What is the quality of quality of medical care measures? Rashomon-like relativism and real-world applications

Much attention has been directed toward the measurement of health outcomes and the quality of medical care. Some policymakers tout outcomes measurement as a promising tool for improving health care, while others question whether current quality of care assessment is valid and of practical importance. Although significant advances have been made in the ability to measure quality of care with validity, several major methodological challenges remain. We analyze the quality of quality of medical care measures, using a conceptual framework that outlines the purpose of the measures; paradigms of the quality of care, including Donabedian's structure-process-outcome model and continuous quality improvement; and other key elements, such as scope, time, unit of analysis, and perspectives. Patient preferences and organizational contexts have been underemphasized, and should be incorporated into the framework for conceptualizing quality of care. Quality of care has relativistic and dynamic aspects. Different perspectives lead to different views of what high quality care is, and quality of care is a changing concept since medical science and treatment are constantly evolving. The most appropriate quality measures depend upon whose perspective one takes and the purpose of the measures; if the measures are chosen wisely, the current state of quality of medical care measurement is adequate for both accountability and quality improvement.     

Maya mobile medicine in Guatemala: the "other" public health

Maya mobile medical providers in highland Guatemala and the goods and services that they offer from "soapboxes" on street corners, local markets, and on buses exemplify an important yet underinvestigated domain of localized health care, one that I refer to as the "other" public health. This medical and linguistic examination of traveling medical salespeople calls for a reconsideration (on a global scale) of what has come to be understood as "public health," arguing that "othered," local forms of public health that are often overlooked by anthropologists as "nontraditional" and delegitimized by bio-medicine as nonscientific merit serious consideration and investigation. This ethnography of marginalized forms of public health offers global insights into emerging heterodoxical forms of public health care that contest bio-medical authority and challenge our preexisting definitions of what counts as "access," wellness seeking, and even health care itself.     

The problematization of medical tourism: a critique of neoliberalism

The past two decades have seen the extensive privatisation and marketisation of health care in an ever reaching number of developing countries. Within this milieu, medical tourism is being promoted as a rational economic development strategy for some developing nations, and a makeshift solution to the escalating waiting lists and exorbitant costs of health care in developed nations. This paper explores the need to problematize medical tourism in order to move beyond one dimensional neoliberal discourses that have, to date, dominated the arena. In this problematization, the paper discusses a range of understandings and uses of the term 'medical tourism' and situates it within the context of the neoliberal economic development of health care internationally. Drawing on theory from critical medical anthropology and health and human rights perspectives, the paper critically analyzes the assumed independence between the medical tourism industry and local populations facing critical health issues, where social, cultural and economic inequities are widening in terms of access, cost and quality of health care. Finally, medical tourism is examined in the local context of India, critiquing the increasingly indistinct roles played by government and private sectors, whilst linking these shifts to global market forces.     

Health Care in Modern Cuba

An extensively organized, centrally controlled system, aimed at equalizing and improving the distribution and quality of medical services according to population and geography, characterizes the modern Cuban health care complex. Facilities of increasing sophistication are located in urban areas while an expanding series of ambulatory, multipotential polyclinics attempts to provide most health services in both urban and rural settings.Maternal and child care, immunization programs and other forms of preventive medicine represent major priorities for expenditures. Occupational health is increasingly understood as a valuable resource, and medical professionals on all levels are being trained in significant numbers for Cuba and its allies.     

Socio-Economics of Medical Care, Report of Bureau of Research and Planning

Interest in the area of medical socio-economics has largely come about due to the proliferation of social welfare programs and advances in the distribution of health services in the private sector of the economy. The increasing role of our government has also been a stimulus. With the advent of new techniques for the financing of care, a large volume of institutional literature has appeared delving into issues which range from the role of the medical profession in the evaluation of quality of medical care to the measurement of demand for and prepayment of numerous types of health care services. Since the area of medical socio-economics is not considered "pure" enough to be categorized as a discipline, the range of periodicals, government and non-government publications and books, in which data are found, is vast. This report will briefly describe some of the more important sources of data in the area of medical socio-economics. Major emphasis is given to the literature which provides current statistical data on the operational aspects of public and private programs providing health care services, and ancillary activities which affect the market for health care activities. Leading publications of governmental and other community agencies are cited to illustrate the range of materials available to the public and to the medical profession.     

