President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Improving Quality in a Changing Health Care Industry

Chapter One
The State of Health Care Quality: How Good Is Care?

Across the Nation, skilled practitioners and high-caliber institutions help to maintain or restore Americans' health and ability to function. While most Americans receive high- quality health care, too many patients receive substandard care. Quality problems have been identified, including (1) avoidable errors, (2) underuse of health care services, (3) overuse of services, and (4) variation in services. These shortcomings endanger the health and lives of all patients, add costs to the health care system, and reduce productivity. Efforts by public and private sector stakeholders have helped to identify problems and begin the process of finding solutions. What is needed now is a national commitment to measure, improve, and maintain quality care for all citizens.

The Best of Care, The Worst of Care

Every day, millions of Americans have access to the best quality health care available in the world. Skilled practitioners, high-caliber institutions, and top-flight researchers continue to advance the science and practice of health care. Yet many Americans increasingly are concerned about the quality of the care they receive and the ability of the health care industry to provide high-quality care on a consistent basis.

Exhaustive research documents the fact that today, in America, there is no guarantee that any individual will receive high-quality care for any particular health problem. The health care industry is plagued with overutilization of services, underutilization of services, and errors in health care practice.

These quality problems are not new, nor are they unique to any particular type of arrangements through which health care is financed and delivered. The term "managed care" denotes a wide spectrum of health care arrangements, including health maintenance organizations, preferred provider organizations, and point-of-service arrangements. Both the best and the worst health care our system has to offer can be found in managed care plans, as it can in traditional fee-for-service (or indemnity) arrangements (Miller and Luft, 1997).

Key indicators of the quality problems we face include:

Despite this growing body of evidence, the American health care industry still does not have the ability to systematically measure and report on the quality of health care that is delivered to patients. What is known, however, indicates that there are substantial areas for improvement in the quality of care.

The lack of comprehensive information on the quality of American health care is unacceptable in an industry that accounts for more than $1 trillion in annual expenditures and comprises nearly one-seventh of the U.S. economy.

These problems with the quality of American health care present a clear and compelling argument for national action. Recent advances in the science of medicine, the measurement of quality, and the public and private commitment to accountability in the health care industry provide the Nation with a tremendous opportunity to improve the quality of health care in the United States. To achieve this necessary progress, we will need a national commitment to quality improvement, beginning with leadership from the highest levels of government, industry, labor, and the health care professions.

Evidence of Quality Problems

Quality of care has been defined by the Institute of Medicine as "the degree to which health services for individuals and populations increase the likelihood of desired health care outcomes and are consistent with current professional knowledge" (Lohr, 1990). Researchers have documented a tremendous amount of unevenness in the quality of health care services rendered in the United States. These problems fall into four distinct categories: avoidable errors, underuse of services, overuse of services, and variation in practice.

Are Things Getting Worse?

In medicine, as in many other fields of study, as we get better at detecting problems, we find more of them. This is true both in clinical practice and in quality assessment. While we have made advances in our ability to detect problems, it also is quite likely that the rapidly expanding base of knowledge, coupled with changes in technology, is contributing to an ever-widening gap between the best care possible and the care that is actually delivered.

Every year brings advances in the interventions available to screen for diseases, prevent diseases from developing, make diagnoses, treat conditions, and monitor the progress of disease. For example:

While these innovations in medicine have significantly, and positively, affected the health of the population, they also pose a challenge for health care practitioners to keep their skills up-to-date. Just reading about advances (as compared to active training in or experience with new techniques) is a daunting task. For instance, according to an analysis of MEDLINE entries, the number of citations reporting on randomized controlled trials has increased from an average of 509 annually between 1975 and 1980 to 8,636 annually from 1993 through 1997 (McGlynn, 1998). Although no practitioner needs to follow advances across all areas of medicine and surgery, rapid expansion of knowledge is occurring even within specific areas. Randomized controlled trials published on coronary artery disease increased from about 6 per year between 1975 and 1980 to 149 per year between 1993 and 1997. For diabetes, the growth was from about 6 per year to about 176 per year in the same time periods. For asthma, citations increased from 13 to 200 annually. And, while there were no randomized trials reported in the literature on laser surgery between 1980 and 1985, about 30 were published per year between 1993 and 1997.

