The paradox of the parts and the whole in understanding and improving general practice.

نویسنده

  • Kurt C Stange
چکیده

that emphasize primary care have better health status among The book reviewed in this issue of the Journal [1] epitomizes their populations than specialist-dominated systems [12–14]. the state of the art of quality measurement in general practice. Most currently available disease-specific quality indicators Currently available quality indicators are based on a mix do not capture the added value [6] of these generalist funcof scientific evidence and expert opinion. Indicators assess tions. Fortunately, measures are now available that begin to processes of care that have been found to be associated with assess the processes of generalist practice [15–22]. Several of markers of patient outcomes. these are based in part on the Institute of Medicine definition Quality of care measures and clinical indicators are typically of primary care [7]. These processes include the domains criticized for the limitations of the scientific evidence on of comprehensiveness, coordination, continuity, accessibility, which they are based and for their strong reliance on what communication, advocacy, family, and community orientation can be measured [2–4]. However, an even more fundamental and integration of care. They also comprise the quality of issue is important to developing indicators of the quality of the relationship, as assessed by trust, accumulated knowledge, general practice. This larger issue is the problem of the parts duration of relationship, and the patient’s preference for the and the whole—that is, indicators of the quality of care for regular clinician. A growing body of inquiry shows the effect specific diseases may not adequately represent the quality of of these domains on the process and outcome of care [15, care for the whole person. 17,23–26]. This is a particular issue in assessing general practice, in In order to capture the quality of general practice, both which patients often present for care of multiple problems disease-specific indicators and measures of the integrative, [5] that span different acute and chronic illnesses, prevention, prioritizing, relationship-centered functions are needed. Fomental health, and family care [6]. The illness presentations cusing quality measurement and improvement efforts only in general practice are often non-specific and undifferentiated on disease-specific measures misses much of what is uniquely [7], and much of the quality of practice involves defining the important about general practice, and may have unintended problem to be addressed. In addition, general practice often detrimental consequences by devaluing fundamental aspects requires prioritizing the most important issue(s) to address of the generalist approach that are essential to its success. within the context of personal knowledge and an ongoing Quality indicators are likely to foster optimal quality of relationship [8]. Quality indicators, as currently configured, care only if disease-specific and general processes of care are are helpful with aspects of primary care that relate to the assessed and valued. This dual focus will minimize unintended care of an individual disease or problem, once it has been negative consequences of the application of quality indicators, defined, and once it is prioritized as the most important issue and will stimulate additional research on the prioritizing to address with a particular patient at a particular time. As function of general practice, which is not adequately assessed a result, current quality indicators may be a more fitting by currently available indicators. It is necessary to simrepresentation of the quality of specialty practice, which ultaneously focus on both the parts and the whole. typically focuses on providing care for specific diseases.

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عنوان ژورنال:
  • International journal for quality in health care : journal of the International Society for Quality in Health Care

دوره 14 4  شماره 

صفحات  -

تاریخ انتشار 2002