This article offers a framework that distinguishes quality as an attribute of the processes of medical care from effectiveness as the results ofthat care. The review ofprocess-outcome studies in the light of this framework reveals not only a confusion of concepts but a variety of methodological and measurement problems. Among the measurement problems is the lack of assessment of the reliability and validity of the process and outcome measures in most quality studies in ambulatory medical care. This article proposes a minimum set of elements to be considered in developing a valid quality assessment method.
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