BOOKREVIEWS 149

different implications for QoL measurement in health the narrower concept of ‘health-related quality of life’ or of the instruments used to measure it. The main care. impression from the book is that different disciplines

ent approaches to define QoL and these have very such as philosophy, sociology and medicine use differ- CLAIRE GUDEX

Centre for Health Economics, University of York

Health Status Measurement: A Perspective on Change by RICHARD G. BROOKS. Macmillan Press Ltd., Basingstoke and London, 1995. No. of pages 142. ISBN 0-333- 52720-8.

Any text surveying the field of health status measure- ment can be criticised for being out-of-date, too narrow and biased. Brooks volume can not avoid such hazards, though in my view he should have been more culpable of the latter crime, since all recent texts in this field have been written by non- economists. His approach has been to offer a surprisingly balanced introduction to Health Status measurement.

The book begins with a chapter on the reasons for the m n t ‘upsurge’ of inkxtxt in Health Status measurement. In this he sets out an economic framework for the book, and the methods of economic evaluation. Cost contain- ment, the inmased importance of quality in health care, technological change and doubts about medical effective- ness along with organisational and cultural developments, are argued to be causes of the increased interest. Whether these causes are complimentary or have different measure- ment needs is not addressed here.

Chapter 2 is an outline of how health status measures have been developed, and this includes an interesting and historically informed discussion of the different categories of measure including functional assessment measures, generic profiles, generic indexes and mental health status measures. Lists of measures in each category are presented and a selection of instruments reproduced (where alleged legal restrictions permit). Some of the key dilemmas of generic versus specific, and profiles versus indexes are addressed here. To the newcomer it provides a useful flavour of the range of such instruments.

A chapter is devoted to the conventional psychiatric issues of reliability and validity, as well as the more practical concern of generalisability , clinical acceptabil- ity and usability. Brooks suggest later that there is increasing agreement about such terminology, but his description of the different types of validity highlights the confusion which exists, and in particular his use of the guidelines by Bombardier and Tugwell is unhelpful in this regard. The use of definitions which disagree (e.g Guyatt, Wilkin et al, and Patrick and Deyo on responsiveness), means the reader is not left with a

clear concept of these ideas. At times, one feels Brooks should have been more prescriptive and utilise his otherwise very clear and straightforward style.

Brooks does not address whether there is a conflict between ideas in psychometrics and economics. I found myself unable to agree with the authors conclusions that: ‘Perhaps the least contentious matter concerns whether the measures and their associated scaling approaches should meet the recommended psychiatric tests’. The application of tests such as Crombach’s alpha and factor analyses by psychometricians, and the basis of many tests of construct validity, can be criti- cised from an economic viewpoint.’v2 Indeed it was over twenty years ago when economists criticised the methods used to scale many health status measure^.^

Chapter 5 describes the measured process, and the methods used to obtain cardinal measures including: category scaling and magnitude estimation, as well as Standard Gamble, Time Trade- off and Willingness to Pay from the economics literature. The construction of QALYs and the recent Health Year Equivalent alterna- tive is discussed. This chapter draws on the economics literature, but the critical implications for existing health status measures is not followed through.

Chapters 4 and 6 cover similar ground. Four is concerned with quality as an issue and includes a discussion of Donabedian’s framework of structure, process and outcome. Again, the choice of diagram (by M c G l y ~ et al) to explain the concepts does not help, and the labelling of symptoms and complications under process, is confusing when they are usually regarded as outcomes. In a section devoted to this subject Brooks says: ‘One way round the alleged process: outcome dichotomy would be the suggestion that valid quality measurement lies not in the choice of elements of process or outcome but the relationship between the components’. My response to this was one of relief after a somewhat confused discussion until the follow- ing sentences: ‘Thus outcome quality may imply process quality-if this is the case then there is no dilemma. If not, as some empirical studies have shown, then process and outcome measures should be consid- ered as independent but perhaps equally important measures of the quality of care’.

