groups consisted of both committee members and other distinguished leaders within the health care arena. Each advisory group was chaired by a member(s) of the QHCA Committee. One of these four groups, the Technical Advisory Panel on the State of Quality, chaired by Mark Chassin, M.D., was asked to review and synthesize literature on the state of quality in the health care industry. Other members of this panel included: Arnold Epstein, M.D., M.A.; Brent James, M.D.; James P.Logerfo, M.D.; Harold Luft, Ph.D.; R.Heather Palmer, M.B., B.Ch.; Kenneth B.Wells, M.D. This appendix presents the panel’s findings.


In developing its approach to this effort, the State of Quality Panel reviewed an earlier synthesis of the literature on quality that was carried out by investigators at the RAND Corporation (Schuster et al., 1998). This earlier review covered papers that, for the most part, were published between 1993 and mid-1997. To extend that earlier work, the IOM commissioned an updated synthesis from the investigators at RAND. This update covered the literature included in the earlier review with the addition of (1) papers published between July 1997 and August 1998, and (2) selected publications identified by members of the State of Quality Panel. A draft of this commissioned paper was reviewed by the State of Quality Panel at its November 1998 meeting, and subsequently revised in accordance with the panel’s suggestions. The final version, provided at the end of this appendix, was completed in January 1999.


A synthesis of findings from the literature on the quality of health care provides abundant evidence of poor quality. There are examples of exemplary care, but the quality of care is not consistent. Thus, the average American cannot assume that he or she will receive the best care modern medicine has to offer.

There are many examples of overuse, underuse, and misuse of health care services. Overuse refers to the provision of health services for which the potential risks outweigh the potential benefits. Underuse indicates that a health care service for which the potential benefits outweigh the potential risks was not provided. Misuse occurs when otherwise appropriate care is provided, but in a manner that does or could lead to avoidable complications.

Overuse of health care services is common. Examples include the following:

  • performance of major surgery (e.g., hysterectomy, coronary artery bypass graft) without appropriate reasons;

  • provision of antibiotics for the common cold and other viral upper respiratory tract infections for which they are ineffective;

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement