The objective assessment of the quality of hospital care: dream or reality?

One of the hottest topics of the international journals is the question: what is the effect of the public indicator-based quality assessment on the quality of care and on the decision of stakeholders, and which criteria should be applied for development of public quality assessment system. According to the international literature the paper discusses 6 topics: (1) the ability of indicators to distinguish providers from the point of view of quality; (2) the appropriateness of outcome indicators to assess providers; (3) the ability of league tables to rank providers; (4) the people's behaviour during choosing providers; (5) the impact of indicator-based public report; (6) recommendations for developing quality assessment system. Based on the literature review, the ability of indicators in distinguishing providers from the point of view of quality is doubtful primarily because of risk-adjustment problems. Other reasons are: the outcomes of care do not definitely refer to the quality of care process; the rankings of providers (league tables) based on more indicators are not reliable; people take into account mainly distance and the opinions of acquaintance when they choose providers; as a result of public reports the overall quality of care is declining. The publication of the results of measurement to assess providers has to be considered as a tool. For the purpose of helping people in choosing providers, the publication of patient satisfaction survey designed according to their preferences could achieve the desired effect. The quality improvement aims are definitely helped by the direct feedback to providers about the indicator values. Furthermore, much finer picture can be made if the standardized audits of care and organisational processes are inserted into external assessment procedures.     

Judging the quality of care at the end of life: can proxies provide reliable information?

A major challenge in research into care at the end of life is the difficulty of obtaining the views and experiences of representative samples of patients. Studies relying on patients' accounts prior to death are potentially biased, as they only represent that proportion of patients with an identifiable terminal illness, who are relatively well and therefore able to participate, and who are willing to take part. An alternative approach that overcomes many of these problems is the retrospective or 'after death' approach. Here, observations are gathered from proxies, usually the patient's next of kin, following the patient's death. However, questions have been raised about the validity of proxies' responses. This paper provides a comprehensive review of studies that have compared patient and proxy views. The evidence suggests that proxies can reliably report on the quality of services, and on observable symptoms. Agreement is poorest for subjective aspects of the patient's experience, such as pain, anxiety and depression. The findings are discussed in relation to literature drawn from survey methodology, psychology, health and palliative care. In addition to this, factors likely to affect levels of agreement are identified. Amongst these are factors associated with the patient and proxy, the measures used to assess palliative care and the quality of the research evaluating the validity of proxies' reports. As proxies are a vital source of information, and for some patients the only source, the paper highlights the need for further research to improve the validity of proxies' reports.     

Proxy assessment of quality of life in patients with prostate cancer: how accurate are partners and urologists?

OBJECTIVES: To assess the ability of partners and clinicians to make proxy judgements on behalf of patients with prostate cancer relating to selection of life priorities and quality of life (QoL). DESIGN: 47 consecutive patients with histologically proven adenocarcinoma, and their partners, were recruited. The partners were asked to assess, by proxy, the QoL of the patient by completion of a series of interview-led questionnaires assessing global QoL (SEIQoL-DW), health-related QoL (FACT-P) and overall QoL (visual analogue score [VAS]). The patients' clinicians were asked to complete the SEIQoL-DW and VAS by proxy as soon as possible after a consultation with the patient. SETTING: Patients with histologically proven adenocarcinoma, their partners and their clinicians. MAIN OUTCOME MEASURES: Proxy scores for SEIQoL-DW, FACT-P and VAS, as provided by partners and clinicians. RESULTS: 25 partners made a proxy assessment of the patients. The results showed that partners were able to select similar QoL cues to those of the patients (Spearman-Rank correlation 0.89). Comparison of the QoL scores obtained from patients and partners in proxy using the questionnaires showed no statistically significant difference (paired t-test). Urologists were poor predictors of areas of life (cues) that were important to their patients. The doctors overemphasized the importance of survival, postoperative complications, urinary symptoms, sexual ability, activities of daily living and finance, but underestimated the importance of wife, family, home and religion. Comparison of the QoL scores obtained from patients and urologists by proxy showed a significantly lower score when assessed by urologists using the SEIQoL-DW questionnaire. CONCLUSIONS: Partners are able to accurately assess, by proxy, the areas of life that are of importance to patients. Clinicians, however, who are charged with making decisions on behalf of patients, are very poor judges of their patients' life priorities and QoL. This illustrates that conventional views held by most doctors regarding the priorities patients set themselves when planning treatment should be called into question and consequently suggests that the way in which doctors and patients arrive at treatment decisions must be reviewed.     

