Commentary: quality and managed care: where is the fit?

Quality in health care is broad, complex, and not easily measured. This essay explores the many dimensions of quality in health care and shows that many understandings of it are narrowly configured to the agendas of the respective participants--providers, patients, and institutions--in today's health care arena. Also, there are many aspects of quality that defy measurement in the epidemiological sense. These are seen in the physician-patient relationship and in special clinical situations, such as the process of dying. Using the idea of quality to buttress ethical and policy decisions, particularly by managed care organizations, is often problematic, given this complexity. It is thus imperative that those so using quality be accountable that their understanding of it be arrived at by responsible means, that it addresses something meaningful, and that it not eclipse the many other dimensions of quality.