Leonard Kenneth L, Masatu Melkiory C
University of Maryland, Department of Agricultural and Resource Economics, Maryland, USA.
Soc Sci Med. 2005 Nov;61(9):1944-51. doi: 10.1016/j.socscimed.2005.03.043.
This paper reports the results of a comparison between two different methods of examining quality in outpatient services in a developing country. Data from rural and urban Tanzania are used to compare the measures of quality collected by direct clinician observation (DCO) (where clinicians are observed in the course of their normal consultations) and vignettes (unblind case studies with an actor). The vignettes are shown to exhibit a strong connection between the inputs provided during consultation (rational history taking, physical examination and health education) and the ability of the clinician to properly diagnose the presented illness. However, the inputs provided in vignettes are not well correlated with the inputs provided in DCO, suggesting that the inputs provided in the vignette are not well correlated with the inputs that would be provided in an actual consultation. We conclude that since vignettes do not appear to be measuring what would be provided in an actual consultation they are not a good measure of quality. Instead, we suggest that vignettes and DCO be used simultaneously. We show how the scores obtained using vignettes in conjunction with DCO can be used to improve the reliability of DCO and therefore our estimates of actual clinician quality.
本文报告了在一个发展中国家对门诊服务质量的两种不同检查方法进行比较的结果。来自坦桑尼亚农村和城市的数据被用于比较通过直接临床医生观察（DCO）（即在临床医生正常会诊过程中进行观察）和案例 vignettes（与一名演员进行的非盲法案例研究）收集的质量指标。结果表明，案例 vignettes 显示出会诊期间提供的信息（合理的病史采集、体格检查和健康教育）与临床医生正确诊断所呈现疾病的能力之间存在紧密联系。然而，案例 vignettes 中提供的信息与 DCO 中提供的信息相关性不佳，这表明案例 vignettes 中提供的信息与实际会诊中会提供的信息相关性不佳。我们得出结论，由于案例 vignettes 似乎并未衡量实际会诊中会提供的内容，因此它们不是衡量质量的好方法。相反，我们建议同时使用案例 vignettes 和 DCO。我们展示了如何将使用案例 vignettes 与 DCO 相结合获得的分数用于提高 DCO 的可靠性，从而提高我们对实际临床医生质量的评估。
