Limited reach found for Hub's top health care

Even with Boston’s world-renowned doctors and teaching hospitals, just over half of the city’s patients received the best medical care for their illnesses, according to researchers who conducted the largest and most comprehensive study of healthcare quality in 12 US communities.

Researchers from RAND Corp., expanding on a study they published last year in the New England Journal of Medicine, interviewed 6,700 patients in the 12 cities and pored through their medical records.

They then compared the care the patients received for 30 of the most serious conditions to the treatment they should have gotten, according to medical experts and the latest guidelines.

While researchers in recent years have reported on gaps in the quality of medical care nationally, few studies have compared cities and regions. Surprisingly, the RAND group found minimal differences between cities as diverse as Seattle and Greenville, S.C. Overall, patients in the 12 communities received to 60 percent of medical care recommended by experts, according to the study published yesterday in the journal Health Affairs. While Boston came out second overall, with 57 percent of patients receiving recommended care, Seattle was the best-performing city.

But even so, 40 percent of Seattle residents did not get the best medical care. The researchers did not know what accounted for the differences among communities.

‘‘It isn’t acceptable to spend much money as we do on healthcare and get these abysmal results,’’ said Elizabeth McGlynn, one of the authors and associate director of RAND Health, a nonprofit research organization based in California.

It’s not that doctors don’t know what to do, the authors said. It’s that medical care has become complicated, with so many tests and treatments recommended for each illness.

Physicians sometimes forget give care they know works, such as aspirin for heart attack patients to prevent future attacks, or to check blood pressure and blood glucose levels of diabetic patients as well as to examine their vision for deterioration and their feet for infection.

To measure quality, RAND researchers, for example, would see whether a doctor had tested diabetic patient for these problems; it then looked for whether the physician followed up. If the patient had high blood pressure, did the doctor prescribe medication or explain how to reduce salt in the patient’s diet? A failure anywhere along this continuum of diagnosing, treatment, and followup would mean a patient did not receive recommended care.

In Boston, 55 percent of diabetics and 57 percent of patients with heart conditions received the care recommended for their conditions. In Orange County, Calif., 41 percent of diabetics got the recommended care, the worst of the communities studied, compared to 59 percent of Miami patients, the highest percentage. For cardiac care, results swung from a low of 52 percent in Orange County and Indianapolis to 70 percent Syracuse, N.Y., the highest.

The researchers pointed to several possible solutions, including ‘‘pay-for-performance’’ contracts, in which a growing number of insurers, including some in Boston, pay higher fees to doctors and hospitals that prove they provide superior medical care.

Another is electronic medical records that remind doctors schedule specific tests and treatments for patients — and alert them when their orders aren’t completed in a specific period time.

‘‘An airline pilot has a computerized checklist,’’ said Dr. Steven Asch, of the Veterans Affairs Greater Los Angeles Health Care System. ‘‘This isn’t the only thing he needs to fly the plane, but helps. I don’t know why we can’t give doctors the same help.’’

But doctors also raised cautions about the RAND results. The researchers looked at patients’ medical records from 1996 2000, but they did not have records for all patients. They said they compared patients’ treatment only to recommended care commonly known during those years. They also collected information patients who refused care and factored that into the results.

Dr. Thomas Lee, network president for Partners HealthCare, the parent organization of two Harvard teaching hospitals, Massachusetts General and Brigham and Women’s, said chances are high that patients will get some, but not all, of recommended care.

‘‘They put together a long list things that are recommended, but they’re not all equally important. The things that are more important are done more often. So the results look worse than the reality,’’ he said.

Employers, doctors, and public health officials have increasingly focused on gaps in the quality the US medical system since 2001, when the Institute of Medicine released its landmark report ‘‘Crossing the Quality Chasm: A New Health System for the 21st Century,’’ which concluded that the system needs dramatic change to improve. Employers are interested because of a growing belief that poor quality leads to sicker workers and even higher costs. The RAND researchers said poor quality also costs lives: 60,000 to 70,000 of Americans die annually from heart attacks or strokes because their blood pressure is out of control, while failing to give elderly Americans pneumonia vaccines causes 10,000 deaths.

‘‘Doctors are normal human beings operating in poorly supported systems, and they’re screwing up,’’ said Dr. Donald Berwick, a Harvard Medical School professor and president of the Institute for Healthcare Improvement, a nonpro fit organization based in Boston.

For example, patients with diabetes or congestive heart failure, he said, see five to 10 different doctors. But they don’t know each other, don’t have a coordinated treatment plan, and no one knows who’s tracking which tests. Even in many hospitals, Berwick said, it’s unclear who is supposed to give aspirin to heart attack patients — the emergency room staff, the intensive care unit nurses, or doctors on the overnight floors. In VA hospitals and a small number of US medical centers, he said, when a heart attack is entered into a patient’s electronic medical record, the computer automatically orders aspirin for most patients — and if a nurse or doctor does not eventually confirm they gave the patient the aspirin, an alarm sounds.

Health insurers also need to pay doctors and hospitals differently, Berwick added. Rather than pay them each time the patient comes in for an office visit or has surgery, they should pay a flat fee for taking care of all the patient’s medical needs to encourage coordination — a controversial system that was widespread in the late 1990s called ‘‘capitation.’’

Berwick said he wasn’t surprised that patients in Boston, with its top medical care, didn’t fare better in the study. ‘‘In some ways Boston is worse,’’ he added. ‘‘If the problem is fragmentation, there are a lot of proud institutions here with many, many walls around them.’’

Liz Kowalczyk can be reached at kowalczyk@globe.com.