Measuring the quality of health care

This Issue Brief examines some of the issues involved in defining and measuring the quality of health care and in implementing quality measures. It discusses the importance of measures of health care quality in the evolving health care delivery system, examines some of the conceptual issues involved in defining quality of care, and discusses some of the measures of health care quality and how these measures have been implemented in the health care delivery system. The major impetus for quality assurance programs is cost management: it is an attempt to allocate scarce health care resources efficiently. This requires making choices among alternatives, which may mean that maximizing quality of care for whole populations may not maximize the quality of care for individuals. Quality, in terms of any single good or service, has a number of dimensions. Health care is a complex bundle of services, and each component service within an episode of care affects the other components and the patients differently. Moreover, patients differ in numerous ways, which means that similar symptoms may require different services if care is to be effective. Measuring quality of health care services requires accounting for all of these factors. In attempting to manage health care costs, employers and other private health plans have begun to employ process measures of quality, i.e., evaluating caregivers' activities, the decisions made at each step in an episode of illness, and the appropriateness of the care provided. Process is an important component of quality measures because it focuses directly on the uncertainty in the efficacy of treatment. Given this uncertainty, the logic of medical decision making is an important determinant of quality and cost effectiveness. Examining the process of care involves assembling a panel of physicians who review medical records to determine the appropriateness of the care received. Providers have increasingly found that their medical decision making and practice styles are being monitored by purchasers as new health care delivery systems are being formed. The American Medical Association found that 39 percent of surveyed physicians were subject to clinical profiling.     

Diagnosis of cardiovascular disease in women

Cardiovascular disease (CVD, comprising coronary heart disease and stroke) is the leading cause of death in both sexes in developed countries. Although women are nine times more likely to die from CVD than they are from breast cancer, there is a general public belief that the most common cause of death is cancer. The symptoms of acute myocardial infarction and acute coronary syndromes differ between the sexes. Women are less likely to experience chest pain and may have non-specific symptoms. Normal or non-obstructive coronary disease, as detected by angiography, is more common in women. Scintigraphy improves the detection of coronary disease in women. There is an urgent need to increase awareness of both coronary heart disease in women and the limitations of commonly used diagnostic tools.     

Tolerance of Uncertainty: Links to Happenstance,Career Decision Self‐Efficacy,and Career Satisfaction

This study investigated the extent to which tolerance of uncertainty affects the relationship between happenstance skills and career satisfaction via career decision self‐efficacy. Moderated mediation analysis was conducted on data collected from 321 graduates (175 men, 146 women) of Korean universities making the school‐to‐work transition. Results showed that career decision self‐efficacy fully mediated the relationship between happenstance skills and career satisfaction. Furthermore, the moderation effect of tolerance of uncertainty had a significant impact on the relationship between happenstance skills and career decision self‐efficacy. Tolerance of uncertainty should be considered an important variable in happenstance career theory and intervention. Unplanned influences should also be considered important factors in the career decision‐making process.     

Decision Making in Voluntary Career Change: An Other‐Than‐Rational Perspective

The authors present a qualitative study of voluntary career change, which highlighted the importance of positive emotions, unplanned action, and building certainty and perceiving continuity in the realization of change. Interpretative phenomenological analysis was used to broaden theoretical understanding of real‐life career decision making. The accounts of 8 women who had changed careers were explored, and the analysis supported other‐than‐rational perspectives of career decision making. An action‐affect‐cognition framework of decision making is proposed. The framework adds the role of emotion and the importance of self‐regulation to existing theory of career decision making. Implications for career counseling are discussed.     

Measuring societal effects of transdisciplinary research projects: design and application of an evaluation method

Most Transdisciplinary Research (TdR) projects combine scientific research with the building of decision making capacity for the involved stakeholders. These projects usually deal with complex, societally relevant, real-world problems. This paper focuses on TdR projects, which integrate the knowledge of researchers and stakeholders in a collaborative transdisciplinary process through structured methods of mutual learning. Previous research on the evaluation of TdR has insufficiently explored the intended effects of transdisciplinary processes on the real world (societal effects). We developed an evaluation framework for assessing the societal effects of transdisciplinary processes. Outputs (measured as procedural and product-related involvement of the stakeholders), impacts (intermediate effects connecting outputs and outcomes) and outcomes (enhanced decision making capacity) are distinguished as three types of societal effects. Our model links outputs and outcomes of transdisciplinary processes via the impacts using a mediating variables approach. We applied this model in an ex post evaluation of a transdisciplinary process. 84 out of 188 agents participated in a survey. The results show significant mediation effects of the two impacts "network building" and "transformation knowledge". These results indicate an influence of a transdisciplinary process on the decision making capacity of stakeholders, especially through social network building and the generation of knowledge relevant for action.     

