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.

Adopción/Adaptación mediante Comentario para Argentina por intermedio de la Federación Iberopanamericana de Periodoncia (FIPP) de la Guía de Práctica Clínica (GPC) de nivel S3: Tratamiento de la periodontitis en los estadios I ­ III, de la Federación Europea de Periodoncia (EFP), traducida por la Sociedad Española de Periodoncia (SEPA) / Adoption/Adaptation by Comment, for Argentina through the Iberopanamerican Federation of Periodontology (FIPP) of the S3 Level Clinical Practice Guideline (CPG): Treatment of periodontitis in stages I ­ III, of the European Federation of Periodontology (EFP), translated by the Spanish Society of Periodontics (SEPA)

La Sociedad Argentina de Periodoncia ha formulado un Comentario, analizando los condicionantes del contexto na- cional, para determinar si las recomendaciones generadas en la Guía de Práctica Clínica de nivel S3 de la Federación Eu- ropea de Periodoncia para el tratamiento de la periodontitis en estadios I-III, podrían ser aplicadas para dar respuesta a la demanda de la población, en lo referido a la salud periodontal (AU)

The Argentine Society of Periodontics has formulated a Commentary, analyzing the determining factors of the nation- al context, to determine if the recommendations generated in the Level S3 Clinical Practice Guideline of the European Fed- eration of Periodontics for the treatment of periodontitis in stages I-III could be applied to respond to the demand of the population, regarding periodontal health (AU)

Las normas técnicas para la formación en ingeniería biomédica, tecnología y administración en salud / Technical standards for the training in biomedical engineering, health technology and health management

Introducción: Los documentos normativos establecen el estado del arte relacionado con determinado campo del conocimiento. Existe una gran cantidad de normas relacionadas con los servicios de salud y su gestión, cuya aplicación es relevante en este sector. Objetivo: Exponer la importancia de las normas técnicas en la formación de los profesionales en ingeniería biomédica, tecnología y administración en salud. Desarrollo: Diferentes aspectos relacionados con el desempeño y las funciones de los profesionales en ingeniería biomédica, tecnología de la salud y administración en salud están recogidos en normas técnicas internacionales y en otras de carácter nacional, que resultan pertinentes y de gran utilidad para su formación en el nivel de grado y el posgrado. Conclusiones: Las profesiones abordadas requieren emplear los documentos normativos relacionados con sus funciones para contribuir con la calidad de los servicios de salud; de ahí la pertinencia de su incorporación en los planes de estudio de estas carreras(AU)

Introduction: Normative documents establish the state of the art related to a certain field of knowledge. There is a large number of standards related to health services and their management, whose application is relevant in this sector. Objective: To show the importance of technical standards in the training of professionals from the fields of biomedical engineering, health technology and health management. Development: Different aspects related to the performance and functions of professionals from the fields of biomedical engineering, health technology and health management are gathered in international and other national technical standards, relevant and useful for their training at the undergraduate and postgraduate levels. Conclusions: The addressed professions require the use of normative documents related to their functions in order to contribute to the quality of health services, hence the relevance of their incorporation into the curriculums of these major(AU)

HCFA's health care quality improvement program: the medical informatics challenge.

The peer-review organizations (PROs) were created by Congress in 1984 to monitor the cost and quality of care received by Medicare beneficiaries. In order to do this, the Health Care Financing Administration (HCFA) contracted with the PROs through a series of contracts referred to as "Scopes of Work." Under the Fourth Scope of Work, the HCFA initiated the Health Care Quality Improvement Program (HCQIP) in 1990, as an application of the principles of continuous quality improvement. Since then, the PROs have participated with health care providers in cooperative projects to improve the quality of primarily inpatient care provided to Medicare beneficiaries. Through HCFA-supplied administrative data and clinical data abstracted from patient records, the PROs have been able to identify opportunities for improvements in patient care. In May 1995, the HCFA proposed a new Fifth Scope of Work, which will shift the focus of HCQIP from inpatient care projects to projects in outpatient and managed care settings. This article describes the HCQIP process, the types of data used by the PROs to conduct cooperative projects with health care providers, and the informatics challenges in improving the quality of care received by Medicare beneficiaries.

Discrepancies between explicit and implicit review: physician and nurse assessments of complications and quality.

OBJECTIVE: To identify and characterize discrepancies between explicit and implicit medical record review of complications and quality of care. SETTING: Forty-two acute-care hospitals in California and Connecticut in 1994. STUDY DESIGN: In a retrospective chart review of 1,025 Medicare beneficiaries age >65, we compared explicit (nurse) and implicit (physician) reviews of complications and quality in individual cases. To understand discrepancies, we calculated the kappa statistic and examined physicians' comments. DATA COLLECTION: With Medicare discharge abstracts, we used the Complications Screening Program to identify and then select a stratified random sample of cases flagged for 1 of 15 surgical complications, 5 medical complications, and unflagged controls. Peer Review Organization nurses and physicians performed chart reviews. PRINCIPAL FINDINGS: Agreement about complications was fair (kappa = 0.36) among surgical and was moderate (kappa = 0.59) among medical cases. In discordant cases, physicians said that complications were insignificant, attributable to a related diagnosis, or present on admission. Agreement about quality was poor among surgical and medical cases (kappa = 0.00 and 0.13, respectively). In discordant cases, physicians said that quality problems were unavoidable, small lapses in otherwise satisfactory care, present on admission, or resulted in no adverse outcome. CONCLUSIONS: We identified many discrepancies between explicit and implicit review of complications and quality. Physician reviewers may not consider process problems that are ubiquitous in hospitals to represent substandard quality.

