• Asthma guidelines
• cystic fibrosis
• clinical epidemiology
• drug reactions

Healthcare quality has received sustained attention since the release of To Err is Human by the US Institute of Medicine in late 1999.1 This report captured widespread interest with the oft-quoted estimate that medical errors annually cause 44 000–98 000 deaths in US hospitals alone. This period also coincided with publication of ‘An organisation with a memory’,2 which described the scale and nature of serious failures in the UK National Health Service.

A widely accepted definition describes quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.3 4 This definition further characterised quality in terms of six dimensions: safety, effectiveness, patient centeredness, timeliness, efficiency and equitability.

Numerous studies document major shortcomings in each of these dimensions across a range of clinical settings.3 One illustrative study5 showed that only 55% of Americans with chronic medical conditions received basic aspects of acute, chronic and preventive care.5 For example, only 50% of patients with asthma received chronic inhaled corticosteroids and a similarly low percentage of patients with chronic obstructive pulmonary disease (COPD) received influenza vaccination. These major shortfalls in effective healthcare do not simply reflect access issues, as comparable data from Canada (with universal public healthcare) show that only 56% of patients with COPD had undergone spirometry as recommended by guidelines and only 34% received guideline-concordant treatment.6 Given that COPD will become the third leading cause of death by 20307 and represents the one common cause of death for which mortality rates continue to climb, we must improve adherence to evidence-based aspects of COPD management.8