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Biomedical subjects

A Donabedian

Publications and source records attributed to A Donabedian.

At least 55 records · Page 3Linked to original sources
PubMed1983

Quality, cost, and clinical decisions.

Clinical decisions require determining the objectives of care as well as selecting and implementing a strategy of care. At the very least the optimal strategy balances the expected benefit and harm from technical interventions. Health care practitioners tend to specify optimal strategies based on what they consider to be best for patients, without regard to monetary cost. This is an absolutist definition of quality. Individuals may place different valuations on the outcomes, are concerned with the monetary costs to themselves, and are particularly sensitive to the attributes of the interpersonal relationship with the practitioners. Including all of these leads to an individualized definition of the quality of care. But this specification of quality may be in conflict with a social definition of quality, which takes into account social as well as individual monetary costs, externalities, and the social distribution of quality. The health care professions may respond to the conflict in several ways, which are described in this article as evasion, rejection and confrontation, anticipation, advocacy, active complicity, passive complicity, and ambiguous adaptations.

Clinical Competence↗
PubMed1983

Quality assessment and monitoring. Retrospect and prospect.

A commentary on the papers in the two special issues on Quality Assurance which shows how they contribute to some important conceptual, methodological, and policy issues. These issues pertain to the definition of quality; the distinction between quality assessment and program evaluation; the role of the market in regulating the quality of care; the role of more direct consumer participation in defining and assessing quality; professional responsibility for quality; the applicability of the structure-process-outcome paradigm to quality assessment; the format, methods of formulation, and validity of the criteria; probability sampling and purposive selection of the topics to be assessed; problems of scaling and measurement; the applicability of industrial control methods to quality monitoring; bringing about behavior change in response to the findings of quality monitoring; measuring the costs and benefits of quality assessment methods, including a consideration of their screening efficiency; and the relationship between quality monitoring and cost containment through competition or by other means.

Community Participation↗
PubMed1983

The quality of care in a health maintenance organization: a personal view.

A health maintenance organization must compete for clients by promising to provide near-comprehensive care, under congenial circumstances, to a defined population, through organized effort, within a budgetary limit. These properties both require and allow the organization to redefine health and health services to correspond more closely to the needs and values of a population, to place greater emphasis on client satisfaction, to foster clinical efficiency and production efficiency, to allocate resources more wisely, and to assess care in coordinated sequences rather than in scattered fragments.

Consumer Behavior↗
PubMed1982

Quality, cost, and health: an integrative model.

This article presents an integrative model of the relations among health status, quality of care, and resource expenditure. It defines medical care quality in terms of outcomes, measured as the expected improvements in health status attributable to care. The consideration of how quality so defined is affected by the unconstrained, efficient use of resources for care leads to the specification of the absolutist definition of quality. Consideration of the incidence of individual and external costs and benefits of care provides the basis for distinguishing further between the individualized definition of quality, which depends upon individual preferences and ability to pay, and the social definition of quality, which includes consideration of external benefits, full social definition of quality, which includes consideration of external benefits, full social costs, and preferences for the distribution of welfare. An additional distinction is made between clinical efficiency and production efficiency. This article examines in detail the implications, for the selection of optimal strategies of care, of the three definitions of quality (absolutist, individualized, and social) and the two types of efficiency (clinical and production).

Attitude to Health↗
PubMed1981

Equity in the distribution of quality of care.

This article examines whether the quality of health care services in the United States is equitably distributed across all groups in the population, especially groups defined by age, race, sex, and income characteristics. The framework within which the question is answered draws distinctions among structural, process, and outcome inequities. The available evidence suggests that all three types of inequity are present, at least to some extent. However, there are too many gaps and weaknesses in what is known about this issue to reveal systematic patterns or to support broad generalizations. The need for additional research on this issue is discussed, as are the policy implications of what is already known about equity in the distribution of quality of care.

Age Factors↗
PubMed1981

Criteria, norms and standards of quality: what do they mean?

