Trying to Balance Quality: Can We Assume that Improving the Quality of Care Delivery also Improves Quality of Life? Sheena Mc Hugh 1 , Margaret Collins 2 and Ivan Perry 1 Affiliations: 1 Department of Epidemiology and Public Health, University College Cork, Cork, Ireland and 2 University of California Cooperative Extension, Tuolumne County, Sonora, California, USA ABSTRACT OBJECTIVE To examine the measurement of quality of life (QoL) in the evaluation of interventions that aim to improve the quality of care for patients with diabetes. METHOD A literature review was conducted using three electronic databases (MEDLINE of the National Library of Medicine, PubMed of the National Centre for Biotechnology Information, and the Cochrane Library) to obtain articles published between 1998 and June 2009. Systematic reviews pertaining to chronic disease management and quality improvement at the professional and organizational level of diabetes care delivery were selected. RESULTS Twelve systematic reviews satisfied the inclusion criteria. Although a number of the reviews included studies that reported to measure QoL, on further investigation few of the studies involved accurate measurement of the outcome. The majority of studies purporting to assess the outcome actually measured concepts such as psychological well-being and health status, most often using the SF-36. While most review authors acknowledged the lack of data on patient-reported outcomes, a number of the reviews were ambiguous as to what measures were included and what outcomes were being evaluated. CONCLUSION The results of this review suggest that there is still ‘‘infrequent and inappropriate’’ measurement of outcomes such as QoL. Quality improvement interventions and chronic disease management programs often lack a theoretical framework to guide the selection of relevant and useful indicators. Without consistent and accurate measurement, we cannot assess the potential trade-off between quality of care and QoL. Keywords: Diabetes, chronic disease management, quality in healthcare, quality improvement, quality of life, quality indicators Correspondence: Sheena Mc Hugh, Department of Epidemiology & Public Health, University College Cork, Brookfield Health Sciences Complex, College Road, Cork, Ireland. Tel: 353-21-420-5253; Fax: 353-21-420-1923; e-mail: s.mchugh@ucc.ie INTRODUCTION Diabetes is fast becoming the condition of choice for modeling improvements in the quality of care delivery. The gaps in diabetes care have been well highlighted [2, 3], despite a substantial body of evidence demonstrating the effectiveness of therapies for managing the illness and its associated complications [47]. This costly illness highlights the need for health services to reorganize care, moving from an acute hospital-based model that cannot possibly meet the demands of the expanding patient population. As well as offering a case study for reform [8], diabetes has been an exemplar of patient-centered care. The important role of the individual patient has had several manifestations, including the St Vincent Declaration [9], the chronic care model (CCM) [10], and a growing emphasis on self-management [11]. But how does the patient-centered approach to care fit in with the drive for quality improvement? Quality of care can be assessed in several domains, including structural changes, process of care measures, and outcomes such as biomedical markers and patient-reported outcomes [12]. Patient-reported outcome measures (PROMS) relate to ‘‘measurement of any aspect of a patient’s health status that comes directly from the patient’’, ranging from symptomatic reports to more complex concepts such as quality of life (QoL) [13]. Championing quality improvement in the USA, the Institute of Medicine views the patient experience as central in defining quality [14]. However, one of the earliest systematic reviews of change to diabetes care delivery, found that certain outcomes, including quality of life, had been ‘‘infrequently and inadequately’’ assessed. JOURNAL OF CLINICAL METABOLISM & DIABETES REVIEW ARTICLE JCMD 2010; 1:(2). September 2010 35 www.slm-jcmd.com