Randomized trials represent only one type of study report that practitioners are expected to track. Large observational studies also contribute new insights into the science of medicine. Considerable attention is being paid to methods for making information more readily available to practitioners, such as through the Internet and information systems within health plans. Meta-analysis, a technique that summarizes findings across multiple studies, is another mechanism that may assist practitioners in understanding the "bottom line" message from the literature. Only one citation classified as a meta-analysis appeared between 1985 and 1990, compared with 416 annually between 1993 and 1997.

There also has been an explosion in the availability of practice guidelines, which increasingly are viewed as mechanisms for communicating information about best practices. Between 1975 and 1980, about 1 publication annually was classified as a practice guideline, compared to 454 annually between 1993 and 1997. Initial resistance among practitioners to guidelines has given way to active participation in constructing such guidelines (Hoyt, 1997). The Directory of Clinical Practice Guidelines, published by the American Medical Association (AMA), currently lists 1,700 clinical practice guidelines. A survey of physician medical groups and independent practice associations found that 87 percent were developing or implementing guidelines to accomplish either cost containment or quality improvement goals (Fang et al., 1996).

The proliferation of guidelines and concerns about the scientific basis for guidelines in general led the AMA to create the Clinical Practice Guidelines Recognition Program, which will identify evidence-based guidelines meeting a set of criteria developed by a partnership among the AMA, national medical specialty societies, the Agency for Health Care Policy and Research (AHCPR), the American Hospital Association, and the Joint Commission on Accreditation of Healthcare Organizations. In addition, the AHCPR, the AMA, and the American Association of Health Plans are working jointly to develop a comprehensive, Internet-based source of clinical practice guidelines. The initiative, known as the National Guideline Clearinghouse (NGC), will make available a full range of current guidance on treatments for specific medical conditions. The NGC will make full-text clinical practice guidelines, abstracts, summaries, and comparisons available to every physician, health plan, provider, purchaser, and consumer with access to the Internet. It is anticipated that the NGC will be launched on the Internet in the fall of 1998.

While the "science" of health care advances, increasing attention is being paid to the "art" of health care as reflected in patient evaluations of their experiences with care. While there is a growing emphasis in health care on patient-provider partnership efforts, patients and their health care providers do not always agree on the importance of different elements of care. One study found differences between doctors and their patients on the importance of 73 of 125 elements of care (Laine et al., 1996). Patients ranked provision of information as the second most important aspect of care (behind clinical skill), whereas physicians ranked information sixth. Communication can affect health outcomes. A review of 21 studies found that in 16 a positive relationship between good doctor-patient communication and health outcomes was documented (Stewart, 1995). Outcomes that were positively influenced included emotional health, symptom resolution, function, clinical outcomes, and pain control.

Poor communication can lead to patient failure to adhere to recommended treatment regimens. A study in five urban teaching hospitals in the Northeast found that dissatisfaction with discharge instructions was a key factor that resulted in 12 percent of patients not filling their prescriptions (Thomas et al., 1996). A study conducted in Canada found that 20 percent of hospitalized patients reported that they were not told about important side effects of medications they were taking and 20 percent of patients undergoing tests indicated that results were not explained (Charles et al., 1994).

In summary, we know enough from the results of studies of variability, overutilization, underutilization, and errors to draw some conclusions about the level of quality. We know that there is a gap between best practices and actual practices. We know that even highly trained health professionals make mistakes from time to time. And we know that the likelihood that any one of us will get the best care possible varies considerably.

Quality Improvement Techniques

While a substantial amount is unknown about how to change behavior of patients and practitioners, we are learning more every day, and a wide range of effective techniques are already available to improve the delivery of health services. Much is being learned about effective techniques used in other industries. A key step in designing effective quality improvement interventions is identifying likely reasons for suboptimal performance and tailoring the interventions to address those deficiencies. Three main targets of intervention are the health professional, the patient, and the health service delivery system. Many interventions are directed at a combination of these targets.