医保体制下过度医疗的成因与控制策略分析

随着新一轮医改的不断深入,我国初步建立了一套适合我国国情的基本医疗卫生体系及医疗保障制度。伴随着医疗卫生事业的蓬勃发展,医疗费用也随之出现了快速增长,过度医疗是导致医疗费用快速上涨的重要原因之一。本文从需方、供方、医疗体制三方分析了其产生的原因,并探讨了国外开展的医疗费用控制对医疗市场参与主体的影响。最后,针对医疗市场自身必须适应国情、适合社会发展阶段的特点,为我国实现新医改目标提供了一些建设性的意见。     

甘肃康乐县基层卫生机构门诊临床路径管理探讨

为了有效发挥基层医疗卫生机构健康“守门人”职能,康乐县借助卫XI项目支持,积极开展基层医疗卫生机构门诊临床路径管理探索,有效发挥了新农合与定点医疗机构管理的协同作用,实现了医疗质量提高与费用控制的有效结合,并在规范诊疗行为、减低医疗服务成本、改善医患关系等方面发挥了积极作用。

     

Larger private-sector role in health care needed now,think tank warns.

The Fraser Institute, a conservative think tank based in Vancouver, has called for the establishment of a parallel private health care sector to relieve pressure on the public system, encourage the development of medical technology, stimulate the economy and create jobs. The proposal includes establishment of competition by separating the roles of purchaser and provider of health care, and the creation of a medical premium account for each Canadian that would be funded by government but apportioned by the patient.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

Assessment of the Quality of Antenatal Care Services Provided by Health Workers Using a Mobile Phone Decision Support Application in Northern Nigeria: A Pre/Post-Intervention Study

BackgroundGiven the shortage of skilled healthcare providers in Nigeria, frontline community health extension workers (CHEWs) are commonly tasked with providing maternal and child health services at primary health centers. In 2012, we introduced a mobile case management and decision support application in twenty primary health centers in northern Nigeria, and conducted a pre-test/post-test study to assess whether the introduction of the app had an effect on the quality of antenatal care services provided by this lower-level cadre.MethodsUsing the CommCare mobile platform, the app dynamically guides CHEWs through antenatal care protocols and collects client data in real time. Thirteen health education audio clips are also embedded in the app for improving and standardizing client counseling. To detect changes in quality, we developed an evidence-based quality score consisting of 25 indicators, and conducted a total of 266 client exit interviews. We analyzed baseline and endline data to assess changes in the overall quality score as well as changes in the provision of key elements of antenatal care.ResultsOverall, the quality score increased from 13.3 at baseline to 17.2 at endline (p<0.0001), out of a total possible score of 25, with the most significant improvements related to health counseling, technical services provided, and quality of health education.ConclusionThese study results suggest that the introduction of a low-cost mobile case management and decision support application can spur behavior change and improve the quality of services provided by a lower level cadre of healthcare workers. Future research should employ a more rigorous experimental design to explore potential longer-term effects on client health outcomes.     

Wall Street's growing influence on plastic surgery

The advent of managed care has unleashed market forces on the health care system. One result of these new pressures is a shift from nonprofit to Wall Street-based financing. This report quantifies these trends by comparing health organizations' financial structures in the 1980s and now. The reasons behind this shift and the function of the stock market are examined. A review of Wall Street's key financial measures confirms that health care has shifted to the stock market as its principal means of financing. The stock market works by assigning a current price to a company's stock based on estimates for future earnings. Thus, companies desire predictability in their costs, revenues, and profits. Plastic surgeons can master this system by meeting the challenges imposed by Wall Street financing. Important steps include continuously measuring costs and outcomes of procedures, demanding cost data from hospitals and payers, using these data to improve costs and outcomes, and taking advantage of the system's openness to innovation and easier access to capital. As they seek to protect their role as medical decision makers under the new free-market system, plastic surgeons can benefit from understanding the mechanisms of the stock market.     

积极的防护意识与健全的防护体系在传染病医院内的影响与效应

目的:通过提高防护意识和进一步完善防护体系实现对传染病医院的全面管理.方法:随机将我院2009年3月至2011年11月的两个病区患者及医护人员作为研究对象,向所有患者发放调查表对政策调整前后的满意程度进行调查,通过针对医护人员防护意识的强化教育和医院设施及防护体系的调整与完善以评估对患者住院期间的临床效应与影响.结果:全院上下的积极防护意识普遍增强并完善健全了防护体系,从而显著降低了感染率,患者满意度反馈良好.结论:通过提高医护人员防护意识和健全医院防护体系有助于进一步减少院内感染,提高医院医疗质量和服务水平.     

