Osterweis M, Bryant E
J Community Health. 1978 Winter;4(2):104-19. doi: 10.1007/BF01318947.
The purpose of the large study reported here was to develop and test methods for assessing the quality of health care that would be broadly applicable to diverse ambulatory care organizations for periodic comparative review. Methodological features included the use of an age-sex stratified random sampling scheme, dependence on medical records as the source of data, a fixed study period year, use of Kessner's tracer methodology (including not only acute and chronic diseases but also screening and immunization rates as indicators), and a fixed tracer matrix at all test sites. This combination of methods proved more efficacious in estimating certain parameters for the total patient populations at each site (including utilization patterns, screening, and immunization rates) and the process of care for acute conditions than it did in examining the process of care for the selected chronic condition. It was found that the actual process of care at all three sites for the three acute conditions (streptococcal pharyngitis, urinary tract infection, and iron deficiency anemia) often differed from the expected process in terms of both diagnostic procedures and treatment. For hypertension, the chronic disease tracer, medical records were frequently a deficient data source from which to draw conclusions about the adequacy of treatment. Several aspects of the study methodology were found to be detrimental to between-site comparisons of the process of care for chronic disease management. The use of an age-sex stratified random sampling scheme resulted in the identification of too few cases of hypertension at some sites for analytic purposes, thereby necessitating supplementary sampling by diagnosis. The use of a fixed study period year resulted in an arbitrary starting point in the course of the disease. Furthermore, in light of the diverse sociodemographic characteristics of the patient populations, the use of a fixed matrix of tracer conditions for all test sites is questionable. The discussion centers on these and other problems encountered in attempting to compare technical performance within diverse ambulatory care organizations and provides some guidelines as to the utility of alternative methods for assessing the quality of health care.
本文所报告的这项大型研究的目的是开发并测试用于评估医疗保健质量的方法，这些方法将广泛适用于各类门诊护理机构，以便进行定期的比较审查。方法学特点包括采用年龄 - 性别分层随机抽样方案、依赖病历作为数据来源、固定的研究年份、使用凯斯纳的追踪方法（不仅包括急性和慢性疾病，还包括筛查和免疫接种率作为指标）以及在所有测试地点使用固定的追踪矩阵。事实证明，这种方法组合在估计每个地点所有患者群体的某些参数（包括使用模式、筛查和免疫接种率）以及急性病症的护理过程方面，比在检查所选慢性病的护理过程时更为有效。研究发现，在所有三个地点，三种急性病症（链球菌性咽炎、尿路感染和缺铁性贫血）的实际护理过程在诊断程序和治疗方面常常与预期过程不同。对于慢性病追踪指标高血压，病历常常是得出关于治疗充分性结论的不足数据源。研究方法的几个方面被发现不利于慢性病管理护理过程的地点间比较。采用年龄 - 性别分层随机抽样方案导致在某些地点为分析目的识别出的高血压病例过少，因此需要通过诊断进行补充抽样。使用固定的研究年份导致疾病进程中的起始点具有任意性。此外，鉴于患者群体多样的社会人口学特征，在所有测试地点使用固定的追踪病症矩阵是值得怀疑的。讨论围绕在试图比较不同门诊护理机构的技术性能时遇到的这些及其他问题展开，并为评估医疗保健质量的替代方法的实用性提供了一些指导方针。