The unexpected influence of physician attributes on clinical decisions: results of an experiment

This experiment was designed to determine: (1) whether patient attributes (specifically a patient's age, gender, race, and socioeconomic status) independently influence clinical decision-making; and (2) whether physician characteristics alone (such as their gender, age, race, and medical specialty), or in combination with patient attributes, influence medical decision-making. METHODS: An experiment was conducted in which 16 (= 2(4)) videotapes portraying patient-physician encounters for two medical conditions (polymyalgia rheumatica (PMR) and depression) were randomly assigned to physicians for viewing. Each video presented a combination of four patient attributes (65 years or 80 years of age; male or female; black or white; blue or white collar occupation). Steps were taken to enhance external validity. One hundred twenty-eight eligible physicians were sampled from the northeastern United States, with numbers balanced across 16 (= 2(4)) strata generated from the following characteristics (male or female; < 15 or > or = 15 years since graduation; black or white; internists or family practitioners). The outcomes studied were: 1) the most likely diagnosis; 2) level of certainty adhering to that diagnosis; and 3) the number of tests that would be ordered. RESULTS: Patient attributes (namely age, race, gender, and socioeconomic status) had no influence on the three outcomes studied (the most likely diagnosis, the level of certainty, and test ordering behavior). This was consistent across the two medical conditions portrayed (PMR and depression). In contrast, characteristics of physicians (namely their medical specialty, race, and age) interactively influenced medical decision-making. CONCLUSION: Epidemiologically important patient attributes (which Bayesian decision theorists hold should be influential) had no effect on medical decision-making for the two conditions, while clinically extraneous physician characteristics (which should not be influential) had a statistically significant effect. The validity of idealized theoretical approaches to medical decision making and the usefulness of further observational approaches are discussed.     

Some implications of the emergence and diffusion of medical expert systems

This paper has two sections. The first introduces the area of medical decision making and the use of artificial intelligence techniques for developing medical expert systems. It also briefly discusses how a physician and an expert system interact, using the INTERNIST-I system as an example. An elaboration of several technical problems which expert systems must overcome for them to be accepted and used by physicians ends this discussion. The second section considers the implications medical expert systems for physicians and patient care. It suggests that medical expert systems regulate and routinize physicians' work. Moreover, the encoding of expert knowledge in a computer program will likely demystify the practice of medicine, nullifying much of the art of medicine. Alternatively, medical expert systems may improve the physician's decision making, extend the practitioner's capabilities, and hence increase the physician's prestige. Moreover, computer aided decision making could speed diagnosis, especially for difficult cases, thus providing the doctor with time for other pursuits. However, medical expert systems will be a mixed blessing for patient care. On the one hand, they could provide expert advice in medically underserved areas, decrease the number of referrals patients and physicians must contend with, while offering expert advice to a greater number of patients. On the other hand, expert systems could further alienate patients from practitioners and from the health system in general. Even more than other medical technologies, computers in the doctor's office could increase the separation between the doctor and patient, while lowering the physician's confidence in her or his own decision making. The conclusion discusses the importance of control over work in determining the use of technology and the influence of the changing medical power structure on the use of expert systems.I thank J. Zvi Namenwirth for his careful review and thoughtful comments on this and previous drafts of this paper. I also appreciate the useful suggestions offered by anonymous reviewers of an earlier draft.     

Patients-in-waiting: Living between sickness and health in the genomics era

What are the social consequences of the recent expansion of newborn screening in the United States? The adoption of new screening technologies has generated diagnostic uncertainty about the nature of screening targets, making it unclear not only whether a newborn will develop a disease but also what the condition actually is. Based on observations in a genetics clinic and in-depth interviews with parents and geneticists, we examine how parents and clinical staff work out the social significance of uncertain newborn screening results. We find that some newborns will experience a specific trajectory of prolonged liminality between a state of normal health and pathology. Based on a review of related literatures, we suggest "patients-in-waiting" as an umbrella concept for those under medical surveillance between health and disease.     