Quality assessment requires specification of: 1) a set of phenomena that are usually attributes of either process or outcome; 2) a general rule of what constitutes goodness; and 3) a precise numerical statement of what constitutes acceptable or optimal goodness with respect to each of these phenomena. The terms "criteria," "norms," and "standards," as currently employed, do not correspond well with these three components, but they could be used effectively if the basic distinctions were understood. Alternatively, one could use, as corresponding terms, "elements," "parameters," and "standards." The terms "criteria," and "norms" would then be redefined and be available to be used more uniformly, while "standards" could be further differentiated according to method of measurement, configuration, level, and flexibility.

Quality of Health Care↗
PubMed1981

Advantages and limitations of explicit criteria for assessing the quality of health care.

Explicit criteria for assessing the quality of health care should appeal to practitioners because such criteria make possible consistent judgments, openly arrived at. The process of their formulation encourages more critical scrutiny of current practice, identifying what the generality of practitioners can accept, and what is still doubtful. But, as instruments of social control, explicit criteria are a two-edged sword-vehicles for the best that medicine can offer, or instruments of institutionalized and pervasive error. Therefore, it is important to see who controls the criteria, whose perspectives and interests they serve, and what images of quality they render at once concrete and dominant.

Medical Audit↗
PubMed1979

The quality of medical care: a concept in search of a definition.

Patient care has two components: technical and interpersonal. The quality of technical management depends on the balance of its expected benefits and risks. The quality of the interpersonal process consists in conformity to legitimate patient expectations and to social and professional norms. Since this conformity is expected to result in social and personal benefit, a unified definition of quality can be derived by including the benefits and risks of both aspects of care. When the patient's health and welfare are judged by professional criteria, and the cost of care is not considered, one has an "absolutist" definition of quality. By contrast, an "individualized" definition accepts the informed patient's valuation of the consequences of care, and includes the cost to the patient as an unwanted consequence. The "social" definition includes monetary cost even when not borne directly by the patient, may place a different valuation on patients and their interests, and pays attention to the social distribution of the cost and net benefits of care. Thus, the physician who wishes to do the best for each patient may be in conflict with what society dictates to be the best of all. The health care professions must resolve this moral dilemma.

Cost-Benefit Analysis↗
PubMed1978

The quality of medical care.

This article classifies the major approaches to the assessment of the process and outcomes of medical care. The apparent need to safeguard and enhance the quality of care has led to the institution of mechanisms that subject care to constant review so that deficiencies may be found and corrected. The article reviews the developments that led to the involvement of the federal government in this activity through its sponsorship of professional standards review organizations (PSRO's). The major features of the PSRO's are described and their possible effects discussed. It is too early to say how the PSRO's will fare, but should they fail to accomplish their objectives the pressure for more radical solutions will be difficult to resist.

Computers↗
PubMed1976

Issues in national health insurance.

Health insurance, by reducing net price to the consumer and increasing the opportunities for revenue to the provider, has profound effects, among other things, on the volume, content and distribution of services, their prices, and the capacity of providers to produce them. The magnitude and nature of these effects depend, partly, on the design of insurance benefits and, partly, on the nature of the health care system, particularly its current and potential capacity and the methods it uses to pay providers. Those who believe that the unique aim of insurance is to protect against unpredictable expenses attempt to suppress these effects, mainly by imposing financial disincentives to utilization which, in turn, reduce protection for those who need it most. Those who wish to reform the system have a broader range of objectives which include protective efficacy, cost control, quantitative adequacy, qualitative adequacy, efficiency of production, efficiency of allocation, equity, and redistribution of capacity. An analysis of the effects of insurance in the light of these objectives reveals favorable as well as unfavorable consequences. The provision of comprehensive benefits generates the necessity for a fundamental change in the organization of health services, if the advantages are to be fully realized and the disadvantages minimized.

Deductibles and Coinsurance↗