The J oumal of the Royal Medlco-Chlrnl'lllll8lSoelety of GlUlliOW. the Medloo-Chlrurti:lcal Society of Edlnbllrllh. and the Scottish Society for Ezperlmental Medicine Volume 20 MARCH 1975 Number 2
THE QUALITY OF HEALTH CARE H ERE could hardly be a less appropriate time in the last decade or so to initiate an examination of the quality of health care. Hospital medicine is under pressure from a number of sources. The re-organisation of the National Health Service has created considerable tensions and uncertainties among both junior hospital staff and consultants. Problems associated with conditions of service, salaries, and the general state of the fabric of Health Service are also causing vociferous and mounting concern not only by nursing staff and paramedical but also more recently by the consultants themselves. There seems to be no escaping the conclusion that the practice of medicine in the United Kingdom, particularly in hospital, is undergoing radical change and is likely to continue to do so for the next decade or so. The most important recent changes include: 1. A major shift in emphasis as a result of re-organisation from hospital medicine to general practice and to community medicine. This appears to be stimulated by the conviction that an excessive emphasis has been laid in the past on hospital medicine at the expense of general practice. An important reason for this shift in emphasis is the considerable gradient in costs between treatment by general practitioners based on the patient's home and that based on hospital. There is also the strong conviction that many cases presently being treated in hospital could be completely managed in the community at much reduced cost. 2. A pre-occupation with costs has been forced on the National Health Service not only by inflation but also by the insatiable demands for health care. These demands have been stimulated by the very existence of a comprehensive health care system and by the increasingly unrealistic expectations by the community about the usefulness of medical treatment as a solution for a widening range
T
Scottish Medical Journal
of both chronic illnessand ofsocial pathology. Given this context of reo-organisation, inflation and rising expectations, the increasing emphasis on the monitoring of the quality of health care may lead to even more change in the professional lives of all clinicians. A number of radical approaches are being proposed, aimed at improving quality. These include the proposals that: (1) the community should only be provided with the health service that it can afford. The attempt at providing a comprehensive health care system should be abandoned since the necessary finance is not available while public support for diverting the money from elsewhere in the economy is lacking; and (2) the proportion of the Gross National Product devoted to health care be increased. Until recently this possibility was regarded as quite academic but with the recent upsurge of unrest among nursing, paramedical and medical staff, this has become a serious debating point in spite of the economic situation. Statistics show that in 1969/70 the United States of America devoted 6.8 per cent of its Gross National Product to health care while Ireland devoted 5.9 per cent, Italy 6.0 per cent, and the United Kingdom 4.8 per cent. Both these approaches, however, are almost certainly politically unacceptable. Emphasis at the present moment is, therefore, being focussed on monitoring and improving the quality of the existing health care system. This task can be tackled in a number of complementary ways which include: (1) monitoring the quality of the system itself with such techniques as medical audit: (2) assessing periodically the clinical competence of the clinicians in the health care system by techniques such as self-assessment combined with a greatly extended. system of continuing medical education; and (3) a third possibility which has not been contemplated in this country but is already under active debate in North America is the
Leading
Artfdes
possibility of provisional licensure so that 'Provisional Standards Review Organisations' clinicians would be allowed to practise in (P.S.R.Os.) which are groups of clinicians in their appropriate area of medical care on an area who agree on sets of objective condition that they passed some periodic criteria or standards for measuring health assessment of their competence. However, care in their area. These criteria might include the emphasis in the United Kingdom is likely a minimum of recorded items in the history, to remain for the forseeable future on volun- physical examination, and a minimum number tary self-assessment and continuing education. of laboratory investigations with different sets of criteria for each problem or disease. Monitoring the quality of care The principle method proposed in the Monitoring of quality of health care has been United States for assessing whether an indiapproached in a number of ways. These vidual or a hospital meets this base line include: Outcome studies where the