Medical knowledge, quality of life and accreditation of quality in health care. The perspective of the clinical nephrologist.

The problem of Quality has three dimensions: the dimension of quality of life (the patients, perspective), the dimension of quality of medical knowledge and of the appropriate use of medical technology (i.e. the "evidence based" medical approach to clinical decision making) and the dimension of accreditation of health care providers. The problem of keeping clinicians well updated is a difficult one but there are solutions. The medical literature can be selectively but thoroughly analysed and on the basis of high quality studies specific recommendations (i.e. guidelines) can be produced. Scientific societies are now making major efforts to produce high quality guidelines for the treatment of patients with chronic renal failure and for those on chronic dialysis. The DOQI and the Standards Document by the Renal Association offer first class examples of how scientific knowledge can be translated into clear practice guidelines. As far as the dimension of quality of medical knowledge is concerned, there is now increasing evidence that the taking into full account of quality of life issues such as those regarding the physical, psychic and social dimensions of health improves substantially patient's satisfaction and the patient-doctor relationship. Quality of life considerations are now fully considered when evaluating the efficacy erythropoietin in the treatment of uraemic anemia. If we accept the perspective that health care organisations should aim at excellence, the performance of a given provider can be evaluated on the basis of various indicators and its performance made transparent to the potential users. The internet has become the most accessible source of such kind of information and it can be easily forecasted that the performances of all major hospitals and health care organisations will soon be in the public domain.