Improving communication skill training in patient centered medical practice for enhancing rational use of laboratory tests: The core of bioinformation for leveraging stakeholder engagement in regulatory science

Requests for laboratory tests are among the most relevant additional tools used by physicians as part of patient''s health problemsolving. However, the overestimation of complementary investigation may be linked to less reflective medical practice as a consequence of a poor physician-patient communication, and may impair patient-centered care. This scenario is likely to result from reduced consultation time, and a clinical model focused on the disease. We propose a new medical intervention program that specifically targets improving the patient-centered communication of laboratory tests results, the core of bioinformation in health care. Expectations are that medical students training in communication skills significantly improve physicians-patient relationship, reduce inappropriate use of laboratorial tests, and raise stakeholder engagement.     

Reforming the NHS reforms.

Rather than improving efficiency, the reforms imposed on the NHS have increased bureaucracy, reduced patient choice, limited the range of core services, and led to inequity of treatment. In this paper I examine how the medical profession might help to solve these problems. Priorities must be set for health care since no government can afford all the possibilities offered by medical science. It is essential to forge a consensus of patients, carers, professionals, the public, and government if a system of priorities is to be equitable and just. We also need to be able to measure quality of outcome in health care. This requires consensus on what is the desired outcome and the development of appropriate guidelines, audit, and performance review. This is primarily a task for the health professions supported by management and by adequate investment. Basically, the government must reinstate the three traditional values of the NHS--equity, consensus, and regard for representative professional advice.     

The quality of health care in prison: results of a year's programme of semistructured inspections.

OBJECTIVES: To assess, as part of wider inspections by HM Inspectorate of Prisons, the extent and quality of health care in prisons in England and Wales. DESIGN: Inspections based on a set of "expectations" derived mainly from existing healthcare quality standards published by the prison service and existing ethical guidelines; questionnaire survey of prisoners. SUBJECTS: 19 prisons in England and Wales, 1996-7. MAIN OUTCOME MEASURES: Appraisals of needs assessment and the commissioning and delivery of health care against the inspectorate''s expectations. RESULTS: The quality of health care varied greatly. A few prisons provided health care broadly equivalent to NHS care, but in many the health care was of low quality, some doctors were not adequately trained to do the work they faced, and some care failed to meet proper ethical standards. Little professional support was available to healthcare staff. CONCLUSIONS: The current policy for improving health care in prisons is not likely to achieve its objectives and is potentially wasteful. The prison service needs to recognise that expertise in the commissioning and delivery of health care is overwhelming based in the NHS. The current review of the provision of health care in prisons offers an opportunity to ensure that prisoners are not excluded from high quality health care.     

医疗服务分档评估指标体系评分标准的制订

医疗服务创造了人类健康价值,是社会繁荣的前提和基础,其价格水平影响基本医疗服务的可及性和公平性。研究在前期以不同等级非营利性医疗机构为研究对象,建立了一套科学、有效、全面、可行的综合反映医疗服务分档的评估指标体系,为医疗服务分档定价提供参考依据。将针对医疗服务分档评估指标体系制定相应的评分标准。     

Health Data and the Physician

California Health Data Corporation was formed to create better health data resources under the direction of hospitals and medicine. Highest priority is being given to developing information systems that will serve physicians, as well as those who are usually considered health data users. This is illustrated in CHD''s first major activity, sponsorship of a medical record information system for California hospitals. This system is designed first of all to provide better information for medical staff committees, and as a byproduct to provide data flow into a CHD data bank. For the practicing physician, the significance of CHD is that the organization will attempt to develop information systems that will help the medical profession maintain its central role in guiding the present and future patterns of health care.     

Influence of health care systems on the market for picture archiving and communication systems

An analysis is given of the relation between health care systems and the PACS market. Two driving forces exist in the market: quality and price. It is argued that the quality driven market is mainly independent of the health care system and will be the force that drives the introduction of the health care system and will be the force that drives the introduction of PACS in the forthcoming years. Finally a change of focus is suggested from only archiving and communication to a more general concept of image networking, serving more goals than only the goal of working filmlessly.