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Quality of Care for Patients Infected with HIV - EDITORIAL COMMENTARY
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Clinical Infectious Diseases 2010 Aug 17 Epub
"it is a very well done effort that gathered broad input and has an unusually wide base of sponsoring organizations, several of which have endorsed all or most of the measures for use. Importantly, the existence of the work of Horberg et al [12] means that HIV infection joins the ranks of chronic diseases for which standards of care are well established. That is, it is another marker of HIV care growing up. HIV providers should take note, since patients, health care systems, and payers should and will."
Samuel A. Bozzette
The University of California, San Diego, and The RAND Corporation, Santa Monica, California
(See the article by Horberg et al, on pages XXX-XX.)
In 2001, the very influential Institute of Medicine report Crossing the Quality Chasm led to a new emphasis on quality in health care [1]. Shortly thereafter, studies showing that care often did not meet professional standards heightened concerns and increased efforts to develop widely accepted quality standards for routine use [2-4]. Calls to measure the quality of care for patients infected with human immunodeficiency virus (HIV) soon followed [5].
The foundation for thinking about health care quality was laid out many years ago by a physician named Avedis Donabedian [6]. The key elements were the structure of care, including the physical and human environment and administrative systems; the process of care, or what is done for the patient; and the outcomes of care. Despite the increasing emphasis on outcomes (especially at the health care system level), outcomes are notoriously difficult to use for the individual level, because it is so difficult to define the unimprovable outcome in the individual case. The structure of care is outside of the provider-patient interaction. Therefore, process of care measures dominate quality measurement in most settings.
Quality process of care is assessed by first establishing the elements or criteria for high-quality care. Next, measures of quality are developed that include details such as the content of the numerator and denominator (ie, which patients should be included). Finally, standards are established to define the range of acceptable variation for a measure, because it is unrealistic and inappropriate to expect that good care will always include 100% fulfillment of a particular measure. Quality of care measures and standards now exist for dozens of conditions.
Quality process of care for HIV has been known to be important, because experience was shown to be a key predictor of outcome for persons with Pneumocystis pneumonia [7]. Defining quality process of care has been more elusive. In the early days of HIV care, this was in part because the care changed so rapidly. Indeed, an old joke was that malpractice in HIV care was what the experts said to do last year. As HIV care became more complex, the need for standardization and guidance became clearer, and several efforts to establish continuing guidelines were begun [8-10]. Some organizations, perhaps most notably the New York State Department of Health AIDS Institute, produced detailed quality criteria and measures [11]. However, until the work of Horberg et al [12] in this issue of Clinical Infectious Diseases, there was no effort at creating national consensus measures.
It is possible to pick on Horberg et al. It might have been better if they had used a formal process, such as a modified Delphi, to measure consensus. Some experts may feel that the bar is set too low in some areas. However, it is a very well done effort that gathered broad input and has an unusually wide base of sponsoring organizations, several of which have endorsed all or most of the measures for use. Importantly, the existence of the work of Horberg et al [12] means that HIV infection joins the ranks of chronic diseases for which standards of care are well established. That is, it is another marker of HIV care growing up. HIV providers should take note, since patients, health care systems, and payers should and will.
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