If you believe (as I do) that all the benefits of a process are by definition an outcome (defined to include

150 BOOKREVIEWS

patient satisfaction as well as health status), the absence of a relationship between a particular process and outcome implies the process should be halted. Measur- ing process can only be useful as a proxy for outcomes where the relationship has already been demonstrated or as a way of explaining outcome variation.

Chapter 4 then considers the role of quality assessment-process and outcome-in Medical Audit and Quality Assurance. He quotes the view of Berwick that most ‘quality assessment’ has been research, and has had little to do with day to day practice. Chapter 6 exam- ines in m m depth the relationship between health services research and decision making. In it he discusses some of the concerns of recent commentators with the ‘tyranny of outcome’. This concern is with the problem of relating outcomes particular to health care interventions. Brooks seems optimistic of the benefits of using outcome in routine practice, and overcoming these problems. He goes on to consider clinical trials, medical ethics and clinical decision making. This chapter provides an important context for the student to consider outcome measurement.

In chapter 7 he discusses trends and issues in the field. The use of health status measures with populations, specific groups, clinical practice, pharmaceuticals, and resource allocation are examined, including a critical discussion of the use of QALYs. Brooks then examines a selection of issues for discussion including theoretical foundations (though not from an economic viewpoint), the importance of measuring health change (but not the obvious parallel with the development of HYEs), scal- ing, and the contentious issue of whose values.

Texts in this field have tended to be rather dry. What Brooks has provided is a more accessible, though necessarily less rigorous introduction to the subject. He has included a review of the work of health economists in the area, which tends to be neglected or dismissed by many psychometricians. However, he has not been critical of health status measures, even where the derivation of their weights is of doubtful validity. Furthermore, he has not considered how, if at all, health status measures such as SF-36, NHP or AIMS can be used in the conduct of economic evaluation. Nonetheless, the book provides a very accessible introduction to the field for economists and non-econ- omists alike. 1. Brazier, J. E. and Cairns, J. An Economic perspec-

tive on health outcome measurement. In: Hutchinson et a f (eds) Outcome Measurement in Primary Care. (forthcoming).

2. Williams, A. Review of Stewart, A. L. and Ware, J. E. (eds) Measuring functioning and well-Wig. The Medical Outcomes Study Approach. Health Economics, 1992;1(4):255-258.

3. Culyer, A. J. Need, values and health status measurement. In Culyer, A. J. and Wright, K. G. (eds) Economics aspects of health services. Lon- don: Martin Robertson, 1978.

JOHN BRAZIER Shefield Centre for Health and Related Research,

University of Shefield

Implementing Community Care Edited by N. MIN. Open University Press, Buckingham, 1994. No. of pages: 214. ISBN 0-335-15738-6.

The community care reforms will not fail for the lack of advice from academics. Recent publications have promised advice on costing, coordinating and evaluating community care (to name but three). Searching for an original title will be only the first challenge for future authors in this series.

This book is a particularly ambitious example of the genre. Rather than focus upon a particular issue or client group, as has been the case with most recent contri- butions, the authors of this volume seek to provide in three main sections ‘an overview of community care policies and the process of managing change in the field.’

The first section examines the policy context, includ- ing chapters on the development of community care, management and finance, and care management. The

second section which concentrates upon staff and user interests, considers professional roles and training issues, the role of the family and informal carers, and service user perspectives, including how to develop user involvement practice, and the emergence of advocacy schemes. The third part discusses different models of care, and recent developments in policy and practice are examined.

As an introductory text, the book has much to com- mend it. The structure is coherent, and it reads well. It is sufficiently weli referenced to comfort researchers while remaining accessible to a practice audience. The editor has gathered together established and respected con- tributors, again from both academic and practice backgrounds. It was refreshing to see the familiar references enlivened by original and insightful anecdo- tal evidence.

The absence of a specific client group focus was at times confusing. Although the early chapters require no such context, staff and user issues and the development