Surrogate end points of quality of life assessment: have we really found what we are looking for?

Outcome research is a new interesting field in medical research. Some years ago, a document of the American Society of Clinical Oncology distinguished the outcomes of a treatment into patient-outcomes (overall survival and quality of life) and cancer-outcomes (response rate), giving higher priority to patient outcomes. This document is one of the best structured instruments to evaluate and classify the outcomes in clinical oncology. Nevertheless, although overall survival and quality of life represent the main patient outcomes in clinical oncology, in the last years many researchers tried to overcome these recommendations, creating new surrogate end points to assess overall survival and quality of life. Surrogate end points can be useful tools when they are used to achieve preliminary data that anticipate the evaluation of the final outcome, but the use of surrogate end points instead of the main outcomes is quite dangerous, as it can provide wrong answers to clinical questions. The use (or abuse) of surrogate end points of quality of life has recently favoured some questionable decisions of the main regulator organs, such as the approval by the Food and Drugs Administration of the use of gemcitabine in advanced chemotherapy-naive pancreatic cancer, or mitoxantrone in the palliative treatment of hormone-resistant pancreatic cancer, based on the improvement in clinical benefit (a non-validated instrument to evaluate the outcome of palliative chemotherapy) besides a minimal and questionable overall survival, or pain control (evaluated with a non-validated instrument). A correct use of surrogate end points of quality of life within and not instead of quality of life assessment should be the engagement of our further efforts in quality of life research.     

Disparities in the prevalence of cognitive delay: how early do they appear?

Cognitively delayed children are at risk for poor mental and physical health throughout their lives. The economically disadvantaged and some race/ethnic groups are more likely to experience cognitive delay, but the age at which delays first emerge and the underlying mechanisms responsible for disparities are not well understood. The objective of this study was to determine when sociodemographic disparities in cognitive functioning emerge, and identify predictors of low cognitive functioning in early childhood. Data were from 7308 singleton and 1463 multiple births in the Early Childhood Longitudinal Study‐Birth Cohort (ECLS‐B), a nationally representative cohort of children born in the USA in 2001. Multiple logistic regression analyses examined associations between sociodemographic characteristics and low cognitive functioning at 9 and 24 months, and tested whether gestational and birth‐related factors mediate these associations. Sociodemographic characteristics were statistically significant predictors of low cognitive functioning among singletons at 24 months, including the three lowest quintiles of socio‐economic status [lowest quintile, odds ratio (OR) = 2.7, 95% confidence interval [CI][1.7, 4.1]], non‐white race/ethnicity (African American OR = 1.8 [95% CI 1.3, 2.5], Hispanic OR = 2.3 [95% CI 1.6, 3.2]), and gender (male OR = 2.1, [95% CI 1.7, 2.5]). Gestational and birth characteristics associated with low cognitive function at 9 months included very low and moderately low birthweight (OR = 55.0 [95% CI 28.3, 107.9] and OR = 3.6 [95% CI 2.6, 5.1]), respectively, and very preterm and moderately preterm delivery (OR = 3.6 [95% CI 2.0, 6.7] and OR = 2.4 [95% CI 1.7, 3.5]), respectively, but they had weaker effects by 24 months (ORs for birthweight: 3.7 [95% CI 2.3, 5.9] and 1.8 [95% CI 1.4, 2.3]; ORs for preterm: 1.8 [95% CI 1.1, 2.9] and 0.9 [95% CI 0.7, 1.3]). Results for multiple births were similar. Sociodemographic disparities in poor cognitive functioning emerged by 24 months of age, but were not mediated by gestational or birth characteristics. Further investigation of processes whereby social disadvantage adversely affects development prior to 24 months is needed.     

