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November 19, 1997, Vol 278, No. 19 >
ARTICLE | November 19, 1997

Health Care Quality: Title and subTitle BreakIncorporating Consumer Perspectives FREE

Paul D. Cleary, PhD; Susan Edgman-Levitan, PA
[+] Author Affiliations

Presented in part before Quality Challenge Areas Across Perspectives and the Role of AHCPR; Washington, DC; February 10, 1997.

Reprints: Paul D. Cleary, PhD, Department of Health Care Policy, 180 Longwood Ave, Boston, MA 02115.


JAMA. 1997;278(19):1608-1612. doi:10.1001/jama.1997.03550190072047
Text Size: A A A
Published online
Article
References

The goal of this article is to address, from the perspective of users of the health care system (consumers), the following questions: What are the most important health care quality gaps and/or challenges; what major changes should we anticipate in this area in the near future; and what should be the role of federal and state agencies, accreditation organizations, and philanthropic foundations in addressing these challenges? We discuss the needs, challenges, and potential action steps for increasing the prominence of the user's perspective in 3 areas: (1) the conceptualization and definition of quality; (2) the measurement of quality; and (3) routine quality assessment and improvement. The article concludes by making recommendations about the role that different agencies and organizations can and should play in meeting these challenges.

REFERENCES

1 +
Cleary PD, McNeil BJ.  Patient satisfaction as an indicator of quality of care . Inquiry . 1988;;25:25-36.
2 +
Lohr KN, Yordy KD, Thier SO.  Current issues in quality of care . Health Aff (Millwood) . 1988;;7:5-18.
3 +
Donabedian A.  Quality assessment and assurance: unity of purpose, diversity of means . Inquiry . 1988;;25:173-192.
4 +
Jencks SF, Wilensky GR.  The health care quality improvement initiative: a new approach to quality assurance in medicine . JAMA . 1992;;268:900-903.
5 +
Siu AL, McGlynn EA, Morgenstern H, Brook RH.  A fair approach to comparing quality of care . Health Aff (Millwood) . 1991;;10:62-75.
6 +
Kassirer JP.  The quality of care and the quality of measuring it . N Engl J Med . 1993;;329:1263-1265.
7 +
Epstein A.  Performance reports on quality: prototypes, problems, and prospects . N Engl J Med . 1995;;333:57-61.
8 +
Brook RH, McGlynn EA, Cleary PD.  Measuring quality of care . N Engl J Med . 1996;;335:966-970.
9 +
Davies AR, Ware JE Jr.  Involving consumers in quality of care assessment . Health Aff (Millwood) . 1988;;7:33-48.
10 +
Cleary PD, Edgman-Levitan S, Roberts M, et al.  Patients evaluate their hospital care: a national survey . Health Aff (Millwood) . 1991;;10:254-267.
11 +
Cleary PD, Edgman-Levitan S, McMullen W, et al.  A national survey of hospital patients: the relationship between reported problems with care and patient evaluations . Qual Rev Bull . 1992;;18:53-59.
12 +
Cleary PD, Fahs MC, McMullen W, et al.  Using patient reports to assess hospital treatment of persons with AIDS: a pilot study . AIDS Care . 1992;;4:325-332.
13 +
Cleary PD, Edgman-Levitan S, Walker JD, et al.  Using patient reports to improve medical care: a preliminary report from ten hospitals . Qual Manage Health Care . 1993;;2:31-38.
14 +
Gerteis M, Edgman-Levitan S, Walker JD, Stokes DM, Cleary PD, Delbanco TL.  What patients really want . Health Manage Q . 1993;;third quarter:2-6.
15 +
Edgman-Levitan S, Cleary PD.  What information do consumers want and need? Health Aff (Mill-wood) . 1996;;15:42-56.
16 +
Cleary PD, Greenfield S, Mulley AG, et al.  Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California . JAMA . 1991;;266:73-79.