quality of care requirement is that the medical records be is assessed by the results produced; examples extracted by specially trained staff and comof this approach are perinatal and operative pared with the criteria. Those records failing to meet the criteria are referred for review mortality studies. Process studies which are concerned with by the medical panel of peers. This approach the actual techniques of health care provision will demand a revolution in the quality of such as which investigations and treatments the record keeping. It can be readily appreciated clinician carries out for his patient. They are that there are very many problems associated usually directed to arriving at criteria for the with this approach to medical audit. The problem-orientated medical record has been optimal management of clinical problems. Facilities.' Studies can be made of the facili- proposed as a basis for medical audit but ties, staff, and equipment available in particu- recent experiences with this approach is not lar hospitals to see if they meet a minimum promising (Fletcher, 1974). In the event of a hospital falling below the base-line standard. minimum requirements a programme of Accessibility. The accessibility of the health remedial education might be suggested. A care facilities can also be studied. For example reviewing geographical siting of coronary similar approach might be considered for care units so as to leave the vast bulk of the individuals. It is not at all clear how closely population within 30 minutes travelling time medical audit in the National Health Service will follow this approach (Dudley, 1974). of a coronary care unit. Acceptability. The acceptability of the The assessment of clinical competence medical care system to the consumer com- The complementary approach to monitoring munity. This is typified by the introduction of the quality of care, based on the assessment members of the public on to the managerial of clinical competence, is likely to remain 'structure of the area Health Boards. more firmly under the control of the medical Where the monitoring concerns the objec- profession itself. The importance of this area tive and systematic review of the quality of is indicated by the setting up of the Merrison care provided by clinicians, this is usually Committee of Inquiry into the regulation of called 'medical audit' and is viewed as one the medical profession., The competence of a type of 'peer review'. clinician is based on a number of key comThe topic of" medical.i.audit in North ponents. These are: (I).A command of America has become a subject of very heated relevant factual knowledge; (2) Skill in interdebate particularly since January of this year. personal relationships; (3) Certain observaIt has become part of the health policy of the .tional and interpretational skills; (4) A United Statesgoverning treatment provided number of complex decision-making skills; in the Medicare and Medicaid system that and (5) Certain attitudes such as compassion from lst January 1974, methods of monitoring or empathy thought desirable in the compeof health care be implemented on a national tent clinician. basis (Sanazaro, 1974). The newly established At the present moment the main avenue of monitoring apparatus is based on the approach to the measurement of clinical 46
Leading Articles
competence is by programmes of selfassessment initiated by the individual clinician himself. The aim of these is to increase the clinician's awareness of the deficiencies in his competence. The emphasis, however, has so far been almost entirely on the measurement of factual knowledgeby multiple choicequestions. One of the key considerations in the assessmentof competence isthat well-established clinicians of undeniable competence fare badly on multiple choice questions especially those 'emphasising basic science. Clearly competence leans much more heavily on clinical judgment than on the fragments of knowledge assessed by multiple choice questions. The next few years will see an increasing interest in techniques for measuring decisionmaking and observational skills among clinicians. The main line of approach at present is by using patient-management problems which aim to provide the clinician with a simulated clinical problem and to test his ability to handle such problems in a logical and competent fashion. An important consideration in all assessment and screening techniques of this type is to ensure that an acceptable range of individual diversity is tolerated and, indeed, encouraged. Competent clinicians vary widely in their approach to clinical problems (Taylor et al., 1971). Such variety must be safeguarded. From this review it must be obvious that the face of clinical medicine in the next decade is likely to change radically. The freedom of the individual clinician, at least in comparison with recent decades, is likely to be increasingly curtailed. As was observed earlier there could hardly be less auspicious times in which to start to subject clinicians to such close scrutiny. It is clearly an area of development in modern medicine which merits close attention. T. TAYLOR
