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The Quality of Pharmacologic Care for Adults in the United States

Shrank, William H. MD, MSHS*†; Asch, Steven M. MD, MPH‡§∥; Adams, John PhD§; Setodji, Claude PhD§; Kerr, Eve A. MD, MPH¶**; Keesey, Joan§; Malik, Shaista MD, MPH§††; McGlynn, Elizabeth A. PhD§

doi: 10.1097/01.mlr.0000223460.60033.79
Original Article

Background: Despite rising annual expenditures for prescription drugs, little systematic information is available concerning the quality of pharmacologic care for adults in the United States. We evaluated how frequently appropriate pharmacologic care is ordered in a national sample of U.S. residents.

Methods: The RAND/UCLA Modified Delphi process was used to select quality-of-care indicators for adults across 30 chronic and acute conditions and preventive care. One hundred thirty-three pharmacologic quality-of-care indicators were identified. We interviewed a random sample of adults living in 12 metropolitan areas in the United States by telephone and received consent to obtain copies of their medical records for the most recent 2-year period. We abstracted patient medical records and evaluated 4 domains of the prescribing process that encompassed the entire pharmacologic care experience: appropriate medication prescribing (underuse), avoidance of inappropriate medications (overuse), medication monitoring, and medication education and documentation. A total of 3457 participants were eligible for at least 1 quality indicator, and 10,739 eligible events were evaluated. We constructed aggregate scores and studied whether patient, insurance, and community factors impact quality.

Results: Participants received 61.9% of recommended pharmacologic care overall (95% confidence interval 60.3–63.5%). Performance was lowest in education and documentation (46.2%); medication monitoring (54.7%) and underuse of appropriate medications (62.6%) performance were higher. Performance was best for avoiding inappropriate medications (83.5%). Patient race and health services utilization were associated with modest quality differences, while insurance status was not.

Conclusions: Significant deficits in the quality of pharmacologic care were seen for adults in the United States, with large shortfalls associated with underuse of appropriate medications. Strategies to measure and improve pharmacologic care quality ought to be considered, especially as we initiate a prescription drug benefit for seniors.

Supplemental Digital Content is Available in the Text.

From the *Harvard Medical School and †Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts; ‡VA Greater Los Angeles Healthcare System, Los Angeles, California; §RAND Health, Santa Monica, California; ¶VA Ann Arbor Healthcare System, Center for Practice Management and Outcomes Research, Ann Arbor, Michigan; ∥Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; **Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; and ††Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine.

Supported by the Robert Wood Johnson Foundation and by a Veterans Affairs Health Services Research and Development fellowship (Dr. Shrank) and career development awards (to Drs. Asch and Kerr) from the Veterans Affairs Health Services Research and Development program.

Reprints: William H. Shrank, MD, MSHS, Division of Pharmacoepideiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont St, Suite 3030, Boston, MA 02120. E-mail:

© 2006 Lippincott Williams & Wilkins, Inc.