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Ann Thorac Surg 1995;59:486-493
© 1995 The Society of Thoracic Surgeons

A Cardiothoracic Surgery Information System for the Next Century: Implications for Managed Care

Timothy A. Denton, MD, Aurelio Chaux, MD, Jack M. Matloff, MD

Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California

Accepted for publication October 21, 1994.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Information: The Currency of...
 Who Needs the Information?
 How Providers Must Respond
 Where From Here?
 References
 
The United States health care system is under tremendous pressure to cut costs while maintaining quality. One mechanism to reduce costs is managed care—a system with both risks and benefits for patients, providers, and payors, and one that requires large volumes of data to ensure optimal medical and financial decision-making. In this review, we describe the types of information needed by managed care systems, including medical outcome data (satisfaction, survival, quality of life, and complications) and financial data (costs and long-term resource utilization). From a provider's point of view, the customers for these data range from individual patients to large self-insured corporations, and we describe the data required for each potential customer. Finally, as a concrete example of how data can be collected and analyzed to improve a provider's competitiveness, we describe the Cedars-Sinai Medical Center cardiothoracic surgery database from a managed care perspective. The concepts presented are generalizable to other subspecialties, and will become more important in the increasingly competitive milieu of American health care.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Information: The Currency of...
 Who Needs the Information?
 How Providers Must Respond
 Where From Here?
 References
 

It is a very sad thing that nowadays there is so little useless information.

Oscar Wilde

The medical profession has never been under greater pressure to change. Because of rising health care costs, frustrated public and private sectors are moving away from the fee-for-service system toward managed care [1, 2]. This move is forcing providers to compete with each other on price while at the same time attempting to maintain quality—the catch-22 of managed care.

Though managed health care may have multiple definitions [3, 4], generally it is a medical service delivery process that provides economic incentives for patients to use specific providers, imposes a set of utilization and quality controls on those providers, and allows the providers to achieve financial benefits in return for assuming financial risks [5]. Systems of managed care usually contain many thousands of members in order to diminish risk. Because of these large numbers, payors who control thousands of patients have tremendous influence in establishing prices and quality controls. As in any free-market (capitalistic) system, those who wish to provide services to the masses must respond to the dynamics of the marketplace. To attract and keep patients and payors, providers must couple excellent quality with competitive pricing. Successful delivery systems will use clinical, administrative, and financial information to their advantage.

In this review, we describe the kinds of information necessary for effective competition in a managed care environment and define the customers for whom these data are relevant. In the latter half of this review, we provide details on the Cedars-Sinai Medical Center cardiothoracic surgery database—its structure and function and how these data are used to improve care and competitiveness. Though this presentation focuses on a cardiac procedure–related database, we believe these concepts are sufficiently generic to allow them to be generalized to other medical specialties.


   Information: The Currency of Managed Care
Top
 Footnotes
 Abstract
 Introduction
 Information: The Currency of...
Who Needs the Information?
 How Providers Must Respond
 Where From Here?
 References
 
Consumers and payors are demanding outcome data to use in making decisions about health care [6, 7]. The Health Care Finance Administration [8], New York State [9], and Pennsylvania [10] were among the first organizations to publish medical outcome data for the general public on a range of providers. Cardiac surgery has been a prime subject for study because of its high visibility and high associated costs. Though debate still rages regarding the data's accuracy and the need to adjust for case mix, such information will continue to be published and used by consumers to make health care decisions [9, 11]. Managed care is a prime example of a data-driven system in which health care decisions are made on the basis of cost and quality information [12–17]. The ability to provide these quality-of-care measures is an advantage to providers who are competing for managed care contracts.

Managed care organizations are interested in four specific types of information: medical outcomes, methods to assess the quality of medical decisions, systems for continuous quality improvement, and financial outcomes.

Medical Outcomes
The four important medical outcomes of interest are survival, complications, quality of life, and patient satisfaction. These outcomes are, to various extents, measures of the quality of the process of care.

Historically, surgical survival has been a major focus because it is unambiguous and the data are easily collected. Surgical survival will continue to be an important measure, but interest is expanding to long-term survival as a better measure of procedural benefit. The collection of routine long-term follow-up data by providers demonstrates a commitment to patient care that extends beyond the perioperative period. This long-term view is important because many insurers are seeking alternate methods of payment, such as an ``episode of care''—the entire care of a patient with chest pain, including all procedures performed and the long-term follow-up care. Capitation is the extreme example of this financial approach in which a single monthly amount is given to a provider to care for the patient for the rest of their life. In this context, there is interest in defining outcomes with a bottom-line measure—the cost of a day of wellness [18]—and providers will become more focused on long-term costs.

