All patients who arrive at or are admitted to the hospital or to any type of medical care facility should be provided with the best care possible given the resources available, independent of the level of care. When an attempt is made to carry out medical interventions in accordance with international standards, it is then very possible for patients to recover their health status without complications and with low morbidity and mortality, and also that they are satisfied with the care provided. However, in order for a medical care facility to offer good quality of care, different elements are required.
Taking into account the model of "structure-process-outcomes" proposed by Avedis Donabedian to achieve good health outcomes, it is necessary that there be sufficient and updated resources (examination rooms, medical equipment, laboratory facilities, X-rays, among others) and that the physicians have the ability to carry out accurate diagnoses as well as to prescribe appropriate treatments according to the patient's condition.1-3
A theoretical approach that has gained acceptance in recent decades, particularly in what refers to quality of care in the field of health, is that which is derived by dividing the quality of care into two dimensions: accessibility and effectiveness. In turn, effectiveness can be subdivided into both technical and interpersonal. In light of this focus, a health organization will provide quality when it facilitates access to services and has competent care in the area of diagnostics and therapeutics as well as treating patients with respect and due consideration. In this context, to determine the degree of quality of care provided in medical hospitals, for many years diverse methods for measuring quality of care have been implemented worldwide with two fundamental goals. The first consists in evaluating the quality of care to learn if the standards that determine good quality of care are met; the second is geared to identify failures in the service provided so as to propose modifications to improve care.
In general terms, within the methodology to measure quality of care, indicators are used that evaluate the components that characterize health care. From the clinical point of view, the most frequently measured indicators are morbidity and mortality that occur in medical hospitals. These are regarded as indicators of outcome, i.e., to determine overall the manner in which services are provided.
However, these types of indicators may not be appropriate in hospitals referred to as second-or third-level of care where patients who are treated have higher rates of mortality and morbidity with a tendency for serious illnesses or co-morbidities, particularly for those treated in a third-level care hospital. In this sense, the higher morbidity or mortality may be explained by the patient's condition more than by the quality of care. However, this does not mean that the quality of care should not be evaluated but that these indicators do not entirely reflect the manner in which health services are provided and, for this reason, it is necessary to use another type of indicators.
There should also be indicators both for the hospital structure as well as for the technical/medical processes and as well for the complexity of patients who arrive for treatment in order to determine in each case those areas where it is necessary to implement actions to improve the quality of care.4,5
In the present issue of Boletín Médico del Hospital Infantil de México, Perez-Cuevas et al. describe the process of care in newborns (NB) with necrotizing enterocolitis (NEC). These patients were seen in 61 hospitals affiliated with the program of "Medical Insurance for a New Generation." The authors reviewed 262 medical records in which the components of the technical-medical processes when providing care to these children were analyzed, from preventive measures and methods to reaching a diagnosis through carrying out the therapeutic actions.6 Although a great variation was observed in each of the three aspects that were analyzed, the most important contribution of this study was that which was related with the creation of 16 indicators to evaluate the quality of care that is provided to the NB with NEC. NEC is one of the complications that causes the most problems for neonatologists because it is the principal reason for morbidity and mortality, particularly for the low birthweight NB.7
The work carried out by the authors was a challenge based on the formulation of these indicators, in view of the complexity that newborns with NEC may present. For example, because of the multiple actions or interventions carried out by the healthcare team in patients with NEC for the prevention and identification of this and other co-morbidities (such as sepsis or hyaline membrane disease), it is understandable that in order to limit them to only NEC an in-depth process of analysis and discussion should be carried out.
The authors described that the development of the 16 indicators was through a methodological process that included pediatricians and neonatologists who reviewed the literature, within which the clinical guidelines and systemic review had a preponderant weight. Nevertheless, the methodology does not mention if, when the 16 actions were carried out, a good quality of care of the NB with NEC was indicated or in what way did carrying out some of the actions described in those indicators contribute or not in the evaluation of the quality of care.
