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Shekelle states in his/her commentary on socio-economic inequalities
in indicator scores for diabetes that processes but not outcomes are
reflections of quality of care. The justification for this is that there
are confounding factors in outcome measures but process measures are
“almost entirely under the control of the doctor or practice”. I believe
this to be at best an oversimplification at worse inaccurate.
As in comparing outcome data there are many factors in the processes
of medical care that make comparative conclusions about quality difficult.
Many of the inequalities that arise in the processes of care are not as
Professor Shekelle suggests, under the control of the doctor and practice.
For example, there may be language and sociocultural barriers that
may make consultations with ethnic minority groups more difficult and lead
to less of a given process being completed within a given time.
Consultations where there are language barriers obviously take longer.
However, time pressures are such that extra time is often not available
and the result is simply that less can be achieved. Cultural barriers may
also have an impact on the process of care, for instance the difficulties
involved in a male doctor examining women in certain cultures.
Smoking and obesity are more common in the low social classes whilst
the latter is more common in women. The consultation with a diabetic who
is a non smoker and within target weight is far easier and quicker than
dealing adequately with the issues with obese diabetics or smokers.
Quality is not just about data collection but applying that data to the
benefit of your patient.
Areas with a high deprivation score tend to be under-doctored this may
lead to shorter consultation times and more problems brought to the
consultation. Women are more likely to consult on behalf of family
members, need information on family planning or have children with them in
the consultation, all of which will reduce the time available to fulfil
the doctors agenda.
I think it important to appreciate these factors because the solution
is not as Shakelle suggests, to provide financial incentives to
“underperforming” practices as this implies that if the doctors try harder
then results will improve. This is not the case because many of the
problems with the delivery and process of care are not effort dependent.
I believe the solution to reducing disparity is to provide more resources
to these target areas to enable them to increase the number of healthcare
professionals, fund more chronic disease clinics, provide better training,
interpreters etc.
Inequalities: measures not related to quality
Editor
British Medical Journal
Dear Editor:
Shekelle states in his/her commentary on socio-economic inequalities
in indicator scores for diabetes that processes but not outcomes are
reflections of quality of care. The justification for this is that there
are confounding factors in outcome measures but process measures are
“almost entirely under the control of the doctor or practice”. I believe
this to be at best an oversimplification at worse inaccurate.
As in comparing outcome data there are many factors in the processes
of medical care that make comparative conclusions about quality difficult.
Many of the inequalities that arise in the processes of care are not as
Professor Shekelle suggests, under the control of the doctor and practice.
For example, there may be language and sociocultural barriers that
may make consultations with ethnic minority groups more difficult and lead
to less of a given process being completed within a given time.
Consultations where there are language barriers obviously take longer.
However, time pressures are such that extra time is often not available
and the result is simply that less can be achieved. Cultural barriers may
also have an impact on the process of care, for instance the difficulties
involved in a male doctor examining women in certain cultures.
Smoking and obesity are more common in the low social classes whilst
the latter is more common in women. The consultation with a diabetic who
is a non smoker and within target weight is far easier and quicker than
dealing adequately with the issues with obese diabetics or smokers.
Quality is not just about data collection but applying that data to the
benefit of your patient.
Areas with a high deprivation score tend to be under-doctored this may
lead to shorter consultation times and more problems brought to the
consultation. Women are more likely to consult on behalf of family
members, need information on family planning or have children with them in
the consultation, all of which will reduce the time available to fulfil
the doctors agenda.
I think it important to appreciate these factors because the solution
is not as Shakelle suggests, to provide financial incentives to
“underperforming” practices as this implies that if the doctors try harder
then results will improve. This is not the case because many of the
problems with the delivery and process of care are not effort dependent.
I believe the solution to reducing disparity is to provide more resources
to these target areas to enable them to increase the number of healthcare
professionals, fund more chronic disease clinics, provide better training,
interpreters etc.
Sincerely,
Dr Sean Allen MBChB MRCP
Salaried General Practitioner
Competing interests:
None declared
Competing interests: No competing interests