INTRODUCTION

For some time, physicians and other medical professionals have assessed the performance of their peers. From Florence Nightingale in the field hospitals of the Crimean War to E.A. Codman in surgical wards of Boston during the early twentieth century and Osler Peterson among general practitioners in North Carolina after World War II, medical professionals motivated by a deep concern for their patients' welfare have strived to measure the quality of medical care so that providers could improve it. Along with medical professionals, concerned people from fields such as statistics, politics, and religion have pioneered techniques to evaluate the efficacy and safety of technologies, and, in turn, the quality of medical care (628).

Quality assessments have customarily taken the perspective of the medical provider. Recent events, however, have promoted consumers' role in evaluating providers and making decisions about medical care. Efforts to advance consumers' interests are occurring throughout society, and the changing role of consumers within medical care reflects this societal trend. The increased emphasis on consumers also reflects the influence of strategies to increase price competition in medical care. People have always had a legitimate in

terest in the quality of their medical care. But recent policy changes have created a milieu in which the consumers and providers of medical care have become more sensitive to price. In that milieu, information about the quality and cost of care is needed by consumers to aid them in selecting physicians and hospitals.

Given that context, it is important to examine the perspective of individual consumers on the quality of medical care. Do consumers' needs and concerns differ from those of medical providers in ways that should be taken into account in the design and content of quality assessments? This chapter explores that question. The chapter first develops a definition of the quality of medical care that incorporates its many dimensions. In a section presenting a framework for assessing quality from an individual consumer's perspective, the chapter describes the progression of a patient through the spectrum of medical care. Then it discusses approaches to assessing quality and aspects of medical care that affect health and patient satisfaction and presents possible indicators of quality. The chapter concludes with a discussion of the indicators selected for evaluation in this report.

Like other intangible concepts, the quality of medical care is difficult to define. Indeed, quality acquires concrete properties only when one measures it. But attempts to define quality in the medical field are plagued not only by the abstract nature of quality but also by particular characteristics of medical care.

Medical care is intended to promote, maintain, and restore health (186). Although the purpose

of medical care is to help patients, appropriate care and desirable outcomes vary tremendously depending on the individual patients' circumstances. Healthy infants require immunizations to prevent once-common childhood diseases and ultimately to lengthen their lives. Screening during infancy and adulthood may detect conditions that treatment can correct or ameliorate. Throughout life, treatment may cure acute conditions and relieve the symptoms of chronic ones. Medical

care may also help people deal with their physical and emotional problems. For people facing death or intractable conditions, medical care may offer palliative measures that reduce suffering and help people to die with dignity. Thus, the appropriate content of medical care stretches from the prevention of illness to diagnosis, rehabilitation, counseling, and other therapy, and desirable outcomes of care range from reduced illness, deterioration, and pain to increased longevity, mobility, and emotional well-being. And all of the activities and outcomes of care presume that people seeking care, especially in emergencies, promptly reach providers who can manage their conditions.

To a large extent, the diversity of acceptable outcomes for patients reflects the many dimensions of health. According to the definition of health adopted by the World Health Organization: "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (718). This definition stresses the positive aspects of health while incorporating the notion that health relates to physical functioning, mental health, and social functioning.

Noting the complexity of medical care, prominent scholars have stressed the importance of evaluating both its technical and interpersonal aspects. Technical care is the application of medical science and technology to a problem; and interpersonal care or the art of care refers to the personal interaction between patient and medical care provider (105,183). In practice, the technical and interpersonal aspects of care are intertwined; sensitivity and caring enter into technical care, and technical expertise is part of interpersonal care. Both these aspects deserve attention in evaluations of the medical care that patients receive.

Besides taking into account the many dimensions of medical care and health outcomes, a definition of the quality of medical care must recognize the limits and continuing evolution of medical knowledge. Medical knowledge and its application in medical technology cannot guarantee improvement in a patient's health. At best, medical care applied appropriately can improve the likelihood that a patient will get better. Rarely is a medical technology 100-percent efficacious. The use

of medical technology also carries some risk, and this must be weighed against the likely benefit.

The probabilistic nature of patient outcomes flows from the variation in patients, providers, and environments. Even medical technologies found to be efficacious for treatment populations in the ideal circumstances of randomized clinical trials may not benefit a particular patient. Patients' physical and emotional conditions differ in ways that affect treatment results, and these differences may be unknown or unpredictable when medical decisions are made. Another point relevant to the quality of hospitals and physicians is that providers themselves vary in ways that may affect what happens to patients' health.

In a larger sense, the uncertainty surrounding patient outcomes stems from the fact that medical care is but one influence on the health of an individual or a population. In fact, an individual's genetic makeup, environment, and lifestyle seem to play a greater role than medical care in

explaining the causes of death and illness that now predominate in the United States.

What is considered appropriate care evolves with advances in medical science and technology. As knowledge continues to expand, some technologies (e.g., gastric freezing for ulcers) become obsolete and should be discarded, and others (e.g., cimetidine) are shown to be efficacious and should be adopted.

Over the years, scholars have taken many different approaches to incorporating these complexities into a definition of the quality of medical care. Quebec's Commission of Inquiry on Health and Social Services (the Castonguay Commission) refused to define quality and commented that "...choosing among the possible definitions of the quality of care leads to rejecting part of reality and to reducing the meaning of quality to one or some of its dimensions" (505). Rather than defining quality, the commission identified how perspectives on quality differ: Producers evaluate technical aspects of services, mostly for care of the sick, but pay scant attention to access or distribution of care; consumers wish a minimum level of technical competence but emphasize more heavily ease of access, continuity and humanization of care, and prevention of disease; and society, from another level, focuses on how care affects the population's health and how the social and economic efficiency of the system conforms to society's priorities.

