Urologic Oncology: Seminars and Original Investigations
Seminar articleDefining high quality health care
Introduction
Health policy decisions and interventions focus for the most part on one or more aspects of the triumvirate of cost for, access to, and quality of health care [1]. While cost and access remain intractable problems in the United States and elsewhere, the current decade has witnessed an unprecedented focus on health care quality. Galvanized by the Institute of Medicine (IOM)'s 2001 report, Crossing the Quality Chasm [2], health care researchers and policymakers at local, regional, and national levels are devoting increasing effort and resources to the assessment, reporting, and improvement of quality.
Although defining quality care is not straightforward, the definition adopted by the IOM—“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” [3]—is frequently repeated and constitutes a useful operational framework. The IOM further identifies 6 domains of quality clinical care (Table 1). While the first 2 domains—safety and efficacy—receive the most attention, particularly in quality reporting efforts, all are important, and each has been studied to some extent in recent years in relation to care of patients with urologic tumors.
Section snippets
Assessing quality
Efforts by health care organizations to assess, report, and improve health quality are frequently considered in relation to Donabedian's well-established paradigm of structure, process, and outcomes [4], recently reviewed in depth in the context of surgical procedures [5]. Structural measures of quality are typically concrete and relatively easy to measure. They may include aspects of health care delivery, such as physical plant adequacy; nursing ratios; board certification of providers; and
The question of surgical volume
Evidence has accumulated over the past quarter-century linking surgical volume with outcomes across multiple disease conditions, and has engendered animated debate regarding the explanations for and significance of the findings. The volume-outcomes relationship was first noted in 1979 [19], and has been extensively explored in a number of areas in surgery and medicine. A systematic review of the United States and European literature commissioned by the Institute of Medicine analyzed 135 studies
Challenges and conclusions
Most large studies to date examining health processes and outcomes in relation to quality of care rely heavily on databases populated from Medicare, private insurance claims, and other administrative sources. While these are excellent sources of population-based data, they are not without limitations. Claims data tend to include few clinical variables and are prone to inaccuracies, at times severe, due to the manner in which such data are collected [31]. Conversely, accumulating sufficient
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2013, Urologic Oncology: Seminars and Original InvestigationsCitation Excerpt :For example, Hollenbeck et al., [24] relying on data from the NIS between 1993 and 2003, showed that for each 100 RP regionalized to high AHC centers, 14.3 (95% CI, 12.9 to 15.4 hospitalizations) prolonged hospitalizations avoided. As such, Birkmeyer [25] and Miller [26] have described a conceptual approach to improve quality of care based on procedure risk and volume [27]. For high-risk low-volume procedures such as esophagectomy [28] and pancreatectomy [29], it is preferable to focus on structural measures, such as regionalization to high quality hospitals and providers.
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2012, Journal of Clinical EpidemiologyCitation Excerpt :As people live longer and have more options, the model moves beyond the familiar outcome of survival to include intermediate outcomes that are important in and of themselves and as they modulate a longitudinal care process. It also includes measures of the structure, process, and outcomes of care, which collectively compose quality of care [50–52]. Overall quality of life joins survival at the end of the model to reflect the trade-off between quality and quantity of life that many people make [53,54].
Complications nearly double the cost of care after pancreaticoduodenectomy
2012, American Journal of SurgeryCitation Excerpt :Further data suggest that cost savings can be achieved if the more experienced surgeons perform most of the pancreas resections.6,11 It is important to note that considerable controversy exists regarding the interaction of patient and surgeon factors in respect to volume and outcome.25–27 The financial impact of the volume-outcome relationship was explored by Gordon et al,6 wherein 4,561 patients with complex abdominal surgeries (1,092 radical pancreas resections) in the state of Maryland were analyzed over an 8-year period.