Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001

JAMA. 2003 Jan 15;289(3):305-12. doi: 10.1001/jama.289.3.305.


Context: Despite widespread concern regarding the quality and safety of health care, and a Medicare Quality Improvement Organization (QIO) program intended to improve that care in the United States, there is only limited information on whether quality is improving.

Objective: To track national and state-level changes in performance on 22 quality indicators for care of Medicare beneficiaries.

Design, patients, and setting: National observational cross-sectional studies of national and state-level fee-for-service data for Medicare beneficiaries during 1998-1999 (baseline) and 2000-2001 (follow-up).

Main outcome measures: Twenty-two QIO quality indicators abstracted from state-wide random samples of medical records for inpatient fee-for-service care and from Medicare beneficiary surveys or Medicare claims for outpatient care. Absolute improvement is defined as the change in performance from baseline to follow-up (measured in percentage points for all indicators except those measured in minutes); relative improvement is defined as the absolute improvement divided by the difference between the baseline performance and perfect performance (100%).

Results: The median state's performance improved from baseline to follow-up on 20 of the 22 indicators. In the median state, the percentage of patients receiving appropriate care on the median indicator increased from 69.5% to 73.4%, a 12.8% relative improvement. The average relative improvement was 19.9% for outpatient indicators combined and 11.9% for inpatient indicators combined (P<.001). For all but one indicator, absolute improvement was greater in states in which performance was low at baseline than those in which it was high at baseline (median r = -0.43; range: 0.12 to -0.93). When states were ranked on each indicator, the state's average rank was highly stable over time (r = 0.93 for 1998-1999 vs 2000-2001).

Conclusions: Care for Medicare fee-for-service plan beneficiaries improved substantially between 1998-1999 and 2000-2001, but a much larger opportunity remains for further improvement. Relative rankings among states changed little. The improved care is consistent with QIO activities over this period, but these cross-sectional data do not provide conclusive information about the degree to which the improvement can be attributed to the QIOs' quality improvement efforts.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Ambulatory Care / standards
  • Cross-Sectional Studies
  • Fee-for-Service Plans / standards*
  • Health Services Research
  • Hospitals / standards
  • Humans
  • Medicare / standards*
  • Quality Indicators, Health Care / statistics & numerical data*
  • Quality of Health Care / classification
  • Quality of Health Care / trends*
  • Total Quality Management / statistics & numerical data*
  • United States