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COMMENT AND DISSENT . . Mildred Morehead While ~ am in general agreement with the statements of the committee to assure the quality of health care, and well appreciate the thought and deliberation that went into the fi- na~ report, there are two points that emerge in the final docu- ment which ~ feel ~ cannot endorse. There is overemphasis on outcome measurements and undue restriction on process evaluation as stated in the recommendation to limit process.measurements to ''only those for which research has demonstrated a definite correlation with patient outcome" (page 22) and excluding entirely those which "constitute usual and customary practices" (page 21~. While the document points out what are indeed potential pitfalls in the use of process and criteria measurements, the conclusion of the above state- ments will, in my opinion, have a deleterious effect on efforts to improve present medical practice on a nationwide basis. Clearly all can endorse the theory that medical care should effect a positive outcome. However, at the present time, there is too limited a number of conditions where definitive outcomes can be measured. There are too many other variables associated with outcome to have this a sole determinant, and the time and expense to secure such judgments are of unproven value. (In- cidenta1ly, ~ do not feel that references to the Rosser and Watts study relating to prognosticating function at the time of hospital discharge as an example of an outcome approach strengthens the position for use of outcome determinations.) On a far less sophisticated level there is much known about the provision of medical services which can be judged from the process of care employed; usual.and customary practice may not always be amenable to definitive proof of efficacy, but modern medicine has taken into account the decision factors redating to diagnosis and therapy and the avoidance of risk (unnecessary surgery, use of overly potent drugs, etc.~. There is a great deal that can be done in this country today to upgrade current practice without the need to defer until science has definite proof for all of the modalities in.use. ~ am also uneasy about the implication that quality assur ance programs should be oriented around clinical research tech niques (page 21~. Clinical research is indeed essential to increase the extent of knowledge, but in my opionion, belongs under the auspices of others (NTH, medical schools, etc.) rather than those who are endeavoring to meet a more basic need, namely, assuring that what is known is not being misused or applied to the detriment of the general population. 53
My second disagreement with the document lies in the place- ment of the recommendation to employ the uniform hospital dis- charge abstract. This is a worthwhile recommendation which more properly belongs among the recommendations for data re- quirements and not as number one of i- -and-'- 4- ¢~ -' assessment of quality. Data collection is a prerequisite to any method of quality assurance. This area, including recom- mendations about the hospital discharge abstract, might more logically be placed prior to the discussion on methods. recommendations _ of the methods to be used in is a prerequisite to 54
