simpson et al., 1997

Health Care Service^a

Sample Description

Data Source

Quality of Care

Reference^b

Intravenous nitroglycerin is beneficial to patients with heart attack who have persistent chest pain, although intravenous nitroglycerin should not be given to patients with certain conditions (e.g., shock or hypotension on admission).

1,754 patients who were “ideal” candidates for treatment with intravenous nitroglycerin from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack.

Medical records for Medicare beneficiaries who were hospitalized in four states (Alabama, Connecticut, Iowa, Wisconsin), as part of Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993.

74% received intravenous nitroglycerin during hospitalization.

Ellerbeck et al., 1995

Smokers with coronary artery disease who stop smoking have a better prognosis than those who keep smoking; at the time of heart attack, these smokers are most susceptible to advice about cessation of smoking.

1,691 smokers who were “ideal” candidates for smoking cessation advice from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack.

Same as above.

28% received smoking cessation advice prior to or at time of discharge.

Ellerbeck et al., 1995

Same as above.

551 patients who were smokers from a sample of 4,300 patients with MI.

Medical records from acute care hospitals in Maryland and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to July 1995.

41% received smoking cessation advice.

Berger et al., 1998

Same as above.

133 patients who were identified as smokers, from a sample of 882 patients ≥ 65 years old with unstable angina.

Medical records of Medicare beneficiaries discharged from 16 hospitals in North Carolina between October 1, 1993, and September 30, 1994.

23% received smoking cessation counseling.

Simpson et al., 1997

ACE inhibitors can reduce post-MI mortality in patients with left ventricular dysfunction, although ACE inhibitors should not be given to patients with certain conditions (e.g., aortic stenosis).

1,473 patients who were “ideal” candidates for treatment with ACE inhibitors from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack.

Medical records for Medicare beneficiaries who were hospitalized in four states (Alabama, Connecticut, Iowa, Wisconsin), as part of Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993.

59% received ACE inhibitors prior to or at time of discharge.

Ellerbeck et al., 1995

Same as above.

407 patients who were considered “ideal” candidates for ACE inhibitors from a sample of 4,300 patients with MI.

Medical records from acute care hospitals in Maryland and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to July 1995.

65% received ACE inhibitors for low ejection fraction (EF).

Berger et al., 1998

Same as above.

177 patients who were considered “ideal” candidates for an ACE

Medical records of Medicare beneficiaries discharged from 16

39% received an ACE inhibitor during hospitalization. 42%

Simpson et al., 1997

Health Care Service^a

Sample Description

Data Source

Quality of Care

Reference^b

inhibitor during hospitalization and 127 who were “ideal” candidates for an ACE inhibitor at discharge, from a sample of 882 patients ≥ 65 years old with unstable angina.

hospitals in North Carolina between October 1, 1993, and September 30, 1994.

received an ACE inhibitor at discharge.

Beta blocker therapy can reduce post-MI mortality by as much as 25%, although beta blockers should not be given to patients with certain conditions (e.g., low left ventricular ejection fraction, pulmonary edema).

2,976 patients who were “ideal” candidates for treatment with beta blockers from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack.

Medical records for Medicare beneficiaries who were hospitalized in four states (Alabama, Connecticut, Iowa, Wisconsin), as part of Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993.

45% received beta blockers prior to or at time of discharge.

Ellerbeck et al., 1995

Same as above.

3,737 Medicare patients ≥ 65 years old with principal diagnosis of heart attack who were eligible for treatment with beta blockers, from a statewide cohort of 5,332 people who had survived a heart attack for at least 30 days and

New Jersey Medicare hospital admissions and enrollment data, 1986– 1992; New Jersey Medicaid drug utilization and enrollment files, 1986– 1991; New Jersey Program of Pharmacy Assistance for the Aged and Disabled drug

21% received beta blockers within 90 days of discharge; adjusted mortality rate for patients with treatment was 43% lower than that of patients without treatment.

Soumerai et al., 1997

who had prescription drug coverage.

utilization data, 1986–1991.

Same as above.

