National interest in the quality
of American health care increased dramatically in 1999. The press, the
Institute of Medicine, legislators, physicians, and hospitals joined in
a vigorous policy discussion. But a similar debate occurred in 1988,
following reports from four public agencies that detailed their concerns
about health care quality. In the intervening decade, research
has not documented much improvement. In this paper we outline
the quality problems in U.S. health care, review some of their most prominent
causes, consider the biggest obstacles to bringing about major improvement,
and discuss the vital role of leadership in achieving this goal.
An intense public debate about health care quality ignited in 1999. Leading newspapers ran series of articles exploring quality problems with local doctors, hospitals, and nursing homes. Late in the year, the Institute of Medicine (IOM) report on medical errors emphasized one aspect of quality, catapulting the discourse into the realm of public policy with a set of specific legislative and administrative recommendations. State and federal legislators drafted proposals; organizations of physicians and hospitals announced their concern and pledged to improve. 
But we have been here before -- and not so long ago. In the first six months of 1988 four prominent public agencies all released lengthy reports detailing their concerns about the quality of health care. These reports did not capture the same media attention as the topic has generated recently, but they did trigger a similarly intense policy discussion. Physician organizations, quality experts, and legislators agreed that a substantial effort to improve health care quality was warranted. Congress created the Agency for Health Care Policy and Research (AHCPR). The new agency was charged with investing in research on the effectiveness of health care services and with developing practice guidelines to assist providers in improving quality. Yet in the decade between these two flurries of public discussion, little improvement has been documented. Instead, a growing body of rigorous research has demonstrated just how serious and widespread our quality problems are. In this paper we briefly summarize this evidence, explore the most salient causes of the problems, and discuss the most important obstacles to improvement. We conclude by discussing the crucial role that visible and effective leadership might play in accomplishing this goal, the potential sources of such leadership, and the likelihood that it will emerge.
Magnitude and Ubiquity of Quality Problems
Patients suffer harm because of
three different types of quality problems. The first occurs when patients
do not get beneficial health services. The second happens when patients
undergo treatments or procedures from which they will not benefit. The
third occurs when patients receive appropriate medical services, but those
services are provided badly, exposing patients to added risk of preventable
Causes of Quality Problems
Why do we have so many quality
problems in a system replete with resources and talent? There are many
reasons, and they differ for each of the major classes of clinical quality
problems. One factor that has often been cited as a probable cause
of overuse is fee-for-service (FFS) payment. Research has established
an association between it and higher rates of use of a variety of health
services. However, higher rates of use do not necessarily imply higher
rates of inappropriate use. In fact, a direct association between FFS
payment and overuse has never been established. No study has used formal
appropriateness criteria for specific procedures to compare rates of overuse
in FFS financing versus other forms of payment.
Obstacles To Improvement
American car makers, banks, and manufacturers of consumer electronics have all made enormous improvements in the quality of their products and services in the past ten to fifteen years. Can we expect the same evolution in health care? We doubt it. Several imposing obstacles stand in the way.
Improving quality begins by defining excellent
care for a condition or problem, a task that requires marshaling evidence
from the research literature about the effectiveness of various treatments
, adding expert judgment to the limited evidence base, and distilling
this knowledge into clinical practice guidelines, detailed statements
about what should and should not be done. Guidelines must be put to
work to measure current practice. Then we must define shortfalls in quality,
ascertain their causes, design and implement interventions and assess
their impact, and sustain and enhance improvements.
Lack of Return on Investment
Another obstacle is the difficulty
of justifying the substantial expenditures the effort requires to chief
financial officers as investments that are highly likely to produce financial
returns. In short, the "business case" for quality improvement in health
care is elusive. This predicament would be unfamiliar to those in
business who have used a variety of techniques to improve quality and
profitability at the same time. Most businesses have strong and consistent
financial incentives to improve the quality of their products and services.
