摘要：Both the medical care and public health systems have invested considerable resources to define, measure, and improve quality and health outcomes. A movement toward accountability has generated performance indicators from the medical arena and “leading health indicators” from the public health arena. The focus on specific conditions by the medical care system has been at odds with public health’s emphasis on improving population health and has perpetuated a bifurcated system. Aligning the goals of medical care with those of public health will require reformulation of performance measurement and accountability into a common language that is valued by both systems. Such a creation would amount to a whole that is stronger than the sum of the component parts. “Would you tell me, please, which way I ought to go from here?” “That depends a good deal on where you want to get to,” said the Cat. “I don’t much care where . . .” said Alice. “Then it doesn’t matter which way you go,” said the Cat. Lewis Carroll, Alice in Wonderland FOURTEEN PERCENT OF Americans are uninsured. 1 White Americans live, on average, 7 years longer than African Americans, and analogous disparities in life expectancy exist between persons of higher and lower income. 2 The average American lives 4 years less than the average Japanese does. Yet the hottest topic in medical care policy circles these days is not about achieving universal coverage or eliminating disparities but rather about reducing medical errors. Analogously, the primary rationale disseminated for rebuilding a creaky public health infrastructure is the threat of bioterrorism. Can attention to issues of safety and security take us down the right path to more effective health care and a healthier nation? We argue that we need to (1) refocus our attention on a broader definition of performance that integrates the perspectives, goals, and strengths of medical care and public health and (2) acknowledge and find ways to implement shared accountability for improvements in health. A decade ago, an Institute of Medicine (IOM) panel defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” 3 The panel’s focus, legitimately, was on the ability of the health care system to improve health both at the individual and community levels. With a sharpened interest in accountability, the medical care and public health systems have moved to develop and refine systemspecific quality and performance indicators to help monitor progress and improve the effectiveness of interventions. The medical care system has gravitated toward process indicators that assess performance primarily in terms of delivery of clinical preventive services (e.g., mammograms, immunizations) or management of chronic conditions (betablockers after heart attacks, comprehensive care for diabetics) for individual patients. 4 By contrast, on the public health side, the Department of Health and Human Services has developed process- and outcome-oriented objectives targeting the nation 2 while public health officials have focused on the influence of physical and social environment, public policies and regulations, and individual behaviors on health and functioning. Neither approach is wrong—the existing evidence suggests that high-quality performance is important in all of these areas. Indeed, increases in life expectancy and declines in disability over the 20th century 5, 6 have been attributed to both the public health and medical care systems. 7 In understanding the determinants of health, 8 we increasingly recognize that although medical care and medical innovations have made significant contributions, almost half of our deaths are attributed to lifestyle and environmental factors, 9 socioeconomic conditions, 10, 11 and physical location. 12 However, the real message of recent research on the determinants of health is that the health of the public depends on a multitude of factors 13 and that no single point of intervention is sufficient to maximize health. We appear to forget that in the lives of individuals, families, and communities, these multiple determinants interact. Effective interventions, therefore, require aligning the medical care and public health systems to maximize potential synergies and breakthroughs. 14 Integration of performance measurement and improvement activities provides an important mechanism for uniting these 2 essential arms of health interventions. Formal linkage of measures of medical care system performance to key population health indicators would create a data-driven method to integrate individual- and population-based strategies to accomplish jointly articulated objectives. In the process, each system would learn from the methods and experiences of the other, and different and combined approaches to improving outcomes and increasing efficiency could be evaluated side by side. In the remainder of this article, we describe key factors that reflect, and often support, the continuing bifurcation of medical care and population health. We then describe some of the problems created by our current approach as well as possible benefits associated with meaningful collaboration in performance review. We conclude with ideas for next steps.
