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Defining the Contents of the Data Set: The National Health Care Quality Framework

This chapter lays out the framework for the National Health Care Quality Report (also referred to as the Quality Report). The framework largely determines the contents of the National Health Care Quality Data Set and categories of measures. The framework proposed by the committee includes two major dimensions: (1) an assessment of the components of health care quality—safety, effectiveness, “patient centeredness,” and timeliness—and (2) an assessment of how well the system responds to consumer perspectives on health care needs— staying healthy, getting better, living with illness or disability, and coping with the end of life. Some measures can be organized by specific condition (for example, diabetes), particularly for effectiveness. Equity can be assessed by analyzing quality of care across different groups of people.

RECOMMENDATION

RECOMMENDATION 1: The conceptual framework for the National Health Care Quality Report should address two dimensions: components of health care quality and consumer perspectives on health care needs. Components of health care quality—the first dimension—include safety, effectiveness, patient centeredness, and timeliness. Consumer perspectives on health care needs—the second dimension—reflect changing needs for care over the life cycle associated with staying healthy, getting better, living with illness or disability, and coping with the end of life. Quality can be examined



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Page 40 2 Defining the Contents of the Data Set: The National Health Care Quality Framework This chapter lays out the framework for the National Health Care Quality Report (also referred to as the Quality Report). The framework largely determines the contents of the National Health Care Quality Data Set and categories of measures. The framework proposed by the committee includes two major dimensions: (1) an assessment of the components of health care quality—safety, effectiveness, “patient centeredness,” and timeliness—and (2) an assessment of how well the system responds to consumer perspectives on health care needs— staying healthy, getting better, living with illness or disability, and coping with the end of life. Some measures can be organized by specific condition (for example, diabetes), particularly for effectiveness. Equity can be assessed by analyzing quality of care across different groups of people. RECOMMENDATION RECOMMENDATION 1: The conceptual framework for the National Health Care Quality Report should address two dimensions: components of health care quality and consumer perspectives on health care needs. Components of health care quality—the first dimension—include safety, effectiveness, patient centeredness, and timeliness. Consumer perspectives on health care needs—the second dimension—reflect changing needs for care over the life cycle associated with staying healthy, getting better, living with illness or disability, and coping with the end of life. Quality can be examined

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Page 41 along both dimensions for health care in general or for specific conditions. The conceptual framework should also provide for the analysis of equity as an issue that cuts across both dimensions and is reflected in differences in the quality of care received by different groups of the population. The four system components of health care quality are defined as follows: 1. Safety refers to “avoiding injuries or harm to patients from care that is intended to help them” (Institute of Medicine, 2001). 2. Effectiveness refers to “providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding overuse and underuse)” (Institute of Medicine, 2001). Overuse occurs when “a health care service is provided under circumstances in which its potential for harm exceeds its potential benefit.” Underuse “is the failure to provide a health care service when it would have produced a favorable outcome for a patient” (Chassin and Galvin, 1998:1002). 3. Patient centeredness refers to health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care. 4. Timeliness refers to obtaining needed care and minimizing unnecessary delays in getting that care. The relative importance of the four components of health care quality may vary over time and for different providers and policy makers. These quality components apply across all health care settings—from institutionalized to inpatient and ambulatory care; from clinicians' offices to home health care and hospice care. Consumers have several perspectives on health care. They want a system that will respond to their needs or reasons for seeking care, ranging from staying healthy to coping with the end of life. These needs vary over the life span and across groups of the population. Consumers would like to know about the overall quality of care, but they are particularly interested in care for specific conditions or situations that affect them or their families. Equity in health care quality is considered an important cross-cutting issue. The framework allows for its consideration by comparing the quality of care for different groups of the population, across geographic areas and by condition, as appropriate. Efficiency is not included in the committee's framework. Some aspects of efficiency are reflected in other components of quality. For example, errors in health care that result in additional procedures, hospitalizations, or other treat-