Postprocedural complications are a measure of quality of care and have a considerable impact on cost. Postoperative bleeding, infections, arrhythmias, strokes, pleural effusions, and all other complications increase cost by increasing the lengths of stay, the rates of readmission, the number of office visits, and the number and quantity of medications. Managed care systems are more concerned with the long view—an entire episode of cardiac care—than they are with, for example, a simple 7-day admission for a bypass graft procedure. Thus, their evaluation of delivered services often begins with postoperative complications.

Cardiac procedures are not always done to improve survival, but also to improve a patient's quality of life. Quality, rather than longevity, is often the most important consideration; thus, objective, patient-provided measures of quality of life are slowly being integrated into routine follow-up care, and will become an important part of outcomes measurement under a managed care system. Though quality of life can have many dimensions, the four that are common to most instruments are (1) overall well-being, (2) physical function, (3) psychologic status, and (4) social and role status. A multitude of instruments are available that have been validated and are easy to administer [19–21]. The ability to report long-term survival and quality-of-life data will be an advantage to providers of cardiac services because procedural benefit can then be judged in terms of periprocedural quality (surgical mortality and complications) and the long-term impact of care (survival and quality of life).

Patient satisfaction is extremely important in the eyes of payors [22], and can be measured by prevalidated, published instruments [23], custom questionnaires, or group discussions with patients. These methods generate data regarding patients' opinions concerning their care, administrative procedures, hospital facilities, family support [24], and likelihood of return to the hospital, and also determine whether the patient would recommend the facilities to others. Demonstrating high patient satisfaction and improving service where patients are dissatisfied are important parts of managed care. Word of mouth has often been the best advertisement for medical care, and managed care organizations anticipate that satisfied patients will be an important sales force.

Quality of Medical Decision-Making
Quality of care is not only defined by the quality of the process, but also by the quality of the decision leading to a particular therapy. The American Heart Association, the American College of Cardiology [25], and the RAND Corporation [26] have published appropriateness criteria for the performance of bypass operations based on consensus. These instruments are used by payors in the preapproval and utilization management processes, and managed care organizations often ask what guidelines are used by providers. The ability to monitor the appropriateness of a procedure is an important differentiating factor for providers, and demonstrates a commitment to optimizing the individual patient decision-making process.

Continuous Quality Improvement
Gathering and disseminating data are insufficient by themselves—one must do something with the data to bring about an improvement in patient care. Many managed care organizations are requesting evidence that a provider is continuously improving care. Continuous quality improvement is a formal process by which data are collected regarding a particular problem; these data are then used to make systematic changes in an effort to improve outcomes, and the outcomes are measured again to determine if the changes have made an impact [27–29]. Implementation of a formal continuous quality improvement program demonstrates a serious commitment by providers to improve the system of care, and will be viewed favorably by payors.

Financial Outcomes
Because the present health care debate has been driven primarily by rising costs, providers wishing to be competitive under a managed care system must be cost-effective. By having accurate and timely financial information, a provider can relate true costs to reimbursement and calculate the value of a given service [30–33]. Financial data are necessary to implement financial continuous quality improvement to contain costs while maintaining quality [34], and are key to determining the financial benefits of individual contracts. Because the essence of managed care is to place the provider at financial risk, not all managed care contracts are profitable, and providers need to evaluate each contract separately [35]. A capitated population that contains many high-risk patients with heart disease may lose money if the capitation rate is set too low.

Individual physician profiling [36–38] is becoming more popular as a mechanism to determine cost-effectiveness and quality of care. Usually physicians are stratified according to their medical outcomes—mortalities, procedural complications, and patient satisfaction. But, given monetary constraints, some health care systems are measuring the cost differences among physicians providing care to similar patients. Physicians whose patient care costs are low and who achieve good quality care are an advantage. Those physicians whose costs are high with no corresponding difference in the quality of the outcomes in their patients may be identified as a drain on the managed care system. When hospital privileges are tied to such data, this process is termed economic credentialing.