17 +
Cleary PD, Greenfield S, McNeil BJ.  Assessing quality of life after surgery . Control Clin Trials . 1991;;12:189S-203S.
18 +
Cleary PD, Epstein AM, Oster G, et al.  Health-related quality of life among patients undergoing percutaneous transluminal coronary angioplasty . Med Care . 1991;;29:939-950.
19 +
Cleary PD, Reilly DT, Greenfield S, et al.  Using patient reports to assess health related quality of life after total hip replacement . Qual Life Res . 1993;; 2:3-11.
20 +
Cleary PD, Fowler FJ Jr, Weissman J, et al.  Health-related quality of life in persons with AIDS . Med Care . 1993;;31:569-580.
21 +
Tsevat J, Weeks JC, Guadagnoli E, et al.  Using health-related quality of life information: clinical encounters, clinical trials, and health policy . J Gen Intern Med . 1994;;9:576-581.
22 +
Cleary PD, Morrissey G, Yver A, Oster G.  The effects of rG-CSF on health-related quality of life in children with congenital agranulocytosis . Qual Life Res . 1994;;3:307-315.
23 +
Wilson IB, Cleary PD.  Linking clinical variables with health-related quality of life: a causal model of patient outcomes . JAMA . 1995;;273:59-65.
24 +
Guadagnoli E, Hauptman PJ, Ayanian JZ, Pashos CL, McNeil BJ, Cleary PD.  Variation in the use of cardiac procedures following acute myocardial infarction: a comparison of practice in two states . N Engl J Med . 1995;;333:573-578.
25 +
Cleary PD, Morrissey G, Oster G.  Health-related quality of life in patients with advanced prostate cancer: a multinational perspective . Qual Life Res . 1995;;4:207-220.
26 +
McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Questionnaires . 2nd ed. New York, NY: Oxford University Press; 1996;.
27 +
Croog SH, Levine S, Testa MA, et al.  The effects of antihypertensive therapy on the quality of life . N Engl J Med . 1986;;314:1657-1664.
28 +
Bombardier C, Ware J, Russell IJ, et al, and the Auranofin Cooperating Group.  Auranofin therapy and quality of life in patients with rheumatoid arthritis . Am J Med . 1986;;81:565-578.
29 +
Parkerson GR, Broadhead WE, Tse CJ.  The Duke health profile: a 17-item measure of health and dysfunction . Med Care . 1990;;28:1056-1072.
30 +
Hunt SM, McEwen J, McKenna SP.  Measuring health status: a new tool for clinicians and epidemiologists . J R Coll Gen Pract . 1985;;35:185-188.
31 +
Nelson EC, Wasson JH, Krik JW.  Assessment of function in routine clinical practice: description of the COOP chart method and preliminary findings . J Chronic Dis . 1987;;40( (suppl 1) ):55S-63S.
32 +
McHorney CA, Ware JE, Rogers W, Raczek AE, Lu JFR.  The validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts . Med Care . 1992;;30:MS253-MS265.
33 +
McHorney CA, Ware JE Jr, Raczek AE.  The MOS 36-item short-form health survey (SF-36), II: psychometric and clinical tests of validity in measuring physical and mental health conditions . Med Care . 1993;;31:247-263.
34 +
McHorney CA, Ware JE, Lu JFR, Sherbourne CD.  The MOS short-form health survey (SF-36), III: tests of data quality, scaling assumptions, and reliability across diverse patient groups . Med Care . 1994;;32:40-66.
35 +
Canadian Erythropoietin Study Group.  Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis . BMJ . 1990;;300:573-578.
36 +
Stewart AL, Hays RD, Ware JE Jr.  The MOS short-form General Health Survey: reliability and validity in a patient population . Med Care . 1988;;26:724-735.
37 +
Ware JE, Sherbourne CD.  The MOS 36-item short-form health survey (SF-36), 1: conceptual framework and item selection . Med Care . 1992;;30:473-483.
