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.
Children with special health care needs—Children with a chronic physical, developmental, behavioral, or emotional condition, or an increased risk of developing one, require more than the typical level of pediatric care. This vulnerable population requires caregivers to work closely with families to develop and coordinate care plans.
Diabetes—Diabetes is the fifth-leading cause of death in America, predisposing 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, with the goal of preventing progression through early and proper management.
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—Cancer is the second-leading cause of death in the United States. 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 followup.
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—Although this disease affects one in four adults in the United States, nearly a third of people with high blood pressure are undiagnosed. Untreated hypertension can lead to life-threatening complications, including stroke, heart attack, and kidney failure. Interventions should emphasize early detection and management.
Immunization—Timely vaccination could prevent the deaths of about 300 children and between 50,000 and 70,000 adults annually. Influenza and pneumonia account for most of the adult deaths. Vaccination 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—Ischemic, or 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—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 each year.
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 pain control programs have been developed. 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 boost patients' skills and confidence in managing and assessing their health problems. Higher levels of health literacy allow people to understand and act on health care information.
Severe and persistent mental illness—The quality of mental health care in the public sector, including state hospitals, community mental-health centers, and various federal and state programs should be improved. The federal government should play a larger role to assure higher standards of care across states.
Stroke—Stroke 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.
Adapted from National Academy of Medicine Press Release, January 7, 2003 “Officials Should Target 20 Key Areas to Transform Health Care System”; accessed April 11, 2003.

From: Appendix A, National Priority Areas Summary with Key Associated Goals

Cover of Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 1: Series Overview and Methodology)
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 1: Series Overview and Methodology).
Technical Reviews, No. 9.1.
Shojania KG, McDonald KM, Wachter RM, et al., editors.

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