Lack of Demand for Improvement
One might argue that even if broad-scale quality improvement cannot be supported by convincing return on investment calculations, it might be undertaken if consumers and their representatives were clamoring for it. Despite the volume of data documenting serious health care quality problems and the harm they do, providers experience little demand from consumers for substantial improvement in performance. [Of course, this information is carefully hidden from the public, and that is the motivation for these web pages that provide information on the pandemic failures of the Medical System ljf] Although consumers express concern about quality in general, the large majority rely on friends and family to recommend doctors and hospitals [What else do they have? ljf]; they do not demand that providers produce evidence of better clinical quality or better health outcomes.[Did anyone ever try to "demand" better quality from their doctor? What an insult to the public, but this reveals the supreme arrogance of medical "professionals" ljf]  Perhaps as a consequence, the vast majority of private and public employers that purchase health care do not place a high priority on seeking out high quality hospitals or physicians. Rather, purchasers have sent the clear message to the marketplace that they are primarily interested in low costs. Further, several studies have documented that even when data on quality are available, neither consumers nor managed care companies use them to guide their health care purchases. In contrast, consumers ardently desire freedom of choice and unhindered access to providers and services. Purchasers have responded to these desires by selecting and offering open-network, point-of service plans. Employees have chosen these plans in large numbers, making them the most rapidly growing form of managed care. This phenomenon also explains why purchasers have not aggressively pursued reducing overuse as a way of both controlling their costs and improving quality. Identifying overuse requires careful assessment of the reasons procedures and other interventions are proposed. Reducing overuse requires saying no when inappropriate services are proposed. Such control mechanisms have been roundly rejected by consumers [When did you as a patient "roundly reject" "inappropriate services"? ljf] and physicians, leading health plans and employers to eliminate them or reduce their use.
Local Nature of Health Care
Some have suggested that competition could force quality improvement to happen. The U.S. automobile and consumer electronics industries were transformed by competitive pressure from higher-quality Japanese products. Could competition force a similar change in health care? It isn't likely. Virtually all health care is produced locally. There is no possibility that the health care equivalent of a Toyotas [sic] or panasonic [sic] will suddenly appear in the US health care market and transform the quality of care. Hospitals, physician practices, and integrated delivery systems in San Francisco need not fear that competitors in Los Angeles, let alone Chicago or tokyo,[sic] will invent a superior way to provide high-quality health care and take patients (and revenue) away.
Who Will Lead?
The cumulative impact of these barriers makes it highly unlikely that a widespread movement toward substantial quality improvement in health care will occur naturally or inevitably in present circumstances. For such movement to occur, new circumstances must emerge. We believe that one of the few avenues to achieving such a new development is bold and visible leadership.[Where are "leaders" in a terminally corrupt society? ljf] Leaders from outside health care could force doctors and hospitals to devote more attention and resources to the difficult work of quality improvement. Leaders from inside could show how to improve quality to unprecedented levels and attract followers to achieve similar goals. A leader would need to focus attention on all of our quality problems -- overuse, underuse, and misuse -- expressly for the sake of improving quality, rather than attacking quality problems selectively with the underlying purpose of reducing costs or increasing revenue. A leader would identify quality improvement as among the highest-priority issues and would keep constant emphasis on it. A leader would take responsibility for marshaling resources and galvanizing improvement across all the dimensions of quality. A leader would forcefully articulate the harms that occur at our present levels of mediocre health care. Or, a leader might create a compelling demonstration of just how beneficial truly high quality care can be.
Leadership could emerge from among
consumers, employers, government, academic medicine, organized medicine,
or the delivery system itself. Examples of broad-scale changes that were
initiated or fueled by consumers are found in the environmental movement,
automobile safety, and reductions in alcohol related crashes. Beginning
with Rachel Carson's Silent Spring, consumer groups have been instrumental
in directing the nation's attention to reducing environmental pollution.
[A failed effort, at best ljf] Similarly, Ralph Nader's [His enduring
presidential candidacy is essentially ignored ljf] Unsafe at Any Speed
triggered a long involvement of consumers in monitoring and advocating
for improvements in auto safety.
Those who direct health care purchasing decisions, whether private employers or public programs, could exert a leadership role in demanding better performance from the delivery system organizations with which they negotiate. As previously stated, however, current evidence suggests that most such purchasing decisions are made with primary attention to issues of cost and accessibility, not quality. If costs were purchasers' principal concern in the 1990s, a period during which costs were reasonably well contained, can we expect quality to become more important now, at a time when health care costs are rising again? Some purchasers advocate more emphasis on quality, but with little impact to date. We doubt that purchasers will establish an effective leadership position in health care quality improvement.