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Page 42 ments are a form of waste or inefficiency. The provision of unnecessary services (that is, overuse or ineffectiveness) is another form of waste. Fragmentation of care and unnecessary waits and delays in service (that is, lack of timeliness) consume the patient's and the clinician's time and other resources that could be put to better use. One basic aspect of efficiency that is not reflected in the framework is the cost per unit of service (for example, cost per laboratory test), but this was viewed as falling outside the purview of a national report focusing on the quality of health care services. IMPORTANCE OF THE FRAMEWORK A framework serves several important purposes. The framework is a tool for organizing the way one thinks about health care quality. It provides a foundation for quality measurement, data collection, and subsequent reporting. A framework is a way of making explicit the aspects of health care that should be measured (Miles and Huberman, 1994) in order to assess quality and define policy accordingly. Given that quality is a multifaceted subject, the framework provides a way to organize the various elements of the National Health Care Quality Data Set and potential report contents. A framework defines durable dimensions and categories of measurement that will outlast any specific measures used at particular times. In essence, it lays down an enduring way of specifying what should be measured while allowing for variation in how it is measured over time. For example, communication between clinicians and patients is an aspect of care that will always have to be measured. However, the ways that patients connect with their clinicians—ranging from office visits to electronic exchanges—will vary over time, and so will the corresponding measures (Balas et al., 1997). When a common framework is established internationally, it also allows for comparisons in the quality of care across countries. Although it will provide continuity for the Quality Report and the measures, the framework should be considered dynamic. In the long term, it may have to be adjusted in response to changes in the conceptualization of quality and/or significant changes in the nature of the U.S. health care system. NATIONAL HEALTH CARE QUALITY FRAMEWORK Overview In order to develop a National Health Care Quality Framework, the committee examined many of the approaches available to analyze quality of care (see Appendix D). The framework proposed herein is based partially on elements from these other approaches. Its foundation ultimately derives from the purpose of the health care system, for which the committee endorses the following statement: “to continuously reduce the burden of illness, injury, and dis-

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Page 43 ability, and to improve the health and functioning of the people of the United States” (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998:2). To assess whether the health care delivery system is making progress in achieving this purpose, the committee developed a framework with two major dimensions. The first dimension consists of the components of health care quality. Building on the work of the Institute of Medicine (IOM) Committee on the Quality of Health Care in America (Institute of Medicine, 2001), these components of quality are defined as safety, effectiveness, patient centeredness, and timeliness. The second dimension addresses the consumer perspective on health care needs, which reflects the life cycle of people's involvement with the health care system or their reasons for seeking care at any particular time. Building on the work of the Foundation for Accountability (FACCT), consumer perspectives on health care needs are defined as staying healthy, getting better, living with illness or disability, and coping with the end of life (Foundation for Accountability, 1997). As the committee refined the framework, it kept in mind the audiences for this report. The framework can be used to encourage measurement and reporting in specific areas to inform national and state policy makers, purchasers, providers, and other specialized audiences. It can also be used to encourage measurement and reporting in areas that consumers and the media will find meaningful and important, including condition-specific care. Equity can be assessed by analyzing the quality of care received by different groups of the population. Defined in this manner, the framework can be used to guide policy and to inform relevant audiences. Components of Health Care Quality For each of the four components of quality—safety, effectiveness, patient centeredness, and timeliness—the committee defined a set of subcategories ( Table 2.1) and specific examples of potential measures for the National Health Care Quality Report ( Box 2.1, Box 2.2, Box 2.3 to Box 2.4). 1 The components of quality can be thought of as subsets of quality of care, but they are not completely independent of each other. There is some overlap at the boundaries. 1 These measures are offered as examples and are in no way intended to represent the ideal measures or a comprehensive measure set. They are based on a limited review and evaluation of existing measures, leaving gaps with reference to the proposed framework. They do provide an appreciation of the type and range of measures that will be required for the Quality Report.

