The quality of quality: is it time for new tools?
The quality of quality: is it time for new tools?
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质量的质量：是时候使用新工具了吗？
DOI：
10.1161/circulationaha.114.008390
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发表时间：
2014
期刊：
影响因子：
37.8
通讯作者：
Roger,VéroniqueL
中科院分区：
文献类型：
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作者：
Roger,VéroniqueL
对于明显的难治性高血压患者，没有开出最佳治疗方案，14强调了考虑药物治疗优化的重要性，包括剂量和方案，以适当地在临床上管理高血压并了解相关的人群趋势。15.第二，如果我们同意监测药物治疗剂量很重要，那么我们对这种监测活动有哪些选择？如上所述，正在推广登记研究，以进行质量测量13，毫无疑问，登记研究具有许多优势，包括样本量和数据收集深度（包含风险因素和合并症的临床数据）。这些特点，反过来，提供强大的分析优势，在精度和调整策略方面的行政和索赔数据。因此，与声明数据相比，登记研究有可能为临床决策和结局提供更深入的见解。然而，如上所述，尽管其内部有效性很强，但登记研究的选择和病例组合可能会阻碍其数据的外部有效性。换句话说，如果在一个特定的注册中的患者比受考虑中的疾病影响的总人口更年轻和更健康，那么来自注册的数据不一定适用于所有人。电子病历，这隐含地被解释为更普遍，是一个有吸引力的选择，以监测药物治疗及其质量。然而，验证研究表明，电子医疗记录在质量评估方面可能还没有准备好。16然而，虽然关于使用电子医疗记录进行业绩监测的警告性报告正在出现，17但这是一个迅速发展的领域，人们可以希望，对目前缺点的认识将导致在不久的将来解决这些问题。第三，TRIUMPH的数据提出了一个挑衅性的问题，即目前的业绩衡量标准是否充分。由于给定药物的剂量对其有效性很重要，因此适当的剂量强化和升级确实反映了患者接受的护理质量。因此，是否应修改性能指标以监测剂量？在我们迈出这一步之前，应该解决几个问题。来自TRIUMPH的当前数据是否反映了现有质量指标的非预期后果，即当前措施导致从业者在涉及他汀类药物时选择是/否框而不考虑剂量？如果是这种情况，那么在性能指标中包括剂量可能会导致更多的“玩的措施”18和不小心剂量递增的老年患者，其中药物副作用和不良后果的多药是关键问题。事实上，实践指南并没有提供一个足够的临床框架，以照顾老年患者的多发性硬化症。19在存在多种慢性病的情况下（老年患者的常态），遵循指南的治疗计划非常复杂，从而产生错误的风险，并导致具有药物不良反应/相互作用固有风险的多药治疗。因此，虽然业绩计量对提高护理质量至关重要，但业绩计量和整体护理之间存在固有的紧张关系，而且人们日益认识到，目前主要以过程为基础的系统对日益增长的老年人口的不足。20最佳治疗应针对目标疾病，同时考虑到整个人，目标是保持甚至提高生活质量。给定药物的剂量虽然重要，但只是复杂护理的一个方面。
with apparent treatment-resistant hypertension are not prescribed an optimal regimen, 14 underscoring the importance of considering drug therapy optimization, including dose and regimen, to appropriately manage hypertension clinically and to understand related population trends. 15 Second, if we agree that surveillance of drug therapy doses is important, then what are our options for such surveillance activities? As mentioned above, registries are being promoted for the purpose of quality measurement13 and unquestionably offer numerous advantages including sample size and depth of data collection (containing clinical data on risk factors and comorbidities). These characteristics, in turn, afford robust analytic advantages in terms of precision and adjustment strategies over administrative and claims data. Hence, registries have the potential of providing greater insights into clinical decision making and outcomes than claims data. However, as discussed above, although their internal validity is strong, the selection and case mix of registries may hinder the external validity of their data. In other words, if patients in a given registry are younger and healthier than the overall population affected by the disease under consideration, then the data from the registry do not necessarily apply to all. Electronic medical records, which implicitly are construed as more generalizable, are an attractive option to monitor drug therapy and its quality. Yet, validation studies suggest that the electronic medical records may not yet be ready for prime time when it comes to quality assessment. 16 However, although cautionary reports on the use of electronic medical records for performance monitoring are surfacing, 17 this is a rapidly evolving field and one can hope that awareness of current shortcomings will lead to addressing them in the near future. Third, the TRIUMPH data raise the provocative question of the adequacy of current performance measures. Because the dose of a given medication is important for its effectiveness, appropriate dose intensification and escalation indeed reflect the quality of the care that a patient receives. Thus, should performance measures be modified to monitor the dose? Before we can take that leap, several questions should be addressed. Could the current data from TRIUMPH reflect an unintended consequence of existing quality metrics whereby current measures lead practitioners to check the yes/no box when it comes to statins without considering the dose? If this were the case, then including the dose in performance metrics could potentially lead to more “playing to the measures” 18 and less than mindful dose escalation in elderly patients in whom drug side effects and adverse consequences of polypharmacy are critical concerns. Indeed, practice guidelines do not provide an adequate clinical framework to care for elderly patients with multimorbidity. 19 In the presence of multiple chronic conditions (the norm in elderly patients), treatment plans that follow guidelines are highly complex, thereby creating a risk of errors and leading to polypharmacy with its inherent risk of adverse drug reactions/interactions. Hence, although performance measures have been essential to improving the quality of care, there is an inherent tension between performance measures and holistic care, and the inadequacy of current, largely process-based systems for the growing elderly population is increasingly recognized. 20 The optimal treatment should address the target disease while considering the whole individual, with the goal of preserving or even enhancing quality of life. The dose of a given medication, although important, is only 1 facet of complex care …