Geography and Destiny

April 10, 2013
A new research study confirms dramatic variations in access to and quality of preventive and primary care across the U.S. Could clinical IT be used to help improve the situation nationwide?

It’s an old adage in the real estate world: “location, location, location.” Obviously, in that industry, the specifics of geography are incredibly important, and are often the single most important determinant of what happens with a particular property, whether commercial or residential. Yet the reality in healthcare has long been that geography is very significant indeed in our industry as well, despite the fact that any patient in any location in the United States should theoretically have the same access to the same level and quality of care as in any other location.
Of course, research has long documented the contrary. Indeed, if there’s a single thing that the folks at the Dartmouth Atlas of Health Care project/ the Dartmouth Institute for Health Policy & Clinical Practice have shown us over the past two-plus decades, it’s that the cost of and access to, patient care continue to vary dramatically across different neighborhoods, metropolitan areas, states, and regions of the U.S., much to the detriment of healthcare consumers.

Now, to add to what’s already been documented, the authors of a July 5 Perspective article in The New England Journal have published a study that adds the element of patient care quality to the mix. David C. Radley, Ph.D., M.P.H., is senior analyst and project director for The Commonwealth Fund Health System Scorecard and Research Project, a grant-funded position located at the Institute for Healthcare Improvement in Boston. He and his co-author, Cathy Schoen, M.S., senior vice president for policy, research and evaluation at the Commonwealth Fund (based in New York City and Washington, D.C.), have put together a comprehensive set of data encompassing 43 health system performance measures around access, prevention and treatment, potentially avoidable hospital use and cost, and health status, and found tremendous variation across 306 regional healthcare markets, defined with the use of patient-flow data from the Dartmouth Atlas of Health Care, using largely publicly available data from 2008 to 2010. And what did they find?

In short, that “there are staggeringly wide gaps in people’s ability to gain access to care in different communities around the country. We also find,” the authors write, “a strong and persistent association between access and healthcare quality, including the receipt of preventive care. Simply put,” they say, “where a person lives matters—it influences the ability to obtain healthcare, as well as the probable quality of care that will be received—though it should not matter in an equitable healthcare system. This and other Scorecard findings,” the add, “have important implications that are relevant to national policy reforms and to newly available resources for improving access and quality of care.”

Among the challenges the authors of the study find are a greater-than-twofold variation between the best- and worst-performing regions of the country with regard to the provision of both preventive care and of diabetes care; as well as a very strong statistical link between a high rate of uninsured residents in a community and the overall quality of care for all residents, both uninsured and insured.

“Ultimately, the authors state, “ensuring timely access and improving the quality of care delivered will depend on collaboration among local clinicians, hospital leaders, insurance companies, policymakers, and other community stakeholders in strategic efforts to redesign healthcare systems.”
What struck me in reading all this was the tremendous potential present in the possible leveraging of clinical information technology to help policymakers assess access to and quality of preventive and primary care across regions in the U.S., and to help patient care organizations and public health agencies make adjustments, within the limits of public policy constraints, to eliminate care quality and access gaps. The potential for clinical IT to be helpful in this arena will emerge particularly strongly, I believe, once insurance access is broadened through healthcare reform, and as health information exchanges grow and encompass more and more patients’ information across intrastate and interstate regions.

So much is possible now, particularly that the Supreme Court’s affirmation of the constitutionality of the Affordable Care Act is bringing greater certainty to the policy and operational landscape in healthcare in the U.S. Who knows where all of these convergences might take us? There will be many challenges ahead, but it’s exciting to know that clinical healthcare IT—and healthcare IT leaders—will inevitably play a role in the transformation of healthcare across multiple dimensions.

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