Toby I.Gropen, Long Island College Hospital, 339 Hicks Street, Brooklyn, NY, 11201tgropen@chpnet.org
Patricia J. Gagliano, Cathy A. Blake, Ralph L. Sacco, Thomas Kwiatkowski, Neal J. Richmond, Dana Leifer, Richard Libman, Salman Azhar, and Maryanne B. Daley
Submitted October 05, 2006
We appreciate the interest of Ms. Downie in our article. She takes
issue with reliance of our study on process measures rather than outcome
data which we acknowledged as a limitation. However, it has been
observed that process data are usually more sensitive measures of quality
than outcome data because a poor outcome does not occur every time there
is an error in the process of care. [6]
The issue is that we must have sound
scientific evidence or a formal consensus of experts that the process of
care, when applied, leads to an improvement in health. [6] Fortunately, as
we pointed out, [1] the benefits of timely and appropriately administered t-
PA and Stroke Unit care have already been established in randomized
clinical trials.
We have a different perspective on what constitutes quality of care.
One definition encompassed by our study is technical quality of care [7]
consisting of the appropriateness of the services provided (i.e., t-PA and
Stroke Unit Care for patients with stroke) and the skill with which
appropriate care is performed (timely administration of t-PA without
increased protocol violations or complications). [1]
Another relevant
perspective on quality is that related to how well an integrated acute
stroke system of care functions. This was shown in our study by improved
access to t-PA and Stroke Unit care for patients in Brooklyn and Queens. [1]
As Ms. Downie points out, definitions of quality of care are
inherently difficult. It has been observed that several formulations
are both possible and legitimate; [5] it follows that different perspectives
on and definitions of quality of care will call for different approaches
to measurement and management. [7] Accordingly, we suspect that no study
design would address quality of care in its totality.
References
6. Brook RH, McGlynn EA, Cleary PD. Quality of health care. Part 2:
measuring quality of care. NEJM 1996;335:966-970.
7. Blumenthal D. Quality of health care. Part 1: quality of care –
what is it? NEJM 1996;335:891-893.
Disclosure: The authors report no conflicts of interest.
We appreciate the interest of Ms. Downie in our article. She takes issue with reliance of our study on process measures rather than outcome data which we acknowledged as a limitation. However, it has been observed that process data are usually more sensitive measures of quality than outcome data because a poor outcome does not occur every time there is an error in the process of care. [6]
The issue is that we must have sound scientific evidence or a formal consensus of experts that the process of care, when applied, leads to an improvement in health. [6] Fortunately, as we pointed out, [1] the benefits of timely and appropriately administered t- PA and Stroke Unit care have already been established in randomized clinical trials.
We have a different perspective on what constitutes quality of care. One definition encompassed by our study is technical quality of care [7] consisting of the appropriateness of the services provided (i.e., t-PA and Stroke Unit Care for patients with stroke) and the skill with which appropriate care is performed (timely administration of t-PA without increased protocol violations or complications). [1]
Another relevant perspective on quality is that related to how well an integrated acute stroke system of care functions. This was shown in our study by improved access to t-PA and Stroke Unit care for patients in Brooklyn and Queens. [1]
As Ms. Downie points out, definitions of quality of care are inherently difficult. It has been observed that several formulations are both possible and legitimate; [5] it follows that different perspectives on and definitions of quality of care will call for different approaches to measurement and management. [7] Accordingly, we suspect that no study design would address quality of care in its totality.
References
6. Brook RH, McGlynn EA, Cleary PD. Quality of health care. Part 2: measuring quality of care. NEJM 1996;335:966-970.
7. Blumenthal D. Quality of health care. Part 1: quality of care – what is it? NEJM 1996;335:891-893.
Disclosure: The authors report no conflicts of interest.