SIDE EFFECTS OF DRUGS USED TO TREAT TUBERCULOSIS
The introduction of effective chemotherapy for tuberculosis has undoubtedly revolutionised its management and prognosis. However the price of modern antitubercular treatment is high when the side effects of the agents employed are considered. Sensitivity reactions occur in about 15 per cent of patients and other toxic effects in about the same proportion. In general allergic reactions occur between the 3rd and 6th week of therapy and comprise skin manifestations such as pruritis, erythema, papular rashes, exfoliative dermatitis and purpura. Fever with lymphadenopathy, splenomegaly and arthralgia may also occur as part of a generalised hypersensitivity reaction and are often associated with hepatitis and jaundice. It is usual in these circumstances for the blood count to show eosinophilia and an increase in the number of atypicallymphocytes. Of the commonly used antituberculous drugs streptomycin and para-aminosalicylic acid most frequently give rise to these manifestations. Allergy to streptomycin is usually of the delayed type and may often produce eczema and other forms of skin hypersensitivity in medical personnel handling the antibiotic. Anaphylaxis following administration of streptomycin occurs in hypersensitive patients but is fortunately very rare. Any of the drugs used in the past in conventional 'triple therapy' (streptomycin, para-aminosalicylic acid and isoniazid) may produce direct toxic effects. In the case of streptomycin damage to the auditory-vestibular organs is of most significance and is a particular problem in elderly patients receiving the drug over a long period. Less frequently, as with other aminoglycosides, it produces 'myasthenia-like' syndrome due to presynaptic neuromuscular blockade and in patients REFERENCES Dudley, H. (1974). Necessity for medical audit. suffering from myasthenia gravis may cause British Medical Journal, 1, 275 marked deterioration in the clinical condition. Fletcher, R. H. (1974). Auditing problem-orientated records and traditional records. New England Other less common toxic reactions include encephalopathy with nystagmus, nausea, Journal of Medicine, 2.90, 829 Sanazaro, P. (1974). Medical audit-experience in the somnolence, delirium and peripheral neuritis. U.S.A. British Medical Journal, 1, 271 Streptomycin is excreted virtually unchanged Taylor, T. R., Aitchison, J., McGirr, E. M. (1971). in the urine. It is therefore essential to Doctors as decision-makers. British Medical consider renal function whenever adminisJournal, 3, 35 47
THE QUALITY OF HEALTH CARE H ERE could hardly be a less appropriate time in the last decade or so to initiate an examination of the quality of health care. Hospital medicine is under pressure from a number of sources. The re-organisation of the National Health Service has created considerable tensions and uncertainties among both junior hospital staff and consultants. Problems associated with conditions of service, salaries, and the general state of the fabric of Health Service are also causing vociferous and mounting concern not only by nursing staff and paramedical but also more recently by the consultants themselves. There seems to be no escaping the conclusion that the practice of medicine in the United Kingdom, particularly in hospital, is undergoing radical change and is likely to continue to do so for the next decade or so. The most important recent changes include: 1. A major shift in emphasis as a result of re-organisation from hospital medicine to general practice and to community medicine. This appears to be stimulated by the conviction that an excessive emphasis has been laid in the past on hospital medicine at the expense of general practice. An important reason for this shift in emphasis is the considerable gradient in costs between treatment by general practitioners based on the patient's home and that based on hospital. There is also the strong conviction that many cases presently being treated in hospital could be completely managed in the community at much reduced cost. 2. A pre-occupation with costs has been forced on the National Health Service not only by inflation but also by the insatiable demands for health care. These demands have been stimulated by the very existence of a comprehensive health care system and by the increasingly unrealistic expectations by the community about the usefulness of medical treatment as a solution for a widening range
T
Scottish Medical Journal
