Elsevier

The Lancet

Volume 362, Issue 9392, 18 October 2003, Pages 1314-1319
The Lancet

Series
The need for research in primary care

https://doi.org/10.1016/S0140-6736(03)14576-XGet rights and content

Summary

Making evidence from scientific studies available to clinical practice has been expected to directly improve quality of care, but this expectation has not been realised. The notion of quality of care is complex, and quality improvement needs medical, contextual, and policy evidence. In primary care, research is needed that takes into account the specific characteristics of its population and the presentation and prevalence of illness and disease. The context of the doctor-patient encounter plays a major part, and needs better understanding. At the policy level, issues of equity must be addressed. The knowledge base for family practice must be expanded by integration of multiple methods of comprehension, so we can bridge the gap between evidence and practice.

Section snippets

Quality of care and caring for quality: a theoretical framework

Demonstration of quality has become increasingly important, and doctors can no longer self-proclaim their work and services to be of high quality. The Institute of Medicine's definition of quality is widely accepted up to today:

“Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”2

Figure 1 shows the complex picture of determinants of quality, starting

Medical, contextual, and policy evidence

Clinical decisions to improve quality of patients' care must be made with a good knowledge of the disease (medical evidence), but at the same time they must take into account patient-specific aspects of medical care (contextual evidence) and efficiency, equity, and rationing (policy evidence).

The scope

In 1961, White and colleagues42 showed—in the ecology of medical care model—that only a few adults having symptoms consult a doctor, and only about 1% receive care in hospital in an average month. An update of this ecology model—despite major changes in the organisation and financing of medical care in the USA—was remarkably similar. In a population of 1000 adults and children in an average month, about 800 report symptoms of some sort, 327 consider seeking medical care, 217 actually visit a

Conclusion

To address all these issues, the knowledge base for family practice must be expanded by integration of self-reflective practice by clinicians; involvement of the patient in generation of research questions and interpretation of data; inquiry into the systems affecting health care and investigation of disease events; and diagnostic approaches and treatment effects in patients over time. This research will look at the many aspects of quality of patient care, as described in figure 1. A

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