A National Commitment Is Needed

Quality of care in the United States varies considerably within and across communities, hospitals, practitioners, patients, delivery systems, geographic areas, and health problems. This variation is itself inconsistent -- meaning that the same groups do not always perform best or worst, making it difficult to develop programs to improve quality based on current knowledge. The real level of quality in most areas of the country is unknown, but what we do know suggests that we can no longer afford the luxury of ignorance.

What is needed to move forward? Significant advances have been made in the methods of quality measurement so that it is possible to assess the quality of care for diverse conditions in a variety of settings. We need to implement such measurement activities systematically, and on a broad national scale. This will require investment in people, methods, and data systems. We also need to find mechanisms for making the lessons of quality improvement available to all participants in the health care industry. The quality of services can be improved, but doing so requires an understanding of the extent of the gap between standards and actual practice, the likely causes of the gap, effective tools for closing the gap, and a cultural change that values engaging in ongoing quality improvement.

To accomplish these vitally important aims, the United States needs a national commitment to the measurement, improvement, and maintenance of high-quality health care for all its citizens. The body of this report lays out a series of steps that must be taken by all sectors -- public and private -- to achieve the goal of a quality health care system for all Americans.


Aaland, Mary O., and Ken Smith, "Delayed Diagnosis in a Rural Trauma Center," Surgery 120(4):774-778, October 1996.

Agency for Health Care Policy and Research, Healthcare Cost and Utilization Project (HCUP-3). Statistics from the HCUP-3 Nationwide Inpatient Sample for 1994: Principal Procedures, AHCPR Pub. No. 97-0057, Rockville, MD, 1997.

Andrews, Lori B., Carol Stocking, Thomas Kriezek, et al., "An Alternative Strategy for Studying Adverse Events in Medical Care," Lancet 349:309-313, 1997.

Banks, Naomi J., R. Heather Palmer, Donald M. Berwick, and Paul Plsek, "Variability in Clinical Systems: Applying Modern Quality Control Methods to Health Care," Joint Commission Journal on Quality Improvement 21:407-419, 21, 1995.

Bates, David W., David J. Cullen, Nan Laird, et al., "Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention," Journal of the American Medical Association 274(1):29-34, July 5, 1995.

Bernstein, S.J., E.A. McGlynn, A.L. Siu, et al., "The Appropriateness of Hysterectomy. A Comparison of Care in Seven Health Plans. Health Maintenance Organization Quality of Care Consortium," Journal of the American Medical Association 269(18):2398-402, May 12, 1993.

Brechner, Ross, Catherine Cowie, Jean Howie, et al., "Ophthalmic Examination Among Adults with Diagnosed Diabetes Mellitus," Journal of the American Medical Association 270(14):1714-1718, October 13, 1993.

Brennan, Troyen A., Lucien L. Leape, Nan M. Laird, et al., "Incidence of Adverse Events and Negligence in Hospitalized Patients," New England Journal of Medicine 324(6):370-376, February 7, 1991.

Buckley, T.A., T.G. Short, Y.M. Rowbottom, and T.E. Oh, "Critical Incident Reporting in the Intensive Care Unit," Anaesthesia 52(5):403-409, 1997.

Carlisle, David M., B. Robert Valdez, Martin F. Shapiro, and Robert H. Brook, "Geographic Variation in Rates of Selected Surgical Procedures Within Los Angeles County," Health Services Research 30(1):27-42, April 1, 1995.

Centers for Disease Control, "Mammography and Clinical Breast Examinations for Women Aged 50 Years and Older -- Behavioral Risk Factor Surveillance System, 1992," Morbidity and Mortality Weekly Reports 42:737-741, 1993a.

Centers for Disease Control, "Physician and Other Health-Care Professional Counseling of Smokers to Quit -- United States, 1991," Morbidity and Mortality Weekly Reports 42:854-857, 1993b.

