Document Type



This report describes a method designed to assess the quality of ambulatory health care in the Indian Health Service. The first part of the evaluation was a description of the design phase of the quality assurance methodology. The second report describes a pilot study in six IHS Service Units, three private practices, and two large Health Maintenance Organizations. This third volume compares the three different types of health care units. The primary purpose of this report is to determine if there is any significant difference in the performance of the different health care providers of ambulatory health care.Seven tracer conditions were selected on the basis of severity of impact on the patient. The tracer conditions included: severe lacerations, iron deficiency anemia, urinary tract infection, prenatal care, infant care, streptococcal infection, and hypertension. Specific patient cohorts were identified by tracer condition and monitored by criteria indicators. These indicators describe the continuity, distribution, and appropriateness of provider care. The indicators are aggregated into three major types: population based, provider based, and health status indicators. The results were tabulated in frequency tables. Comparisons of tracer cohorts were then made for all three types of health care providers.This comparative phase of the study found that there was no substantial or consistent difference in the performance of the care providers across units. Most of the differences observed were attributable to the provider's ability or inability to recognize the patient's needs, and the patient's ability to articulate their needs. It appeared that IHS units did a more comprehensive job of consumer education. That may be attributable to the multidisciplinary health care teams, and extensive field operations of IHS. Conversely, the recognition of patient needs tends to be higher with private practitioners and HMOs.The study suggests four major methodological areas of concern in the application of quality assurance techniques. First, the evaluation of provider performance alone does not necessarily reflect the adequacy of care provided. Second, the study indicates a continuing need to improve the continuity of care provision. Health status indicators were the weakest part of the quality assessment methodology and require further research and development. Finally, one must use tracer conditions with caution. The adequacy of care resulting from the assessment of one condition may not always be generalizable to insure adequacy of care for similar conditions. Focusing on specific conditions may serve to blind the care provider to other symptomatically similar conditions.

Publication Date



Indian Health Service, Staff Office of Planning, Evaluation and Research, Rockville, MD 20857 (E-13).