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Page 44 TABLE 2.1 Components of Health Care Quality and Their Subcategories Safety Effectiveness Patient Centeredness Timeliness 1. Diagnosis 1. Preventive care 1. Experience of care 1. Access to the system of care 2. Treatment a. Medication b. Follow-up 2. Acute, chronic, and end-of-life care 2. Effective partnership 2. Timeliness in getting to care for a particular problem 3. Health care environment 3. Appropriateness of procedures   3. Timeliness within and across episodes of care Safety refers to “avoiding injuries to patients from care that is intended to help them” (Institute of Medicine, 2001). Safety In operational terms, improving safety means designing and implementing health care processes to avoid, prevent, and ameliorate adverse outcomes or injuries that stem from the processes of health care itself (National Patient Safety Foundation, 2000). Safety is best understood in terms of injuries that occur to patients and the errors or latent failures that lead to these injuries or harm. Although both perspectives are essential in building a safer health care system, the overriding priority in the short term is the reduction of injuries or harm to patients. Assessing errors that lead to patient injuries or harm is one method for organizing a framework of measures that will define the safety of the health care system. An error of execution is the failure of a planned action to be completed as intended, while an error of planning is the use of a wrong plan to achieve an aim (Reason, 1990). Errors have also been classified into errors of commission (doing unnecessary things or doing them wrongly) and errors of omission (failing to do necessary things) (Iezzoni, 1997; Leape et al., 1991). As a component of quality health care, safety problems or patient injuries have been found to occur along the continuum of clinical care functions and in the general environment of care (see examples of safety measures in Box 2.1). Errors in diagnosis, including misdiagnosis (wrong diagnosis) and missed diagnosis (failure to diagnose), are relatively

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Page 45 BOX 2.1 Examples of Areas in Which Measures of Safety May Be Applied and Selected Measures Diagnosis Death within 30 days after elective outpatient cardiac stress test (e.g., treadmill, thallium, echocardiogram) Misdiagnosis rates based on autopsies Preoperative assessment of patients with chronic lung disease or cardiac disease before elective surgery Death within 30 days after elective outpatient colonoscopy Unplanned readmission after hospitalization at 1 day, 7 days (overall rate for both), and 30 days (diagnosis- or procedure-specific rate) Treatment Death within 30 days after elective outpatient surgical procedures (e.g., cosmetic surgery such as liposuction, facelifts) Maternal death within seven days after delivery Neonatal death within seven days after birth (>2,500 grams, no congenital abnormalities) 30-day mortality following acute myocardial infarction or cardiac bypass surgery Deep surgical wound infection rates within 30 days of selected surgical procedures (e.g., cardiac bypass surgery, hip and knee replacement surgery) Surgical sentinel event (e.g., rates of wrong-siite, wrong-organ, or wrong- patient surgery) Rate of inpatient transfusion reactions (overall rate and rate of death-related transfusion reactions) Rate of deep venous thrombosis after hip and knee replacement in patients younger than 50 years of age Rate of unplanned returns to the operating room within 24 hours for both inpatient and outpatient settings Medication Rates of adverse drug events in diverse settings including inpatient (adult and pediatric), outpatient, and nursing home Rates of adverse drug events for specific drug classes Follow-Up Lack of routine medication review for the elderly, the disabled, and patients with chronic illness Failure to follow up significant diagnostic abnormalities (e.g., Pap smears, breast biopsies, chest X-rays, HIV serology) Proportion of patients with do-not-resuscitate orders on admission who are subsequently intubated or resuscitated

