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The Continuing Quest for Measuring and Improving Access to Necessary Care

The Continuing Quest for Measuring and Improving Access to Necessary Care A decade ago, the Institute of Medicine defined quality of care 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."1 This definition is complex and comprehensive, and its many facets are described in detail in an article by Chassin et al2 based on the consensus of the Institute of Medicine's National Roundtable on Health Care Quality. For instance, for "health services for individuals and populations to increase the likelihood of desired health outcomes" they must be used both appropriately and effectively. Quality-of-care problems related to undesirable health outcomes can arise as a result of underuse, overuse, or misuse.2 Underuse is defined as "failure to provide a health care service when it would have produced a favorable outcome for a patient."2 There is considerable evidence of underuse of a variety of medical and surgical interventions in the medical and health services research literature.2-8 Furthermore, numerous studies have demonstrated that underuse of medical care is much more prevalent among minorities and the poor than among other patients.9-16 In this issue of THE JOURNAL, Asch et al17 introduce a system for measuring underuse among Medicare patients using the well-known and respected RAND method that has been used to assess numerous medical and surgical interventions.18-20 In the study, a specialty medical panel used a modified Delphi method to determine whether each of many proposed indicators was necessary, meaning that "the benefits outweigh the risks, the benefits are likely and substantial, and physicians have judged that not recommending the care would be improper." These indicators, which denote the absence of processes of care that have been judged or proven to be necessary for optimal care, provide strong evidence of access problems in the Medicare population. For 14 of the 37 necessary care indicators, beneficiaries received the care less than two thirds of the time. The 3 indicators with the lowest proportions of necessary care were the indication for cholecystectomy (0.410), an eye examination once a year for diabetic patients (0.428), and a mammography every 2 years for women younger than 75 years (0.492), all of which were supported by evidence from randomized controlled trials. Asch et al also found that minorities and the poor have significantly more underuse than other Medicare beneficiaries. African Americans had significantly worse access to medical care for 16 of the 37 necessary care indicators and had significantly better access for only 2 indicators. Residents of poverty ZIP codes and residents of Health Professional Shortage Areas experienced accentuated access problems similar to those of African Americans. Also, because the study by Asch et al focuses on an insured population, its findings underscore the fact that lack of insurance is not the only reason that minorities and the poor have more problems than others accessing necessary medical care. In a recent related study, Jencks et al21 developed 24 process measures pertaining to primary prevention, secondary prevention, or treatment of 6 medical conditions in the Medicare population. The study included many of the same conditions as those used by Asch et al, such as acute myocardial infarction (AMI), heart failure, breast cancer, and diabetes. Also, the indicators used for chronic conditions in the 2 studies, such as mammography every 2 years, were similar. However, not all conditions were the same, and the indicators used for acute conditions in the study by Jencks et al tended to be related to treatment of the condition in its acute phase (eg, aspirin within 24 hours of admission for AMI), whereas the processes for acute conditions in the study by Asch et al tended to be related to subsequent care (eg, visit within 4 weeks of hospital discharge after admission for AMI). The results of the 2 studies are difficult to compare because Jencks et al reported only the median rates across all 50 states for each measure rather than performance at the patient level. Nevertheless, Jencks et al also suggest that there is considerable room for improvement, with their median measure having a median state performance of only 69%, with relatively large variations among states. There is an urgent need to develop ongoing systems for minimizing problems of misuse, underuse, and overuse of medical care in the United States. For many years, evidence has existed that the cost-effectiveness of medical care in the United States is poor relative to the care provided in other industrialized countries. For example, recent data from the Organisation for Economic Co-operation and