104 patients with confirmed heart attack who were alive at discharge and who had no contraindications to beta blockers from a sample of 300 Medicare patients ≥ 65 years old hospitalized with a principal diagnosis of heart attack.

Medicare mortality data issued by HCFA and medical records for Medicare patients from 6 hospitals in Connecticut, as part of the Medicare Hospital Information Project, October 1, 1988, to September 30, 1991.

41% received beta blockers at time of discharge.

Meehan et al., 1995

Same as above.

Subset of 2,938 patients with admitting diagnosis of MI.

Medical records from 16 Minnesota hospitals for patients admitted August 1, 1995, to April 30, 1996.

The median percentage of eligible patients receiving beta blockers in the first 48 hours of hospitalization was 78%.

Soumerai et al., 1998

Same as above.

302 patients who were considered “ideal” candidates for beta blockers at discharge from a sample of 4,300 patients with MI.

Medical records from acute care hospitals in Maryland and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to July 1995.

60% received beta blockers at discharge.

Berger et al., 1998

Same as above.

815 patients who were “ideal” candidates for beta

Medical records of Medicare beneficiaries

45% received beta blockers during hospitalization.

Simpson et al., 1997

Health Care Service^a

Sample Description

Data Source

Quality of Care

Reference^b

blockers during hospitalization and 589 who were “ideal” candidates for beta blockers at discharge, from a sample of 882 patients ≥ 65 years old with unstable angina.

discharged from sixteen hospitals in North Carolina between October 1, 1993, and September 30, 1994.

38% received beta blockers at discharge.

Includes documentation of examination of jugular veins and alcoholism/smoking habits.

1,437 patients hospitalized with acute myocardial infarction from a nationally representative sample of 7,156 patients hospitalized with any of five conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990).

Medical records for Medicare patients from 297 hospitals in five states (California, Florida, Indiana, Pennsylvania, Texas), July 1, 1985, to June 30, 1986.

64%–68% of patients with acute myocardial infarction received appropriate components of care.

Kahn et al., 1990

Includes care for unstable angina consistent with prevailing standards of care.

637 discharged patients who were “ideal” candidates for a low-cholesterol diet, from a sample of 882 patients ≥ 65 years old with unstable angina.

Medical records of Medicare beneficiaries discharged from 16 hospitals in North Carolina and Septemeber 30, 1994.

38% were prescribed a low-cholesterol diet at discharge.

Simpson et al., 1997

Includes care for unstable angina consistent with prevailing standards of care.

637 patients who were “ideal” candidates for a lipid-lowering drug at discharge, from a sample of 882 patients ≥ 65 years old with unstable angina.

Same as above.

16% received lipid-lowering drugs at discharge.

Simpson et al., 1997

Includes documentation of past surgery and lung examination, blood pressure readings, electrocardiogram, serum potassium level, oxygen therapy or intubation for hypoxic patients.

1,465 patients hospitalized with congestive heart failure from a nationally representative sample of 7,156 patients hospitalized with any of five conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990).

Same as above.

66%–97% of patients with congestive heart failure received appropriate components of care.

Kahn et al., 1990

Includes documentation of previous stroke and gag reflex, blood pressure readings, electrocardiogram, serum potassium level.

1,442 patients hospitalized with stroke from a sample of 7,156 patients hospitalized with any of five conditions (congestive heart failure, acute myocardial infarction, pneumonia, stroke, hip fracture) (Draper et al., 1990).

Same as above.

38%–94% of patients with stroke received appropriate components of care.

Kahn et al., 1990

Almost all colds are caused by a virus, for which antibiotics are not an effective treatment.

1,439 patients with 2,171 outpatient and emergency department visits for the common cold (acute nasopharyngitis) from a random sample of 50,000 patients with at least one claim for care by a physician, dentist, or optometrist.

Kentucky Medicaid claims data, July 1, 1993, to June 30, 1994.

In 60% of encounters for the common cold, patients filled prescriptions for antibiotics.

Mainous et al., 1996

Same as above.

Patients ≥ 18 years old with a diagnosis of the common cold, exclusive of adults with underlying lung disease, from a nationally representative sample of 1,529 physicians representing 28,787 adult patient ambulatory care visits.

