BOOKS OF RtfiDIfGS - PAHO/WHO

NUTTING ET AL.
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ficiencies. The anecdotal data presented
on corrective actions suggests that in some
cases the method may enhance the assurance
tfunction, although we do not yet Ihave
systematic evidence.
Discussion
Requirements for a method to assess the
quality of care in Indian Health Service
service units were defined. A method was
developed to try to fulfill these requirements
and was applied in 25 health systems
to test whether the requirements had
been met. Some of the requirements were
fulfilled while others were not.
The first requirement calls for examining
the performance of the entire health
system and is based on the assumption that
the performance of the total health system
cannot be inferred from the performance of
individual components, which is especially
important in Indian Health Service,
where consumers are often scattered geographically
and highly mobile. Rather thia
being limited to specific facilities or provider
groups, the assessment begins with a
sample of the community with specific
needs for health service and tracks them
through their encounters with all system
components, including components that
do not necessarily view themselves as part
of the system, thus fulfilling the
requirement.
The second requirement calls for the
examination of care for all members of the
community, not just patients, and for differentiation
among subgroups. By selecting
study cohorts from the entire known
community ofconsumers, as demonstrated
in the immunization and prenatal care
tracers, and using original source documents,
as demonstrated in the anemia and
urinary tract infection tracers, the second
requirement is largely met. However,
more work must be done to determine the
extent to which the entire com-nunity of
consumers has been identified in [HS service
units.
MEDICAL CARE
The distribution of care by risk group
was successfully examined, with the finding
that two materna! and child health
clinies provide d better care to avsrage-rinsk
mothers than to high-risk mothers because
ofdifferent utilization patterns. Although it
appears that the method could also
examine the distribution of care across
other subgroups of the population, this has
not yet been demonstrated. *o
The assessment focuses on the performance
of a broad range of functions, including
especially those most important for
ambulatory care, rather than on particular
health conditions, as called for in the third
requirement. However, the usefulness of
the resulting information depends on the
assumption that the care received for the
tracers is representative of all care. The
original application of this method found
that the functions had similar relative performances
for all the tracers used,' which
was supportive of this assumption. More
recent applications of the method also
found similar pattems for most tracers, but
with some notable exceptions, for example
the high recognition rate for suture
follow-up care compared with much lower
recognition rates in follow-up care for other
tracers. Such variation across tracers indicates
that a'thorough investigation is
needed on whether and how to aggregate
across tracers. For example, classes of tracers
might be found that have similar patterns
of care within classes but different
patterns across classes. Although current
aggregates are possibly useful starting
points, they are not based on sound
theoretical or empirical foundations and
therefore should be accompained by the
tracer-specific results.
*o In concept, any attribute of medical care can be
distríbuted across different subgroups of the p opulation.
The distribution of accessibility" and
utilization" across various types of population sibgroups
has been widely studied, but the process of
care as we have defined it has not. Shortell hbis
attempted a more precise definition of distrhibution of
cwae by applying concepts of ecoinolics.