Development22 document that in 1996, the life expectancy at birth for females in the United States was lower than the life expectancy for females in 19 other countries, and that the life expectancy for males in the United States was lower than the life expectancy for males in 21 other countries. In addition, infant mortality was higher in the United States than in 24 other countries.22 These performance statistics are especially abysmal given that the United States spends on medical care between 51% and 246% more per capita and between 30% and 94% more as a percentage of gross domestic product than all other countries with higher life expectancies and lower infant mortality rates.22 Other reports, including the recent Institute of Medicine report on medical errors, contain similarly alarming statistics.23-26 The study by Asch et al offers the potential to address these problems because it is far more comprehensive than most other efforts to identify underuse. It covers different phases of care, ranging from prevention to diagnostic testing and interventions. Both outpatient and inpatient care are included, and 15 different acute and chronic conditions are examined through use of 46 different indicators of underuse. Also, because existing Medicare data are used, there is no need to develop new clinical data systems or to rely on extremely costly patient surveys or chart reviews to measure changes in access to medical care over time. Thus, along with the study by Jencks et al, the report by Asch et al offers the potential for an ongoing system that can be used to dynamically measure, monitor, and improve numerous access problems. In fact, Jencks et al, who are affiliated with the Health Care Financing Administration (HCFA), indicate that HCFA will be using their process of care measures to evaluate the success of each state's peer review organization in improving quality on a statewide basis.21 Unfortunately, these efforts are just the tip of the iceberg in terms of measuring and monitoring the overall quality of medical care in the United States. With regard to identifying underuse, it is important that the scope of the indicators used by Asch et al and Jencks et al be extended to Medicare managed care. This will be possible in the future because Medicare health maintenance organizations will be required to submit outpatient encounter data to HCFA for care other than inpatient hospital stays by 2004.21 In addition, these indicators should be used for other payers, although billing data for outpatient services may be difficult or impossible to obtain. Efforts also should be made to include measures for proper use of surgical procedures and prescription drugs. As recommended by Jencks et al, other settings also must be included, such as nursing homes and home health care agencies.21 Other indicators for underuse as well as indicators for overuse have been identified by RAND,18,19 and can be obtained from the groundbreaking work done to establish numerous practice guidelines by the Agency for Healthcare Research and Quality.27 For misuse problems, outcomes will frequently be better indicators than processes of care. Investigators examining these issues can emulate what has been done in cardiac surgery for specific high-volume or high-mortality procedures or conditions, although to do so requires either development of expensive new clinical databases or learning to improve the quality and richness of existing administrative databases.28,29 A supplementary, generic approach is to develop and use systems that identify adverse outcomes for all types of acute care patients. Although some statewide mandatory systems now exist for the reporting of medical errors, it is essential to expand the number of programs, make them more uniform, and ensure that reporting is complete and accurate.26 For both of these approaches, outcomes must be linked to processes of care to effectively achieve quality improvement. Finally, the reasons minorities and the poor have accentuated access problems must be investigated. These inequities are so pervasive and persistent that the systems for monitoring and correcting underuse mentioned herein may not suffice. There is a compelling need to engage in painstaking studies of how treatment decisions are made, including identifying the gatekeepers and determining how patient-clinician interactions influence decisions.14 This is an enormously ambitious and costly agenda that should include the construction of an information infrastructure in addition to the development of myriad new measures. These efforts must be coordinated and the relative merits of different approaches to changing practitioner behavior must be explored.2,30,31 To succeed, however, all stakeholders (physicians, health care organizations, purchasers, managed care plans, researchers, funding agencies) must unite in devising effective strategies, securing funds to support those strategies, and measuring the progress of their efforts. References 1. Lohr KN. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990. 2. Chassin MR, Galvin RW.and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA.1998;280:1000-1005.Google Scholar 3. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. Adverse outcomes in elderly survivors of myocardial infarction. JAMA.1997;277:115-121.Google Scholar 4. Whittle J, Wickenhauser L, Venditti LN. Is warfarin underused in the treatment of elderly persons with atrial fibrillation? Arch Intern Med.1997;157:441-445.Google Scholar 5. Fargason Jr CA, Bronstein JM, Johnson VA. Patterns of care received by Medicaid recipients with urinary tract infections. Pediatrics.1995;96:638-642.Google Scholar 6. Senni M, Rodeheffer RJ, Tribouilloy CM. et al. Use of echocardiography in the management of congestive heart failure in the community. J Am Coll Cardiol.1999;33:164-170.Google Scholar 7. Seto TB, Kwiat D, Taira DA, Douglas PS, Manning WJ. Physicians' recommendations to patients for use of antibiotic prophylaxis to prevent endocarditis. JAMA.2000;284:68-71.Google Scholar 8. Druss BG, Hoff RA, Rosenheck RA. Underuse of antidepressants in major depression: prevalence and correlates in a national sample of young adults. J Clin Psychiatry.2000;61:234-237.Google Scholar 9. Wenneker M, Epstein A. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. JAMA.1989;261:253-257.Google Scholar 10. Hannan E, Kilburn H, O'Donnell J, Lukacik G, Shields E. Interracial access to selected cardiac procedures for patients hospitalized with coronary artery disease in New York State. Med Care.1991;29:430-441.Google Scholar 11. Stone P, Thompson B, Anderson V. et al. Influence of race, gender, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III Registry. JAMA.1996;275:1104-1112.Google Scholar 12. Ball JD, Elixhauser A. Treatment differences between blacks and whites with colorectal cancer. Med Care.1996;34:970-984.Google Scholar 13. Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly's use of medical procedures and diagnostic tests. Am J Public Health.1993;83:948-954.Google Scholar 14. Hannan EL, van Ryn M, Burke J. et al. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Med Care.1999;37:68-77.Google Scholar 15. Wenneker MB, Weissman JS, Epstein AM. The association of payer with utilization of cardiac procedures in Massachusetts. JAMA.1990;264:1255-1260.Google Scholar 16. Gittelsohn K, Halpern J, Sanchez R. Income, race and surgery in Maryland. Am J Public Health.1991;81:1435-1441.Google Scholar 17. Asch SM, Sloss EM, Hogan C, Brook RH, Kravitz RL. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA.2000;284:2325-2333.Google Scholar 18. Leape LL, Hilborne LH, Park RE. et al. The appropriateness of use of coronary artery bypass graft surgery in New York State. JAMA.1993;269:753-760.Google Scholar 19. Bernstein SJ, McGlynn EA, Siu AL. et al. The appropriateness of hysterectomy: a comparison of care in seven health plans. JAMA.1993;269:2398-2402.Google Scholar 20. Shekelle PG, Kahan JP, Bernstein SJ, Leape LL, Kamberg CJ, Park RE. The reproducibility of a method to identify the overuse and underuse of medical procedures. N Engl J Med.1998;338:1888-1895.Google Scholar 21. Jencks SF, Cuerdon T, Burwen DR. et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA.2000;284:1670-1676.Google Scholar 22. Organisation for Economic Co-operation and Development Health Care and Policy. Not Available Available at: http://www.oecd.org/els/health/software. Accessed September 11, 2000. 23. Starfield B. Primary Care: Balancing Health Needs, Services and Technology. New York, NY: Oxford University Press; 1998. 24. World Health Report 2000. Available at: http://www.who.int/whr/2000/en/report.htm. Accessed September 11, 2000. 25. Starfield B. Is US health really the best in the world? JAMA.2000;284:483-485.Google Scholar 26. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. 27. Agency for Healthcare Research and Quality Web site. Not Available Available at: http://www.ahrq.gov. Accessed September 11, 2000. 28. Hannan EL, Kilburn Jr H, Racz M, Shields E, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York State. JAMA.1994;271:761-766.Google Scholar 29. Chassin MR, Hannan EL, DeBuono BA. Benefits and hazards of reporting medical outcomes publicly. N Engl J Med.1996;334:394-398.Google Scholar 30. Chassin MR. Improving the quality of health care. N Engl J Med.1996;335:1060-1063.Google Scholar 31. Brook RH, McGlynn EA, Cleary PD. Measuring quality of care. N Engl J Med.1996;335:966-970.Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

The Continuing Quest for Measuring and Improving Access to Necessary Care

JAMA , Volume 284 (18) – Nov 8, 2000