National Ambulatory Medical Care Survey (NAMCS), 1992.

51% of patients diagnosed with a cold were treated with antibiotics.

Gonzales et al., 1997

Same as above.

Children≤18 years diagnosed with common colds from a total of 531 pediatric office visits with a primary diagnosis of cold, upper respiratory tract infection (URI), or bronchitis, exclusive of children with underlying lung disease, from a sample representative of the U.S. population.

Same as above.

Antibiotics were prescribed at 44% of visits of patients with common colds

Nyquist et al., 1998

Antimicrobial drugs do not shorten the course of viral URI, nor do they prevent secondary bacterial infections.

Physicians who participated from a nationally representative sample of 3,000 office-based physicians.

Same as above.

16% of all antimicrobial drug prescriptions (an estimated 17,922,000 prescriptions nationally) were written for upper respiratory tract infections in 1992.

McCaig and Hughes, 1995

Same as above.

Patients ≥ 18 years old with a diagnosis of URI, exclusive of adults with underlying lung disease, from a nationally representative sample of 1,529 physicians representing 28,787 adult patient ambulatory care visits.

Same as above.

52% of patients diagnosed with a URI were treated with antibiotics.

Gonzales et al., 1997

Same as above.

Children≤18 years diagnosed with URIs from a total of 531 pediatric office visits with a primary diagnosis of cold, URI, or bronchitis, exclusive of children with underlying lung disease, from a sample representative of the U.S. population.

Same as above.

Antibiotics were prescribed at 46% of visits of patients with URIs.

Nyquist et al., 1998

Since most of these conditions are viral, antibiotics have no benefit.

Physicians who participated from a nationally representative sample of 3,000 office-based physicians.

Same as above.

Over 70% of patients received antibiotic prescriptions for pharyngitis (excluding streptococcal), over 50% received them for rhinitis, and over 30% received them for a nonspecific URI, cough, or cold.

Dowell and Schwartz, 1997

Most cases of bronchitis are caused by a virus, for which antibiotics are not an effective treatment.

Patients≥18 years old with a diagnosis of bronchitis, exclusive of adults with underlying lung disease, from a nationally representative sample of 1,529 physicians representing 28,787 adult patient ambulatory care visits.

Same as above.

66% of patients diagnosed with bronchitis were treated with antibiotics.

Gonzales et al., 1997

Same as above.

Children ≤ 18 years diagnosed with bronchitis from a total of 531 pediatric office visits with a primary diagnosis of cold, URI, or bronchitis, exclusive of children with underlying lung disease, from a sample representative of the U.S. population.

Same as above.

Antibiotics were prescribed at 75% of visits of patients with bronchitis.

Nyquist et al., 1998

Hospital admissions for pneumonia are considered appropriate when, for example, a patient fails to improve with outpatient oral medication or has a pleural effusion or an empyema.

445 hospital admissions of children < 18 years old admitted with pneumonia.

Medical records for patients from 12 hospitals in five communities in Boston and nearby suburbs, July 1, 1985, to June 30, 1986.

9.4% of admissions were inappropriate.

Payne et al., 1995

Hospital admissions for bronchitis/asthma are considered appropriate when, for example, a patient has failed to improve with outpatient therapy or has a pneumothorax.

1,038 hospital admissions of children < 18 years old admitted with bronchitis/ asthma.

Same as above.

4.4% of admissions were inappropriate.

Payne et al., 1995

Indications for tympanostomy tube placement include refractory middle ear infection and chronic mastoiditis.

6,429 children < 16 years old with recurrent acute otitis media and/or persistent otitis media with effusion who were insured in health plans requiring precertification by a utilization review firm.

Interviews with physicians’ office staff at otolaryngology practices from 49 states and the District of Columbia, January 1, 1990, to July 30, 1991; additional interviews were conducted with otolaryngologists to determine the existence of extenuating clinical circumstances.

41% of tube insertions were appropriate, 32% equivocal, and 27% inappropriate. If extenuating clinical circumstances were taken into account, 42% of tube insertions were appropriate, 35% equivocal, and 23% inappropriate.

