Quality of care - Definition
Appropriateness of health care
Determining the appropriateness of health care
Appropriateness of health care: the RAND method
Appropriateness of medical care - definition
There are numerous definitions of quality of health care. The most widely quoted definition is that of the Institute of Medicine:
Quality of care is the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and are consistent with
current professional knowledge."
Source: Lohr KN (ed.). Medicare: a strategy for quality assurance. Washington: National Academy Press, 1990, p. 21.
Quality of health care has several dimensions. Quite often reference is made to the
following three elements of quality first proposed by Avedis Donabedian: structure, process,
outcome. Quality of health care structure refers to the quality of the facilities and the
environment in which health care is provided: buildings, equipment, degree of training of
health care professionals and so on. Quality of health care process refers to the correctness
and appropriateness of the actual care that is provided: decisions concerning an indication to
operate, how the operation was carried out, etc. Quality of health care outcomes refers to the
actual result of the care provided: improved health, patient satisfaction, reduced pain and so on.
The appropriateness of care is one element of the process of care. Brook RH. Quality of care: Do we care ? Ann Intern Med 1991;115:486-90, has identified three essential components of the process of care:
The appropriateness of care is ideally determined on the basis of applying the results of high-quality clinical studies to individual patients with characteristics similar to those of patients enrolled in such studies. Ideally, gastrointestinal endoscopy would be performed only in clinical situations where the procedure has been proven to have a favourable impact on patient management or outcome. Desirable outcomes might include reductions in morbidity and mortality, relief of symptoms, reassurance about the absence of serious disease, and improved quality of life or health status. There is, however, still considerable uncertainty about the efficacy of endoscopy in many situations. When strong evidence of efficacy, obtained from well conducted clinical trials, or even from high-quality observational studies, is lacking, the best available evidence must be used. The method applied in the EPACT project used a standardized procedure to elicit collective expert opinion based on available evidence from the medical literature and the expertise of clinical specialists dealing daily with the appropriateness of gastrointestinal endoscopy.
Appropriateness of health care: the RAND method
The 5 stages of the process are as follows :
A literature review focusing on the efficacy of treatments and their safety in use is carried out using the databases of Pubmed, the Cochrane Database and from many other Internet sites, which is subsequently expanded manually using references contained in review articles and other references suggested by the panel experts. The selected studies are thereafter arranged hierarchically according to evidence-based medicine criteria, and then grouped and commented on in a review article.
As the literature review progresses, an algorithm comprising the principal criteria necessary for decision-making in the various different clinical situations (mild, moderate or severe active disease, steroid-dependent or -refractory disease, fistulizing disease, stenotic disease, maintenance of medically- or surgically-induced remission, extra-intestinal manifestations, upper GI disease and pregnancy) is created.
The first rating round is conducted individually by the experts by mail, based on their own personal experience and clinical knowledge, and after careful study of the articles contained in the literature review. The vote thus obtained on several hundred clinical scenarios on a 9-point scale permits a judgement of a theoretical or practical use of a treatment as being appropriate (=9), uncertain (=5) or inappropriate (=1). The appropriateness of a treatment is defined as being a situation where the benefit to the patient exceeds the potential risks (possible side-effects) by a sufficiently wide margin that the treatment is worth giving.
The second rating round takes place some weeks later in the context of a panel meeting led by one or two moderators, in which the expert panellists discuss their opinions based on the anonymous first rating round results of the other experts. After discussion, all the clinical scenarios are then rerated.
A third rating round at the panel meeting introduces the notion of necessity, enabling identification of situations where over- or under-utilization of a treatment are present. This applies only to scenarios where the median vote was between 7 and 9 (= appropriate treatment). Treatment that is defined as necessary should be appropriate, with a high probability of substantial benefit to the patient, should thus in these circumstances be proposed to the patient, unless of course there are strong contra-indications for such a treatment.
The indication to perform a medical procedure is appropriate when the expected health benefit (i.e., increased life-expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (i.e., mortality, morbidity, anxiety of anticipating the procedure, pain produced by the procedure) by a sufficiently wide margin that the procedure is worth doing.