TESTING COMMITMENT COST THEORY IN CHOICE EXPERIMENTS

In choice experiments, it is commonly assumed that individuals make choices in static and certainty decision‐making conditions. Real‐world choices, however, are usually made in a dynamic setting. Committing a purchase decision under conditions of uncertainty might have a “Commitment Cost” (CC). In this study, we test CC theory using a nonhypothetical choice experiment. Specifically, we test whether choice behavior and willingness to pay estimates differ when individuals have the option to gain present or delayed information or reverse the transaction. Our results suggest that the construction of a dynamic decision context can be relevant in the design of choice experiments. (JEL C90, C93, Q18)     

Forms of uncertainty reduction: decision,valuation, and contest

Uncertainty is an intriguing aspect of social life. Uncertainty is epistemic, future-oriented, and implies that we can neither predict nor foresee what will happen when acting. In cases in which no institutionalized certainty about future states exists, or can be generated, judgment is needed. This article presents the forms by which uncertainty is reduced as a result of judgments made about different alternatives in a process involving several actors. This type of uncertainty may exist, for example, about which artist is the best, which offer in the market is more valuable, which football team is better than all the rest, or which research proposal will get a grant. The result of different forms of uncertainty reduction is increased certainty concerning alternatives in relation to one another, such as good and bad, rank lists, scores, quality assessment, and “winner and losers.” Based on the result, uncertainty is reduced and action is facilitated. The forms are structural and comprise roles; may be legitimate in a smaller or larger domain; and may exist in all spheres of life, as exemplified in sports competitions, in labor markets, and in the ranking of universities. Three forms of uncertainty reduction based on judgment are identified in this article: (1) decision, made by an authority; (2) valuation, by means of which order arises as a result of actors ascribing values; and (3) contest, by which an order is the result of direct struggle.     

Medical Uncertainty in Students Entering Medical School

Abstract

Uncertainty is a fundamental characteristic of medical practice. Renee Fox described three types of uncertainty: limitations in the body of medical knowledge, incomplete mastery of existing knowledge, and distinguishing between limitations and mastery of knowledge. This investigation administered ten Likert-format questions about uncertainty to 171 incoming medical students at one state medical school Items were reliable over a six week test-retest, and validity was supported by correlations with an Intolerance of Ambiguity scale. Entering students recognized that uncertainty exists in medical knowledge and mastery of medical knowledge. Factor analysis of the ten item uncertainty scale revealed three dimensions: uncertainty of the profession, practice certainty, and growth in uncertainty. No significant differences in the uncertainty items, scale, or factors existed by demographic characteristics or medical specialty preferences. These findings suggest that students are aware of issues surrounding uncertainty in medicine as they begin medical school, but medical uncertainty at this early stage in medical socialization is not sufficiently powerful to be associated with medical specialty preference.     

Base rates revisited: Assessment strategies for HIV/AIDS

The efficiency of a diagnostic test is largely determined by the base rate, or prevalence, of disease in the population under study, with the consequence that low prevalence diseases are often difficult to detect. However, a review of clinical decision‐making, from a Bayesian standpoint, indicates that even relatively inefficient measures may be effective when combined in appropriate ways, and when the costs and benefits of detection versus non‐detection are considered. In the case of HIV/AIDS, a number of factors, including low prevalence population characteristics, the tendency to distort critical information, and the horrendous consequences of this disease, severely complicate the decision‐making task. The present paper reevaluates the problem of prediction as it relates to HIV/AIDS by examining the use of multiple tests, the relevance of Bayesian utility theory, and the significance of both immediate and projected costs and benefits.     

Evidence-based medicine, clinical uncertainty, and learning to doctor

For the past two decades, evidence-based medicine (EBM), or the reliance on current scientific evidence to reach medical decisions, has been embraced as a new paradigm to standardize clinical care. Drawing from in-depth interviews with seventeen pediatric residents in two residency programs, we evaluate the extent to which the medical sociology scholarship on uncertainty analytically elucidates the recent influx of EBM during residency training. Our findings suggest that residents interpret EBM in varying ways to match their work practices: "Librarians" consult the literature while "researchers" evaluate it critically. For both groups, EBM might generate new uncertainties due to the increased reliance on information technologies and epidemiology. Whether EBM reduces uncertainty depends upon the residents' understanding of standardized knowledge and consequent incorporation of EBM in their clinical practice. Contrary to the predictions of some sociologists, EBM does not lead to a diminishment of humanitarian values in medical care. Nor does EBM lead to a science-based meritocracy on the patient ward, as claimed by some EBM advocates. Our conceptual updating of uncertainty emphasizes the continuous management of uncertainty during the medical socialization process. We argue that managing uncertainty develops along with what we term evidence-based clinical judgment.     

