Quality assessment: is the truth in the outcome?

H ealthcare workers and medical centres are increasingly requested to report data about their results of medical treatment. Governments call hospitals to account for their results in order to plan new healthcare structures, and to support new regulations in medical systems. Insurance companies are highly interested in the results of medical treatments to enable cost-effectiveness of care and benchmark-ing between different providers. Centres with the ''best care'' for the ''lowest price'' are popular in the financial departments of healthcare agencies. Newspapers and magazines regularly fill their columns with comparisons of hospital performances regarding patient safety and satisfaction. And last, but not least, patients themselves want to know and have the right to know whether their medical centre and their doctor deliver good quality of care. Several systems have been developed to evaluate quality of care, sometimes with far-reaching consequences. In the UK, general practitioners' remuneration is now directly linked to the scores attained in the Quality and Outcomes Framework [1]. The success of such an approach depends, in part, on designing a robust and clinically meaningful set of indicators. Outcome measures regarding the results of treatment are often attractive at first glance, but their interpretation can be complicated. Patients can be pleased to know that their doctor has the highest lung function results for chronic obstructive pulmonary disease or asthma patients in the country, but in most cases they cannot judge the meaning of such information. What is the meaning of a forced expiratory volume in one second (FEV1) value of 80% of predicted? Is such a number clinically relevant? Is it reliable? Is the number corrected for all sorts of influences, such as age, comorbidity and case mix? For proper evaluation of quality of care, more information is needed. In two studies, DONABEDIAN [2, 3] advocates the evaluation of the three indicators ''structure, process and outcome''. Structure indicators point to the background of the care-delivery system. For example, is care for cystic fibrosis (CF) delivered by a dedicated team, consisting of a pulmonary physician, a physiotherapist, a dietician and a social worker? Is a microbiologist and a pharmacist involved in the care for these patients? Is there a specialised nurse available for all patients with asthma? Process indicators deal with the organisation of care. Does the hospital use a protocol for lung function measurements and microbiological evaluations? Are there clear rules for segregation of patients with methicillin-resistant Staphylococcus aureus? …