title: An empirical assessment of the validity of explicit and implicit process-of-care criteria for quality assessment.
abstract: OBJECTIVE
  To evaluate the validity of three criteria-based methods of quality assessment: unit weighted explicit process-of-care criteria; differentially weighted explicit process-of-care criteria; and structured implicit process-of-care criteria.
  
  
  METHODS
  The three methods were applied to records of index hospitalizations in a study of unplanned readmission involving roughly 2,500 patients with one of three diagnoses treated at 12 Veterans Affairs hospitals. Convergent validity among the three methods was estimated using Spearman rank correlation. Predictive validity was evaluated by comparing process-of-care scores between patients who were or were not subsequently readmitted within 14 days.
  
  
  RESULTS
  The three methods displayed high convergent validity and substantial predictive validity. Index-stay mean scores, using explicit criteria, were generally lower in patients subsequently readmitted, and differences between readmitted and nonreadmitted patients achieved statistical significance as follows: mean readiness-for-discharge scores were significantly lower in patients with heart failure or with diabetes who were readmitted; and mean admission work-up scores were significantly lower in patients with lung disease who were readmitted. Scores derived from the structured implicit review were lower in patients eventually readmitted but significantly so only in diabetics.
  
  
  CONCLUSIONS
  These three criteria-based methods of assessing process of care appear to be measuring the same construct, presumably "quality of care." Both the explicit and implicit methods had substantial validity, but the explicit method is preferable. In this study, as in others, it had greater inter-rater reliability.
authors.affiliation: Center for Quality of Care and Utilization Studies, Veterans Affairs Health Services Research and Development Field Program, Houston, TX 77030, USA. cashton@bcm.tmc.edu
authors.forename: C M
authors.initials: CM
authors.lastname: Ashton
authors.forename: D H
authors.initials: DH
authors.lastname: Kuykendall
authors.forename: M L
authors.initials: ML
authors.lastname: Johnson
authors.forename: N P
authors.initials: NP
authors.lastname: Wray
mesh_terms: D016022:Case-Control Studies; D003920:Diabetes Mellitus / Q000628:therapy; D006333:Heart Failure / Q000628:therapy; D006787:Hospitals, Veterans / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D008173:Lung Diseases, Obstructive / Q000628:therapy; D008297:Male; D015588:Observer Variation; D010359:Patient Readmission / Q000592:standards / Q000706:statistics & numerical data; D017064:Process Assessment, Health Care / Q000379:methods / Q000592:standards* / Q000706:statistics & numerical data; D019984:Quality Indicators, Health Care; D015203:Reproducibility of Results; D018709:Statistics, Nonparametric; D014481:United States