   Who Needs the Information?
Top
 Footnotes
 Abstract
 Introduction
 Information: The Currency of...
 Who Needs the Information?
How Providers Must Respond
 Where From Here?
 References
 
Under a managed health care system, the decision as to who will provide the care is made by a variety of entities. The most obvious are the health insurance corporations to which patients pay their premiums, and who, in turn, pay their enrollees' health care costs. Large health insurance corporations are rapidly developing local and national managed care networks, and will always be important sources of patients. The federal government, through Medicare, also provides patients to managed care systems [39].

Other, less obvious, players are also emerging as patient sources [40]. First, corporations are now self-insuring because of the cost savings involved [41]. A corporation may hire a health insurance firm to develop and administer its insurance plan, but the primary decision-maker—with respect to providers—is the corporation. In this case, providers have to satisfy the corporation first, not necessarily a health insurance company. Large corporations are developing networks with other corporations so that they can gain negotiating power. These networks, called business coalitions, serve as a major force in determining quality standards and the pricing of health care for their employees. In many ways, they fulfill the role of the Alliances proposed in Clinton's Health Security Act of 1993 [42].

Trade unions also play an important role. Individual members may prefer one provider over another on the basis of satisfaction and excellence of outcome. Thus, the union may insist on that particular provider in the next contract negotiation. Finally, individual patients may be able to decide their choice of plans, and may choose based on the presence or absence of a particular provider on a list—thus direct marketing to patients will remain important.

All of these groups need different types of information to make their health care decisions. The insurance corporation will probably focus on financial aspects, while individuals, unions, and self-insured corporations—though concerned about costs—may focus more on quality of care, access, and member satisfaction. The data presented to each group should correspond to their primary concerns.


   How Providers Must Respond
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 Footnotes
 Abstract
 Introduction
 Information: The Currency of...
 Who Needs the Information?
 How Providers Must Respond
Where From Here?
 References
 
The rules have been rewritten and competition in medical care has become a mechanism to control costs. Competition will become more intense, resulting in consolidation over the next few years. Large systems with good, documentable outcomes will be at an advantage. Further, because single providers (individual physicians or hospitals, or both) cannot be competitive in a managed care environment, they must join together and develop networks of care [43–45] to improve their marketability. These integrated health care systems must also develop corresponding integrated information systems to provide all customers—managed health care plans and self-insured groups at the local, regional, and national levels—access to important clinical, administrative, and financial data [46].

In addition, third-party payors are often required to present clinical data to the corporations they insure (including governmental agencies). For example, the Health Plan Employer Data and Information Set is a series of performance measures (data and formal data analyses) developed to allow an employer to determine the value of a health plan and hold the plan accountable for care [47]. Health care delivery systems that can provide this information to clients have a significant marketing advantage.

The Cardiothoracic Surgery Database at Cedars-Sinai Medical Center
To provide a concrete example of how data for managed health care can be collected, analyzed, and presented, we describe the structure and methods that are currently being used in the Cedars-Sinai Medical Center cardiothoracic surgery database. This system was built on a foundation of almost 20 years of data collection, and has recently been modified to adapt it to a managed care setting. It has much in common with other well-known databases, but these have been developed for purposes other than health care delivery in a managed care system [48–51]. Ours is singular, in that it links administrative, clinical, and financial databases into one system that allows constant tracking of medical and financial outcomes. We will discuss the database structure, the process of data collection, and how these data are used in a competitive managed care realm.

Database Structure
The database resides on a Digital Equipment Corporation (DEC) VAX cluster running RDB as its database engine. The interface and analysis routines are written in a fourth generation language (PowerHouse; Cognos, Burlington, MA). The structure is open, such that any user connected to the hospital network (directly or via modem) can access the database through custom screens, or through SQL (structured query language).

Figure 1Go is a logical diagram of the database. The core contains a series of tables corresponding to each of the relevant datasets, which will be described. The database is linked to the hospital's central administrative, financial, and physician databases. This linking of databases strengthens the inherent weaknesses of each and eliminates the need for double-entry. All other data are input from forms collected at the site of data generation.



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  		Fig 1. . The logical structure of the Cedars-Sinai Cardiothoracic Surgery database. The core database (inside dotted lines) has direct links to the hospital's central administrative, financial, and physician databases (left). Data access is accomplished by means of the clinical interface, the automated report system, and a client/server tool for ad hoc and research purposes (right). (H&P = history and physical examination data.)

