Seminar article
Defining high quality health care

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Abstract

Most health care quality improvement efforts target measures of health care structures, processes, and/or outcomes. Structural measures examine relatively fixed aspects of health care delivery such as physical plant and human resources. Process measures, the focus of the largest proportion of quality improvement efforts, assess specific transactions in clinical-patient encounters, such as use of appropriate surgical antibiotic prophylaxis, which are expected to improve outcomes. Outcome measures, which comprise quality of life endpoints as well as morbidity and mortality, are of greatest interest to clinicians and patients, but entail the greatest complexity, as the majority of variance in outcomes is attributable to patient and environmental factors that may not be readily modifiable. Selecting among structure, process, and outcome measures for quality improvement efforts generally will be dictated by the specific clinical situation for which improvement is desired.

One aspect of health care quality that has received a great deal of attention in recent years is the relationship between surgical volume and health outcomes. Volume, an inherent characteristic of a health care facility or provider, is generally considered a structural measure of quality. Many studies have demonstrated a positive association between volume and outcomes, and policymakers in the private and public sectors have begun to consider volume in certification and reimbursement decisions. The volume-outcome association is not without controversy, however. Most studies in the field are limited by the nature of the administrative data on which they are based, and some studies have found that variation in quality within volume quantiles exceeds differences between quantiles. Moreover, regionalization driven by a focus on volume may exert adverse effects on access to care.

The movement for health care quality improvement faces substantial methodological, clinical, financial, and political challenges. Despite these challenges, it is a movement that is gaining momentum, and the emphasis on quality in health care delivery is likely only to increase in the future. It is crucial, therefore, that physicians assume increasing leadership roles in efforts to define, measure, report, and improve quality of 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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