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Date: Jan. 7, 2003
Contacts: Christine Stencel, Media Relations Officer
Chris Dobbins, Media Relations Assistant
Office of News and Public Information
(202) 334-2138; e-mail <>

For Immediate Release

Publication Announcement

Officials Should Target 20 Key Areas to Transform Health Care System

The United States has the know-how and technology to deliver world-class health care to the public, but often fails to translate such expertise into everyday clinical practice. For many Americans, this situation results in suffering that could be prevented. To help bring about major improvements in health care quality and delivery for all Americans, the U.S. Department of Health and Human Services and other public and private stakeholders should focus on 20 priority areas, says a new report from the Institute of Medicine of the National Academies. Collective action in these areas could help transform the entire health care system.

The committee that wrote the report developed and used an eight-step process to select the top 20 areas, which range from broad interventions to preventive services to palliative care for the dying. The selection process employed three criteria: the breadth of impact on patients, families, and communities; improvability, or the likelihood of closing large quality gaps; and inclusiveness, which deals with both the diversity of people affected and the likelihood of improvements having positive effects throughout the health care industry. The committee intentionally did not rank the priority areas.

The 20 domains should serve as a starting point to dramatically increase the level of quality across the board, says the report, which is part of the Institute's series of recent studies looking at health care quality in America. In the selected areas, low-quality care typically does not stem from a lack of effective treatments, but from inadequate systems to carry them out. Policy-makers also could use the committee's scientific framework to identify other priorities in the future.

A brief look at the 20 priority areas follows. Two of the areas listed below – care coordination and self-management/health literacy – are classified as "cross-cutting" because they cut across specific conditions and would benefit many patients. Obesity is classified as "emerging" because researchers are still working to determine which interventions are effective.

Asthma – In 2000 asthma affected 10 million adults and up to 5 million children, and each year it causes up to 500,000 people to be hospitalized. Using anti-inflammatory medications and doing a better job of treating and supporting people who have persistent mild or moderate cases would significantly improve outcomes. Caregivers should work closely with patients to develop plans for care.

Care coordination (cross-cutting area) – About 60 million Americans live with multiple chronic conditions, such as hypertension and diabetes. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care. This is key in the effective treatment of chronic conditions.

Children with special health care needs – Children who have a chronic physical, developmental, behavioral, or emotional condition, or who are at increased risk of developing one, require more than the typical level of pediatric care. They are an especially vulnerable population, and the costs to serve them are substantial. Caregivers should work closely with families to develop and coordinate care plans.

Diabetes – Diabetes is the fifth-leading cause of death in America, and it predisposes people to serious, long-term medical complications, including heart disease, hypertension, and blindness. There are several well-known and effective models for improving the delivery of care. The goal should be to prevent the progression of diabetes cases by properly managing the disease early on.

End of life with advanced organ system failure – Heart, lung, and liver failures account for about one-fifth of all fatalities in America. Care should minimize symptoms and reduce the rate of exacerbations of organ malfunction. Improving care requires continuity of care over time and across settings; close monitoring; and rapid responses.

Evidence-based cancer screening – Behind heart disease, cancer is the second-leading cause of death in the United States. Scientific research indicates that screening can significantly reduce death rates for several forms of cancer, especially colorectal and cervical cancer. Goals should be to increase the number of people who receive screenings and to provide timely follow-up.

Frailty associated with old age – With more Americans living longer, more people will experience the multiple mental and physical health challenges associated with advanced age. Health care efforts should focus on preventing falls and pressure ulcers, maximizing function, and developing advanced care plans.

Hypertension – This disease affects one in four adults in the United States, but nearly a third of people with high blood pressure do not know that they have it. If left untreated, it can lead to life-threatening complications, including stroke, heart attack, and kidney failure. Interventions should emphasize early detection and management.

Immunization – Every year diseases that can be prevented by vaccination kill about 300 children and between 50,000 and 70,000 adults. Influenza and pneumonia account for most of the adult deaths. Efforts should target nursing-home residents, who are susceptible to contagious illnesses because of advanced age and close living quarters. Also, new strategies should be developed to reach out to black and Hispanic adults, as well as low-income, inner-city children – populations that tend to have lower-than-average immunization rates.

Ischemic heart disease – This condition, also known as coronary heart disease, is the leading cause of death among adults in the United States. Efforts should focus on preventing heart disease and reducing recurrence of heart attacks through promotion of healthy lifestyle changes and use of cholesterol-lowering drugs, surgery, and timely administration of medications after a heart attack. In addition, efforts should ensure that those with heart disease are functioning at their greatest capacity.

Major depression – Treatment rates for depression are significantly lower than those for many other chronic conditions; fewer than half of individuals with depression are correctly diagnosed. National rates of screening and treatment should be improved.

Medication management – Efforts should focus on preventing medication errors, particularly through greater use of computer technology. In addition, educational interventions that warn physicians and patients about problems associated with overuse of antibiotics have been successful.

Nosocomial infections – These hospital-acquired infections kill nearly 90,000 patients in the United States each year and cost an additional $5 billion to treat. Wider implementation of the nosocomial infection guidelines from the Centers for Disease Control and Prevention would save more than 40,000 lives annually, reduce infection rates by up to 50 percent, and save nearly $2.75 billion.