 
The data elements deemed important enough to collect were selected on the basis of our prior experience and our findings from the review of other databases. Each data element was carefully reviewed in terms of its relevance to clinical care, its administrative necessity, and its importance in a managed care environment. Patient privacy is closely guarded by providing multiple security levels. Access to the hospital network is controlled by the hospital's information systems department, and access to the surgical database is further controlled by the department of cardiothoracic surgery.

Process of Data Collection
Data are prospectively collected at the source of generation. All data definitions are on the collection forms, and all personnel have received special training in the proper methods of collection. The reliability of the data collected is assessed through routine and ad hoc quality assurance procedures. Demographics and the patient's physician information are obtained by an electronic link to the hospital's central database. History and physical examination data are obtained by clinical staff by means of patient interviews, chart reviews, and referring physician contacts, all before the procedure. The surgical data are collected by the perfusionists from direct interviews with the surgeons and anesthesiologists during the procedure. Within minutes of the completion of the procedure, the data are entered by specially trained personnel and a preliminary operative report is generated and automatically faxed to all referring physicians. Though at present these data are not an official part of the medical record, we envision them becoming an aspect of a hospital-wide electronic patient record when such a system is installed.

Follow-up data (complications) are obtained by liaison nurses from the time of the patient's admission to 2 months after discharge. Long-term follow-up is conducted by means of annual mailings or office visits, or both, and consists of questions on symptom status, resource utilization (readmission, office visits, and repeat procedures) and a formal quality-of-life assessment tool [52, 53]. The long-term follow-up at our institution exceeds 90%.

How the Data Are Used
The most important goal of the database is to provide clinical data in an easy-to-use interface. The clinician interface consists of a single screen that is easily accessed from within the hospital or the physician's office or home, and contains three types of data: clinical information, information on protocols of care, and decision aids (Fig 2Go). This small dataset of 55 variables provides the primary physician, emergency room physician, or invasive cardiologist with sufficient information to care for a patient from the time of discharge to many years of long-term follow-up.



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  		Fig 2. . An example of the clinical user interface consisting of simple administrative variables, along with limited coronary artery bypass grafting, valve, in-hospital, and short-term follow-up data, in addition to information on other procedures. The 55 variables were chosen from among the hundreds of variables in the entire database as being those most relevant to patient care in the near or long term. (AICD = automatic implantable cardioverter defibrillator; CABG = coronary artery bypass grafting; CE = Carpentier-Edwards; Compl = complications; CVS = cardiovascular surgery; Cx = circumflex artery; Infec = infection; inter = intermediate; LAD = left anterior descending artery; LITA = left internal thoracic artery; Marg = marginal; MRN = medical records number; PCD = pacer/cardioverter/defibrillator; PD = posterior descending; PL = posterolateral; Prol Intub = prolonged intubation; RCA = right coronary artery; RV = right ventricle; St = status; SVG = saphenous vein graft; SVT = supraventricular tachycardia; Sx = surgery; VT/VF = ventricular tachycardia/fibrillation; Xplant = transplantation.)

 
Second, the clinical interface allows access to information on our recommended protocols of care. A common question from referring physicians is ``What antibiotics are you recommending for a patient with an artificial valve during a dental procedure?'' The physician can now obtain this information and information on other related protocols directly from this screen.

Finally, the clinical interface provides the physician with decision aids. Using models developed in our database, physicians can enter individual patient characteristics and receive immediate estimates of surgical survival. Estimates of procedural benefit (in terms of improvement in survival and quality of life), cost estimates, and appropriateness models will be added to the system as they are developed [54].

The second goal of the database is to increase the competitiveness of the department through the implementation of administrative efficiencies and cost containment. The administrative portion of the database allows members of the department to access all clinical and follow-up data, our referring physician database, financial variables, and the reporting module. The financial module allows reference to procedural costs, broken into 12 categories, as noted in Figure 3Go. Costs are calculated by the hospital financial system and include all hospital overhead costs, salaries, and benefit costs for the hospital staff. Professional fees are not yet included. Using preoperative clinical information and cost outcome data, we have developed financial models to provide patient-specific cost estimates before a procedure. In addition, with these data, we are able to accurately calculate capitation levels for tertiary surgical care.