In a similar vein, Donabedian acknowledged the different views of providers, consumers, and the overall society: Physicians have usually confined their evaluations to technical performance, patients have shown more sensitivity to how they are treated, and society has had more interest than individual providers or consumers in the equitable distribution of medical care and the public health benefits of care, such as prevention of communicable disease (186). But Donabedian also stressed that all view both the technical and interpersonal as important (183).

losses that attend the process of care in all its parts" (183). To the extent that the patient bears the cost of care, Donabedian includes cost in this concept of quality on the grounds that one may add cost, as an unwanted consequence of care, to expected risk in assessing the patient's net benefit. However, Donabedian keeps accessibility, the ease with which care is initiated and maintained, separate from quality.

Although it was not developed specifically for quality assessment, Palmer has used an Institute of Medicine definition of a quality assurance system that also refers to resource constraints: "The primary goal of a quality assurance system should be to make health care more effective in bettering the health status and satisfaction of a population, within the resources that society and individuals have chosen to spend for that care" (475).

Another definition stresses the response to needs and defines quality as "the degree to which health care needs (educational, preventive, restorative, and maintenance) of an individual or group are identified in an accurate, complete, timely manner, and the resources (human and other) necessary to meet these needs are applied in a timely manner and as effectively as current knowledge allows" (524).

This OTA report examines several possible indicators of the quality of care provided by hospitals and physicians, not the quality of care of a managed health care system or the quality of the entire U.S. health system. Reflecting this task and the points discussed above, the report uses the following definition of quality to guide the discussion:

The quality of a provider's medical care is the degree to which the process of care increases the probability of desired patient outcomes and reduces the probability of undesired outcomes, given the state of medical knowledge.

Under this definition, medical care consists of the technical and interpersonal interventions that providers apply to improve patients' health and satisfaction. The quality of medical care delivered by a hospital or physician is judged by the likelihood that the care will achieve the patient outcomes desired, and this likelihood depends on the

relationship between certain medical practices and the effects on patients. Desired and undesired outcomes, comprising positive and negative effects, relate to the many dimensions of health and patient satisfaction. Which ones predominate varies with the individual patient or condition.

The definition of quality of care used in this report incorporates some, but not all, aspects of people's access to care. A host of factorspsychological, physical, social, and economicdetermines whether a particular person decides to seek care for a medical condition. All of these factors relate to the accessibility of care to an individual (i.e., the ease with which a person can gain entry into the medical care system). One important factor is the cost that the person expects to pay, which in turn depends on insurance coverage (or the lack of it) and the provider's charges (386,463).

Although the choice of health insurance coverage and the decision to seek care wield great importance, scholars have usually separated issues of access from those of quality, and this report generally follows that convention. But two aspects of access overlap with quality and have such strong implications for patient outcomes that they are included in this report: providers' responsiveness to urgent or emergency care and providers' referral of patients to the appropriate level of care. Even after a person decides to seek care from a specific provider, barriers may prevent the person from obtaining care or from reaching the appropriate level of care. At the same time, the responsiveness of hospitals and physicians, especially to urgent or emergency situations, may well affect the person's eventual health outcome. The procedures of a hospital or physician may keep the patient from seeing a health professional in a timely manner. A hospital emergency room that transfers a patient in an unstable condition to another institution because the patient lacks insurance may jeopardize the person's health. On the other hand, failure to transfer a high-risk mother or baby to an institution with a higher level neonatal intensive care unit may also jeopardize health.

Most hospitals and physicians practice independently and typically do not assume responsibility for a clearly defined population. It would

not be reasonable to hold these providers responsible for the ease of access perceived by all the people in a certain area, even if barriers had impeded people's access to care and harmed their health. Physicians and hospitals operating as separate units have not had the same responsibility for ensuring that certain facilities and personnel are available as health care systems, such as prepaid group practices. On the other hand, hospitals and physicians have a core group of people who rely on them for care. Once that relationship has been established, it seems reasonable to hold providers responsible for making their services easily accessible to these patients. Moreover, it would be reasonable to include issues of access in evaluating the quality of a health care plan that assumed responsibility for a given population and the quality of a national health care system, which bore responsibility for the country's population.

Excluded from this report's definition of the quality of care are considerations of cost and efficiency. Conceptually, medical care's effects on patients' health and satisfaction differ from its effects on costs. Even more important, however, when making decisions about medical care, consumers, providers, and policymakers weigh the likely health benefits against their costs. Costs indicate what people must forgo in other goods and services in order to obtain the health outcomes that they desire. Indeed, behind recent changes in payment policies has lain the intention of heightening the cost consciousness of consumers and providers who make decisions about using medical services. From a policy perspective, separating cost from quality or health effects permits analysts to monitor any changes in health that occur as costs change and to identify what is being gained or lost. Such information also permits one to evaluate the efficiency of the provider, in this case the use of resources (costs) to achieve a given level of health benefits.1

'In spite of the conceptual distinction between cost and health effects or quality, it is unlikely that peer reviewers will incorporate the distinction into actual assessments of providers' performance. Either implicitly or explicitly, quality assessors develop indications for the appropriate use of a certain procedure, such as coronary artery bypass surgery, or identify medical interventions deemed necessary to manage a particular diagnosis. With the increased cost consciousness in the U.S. medical community, peer reviewers most likely will factor cost as well as health effects into their criteria.