MJ Sexton,
Pediatric Radiation Oncologist
Peter MacCAllum CAncer Institute Melbourne Australia
Send letter to journal:
Re: Quality or Inequality?
msexton{at}infoxchange.net.au MJ Sexton
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This paper raises a number of interesting questions about assessment
of quality in pediatric primary care.
The most obvious, of course, is what definition of quality is appropriate
in this study and whether the outcome studied is of itself an adequate
assessment of quality. The authors address the perspective of the provider
physician whose main concern understandably is the effectiveness of their
clinical practice. Little attention is paid to the dimensions of quality
care from the other stake holders perspective such as access, safety and
acceptability for the patient and efficiency, including cost, from the
funder’s (government and taxpayers) point of view. In fact the authors
point out that the users of the EMR system noted an increase in time of
consultation, a negative effect on efficiency and therefore access to
other patients and reduced eye to eye contact during the consult. No
assessment is made as to whether the patients perceived this reduced
access to the physician as far as both waiting times and interpersonal
communication and attention during the consult as a reduction in the
quality of their care. Users of the EMR demonstrated an improvement in
risk assessment due to the prompting in the computerized system and an
improvement in anticipatory guidance with the use of multilingual
handouts. The paper based records did not have the risk assessment
prompts. Could the same be achieved simply by updating the paper records
to include better prompting in key areas and by providing adequate
educational handouts in each clinic room without sacrificing other aspects
of quality. As the authors point out there is no evidence that an increase
in risk assessment translates to any better health outcomes. Widespread
health reforms throughout the developed world are pushing for changes in
clinician behaviors and new technological approaches to patient care in
order to improve quality of care. We must be sure that in our haste to
implement change we do not neglect to address all dimensions of care.
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