Centers for Disease Control, "Influenza and Pneumococcal Vaccination Coverage Levels Among Persons Age > 65 Years -- United States, 1973-1993," Morbidity and Morality Weekly Reports 44:506-515, 1995a.

Centers for Disease Control, "Trends in Cancer Screening -- United States, 1987 and 1992," Morbidity and Mortality Weekly Reports 45:57-61, 1995b.

Centers for Disease Control, "National, State, and Urban Area Vaccination Coverage Levels Among Children 19-35 Months -- United States, January to December, 1995," Morbidity and Mortality Weekly Reports 46:176-183, 1997.

Charles C., M. Gauld, L. Chambers, et al., "How Was Your Hospital Stay? Patients' Reports About Their Care in Canadian Hospitals," Canadian Medical Association Journal 150:1813-1822, 1994.

Chassin, Mark R., "Assessing Strategies For Quality Improvement," Health Affairs 16(3):151-161, May/June 1997.

Chassin, Mark R., Robert H. Brook, Rolla Edward Park, et al., "Variations in the Use of Medical and Surgical Services by the Medicare Population," New England Journal of Medicine 314(5):285-290, January 30, 1986.

Davis, David A., Mary Ann Thomson, Andrew D. Oxman, and R. Brian Haynes, "Changing Physician Performance: A Systematic Review of the Effect of Continuing Medical Education Strategies," Journal of the American Medical Association 274(9):700-705, September 6, 1995.

Davis, Nancy A., Esther Nash, Catherine Bailey, et al., "Evaluation of Three Methods for Improving Mammography Rates in a Managed Care Plan," American Journal of Preventive Medicine 13(4):298-302, July-August 1997.

Dowell, Scott, and Benjamin Schwartz, "Resistant Pneumococci: Protecting Patients Through Judicious Use of Antibiotics," American Family Physician 55(5):1647-1654, April 1997.

Dubois, Robert, and Robert H. Brook, "Preventable Deaths: Who, How Often, and Why?" Annals of Internal Medicine 109(7):582-589, October 1, 1988.

Ellerbeck, Edward, Steven Jencks, Martha Radford, et al., "Quality of Care for Medicare Patients With Acute Myocardial Infarction: A Four-State Pilot Project From the Cooperative Cardiovascular Project," Journal of the American Medical Association 273(19):1509-1514, May 17, 1995.

Fang, Edward, Brian S. Mittman, and Scott Weingarten, "Use of Clinical Practice Guidelines in Managed Care Physician Groups," Archives of Family Medicine 5(9):528-531, October 1996.

Goyert, Gregory L., Sidney F. Bottoms, Marjorie C. Treadwell, and Paul C. Nehra, "The Physician Factor in Cesarean Birth Rates," New England Journal of Medicine 320(11):706-709, March 16, 1989.

Graves, Edmund J., and B.S. Gillum, "National Hospital Discharge Survey: Annual Summary, 1994." Vital and Health Statistics 13(128):1-146, November 1997.

Haas, Susan, David Acker, Charles Donahue, and Martha E. Katz, "Variation in Hysterectomy Rates Across Small Geographic Areas Within Massachusetts," American Journal of Obstetrics and Gynecology 169(1):1-146, July 1993.

Hanlon, Joseph T., Morris Weinberger, Gregory P. Samsa, et al., "A Randomized Controlled Trial of a Clinical Pharmacist Intervention to Improve Inappropriate Prescribing in Elderly Outpatients with Polypharmacy," American Journal of Medicine 100(4):428-437, April 1996.

Hannan, Edward L., H. Kilburn, Michael Racz, et al., "Improving the Outcomes of Coronary Artery Bypass Graft Surgery in New York State," Journal of the American Medical Association 271(10):761-766, March 9, 1994.

Hirschfeld, Robert M., Martin B. Keller, Susan Panico, et al., "The National Depressive and Manic-Depressive Association Consensus Statement on the Undertreatment of Depression," Journal of the American Medical Association 277(4):333-340, January 22-29, 1997.

