History of routine health outcomes measurement Routine health outcomes measurement

1 history of routine health outcomes measurement

1.1 florence nightingale
1.2 ernest amory codman
1.3 avedis donabedian

history of routine health outcomes measurement
florence nightingale

an example of routine clinical outcomes system set florence nightingale in crimean war. outcome under study death. context season , cause of death– wounds, infections , other cause. interventions nursing , administrative. arrived before barracks in scutari accepting first soldiers wounded @ battle of inkerman in november 1854, , mortality high. appalled @ disorganisation , standards of hygiene , set cleaning , reorganisation. however, mortality continued rise. after sewers cleared , ventilation improved in march 1856 mortality fell. on return uk reflected on these data , produced new sorts of chart (she had trained in mathematics rather worsted work , practising quadrilles ) show these excess deaths caused living conditions rather than, believed, poor nutrition. showed soldiers in peacetime had excess mortality on other young men, presumably same causes. reputation damaged, however, when , william farr, registrar general, collaborated in producing table appeared show mortality in london hospitals of on 90% compared less 13% in margate. had made elementary error in denominator; true rate london hospitals 9% admitted patients. never keen on hospital mortality figures outcome measures anyway:

if function of hospital kill sick, statistical comparisons of nature admissible. as, however, proper function restore sick health speedily possible, elements give information whether done or not, show proportion of sick restored health, , average time has been required object…

here presaged next key figure in development of routine outcomes measurement

ernest amory codman

codman boston orthopaedic surgeon developed end result idea . @ core was

common sense notion every hospital should follow every patient treats, long enough determine whether or not treatment has been successful, , inquire if not, why not? view of preventing similar failures in future.

he said have first articulated idea gynaecologist colleague , chicagoan franklin h martin, later founded american college of surgeons, in hansom cab journey frimley park, surrey, uk in summer of 1910. put idea practice in massachusetts general hospital.

each patient entered operating room provided 5-inch 8-inch card on operating surgeon filled out details of case before , after surgery. card brought 1 year later, patient examined, , previous years treatment evaluated based on patient s condition. system enabled hospital , public evaluate results of treatments , provide comparisons among individual surgeons , different hospitals

he able demonstrate own patients’ outcomes , of of colleagues unaccountably system not embraced colleagues. frustrated resistance, provoked uproar @ public meeting , fell dramatically favour in hospital , @ harvard, held teaching post, , able realize idea in own, struggling small private hospital although colleagues continued @ larger hospitals. died in 1940 disappointed dream of publicly available outcomes data not on horizon, hoped posterity vindicate him.

avedis donabedian

in classic 1966 paper, avedis donabedian, renowned public health pioneer, described 3 distinct aspects of quality in health care: outcome, process , structure (in order in original paper). had misgivings solely using outcomes measure of quality, concluded that:

outcomes, , large, remain ultimate validation of effectiveness , quality of medical care.

he may have muddied waters bit when discussing patient satisfaction treatment (usually regarded measure of process) outcome, more importantly has become apparent three-aspect model has been subverted called structure-process-outcomes model, directional, putatively causal chain never described. subversion has been justification repeated attempts improve process , outcomes reorganizing structure of health care, wittily described oxman et al. donabedian himself cautioned outcomes measurement cannot distinguish efficacy effectiveness: (outcomes may poor because right treatment badly applied or wrong treatment carried out well), outcomes measurement must take account context (factors other intervention may important in determining outcomes), , important outcomes may least easy measure, measured irrelevant outcomes chosen (e.g. mortality instead of disability).