Even though it is talked and written about incessantly, quality health care has no readily available, accepted, and specific definition. For many, quality health care is like beauty or pornography—they know it when they see it but they just can't define it. Yet, a widely accepted and specific definition of quality health care is required for its assessment and promotion, and a lack of this definition makes these impossible. The sum and substance, then, is “What is an acceptable and specific definition of quality health care?”
Quality cannot be measured. A “measured quality” is a quantity and no longer a quality. What we can measure are attributes that are consistently (but not invariably) associated with quality. In this sense, outcomes measurement is an approach to defining quality health care. Outcomes measurement assumes that consistently good outcomes can come from only quality health care. We know now (such as with the use of antibiotics for influenza) that this is not necessarily true. So, good outcomes are insufficient to define quality health care.
Another approach is evidence-based medicine. Its proponents hold that if processes proven by clinical studies are widely applied, predictable outcomes can be expected. These processes and outcomes combined would then define quality health care. The problem with evidence-based medicine is that there is no evidence that evidence-based medicine improves outcomes or delivers quality health care to other than the study population. This is because evidence-based medicine is grounded in clinical studies that purposely exclude many participants to gain homogeneous study populations. These studies are then applied to widely heterogeneous general populations, most of whom would not have qualified to participate in the study being applied. The results are then expected to be the same. There is no evidence that this is so. Hence, until there is evidence that it improves outcomes in the general populations, evidence–based medicine cannot define quality health care.
A third methodology for assessing quality health care is measuring patient satisfaction. Due to the complex science and art of health care, patients can determine satisfaction only with their provider interactions and the outcome. Patients cannot know if the services received were indicated or whether they had anything to do with the outcome. For example, many patients still demand antibiotics for influenza since their use by a trusted provider in the past had “improved” their outcomes. It's hard to overcome “success” even if misattributed. Thus, a patient satisfaction-based definition of quality health care is fallacious and wrought with errors.
Another problem with the above approaches is that they are based on patient populations, and their applicability to individual patients is unknown. Whereas percentage response, success, satisfaction, etc. hold true for study populations, these statistics do not hold true for individuals. For individuals, the relevant statistics are either zero or 100%: they respond or don't; they live or die; they are satisfied or not. Generally, there is nothing in these methodologies that determines who (i.e., which specific individual) in a study population is the responder, survivor, etc. Consequently, these methodologies are relatively useless when practiced prospectively at the individual patient's side. Paradoxically, these approaches are used retrospectively in individual cases by quality improvement committees to conclude poor-quality health care. These committees forget that hindsight is infinitely superior to foresight.
For the reasons given above, a specific quality health care definition must be usable at the patient's side, and, in spite of major gaps, must incorporate as much medical science as may be relevant. The following specific definition developed during 25 years of medical practice and teaching has proven useful in assessing and promoting quality health care:
The health care delivered must be indicated and efficacious for both the specific and general condition(s) present.
The risk-to-benefit ratios must be reasonably minimized.
The health care delivered must be cost efficient.
Patient expectations must be met.
The amount of indicated and not efficacious health care delivered is remarkable and disconcerting. Antibiotics for viral syndromes, unproven or outmoded therapies, unsubstantiated off-label drug use, and new procedures with unknown efficacy are just some. As remarkable and distressing is the amount of indicated and efficacious care for specific conditions that completely ignores the usually more significant general condition(s). Advanced life-support interventions indicated for specific conditions are not uncommon in patients terminally ill and near death from their general condition(s). Since the overall benefit of such care is generally zero, the general risk-to-benefit ratio is maximized, i.e., infinite!
That risk-to-benefit ratios must be reasonably minimized is a given. Nevertheless, it needs to be kept in mind that being more aggressive or invasive is sometimes less risky than being conservative or noninvasive. Spinal anesthesia may be riskier than general anesthesia. Not mechanically ventilating an early ventilatory failure patient may be riskier than treating the patient without interventions. Also, it is the patient's risk-to-benefit assessment—not the provider's—that must determine the health care delivered.
Cost efficiency means, for example, that if treatment can be provided for $500, spending $1000 doesn't make it better. The major culprit in cost inefficiency is the location of service, with too many services still being provided in hospitals. Many of these services can be provided as easily, more conveniently (for the patient), and possible more safely at alternative, more cost-efficient locations. Too frequently the choice of treatment location is for the convenience of the provider. The economic costs of these provider conveniences are staggering.
Finally, meeting the patient's expectation is an absolute requirement. This means being completely honest with patients. This honesty includes informing patients that their expectations cannot be medically met when they cannot, informing patients that there is no indicated and efficacious health care when there is none, and informing patients that treatment of specific conditions will not change the ultimate outcome due to the general condition(s). It means helping a patient decide if the risks are worth the benefits using the patient's value system. Finally, it includes leading and facilitating dying according to the patient's death wishes. Complete honesty with patients is heroic and requires acts of courage. Honesty checks should be part of our own medical documentation evaluation. If we read what we document and it is not completely honest, we should go back to the patient (or proxy) and try again.
Regardless of what methodology or definition of quality health care is used, it must be kept in mind that every patient is different. Thus, mass customization of health care rather than novelty health care for each patient is the key to achieving quality. Ultimately, the answer to the question “Should it be done?” rather than “Can it be done?” will determine what quality health care is and is not.
Footnotes
The views expressed in this commentary are solely those of the author and do not reflect those of CIGNA or its divisions or subsidiaries.