al., 2001; Freeman et al., 2002; Learhinan and Alderman, 2003; Scott et al., 2003; Tan and Tan, 2004; Chopard et al., 2005).

In a study of residents over age 65 in assisted-living facilities, 62 percent of those with congestive heart failure were not receiving an ACE inhibitor; of those with a history of myocardial infarction, 60.5 percent were not receiving aspirin, and 76 percent were not receiving beta-blockers; of those with a history of stroke, 37.5 percent were not receiving an anti-coagulant or antiplatelet product; and of those with osteoporosis, 61 percent were not receiving calcium supplements (Sloane et al., 2004). In a second study of nursing home residents, only 53 percent of ideal candidates with atrial fibrillation were receiving warfarin (McCormick et al., 2001). A third study showed that only 25 percent of nursing home residents with congestive heart failure had been prescribed an ACE inhibitor (Gambassi et al., 2000). A fourth study showed that only 55 percent of residents identified as depressed had received antidepressants (Brown et al., 2002).

Inadequate pain management is well documented in nursing homes, with 45–80 percent of residents experiencing unrelieved pain (AGS, 2002). Results of cross-sectional studies indicate that 26 percent of nursing home residents overall and 30 percent of those with a cancer diagnosis have daily pain, and approximately 25 percent of these patients receive no analgesics (Bernabei et al., 1998; Won et al., 1999, 2004).

A number of studies have examined underutilization of medications in ambulatory care. A major U.S. study of both inpatient and outpatient care carried out during 1998–2000 found high levels of errors of omission generally: across a wide range of acute and chronic conditions, patients received 55 percent of recommended care (McGlynn et al., 2003). Regarding the use of medications in particular, 69 percent of patients received recommended care; of those presenting with myocardial infarction, however, only 45 percent of ideal candidates received beta-blockers and 61 percent aspirin.

Analysis of the results of three phases of the National Health and Nutrition Examination Survey shows that rates of hypertension control, although improving, continue to be low (Hajjar and Kotchen, 2003). Of those with hypertension in the 1988–1991 phase of the survey, 52 percent received treatment, and 25 percent achieved control of their hypertension; in the 1991–1994 phase, 52 percent received treatment, and 23 percent achieved control; and in the 1999–2000 phase, 58 percent received treatment, and 31 percent achieved control.