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Quality Of Care For Coronary Heart Disease In Two Countries
Coronary heart disease is the leading cause of death in the United States and England, and each country devotes substantial resources to its prevention and treatment. We review recent strategies for improving quality of care for coronary heart disease in each country, including clinical guidelines; national standards; performance reports; benchmarking, feedback, and professional leadership; and market-oriented approaches. These strategies highlight the importance of information systems, organizational culture, and incentives to improve the quality of care in both the decentralized health care system of the United States and England’s more centralized system.
Scientific advances in the prevention and treatment of coronary heart disease have been among the most substantial achievements of biomedical research over the past fifty years. Through the public health policies and health care delivery systems of each country, these advances have prolonged survival and improved quality of life for many middle-aged and older adults with coronary heart disease, the leading cause of death in both countries.1 In this paper we evaluate efforts to improve quality of care for coronary heart disease in the United States and England. Rather than presenting a comprehensive review of all such efforts, we compare key strategies that have been implemented in each country, including clinical guidelines; national standards; performance reports; benchmarking, feedback, and professional leadership; and market-oriented approaches. Our objective is to highlight lessons learned from these efforts and underscore shared issues, recognizing distinctive features of the decentralized U.S. health care system and the more centralized system of England.
In the U.S. population of 270.3 million during 1998, coronary heart disease accounted for 460,000 deaths—about one-fifth of all deaths. This represents a substantial reduction in expected mortality. For example, mortality in 1990 was about 34 percent lower than expected if outcomes had remained unchanged from 1980.2 Primary and secondary prevention each accounted for about one-quarter of this improvement, and improved treatment explained almost half of the mortality reduction.
In England and Wales during 1998, coronary heart disease accounted for 121,000 deaths in a population of 52.4 million. The coronary heart disease mortality rate was about 36 percent higher than in the United States (Exhibit 1
In both the United States and England, the burden of coronary heart disease is not distributed equally. In the United States, uninsured adults have limited access to optimal care for coronary heart disease, yielding inadequate treatment of cardiac risk factors and delayed care for symptoms.4 Black patients receive fewer effective cardiac drugs and procedures, even when insured and treated by specialists and tertiary hospitals.5 Between 1987 and 1994 annual reductions in coronary heart disease mortality were only about half as great among black men (2.5 percent) as among white men (4.7 percent).6 In England, death rates from coronary heart disease have declined faster among more affluent persons. Cardiac death rates among men in unskilled manual occupations are 40 percent higher than for nonmanual workers, and the wives of manual workers have nearly twice the risk that wives of nonmanual workers have. There are also ethnic variations, with people born on the Indian subcontinent suffering coronary heart disease death rates that are 38 percent higher in men and 43 percent higher in women, compared with the country as a whole.
In 1995 expenditures for cardiac care in the United States totaled $76 billion, representing about 10 percent of all health care expenditures.7 Public and private investments in basic and clinical research have fostered expensive treatments, such as thrombolytic therapy, cholesterol-lowering drugs, and implantable defibrillators, that prolong survival when used appropriately. Fee-for-service (FFS) reimbursement has created financial incentives to train an abundant supply of cardiologists and widely disseminate expensive cardiac technologies, such as coronary angioplasty, even when they are redundant in local areas. As a result, well-insured persons generally have ready access to their choice of cardiologists and hospitals. In contrast to England, most United States patients face little or no wait for elective cardiac care. Despite these strengths, cardiac care has been fragmented for many patients, with insufficient coordination between primary care physicians and specialists or between community and tertiary hospitals, even though patients highly value such coordination.8 This fragmentation often results in sub optimal care, as demonstrated by under use of beta-blockers and substantial variation in outcomes of cardiac surgery.9 Economic incentives in the United States have focused almost entirely on the volume of services, rather than the quality of care. The FFS system rewards over treatment, and capitation provides incentives for under treatment. The integrated information systems of managed care organizations hold promise to monitor and improve cardiac care, but these systems have focused mainly on managing costs rather than quality. In direct comparisons of treatment of coronary heart disease between FFS and managed care, quality of care has generally been equivalent, but coronary angiography has been used less often when indicated for elderly patients in managed care.10
In England suboptimal cardiac care is evident in uneven access to specialists, long waits for coronary angiography and revascularization procedures, and insufficient use of effective cardiac drugs. Thrombolytic therapy has been routinely available in only one-third of emergency departments, and effective treatments such as aspirin and beta-blockers have not been uniformly prescribed for patients with myocardial infarction (MI).11 Facilities for coronary artery bypass graft (CABG) surgery have not been developed according to geographic needs, with an excess in London and the south compared to the rest of the country. On a more positive note, the expansion of consultant cardiologist posts in general hospitals has improved access to specialist care for patients residing far from tertiary hospitals, but the availability of cardiologists and coronary procedures has remained much lower than in the United States (Exhibit 1