Obesity (emerging area) – Each year more than 300,000 deaths can be attributed to obesity. The condition eventually could become the nation's single most preventable cause of premature death and disability. Changes in social norms and national policies to promote physical activity and healthy diets are essential. Effective national strategies for obesity prevention, treatment, and control will require a combination of public health and clinical interventions.

Pain control in advanced cancer – Twenty percent of Americans die from cancer, often after months of painful, progressive illness. Effective programs have shown that this pain typically can be controlled enough to give patients a satisfactory level of comfort. Efforts should emphasize cooperation in protocols across care settings; advance planning for changes in settings as well as heightened pain; and public education regarding the merits of opioid medications in this area.

Pregnancy and childbirth – The quality of prenatal care and care related to labor and delivery should be enhanced to boost the long-term health of women and their children. Some key goals should be to increase the number of women who start prenatal care in the first trimester and to screen more pregnant women for sexually transmitted diseases.

Self-management/health literacy (cross-cutting area) – Public and private entities should systematically provide educational programs and interventions that aim to boost patients' skills and confidence in managing and assessing their health problems. With a higher level of health literacy, more people also would have the skills to understand and act on health care information.

Severe and persistent mental illness – The goal should be to improve the quality of mental health care in the public sector, which includes state hospitals, community mental-health centers, and various federal and state programs. The federal government should play a larger role to assure higher standards of care across states.

Stroke – This is the third-leading cause of death in the United States. Efforts should focus on seamlessly integrating care across health care settings and clinical disciplines. Beginning rehabilitation as soon as possible after a stroke also helps patients regain their abilities.

Tobacco-dependence treatment in adults – Tobacco use and dependence are the nation's most preventable causes of disease and death. Many successful efforts to improve health care in this area have used multilayered interventions that include systems to remind caregivers to discuss tobacco use with patients, as well as provider-education programs centered on best practices.

The Agency for Healthcare Research and Quality, a division of the U.S. Department of Health and Human Services, should work with other organizations to monitor progress in the priority areas, oversee the collection of more detailed U.S. health data, and update the list as circumstances change, the report adds. Congress and the executive branch should provide adequate funding and support for this work.

The study was sponsored by the U.S. Department of Health and Human Services. The Institute of Medicine is a private, nonprofit organization that provides advice on health policy issues under a congressional charter to the National Academy of Sciences. A committee roster follows.

Copies of Priority Areas for National Action: Transforming Health Care Quality will be available this winter from the National Academies Press; tel. (202) 334-3313 or 1-800-624-6242 or order on the Internet at Reporters may obtain a pre-publication copy from the Office of News and Public Information (contacts listed above).

Board on Health Care Services

Committee on Identifying Priority Areas for Quality Improvement

George J. Isham, M.D. (chair)
Medical Director and Chief Health Officer
HealthPartners Inc.
Bloomington, Minn.

Brian Austin
Deputy Director
Improving Chronic Illness Care
MacColl Institute for Healthcare Innovation

Stephen Berman, M.D.
Professor of Pediatrics;
Director of Children's Outcomes Research Center; and
Director, Academic Section of General Pediatrics
University of Colorado Health Sciences Center
The Children's Hospital

Karen A. Bodenhorn, R.N., M.P.H.
President and Chief Executive Officer
Center for Health Improvement
Sacramento, Calif.

David M. Cutler, Ph.D.*
Professor of Economics
Harvard University
Cambridge, Mass.

Jaime A. Davidson, M.D., F.A.C.P., F.A.C.E.
Associate Professor of Medicine
University of Texas Southwestern Medical School

Benjamin G. Druss, M.D., M.P.H.
Rosalynn Carter Chair in Mental Health
Emory University

Jack C. Ebeler, M.P.A.
President and Chief Executive Officer
Alliance of Community Health Plans
Washington, D.C.

Lisa I. Iezzoni, M.D.*
Professor of Medicine
Harvard Medical School

Charles B. Inlander
People's Medical Society
Fogelsville, Pa.

Joanne Lynn, M.D., M.A., M.S.*
Washington Home Center for Palliative Care Studies;
Senior Researcher, RAND Health; and
Americans for Better Care of the Dying
Washington, D.C.

C. Tracy Orleans, Ph.D.
Senior Scientist and Senior Program Officer
Robert Wood Johnson Foundation
Princeton, N.J.

Greg Pawlson, M.D., M.P.H.
Executive Vice President
National Committee for Quality Assurance
Washington, D.C.

Paul D. Stolley, M.D., M.P.H.*
Clinical Professor of Medicine
Department of Epidemiology and Preventive Medicine
University of Maryland School of Medicine

A. Eugene Washington, M.D., M.Sc.*
Professor and Chair
Department of Obstetrics, Gynecology, and Reproductive Sciences
University of California
San Francisco

Kevin Weiss, M.D., M.P.H., F.A.C.P.
Midwest Center for Health Services and Policy Research, and
Professor of Medicine and Director
Center for Healthcare Studies
Feinberg School of Medicine
Northwestern University

Gail R. Wilensky, Ph.D.*
John M. Olin Senior Fellow
Project HOPE
Bethesda, Md.


Janet M. Corrigan, Ph.D.
Board on Health Care Services

Karen Adams
Study Director

* Member, Institute of Medicine