Government as regulator or producer of public goods might be a source of leadership. [The rampant, institutionalized corruption in Congress and the lobbyists make this impossible. ljf] The AHCPR was created with great fanfare and expectation in 1989, with a substantial part of its mission devoted to developing clinical practice guidelines to improve health care quality. At first, the effort to produce guidelines was highly productive. Many of the agency's guidelines remain the definitive statements of what constitutes excellence in their clinical areas. Several forces combined, however, to kill this effort: the strong political trend against government involvement in society in general, the even stronger back lash against the Clinton administration's effort at health care reform, and the reactions of some orthopedic surgeons against one of the agency's guidelines. In 1999 the AHCPR's authorizing legislation was rewritten specifically to exclude guideline development and health policy from its mission. If today's political climate cannot tolerate the production of advisory practice guidelines by government, we doubt that any other governmental entity could break sufficiently free of the bonds of the current antiregulatory fervor to exert strong leadership in this arena.
Could academic medicine -- the engine driving the enormously effective consensus that has sustained and is now increasing national funding for biomedical research [For its own economic gain ljf] -- provide such leadership? We see few signs that academic medical leaders are prepared to expend much effort on health care issues outside the realms of biomedical research and medical education.[Read: their own income ljf] They exerted little leadership in what may arguably be characterized as the most important health policy debates of the past thirty years: tobacco control, health care cost containment, and universal access. State health departments, the federal Food and Drug Administration (FDA), and trial lawyers all had greater impacts than any efforts by academic medical leaders on forming the nation's current, robust anti tobacco policy posture [This was a hoax to limit future legal awards ljf ]. Academic medicine, as well as almost all other medical organizations, was indifferent to the problem of rapidly rising health care costs [Read: rising income ljf] in the 1970s and 1980s. During the vibrant health policy discourse of the early 1990s, in which universal access to health insurance and health care took center stage, academic leaders were not at the forefront of the debate. Instead, a series of delegations from the nation's medical schools descended on Washington, focused primarily on preserving existing governmentally supported research and education. Perhaps academic medicine will produce leadership in health care quality in the future, but current indications do not point in that direction.
State medical societies, the American Medical Association (AMA), and various national medical specialty societies are additional potential sources of leadership. Some have already undertaken important quality initiatives. The guidelines developed by the American College of Cardiology, the American Heart Association, and the American College of Physicians are among the most rigorous and useful in the field. The AMA was a leading founder of the National Patient Safety Foundation, one of the few entities devoted to the study and elimination of medical errors. Despite these notable exceptions, though, the current efforts of these organizations cannot be characterized as establishing a leadership role. None of these organizations has met the test of leadership sketched out above. Their principal attentions have been directed elsewhere: supporting members' economic interests, fighting against the intrusions of managed care into medical practice, or advancing the goals of scientific research and education within their specialties. Little in their histories suggests the imminent emergence of a national leader in quality improvement from among their ranks.
Health Care Providers
The only other place from which effective leadership could spring is among the organizations engaged in providing health care directly to patients. Such institutions already have as their primary mission the obligation to provide health care of the highest quality. They also share a common frustration at having witnessed the steady erosion of their once unchallenged control over the delivery of health care. Leading a major quality improvement effort could be an effective way to recapture a significant measure of this lost autonomy.
How Providers Can Lead
Quality improvement on a substantial scale requires major investment. Many delivery system institutions are too small or financially stressed to make such investments. But some are not -- and not many leaders are needed. Some large hospitals and IDSs are well positioned to access the capital necessary to initiate a vigorous program of improvement. Accomplishing this objective also requires access to the intellectual capital required to develop the kind of evidence-based performance measures that will be convincing to clinicians and will impel them to action. Many academic medical centers and some of the largest IDSs (many of which are closely affiliated with medical schools) are in close enough proximity to the requisite skills and academic disciplines.
Although current payment incentives
do not uniformly promote and often directly conflict with quality goals,
it is nonetheless possible for hospitals, medical practices, and IDSs
to implement a strategy that first targets quality improvement priorities
that would produce financial returns. For example, research has documented
that each preventable injury due to a medication error adds approximately
$4,700 to the cost of the hospitalization in which it occurs.[A strong
economic disincentive for reform ljf]  One of the most successful
hospital programs in this arena focused on reducing errors in antibiotic
use and their related injuries; researchers documented a 30 percent reduction
in such injuries and a 58 percent reduction in antibiotic costs per treated
patient over a seven-year period. Improvements such as these can in
turn provide the investment necessary to broaden and deepen the quality
improvement program, extending it to projects that may be neutral with
respect to revenue and cost and eventually including projects that may
increase cost (or decrease revenue) to achieve the desired quality benefit.