Clinical guidelines. Clinical guidelines were one of the first strategies to improve cardiac care in the United States and England. In the United States major public agencies and professional organizations, such as the American College of Cardiology, have devoted substantial effort to assembling expert panels that have integrated clinical research into coronary heart disease guidelines for health care providers. These guidelines have been catalogued by the National Guidelines Clearinghouse, and some U.S. guidelines have become de facto standards for the treatment of cholesterol, hypertension, and MI.12 Professional societies have played a comparable role in developing such guidelines in England.13 In 1999 the National Institute for Clinical Excellence (NICE) was authorized as a special public health authority for England and Wales to provide patients and providers with national guidelines for specific treatments based on systematic appraisal of clinical benefits and cost effectiveness. To date, NICE has published cardiac guidelines relating to intracoronary stents, implantable defibrillators, and glycoprotein IIb/IIIa inhibitors.14 Uptake of NICE guidelines will be assessed by the Commission for Health Improvement in England, and National Health Service (NHS) providers will be expected to justify their actions if they opt not to comply with these guidelines. In the United States the Agency for Healthcare Research and Quality (AHRQ) has coordinated the National Guidelines Clearinghouse, but adherence to clinical guidelines has remained voluntary. Despite the initial emphasis on clinical guidelines as a cornerstone of quality improvement efforts in both countries, published research has yet to document strong effects of guidelines in changing physicians’ behavior, and inappropriate care remains common.15 In the United States practicing physicians have been most receptive to guidelines from major professional organizations, moderately receptive to guidelines from federal agencies, and least receptive to guidelines from insurers or managed care organizations.16 Practicing physicians are generally concordant with clinical experts about the appropriate use of coronary angiography, but physicians’ opinions vary greatly by specialty and site of practice.17 Evidence-based guidelines may have their greatest impact by providing a framework for setting standards of care. National standards. National standards for cardiac care have become a much more prominent strategy for quality improvement in England than in the United States, reflecting the centralized nature of health care funding and planning in the British NHS. The English National Service Framework for Coronary Heart Disease was developed by a wide range of clinical, managerial, and patient experts using available evidence from published guidelines. Released in March 2000, the framework set new national standards for the spectrum of cardiac care, including primary prevention, emergency care, specialist hospital care, services for people with heart failure, and rehabilitation. Immediate priorities for rapid improvement include smoking cessation services, ambulance response times, use of thrombolysis and other effective cardiac drugs, and access to chest pain clinics and revascularization procedures. Hospital mortality rates for MI and coronary procedures will also be monitored. Primary care teams and hospital staffs will meet regularly to discuss clinical issues, organize medical records, develop practice-based coronary heart disease registries, and establish protocols to ensure that standards are met locally. Without a national health system, the United States has neither the political mandate nor the mechanisms to implement national standards for cardiac care that are comparable to the new National Service Framework in England. Abundant evidence about the uneven quality of care in the United States has been insufficient to generate public or professional support for quality standards emanating from the federal government or large private health plans.18 In the market-based U.S. health care system, quality reports have been viewed as more acceptable than standards to promote consumer choice and provider accountability. Public release of performance reports. Coronary heart disease has been a primary focus of public performance reports compiled by individual states, private health plans participating in the Health Plan Employer Data and Information Set (HEDIS), and the Health Care Financing Administration (HCFA). Some of the most visible efforts to profile U.S. physicians and hospitals have focused on coronary heart disease mortality, including statewide reports on cardiac surgery in New York and Pennsylvania and on MI in California and Pennsylvania. These performance reports have stimulated internal efforts by hospitals to improve quality, and they may have contributed to better clinical outcomes.19 However, performance reports have had only a limited impact on the decisions of patients, physicians, or health plans in selecting hospitals or surgeons for cardiac surgery.20 HEDIS, a product of the National Committee for Quality Assurance (NCQA), has emphasized process measures, such as the use of beta-blockers and reduction of cholesterol levels within managed care plans.21 Among health plans, post-MI beta-blocker use during 1999 ranged from 70 percent in the tenth percentile to 96 percent in the ninetieth percentile, underscoring the wide variation in adherence to this quality indicator. However, average rates of beta-blocker use among health plans participating in HEDIS have risen from 62 percent in 1996 to 85 percent in 1999, suggesting that public