Part 1: Quality of care--what is it?

Concepts of quality and the provision of periodontal care: a survey

This is a survey of various concepts of quality of care in the health care field and their application to periodontics. Definitions of quality care, measuring and improving quality, third party payment and quality of care, and the role of periodontists in managing quality are presented. The definitions of quality care include the following dimensions: access, appropriateness, technical quality, and the art of care. Examples of each of these dimensions are presented, and their implications for quality assessment are discussed. Emphasis is placed on appropriateness of care and the strengths and weaknesses of mechanisms for deriving evidence-based decision making. The use of randomized clinical trials (RCT), employing expert opinion such as consensus panels, and meta-analysis are discussed as they apply to appropriateness of periodontal treatment. Work in the area of technical quality of care (i.e., the third dimension of quality care) has resulted in the development of quality assurance guidelines. Examples of guidelines and practice parameters such as those developed by the U.S. Food and Drug Administration and by various dental specialties are presented. The fourth dimension of quality deals with the art of care. It focuses on the patient's participation in the process of care and the input of the provider in this interaction. The description of outcomes of care includes the concept of measuring clinical outcomes of treatment as well as efforts to measure the health and well-being of a patient. It deals with quality of life measures. Patient satisfaction is another outcome that is presented. Examples of these aspects of quality measurement are discussed. These concepts and measures are presented within the context of a quality assurance program. The steps used to assess and assure quality are outlined. Examples of provider and patient profiles are presented, along with a discussion on how they are used in a quality assurance system. Lastly, the role of the periodontist in quality of care is presented, emphasizing the efforts that have already been made as well as the leadership role that the periodontist has in influencing the profession of dentistry. The advent of managed care and its implications for the quality of periodontal treatment and patient management are discussed using situations obtained from dental plans.

A computer-assisted management program for antibiotics and other antiinfective agents

BACKGROUND AND METHODS

Optimal decisions about the use of antibiotics and other antiinfective agents in critically ill patients require access to a large amount of complex information. We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit.

RESULTS

During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P<0.01), excess drug dosages (87 vs. 405, P<0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P<0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P<0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P<0.02). In analyses of patients who received antiinfective agents, those treated during the intervention period who always received the regimens recommended by the computer program (n=203) had significant reductions, as compared with those who did not always receive the recommended regimens (n= 195) and those in the preintervention cohort (n = 766), in the cost of antiinfective agents (adjusted mean, $102 vs. $427 and $340, respectively; P<0.001), in total hospital costs (adjusted mean, $26,315 vs. $44,865 and $35,283; P<0.001), and in the length of the hospital stay days (adjusted mean, 10.0 vs. 16.7 and 12.9; P<0.001). CONCLUSIONS; A computerized antiinfectives-management program can improve the quality of patient care and reduce costs.

Health plan report cards: exploring differences in plan ratings

BACKGROUND

Despite the considerable attention paid to the collection of data and the publication of health plan report cards, there is no available study on the comparability of published report cards. Ratings from seven health plan report cards publicly available in fall 1996 were compared--including those produced by major periodicals, a large national employer, a nonprofit consumer group, a health maintenance organization accreditation agency, and a consortium of employers.

METHODS

Dimensions of plan performance common to the seven report cards were identified. Spearman rank correlation coefficients were computed for each pair of report cards for each of the three dimensions that were evaluated. COMPARABILITY OF REPORT CARDS: Although plan ratings tended to be positively correlated as hypothesized, the magnitude of the estimated correlation coefficients varied. For example, the estimated correlation coefficient between two periodicals' overall plan ratings was 0.48. The ranges of estimated correlations were 0.18-0.70 for preventive care (among four report cards) and 0.19-0.73 for enrollee satisfaction (among three report cards).

DISCUSSION

Discrepancies in ratings may reflect methodologic issues pertaining to the sample of health plans used, plan performance measures included, and the processes by which individual measures were aggregated to construct indices and ratings. Health plan report cards may be sending mixed signals to consumers. These inconsistencies may explain why focus group studies have found that despite the widespread indication that plan performance measures would be useful, relatively few of those who had seen such information report using it in making their plan choice. Future efforts to evaluate health plans should clearly identify assumptions, methods, normative judgments, and limitations.

What is adequate health care and how can quality of care be improved?

Attempts to improve patient care, its increasing cost and the aggressive malpractice environment have highlighted the need for standards of professional accountability. However, current measures of quality of care have mostly been met with skepticism by the medical community. These measures have been criticized for their uncertain validity and for focusing on secondary aspects of service that measure what is minimally acceptable. The objective of this essay is to review quality improvement methods that have been reported to be feasible, effective and acceptable by practicing physicians. The successful implementation of these methods seems to be related to their being nonintrusive, nonthreatening, and based on agreed upon standards of care. We believe that these three features are essential for a continuous quality improvement process in health care.