Kleinman et al., 1994

There is no evidence that minor tranquilizers are effective for depression, but there is evidence that antidepressant medications are effective for depression.

634 patients with current depressive disorder or depressive symptoms from a sample of 22,399 adult patients who visited one large HMO or several multispecialty, mixed-group practices in each city during the study period.

Medical Outcomes Study (MOS) in three cities (Boston, Chicago, Los Angeles); questionnaires completed February to October 1986; phone interviews completed May to December 1986.

19% of patients were treated with minor tranquilizers; 12% were treated with antidepressant medications; 11% were treated with a combination of minor tranquilizers and antidepressant medications; 59% received neither.

Wells et al., 1994a

Appropriate reasons for admission include depression, medical condition meriting acute care, comorbid major psychiatric disorder, or medical reasons precluding outpatient care for depression.

1,198 patients hospitalized with depression, representative of all Medicare elderly patients hospitalized in general medical hospitals with a discharge diagnosis of depression.

Medical records for Medicare patients from 297 hospitals in five states (California, Florida, Indiana, Pennsylvania, Texas), July 1, 1985, to June 30, 1986.

93% were admitted for clearly or possibly appropriate reasons, and 7% were admitted for inappropriate reasons.

Wells et al., 1993

Hysterectomy is the surgical removal of the uterus.

642 women ≥ 20 years old who underwent nonemergency, nononcologic hysterectomies.

Medical records for patients from seven managed care organizations, August 1, 1989, to July 31, 1990.

16% of hysterectomies were inappropriate, 25% were equivocal, and 58% were appropriate.

Bernstein et al., 1993b

Coronary angiography is a method for evaluating coronary artery anatomy to determine whether a patient is a candidate for coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty.

Random sample of 1,335 patients who had coronary angiography.

Medical records from 15 nonfederal hospitals providing coronary angiography in New York State, selected through a stratified random sample (for location, volume of coronary angiography, and authorization to perform coronary artery bypass graft surgery), 1990.

4% of coronary angiographies were inappropriate, 20% were equivocal, and 76% were appropriate.

Bernstein et al., 1993a

Same as above.

Random sample of 1,677 cases of coronary angiography.

Medicare physician claims from three sites selected from 13 sites in eight states (Arizona, California, Colorado, Iowa, Massachusetts, Montana, Pennsylvania, South Carolina), 1981.

17% of coronary inappropriate, 9% were equivocal, and 74% were appropriate.

Chassin et al., 1987

In CABG surgery, damaged blood vessels supplying the heart are replaced with vessels from elsewhere in the body.

Stratified random sample of 386 patients who underwent CABG surgery in the three hospitals.

Medical records from three hospitals (excluding Veterans Administration, other governmental, and specialty hospitals) selected through a stratified random sample (for size and teaching status) in a western state as part of the National Institutes of Health Consensus Development Program, 1979, 1980, and 1982

14% of CABG surgeries were inappropriate, 30% were equivocal, and 56% were appropriate.

Winslow et al., 1988

Same as above.

Random sample of 1,156 patients who had isolated CABG surgery.

Medical records for patients from 12 Academic Medical Center Consortium hospitals in 10 states (California, Iowa, Louisiana, Maryland, Massachusetts, Minnesota, New Hampshire, New York, North Carolina, Pennsylvania), 1990.

1.6% of CABG surgeries were inappropriate, 7% were equivocal, and 92% were appropriate.

Leape et al., 1996

Same as above.

Random sample of 1,338 patients who had isolated CABG surgery.

Medical records from 15 nonfederal hospitals providing CABG procedure in New York State, selected through a stratified random sample (for location and volume of CABG operations), 1990.

2.4% of CABG surgeries were inappropriate, 7% were equivocal, and 91% were appropriate.

Leape et al., 1993

PTCA uses a miniature balloon catheter to decrease stenosis (blockage) in blood vessels supplying the heart.

Random sample of 1,306 patients who had PTCA.

Medical records from 15 nonfederal hospitals providing PTCA in New York State, selected through a stratified random sample (for location and volume of PTCA), 1990.

4% of PTCAs were inappropriate, 38% were equivocal, and 58% were appropriate.