reporting of quality measures can contribute to meaningful improvements in care. At the federal level, HCFA has recently published state-level performance measures for numerous quality indicators for 1997–1999.22 Among Medicare beneficiaries hospitalized for acute MI, these measures include use of aspirin, beta-blockers, angiotensin converting enzyme (ACE) inhibitors, smoking cessation counseling, and reperfusion therapies—processes that have all been shown to improve outcomes. State Peer Review Organizations (PROs) have been mandated by HCFA to continue monitoring these measures and promote improvements in systems of care, but the PROs do not have legal or financial authority to require changes by health care providers. In England public performance reports for coronary heart disease care have been more limited, but their role is likely to increase.23 A central cardiac audit database has evolved from a system to monitor pacemaker use at the National Heart Hospital in the 1970s.24 Six sites are currently operational, and the project, which incorporates a database for MI recently launched by the Royal College of Physicians, is being assessed for national use.25 A national survey of the experiences of coronary heart disease patients in England was published in 2000.26 With results available for individual providers, regional NHS offices will require action by providers to improve patients’ experiences with care. Benchmarking, feedback, and professional leadership. In addition to public dissemination of performance reports, these reports can be a useful tool to promote quality improvement by local providers through benchmarking and feedback.27 Such efforts represent one of the most promising avenues for shared learning between the United States and England, particularly if successful efforts of local organizations can be understood and disseminated. In the United States a prominent program of benchmarking and feedback has been the HCFA Cooperative Cardiovascular Project performed by state PROs.28 PROs provided process and mortality data to hospitals and physicians in four states, then providers devised clinical changes to improve care. Almost all process and mortality measures improved in this project, but the independent effect of the interventions was difficult to gauge. Another notable U.S. effort in cardiac care has been the Northern New England Cardiac Surgery Project. In this project, benchmarking and feedback were combined with quality improvement training for twenty-three cardiac surgeons and staff from five hospitals in three states.29 Over the ensuing two years, risk-adjusted mortality was 24 percent lower than expected based on prior experience, with benefits in nearly all subgroups of patients. One randomized trial in the United States evaluated the use of local physician opinion leaders to educate other physicians and nurses about improving care for MI in Minnesota.30 Intervention hospitals showed much greater improvements in aspirin and beta-blocker use than other hospitals did, but similar rates of thrombolytic therapy for elderly patients and comparable reductions in lidocaine use. Further research will be needed to assess the ongoing role of local professional leadership in sustaining improved quality of care. Comparable efforts by local organizations in England are at an earlier stage of development than in the United States, but they are being applied more systematically. To achieve standards outlined in the National Service Framework, health care providers will translate these standards into local delivery plans. Regional offices of the Department of Health will play a key role in monitoring and supporting these efforts. To promote sharing of good practice and service reengineering, the government has sponsored ten local networks of cardiac care. An NHS assessment of the effectiveness of this approach for coronary revascularization is currently under way. Market-oriented approaches. Providers in the United States and England may respond to market-oriented approaches that reward high-quality providers with increased patient volume and funding. With greater availability of standardized data for comparing quality of care among health plans and providers in the United States, it has become more feasible for purchasers to select health plans based on quality and for health plans to contract with high quality hospitals or physicians. Even without standardized data on quality of cardiac care, such arrangements are supported by studies showing improved outcomes for patients in high-volume centers for MI, coronary angioplasty, and cardiac surgery.31 Among large U.S. employers, about half use HEDIS data to select health plans for their employees.32 Quality of care has been a consideration for some health plans when contracting with specific hospitals to provide cardiac surgery, but there is little evidence that quality considerations have played a major role in the contracting decisions of managed care organizations.33 The use of financial incentives to promote better quality of care has received scant attention to date, probably because such incentives have been used surprisingly little in the market-based U.S. system.34 In one study, hospitals with better outcomes of cardiac surgery were able to garner higher payments for this procedure.35 Some health plans and provider groups have provided small bonuses to primary care physicians for better performance on quality measures related to preventive services or patient satisfaction, but these payments represent only a small portion of total spending on physician services.36 In England the implementation of internal markets in 1989 may have contributed to increased efficiency in the NHS, but the effect of market reforms on quality of care has been unclear.37 More recent NHS reforms aim to bolster the ability of Primary Care Trusts to purchase high-quality specialty care for their patients. The National Service Frameworks outline financial and professional incentives to improve quality of care, but such incentives remain at an early stage of development.