Examples of Improvement
Some stellar -- but narrowly focused -- examples of improvement do exist. Even the most successful of these, however, have found it difficult to spread improvement widely or have happened in such uncommon circumstances that few others have attempted to replicate them.
Intermountain Health Care (Utah)
Intermountain Health Care (IHC) has been a leader in clinical quality improvement for more than a decade. IHC is an integrated delivery system based in Salt Lake City, consisting of twenty-two hospitals (in Utah and Idaho) and 2,200 affiliated physicians. IHC's efforts to reduce injuries due to medication errors have produced the most impressive gains of any such program. At some of its sites, IHC has also pioneered innovative approaches to quality improvement that have enhanced outcomes for patients with diabetes, pneumonia, and respiratory failure, among other conditions. In addition, Brent James, the leader of this effort, has established a popular program that teaches physicians and other clinicians how to succeed in quality improvement. Despite its success in quality improvement and its dominant market position in its geographic region, however, IHC has encountered difficulty in disseminating its successes systemwide. James has stated that only three of sixty-five innovative programs have spread throughout IHC. Some of the factors that have hindered more rapid adoption include physician resistance, perverse financial incentives, barriers between units within the organization, and the high cost of investing in robust information system solutions.
Cardiac Surgery Reporting System (New York)
Another leading quality improvement
program is New York State's Cardiac Surgery Reporting System (CSRS), which
has released data publicly on risk adjusted death rates following coronary
artery bypass graft (CABG) surgery by hospital and surgeon for a decade.
This program is operated by the state health department and overseen by
a multidisciplinary advisory committee. The program has no basis in law
or regulation. Rather, it's [sic] emergence is closely related to the
nearly unique breadth of regulatory authority vested in the health department
in New York State. The department conducts a vigorous certificate-of need
program (including one specific to cardiac surgery); it has broad authority
to regulate and assure quality in hospitals, physician practices, and
managed care plans; and it set rates of payment for hospitals for nearly
two decades (until 1996). Therefore, when the commissioner and his advisory
committee asked hospitals to begin submitting data to the CSRS in 1989,
[Actually, the time for individuals to take responsibility for their own health, and thus avoid the corruption of a greed-based "medical system" is now, as it always has been ljf]
 The first of four consecutive articles of each series is listed: L. Tye, "Family's Tragedies Reveal Flaws in Medical Systems," Boston Globe, 14 March 1999; A. Gerlin, "Health Care's Deadly Secret: Accidents Routinely Happen," Philadelphia Inquirer, 12 September 1999; and T. Maier, "Managed Care and Doctors: The Broken Promise," New York Newsday, 14 November 1999.
 Institute of Medicine, To Err Is Human: Building a Safer Health System (Washington: National Academy Press, 1999).
 "Moving Fast on Patient Safety," Editorial, New York Times, 8 December 1999; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000;M. Langberg, "Testimony of the American Hospital Association before the Subcommittee on Health of the House Committee on Waysand Means" (10 February 2000); and N. Dickey, "Statement of the American Medical Association to the Senate Committee on Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies" (13 December 1999).
 The four reports (from the Prospective Payment Assessment Commission, Physician Payment Review Commission, U.S. General Accounting Office, and Office of Technology Assessment) are discussed in M.R. Chassin, "Practice Guidelines: Best Hope for Quality Improvement in the 1990s," Journal of Occupational Medicine 32, no. 12 (1990): 1199-1206.
 B.H. Gray, "The Legislative Battle over Health Services Research," Health Affairs (Winter 1992): 38-66.
 See, for example, M. Schuster, E. McGlynn, and R. Brook, "How Good Is the Quality of health Care in the United States?" Milbank Quarterly 76, no. 4 (1998): 517-563; and M.R. Chassin et al., "The Urgent Need to Improve Health Care Quality," Journal of the American Medical Association 280, no. 11 (1998): 1000-1005.
 Schuster et al., "How Good Is the Quality of Health Care?"
 S.F. Jenckset al., "Quality of Medical Care Delivered to Medicare Beneficiaries," Journal of the American Medical Association 284, no. 13 (2000): 1670-1676.