38 +
Hibbard JH, Jewett JJ.  Will quality report cards help consumers? Health Aff (Millwood) . 1997;;16:218-228.
39 +
Hibbard JH, Jewett JJ.  What type of quality information do consumers want in a health care report card? Med Care Res Rev . 1996;;53:28-47.
40 +
Acs G, Marquis MS, Long SH, Short PF.  Self-insured employer health plans: prevalence, profile, provisions, and premiums . Health Aff (Millwood) . 1996;;15:266-278.
41 +
Robinson S, Brodie M.  Understanding the quality challenge for health consumers: the Kaiser/ACHPR survey . Jt Comm J Qual Improve . 1997;;23:239-244.
42 +
Cleary PD, Rogers TF, Singer E, et al.  Health education about AIDS among seropositive blood donors . Health Educ Q . 1986;;13:317-329.
43 +
Cleary PD, Hitchcock JL, Semmer N, Flinchbaugh LJ, Pinney JM.  Adolescent smoking: research and health policy . Milbank Q . 1988;;66:185-235.
44 +
Cleary PD.  Illness behavior: a multidisciplinary model . In: McHugh S, Vallis TM, eds. New Directions in Illness Behavior Research . New York, NY: Plenum Press; 1986;:119-149.
45 +
Cleary PD.  Why people take precautions against health risks . In: Weinstein ND, ed. Taking Care: Understanding and Encouraging Self-protective Behavior . New York, NY: Cambridge University Press; 1987;:119-149.
46 +
Gustafson DH, Bosworth K, Chewing B, Hawkins RP.  Computer-based health promotion: combining technological advances with problem-solving techniques to effect successful health behavior changes . Annu Rev Public Health . 1987;;8:387-415.
47 +
Gustafson D, Wise M, McTavish F, et al.  Development and pilot evaluation of a computer-based support system for women with breast cancer . J Psychosoc Oncol . 1993;;11:69-93.
48 +
Gold MR, Hurley R, Lake T, Ensor T, Berenson R.  A national survey of the arrangements managed-care plans make with physicians . N Engl J Med . 1995;;333:1678-1683.
49 +
Eisenhardt KM,  Control: organizational and economic approaches . Manage Sci . 1985;;31:134-149.
50 +
Goss MEW.  Influence and authority among physicians in an outpatient clinic . Am Sociol Rev . 1961;;26:39-50.
51 +
Lincoln JR, Kalleberg AL. Culture, Control, and Commitment: A Study of Work Organization and Work Attitudes in the United States and Japan . New York, NY: Cambridge University Press; 1990;.
52 +
Scott RW.  Managing professional work: three models of control for health organizations . Health Serv Res . 1982;;17:213-240.
53 +
Ziskind AA, Portelli J, Rodrigues S, Stafford JL, Herzog WR.  Successful use of education and cost-based feedback strategies to reduce physician utilization of low-osmolality contrast agents in the cardiac catheterization laboratory . Am J Cardiology . 1994;;73:1219-1221.
54 +
Weingarten S, Agocs L, Tankel N, Sheng A, Ellrodt AG.  Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders . Am J Cardiol . 1993;;71:259-262.
55 +
Schectman JM, Elinsky EG, Pawlson LG.  Effect of education and feedback on thyroid function testing strategies of primary care clinicians . Arch Intern Med . 1991;;151:2163-2166.
56 +
Spiegel JS, Shapiro MF, Berman B, Greenfield S.  Changing physician test ordering in a university hospital: an intervention of physician participation, explicit criteria, and feedback . Arch Intern Med . 1989;;149:549-553.
57 +
Pugh JA, Fazier LM, DeLong E, Wallace AG, Ellenbogen R, Linfors E.  Effect of daily charge feedback on inpatient charges and physician knowledge and behavior . Arch Intern Med . 1989;;149:426-429.
58 +
Eagle KA, Mulley AG, Skates SJ, et al.  Length of stay in the intensive care unit: effects of practice guidelines and feedback . JAMA . 1990;;264:992-997.