Hilborne et al., 1993

Pacemakers help regularize abnormal heart rates and rhythms.

Medicare patients who underwent a total of 382 pacemaker implantations.

Medical records from six university teaching hospitals, 11 university-affiliated hospitals, and 13 community hospitals in Philadelphia County, January 1, to June 30, 1983.

20% of pacemaker implantations were inappropriate, 36% were equivocal, and 44% were appropriate.

Greenspan et al., 1988

Lidocaine prophylaxis used to prevent ventricular fibrillation in patients treated for probable MI has been shown to increase mortality.

Subset of 2,938 patients with admitting diagnosis of MI.

Medical records from sixteen Minnesota hospitals for patients admitted August 1, 1995, to April 30, 1996.

The median percentage of patients ineligible for lidocaine who received it in the first 48 hours of hospitalization was 12%.

Soumerai et al., 1998

Calcium channel blockers should not be given to patients with certain conditions (e.g., low left ventricular ejection fraction, evidence of shock, or pulmonary edema during hospitalization).

785 patients with clear contraindication to calcium channel blockers from a sample of 16,124 Medicare patients hospitalized with a principal diagnosis of heart attack.

Medical records for Medicare beneficiaries who were hospitalized in four states (Alabama, Connecticut, Iowa, Wisconsin), as part of the Cooperative Cardiovascular Project Pilot, June 1, 1992, to February 28, 1993.

21% of those for whom calcium channel blockers were contraindicated received them.

Ellerbeck et al., 1995

Same as above.

220 patients with a contraindication for calcium channel blockers (i.e., a left ventricular ejection fraction < 40%) from a sample of 4,300 patients with MI.

Medical records from acute care hospitals in Maryland and the District of Columbia in Medicare’s National Claims History File sampled during January 1994, to July 1995.

18% of those for whom calcium blockers were contraindicated received them.

Berger et al., 1998

Same as above.

218 patients with contraindications for calcium channel blocking drugs, from a sample of 882 patients ≥ 65 years old with unstable angina.

Medical records of Medicare beneficiaries discharged from 16 hospitals in North Carolina between October 1, 1993, and September 30, 1994.

62% of those for whom calcium blockers were contraindicated received them.

Simpson et al., 1997

Carotid endarterectomy is a procedure that opens up stenotic (blocked) carotid arteries (which supply blood to the brain).

Random sample of 1,302 cases of carotid endarterectomy.

Medicare physician claims data and medical records from three sites selected from thirteen sites in eight states (Arizona, California, Colorado, Iowa, Massachusetts, Montana, Pennsylvania, South Carolina), 1981.

32% of carotid endarterectomies were inappropriate, 32% were equivocal, and 35% were appropriate.

Chassin et al., 1987

Endoscopy enables visualization of the gastrointestinal tract, and permits biopsy and brush cytologic examination.

Random sample of 1,585 cases of upper gastrointestinal tract endoscopy.

Same as above.

17% of upper gastrointestinal tract endoscopies were inappropriate, 11% were equivocal, and 72% were appropriate.

Chassin et al., 1987

Cataract surgery is a commonly performed surgery in adults ≥ 65 years old. Cataract surgery should not be performed on people with certain conditions (e.g., macular degeneration or diabetic retinopathy).

1,020 patients who underwent a total of 1,139 cataract surgeries.

Medical records for patients from 10 academic medical centers, 1990.

2% of cataract surgeries were inappropriate, 7% were equivocal, and 91% were appropriate.

Tobacman et al. 1996

AHCPR has concluded that spinal manipulation hastens recovery from acute low back pain not caused by such conditions as fracture, tumor, infection, and cauda equina syndrome (AHCPR, 1994).

A random sample of 10 patients per office (920 patients) who sought chiropractic care for low back pain for the first time during the study period.

Medical records of patients from 92 chiropractic offices in or near Miami, Florida; Minneapolis-St. Paul, Minnesota; Portland, Oregon; and San Diego, California; who sought care for the first time between January 1, 1985, and December 31, 1991.