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Page 46 Safety of the Environment Neonatal abduction or mixup after birth Patient falls (inpatient overall rate and rate with serious injury) Patient suicides within health care settings (e.g., inpatient or mental health care setting) Rate of hip fractures among nursing home patients Rate of restraint-related deaths in any health care setting Rate of inpatient nosocomial decubitus ulcers SOURCES: Joint Commission on Accreditation of Healthcare Organizations, 2000 (see text and Appendix C for additional sources). common (Leape et al., 1991). Their prevalence is estimated at 10 percent among hospital populations based on autopsy studies (Bordage, 1999) and even higher for patients in intensive care units (Mort and Teston, 1999). Treatment errors are problems related to planning, technical proficiency, or prescription practices. Lack of technical proficiency or competence in procedures such as colonoscopy (Miller, 1997) can lead to complications or nosocomial infections. Medication-related adverse events are a subset of treatment errors that has been studied extensively (Institute of Medicine, 2000). It has been estimated that medication-related adverse drug events occur In nearly 10 percent of all hospital admissions (Leape et al., 1995). Errors can also occur in follow-up care (Christakis and Lamont, 2000). Finally, the safety of the overall health care environment (Gershon et al., 2000) is essential to avoid gross errors such as wrong-site surgery, patient suicide, homicide, and other sentinel events (Joint Commission on Accreditation of Healthcare Organizations, 2000a). The site of care is one of several characteristics that can be used to further subclassify safety problems. This is an increasingly important aspect to document, given that much of health care, including surgery, is gradually moving away from the hospital to the ambulatory sector (Phillips et al., 1998; Quattrone, 2000). In order to ultimately improve patient safety in health care (as has occurred in high-reliability industries such as aerospace and nuclear power) safety has to be designed or built into the care system at all levels. The Quality Inter-agency Coordination Task Force (QuIC) has issued a report to the President defining needed actions to improve patient safety, which begins to address many of these issues (Quality Interagency Coordination Task Force, 2000). The Quality Report should include measures to assess the effects of some of these actions as they are implemented.

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Page 47 Effectiveness refers to “providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding overuse and underuse)” (Institute of Medicine, 2001). Effectiveness Overuse occurs when “a health care service is provided under circumstances in which its potential for harm exceeds its potential benefit”. Underuse “is the failure to provide a health care service when it would have produced a favorable outcome for a patient” (Chassin and Galvin, 1998:1002). Effectiveness is probably the component of health care quality most readily identified because ultimately it represents the “bottom line,” that is, whether care leads to improved outcomes in terms of health status and quality of life for patients (Greenfield et al., 1994). People assume that care will be safe, but they want it to be effective as well. A growing body of evidence has documented problems of effectiveness with respect to the overuse of services that cannot help and may harm the patient, as well as problems arising from the underuse of care where benefit is likely to exceed harm (Chassin and Galvin, 1998). A number of studies have also documented the inappropriateness of specific procedures (McGlynn and Brook, 1996). These problems of effectiveness occur in all types of care and across sites. Effectiveness should be distinguished from efficacy. The latter refers to the benefits achievable from a therapy or intervention under ideal conditions (such as a randomized controlled trial) while the former refers to the results of care in everyday clinical practice settings (Brook and Lohr, 1985). In evaluating the quality of the health care delivery system under actual operating conditions, it is effectiveness rather than efficacy that should be assessed. Effectiveness can be assessed according to the type of care (for example, preventive care, acute, chronic, and end-of-life care) or for specific conditions. The appropriateness of selected procedures is another subcategory of effectiveness (see examples of effectiveness measures in Box 2.2 and Appendix B). The effectiveness of preventive care can be assessed comprehensively by examining the full spectrum of needs for a defined population or age group such as children or the elderly (see Appendix B). In this case, the services actually received by a specific group as reflected in medical records or a similar data source are compared to the services they should receive according to prevailing guidelines (U.S. Preventive Services Task Force, 1996). The effectiveness of preventive care can also be assessed selectively by examining screening and interventions for specific conditions or problems such as childhood immunizations (Centers for Disease Control and Prevention, 1999), prenatal care (Expert Panel on Prenatal Care, 1989; Genest, 1981; Grad and Hill, 1992), or cervical cancer screening (National Institutes of Health, 1996).

