Hanks G E, Kramer S
Int J Radiat Oncol Biol Phys. 1984 Jun;10 Suppl 1:87-97. doi: 10.1016/0360-3016(84)90455-3.
Consensus of best current management developed by a rational and deliberative process can provide the basis for clinical quality assessment. Unfortunately, it is not always possible to arrive at a consensus at all cancer sites, and this generally indicates areas where clinical research is needed. Assessing the quality of care in these situations presents special problems. When it is possible to arrive at consensus in a specific disease, this consensus should detail appropriate pretreatment evaluation and the details of the treatment. Committees of experts for each specific disease site can formulate the consensus and must document their decisions based on information from the current world literature. A carefully thought out and documented consensus can then provide the basis for the development of process based questionnaires in assessing quality. We have observed that individuals formulating consensus of best current management do not strictly follow their own criteria, and that compliance in various strata of practice throughout the United States shows a greater deviation from consensus than anticipated and indeed this deviation crosses all types of practice. It was then necessary to conduct outcome surveys in the same patients to validate the processes of care by showing a correlation of process performance with outcome or indeed to change our concepts of best current management. We recognize from these outcome studies that relatively few processes have direct association with outcome and the majority of our consensus points relate to either good general patient management or items important to individual patients but not to large groups of patients. In addition to validating processes through outcome correlations, we have found that process verification is important. We have observed quite different outcomes for two groups of patients with Hodgkin's disease treated with the same processes (i.e., mantle field technology and adequate radiation dose, etc.). We were unable to identify the reason for an increased failure rate in one group of these patients until we looked at each individual mantle port film from the two groups of patients. We then identified that one facility was not including the Hodgkin's disease in the treatment portal due to poor technical performance. We believe that this program of process verification may be important in evaluating quality for any disease site. Data will be presented that illustrates the above problems.
通过合理且审慎的过程得出的当前最佳管理共识可为临床质量评估提供基础。不幸的是，并非在所有癌症部位都总能达成共识，而这通常表明需要开展临床研究的领域。在这些情况下评估医疗质量存在特殊问题。当能够就某一特定疾病达成共识时，该共识应详细说明适当的预处理评估及治疗细节。针对每个特定疾病部位的专家委员会可制定共识，并必须根据当前世界文献中的信息记录其决策。经过深思熟虑并记录在案的共识随后可为开发基于过程的质量评估问卷提供基础。我们观察到，制定当前最佳管理共识的人员并未严格遵循他们自己的标准，而且在美国各地不同层面的实践中，与共识的偏差比预期的更大，实际上这种偏差跨越了所有类型的实践。因此，有必要对同一批患者进行结果调查，通过展示过程表现与结果之间的相关性来验证医疗过程，或者实际上是为了改变我们对当前最佳管理的观念。我们从这些结果研究中认识到，相对较少的过程与结果有直接关联，而且我们的大多数共识点要么涉及良好的一般患者管理，要么涉及对个体患者重要但对大量患者不重要的项目。除了通过结果相关性验证过程外，我们还发现过程核查很重要。我们观察到两组接受相同治疗过程（即斗篷野技术和足够的放射剂量等）的霍奇金病患者有截然不同的结果。在查看两组患者的每张个体斗篷野端口片之前，我们无法确定其中一组患者失败率增加的原因。然后我们发现，由于技术操作不佳，一个机构在治疗野中未包括霍奇金病。我们认为，这个过程核查计划对于评估任何疾病部位的质量可能都很重要。将展示说明上述问题的数据。