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Publisher
American Medical Association
Copyright
Copyright © 2000 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.284.18.2374
Publisher site
See Article on Publisher Site

Abstract

A decade ago, the Institute of Medicine defined quality of care 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."1 This definition is complex and comprehensive, and its many facets are described in detail in an article by Chassin et al2 based on the consensus of the Institute of Medicine's National Roundtable on Health Care Quality. For instance, for "health services for individuals and populations to increase the likelihood of desired health outcomes" they must be used both appropriately and effectively. Quality-of-care problems related to undesirable health outcomes can arise as a result of underuse, overuse, or misuse.2 Underuse is defined as "failure to provide a health care service when it would have produced a favorable outcome for a patient."2 There is considerable evidence of underuse of a variety of medical and surgical interventions in the medical and health services research literature.2-8 Furthermore, numerous studies have demonstrated that underuse of medical care is much more prevalent among minorities and the poor than among other patients.9-16 In this issue of THE JOURNAL, Asch et al17 introduce a system for measuring underuse among Medicare patients using the well-known and respected RAND method that has been used to assess numerous medical and surgical interventions.18-20 In the study, a specialty medical panel used a modified Delphi method to determine whether each of many proposed indicators was necessary, meaning that "the benefits outweigh the risks, the benefits are likely and substantial, and physicians have judged that not recommending the care would be improper." These indicators, which denote the absence of processes of care that have been judged or proven to be necessary for optimal care, provide strong evidence of access problems in the Medicare population. For 14 of the 37 necessary care indicators, beneficiaries received the care less than two thirds of the time. The 3 indicators with the lowest proportions of necessary care were the indication for cholecystectomy (0.410), an eye examination once a year for diabetic patients (0.428), and a mammography every 2 years for women younger than 75 years (0.492), all of which were supported by evidence from randomized controlled trials. Asch et al also found that minorities and the poor have significantly more underuse than other Medicare beneficiaries. African Americans had significantly worse access to medical care for 16 of the 37 necessary care indicators and had significantly better access for only 2 indicators. Residents of poverty ZIP codes and residents of Health Professional Shortage Areas experienced accentuated access problems similar to those of African Americans. Also, because the study by Asch et al focuses on an insured population, its findings underscore the fact that lack of insurance is not the only reason that minorities and the poor have more problems than others accessing necessary medical care. In a recent related study, Jencks et al21 developed 24 process measures pertaining to primary prevention, secondary prevention, or treatment of 6 medical conditions in the Medicare population. The study included many of the same conditions as those used by Asch et al, such as acute myocardial infarction (AMI), heart failure, breast cancer, and diabetes. Also, the indicators used for chronic conditions in the 2 studies, such as mammography every 2 years, were similar. However, not all conditions were the same, and the indicators used for acute conditions in the study by Jencks et al tended to be related to treatment of the condition in its acute phase (eg, aspirin within 24 hours of admission for AMI), whereas the processes for acute conditions in the study by Asch et al tended to be related to subsequent care (eg, visit within 4 weeks of hospital discharge after admission for AMI). The results of the 2 studies are difficult to compare because Jencks et al reported only the median rates across all 50 states for each measure rather than performance at the patient level. Nevertheless, Jencks et al also suggest that there is considerable room for improvement, with their median measure having a median state performance of only 69%, with relatively large variations among states. There is an urgent need to develop ongoing systems for minimizing problems of misuse, underuse, and overuse of medical care in the United States. For many years, evidence has existed that the cost-effectiveness of medical care in the United States is poor relative to the care provided in other industrialized countries. For example, recent data from the Organisation