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Page 48 BOX 2.2 Examples of Areas in Which Measures of Effectiveness May Be Applied and Selected Measures Preventive Care Advising smokers to quit Flu shots for adults over age 65 Chlamydia screening Pap smears Childhood immunization rates Prenatal and postpartum care (includes timely initiation of prenatal care and checkups after delivery) Biennial mammography screening for women 52 to 69 years of age Screening for depression Active, Chronic, and End-of-Life Care Asthma Appropriate medications for people with asthma Asthma-specific function as reported by the patient Asthma episodes of exacerbation Specific treatment such as appropriate inhaler use Heart Disease Appropriate drug treatment for acute myocardial infarction (AMI) (e.g., beta-blockers, aspirin, angiotensin-converting enzyme [ACE] inhibitors) Use of alternate forms of vascularization for discrete indications 30-day mortality after AMI Cholesterol management after acute cardiovascular events Coronary artery bypass graft (CABG) mortality Cancer (breast, prostate, colon) Breast Cancer Biennial mammography screening Radiation therapy following breast conservation surgery Prostate Cancer Patient-reported understanding of options Colon Cancer Colon cancer screening tests beginning at age 40 for patients who have one or more first-degree relatives with colorectal cancer (fetal occult blood test every 2 years; Sigmoidoscopy every 5 years; colonoscopy every 10 years; double-contrast barium enema every 5 years) HIV/AIDS Alternate regimens offered and used appropriately

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Page 49 Diabetes Diabetes Quality Improvement (DQuIP) measure set including Percentage of patients with diabetes with blood pressure below 140/90 mmHg Percentage of patients with diabetes receiving a dilated eye examin the past year (or two) Percentage of patients with diabetes with low-density lipoprotein (LDL) below 130mg/dl Percentage of patients with diabetes receiving one or more hemoglobin A1c tests per year Hemoglobin A1c levels for people with diabetes Depression Depression screening in primary care Percentage of patients with a current diagnosis of chronic, moderate, or severe depression (not in remission) receiving an antidepressant medication or electroconvulsive therapy Percentage of patients with a current diagnosis of depression with psychotic features (not in remission) receiving either a combination of an antidepressant medication and an antipsychotic medication or electroconvulsive therapy Percentage of patients with a current diagnosis of depression that is mild and not chronic (not in remission) receiving medication and/or psychotherapy Hypertension Controlling high blood pressure Blood pressure levels General Pain management at the end of life Proportion of nursing home residents with pressure ulcers at stage 2 or higher Inappropriate prescribing of antibiotics (e.g., for a cold) Appropriateness of Procedures Procedures likely to be overused by 20 percent or more (e.g., carotid endarterectomy, coronary angiography, coronary angioplasty, tympanostomy tube insertion) SOURCES: American Diabetes Association, 1998; Foundation for Accountability, 1996; Health Care Financing Administration, 2000; Joint Commission on Accreditation of Healthcare Organizations, 2000a; National Committee for Quality Assurance, 2000; Tuckson, 2000 (see text and Appendix B and Appendix C for additional sources).

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Page 50 Effectiveness can also be assessed by examining care for particular chronic or acute conditions as well as end-of-life care. For example, effective care for diabetes includes the reduction of potential complications through preventive retinal eye exams, monitoring of hemoglobin A1c, and regular lipid profiles (American Diabetes Association, 1998; Health Care Financing Administration, 2000; National Committee for Quality Assurance, 2000). Care for selected types of cancer and terminal conditions includes appropriate pain management near the end of life (American Pain Society, 1995; Cherny and Catane, 1995; Wagner et al., 1996). Much of the work on measures of quality of care has concentrated on effectiveness, usually based on practice guidelines for specific conditions (Medscape, 2000). Practice guidelines and well-tested quality measures are available for a variety of conditions including diabetes, acute myocardial infarction, heart failure, asthma, breast cancer, pneumonia, and stroke (Health Care Financing Administration, 2000; Jans et al., 2000; National Committee for Quality Assurance, 2000; Rolnick et al., 2000; Shiffman et al., 2000; Soumerai et al., 1998). However, well-defined measure sets that include both process and outcome measures and cover the entire spectrum of care are available for only a few conditions such as diabetes (American Diabetes Association, 1998; Health Care Financing Administration, 2000; Loeb, 2000; Tuckson, 2000). In addition, effectiveness is reflected in the appropriateness with which selected surgical and diagnostic procedures are performed. One of the largest studies of overuse ever conducted found that 17 percent of coronary angiographies, 32 percent of carotid endarterectomies, and 17 percent of upper gastrointestinal tract endoscopies performed on Medicare beneficiaries were for inappropriate indications (Chassin et al., 1987). Overall, it is estimated that about one-third of the procedures performed in the United States are of questionable health benefit relative to their risks (McGlynn and Brook, 1996). Patient Centeredness2 Patient centeredness is a characteristic of the relationship between clinician and patient (Charles et al., 1999a; Roter, 2000) and can be contrasted to disease- Patient centeredness refers to health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care. 2 This topic is treated in depth in a paper commissioned by the committee from Christina Bethell on measures of patient centeredness for the National Health Care Quality Report (2000).