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  		Fig 3. . The financial screen, demonstrating 12 cost and charge categories in addition to indirect costs, and estimated and actual reimbursements. (CVS = cardiovascular surgery; DRG = diagnosis-related groups; ER = emergency room; ICU = intensive care unit; MRN = medical records number; OR = operating room; Rx = drugs; St = status.)

 
A departmental ``report card'' [55], generated from our reporting module, includes information regarding the department's activities, case mix, and demographics, as well as detailed information on mortality as a function of the procedure, perioperative complications, appropriateness, the quality-of-life assessment, and patient satisfaction. Figure 4Go shows the quality-of-life scores (from our report card) for a typical subset of patients who have undergone various cardiac surgical procedures. The four graphs represent the four dimensions of quality of life as measured by published, validated instruments [52, 53]. Figure 5Go shows the findings from four representative questions on our most recent patient satisfaction questionnaire—also from our report card.



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  		Fig 4. . A random sample of quality-of-life scores from patients after cardiac surgical procedures. The four dimensions are well-being, physical functioning, social functioning, and psychologic status.

 


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  		Fig 5. . Four representative questions from the 12 asked in the patient satisfaction survey. The results of these are used in presentations to prospective payors, and for feedback to the respective sections of the department of cardiothoracic surgery for purposes of quality improvement.

 
Data from the information system and report card are actively used for the purpose of continuous quality improvement. Over the past 3 years, we have reduced the length of hospital stay in patients undergoing coronary artery bypass grafting by 36% through the use of guidelines and the feedback of data to physicians. We are now undertaking projects to reduce the use of blood transfusions and the occurrence of wound infections. The database has also allowed us to respond quickly to requests for proposals, often within as little as 24 hours. The data and report card are actively used in marketing efforts, and have had an impact on our ability to attract contracts from large payors.

As already mentioned, the future of health care lies in the creation of large, integrated systems. We have designed our database in such a way that it can become the hub of a large network of primary and tertiary care providers. Figure 6Go shows what we envision the information flow will be within a hypothetical network. In it, links between primary care physicians, specialists, and the central database are established around a primary hospital, which shares data with affiliated hospitals and medical groups in real time. Further, we are developing a link to third-party payors, so that clinically relevant individual patient information can be transmitted to them for quality assurance purposes and to satisfy governmental regulations (eg, the Health Plan Employer Data and Information Set).



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  		Fig 6. . An example of a hypothetical network for a central hospital (CSMC) with links to referring physicians and support personnel. Additional links are supplied to affiliated hospitals and to payors for the purpose of exchanging relevant clinical and financial information.

 

   Where From Here?
Top
 Footnotes
 Abstract
 Introduction
 Information: The Currency of...
 Who Needs the Information?
 How Providers Must Respond
 Where From Here?
References
 
No matter what the federal government imposes in the form of health care reform, the die has already been cast by market forces. The future of our system lies in the active cooperation of providers participating in large, competitive networks. Individual patients, government-administered programs, unions, self-insured corporations, business coalitions, and health insurance companies will contract with networks to provide quality care at the lowest possible price. This new system will be data driven. Providers with access to relevant administrative, clinical, and financial data will therefore be the most competitive.

Though physicians have not played a major role in the restructuring of health care, they must become actively involved in the health care debate [56] and in developing the data to support a health care system based on excellence. Physicians must supervise the management of the data [57], and must realize that the database itself will become a means to improve care [58]. An opportunity exists to objectively demonstrate the benefit of high-technology care while maintaining excellence at reasonable cost. It is time for us to take the lead in this effort.


   Footnotes
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 Footnotes
Abstract
 Introduction
 Information: The Currency of...
 Who Needs the Information?
 How Providers Must Respond
 Where From Here?
 References
 
Address reprint requests to Dr Denton, Cedars-Sinai Medical Center, Room 6215, 8700 Beverly Blvd, Los Angeles, CA 90048.


