ices. Effectiveness, defined by PPRC (1989) as the probability of benefit to a given individual from a medical procedure applied to a given medical problem, relates to the value of resource use—that is, the combination of quality and cost. According to Roper and Hackbarth (1988), the goal of effectiveness research is to assure that any given patient receives the maximum benefit in improved health for any given level of health care expenditure. Appropriateness relates the procedures recommended for a given patient to the current knowledge of effectiveness. Knowledge about effective and appropriate medical care can be increased through clinical and health services research, including clinical trials, epidemiological studies, analysis of cost effectiveness, and assessment of techniques to influence clinical decision making.

Process-of-Care Measures

Technical aspects of care. Process-of-care measures have long been the yardsticks against which to measure quality of care. Properly evaluating the technical process of care requires the use of explicit criteria. Much needs to be done in the area of developing adequate process measures. This topic may be more an issue of application than of basic research; for instance, ways need to be found to make good criteria sets, which may be developed for research or program evaluation purposes, more easily accessible to quality assurance professionals.

Process criteria typically contain statements about diagnosis- or problem-specific elements of care that practitioners agree are relevant, important, and measurable. For instance, criteria sets may ask whether the right problems were identified and diagnosed, whether the correct diagnostic steps were taken, whether the appropriate treatments were recommended or delivered, and whether those treatments were correctly administered in a timely fashion. Developing criteria sets that are reliable, valid, and parsimonious with respect to data-collection requirements is a very difficult task, and existing criteria sets vary widely in these respects. Very few meet the standards of clarity, validity, reliability, flexibility, and clinical adaptability discussed in Chapter 10.

Art-of-care measures. The art of care is both extremely important and difficult to measure. This interpersonal dimension includes the practitioners’ responsiveness to patient needs, ability to elicit information about patient preferences for treatment alternatives and generally their caring attitude. These aspects resist quantification, but they influence outcomes of care, often in the form of patient satisfaction. A substantial research effort is needed to establish the reliability, validity, and generalizability of the



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