Why Measure Quality of Cancer Care?

There are several reasons for measuring the quality of care:

  • To help consumers and purchasers make informed choices about health care (e.g., selecting health care coverage that balances likely health care effectiveness and costs).
  • To help clinicians and patients make informed treatment and referral decisions (e.g., evaluating mortality and quality of life trade-offs when deciding between two alternative treatments for cancer, comparing the relative success of two hospitals for a high-risk surgical procedure).
  • To help clinicians and health plans improve their care (e.g., assessing levels of cancer screening or monitoring surgical complication rates).
  • To determine the impact of new policies and systems (e.g., evaluating the consequences of increasing Medicare enrollment in health maintenance organizations [HMOs]).
  • To provide clinical input to financial decision-making processes (e.g., determining services to be included in an insurer's benefit package).
  • To guide public policy decisions (e.g., resource allocation decisions pertaining to the Medicaid or Medicare programs).

How is Quality Measured?

Quality assessment is the measurement of quality by expert judgment (implicit review) or by systematic reference to objective standards (explicit review). Quality may be evaluated at any level of the health care system: for physicians and other health care professionals; for hospitals, clinics, rehabilitation centers, and other institutions; for health plans; and for communities.

Different approaches to assessing quality have different strengths and weaknesses, and some approaches work better in one setting than another. An example of implicit review is having a clinician review the medical records of a patient and expressing a judgment on whether the care was good or bad. The clinician may base an opinion on years of experience and understanding of the clinical situation for which care was provided. However, the same rating may not be given on another day, and different colleagues might give a different rating.

Explicit review provides a more systematic approach and can be based on one or more of three dimensions: structure, process, and outcomes (Donabedian, 1980). ''Structural quality'' refers to health system characteristics, "process quality" refers to what the provider does, and "outcome" refers to patients' health. Although producing good outcomes is the ultimate goal of the health care system, for a variety of technical reasons, using outcome measures to assess quality is not generally the most effective approach (discussed below). Instead, process measures are used.

Structural Quality

Structural quality refers to characteristics of the health care system that affect its ability to meet the needs of individual patients or communities. These characteristics include clinician characteristics (e.g., board certification, average years of experience, distribution of specialties), organizational characteristics (e.g., staffing patterns, reimbursement method), patient character-

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