International Journal for Quality in Health Care Advance Access originally published online on April 23, 2008
International Journal for Quality in Health Care 2008 20(3):153-154; doi:10.1093/intqhc/mzn014
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Editorial |
Quality of Care as a Field of Research: What We Published, 2004–2007
What defines quality of care as a field of scientific enquiry? Experts generally agree on the main dimensions of quality of care [1] and on the key ingredients of quality management [2]. What kinds of studies should be done is less clear. Some people believe that descriptive studies of quality may be important locally but do little to further the evidence base for effective quality improvement—they demand more empirical intervention studies. Others deplore the lack of an integrated theoretical framework for quality improvement and the deficiencies of instruments and methods used in quality assessment—they call for more contributions in these areas.To assess how the Journal's publications contribute to various aspects of quality in health care, I classified the 229 full papers published between 2004 and 2007 in the Journal (excluding supplements) according to two variables: the main topic of the paper and the type of paper or study (Table 1). While dimensions of quality could readily be identified for most papers, papers that dealt with management could rarely be allocated to a specific component, with the exception of papers that dealt with quality measurement and with health care staff. The type of paper or study was generally easy to determine. I decided to put qualitative research papers in a separate category, because of the potential of such studies to contribute to theory.
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Overall, 158 papers (69%) dealt with quality of care as such or with a particular dimension of quality, whereas 71 papers addressed quality management (31%). The most frequent topic was appropriateness of care, i.e. the conformity of care with state-of-the-art practice and expert recommendations (46 papers, 20% of the 229 articles). Next came quality management (36, 16%), patient safety (34, 15%), patient-centeredness (28, 12%) and indicators and measurement (28, 12%). In contrast, few papers addressed clinical effectiveness, timeliness, accessibility and equity of health care. As expected, observational studies were the most common type of paper (99, 45%), followed by intervention studies (47, 21%) and methodologic contributions (41, 18%).
If we consider both the topic and the type of study, the most common papers were observational studies of appropriateness of care (N = 21). A typical example was an international study of the appropriateness of colonoscopy in more than 5000 patients who underwent the procedure [3]; depressingly enough fewer than half of the procedures were deemed necessary or appropriate; inappropriate procedures were most frequent among younger, healthier patients investigated for diarrhea or abdominal pain. Intervention studies that used appropriateness of care as their main variable were also frequent (N = 17). An example is a cluster randomized trial which showed that a staff training package can increase the conformity with guidelines in family planning clinics in Kenya [4].
Observational studies of patient safety were the second most common type of study (N = 19). A study demonstrated that in US hospitals, patients who have an insufficient command of English are at greater risk of adverse events during hospitalization [5]. This research illustrates that the dimensions of quality are not neatly separated—here safety appears to relate to patient communication, which is an aspect of patient-centeredness. Another innovative study that I classified among the 14 papers on patient-centeredness but which clearly also concerns quality management examined the roles of patients in the Irish hospital accreditation process [6].
We also published methodologic contributions to quality measurement (N = 15) regularly. An example is the set of quality indicators for hospitals developed by an international panel [7]. Papers that described the development of patient opinion questionnaires were classified under methodologic contributions to patient-centeredness (N = 10); had I included them under indicators/measurement, this would have been the most frequent type of paper.
Somewhat less frequent were theory-oriented papers; most dealt with quality management (N = 9). A recent example is an ambitious and much needed framework for national quality reforms [8].
What about the less populated categories? We, at this Journal, consider the empty (or almost empty) cells in Table 1 as missed opportunities for publication on these topics. Instead of publishing safe me-too studies of known quality issues, we would like to see more papers about relatively neglected aspects of quality of care. This includes, but is not limited to, interventional studies that look beyond appropriateness of care, methodologic papers on issues other than measurement, theoretical papers and reviews on just about any topic and any type of paper on equity and access to care. In the next 4 years, the grid should be more evenly filled.
Clinical Epidemiology Service
University Hospitals of Geneva
University of Geneva
Geneva
Switzerland
E-mail: eic-ijqhc{at}hcuge.ch
References
- Arah OA, Westert GP, Hurst J, et al. A conceptual framework for the OECD Health Care Indicators Project. Int J Qual Health Care (2006) 18((Suppl 1)):5–13.
[Abstract/Free Full Text] - Hudelson P, Cleopas A, Kolly V, et al. What is quality and how is it achieved? Practitioners vs. quality experts. Qual Saf Health Care (2008) 17:31–6.
[Abstract/Free Full Text] - Harris JK, Froehlich F, Gonvers JJ, et al. The appropriateness of colonoscopy: a multi-center, international, observational study. Int J Qual Health Care (2007) 19:150–7.
[Abstract/Free Full Text] - Stanback J, Griffey S, Lynam P, et al. Improving adherence to family planning guidelines in Kenya: an experiment. Int J Qual Health Care (2007) 19:68–73.
[Abstract/Free Full Text] - Divi C, Koss RG, Schmaltz SP, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care (2007) 19:60–7.
[Abstract/Free Full Text] - O'Connor E, Fortune T, Doran J, et al. Involving consumers in accreditation: the Irish experience. Int J Qual Health Care (2007) 19:296–300.
[Abstract/Free Full Text] - Veillard J, Champagne F, Klazinga N, et al. A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. Int J Qual Health Care (2005) 17:487–96.
[Abstract/Free Full Text] - Leatherman S, Sutherland K. Designing national quality reforms: a framework for action. Int J Qual Health Care (2007) 19:334–40.
[Abstract/Free Full Text]
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