Hoyt, David B., "Clinical Practice Guidelines," American Journal of Surgery 173:32-34, 1997.

Ives, Diane G., Judith R. Lave, Neal D.Traven, and Lewis H. Kuller, "Impact of Medicare Reimbursement on Influenza Vaccination Rates in the Elderly," Preventive Medicine 23(2):134-141, March 1994.

Karuza, Jurgis, Evan Calkins, John Feather, et al., "Enhancing Physician Adoption of Practice Guidelines: Dissemination of Influenza Vaccination Guideline Using a Small Group Consensus Process," Archives of Internal Medicine 155(6):625-632, March 27, 1995.

Katon, Wayne, Michael Von Korff, Elizabeth Lin, et al., "Collaborative Management to Achieve Treatment Guidelines: Impact on Depression in Primary Care," Journal of the American Medical Association 273(13):1026-1031, April 5, 1995.

Kleinman, Lawrence, Jacqueline Kosecoff, Robert W. Dubois, and Robert H. Brook, "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger Than 16 Years in the United States," Journal of the American Medical Association 271(16):1250-1255, April 27, 1994.

Knesper D.J., B.E. Belcher, J.G. Cross, "A Market Analysis Comparing the Practices of Psychiatrists and Psychologists," Archives of General Psychiatry 46(4):305-314, April 1989.

Kramer, A.M., J.F. Steiner, R.E. Schlenker, et al., "Outcomes and Costs After Hip Fracture and Stroke: A Comparison of Rehabilitation Settings," Journal of the American Medical Association 277(5):396-404, February 5, 1997.

Krumholz, Harlan, Martha Radford, Edward Ellerbeck, et al., "Aspirin in the Treatment of Acute Myocardial Infarction in Elderly Medicare Beneficiaries: Patterns of Use and Outcomes," Circulation 92(10):2841-2847, November 15, 1995.

Laine, Christine, Frank Davidoff, Charles E. Lewis, et al., "Important Elements of Outpatient Care: A Comparison of Patients' and Physicians' Opinions," Annals of Internal Medicine 125(8):640-645, October 15, 1996.

Lammers, John C., Shan Cretin, Stuart Gilman, and Emeloy Calingo, "Total Quality Management in Hospitals: The Contributions of Commitment, Quality Councils, Teams, Budgets, and Training to Perceived Improvement at Veterans Health Administration Hospitals," Medical Care 34(5):463-478, May 1996.

Leape, Lucian L., "Error in Medicine," Journal of the American Medical Association 272(23):1851-1857, December 21, 1994.

Leape, Lucian L., Lee H. Hilborne, Rolland E. Park, et al., "The Appropriateness of Use of Coronary Artery Bypass Graft Surgery in New York State," Journal of the American Medical Association 269:753-760, 1993.

Lesar, Timothy S., L. Briceland, and D.S. Stein, "Factors Related to Errors in Medication Prescribing," Journal of the American Medical Association 277(4):312-317, January 22-29, 1997.

Lesar, Timothy, Ben M. Lomaestro, and Henry Pohl, "Medication-Prescribing Errors in a Teaching Hospital: A 9-Year Experience," Archives of Internal Medicine 157(14):1569-1576, July 28, 1997.

Lind, Anne C., Chhanda Bewtra, James C. Healy, and Kenneth L. Sims, "Prospective Peer Review in Surgical Pathology," American Journal of Clinical Pathology 104(5):560-566, November 1995.

Lohr, Katherine, ed., Medicare: A Strategy for Quality Assurance (Washington, DC: National Academy Press, 1990).

Mainous, Arch, William Hueston, and Jonathan Clark, "Antibiotics and Upper Respiratory Infection: Do Some Folks Think There Is a Cure for the Common Cold?" Journal of Family Practice 42(4):357-361, April 1996.

