Patient Benefit and -Risks

Abstract Quality of care is complicated, especially in the elderly. For a start we need drugs with evidence for the benefits and risks in the elderly, this is currently not always the case. Thereafter we need to use the drugs in an evidence based way, which may be difficult in the complex health care system. To achieve maximum benefit for the patient (outcome) and society (health-economy) a well planned process is needed. This includes identification, prevention and resolving of the patients drug-related problems decisions and selection of treatment, communication and decisions together with the patient, risk minimisation, and communication within health care. Several of these aspects are presented in this chapter. 

Keywords Quality Benefits Risks Evidence based medicine 

Quality assurance is defined by Donaobedian as all actions taken to establish, protect, promote, and improve the quality of health care (Donobedian 2003). He describes quality of care as an attribute of a system (structure), a set of organized activities (process), and an outcome that results from both. The definitions are described in Table 3.1. It should be noted that the efficacy of a drug (the ability for improvement under the most favourable circumstances) is included in the structure and that the effectiveness of a dmg (real improvement in the care) is included in the process. 

Quality can not be guaranteed. One can increase the probability that a care is good or better . If the different components in the structure and process are improved the probability of a better patient outcome is increased. Sometimes it is not possible to measure patient outcomes. Instead surrogate outcomes of the process performance can be used especially if there is evidences for a link to real patient outcomes. For improvement and assessing improvement Donobedian suggests a mix of approaches in the structure, process, outcome model. For improving clinical performance Donobedian also suggests a stepwise approach as described in Box 3.1. 

For improved quality of care in the elderly we must first define and measure the problem and the magnitude of the problem. We must also prioritise between problems and select the most important issue. Of course the aim must be improvement for the individual patient. But since quality in healthcare normally is complicated and multifactorial a systematic change in structures and processes is required. 

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