for Economic Co-operation and Development22 document that in 1996, the life expectancy at birth for females in the United States was lower than the life expectancy for females in 19 other countries, and that the life expectancy for males in the United States was lower than the life expectancy for males in 21 other countries. In addition, infant mortality was higher in the United States than in 24 other countries.22 These performance statistics are especially abysmal given that the United States spends on medical care between 51% and 246% more per capita and between 30% and 94% more as a percentage of gross domestic product than all other countries with higher life expectancies and lower infant mortality rates.22 Other reports, including the recent Institute of Medicine report on medical errors, contain similarly alarming statistics.23-26 The study by Asch et al offers the potential to address these problems because it is far more comprehensive than most other efforts to identify underuse. It covers different phases of care, ranging from prevention to diagnostic testing and interventions. Both outpatient and inpatient care are included, and 15 different acute and chronic conditions are examined through use of 46 different indicators of underuse. Also, because existing Medicare data are used, there is no need to develop new clinical data systems or to rely on extremely costly patient surveys or chart reviews to measure changes in access to medical care over time. Thus, along with the study by Jencks et al, the report by Asch et al offers the potential for an ongoing system that can be used to dynamically measure, monitor, and improve numerous access problems. In fact, Jencks et al, who are affiliated with the Health Care Financing Administration (HCFA), indicate that HCFA will be using their process of care measures to evaluate the success of each state's peer review organization in improving quality on a statewide basis.21 Unfortunately, these efforts are just the tip of the iceberg in terms of measuring and monitoring the overall quality of medical care in the United States. With regard to identifying underuse, it is important that the scope of the indicators used by Asch et al and Jencks et al be extended to Medicare managed care. This will be possible in the future because Medicare health maintenance organizations will be required to submit outpatient encounter data to HCFA for care other than inpatient hospital stays by 2004.21 In addition, these indicators should be used for other payers, although billing data for outpatient services may be difficult or impossible to obtain. Efforts also should be made to include measures for proper use of surgical procedures and prescription drugs. As recommended by Jencks et al, other settings also must be included, such as nursing homes and home health care agencies.21 Other indicators for underuse as well as indicators for overuse have been identified by RAND,18,19 and can be obtained from the groundbreaking work done to establish numerous practice guidelines by the Agency for Healthcare Research and Quality.27 For misuse problems, outcomes will frequently be better indicators than processes of care. Investigators examining these issues can emulate what has been done in cardiac surgery for specific high-volume or high-mortality procedures or conditions, although to do so requires either development of expensive new clinical databases or learning to improve the quality and richness of existing administrative databases.28,29 A supplementary, generic approach is to develop and use systems that identify adverse outcomes for all types of acute care patients. Although some statewide mandatory systems now exist for the reporting of medical errors, it is essential to expand the number of programs, make them more uniform, and ensure that reporting is complete and accurate.26 For both of these approaches, outcomes must be linked to processes of care to effectively achieve quality improvement. Finally, the reasons minorities and the poor have accentuated access problems must be investigated. These inequities are so pervasive and persistent that the systems for monitoring and correcting underuse mentioned herein may not suffice. There is a compelling need to engage in painstaking studies of how treatment decisions are made, including identifying the gatekeepers and determining how patient-clinician interactions influence decisions.14 This is an enormously ambitious and costly agenda that should include the construction of an information infrastructure in addition to the development of myriad new measures. These efforts must be coordinated and the relative merits of different approaches to changing practitioner behavior must be explored.2,30,31 To succeed, however, all stakeholders (physicians, health care organizations, purchasers, managed care plans, researchers, funding agencies) must unite in devising effective strategies, securing funds to support those strategies, and measuring the progress of their efforts. References 1. Lohr KN. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990. 2. Chassin MR, Galvin RW.and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA.1998;280:1000-1005.Google Scholar 3. Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Goldman L. Adverse outcomes in elderly survivors of myocardial infarction. JAMA.1997;277:115-121.Google Scholar 4. Whittle J, Wickenhauser L, Venditti LN. Is warfarin underused in the treatment of elderly persons with atrial fibrillation? Arch Intern Med.1997;157:441-445.Google Scholar 5. Fargason Jr CA, Bronstein JM, Johnson VA. Patterns of care received by Medicaid recipients with urinary tract infections. Pediatrics.1995;96:638-642.Google Scholar 6. Senni M, Rodeheffer RJ, Tribouilloy CM. et al. Use of echocardiography in the management of congestive heart failure in the community. J Am Coll Cardiol.1999;33:164-170.Google Scholar 7. Seto TB, Kwiat D, Taira DA, Douglas PS, Manning WJ. Physicians' recommendations to patients for use of antibiotic prophylaxis to prevent endocarditis. JAMA.2000;284:68-71.Google Scholar 8. Druss BG, Hoff RA, Rosenheck RA. Underuse of antidepressants in major depression: prevalence and correlates in a national sample of young adults. J Clin Psychiatry.2000;61:234-237.Google Scholar 9. Wenneker M, Epstein A. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. JAMA.1989;261:253-257.Google Scholar 10. Hannan E, Kilburn H, O'Donnell J, Lukacik G, Shields E. Interracial access to selected cardiac procedures for patients hospitalized with coronary artery disease in New York State. Med Care.1991;29:430-441.Google Scholar 11. Stone P, Thompson B, Anderson V. et al. Influence of race, gender, and age on management of unstable angina and non-Q-wave myocardial infarction: the TIMI III Registry. JAMA.1996;275:1104-1112.Google Scholar 12. Ball JD, Elixhauser A. Treatment differences between blacks and whites with colorectal cancer. Med Care.1996;34:970-984.Google Scholar 13. Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly's use of medical procedures and diagnostic tests. Am J Public Health.1993;83:948-954.Google Scholar 14. Hannan EL, van Ryn M, Burke J. et al. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Med Care.1999;37:68-77.Google Scholar 15. Wenneker MB, Weissman JS, Epstein AM. The association of payer with utilization of cardiac procedures in Massachusetts. JAMA.1990;264:1255-1260.Google Scholar 16. Gittelsohn K, Halpern J, Sanchez R. Income, race and surgery in Maryland. Am J Public Health.1991;81:1435-1441.Google Scholar 17. Asch SM, Sloss EM, Hogan C, Brook RH, Kravitz RL. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA.2000;284:2325-2333.Google Scholar 18. Leape LL, Hilborne LH, Park RE. et al. The appropriateness of use of coronary artery bypass graft surgery in New York State. JAMA.1993;269:753-760.Google Scholar 19. Bernstein SJ, McGlynn EA, Siu AL. et al. The appropriateness of hysterectomy: a comparison of care in seven health plans. JAMA.1993;269:2398-2402.Google Scholar 20. Shekelle PG, Kahan JP, Bernstein SJ, Leape LL, Kamberg CJ, Park RE. The reproducibility of a method to identify the overuse and underuse of medical procedures. N Engl J Med.1998;338:1888-1895.Google Scholar 21. Jencks SF, Cuerdon T, Burwen DR. et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA.2000;284:1670-1676.Google Scholar 22. Organisation for Economic Co-operation and Development Health Care and Policy. Not Available Available at: http://www.oecd.org/els/health/software. Accessed September 11, 2000. 23. Starfield B. Primary Care: Balancing Health Needs, Services and Technology. New York, NY: Oxford University Press; 1998. 24. World Health Report 2000. Available at: http://www.who.int/whr/2000/en/report.htm. Accessed September 11, 2000. 25. Starfield B. Is US health really the best in the world? JAMA.2000;284:483-485.Google Scholar 26. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. 27. Agency for Healthcare Research and Quality Web site. Not Available Available at: http://www.ahrq.gov. Accessed September 11, 2000. 28. Hannan EL, Kilburn Jr H, Racz M, Shields E, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York State. JAMA.1994;271:761-766.Google Scholar 29. Chassin MR, Hannan EL, DeBuono BA. Benefits and hazards of reporting medical outcomes publicly. N Engl J Med.1996;334:394-398.Google Scholar 30. Chassin MR. Improving the quality of health care. N Engl J Med.1996;335:1060-1063.Google Scholar 31. Brook RH, McGlynn EA, Cleary PD. Measuring quality of care. N Engl J Med.1996;335:966-970.Google Scholar

Journal

JAMAAmerican Medical Association

Published: Nov 8, 2000

References