   References
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 Footnotes
 Abstract
 Introduction
 Information: The Currency of...
 Who Needs the Information?
 How Providers Must Respond
 Where From Here?
 References
 

  1. Carrol MS. Managed care programs: an employer perspective. Top Health Care Financ 1993;20:10–6.
  2. Weinberg SL. Managed care: an assault on medicine's professional imperatives [President's Page]. J Am Coll Cardiol 1994;23:988–9.[Medline]
  3. Mechanic D. Managed care: rhetoric and realities. Inquiry 1994;31:124–8.[Medline]
  4. Weil TP. Managed-care plans: the future under national health insurance. West J Med 1991;155:533–7.[Medline]
  5. Inglehart JK. The American health care system: managed care. N Engl J Med 1992;327:742–7.[Medline]
  6. Dragalin D, Perkins P, Plocher DW. Institutes of quality: Prudential's approach to outcomes management for specialty procedures. Qual Rev Bull, March 1990:111–5.
  7. Dallek G, Harper A, Jimenez C, Daw C. Medicare risk–contract HMOs in California: a study of marketing, quality, and due process rights. Los Angeles: Medicare Advocacy Project, 1993.
  8. Health Care Financing Administration. Medicare hospital mortality information, 1987, 1988, 1989 (HCFA Publication #00744). Washington, DC: U.S. Department of Health and Human Services, 1990.
  9. Hannan EL, Kilburn H, Racz M, Shields E, Chassin MR. Improving the outcomes of coronary artery bypass surgery in New York State. JAMA 1994;271:761–6.[Abstract/Free Full Text]
  10. A consumer guide to coronary artery bypass graft surgery. Harrisburg, PA: The Pennsylvania Health Care Cost Containment Council, 1992.
  11. Ballard DJ, Bryant SC, O'Brien PC, Smith DW, Pine MB, Cortese DA. Referral selection bias in the Medicare hospital mortality prediction model: are centers of referral for Medicare beneficiaries necessarily centers of excellence? Health Serv Res 1994;28:771–84.[Medline]
  12. Hampshire DA, Rosborough BJ. The evolution of decision support in a managed care organization. Top Health Care Financ 1993;20:26–37.[Medline]
  13. Welge WL. Managed care is limited by the information system. Top Health Care Financ 1992;19:23–32.[Medline]
  14. Lipson EH. What are purchasers looking for in managed care quality? Top Health Care Financ 1993;20:1–9.
  15. Goldfield N. Measurement and management of quality in managed care organizations. Alive and improving. Qual Rev Bull, Nov 1991:343–8.
  16. Miller RH, Luft HS. Managed care plan performance since 1980. A literature analysis. JAMA 1994;271:1512–9.[Abstract/Free Full Text]
  17. Leatherman S, Peterson E, Heinen L, Quam L. Quality screening and management using claims data in a managed care setting. Qual Rev Bull, Nov 1991:349–59.
  18. Matloff JM. The practice of medicine in the year 2010. Ann Thorac Surg 1993;55:1311–25.[Medline]
  19. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med 1993;118:622–9.[Abstract/Free Full Text]
  20. Cook DJ, Guyatt GH, Juniper E, et al. Interviewer versus self-administered questionnaires in developing a disease-specific, health-related quality of life instrument for asthma. J Clin Epidemiol 1993;46:529–34.[Medline]
  21. Visser MC, Fletcher AE, Parr G, Simpson A, Bulpitt CJ. A comparison of three quality of life instruments in subjects with angina pectoris: the sickness impact profile, the Nottingham health profile, and the quality of well being scale. J Clin Epidemiol 1994;47:157–63.[Medline]
  22. The Health Poll, Metropolitan Life Insurance Co. Business and Health, Aug 1990.
  23. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry 1988;25:25–36.[Medline]
  24. Gustafson DH. Expanding on the role of patient as consumer. Qual Rev Bull, Oct 1991:324–5.
  25. Guidelines and indications for coronary artery bypass graft surgery. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Graft Surgery). J Am Coll Cardiol 1991;17:543–89.[Medline]
  26. Leape LL, Hilborne LH, Kahan JP, Park RE, Kamberg CJ, Brook RH. Coronary artery bypass graft: a literature review and ratings of appropriateness and necessity. Santa Monica, CA: RAND, 1991.
  27. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989;320:53–6.[Medline]
  28. Hammermeister KE, Johnson R, Marshall G, Grover FL. Continuous assessment and improvement in quality of care: a model from the Department of Veterans Affairs Cardiac Surgery. Ann Surg 1994;219:281–90.[Medline]