of both chronic illnessand ofsocial pathology. Given this context of reo-organisation, inflation and rising expectations, the increasing emphasis on the monitoring of the quality of health care may lead to even more change in the professional lives of all clinicians. A number of radical approaches are being proposed, aimed at improving quality. These include the proposals that: (1) the community should only be provided with the health service that it can afford. The attempt at providing a comprehensive health care system should be abandoned since the necessary finance is not available while public support for diverting the money from elsewhere in the economy is lacking; and (2) the proportion of the Gross National Product devoted to health care be increased. Until recently this possibility was regarded as quite academic but with the recent upsurge of unrest among nursing, paramedical and medical staff, this has become a serious debating point in spite of the economic situation. Statistics show that in 1969/70 the United States of America devoted 6.8 per cent of its Gross National Product to health care while Ireland devoted 5.9 per cent, Italy 6.0 per cent, and the United Kingdom 4.8 per cent. Both these approaches, however, are almost certainly politically unacceptable. Emphasis at the present moment is, therefore, being focussed on monitoring and improving the quality of the existing health care system. This task can be tackled in a number of complementary ways which include: (1) monitoring the quality of the system itself with such techniques as medical audit: (2) assessing periodically the clinical competence of the clinicians in the health care system by techniques such as self-assessment combined with a greatly extended. system of continuing medical education; and (3) a third possibility which has not been contemplated in this country but is already under active debate in North America is the
Leading
Artfdes
possibility of provisional licensure so that 'Provisional Standards Review Organisations' clinicians would be allowed to practise in (P.S.R.Os.) which are groups of clinicians in their appropriate area of medical care on an area who agree on sets of objective condition that they passed some periodic criteria or standards for measuring health assessment of their competence. However, care in their area. These criteria might include the emphasis in the United Kingdom is likely a minimum of recorded items in the history, to remain for the forseeable future on volun- physical examination, and a minimum number tary self-assessment and continuing education. of laboratory investigations with different sets of criteria for each problem or disease. Monitoring the quality of care The principle method proposed in the Monitoring of quality of health care has been United States for assessing whether an indiapproached in a number of ways. These vidual or a hospital meets this base line include: Outcome studies where the quality of care requirement is that the medical records be is assessed by the results produced; examples extracted by specially trained staff and comof this approach are perinatal and operative pared with the criteria. Those records failing to meet the criteria are referred for review mortality studies. Process studies which are concerned with by the medical panel of peers. This approach the actual techniques of health care provision will demand a revolution in the quality of such as which investigations and treatments the record keeping. It can be readily appreciated clinician carries out for his patient. They are that there are very many problems associated usually directed to arriving at criteria for the with this approach to medical audit. The problem-orientated medical record has been optimal management of clinical problems. Facilities.' Studies can be made of the facili- proposed as a basis for medical audit but ties, staff, and equipment available in particu- recent experiences with this approach is not lar hospitals to see if they meet a minimum promising (Fletcher, 1974). In the event of a hospital falling below the base-line standard. minimum requirements a programme of Accessibility. The accessibility of the health remedial education might be suggested. A care facilities can also be studied. For example reviewing geographical siting of coronary similar approach might be considered for care units so as to leave the vast bulk of the individuals. It is not at all clear how closely population within 30 minutes travelling time medical audit in the National Health Service will follow this approach (Dudley, 1974). of a coronary care unit. Acceptability. The acceptability of the The assessment of clinical competence medical care system to the consumer com- The complementary approach to monitoring munity. This is typified by the introduction of the quality of care, based on the assessment members of the public on to the managerial of clinical competence, is likely to remain 'structure of the area Health Boards. more firmly under the control of the medical Where the monitoring concerns the objec- profession itself. The importance of this area tive and systematic review of the quality of is indicated by the setting up of the Merrison care provided by clinicians, this is usually Committee of Inquiry into the regulation of called 'medical audit' and is viewed as one the medical profession., The competence of a type of 'peer review'. clinician is based on a number of key comThe topic of" medical.i.audit in North ponents. These are: (I).A command of America has become a subject of very heated relevant factual knowledge; (2) Skill in interdebate particularly since January of this year. personal relationships; (3) Certain observaIt has become part of the health policy of the .tional and interpretational skills; (4) A United Statesgoverning treatment provided number of complex decision-making skills; in the Medicare and Medicaid system that and (5) Certain attitudes such as compassion from lst January 1974, methods of monitoring or empathy thought desirable in the compeof health care be implemented on a national tent clinician. basis (Sanazaro, 1974). The newly established At the present moment the main avenue of monitoring apparatus is based on the approach to the measurement of clinical 46