McCaig, Linda, and James Hughes, "Trends in Antimicrobial Drug Prescribing Among Office-Based Physicians in the United States," Journal of the American Medical Association 273(3):214-219, January 18, 1995.

McCarthy, Bruce D., Marianne U. Yood, Mary Beth Bolton, et al., "Redesigning Primary Care Processes to Improve the Offering of Mammography. The Use of Clinic Protocols by Nonphysicians," Journal of General Internal Medicine 12(6):357-363, June 1997.

McGinnis, Michael J., and William H. Foege, "Actual Causes of Death in the United States," Journal of the American Medical Association 270(18):2207-2212, November 10, 1993.

McGlynn, Elizabeth A., written statement to the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, January 28, 1998.

Miller, Robert H., and Harold S. Luft, "Does Managed Care Lead to Better or Worse Quality of Care," Health Affairs 16(5):7-25, September/October 1997.

Morris, John A. Jr., Todd J. Rosenbower, Gregory J. Jurkovich, et al., "Infant Survival After Cesarean Section for Trauma," Annals of Surgery 223(5):481-488, May 1996.

National Center for Health Statistics, Current Estimates from the National Health Interview Survey, 1993 (Hyattsville, MD: U.S. Department of Health and Human Services, 1994a).

National Center for Health Statistics, National Ambulatory Medical Care Survey, 1991 Summary (Hyattsville, MD: U.S. Department of Health and Human Services, 1994b).

National Committee for Quality Assurance, The State of Managed Care Quality (Washington, DC, 1997).

Paes, Bosco A., Anjana Modi, and Ray Dunmore, "Changing Physicians' Behavior Using Combined Strategies and an Evidence-Based Protocol," Archives of Pediatric and Adolescent Medicine 148(12):1277-1280, December 1994.

Paul-Shaheen, Pamela, Jane D. Clark, and Daniel Williams, "Small Area Analysis: A Review and Analysis of the North American Literature," Journal of Health Politics, Policy, and Law 12:741-809, 1987.

Perneger, Thomas V., Pierre Chopard, Francois P. Sarasin, et al., "Risk Factors for a Medically Inappropriate Admission to a Department of Internal Medicine," Archives of Internal Medicine 157(13):1495-1500, July 14, 1997.

Phillips, David P., Nicholas Christenfeld, and Laura M. Glynn, "Increase in U.S. Medication-Error Deaths Between 1983 and 1993." Lancet 351(9103), February 1998.

Porath, Avi, Fransisco Schlaeffer, and David Lieberman, "Appropriateness of Hospitalization of Patients with Community-Acquired Pneumonia," Annals of Emergency Medicine 27(2):176-183, February 1996.

Public Health Service, Department of Health and Human Services, Healthy People 2000 Review 1994 (Hyattsville, MD: Public Health Service, 1995).

Shields, Marc C., Kenneth W. Griffin, and Wylie L. McNabb, "The Effect of a Patient Education Program on Emergency Room Use for Inner-City Children With Asthma," American Journal of Public Health 80(1):36-38, January 1990.

Siu, Albert L., Frank A. Sonnenberg, Willard G. Manning, et al., "Inappropriate Use of Hospitals in a Randomized Trial of Health Insurance Plans," New England Journal of Medicine 315(20):1259-1266, November 13, 1986.

Soumerai, Stephen B., and Jerome Avorn, "Principles of Educational Outreach ('Academic Detailing') to Improve Clinical Decision Making," Journal of the American Medical Association 263:549-556, 1990.

Soumerai, Stephen, Thomas McLaughlin, Ellen Hertzmark, et al., "Adverse Outcomes of Underuse of Beta Blockers in Elderly Survivors of Acute Myocardial Infarction," Journal of the American Medical Association 277(2):115-121, January 8, 1997.

Soumerai, Stephen, Suzanne Salem-Schatz, Jerome Avorn, et al., "A Controlled Trial of Educational Outreach to Improve Blood Transfusion Practice," Journal of the American Medical Association 270(8):961-966, August 25, 1993.

