P4P Quality

How to Assess Quality of Care

Avedis Donabedian has a revealing article regarding how to assess quality in the medical profession.  His 1988 JAMA and 2005 Milbank Quarterly articles include the following important points:

  • Physician quality is not only technicalInterpersonal skills are also important.  The patient must communicate information to the physician and the physician must provide information to the patient on the nature of the illness and its management.  The interpersonal process must also take into account social norms such as privacy, confidentiality, patient choice, empathy, and honesty.
  • The goodness of technical performance is judged in comparison with the best in practice…[however], judgments of technical quality are contingent on the best in current knowledge and technology; they cannot go beyond this limit…Even if the actual consequences of care in any given instance prove to be disastrous, quality must be judged as good if care, at the time it was given, conformed to the practice that could have been expected to achieve the best results.”
  • The patient and family must, themselves, also carry some of the responsibility for the success or failure of care.”  For instance, lack of adherence to physician’s medication directions often is a cause of poor outcomes.
  • The introduction of patient preferences, though necessary to the assessment of quality, is another source of difficulty in implementing assessment.”  For instance, surgery may be the best option to improve life expectancy, but the patient may prefer less invasive, less painful treatment.
  • Maximalists vs. Optimalists.  Donabedian says their are two schools of quality.  The first says to measure quality against a ‘best practice’ which is the maximum health improvement regardless of cost.  This is the school to which most American physicians ascribe.  The optimalist says that “care must stop short of including elements that are disproportionately costly compared with the improvements in health they produce.”  Economist generally ascribe to this school.  In econo-lingo, one should perform additional care only insofar as marginal benefit exceeds marginal cost.
  • Implicit vs. Explicit criteria.  Implicit criteria…are adaptable to the precise characteristics of each case, making possible the highly individualized assessments that the conceptual formation of quality envisaged…By comparison, explicit criteria are costly to develop, but they can be used subsequently to produce precise assessments at low cost, although only cases for which explicit criteria are available can be used in assessment.
  • Correlation of Quality with other factors.  Two studies find “positive relationships between quality and better office facilities for practice, the presence or availabilty of laboratory equipment, and the institution of an appointment system.  No relationship was shown between quality and membership of professional associations, the income of the physician or the presence of x-ray equipment in the office…Hospital accreditation, presumably a mark of quality conferred mainly for compliance with a wide range of organizational standards, does not appear, in and of itself, to be related to the quality of care…”
  • Medical record data.  Medical records are frequently used to measure quality.  However, there are often errors in “diagnostic testing, in clinical observation, in clinical assessment, in recording, and in coding.”  Further, medical records in the U.S. are not system-wide and frequently an individual medical record will not document care from other providers.
  • Weighting components of numerical physician score.  How to weight each component is difficult.  Should labs, terpay, clnical history, clinical record accuracy or other items have the most weight in the overall physician score.  According to Peterson et al. (1956) “Greatest importance is attached to the process of arriving at a diagnosis since, without a diagnosis, therapy cannot be rational. Furthermore, therapy is in the process of constant change, while the form of history and physical examination has changed very little over the years.”
  • Single or multiple scores? “The search for easy ways to measure a highly complex phenomenon such as medical care may be pursuing a will-o’-the-wisp. The use of simple indices in lieu of more complex measures may be justified by demonstrating high correlations among them. But, in the absence of demonstrated causal links, this may be an unsure foundation upon which to build.  Onthe other hand, each index can be a measure of a dimension or ingredient of care. Judiciously selected multiple indices may, therefore, constitute the equivalent of borings in a geological survey which yield sufficient information about the parts to permit reconstruction of the whole.”
  • Structure, Process and Outcomes.  Donabedian describes the three types of quality measures.  Outcomes are generally favored by policymakers.   “Outcomes do have, however, the advantage of reflecting all contributions to care, including those of the patient.  But this advantage is also a handicap, since it is not possible to say precisely what went wrong unless the antecedent process is scrutinized.”

Finally and most importantly:

  • It cannot be emphasized too strongly that our ability to assess the quality of technical care is bounded by the strengths and weaknesses of our clinical science.


1 Comment

  1. Donabedian died in 2000, so the 2005 article is a reprint (from 1966) which does not diminish it as the foundational intellectual framework for discussing quality. More people should read Donabedian, or at least your summary, before placing all their faith in quality measures.

    The quality movement’s credibility can be diminished if it does not proceed with a healthy respect for the limitations of the tools and the science.

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