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To the Editor,
This article covers key aspects of quality medical care for patients. The basis of modern approach to improve the care quality is clinical guidelines, clinical audit and registers of diseases. The development of evidence-based medicine ensures that the personal experience of physicians ceases to be a leader in the treatment of patients. Evidences of emerging studies of interventions that are effective in the treating various diseases are accumulated in clinical guidelines for physicians. Quality of health care is determined by full physicians’ compliance with clinical guidelines. However, implementing clinical guidelines into clinical practice remains a major public health problem.1-4
In economically developed countries, results of evidence-based medical research used to reduce the costs associated with ineffective medical care.5,6 In some countries, the problem of providing quality medical care to patients is successfully solved by development of quality improvement programs. These programs provide structure, timing and sequence of activities to improve the medical care quality. An example is a program to improve the medical care quality for patients with acute coronary syndrome (ACS), which was published in 2000 and was revised in 2008.7,8 Initially the focus was on timely thrombolysis in all ACS patients with elevation ST. This program has achieved its goal in most patients due to its implementation at the state level. In 2008, the focus has shifted to the availability and timeliness of primary angioplasty in ACS patients.
The implementation of such tasks is impossible without an adequate system to measure results. The key to quality care management is the development of clinical indicators. Clinical indicators are criteria for the implementation of clinical guidelines in clinical practice. Recently, the development of clinical guidelines was accompanied by the development of quality care indicators. For example in 2008, guidelines for familial hypercholesterolemia,9 and criteria for evaluating their performance was established.10
However, the system of clinical indicators is not enough for improvements in the quality of medical care, it also requires clinical indicators. The effectiveness of this method has been proven for many years. Clinical audit is a systematic evaluation of care quality by experts in order to improve quality of care, based on the adequate use of clinical indicators.11,12
The objectives of clinical audit are:
- Identifying deficiencies of health care and to develop measures to improve these,
- monitoring the implementation of improvements,
- Prevention of medical care errors.
Clinical audit is a cyclical process. Audit cycle consists of the following activities:
1) Identifying the problem to be solved,
2) Selection or development of clinical standards and clinical indicators for evaluation of clinical practice,
3) Comparison of clinical practice with clinical standard on the basis of clinical indicators,
4) Identifying reasons for problems of care,
5) Implementation of changes in medical care,
6) Evaluation of final effect of this implementation.
To solve most problems, one cycle of clinical audit is not enough. This cycle must be repeated until such time all problems are solved. The meaning of clinical audit is to assess the implementation of clinical guidelines in clinical practice. Therefore, one of the important goals is getting information about the clinical practice. The main sources of information on clinical practice are the registers of diseases.13 For example, the availability of the registry of arterial hypertension is itself an indicator of quality of care to patients with hypertension.14 The data of registers is processed by the expert group. Their final report on care quality assessment shall be communicated to all stakeholders.
National Institute for Health and Clinical Excellence (www.nice.org.uk) is one of the largest organizations dealing with quality of medical care. This organization publishes regular reports on care quality for patients with major social diseases and prepares evidence-based strategies for improving the care quality.
The main properties of the quality management system of care should be:
- Systematic approach;
- The duration and continuity of implementation;
- Public interest and support;
- involving a wide range of stakeholders;
- Transparency;
- basing on the data of evidence-based medicine;
- focus on the patient.
This system is constantly evolving, searching new areas and new ways of improving quality.An indisputable indicator of the success of modern model of quality care management is a steady decline in mortality from cardiovascular disease, which observed since 1980 according to the study Euro Heart Survey.15
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References
1. Seddon ME, Marshall MN, Campbell SM, Roland MO. Systematic review of studies of quality of clinical care in general practice in the UK, Australia and New Zealand. Qual Health Care 2001 Sep;10(3):152-158.
2. Cuspidi C, Michev I, Meani S, Severgnini B, Sala C, Salerno M, et al; Lombardy Regional Section of the Italian Society of Hypertension. Awareness of hypertension guidelines in primary care: results of a regionwide survey in Italy. J Hum Hypertens 2003 Aug;17(8):541-547.
3. Cuspidi C, Michev I, Lonati L, Vaccarella A, Cristofari M, Garavelli G, et al; Lombardy Regional Section of Italian Society of Hypertension. Compliance to hypertension guidelines in clinical practice: a multicentre pilot study in Italy. J Hum Hypertens 2002 Oct;16(10):699-703.
4. Andrade SE, Gurwitz JH, Field TS, Kelleher M, Majumdar SR, Reed G, et al. Hypertension management: the care gap between clinical guidelines and clinical practice. Am J Manag Care 2004 Jul;10(7 Pt 2):481-486.
5. Allender S, Scarborough P, Peto V, Rayner M, Leal J, Luengo-Fernandez R. G et al. European cardiovascular disease statistics., Department of Public Health, University of Oxford., 2008.
6. Scarborough P, Bhatnagar P, Wickramasinghe K, Smolina K, Mitchell C, Rayner M. Coronary heart disease statistics, 2010 edition., British Heart Foundation: London, 2010.
7. National Service Framework for Coronary Heart Disease. Chapter Three Heart attacks & other acute coronary syndromes., National Health Service (NHS), 2000.
8. DH Vascular Programme Team. Treatment of heart attack national guidance, final report of the national infarct angioplasty project (NIAP)., Department of Health (DH), 2008.
9. DeMott K, Nherera L, Shaw EJ, et al. Clinical Guidelines and Evidence Review for Familial hypercholesterolaemia: the identification and management of adults and children with familial hypercholesterolaemia., London: National Collaborating Centre for Primary Care and Royal College of General Practitioners, 2008.
10. Familial hypercholesterolaemia: audit support., NHS. 2008.
11. Dixon N. 4th ed. Medical Audit Primer. Hampshire: Hampshire Healthcare Quality Quest; 1991.
12. Crombie J, Davis H, Abracham S, Florey C du V. Audit Handbook. Chichester, 1997.
13. Gitt AK, Bueno H, Danchin N, Fox K, Hochadel M, Kearney P, et al. The role of cardiac registries in evidence-based medicine. Eur Heart J 2010 Mar;31(5):525-529.
14. NHS Employers and the General Practitioners Committee. Quality and Outcomes Framework Guidance for GMS Contract 2009/10.
15. Scholte op Reimer WJM, Gitt AK, Boersma E, et al. Cardiovascular Diseases in Europe. Euro Heart Survey., Sophia Antipolis: European Society of Cardiology, 2006.
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