The greatest challenge to achieving further improvements in cardiac care in both countries will be to develop systems of care that promote quality, rather than relying on well-intentioned but fragmented efforts of individual providers to improve care. Systems that use multiple strategies described above will likely be more successful than those that employ a single approach. We foresee three themes—information systems, organizational culture, and incentives that together will determine whether sustainable improvements in cardiac care can be achieved in both countries. Standardized information systems and risk adjustment methods are a necessary foundation to assess quality and compare providers at the population level, as well as for individual organizations to gauge their own quality of care. Striking an appropriate balance between public reporting and internal benchmarking and feedback will remain an important issue in the United States and England. The value of information systems in these efforts can be justified by demonstrating a measurable impact on quality through timely reporting and improvements in care by providers. Enhanced information systems, however, will be insufficient to improve quality without corresponding changes in the way providers and organizations use this information. The culture of health care organizations will be pivotal in their efforts to improve quality of care. The role of organizational culture and professional leadership in fostering quality improvement must be better understood.38 Amid recent political and media attention regarding medical errors in both countries, quality improvement efforts must maintain a focus on improving systems of care as well as addressing poor-quality care by individual providers.39 With increasing investments in the NHS as a response to perceived underfunding, England is better positioned to use public funds to stimulate improvements in quality of care through organizational change. Because the United States faces persistent pressures to contain health care costs, fragmentation of health care funding, and skepticism toward centralized planning, changes in organizational culture will be determined more by the actions of individual provider groups and networks than by government initiatives. Nonetheless, the U.S. government, particularly through HCFA, AHRQ, and the Department of Veterans Affairs (VA), can continue to stimulate these actions through research funding and dissemination of effective practices. Greater use of financial and nonfinancial incentives by public and private purchasers in the United States and England would also accelerate the pace of quality improvement. Health services research could advance the field of quality improvement by developing a better theoretical and empirical understanding of how incentives to promote better quality of care influence the actions of individual providers and organizations, analogous to prior research that has explored the effect of financial incentives on the quantity of care delivered. Because of its prevalence and clinical impact, coronary heart disease is an important condition to use in implementing and evaluating incentives related to quality of care. As health care providers and policymakers in the United States and England strive to improve the quality of care and outcomes for coronary heart disease, they have the potential to learn from the experiences in each country. The strong base of health services research and local quality improvement efforts in the United States offer numerous opportunities to assess the effectiveness of various strategies, but the United States lacks comprehensive national standards and monitoring systems to determine whether cardiac care is improving. In contrast, national and regional standards for cardiac care have been implemented more rapidly in England, but evaluative mechanisms are still under development. Both countries will continue to face the challenge of ensuring that scientific advances in cardiac care are implemented effectively and equitably in their respective health care systems.
John Ayanian, a practicing general internist and health services researcher, is associate professor of medicine and health care policy at the Harvard Medical School and Brigham and Women’s Hospital. Thomas Quinn, a registered nurse specializing in cardiac care, is section head for cardiac services in the Department of Health, England. The authors are grateful to Donald Berwick, Mark Merlis, Robin Osborn, John Wyn Owen, and Stephen Schoenbaum for reviewing an earlier draft of this manuscript, prepared for the Ditchley Park Conference on Improving the Quality of Health Care in the United States and the United Kingdom, cosponsored by the Commonwealth Fund and the Nuffield Trust, Oxfordshire, England, 10 June 2000. The views expressed in this paper are not necessarily those of the U.K. government/Department of Health. John Ayanian has been supported by grants from the Agency for Healthcare Research and Quality (R01 HS08071 and R01 HS09718).
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