Stafford, Randall S., Demet Saglam, Nancyanne Causino, and David Blumenthal, "Low Rates of Hormone Replacement in Visits to United States Primary Care Physicians," American Journal of Obstetrics and Gynecology 177(2):381-387, August 1997.

Stewart, M. Anita, "Effective Physician-Patient Communication and Health Outcomes: A Review," Canadian Medical Association Journal 152(9):1423-1433, May 1, 1995.

Tamblyn, Robin, Leora Berkson, W. Dale Dauphinee, et al., "Unnecessary Prescribing of NSAIDs and the Management of NSAID-Related Gastropathy in Medical Practice," Annals of Internal Medicine 127(6):429-438, September 15, 1997.

Thomas, Eric J., Helen R. Burstin, Anne C. O'Neil, et al., "Patient Noncompliance With Medical Advice After the Emergency Department Visit," Annals of Emergency Medicine 27(1):49-55, January 1996.

Thompson, Robert S., Stephen H. Taplin, Timothy A. McAfee, et al., "Primary and Secondary Prevention Services in Clinical Practice. Twenty Years' Experience in Development, Implementation and Evaluation," Journal of the American Medical Association 273(14):1130-1135, April 12, 1995.

Tobacman, Joanne K., Paul Lee, Bridget Zimmerman, et al., "Assessment of Appropriateness of Cataract Surgery at Ten Academic Medical Centers in 1990," Ophthalmology 103(2):207-215, February 1996.

U.S. Preventive Services Task Force, Department of Health and Human Services, Guide to Clinical Preventive Services, 2nd Edition (Baltimore: Williams and Wilkins, 1996).

Von Korff, Michael, W. Barlow, Daniel Cherkin, and Richard A. Deyo, "Effects of Practice Style in Managing Back Pain," Annals of Internal Medicine 121(3):187-195, August 1, 1994.

Weiner, Jonathan P., Stephen T. Parente, Deborah W. Garnick, et al., "Variation in Office Based Quality: A Claims Based Profile of Care Provided to Medicare Patients With Diabetes," Journal of the American Medical Association 273(19):1503-1508, May 17, 1995.

Wells, Kenneth B., William Katon, William R. Rogers, and Patricia Camp, "Use of Minor Tranquilizers and Antidepressant Medications by Depressed Outpatients: Results from the Medical Outcomes Study," American Journal of Psychiatry 151(5):694-700, May 1994.

Wennberg, John E., and Megan McAndrew, eds., The Dartmouth Atlas of Health Care in the United States (Chicago: American Hospital Publishing, Inc., 1998).

Wennberg, John E., and Alan Gittelsohn, "Small Area Variations in Health Care Delivery," Science 142:1102-1108, 1973.

West, D.W., S. Levine, G. Magram, et al., "Pediatric Medication Order Error Rates Related to the Mode of Order Transmission," Archives of Pediatric and Adolescent Medicine 148(12):1322-1326, December 1994.

Wilbur, David C., "False Negatives in Focused Rescreening of Papincolaou Smears: How Frequently Are 'Abnormal' Cells Detected in Retrospective Review of Smears Preceding Cancer or High-Grade Intraepithelial Neoplasia?" Archives of Pathology and Laboratory Medicine 121(3):273-276, March 1997.

Winslow, Constance M., Jacqueline B. Kosecoff, Mark R. Chassin, et al., "The Appropriateness of Performing Coronary Artery Bypass Graft Surgery," Journal of the American Medical Association 260(4):505-509, July 22-29, 1988.

Wong, John H., Max J. Findlay, and Maria E. Suarez-Almazor, "Regional Performance of Carotid Endarterectomy: Appropriateness, Outcomes, and Risk Factors for Complications," Stroke 28:891-898, 1997.

Zenni, Elissa A., and Thomas N. Robinson, "Effects of Structured Encounter Forms on Pediatric House Staff Knowledge, Parent Satisfaction, and Quality of Care. A Randomized Controlled Trial," Archives of Pediatric and Adolescent Medicine 150(9):975-980, September 1996.

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