 Schuster et al., "How Good Is the Quality of Health Care?" For specific overuse studies, see, for example, L.C. Kleinman et al., "The Medical Appropriateness of Tympan ostomy Tubes Proposed for Children Younger than 16 Years in the United States," Journal of the American Medical Association 271, no. 16 (1994): 1250-1255; and A.C. Nyquist et al., "Antibiotic Prescribing for Children with Colds, Upper Respiratory Tract Infections, and Bronchitis," Journal of the American Medical Association 279, no. 11 (1998): 875-877.
 T.A. Brennan et al., "Incidence of Adverse Events and Negligence in Hospitalized Patients," New England Journal of Medicine 324, no. 16 (1991): 370-376.
 E.J. Thomaset al., "Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado," Medical Care 38, no. 3 (2000): 261-271.
 See, for example, S. Greenfield et al., "Variations in Resource Utilization among Medical Specialties and Systems of Care," Journal of the American Medical Association 267, no. 12 (1992): 1624-1630.
 P. Nicod and U. Scherrer, "Money, Fun, and Angioplasty," Annals of Internal Medicine 116, no. 9 (1992): 779; and R.A. Lange and L.D. Hillis, "Use and Overuse of Angiography and Revascularization for Acute Coronary Syndromes," New England Journal of Medicine 338, no. 25 (1998): 1838-1839; and M.R. Chassin, "Explaining Geographic Variations: The Enthusiasm Hypothesis," Medical Care 31, no. 5 Supplement (1993): YS37-44.
 See, for example, A.R. Localio et al., "Relationship between Malpractice Claims and Cesarean Delivery," Journal of the American Medical Association 269, no. 3 (1993): 366-373.
 E.B. Keeler et al., "How Free Care Reduced Hypertension in the Health Insurance Experiment," Journal of the American Medical Association 254, no. 14 (1985): 1926-1931; and P. Franks, C.M. Clancy, and M.R. Gold, "Health Insurance and Mortality," Journal of the American Medical Association 270, no. 6 (1993): 737-741.
 See, for example, K.B. Wells et al., "Detection of Depressive Disorder for Patients Receiving Prepaid or Fee-for-Service Care," Journal of the American Medical Association 262, no. 23 (1989): 3298-3302.
 L.G. Canlas, "Issues of Health Care Mistrust in East Harlem," Mount Sinai Journal of Medicine 66, no. 4 (1999): 257-258.
 L.L. Leape, "Error in Medicine," Journal of the American Medical Association 272, no. 23 (1994): 1851-1857.
 J. Steinhauer,"Death in Surgery Reveals Troubled Practice and Lax Hospital," New York Times, 15 November 1998; and J. Steinhauer, "Doctors' Licenses Suspended over Faulty Mammograms," New York Times, 1 June 2000.
 IOM, Committee on Clinical Practice Guidelines, Guidelines for Clinical Practice: From Development to Use (Washington: National Academy Press, 1992).
 Chassin et al., "The Urgent Need to Improve Health Care Quality."
 NHS Centre for Reviews and Dissemination, "Getting Evidence into Practice," Effective Health Care 5, no. 1 (1999): 1-16; and L.A. Bero et al., "Getting Research Findings into Practice," British Medical Journal 317, no. 7156 (1998): 465-468.
 R. Wieland, "No Tears for Cleveland Health Quality Choice," Editorials and Forum, Plain Dealer, 3 September 1999.
 M.R. Chassin, E.L. Hannan, and B.A. DeBuono, "Benefits and Hazards of Reporting Medical Outcomes Publicly," New England Journal of Medicine 334, no. 6 (1996): 394-398; J.H. Hibbard and J.J. Jewett, "What Type of Quality Information Do Consumers Want in a Health Care Report Card?" Medical Care Research and Review 53, no. 1 (1996): 28-47; and S. Robinson and M. Brodie, "Understanding the Quality Challenge for Health Consumers: The Kaiser/AHCPR Survey," Joint Commission Journal on Quality Improvement 23, no. 5 (1997): 239-244.
 M.N. Marshall et al., "The Public Release of Performance Data: What Do We Expect to Gain?" Journal of the American Medical Association 283, no. 14 (2000): 1866-1874; J.H. Hibbard et al., "Choosing a Health Plan: Do Large Employers Use the Data?" Health Affairs (Nov/Dec 1997): 172-180; and L.C. Erickson et al., "The Relationship between Managed Care Insurance and Use of Lower- Mortality Hospitals for CABG Surgery," Journal of the American Medical Association 283, no. 15 (2000): 1976-1982.