To bin or not to bin? A comparison of symptom frequency response formats in the assessment of health-related quality of life

Quality of Life Research - The goal of this study is to compare three different types of retrospective frequency response formats on the Healthy Days Symptoms Module (HDSM). Responses are compared...     

Clarifying concerns about doctors' clinical performance: what is the contribution of assessment by the National Clinical Assessment Service?

PURPOSE: The UK National Clinical Assessment Service (NCAS) provides local NHS bodies with advice and support in relation to concerns about individual doctors and dentists and in some cases also conducts a detailed assessment of practitioner performance. The purpose of this paper is to identify the contribution of NCAS performance assessment to clarifying concerns about clinical performance through comparison of concerns suspected at initial referral with those identified at assessment. DESIGN/METHODOLOGY/APPROACH: In the paper a sample of 50 NCAS medical cases, performance issues reported at the point of referral to NCAS and those identified at assessment were grouped into five broad domains (clinical care, behaviour, health, education and training, organisation). Concerns identified at assessment were compared with those reported at referral for each domain of concern. Conclusions and recommendations following assessment were also reviewed. FINDINGS: Within each domain, some concerns noted at referral were confirmed; others were challenged or redefined. In all areas, but particularly in respect of the work environment, new concerns were identified for the first time at assessment. In 20 percent of cases, the concerns identified at referral were not borne out at assessment. In 12 percent of cases the issues revealed at assessment were more serious than anticipated. PRACTICAL IMPLICATIONS: Findings indicate that the NCAS assessment process provides a more accurate and comprehensive "diagnosis" of performance issues, enabling more appropriate recommendations for "treatment" and helping to differentiate between potentially remediable and more fundamental problems. ORIGINALITY/VALUE: There is currently little published evidence about the contribution of this type of performance assessment programme to clarifying performance issues.     

Assessing health-related quality of life following myocardial infarction: is the SF-12 useful?

We report on the responsiveness of the SF-12 to changes in quality of life following acute myocardial infarction. Scores at 1, 6, 12, and 24 weeks postdischarge were compared with pre-MI health. Statistically significant differences and standardized response means were examined. Results were compared with the SF-36 subscales and previous reports. Respondents (n = 65) reported the expected poorer physical health at every follow-up, while expected changes in emotional health were observed at 6 but not 24 weeks. Comparison with the SF-36 subscales showed that although the SF-12 reflected the expected pattern of physical health, the summary score obscured an important association between perceptions of general health and participation in usual activities. This information is relevant for developing and evaluating rehabilitation interventions and self-managed recovery following MI. The SF-12 scores obscure important distinctions between quality of life domains, and are therefore not recommended for use following acute MI.     

How much do doctors use quality of life information in primary care? Testing the Trans-Theoretical Model of behaviour change

This study aimed to find out whether General Practitioners (GPs) use quality of life (QOL) information in primary care, to explore their reasoning and to assess any barriers to use. A second purpose was to see whether the Trans-Theoretical Model (TTM) of behaviour change could be applied to doctors use of QOL information in primary care. A representative, cross-sectional sample of 800 GPs was approached in a national postal survey; 280 (38%) provided qualitative and quantitative information. Most GPs said that QOL was interesting and important. Users had seen more information and scales, and were more aware of its uses; only 8% had ever used formal standardised questionnaires. The main barriers to implementation were a shortage of time and information, and experience with using QOL assessment. A sizable minority wanted to know more. Seventy-one percent would use QOL to monitor treatment effectiveness. The five stages of the TTM were used to identify whether GPs were predisposed to use QOL information from their knowledge levels and values. While there was some support for the model, the TTM did not sensitively and reliably discriminate between users and non-users on all variables, and so has limited value here.     

How do psychological characteristics of family members affected by substance use influence quality of life?

Quality of Life Research - Addiction is a major health stressor for families, representing an under-researched area with important policy implications. The current aim was to validate the Composite...     

Predictors of health-related quality of life in Parkinson’s disease: the impact of overlap between health-related quality of life and clinical measures

Quality of Life Research - This study aimed to determine predictors of health-related quality of life (HRQoL) in Parkinson's disease (PD) and to explore their predictive value before and after...