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Page 65 BOX 2.6 Questions Addressed by the National Health Care Quality Report Overall What do we know about the level of quality of care in the United States? Is quality improving, staying the same, or progressively worsening over time? Components of Health Care Quality Is the system providing care safely and decreasing the rate of patient injuries and harm? Is the care provided effective and contributing to desired outcomes? Is care patient centered and tailored to the needs, values, and preferences of consumers? Is care provided in a timely manner? Consumer Perspectives on Health Care Needs How well does the health care system help people maintain good health and avoid illness? How well does the system care for people when they become sick? How well does the system care for people with chronic conditions or people with disabilities? How well does the health care system help people to cope with the end of life? What is the quality of care for people with breast cancer, diabetes, or other specific conditions? Equity What types of patients or consumers are receiving better quality of care? Who is better off? Who is worse off? Which states or regions of the country provide better care? Are differences in quality over time and between geographic regions getting smaller or larger? Are there unwarranted differences in the quality of care received by people of different races and ethniciities? Are there differences by age, gender, or other population characteristics? Are these differences increasing or decreasing over time? In which areas of quality of care are the differences the greatest? Which groups are the worst off? What is the quality of care for those wiithout health insurance compared to those with insurance? If there is a difference, is it increasing or decreasing over time?

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Page 66 wasteful due to deficiencies in any of the four components of quality as defined in the framework. Quality measures related to safety, effectiveness, patient centeredness, or timeliness can indicate potential problems in the efficiency of production and/or the allocation of services. For example, lack of safety indicated by errors in health care that lead to avoidable complications can result in greater resource use. Efficiency is clearly related to the quality of care. For example, quality measures of specific aspects of effectiveness—particularly overuse and inappropriateness—may indicate potential problems of efficiency in service allocation. Ineffectiveness stemming from overuse or inappropriateness can result in wasted resources, as well as problems that include poor health associated with readmissions (Oddone et al., 1996) and lengthened hospital stays (Broderick et al., 1990). Ultimately, inefficiency is characterized by the use of resources that do not provide the best value in meeting people's health care needs. Efficiency is clearly related to the quality of care. Many of the quality issues that will be presented in the Quality Report will require potential trade-offs. However, efficiency, particularly with regard to cost per unit of service, falls outside the scope of the Quality Report and will be better addressed by specific efforts designed to face the considerable methodological and measurement challenges involved (McClellan, 2000). Doing so will allow for examination of the value of health care as reflected in the relationship between quality and costs. It will also make possible the definition of appropriate policies to address each of these aspects of value separately. SUMMARY The National Health Care Quality Framework described in this chapter responds to a set of basic questions that together provide a picture of the quality of health care being delivered in this country over time. These questions refer to the components of health care quality and consumer perspectives on health care needs, including care for specific conditions. The measures included in the framework can be used to examine equity, or how certain groups of people fare compared to others, and to describe the evolution in the quality of care being delivered in the United States over time. Box 2.6 presents the list of basic questions that should be addressed by the Quality Report. REFERENCES Aday, Lu Ann, and Ronald M. Anderson. 1975. Development of Indices of Access to Medical Care. Ann Arbor, Mich.: Health Administration Press. Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. Quality First: Better Health Care for All Americans. Washington, D.C. : U.S. Government Printing Office. Agency for Health Care Policy and Research. 1998. CAHPS 2.0 Questionnaires . [on-line] http://www.ahrq.gov/qual/cahps/cahpques/htm [Feb. 18,. 2001].