Transversal European survey on testosterone deficiency diagnosis

Background: Despite being one of the relevant public health threats among ageing men, testosterone deficiency syndrome (TDS) is under-recognized and under-diagnosed. Objective: To assess current clinical practices of European physicians regarding diagnosis and management of TDS compared with current guidelines. Methods: Postal survey conducted June–November 2008 in France, Germany, Italy and Spain among urologists, endocrinologists and general practitioners to collect information regarding knowledge of TDS. Results: Among 801 respondents, the majority of endocrinologists and urologists had received training on TDS, either initially or as part of continuous medical education. TDS was recognized by 86.5% of physicians as a true clinical entity, and estimated the prevalence at 10–15% of the male population; 73.5% considered that symptoms and a low level of testosterone were required for diagnosis. Treatment preferences were quarterly intramuscular injections (26.3% of physicians), percutaneous gels (23.9%), matrix patch (21.2%), semi-monthly injections (15.4%) and oral therapy (13.4%). Adverse effects of testosterone replacement therapy, such as benign prostatic hyperplasia and prostate cancer, were a concern for physicians. Conclusions: TDS management appeared to be close to that recommended in international guidelines. Signs and symptoms of testosterone deficiency were fairly well known, but some diagnostic and treatment variations were observed.     

Coronary Risk Factors in Jerusalem Medical Students

Abstract

Thirty-nine male and 25 female Jerusalem medical students participated in a class exercise to determine their own risk factors for coronary heart disease. Systolic and diastolic blood pressures, body-mass index, and proportion of smokers were all lower in females and gave them a significantly lower estimated coronary heart disease (CHD) risk function. There was no sex difference for measures of serum cholesterol. A comparison of the Israeli data with those from three studies of American medical students revealed that Israelis smoke more than their American counterparts but otherwise appear to have similar risk profiles. The authors felt that the exercise was useful in helping these soon-to-be physicians understand the significance of the concepts of risk factors and risk and hope it will induce some of them to improve their own modifiable risk factors.     

TEMPATIONS OF POWER AND CERTAINTY

In our search for guiding principles out of which to conduct therapy, we encounter two temptations: temptations of power and certainty. When therapists do not adequately account for the position of our clients, we fall prey to the temptation of certainty. When we attempt to impose corrections from such certainty, we fall victim to the temptation of power. Colonization occurs in therapy when our commitment to "expert knowledge" blinds us to the experience in the room. This paper offers suggestions for sidestepping power/certainty by constrating therapies of power and certainty with therapies of curiosity and empowernment.     

Computerizing protective services intake expertise: Preliminary research

Decision making at child welfare intake has been the subject of considerable investigation for the last thirty years. Previous reserach on the dynamics of abuse and neglect resulted in complexity and inconsistency to the extent that research moved away from determining the relevant information for creating a more structured decision making process. Recent developments in knowledge engineering and computerized expert systems provide new tools for examining protective services intake decision making. These tools are appropriate for organizing the vast amount of information workers use during decision making, extracting decisions from that information, and presenting the decisions and their supporting logic. This research examines existing expertise with a small sample of child welfare experts to determine the feasibility of developing an expert system for supporting intake decisions.     

A Moderated Mediation Model of Planned Happenstance Skills,Career Engagement,Career Decision Self‐Efficacy,and Career Decision Certainty

This study examined how college students’ levels of planned happenstance skills influenced the relationships among career engagement, career decision self‐efficacy, and career decision certainty. Moderated mediation analysis was used with a sample of 217 Korean undergraduate students. The results indicated that career decision self‐efficacy mediated the relationship between career engagement and career decision certainty. Moreover, the positive indirect effect of career engagement on career decision through career decision self‐efficacy was strengthened as the level of planned happenstance skills increased. In conclusion, college students’ career engagement strengthens their career decision certainty via career decision self‐efficacy when they have enough planned happenstance skills to discover unexpected career opportunities.     

How are drugs approved? Part 2: ethical foundations of clinical research

In the United States, the U.S. Food and Drug Administration (FDA) evaluates and approves drugs through a process that includes clinical research. The purpose of clinical research is to diminish uncertainty by acquiring knowledge. For drug development, the goal is to approve drugs that are safe and effective. Because of the uncertainty, however, participation in clinical research entails some degree of risk. Ethical principles provide the framework on which studies can be designed and conducted and which appropriately balance benefits and risks for research participants. As part of a broad overview of the drug development process, this article reviews the ethical foundations of clinical research.     

“Sensory Ordering” in Nurses' Clinical Decision‐Making: Making Visible Senses,Sensing, and “Sensory Work” in the Hospital

The objective of this article is to present a study on the constitutive role of senses in clinical decision‐making. The methodology is based on a series of focus groups with nurses in various hospital departments. Based on a narrative approach, our study examines “sensory work” in clinical decision‐making in order to reveal its specificity in the clinical work of nurses. Nurses shared stories—in focus groups—about the influence of senses in clinical decision‐making. The analysis of clinical narratives helped to identify various situations revealing the “sensory work” that underlines clinical decision‐making. We put the emphasis on the spectrum of sensory activities and the interactions occurring during a clinical decision‐making. One specific contribution of our study is to make visible the “sensory ordering” at work as constituted by interactions between nurses during a clinical assessment.