The transformation of medicine: the role of outcomes research.

Health has been defined as a state of physical, psycho-logical, emotional, and social well being, not merely theabsence of disease or infirmity (1). Over the last decade,competing market forces and the health-care delivery sys-tem have been instrumental in redefining our concepts ofhealth and health care. Increasingly, there is the perceptionthat the health-care system should do more than just treatdisease. It must also foster and promote health.These changing perceptions of health and health carehave been distressing for patients and for health-care pro-viders. There is anxiety as change occurs and understand-able cynicism about whether the change will result in abetter health-care system and a healthier population. Tounderstand the promise of an approach to care that focuseson measuring and improving patient outcomes, it is usefulfor us to think of where we were 15 years ago, where wewant to go, and were we are now.Where We WereUntil fairly recently the health-care system was directedtoward identifying, measuring, treating, and curing disease.The formula was relatively simple. Patients have health prob-lems of some sort (pain, nausea, shortness of breath, rash, etc.);they go to see their doctor. The doctor evaluates them throughhistory, physical examination, and laboratory testing. The doc-tor considers all of the information and makes a diagnosis.Treatment is recommended for the patient based on the diseasethat is identified. The treatment cures the disease or relieves thesymptom. Their problem is resolved. This has been the classicmodel for health care. It varies somewhat for chronic diseasebut the model basically holds.This system places most of the responsibility on thephysician to provide prompt, accurate diagnoses and appro-priate therapy. The patients simply have to present them-selves for care when ill-health or disease presents itself.Where Do We Want To Be?In the future, health care will be provided by teams thatinclude not just physicians, but also nurses, dieticians, ther-apists, psychologists, and other health professionals. Peoplewill look to their health-care providers not just to identifyand treat disease (which of course they will still do), but alsoto guide them as they try to avoid disease and live fullhealthy lives. They will come to their physicians to beevaluated not just for disease, but also to identify risk ofdisease including genetic risk, behavioral risk, environmen-tal risk, or occupational risk. The health-care team will treata disease if present, but will also encourage health-promot-ing behavior in the healthy. Health will be measured andmonitored. The success of the health-care team will bemeasured by how healthy their charges are rather than byhow many treatments they provide. People will live longerlives with less disease and less morbidity.Where We Are NowCurrently we are in the midst of change. Everyone isuncomfortable. Doctors, nurses and therapists are adjustingtheir roles and learning to work together. Patients are start-ing to take responsibility for their health. They are changingbehavior to reduce the risk of disease. Many, but not all, arelearning to focus on promoting health rather than simplytreating disease.Defining HealthHealth can be defined in positive terms. To be healthy isto be alive, free from disease, free of troublesome symp-toms, functioning normally, and enjoying life. Health canalso be defined in more negative terms. To be unhealthy isto be diseased, uncomfortable, disabled, dissatisfied, ordead. Important aspects of health are captured in bothapproaches.It is also helpful to think of health from different viewpoints. The definition of health care can vary depending onthe perspective you take. Health may mean different thingsto a patient, to a physician, or to a health-care administrator.The consensus of opinion is that the best perspective to takewhen defining health is that of the patient.Let us consider the patient’s perspective for determiningimportant measures of health and health outcomes. General