Bobbio M, Pintor P P
Divisione Universitaria di Cardiologia, Ospedale Molinette, Fondazione Arturo Pinna Pintor, Torino.
G Ital Cardiol. 1997 Sep;27(9):945-51.
In the process of health planning and of the evaluation of health care, there is growing interest in assessing the quality of medical care. Traditionally, quality indexes are divided into three groups: structure, process and outcome. The first two indexes can be measured more easily and quickly, but outcome indexes are more appropriate care indicators for both health planners and patients. The introduction of quality assessment means that physicians work in order to achieve the required standards even if it does not increase the real quality of care, that data are systematically biased in order to increase the quality score and, lastly, that physicians do not rely on case-mix statistical adjustment of results. All these problems have already been evaluated by the Health Department of New York State. Since 1989, outcome data of open-heart surgery have been monitored in all cardiac surgery centers in the state. It is still open to debate whether the decreased mortality in New York State is due to the quality assessment program, to the migration of sicker patients to nearby states, or to the refusal of heart surgeons to operate on high-risk patients. In Italy as well, new rules have been introduced into health legislation in order to assess the quality of health care. Even if methodological and legislative instruments to assess quality of care are still not completely reliable in terms of assessing the quality of care with simple and effective methods, this does not exclude the need to proceed in assessing the quality of health care.
在卫生规划和医疗保健评估过程中，人们对评估医疗质量的兴趣日益浓厚。传统上，质量指标分为三类：结构、过程和结果。前两类指标更容易、更快速地进行衡量，但结果指标对于卫生规划者和患者而言都是更合适的医疗指标。引入质量评估意味着，即使这并不会提高实际医疗质量，医生仍会为达到所需标准而努力；数据会被系统性地歪曲以提高质量得分；最后，医生不依赖于对结果进行病例组合统计调整。纽约州卫生部已经对所有这些问题进行了评估。自1989年以来，该州所有心脏外科中心都在监测心脏直视手术的结果数据。纽约州死亡率的下降究竟是由于质量评估项目、病情较重的患者向周边州转移，还是由于心脏外科医生拒绝为高危患者做手术，目前仍存在争议。在意大利，卫生立法也引入了新规定，以评估医疗保健质量。即使在采用简单有效的方法评估医疗质量方面，评估质量的方法和立法工具仍不完全可靠，但这并不排除开展医疗质量评估的必要性。