 J.C. Robinson, "The End of Managed Care," Journal of the American Medical Association 285, no. 20 (2001): 2622-2628.
 M. Freudenheim, "Big HMO to Give Decisions on Care Back to Doctors," New York Times, 9 November 1999; and E.C. Becher et al., "What Are Medicare Managed Care Plans Doing to Measure and Improve Quality of Care?" Quality Management in Health Care 9, no. 1 (2000): 49-58.
 R. Carson, Silent Spring (Boston: Houghton Mifflin, 1962).
 R. Nader, Unsafe at Any Speed (New York: Grossman Publishers, 1965).
 See, for example, A. Milstein et al., "Improving the Safety of Health Care: The Leapfrog Group," Effective Clinical Practice 3, no. 6 (2000): 313-316.
 See, for example, Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline no. 1, AHCPR Pub no. 92-0032 (Rockville, Md.: Agency for Health Care Policy and Research, 1992), 145.
 R.A. Deyo et al., "The Messenger Under Attack -- Intimidation of Researchers by Special-Interest Groups," New England Journal of Medicine 336, no. 16 (1997): 1176-1180.
 T.S. Purdum, "New York Hospitals Fear Harm in Plan to Reduce Specialization," New York Times, 24 January 1994; and A. Clymer, "Clinton Is Offering a Compromise to Medical Centers," New York Times, 21 March 1994.
 T.J. Ryan et al., "ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction," Journal of the American College of Cardiology 28, no. 5 (1996): 1328-1428; and M. Linzer et al., "Diagnosing Syncope: Clinical Efficacy Assessment Project of the American College of Physicians," Annals of Internal Medicine 126, no. 12 (1997): 989-996.
 D.W. Bates et al., "The Costs of Adverse Drug Events in Hospitalized Patients," Journal of the American Medical Association 277, no. 4 (1997): 307-311.
 S.L. Pestotnik et al., "Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support: Clinical and Financial Outcomes," Annals of Internal Medicine 124, no. 10 (1996): 884-890.
 D.W. Bates, et al., "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors," Journal of the American Medical Association 280, no. 15 (1998): 1311-1316; L.L. Leape et al., "Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit," Journal of the American Medical Association 282, no. 3 (1999): 267-270; R. Gonzales et al., "Decreasing Antibiotic Use in Ambulatory Practice," Journal of the American Medical Association 281, no. 16 (1999): 1512-1519; and E.D. Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly," Journal of the American College of Cardiology 32, no. 4 (1998): 993-999.
 Pestotnik, "Implementing Antibiotic Practice Guidelines."
 B.C. James, "Implementing Practice Guidelines through Clinical Quality Improvement," Frontiers of Health Services Management 10, no. 1 (1993): 3-37; M.R. Suchyta et al., "Effects of a Practice Guideline for Community-Acquired Pneumonia in an Outpatient Setting," American Journal of Medicine 110, no. 4 (2001): 306-309; "The Quality Gap: Medicine's Secret Killer," transcript, (25 May 2001); and IOM, Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academy Press, 2001), 137, 204. E.L. Hannan et al., "The Decline in Coronary Artery Bypass Graft Surgery Mortality in New York State: The Role of Surgeon Volume," Journal of the American Medical Association 273, no. 3 (1995): 209-213;
 E.L. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Mortality in New York State," Journal of the American Medical Association 271, no. 10 (1994): 761-766; S.W. Dziuban et al., "How a New York Cardiac Surgery Program Uses Outcomes Data," Annals of Thoracic Surgery 58, no. 6 (1994): 1871-1876; and Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling."
 Chassin et al., "Benefits and Hazards"; Erickson et al., "The Relationship"; and G. Anders, "Who Pays Cost of Cut-Rate Heart Care?" Wall Street Journal, 15 October 1996.
 Lexis Nexis search, July 2001.
 New York State Department of Health, Angioplasty in New York State 1994 (September 1996); New York State Department of Health, Angioplasty in New York State 1995 (October 1997); and AIDS Institute, New York State Department of Health, Clinical Management of HIV Infection: Quality of Care Performance in New York State, 1996-1998 (June 2000). For recent cardiac surgery and angioplasty reports, see the department's Web site,