Profiling quality of care: Is there a role for peer review?

BACKGROUND: We sought to develop a more reliable structured implicit chart review instrument for use in assessing the quality of care for chronic disease and to examine if ratings are more reliable for conditions in which the evidence base for practice is more developed. METHODS: We conducted a reliability study in a cohort with patient records including both outpatient and inpatient care as the objects of measurement. We developed a structured implicit review instrument to assess the quality of care over one year of treatment. 12 reviewers conducted a total of 496 reviews of 70 patient records selected from 26 VA clinical sites in two regions of the country. Each patient had between one and four conditions specified as having a highly developed evidence base (diabetes and hypertension) or a less developed evidence base (chronic obstructive pulmonary disease or a collection of acute conditions). Multilevel analysis that accounts for the nested and cross-classified structure of the data was used to estimate the signal and noise components of the measurement of quality and the reliability of implicit review. RESULTS: For COPD and a collection of acute conditions the reliability of a single physician review was quite low (intra-class correlation = 0.16–0.26) but comparable to most previously published estimates for the use of this method in inpatient settings. However, for diabetes and hypertension the reliability is significantly higher at 0.46. The higher reliability is a result of the reviewers collectively being able to distinguish more differences in the quality of care between patients (p < 0.007) and not due to less random noise or individual reviewer bias in the measurement. For these conditions the level of true quality (i.e. the rating of quality of care that would result from the full population of physician reviewers reviewing a record) varied from poor to good across patients. CONCLUSIONS: For conditions with a well-developed quality of care evidence base, such as hypertension and diabetes, a single structured implicit review to assess the quality of care over a period of time is moderately reliable. This method could be a reasonable complement or alternative to explicit indicator approaches for assessing and comparing quality of care. Structured implicit review, like explicit quality measures, must be used more cautiously for illnesses for which the evidence base is less well developed, such as COPD and acute, short-course illnesses

This is Just for Me(n): How the Regulation of Postfeminist Lingerie Advertising Perpetuates Woman as Object

This article argues that the official process by which advertising is regulated in the UK, when applied to the advertising of women&rsquo;s underwear, restricts and undermines, rather than encourages, attempts to renegotiate the discourse that surrounds the representation of women in advertising, particularly when it seeks to construct a discourse that questions the centrality of men to female sexual pleasure. This process judges ads on the basis of whether they are likely to cause 'serious or widespread offence'. The regulators' interpretation of this ensures that lingerie advertising that represents women as objects for the male gaze remains acceptable, as do ads in which women are deliberately offering up a sexualised self-presentation, while images that seek to negotiate a discourse outside a heterosexuality governed by the coital imperative are considered problematic. This encourages the perpetuation of a conservative framework in which women can be viewed as objects rather than subjects

Regulating Against Offence: lessons from the field of UK advertising

This article looks at the question of offence in UK advertising. It examines what constitutes offence, who claims to be offended, and on whose behalf. The article highlights the flaws in the current system of advertising regulation and concludes that efforts to regulate offence should be abandoned