Medicare managed care. How physicians can make it better

The federal government is attempting to control anticipated, increased Medicare health care costs by providing the senior population with incentives to encourage their movement into managed care programs. For-profit corporate HMOs that currently dominate the managed care arena are coming under increased competitive pressure at a time when their perception of profiteering is undergoing increased public scrutiny. If physicians are to take advantage of this window of opportunity and successfully enter the Medicare managed care marketplace, they must identify the major deficiencies existing in the current model, and fashion a new product that divests itself of the profit orientation of current corporate HMOs. A nonprofit version of a highly integrated, multispecialty provider service organization (PSO) provides an appropriate model to effectively compete with the corporate HMO. The ideal physician-controlled managed care model must: develop a responsive policy board structure; create practice guidelines that decrease variation in physician practice; achieve an appropriate balance between primary and specialty medical care; and adopt a quality-assurance program that effectively addresses both process and outcome data.

Quality and outcomes management in gastroenterology

The delivery of medical care is undeniably changing. Resources are becoming increasingly scarce, and the progressive rise of health care expenditures needs to be restrained. Although the field of outcomes assessment is not well understood, it is increasingly being applied to the practice of medicine. The underlying goal of outcomes management should be to improve quality by identifying the most efficient use of finite resources and integrating these into practice guidelines. Although reduction of health care costs is important, it should be a secondary goal. Providers of health care must take an active role in outcomes research and management both in understanding and in implementing these techniques in medical practice. In doing so, it is essential that physicians maintain the proper emphasis on quality patient care.

Quality assessment and tracking results of cardiac surgery

Long-standing efforts to assess quality in medical care have been intensified by the striking expansion of managed care plans. Agencies such as the Joint Commission on Accreditation of Health Care Organizations and the National Committee on Quality Assurance have formalized the evaluation of health plan quality using criteria of structure, process, and outcome. A review of attempts to apply these criteria to individual physicians and to disease-specific interventions such as myocardial revascularization demonstrates the great difficulty of reliable quality assessment in this evolving surgical field. Cardiac surgeons must continue their work in deriving valid socioeconomic and clinical conclusions from The Society of Thoracic Surgeons and Veterans Affairs databases. This may prevent the precipitate adoption of newer treatment methods driven by entrepreneurial technology companies and large group purchasers of care. These entities tend to focus on economics rather than patient welfare. New technologies may also delude patients into insisting on treatment featuring short-term convenience and comfort despite less satisfactory long-term results. "Black box" methodology providing practice profiles and physician report cards must have critical validation.

[Quality in hospital treatment. How is it assured and who determines the guidelines?]

BACKGROUND

Internal quality control of medical performance in the interest of patient safety is not a new idea. In fact it has been implemented in varying degrees since the beginnings of medicine.

ACTUAL SITUATION AND METHODS

Ever since hospitals are compelled by law to apply methods of quality assurance and external quality control, the question arises as to whether this law can achieve a concrete increase in quality of patient care or whether it rather serves to support economically motivated goals of health care policies, in the sense of an increase in efficiency of performance by physicians. Seen in the light of the overall situation of hospital care, the attempt to create mandatory quality standards is problematical. A reduction of hospital beds and a decrease in the average length of hospital stay contrasts the growing number of treated patients. This presents a problem which must be compensated for, despite cutbacks in budget and personnel. Methods of quality analysis are of the implicit as well as of the explicit type. Implicit methods are based on retrospective data analysis lacking previously set standards of comparison. These methods harbor the danger of viewer-dependent subjectivity (restricted reliability). Explicit methods are based upon comparison to previously defined standards. These methods are more objective, but often fail to give consideration to individual situations (restricted validity). The infrastructure necessary in order to sensibly apply quality control in the hospitals is not yet present in Germany. The software required in order to record and analyse data is still in a stage of development in many places.

CONCLUSION

It is of importance not to leave external quality control to politicians and economists unfamiliar with the subject matter, but rather that quality control is implemented by experts in the medical field.

Home care, medical care and the new competitive environment

Health-care organization and financing is rapidly changing in the USA due to competitive pressures. Parallel changes are occurring in other countries. These changes are affecting, and will affect, home care services. Watching these changes, and building on social models, leads one to focus on important developments. These developments include: point of service plans, disease management, outcomes measurement, price and quality competition. These changes will make measured outcomes and demonstrated value essential in home care.