Initiation of spinal manipulation was inappropriate in 20%–40% of cases, uncertain in 20%– 30% of cases, and appropriate in 40%–54% of cases (depending on city).

Shekelle et al., 1998

A death is considered preventable when the patient received poor care, and the poor care probably resulted in the patient’s death.

182 patients who died in hospitals from stroke, pneumonia, or heart attack.

Medical records for patients from 12 hospitals, 1985.

14% of deaths resulted from inadequate diagnosis or treatment and could have been prevented.

Dubois and Brook, 1988

An adverse event is an injury that is caused by medical management rather than the underlying disease and that prolongs hospitalization, produces a disability at

discharge, or both.

30,121 medical records from a weighted sample of 31,429 records of hospitalized patients from a population of 2,671,863 nonpsychiatric discharged patients.

51 randomly selected acute care, nonpsychiatric hospitals in New York State, 1984.

There were 1,133 adverse events and 280 negligent events during 1984 admissions, representing a 3.7% statewide incidence rate of adverse events, and a 1.0% statewide incidence rate of adverse events due to negligence.

Brennan et al., 1991

Same as above.

30,121 medical records from a weighted sample of 31,429 records of hospitalized patients from a population of 2,671,863 nonpsychiatric discharged patients.

51 randomly selected acute care, nonpsychiatric hospitals in New York State, 1984.

17% of adverse events resulting from operations and 37% of other adverse events were due to negligence; 47% of physician errors leading to adverse events were due to negligence.

Leape et al., 1991

Same as above.

4,031 adult nonobstetric admissions to a stratified random sample of 11 medical and surgical units in two hospitals.

Medical records and reports of hospital staff for 2 tertiary care hospitals in Boston, February to July 1993.

There were 1.8 preventable adverse drugs events (ADEs) per 100 admissions (adjusted rate), of which 20% were life threatening, 43% were serious, and 37% were significant. There were an additional 5.5 potential ADEs per 100 admissions (adjusted rate).

Bates et al., 1995

Same as above.

4,031 patients admitted to 5 intensive care units (3 medical, 2 surgical) and 6 general care units (4 medical, 2 surgical) selected from a stratified random sample of units in 2 tertiary care hospitals in Boston.

Case-investigation reports (including staff interviews, medical record review, etc.) for patients admitted between February and July 1993.

There were 19 preventable or potential ADEs per 1000 patient days in the ICUs. There were 10 preventable or potential ADEs per 1000 patient days in general care units. Rates adjusted for number of medications per patient showed no significant differences for the two settings.

Cullen et al., 1997

Includes treatment consistent with prevailing standards of care.

1,198 patients hospitalized with depression, representative of all Medicare elderly patients hospitalized in general medical hospitals with a discharge diagnosis of depression.

Medical records for Medicare patients from 297 hospitals in five states (California, Florida, Indiana, Pennsylvania, Texas), July 1, 1985, to June 30, 1986.

33% of patients discharged with antidepressants had doses below recommended level.

Wells et al., 1994b

Includes treatment consistent with prevailing standards of care.

64 patients with major depression from a sample of 2,592 consecutive primary care patients 18–65 years old who attended one of the study clinics.

Patient surveys and interviews, physician surveys, and computerized pharmacy records from 3 primary care clinics of Group Health Cooperative of Puget Sound in Washington.

Among patients with major depression who received antidepressant medications, 78% received dosages within the recommended ranges.

Simon and VonKorff, 1995

People infected with tuberculosis (TB) in areas with≥4% isoniazid resistance should be treated with a four-drug regimen.

1,230 culture-positive TB patients, 98% of whom were in counties for which a four-drug regimen is recommended.

Data from the Tuberculosis Control Program, New Jersey Department of Health and Senior Services, 1994 to 1995.

36% of patients were not initially treated with four or more drugs.

Liu et al., 1998

Subject

Quality of health care

N4.761

or

Subject

Guideline adherence

N4.761.337

or

Explode exact subject^b

Outcome and process assessment, health care

N4.761.761.559

Subject

Professional review organization

N4.761.673

or

Subject

Quality indicators, health care

N4.761.789

and

Language

English

and

Date

1997, 1998