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Page 67 Agency for Healthcare Research and Quality. 2000a. Overview of MEPS [on-line]. Available at: http://www.meps.ahrq.gov/WhatIsMEPS/Overview.htm [Jan. 3, 2001]. Agency for Healthcare Research and Quality. 2000b. What Is MEPS? [on-line]. Available at: http://www.meps.ahrq.gov/whatis/htm [Jan. 3, 2001]. Agency for Healthcare Research and Quality. 2000c. MEPS HC-006R: 1996 Medical Conditions [on-line]. Available at: http://www.meps.ahcpr.gov/pubdoc/hc6rdoc.pdf [Feb.26, 2001]. Agency for Healthcare Research and Quality. 2001. Survey Instruments and Associated Documentation [on-line]. Available at: http://www.meps.ahrq.gov/survey.htm [Feb. 18, 2001]. American College of Physicians–American Society of Internal Medicine. 1999. No Health Insurance? It's Enough to Make You Sick. Philadelphia. Available at: http://www.acponline.org/uninsured/lack-contents.htm . American Diabetes Association. 1998. The Diabetes Quality Improvement Project [on-line]. Available at: http://www.diabetes.org/dqip.asp [Jan. 12, 2001]. American Pain Society, Quality of Care Committee. 1995. Quality improvement guidelines for the treatment of acute pain and cancer pain. Journal of the American Medical Association 274: 1874–1880. Anderson, Robert, Martha M. Funell, Patricia M. Butler, Marilynn S. Arnold, James T. Fitzgerald, and Catherine C. Feste. 1995. Patient empowerment: Results of a randomized control trial. Diabetes Care 18(7): 943–949. Andrews, Roxanne M., and Anne Elixhauser. 2000. Use of major therapeutic procedures: Are Hispanics treated differently than non-Hispanic whites? Ethnicity and Disease 10: 384–394. Appleton, P. L., V. Boll, and J. M. Everett. 1997. Beyond child development centres: Care coordination for children with disabilities. Child: Care, Health and Development 23: 29–40. Arora, Neeraj K., and Colleen A. McHorney. 2000. Patient preferences for medical decision making: Who really wants to participate? Medical Care 38(3): 335–341. Ayanian, John Z., and Arnold M. Epstein. 1991. Differences in the use of procedures between women and men hospitalized for coronary heart disease. New England Journal of Medicine 325(4): 221–225. Ayanian, John Z., Joel S. Weissman, Scott Chasan-Taber, and Arnold M. Epstein. 1999. Quality of care by race and gender for congestive heart failure and pneumonia. Medical Care 37(12): 1260–1269. Ayanian, John Z., Joel S. Weissman, Eric C. Schneider, Jack A. Ginsburg, and Alan M. Zaslavsky. 2000. Unmet health needs of uninsured adults in the United States. Journal of the American Medical Association 284(16): 2061–2069. Balas, E. Andrew, Farah Jaffrey, Gilad J. Kuperman, Suzanne Austin Boren, Gordon D. Brown, Francesco Pinciroli , and Joyce A. Mitchell. 1997. Electronic communication with patients: Evaluation of distance medicine technology. Journal of the American Medical Association 278(2): 152–159. Beisecker, Analee E., and Thomas D. Beisecker. 1990. Patient information-seeking behaviors when communicating with doctors. Medical Care 28(1): 19–28. Benbassat, Jochanan, Dina Pilpel, and Meira Tidhar. 1998. Patients' preferences for participation in clinical decision making: A review of published surveys. Behavioral Medicine 24(2): 81–88. Bennett, Charles L., Sheldon Greenfield, Harriet Aronow, Patricia Ganz, , and Nicholas J. Vogelzang and Robert M. Elashoff. 1991. Patterns of care related to age of men with prostate cancer. Cancer 67(10): 2633–2641.

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