59 +
Schectman JM, Kanwal NK, Schroth WS, Elinsky EG.  The effect of an education and feedback intervention on group-model and network-model health maintenance organization physician prescribing behavior . Med Care . 1995;;33:139-144.
60 +
Levinson DF.  Toward full disclosure of referral restrictions and financial incentives by prepaid health plans . N Engl J Med . 1987;;317:1729-1733.
61 +
Appelbaum PS.  Must we forgo informed consent to control health care costs? Milbank Q . 1993;;71:669-676.

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Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Cleary PD, McNeil BJ.  Patient satisfaction as an indicator of quality of care . Inquiry . 1988;;25:25-36.
2 +
Lohr KN, Yordy KD, Thier SO.  Current issues in quality of care . Health Aff (Millwood) . 1988;;7:5-18.
3 +
Donabedian A.  Quality assessment and assurance: unity of purpose, diversity of means . Inquiry . 1988;;25:173-192.
4 +
Jencks SF, Wilensky GR.  The health care quality improvement initiative: a new approach to quality assurance in medicine . JAMA . 1992;;268:900-903.
5 +
Siu AL, McGlynn EA, Morgenstern H, Brook RH.  A fair approach to comparing quality of care . Health Aff (Millwood) . 1991;;10:62-75.
6 +
Kassirer JP.  The quality of care and the quality of measuring it . N Engl J Med . 1993;;329:1263-1265.
7 +
Epstein A.  Performance reports on quality: prototypes, problems, and prospects . N Engl J Med . 1995;;333:57-61.
8 +
Brook RH, McGlynn EA, Cleary PD.  Measuring quality of care . N Engl J Med . 1996;;335:966-970.
9 +
Davies AR, Ware JE Jr.  Involving consumers in quality of care assessment . Health Aff (Millwood) . 1988;;7:33-48.
10 +
Cleary PD, Edgman-Levitan S, Roberts M, et al.  Patients evaluate their hospital care: a national survey . Health Aff (Millwood) . 1991;;10:254-267.
11 +
Cleary PD, Edgman-Levitan S, McMullen W, et al.  A national survey of hospital patients: the relationship between reported problems with care and patient evaluations . Qual Rev Bull . 1992;;18:53-59.
12 +
Cleary PD, Fahs MC, McMullen W, et al.  Using patient reports to assess hospital treatment of persons with AIDS: a pilot study . AIDS Care . 1992;;4:325-332.
13 +
Cleary PD, Edgman-Levitan S, Walker JD, et al.  Using patient reports to improve medical care: a preliminary report from ten hospitals . Qual Manage Health Care . 1993;;2:31-38.
14 +
Gerteis M, Edgman-Levitan S, Walker JD, Stokes DM, Cleary PD, Delbanco TL.  What patients really want . Health Manage Q . 1993;;third quarter:2-6.
15 +
Edgman-Levitan S, Cleary PD.  What information do consumers want and need? Health Aff (Mill-wood) . 1996;;15:42-56.
16 +
Cleary PD, Greenfield S, Mulley AG, et al.  Variations in length of stay and outcomes for six medical and surgical conditions in Massachusetts and California . JAMA . 1991;;266:73-79.
17 +
Cleary PD, Greenfield S, McNeil BJ.  Assessing quality of life after surgery . Control Clin Trials . 1991;;12:189S-203S.
18 +
Cleary PD, Epstein AM, Oster G, et al.  Health-related quality of life among patients undergoing percutaneous transluminal coronary angioplasty . Med Care . 1991;;29:939-950.
19 +
Cleary PD, Reilly DT, Greenfield S, et al.  Using patient reports to assess health related quality of life after total hip replacement . Qual Life Res . 1993;; 2:3-11.
20 +
Cleary PD, Fowler FJ Jr, Weissman J, et al.  Health-related quality of life in persons with AIDS . Med Care . 1993;;31:569-580.
21 +
Tsevat J, Weeks JC, Guadagnoli E, et al.  Using health-related quality of life information: clinical encounters, clinical trials, and health policy . J Gen Intern Med . 1994;;9:576-581.
22 +
Cleary PD, Morrissey G, Yver A, Oster G.  The effects of rG-CSF on health-related quality of life in children with congenital agranulocytosis . Qual Life Res . 1994;;3:307-315.
23 +
Wilson IB, Cleary PD.  Linking clinical variables with health-related quality of life: a causal model of patient outcomes . JAMA . 1995;;273:59-65.
24 +
Guadagnoli E, Hauptman PJ, Ayanian JZ, Pashos CL, McNeil BJ, Cleary PD.  Variation in the use of cardiac procedures following acute myocardial infarction: a comparison of practice in two states . N Engl J Med . 1995;;333:573-578.
25 +
Cleary PD, Morrissey G, Oster G.  Health-related quality of life in patients with advanced prostate cancer: a multinational perspective . Qual Life Res . 1995;;4:207-220.
26 +
McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Questionnaires . 2nd ed. New York, NY: Oxford University Press; 1996;.
27 +
Croog SH, Levine S, Testa MA, et al.  The effects of antihypertensive therapy on the quality of life . N Engl J Med . 1986;;314:1657-1664.
28 +
Bombardier C, Ware J, Russell IJ, et al, and the Auranofin Cooperating Group.  Auranofin therapy and quality of life in patients with rheumatoid arthritis . Am J Med . 1986;;81:565-578.
29 +
Parkerson GR, Broadhead WE, Tse CJ.  The Duke health profile: a 17-item measure of health and dysfunction . Med Care . 1990;;28:1056-1072.
30 +
Hunt SM, McEwen J, McKenna SP.  Measuring health status: a new tool for clinicians and epidemiologists . J R Coll Gen Pract . 1985;;35:185-188.
31 +
Nelson EC, Wasson JH, Krik JW.  Assessment of function in routine clinical practice: description of the COOP chart method and preliminary findings . J Chronic Dis . 1987;;40( (suppl 1) ):55S-63S.
32 +
McHorney CA, Ware JE, Rogers W, Raczek AE, Lu JFR.  The validity and relative precision of MOS short- and long-form health status scales and Dartmouth COOP charts . Med Care . 1992;;30:MS253-MS265.
33 +
McHorney CA, Ware JE Jr, Raczek AE.  The MOS 36-item short-form health survey (SF-36), II: psychometric and clinical tests of validity in measuring physical and mental health conditions . Med Care . 1993;;31:247-263.
34 +
McHorney CA, Ware JE, Lu JFR, Sherbourne CD.  The MOS short-form health survey (SF-36), III: tests of data quality, scaling assumptions, and reliability across diverse patient groups . Med Care . 1994;;32:40-66.
35 +
Canadian Erythropoietin Study Group.  Association between recombinant human erythropoietin and quality of life and exercise capacity of patients receiving haemodialysis . BMJ . 1990;;300:573-578.
36 +
Stewart AL, Hays RD, Ware JE Jr.  The MOS short-form General Health Survey: reliability and validity in a patient population . Med Care . 1988;;26:724-735.
37 +
Ware JE, Sherbourne CD.  The MOS 36-item short-form health survey (SF-36), 1: conceptual framework and item selection . Med Care . 1992;;30:473-483.
38 +
Hibbard JH, Jewett JJ.  Will quality report cards help consumers? Health Aff (Millwood) . 1997;;16:218-228.
39 +
Hibbard JH, Jewett JJ.  What type of quality information do consumers want in a health care report card? Med Care Res Rev . 1996;;53:28-47.
40 +
Acs G, Marquis MS, Long SH, Short PF.  Self-insured employer health plans: prevalence, profile, provisions, and premiums . Health Aff (Millwood) . 1996;;15:266-278.
41 +
Robinson S, Brodie M.  Understanding the quality challenge for health consumers: the Kaiser/ACHPR survey . Jt Comm J Qual Improve . 1997;;23:239-244.
