Shattuck lecture—Hidden barriers to improvement in the quality of care

The public has just begun to recognize that despite the enormous achievements of American medicine and the American health care system, the quality of care in this country needs to be and can be improved. Two recent reports from the Institute of Medicine dramatized the need for greater attention not only to potential problems with quality but also to the entire structure of the delivery system. The reports also proposed many approaches to improving quality, based to a great extent on the paradigm of the overuse, misuse, and underuse of medical technology (drugs, devices, and procedures). Reducing errors has become a key component of these approaches, and considerable resources for research and demonstration activities to reduce errors have recently been made available throughout the health care system. There are two underlying problems that play a part in the overuse, misuse, and underuse of medical technology and associated errors. The first problem is uncertainty with regard to decision making in individual cases and, more broadly, with regard to the establishment of guidelines or criteria for determining the appropriateness of care (e.g., the criteria developed by RAND and the guidelines of the American College of Cardiology and the American Heart Association). Uncertainty can be interpreted not only as lack of convincing evidence but also as impaired access to convincing evidence. The second problem is rising costs. Both rising costs and efforts to contain costs can promote the underuse of new, particularly expensive but effective, even cost-effective medical technology. Underuse may well be as critical a problem in this country in the future as the problems of overuse and misuse are now believed to be. (November 29, 2001)