Measuring the Quality of Health Care : The Connection Between Structure, Process and Outcomes of Care Within Germany; Exemplified by Myocardial Infarction

Background: Recently, enormous efforts to measure the quality of health care have been made (i.e. AHRQ, OECD) in order to get information about ways to improve the quality of health care. However this area of research is still in an early stage of development and more research has to be done. Objectives: The research plan outlines a framework to analyse the quality of health care on the basis of the three quality dimensions introduced by Donabedian. It tries to develop a consistent line of arguments to clarify the logic of how structure and process measures affect outcome measures. Further it tests the validity of this (theoretical) framework within an empirical analysis. Methods: Because of increasing financial shortages within health systems we refer to myocardical infarction, which is one of the costliest and most prevalent diseases. This approach establishes a connection between medical and economic problems. The variables for structure quality (i.e. number of cardiologist, number of catheterisation facilities) were sourced and evaluated from the heart reports compiled by Bruckenberger for the period from1994 to 2004 regarding the 16 German Federal States ("Bundesländer"). Data from the Federation of Quality Assurance (BQS) were used for the evaluation of process quality (i.e. adequacy of indication to coronary angiography). Finally, administrative data from the Federal Office for Statistics for the period from 1994 to 2004 were used for the determination of the variables of outcome quality (i.e. standardized mortality rate due to myocardial infarction, potential years of life lost under 65/70 years due to myocardial infarction). By using panel data we tested the hypothesis, that good outcome indicators are depending on good structure and good process indicators with the help of a fixed effects estimation. Results: Empirical analysis comes up with two results: First, the analysis confirms the predicted connection between the different dimensions of quality of care for the German "Bundesländer". Especially the number of catheterisation facilities has a highly significant positive influence on the outcome quality. Secondly, however, a good structure and a good process quality on its own cannot guarantee a good outcome quality. Conclusion: In addition to the health system, there are other determinants (i.e. education, unemployment rate, income per capita) that also affect the outcome quality of health care. Further empirical investigation regarding the influence of these factors on the outcome dimension could close the "explanation gap" and could deliver additional insights