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Greater Use of Evidence-Based Medicine Needed in U.S. Outpatient Care

Chicago - Although the quality of outpatient care in the United States has improved over the last decade, greater use of evidence-based medicine is needed, however, and quality of care is not significantly associated with the patient's racial or ethnic background, according to a study in the June 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

The recently released National Healthcare Quality Report (NHQR) identified a variety of areas where health care has markedly improved across time and is now reaching or surpassing national performance goals, as well as many more areas where the quality of health care delivery is suboptimal, according to background information in the article. Its companion document, the National Healthcare Disparities Report, demonstrated that racial, ethnic, and socioeconomic disparities in health care are national problems. However, the authors suggest, limited use has been made of readily available national survey data to measure quality of care and racial disparities in outpatient settings.

Jun Ma, M.D., Ph.D., and Randall S. Stafford, M.D., Ph.D., of Stanford University School of Medicine, Stanford, Calif., used data from the two national surveys of outpatient care to assess overall performance and racial/ethnic disparities in private physician offices and hospital outpatient departments in 1992 and 2002. The researchers examined 23 outpatient quality indicators, including appropriate antibiotic use, treatment of depression, avoiding unnecessary screening and avoiding inappropriate medications in the elderly. Quality indicator performance was defined as the percentage of applicable visits receiving appropriate care.

In 2002, mean performance was 50 percent or more of applicable visits for 12 quality indicators, seven of which were in the areas of appropriate antibiotic use and avoiding unnecessary routine screening. Overall, the researchers found, changes between 1992 and 2002 were modest, with significant improvements in six indicators: treatment of depression (47 vs. 83 percent), statin use for hyperlipidemia [high blood lipid levels] (10 vs. 37 percent), inhaled corticosteroid use for asthma in adults (25 vs. 42 percent), and children (11 vs. 36 percent), avoiding routine urinalysis during general medical examinations (63 vs. 73 percent), and avoiding inappropriate medications in the elderly (92 vs. 95 percent). "We observed that similar, although less than optimal, care is being provided on a per-visit basis regardless of patient racial/ethnic background," the authors write.

"This study contributes to the ongoing efforts to develop a national system for measuring and reporting the quality of outpatient health care in the United States," the authors write. "The present findings suggest that large gaps exist between actual clinical practices and evidence-based recommendations in many areas of outpatient care. We found limited evidence that these performance gaps are closing as a result of proliferating evidence-based practice guidelines."

(Arch Intern Med. 2005; 165:1354-1361.)

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