Qualitative research: a path to better healthcare

Improving quality and safety of hospital care: a reappraisal and an agenda for clinically relevant reform

Improving quality and safety of hospital care is now firmly on the health-care agenda. Various agencies within different levels of government are pursuing initiatives targeting hospitals and health professionals that aim to identify, quantify and lessen medical error and suboptimal care. Although not denying the value of such 'top-down' initiatives, more attention may be needed towards 'bottom-up' reform led by practising physicians. This article discusses factors integral to delivery of safe, high-quality care grouped under six themes: clinical workforce, teamwork, patient participation in care decisions, indications for health-care interventions, clinical governance and information systems. Following this discussion, a 20-point action plan is proposed as an agenda for future reform capable of being led by physicians, together with some cautionary notes about relying too heavily on information technology, use of non-clinical quality personnel and quantitative evaluative approaches as primary strategies in improving quality.

Patients' views of the burden of asthma: a qualitative study

OBJECTIVES

To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment.

DESIGN

A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records.

SETTING

A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000.

PARTICIPANTS

Sixty-two participants (19 male and 43 female), aged 18-70 years.

RESULTS

The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost-benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities.

CONCLUSIONS

To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.

Management of women with minor abnormalities of the cervix detected on screening: a qualitative study

OBJECTIVE

To examine the consistency of decisions by pathology staff and general practitioners in managing women in whom minor cervical abnormalities are detected by screening, with current National Health and Medical Research (NHMRC) Council guidelines, and to look at reasons for inconsistencies.

DESIGN

Qualitative interview study.

PARTICIPANTS

14 pathology staff (12 pathologists and two cytoscientists) from 10 of the 17 laboratories providing cervical cytology services in Victoria, and a sample of 22 GPs from metropolitan and rural locations in Victoria.

MAIN OUTCOME MEASURES

Comparison of management practice with NHMRC guidelines; reasons for current decision-making practice.

RESULTS

Most pathologists provided more cautious recommendations for minor abnormalities of the cervix than the NHMRC recommendations in all reporting categories except human papillomavirus. Pathologists had concerns about the appropriateness of the NHMRC recommendations, particularly for glandular atypia, lack of an endocervical component and inflammatory smears, where they believed that the NHMRC recommendations were not well supported by evidence. GPs generally followed the recommendations of their laboratories. Medicolegal concerns were a major influence on clinical decisions for both pathologists and GPs, and have contributed to the development of cautious management practice. Reporting and management practice of pathologists and GPs reflects the ambiguity of minor cervical abnormalities that the NHMRC guidelines fail to highlight.

CONCLUSION

Many pathologists and GPs are reluctant to follow NHMRC guidelines because they believe they are inadequate for some minor cervical abnormalities. The cervical screening guidelines should be reviewed according to the NHMRC guidelines for developing clinical practice guidelines, to promote consistent practice based on an up-to-date, accurate evidence base.