Int J Qual Health Care-2001-Rubin-469-74

R rubin et al thirdly process measures can usually be

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Unformatted text preview: r faulty process; benchmarking is needed for comparisons among groups and adjusted outcomes can be difficult to understand 471 H. R. Rubin et al. Thirdly, process measures can usually be collected more quickly than outcome data for two reasons, Firstly, outcome events may be rare where only a small percentage of the patients have the outcome, requiring one to accrue a larger sample of patients. In addition, many outcomes that are important to patients, such as quality of life and functional status, may require years after the illness to evaluate, increasing the time for measurement. In contrast, care delivery occurs in a shorter period of time, and every eligible patient receives the specific process of care being evaluated. On the other hand, there are several disadvantages to process measures. Firstly, to be valid, there must be a strong relationship between the process and outcome measures. These links between process and outcomes can come from previously published evidence, or may be demonstrated for the group whose quality of care is being evaluated. The prior evidence supporting the relationship may be weak or nonexistent for many processes even when they are truly linked to outcomes. Even when studies have been carried out, they may not demonstrate true process–outcome linkages. For example, observational studies may show paradoxical associations of good care with inferior outcomes because of confounding by indication. In confounding by indication, sicker patients (who subsequently have worse outcomes) receive more or better care, setting up the paradoxical observation that good care is linked to inferior outcomes. This phenomenon is particularly problematic for patients with chronic illnesses such as asthma, for which measures of intrinsic disease severity are poor. Therefore, it may be difficult to find evidence to support valid process measures. Secondly, when evidence linking process and outcomes is absent yet providers believe the process is important, or even if...
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