Assessing the quality of care

doi:10.1136/bmj.311.7008.766

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Huw T O Davies,
Iain K Crombie

Research fellow Reader Department of Epidemiology and Public Health, University of Dundee, Ninewells Hospital and Medical School, Dundee DDI 9SY

Measuring well supported processes may be more enlightening than monitoring outcomes

Everyone wants information on clinical outcomes.1 These measures have an intuitive appeal: high quality care should be reflected by good outcomes. Therefore, poorer outcomes should indicate deficiencies in care, including missed opportunities or wasted resources. The hope is that data on outcomes will provide a barometer for health care, indicating the effectiveness and efficiency of service delivery.

Many purchasers are pushing to include outcomes criteria in their contracts as a means of assessing effectiveness. In clinical audit, measurement of outcome is generally considered superior to audits that simply assess the process of care.2 But perhaps this emphasis on outcomes is being overplayed. Are outcomes data always so enlightening?

Outcome measures have a major weakness: interpretation. Suppose a hospital reported that patients admitted with coronary heart disease in 1994 had a 30 day mortality of 25%. This can be interpreted only by comparison with …