Leading Articles
competence is by programmes of selfassessment initiated by the individual clinician himself. The aim of these is to increase the clinician's awareness of the deficiencies in his competence. The emphasis, however, has so far been almost entirely on the measurement of factual knowledgeby multiple choicequestions. One of the key considerations in the assessmentof competence isthat well-established clinicians of undeniable competence fare badly on multiple choice questions especially those 'emphasising basic science. Clearly competence leans much more heavily on clinical judgment than on the fragments of knowledge assessed by multiple choice questions. The next few years will see an increasing interest in techniques for measuring decisionmaking and observational skills among clinicians. The main line of approach at present is by using patient-management problems which aim to provide the clinician with a simulated clinical problem and to test his ability to handle such problems in a logical and competent fashion. An important consideration in all assessment and screening techniques of this type is to ensure that an acceptable range of individual diversity is tolerated and, indeed, encouraged. Competent clinicians vary widely in their approach to clinical problems (Taylor et al., 1971). Such variety must be safeguarded. From this review it must be obvious that the face of clinical medicine in the next decade is likely to change radically. The freedom of the individual clinician, at least in comparison with recent decades, is likely to be increasingly curtailed. As was observed earlier there could hardly be less auspicious times in which to start to subject clinicians to such close scrutiny. It is clearly an area of development in modern medicine which merits close attention. T. TAYLOR
SIDE EFFECTS OF DRUGS USED TO TREAT TUBERCULOSIS
The introduction of effective chemotherapy for tuberculosis has undoubtedly revolutionised its management and prognosis. However the price of modern antitubercular treatment is high when the side effects of the agents employed are considered. Sensitivity reactions occur in about 15 per cent of patients and other toxic effects in about the same proportion. In general allergic reactions occur between the 3rd and 6th week of therapy and comprise skin manifestations such as pruritis, erythema, papular rashes, exfoliative dermatitis and purpura. Fever with lymphadenopathy, splenomegaly and arthralgia may also occur as part of a generalised hypersensitivity reaction and are often associated with hepatitis and jaundice. It is usual in these circumstances for the blood count to show eosinophilia and an increase in the number of atypicallymphocytes. Of the commonly used antituberculous drugs streptomycin and para-aminosalicylic acid most frequently give rise to these manifestations. Allergy to streptomycin is usually of the delayed type and may often produce eczema and other forms of skin hypersensitivity in medical personnel handling the antibiotic. Anaphylaxis following administration of streptomycin occurs in hypersensitive patients but is fortunately very rare. Any of the drugs used in the past in conventional 'triple therapy' (streptomycin, para-aminosalicylic acid and isoniazid) may produce direct toxic effects. In the case of streptomycin damage to the auditory-vestibular organs is of most significance and is a particular problem in elderly patients receiving the drug over a long period. Less frequently, as with other aminoglycosides, it produces 'myasthenia-like' syndrome due to presynaptic neuromuscular blockade and in patients REFERENCES Dudley, H. (1974). Necessity for medical audit. suffering from myasthenia gravis may cause British Medical Journal, 1, 275 marked deterioration in the clinical condition. Fletcher, R. H. (1974). Auditing problem-orientated records and traditional records. New England Other less common toxic reactions include encephalopathy with nystagmus, nausea, Journal of Medicine, 2.90, 829 Sanazaro, P. (1974). Medical audit-experience in the somnolence, delirium and peripheral neuritis. U.S.A. British Medical Journal, 1, 271 Streptomycin is excreted virtually unchanged Taylor, T. R., Aitchison, J., McGirr, E. M. (1971). in the urine. It is therefore essential to Doctors as decision-makers. British Medical consider renal function whenever adminisJournal, 3, 35 47
