Providing Quality Care: The Challenge to Physicians.

As children, we often left food on our plates. Sometimes we were told that we should eat it up because of the starving children in other countries across the world. It was never explained to me how that simple spoonful of good food could actually be delivered to the needy.

Perhaps this is a parable with applicability to health care. We in the health care field have benefited from a long period of plenty. There has undoubtedly been much overuse of resources. When there are more than enough resources to spread around, needs may be fulfilled with resources to spare. Times have changed; society now seems to be ready to say that we are spending enough on health care. Yet there is still abundant evidence of great variations in the use and provision of resources. At one extreme, there is gross overuse of resources and probable poorer outcomes because of it. At the other extreme, there is underuse of resources to an extent that is, most literally, fatal.

We have entered an era in which it is not just the underuse of resources that quickly causes a problem with the quality of care that is given. The overuse of services in one area causes a redistribution in other areas, creating patterns of underuse. It is important to understand that, in the present political climate, decisions on limits on funds for health care services will have to be made at the local, state, and federal levels, however abhorrent those decisions maybe to the local practitioner. Indeed, not long ago the State of Oregon determined that transplantation services could drain the state's Medicaid fund to such a degree that other programs would suffer. In this case, the battle to limit such services was led by a physician, the leader of the Oregon State Senate.

The message to be learned from the Oregon legislature is that these tough decisions are going to have to be made. Who better to be involved in the decision making process than ourselves, members of the medical profession? We simply cannot continue to demand more and more resources. We must actively choose to place or have placed resources where they are most needed.

It is in this milieu that the small anthology Providing Quality Care: The Challenge to Physicians, edited by Drs. Goldfield and Nash is delivered. If physicians are to be the ones responsible for administering health care, we must surely review some of the tenets of quality in the provision of care. While a lot of the studies quoted and concepts expressed in this publicaion are familiar to those involved in health systems research, much of what is contained in the book will be foreign to the physician practicing in a managed care environment and even more so to the solo practitioner.

The author of the "Foreword," John Iglehart, quotes Arnold Relman, MD, editor of the New England Journal of Mediciize, who believes that we are now in "a new era of assessment and accountability...."

The editors, who are also the authors of Chapter One, in that chapter indicate that purchasers, faced with ever-escalating health care costs, are seeking ways to purchase value in health care. They are requesting more details from providers and consumers.

In Chapter Two, two experts in the field of patient assessment discuss the role for patients in the medical care process. This chapter is a prototype for the others in the book. It is well written and exhaustively referenced and, in a logical and scientific way, attempts to take the reader through the questions that the authors themselves have posed as they work in this field. There are, in fact, 209 references in this chapter.

Instead of rewriting for the sake of editorial evenness or even developing perspectives from other workers in the field, the editors write a commentary for each chapter. These commentaries are useful summaries of the chapters. For this is probably not the book that one wants to read from cover to cover. Rather it is the book that accompanies one on flights, where one can read or reread a chapter or two at a time. Subsequently, one can search for and find selected references, which in some chapters are fisted after the actual textual references.

The author of Chapter Three succinctly describes the background to the severityof-illness measuring industry. She takes five different systems and describes why they were developed. She mentions the newer applications that the entrepreneurial world has developed for the severity systems and demonstrates that they' naturally give different answers when asked to do things for which they were not designed. Appropriately, she does not criticize the systems for what they do or do not do. She uses them to illustrate the point that concern about severity of illness is a real phenomenon, but that there are two (or more) sides to this debate, as there are to most debates. For instance, in some cases a patient presenting with a more severe manifestation of a disease maybe less of a diagnostic dilemma, and therefore may consume less resources and not more.

In Chapter Four, hospital mortality is discussed in great detail. Whether or not one believes that the release by the New York Times on March 12, 1986, of Health Care Financing Administration mortality data was appropriate, that is now a watershed date. Any physician or other provider who uses, reviews, or is asked about hospital mortality needs to understand these data. No mortality or adverse outcome is ever acceptable. Some outcomes may be inevitable, but there is always room for improvement. The notion of continuous quality improvement is taken up in the next two chapters of the book. By now, everybody interested must surely have heard or read about the notion of continuous quality improvement versus the bad apple theory. For those who haven't, Chapters Five and Six will make excellent reading. On the other hand, even those familiar with W. Edward Deming's sentinel work on quality will find Chapter Five a succinct revision.

The remaining three chapters of the book are devoted to measuring quality in the office practice, the Joint Commission on Accreditation of Healthcare Organizations, and, finally, malpractice, clinical risk management, and quality assessment.

I think that this anthology will be useful for both professionals who know a lot about the field and those who are just learning. It is written by experts in their fields. The book is well referenced, and the commentaries by the editors are helpful for the most part. It is not exhaustive and will certainly not be the last word in the field. It is, however, a slim volume that will stimulate me to think as I reread it on those frequent flights.