17_114153

U S I N G E P I D E M I O L O GY T O E VA LU AT E
Health Services
CHAPTER 17
STUDIES OF PROCESS
A N D O U TC O M E
Avedis Donabedian developed a framework for assessing

healthcare quality, focusing on three key factors: structure,
process, and outcome. Structure refers to the settings, staff,
equipment, and resources involved in care.
S T U DY O F P R O C E S S
• Process and outcome studies in healthcare are
different.
• Process refers to how well care is provided based on
established guidelines or standards, often set by
experts.
For example, in primary care, we can check what

percentage of patients had their blood pressure taken.
However, just following the process doesn’t always
mean patients will improve. For instance, taking
someone's blood pressure doesn’t guarantee it will be
controlled or that the patient will take their medication.
The downside to process measures is that they don’t always show if the patient’s health actually gets better. Also,
these standards can change over time.
S T U D I E S O F O U TC O M E
• Given the limitations of process studies, the focus

shifts to outcome measures, which assess whether
patients or communities benefit from medical care.
• Outcomes research has expanded to include
measures like patient satisfaction, quality of life, and
levels of dependence or disability.
EFFICACY, EFFECTIVENESS,
AND EFFICIENCY
Three key terms commonly found in the evaluation of health services are efficacy,
effectiveness, and efficiency. These terms are often linked to the results of
randomized trials.
Efficacy Effectivenes Efficiency

Efficacy refers to whether a s
Effectiveness looks at how well it Efficiency focuses on the cost-
treatment or intervention works works in real-world settings. effectiveness of the care provided.
under ideal conditions.
M E A S U R E S O F O U TC O M E
1. The outcome must be quantifiable, meaning it

can be measured in clear, numerical terms.
2. The measure should be easy to define and

diagnose—it shouldn't require invasive procedures,
especially in population studies.
3. The outcome must be standardized for study

purposes to ensure consistent results.
4. The population being studied should be at risk for

the condition the intervention targets.
M E A S U R E S O F O U TC O M E
Box 17.2 lists measures for evaluating a throat

culture program in children. While traditional
measures like service volume and clinic visits are
easy to count, they don’t assess effectiveness. More
relevant measures should be chosen based on the
specific question being asked, as just asking "how
good is the program?" isn’t enough.
C O M PA R I N G E P I D E M I O LO G I C S T U D I E S O F D I S E A S E
E T I O L O GY A N D E P I D E M I O L O G I C R E S E A RC H E VA LU AT I N G
E F F E C T I V E N E S S O F H E A LT H S E R V I C E S
• In classic epidemiologic studies, we explore the relationship between a potential cause (the "exposure") and an
adverse health effect (the "outcome"). We also consider other factors, such as healthcare, that may either
modify or confound this relationship.
• In health services research, the health service is the independent variable, aiming to reduce adverse health
effects as the outcome. Like epidemiologic studies, it considers other factors that may influence the relationship.
Both types of research share similar study designs and potential biases.
E VA LU AT I O N U S I N G
G R O U P D ATA
• In evaluation studies, regularly available data like
mortality and hospitalization data are often used.
For example, changes in the estimated proportion of the US

population with influenza-like illness (ILI) over time can be
tracked using data from CDC surveillance sites, Google Flu
Trends, and Flu Near You, as shown in Fig. 17.3.
R E S E A RC H O U TC O M E S
• Outcomes research compares the effects of different
healthcare interventions on health and economic
outcomes, including morbidity, mortality, quality of life,
and patient satisfaction.
• Outcomes research uses large datasets from large

populations.
• The purpose of the Electronic Medical Record (EMR) is to
provide healthcare providers with all relevant information
about individual patients, including office visit findings,
preventive services, prescribed medications, procedures,
radiologic results, and lab test results, continuously over
time (prospectively).
E VA LU AT I O N U S I N G
I N D I V I D U A L D ATA
Studies using grouped data (without individual-level

health care and outcome data) are less ideal than
studies using individual data.
Comparing two populations: To compare groups (e.g.,

new treatment vs. usual care), two questions must be
answered:
• Are the groups comparable in demographics, medical
history, and prognosis?
• Are the measurement methods (e.g., diagnostics) the
same for both groups?
Nonrandomized Design
• A non-randomized design refers to a type of research
design where participants or subjects are not randomly
assigned to different groups or conditions. This
contrasts with randomized designs, where participants
are randomly assigned to different experimental groups
to ensure that each group is comparable at the start of
the study.
Case Control Study

• Case-control studies are increasingly used in public
Randomized Design health to evaluate health services, including vaccines,
prevention, and screening programs. While primarily
• Helps eliminate selection bias caused by used for etiologic research, they can serve as a
self-selection or provider selection of surrogate for randomized trials when appropriate data
patients. is available. These studies focus on defining cases
• Participants are typically assigned to (individuals with a specific disease) and assessing
receive one type of care versus another, exposure to a preventive measure. Stratification by
not care versus no care. disease severity and other prognostic factors is crucial
• Randomizing patients to receive no care is for interpreting results.
usually not considered.
END.

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U S I N G E P I D E M I O L O GY T O E VA LU AT E

Avedis Donabedian developed a framework for assessing

For example, in primary care, we can check what

• Given the limitations of process studies, the focus

Efficacy Effectivenes Efficiency

1. The outcome must be quantifiable, meaning it

2. The measure should be easy to define and

3. The outcome must be standardized for study

4. The population being studied should be at risk for

Box 17.2 lists measures for evaluating a throat

For example, changes in the estimated proportion of the US

• Outcomes research uses large datasets from large

Studies using grouped data (without individual-level

Comparing two populations: To compare groups (e.g.,

Case Control Study

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