Can we be certain of PRO accuracy and accountability? Inaccurate "report cards" generated by medicare claims data as a marker for laboratory testing in diabetic patients.

Quality of care attributed to individual physicians will be made public more frequently in the future. Inaccurate reports could damage physicians both professionally and financially. Using claims data for services rendered to Medicare patients from 1997 through 2000, The New Jersey Peer Review Organization (PRO) reported the percentage of each physician's patients who received testing for HgB A1c and for lipid profiles. We reviewed the patient records kept by these physicians to calculate the actual percentage of patients who received these tests. A statistically significant difference existed between the PRO's data and our results. Use of claims data as a marker for services provided can lead to inaccurate inferences about the quality of care provided by individual physicians, which can have potentially negative consequences to these providers.

Medicare program; description of the Health Care Financing Administration's evaluation methodology for the Peer Review Organization 5th Scope of Work contracts--HCFA. General notice with comment period.

This notice describes how HCFA intends to evaluate the Peer Review Organizations (PROs) for quality improvement activities, under their 5th Scope of Work (SOW) contracts, for efficiency and effectiveness in accordance with the Social Security Act. In accordance with the provisions of the Government Performance and Results Act of 1993, the 5th SOW contracts with the PROs are performance-based contracts.

[Medical scientific research with people: what the law does not regulate]. / Medisch-wetenschappelijk onderzoek met mensen: waarin de wet niet voorziet.

The 'Bill on Medical Scientific Research with Humans' fail to state clearly which research may and which research may not be carried out without previous approval from a review committee. This is a problem especially with regard to studies using human body material and studies involving questioning people to collect study data. For the sake of clarity in practice it would be advisable if researchers and review committees would observe the following rules: every planned research project which involves patients or other persons having to do or to undergo something for the special purpose of the study must be submitted by the researchers to a review committee. However, actual reviewing is only necessary in the case of studies which, in the review committee's opinion, entail a real health risk or cause significant physical inconvenience or mental stress. Research involving persons who are vulnerable with respect to self-determination, such as the mentally incompetent, should always be reviewed, even if it does not seriously threaten the subjects' physical or mental well-being.

[A lack of understanding of the rulings by disciplinary committees]. / Onbegrip over tuchtrechtelijke beslissingen.

The fact that certain rulings of disciplinary committees evoked much criticism among colleagues is distressing in itself, but such criticism should be interpreted with due caution, as different explanations are conceivable. For instance, the published abstract of the committee ruling may have gaps with regard to facts and motivation. It is also possible that the committee has good grounds to accentuate the professional standards, which understandably may meet some resistance among the medical profession. Finally, it is theoretically possible that the disciplinary tribunal is not fully informed about relevant professional standards and current practice. It is precisely to minimize such possible communication breakdowns that disciplinary powers have largely been entrusted to persons from the medical profession.

The politics of medical quality: auditing doctors in the UK and the USA.

Following the 1989 white paper Working for Patients, medical audit has emerged as the principal officially-approved means of assuring the quality of NHS medical care. Beneath the surface consensus, however, significant arguments continue concerning both the purposes and the character of such audit. A 'medical model' of medical audit is in competition with a more managerial approach, while consumer interests, however unsuccessfully, are also trying to claim a role. Comparison with the system of peer review in the USA indicates that medical audit in the NHS is likely to be particularly weak with respect to public accountability. Nevertheless, when taken together with other features of the white paper's proposals, the universalization of medical audit offers managers an opportunity to begin to constrain the behaviour of hospital doctors at the local level.

The elements of provider credentialing.

HIM professionals manage patient information. But in the provider credentialing process, another kind of information management is necessary--handling the varied and important information compiled on doctors throughout the country. Here's how the credentialing process works.

Improving "medical necessity" acceptance by health care providers and consumers.

A major problem for patients and providers has existed since establishment of peer review and authorization agency medical necessity guide lines, because physicians and patients who receive denial of proposed procedures and tests on the basis of so called "medical necessity" presume that the authorization agency considers the proposed procedure or test to be medically unnecessary, meaning of no health value to the patient. This may well not be the case. Both providers and consumers can be expected to be more accepting of negative authorization decisions if the principles of continuous quality improvement are brought to bear on the authorization process.

Current and future state of FDA-CMS parallel reviews.

The US Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) recently proposed a partial alignment of their respective review processes for new medical products. The proposed "parallel review" not only offers an opportunity for some products to reach the market with Medicare coverage more quickly but may also create new incentives for product developers to conduct studies designed to address simultaneously the information needs of regulators, payers, patients, and clinicians.