  29. Laffel G, Blumenthal D. The case for using industrial quality management science in health care organizations. JAMA 1989;262:2869–73.[Abstract/Free Full Text]
  30. Eddy DM. Connecting value and costs: whom do we ask, and what do we ask them? JAMA 1990;264:1737–9.[Abstract/Free Full Text]
  31. Gregg SA. How can we achieve more value from our managed care efforts? Top Health Care Financ 1992;19:89–95.[Medline]
  32. Dudley RA, Harrell FE, Smith LR, et al. Comparison of analytic models for estimating the effect of clinical factors on the cost of coronary artery bypass graft surgery. J Clin Epidemiol 1993;46:261–71.[Medline]
  33. Malcolm CL, Fukui M. Specialty service contracting. Top Health Care Financ 1993;20:68–75.[Medline]
  34. Jacobson JM. Promoting and measuring productivity in the HMO. Top Health Care Financ 1992;19:75–82.[Medline]
  35. Lewis JB. Hospital strategic management and managed care. Top Health Care Financ 1992;19:11–7.[Medline]
  36. Welch HG, Miller ME, Welch WP. Physician profiling. An analysis of inpatient practice patterns in Florida and Oregon. N Engl J Med 1994;330:607–12.[Abstract/Free Full Text]
  37. Kassirer JP. The use and abuse of practice profiles. N Engl J Med 1994;330:635–7.
  38. Shapiro DW, Lasker RD, Bindman AB, Lee PR. Containing costs while improving quality of care: the role of profiling and practice guidelines. Annu Rev Public Health 1993;14:219–41.[Medline]
  39. Clement DG, Retchin SM, Brown RS, Stegall MH. Access and outcomes of elderly patients enrolled in managed care. JAMA 1994;271:1487–92.[Abstract/Free Full Text]
  40. Findlay S. What's ahead in 1994? Business Health 1993;11: 28–37.
  41. Jones LF, Font JA. Meeting employer needs in the managed care request for proposal. Top Health Care Financ 1992;19: 18–22.[Medline]
  42. Health Security: the President's report to the American people. New York: Simon and Schuster, 1993.
  43. Peters GR. Organizational and business issues affecting integrated delivery systems. Top Health Care Financ 1994;20:1–12.
  44. Smith JR. Creating an integrated health care delivery system: a regional nonprofit provider case study. Top Health Care Financ 1993;20:82–8.[Medline]
  45. Masters GM. Managed care and competitive warfare in the 1990's. Top Health Care Financ 1993;20:vi–viii.
  46. Brooke PP. Successfully managing managed care: organizational skills needed by hospitals to compete in an era of managed care. Top Health Care Financ 1992;19:1–10.
  47. Health plan employer data and information set and user's manual. Washington DC: The National Committee for Quality Assurance, 1993.
  48. Anderson RP. First publications from The Society of Thoracic Surgeons Nation Database. Ann Thorac Surg 1994; 57:6–7.[Medline]
  49. Clark RE. The Society of Thoracic Surgeons National Database status report. Ann Thorac Surg 1994;57:20–6.[Abstract]
  50. Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: The Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 1994;57:12–9.[Abstract]
  51. Edwards FH, Clark RE, Schwartz M. Impact of internal mammary artery conduits on operative mortality in coronary revascularization. Ann Thorac Surg 1994;57:27–32.[Abstract]
  52. Abramson JH, Ritter M, Gofin J, Kark JD. A simplified index of physical health for use in epidemiological studies. J Clin Epidemiol 1992;45:651–8.[Medline]
  53. Jette AM, Davies AR, Cleary PD, et al. The functional status questionnaire: reliability and validity when used in primary care. J Gen Intern Med 1986;1:143–9.[Medline]
  54. Diamond GA, Denton TA, Matloff JM. Fee-for-benefit: a strategy to improve the quality of health care and control costs through reimbursement incentives. J Am Coll Cardiol 1993;22:343–52.[Abstract]
  55. Topol EJ, Califf RM. Scorecard cardiovascular medicine. Its impact and future directions. Ann Intern Med 1994;120: 65–70.[Abstract/Free Full Text]
  56. Thier SO. Health care reform: who will lead? Ann Intern Med 1991;115:54–8.
  57. Friedman BA, Martin JB. The physician as a locus of authority, responsibility, and operational control of medical systems. J Med Syst 1988;12:389–96.[Medline]
  58. Pryor DB, Lee KL. Methods for the analysis and assessment of clinical databases: the clinician's perspective. Stat Med 1991;10:617–28.[Medline]



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