42 +
Cleary PD, Rogers TF, Singer E, et al.  Health education about AIDS among seropositive blood donors . Health Educ Q . 1986;;13:317-329.
43 +
Cleary PD, Hitchcock JL, Semmer N, Flinchbaugh LJ, Pinney JM.  Adolescent smoking: research and health policy . Milbank Q . 1988;;66:185-235.
44 +
Cleary PD.  Illness behavior: a multidisciplinary model . In: McHugh S, Vallis TM, eds. New Directions in Illness Behavior Research . New York, NY: Plenum Press; 1986;:119-149.
45 +
Cleary PD.  Why people take precautions against health risks . In: Weinstein ND, ed. Taking Care: Understanding and Encouraging Self-protective Behavior . New York, NY: Cambridge University Press; 1987;:119-149.
46 +
Gustafson DH, Bosworth K, Chewing B, Hawkins RP.  Computer-based health promotion: combining technological advances with problem-solving techniques to effect successful health behavior changes . Annu Rev Public Health . 1987;;8:387-415.
47 +
Gustafson D, Wise M, McTavish F, et al.  Development and pilot evaluation of a computer-based support system for women with breast cancer . J Psychosoc Oncol . 1993;;11:69-93.
48 +
Gold MR, Hurley R, Lake T, Ensor T, Berenson R.  A national survey of the arrangements managed-care plans make with physicians . N Engl J Med . 1995;;333:1678-1683.
49 +
Eisenhardt KM,  Control: organizational and economic approaches . Manage Sci . 1985;;31:134-149.
50 +
Goss MEW.  Influence and authority among physicians in an outpatient clinic . Am Sociol Rev . 1961;;26:39-50.
51 +
Lincoln JR, Kalleberg AL. Culture, Control, and Commitment: A Study of Work Organization and Work Attitudes in the United States and Japan . New York, NY: Cambridge University Press; 1990;.
52 +
Scott RW.  Managing professional work: three models of control for health organizations . Health Serv Res . 1982;;17:213-240.
53 +
Ziskind AA, Portelli J, Rodrigues S, Stafford JL, Herzog WR.  Successful use of education and cost-based feedback strategies to reduce physician utilization of low-osmolality contrast agents in the cardiac catheterization laboratory . Am J Cardiology . 1994;;73:1219-1221.
54 +
Weingarten S, Agocs L, Tankel N, Sheng A, Ellrodt AG.  Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders . Am J Cardiol . 1993;;71:259-262.
55 +
Schectman JM, Elinsky EG, Pawlson LG.  Effect of education and feedback on thyroid function testing strategies of primary care clinicians . Arch Intern Med . 1991;;151:2163-2166.
56 +
Spiegel JS, Shapiro MF, Berman B, Greenfield S.  Changing physician test ordering in a university hospital: an intervention of physician participation, explicit criteria, and feedback . Arch Intern Med . 1989;;149:549-553.
57 +
Pugh JA, Fazier LM, DeLong E, Wallace AG, Ellenbogen R, Linfors E.  Effect of daily charge feedback on inpatient charges and physician knowledge and behavior . Arch Intern Med . 1989;;149:426-429.
58 +
Eagle KA, Mulley AG, Skates SJ, et al.  Length of stay in the intensive care unit: effects of practice guidelines and feedback . JAMA . 1990;;264:992-997.
59 +
Schectman JM, Kanwal NK, Schroth WS, Elinsky EG.  The effect of an education and feedback intervention on group-model and network-model health maintenance organization physician prescribing behavior . Med Care . 1995;;33:139-144.
60 +
Levinson DF.  Toward full disclosure of referral restrictions and financial incentives by prepaid health plans . N Engl J Med . 1987;;317:1729-1733.
61 +
Appelbaum PS.  Must we forgo informed consent to control health care costs? Milbank Q . 1993;;71:669-676.

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