It is very clear that when a NB is identified with or is suspected of having NEC it is necessary to suspend enteral feeding to avoid continuation of the damage; however, within the diagnostic process, the measurement of serum electrolytes or urinalysis does not appear to have a similar weight from the point of clinical relevance. In this regard, to completely evaluate the quality of care that is provided to this group of patients, one still needs to define, among other things, which indicators are indispensable. Or, alternatively, to carry out a weighting exercise so as to evaluate if, when the actions are appropriately applied by healthcare personnel, a good quality of care is being guaranteed. Above all, the authors recognized the need to carry out, in the future, a process of validation of these indicators. This thought addresses the need to continue working on these types of indicators so that in the future one may have a more standardized way of measuring quality of care of NB with NEC.
Also, it is appropriate to consider that the fact of letting these indicators be known should result in paramount importance in hospitals treating such diseases, to identify areas and aspects of the process of care to be taken into account and to propose and implement interventions that aim to improve the quality of care. This situation is important because, according to what has been described by the authors, none of the aspects of the indicators investigated are carried out in 100% of the hospitals where the study was carried out. It is also noteworthy that only in 25% was the Bell scale used to establish the diagnosis of NEC and, that only in a third of the children who required surgery, was there evidence about whether or not radiographic data had been taken into account when deciding on performing such an intervention.
Data offered by Perez-Cuevas et al. is a little worrisome because these authors indicate that in a large number of hospitals the quality of care of the NB with NEC is not appropriate. However, some of the aspects that should be viewed with caution with regard to the data described are worth mentioning. One is the instrument used to measure the quality of care. Usually, in order to evaluate the performance of the healthcare team in the care of patients, medical records are used as basic tools to determine if the actions included in the indicators are carried out. As is known, for different reasons, patient chart notes do not correspond completely with what is carried out in patient care, but it is the only document that records what happens in the diagnostic-therapeutic process of the patient.8 It is possible that in the sample of medical records reviewed by Perez-Cuevas et al. of children with NEC, the high variability in regard to the absence of interventions that were not able to be documented was a consequence of inappropriate documen tation of medical notes. For this reason, evaluation of medical records is another quality of care indicator of the medical facilities. In this sense, and to complete what has been described in the clinical records, it is necessary that in the medical departments there be documents or guidelines that support the manner in which care is carried out, with the goal of more fully determining the performance of the healthcare team.9 Based on these arguments, the review of the guidelines and the interview with the physicians responsible for the NICU was part of the evaluation of the quality of care of NB with respiratory insufficiency in 12 states of the Mexican Republic.10
Another point to take into consideration is that related to mortality. In the study by Perez-Cuevas et al. it was noted that 12.2% of the 262 NB with NEC analyzed died. In contrast with the findings related with the medical performance indicators, the rate of mortality is similar to that reported in other national or international hospitals where it was described that the mortality rate varies between 15 and 30%.11 This fact could be interpreted as the quality of care being appropriate, as the mortality is comparable to that reported and globally reflects what happens in regard to the care of these patients. However, it should be noted that the mortality rate of 12.2% corresponds to the average in the 61 hospitals where the study was done and does not reflect the individual results for each hospital. For the study there were only four medical records selected from each of the hospitals, without noting in which hospital there were deaths. Also, characteristics of the patients who died were not indicated. Mortality in NB with NEC is much higher when patients are subjected to surgery compared to those who only receive medical treatment.7,11 Because of this, the results shown do not allow for the determination of the quality of care by each hospital or assume that the quality of care has some influence on mortality.
The difference in mortality among hospitals has already been described in Mexico. In a study where hospitals that care for children with acute lymphoblastic leukemia were analyzed, a variation between 57.1 and 92.7% was observed.12
In brief, the work of Perez-Cuevas et al. provides, for the first time in Mexico, an overview of the process of care that NB with NEC receive. The results invite reflection to implement measures that contribute to improving the quality of care in all hospitals serving pediatric patients.
* Corresponding author.
E-mail:miguel.villasis@imss.gob.mx (M.A. Villasís Keever).