|
Items in cart [0] |
Questions? Call 888-624-8373 |
PAPERBACK + PDF PAPERBACK PDF BOOK PDF CHAPTERS Free Resources |
||||||||||||||||
|
||||||||||||||||
|
|
|||||||||||||||
| ||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 19
Chapter 1
Introduction
Many organizations, experts, health professionals, and, increasingly, the American public
question whether quality health care can be delivered under the existing health care system, noting
that health care today harms too frequently and consistently fails to deliver its potential benefits
(Blendon et al., 2001; Kaiser Family Foundation and Agency for Healthcare Research and Quality,
2000; Wirthlin Worldwide, 20014. Studies by expert bodies first documented the serious and
pervasive nature of the quality problem with reports of overuse of services, such as excessive
prescribing of antibiotics to children; misuse of services, such as incorrect dosages of drugs being
administered to patients; and underuse of services, such as not employing effective prevention
strategies with patients (Chassin, 1998; President's Advisory Commission on Consumer Protection
and Quality in the Health Care Industry, 1998; Schuster et al., 19984. Such errors, as documented by
the authors of To Err Is Human: Building a Safer Health System, result in tens of thousands of
Americans dying each year and hundreds of thousands suffering or being sick (Institute of Medicine,
2000~.
In the report Crossing the Quality Chasm: A New Health System for the 21st Century (Institute
of Medicine, 2001) the same Institute of Medicine (IOM) committee that authored To Err Is Human
emphasizes that such safety problems occur because of the system's inability to translate knowledge
into practice, to apply new technology safely and appropriately, and to make best use of its
resources both financial and human. In the face of these system failures, the Quality Chasm report
stresses that the rapidly increasing chronic care population only compounds the need for a redesigned
health system. Fully 40 percent of the U.S. population 125 million Americans live with some
type of chronic condition, and about half of them live with multiple such conditions (Wu and Green,
2000~.
The Quality Chasm report also emphasizes that blaming health providers or asking them to just
19
OCR for page 20
HEALTH PROFESSIONS EDUCATION
try harder is not the answer to addressing the
health care system's current flaws and future
challenges. Gaps in quality are occurring in the
hands of health professionals highly dedicated
to doing a good job, but working within a
system that does not support them in achieving
what they want and ought to be providing for
patients. The Quality Chasm report sets forth
an ambitious agenda for the redesign of this
broken health care system. First, the system
must be designed to provide care that achieves
six national quality aims: safety, effectiveness,
patient-centeredness, timeliness, efficiency, and
equity. The system must serve the needs of
patients, ensuring that they are fully informed,
retain control, participate in care delivery
whenever possible, and receive care that is
respectful of their values and preferences.
Moreover, the system must facilitate the
application of scientific knowledge to practice
by providing clinicians with the tools and
support necessary to deliver evidence-based
care consistently and safely.
Implementing this agenda has important
implications for current and future health
professionals. Such changes mean that health
professionals need to be better prepared. They
must be educated, trained, and regulated
differently so they can function as effectively as
possible in a reformed health system, a system
founded on enhanced quality and safety as
envisioned in the Quality Chasm report.
Origins of the Study
The Quality Chasm report emphasizes the
need for additional study to understand the
effects of the recommended changes on how the
workforce is educated for practice, how it is
deployed, and how it is held accountable. One
recommendation of the report is that a
multidisciplinary summit of leaders within the
health professions be held to discuss and
develop strategies for restructuring clinical
education to be consistent with the six national
quality aims outlined above across the
continuum of education for the allied health,
medical, nursing, and pharmacy professions.
In 2001, the Health Resources and Services
Administration (HRSA) within the Department
of Health and Human Services (DHHS) asked
the IOM's Board on Health Care Services to
convene a committee that would be charged
with coordinating the recommended summit and
drafting a follow-up report. The Committee on
the Health Professions Education Summit was
formed for this purpose. The committee
included members with expertise and
experience in academic and continuing allied
health, medical, nursing, and pharmacy
education; multidisciplinary clinical training;
health professions licensure and oversight
processes; professional credentialing; and health
care delivery and quality.
Health Professions Education
Summit
Summit Planning
The committee held three meetings during
2002 a planning meeting to review the
literature and prepare for the summit, a meeting
during the summit to identify major objectives
for reform that would inform the specific
actions proposed by participants, and a post-
summit meeting. At this last meeting, the
committee reviewed a draft of this report and its
recommendations .
In preparation for the summit, the
committee reviewed the new or enhanced skills
required by health professionals to function in
the changing health care environment as cited in
the Quality Chasm report (Chapter 94. (See
Chapter 3 for a more in-depth discussion.) The
committee grouped those skills and defined five
overarching competencies needed by today's
health care professionals: provide patient-
centered care, work in interdisciplinary teams,
employ evidence-based practice, apply quality
improvement approaches, and utilize
informatics.
The committee then examined the extent to
which students and practicing health
professionals were required to receive education
20
OCR for page 21
~ NTRODUCTION
in these areas. To perform this examination, the
committee worked with IOM staff on papers
that surveyed the published literature and
existing requirements and standards
promulgated by the accrediting and licensing
bodies of various health professions, consulted
with experts in clinical education, and gathered
input from other interested organizations. An
examination of available evaluation data
provided insight into what is and is not working,
as well as the limitations of education efforts to
date. Background papers on each of the five
competencies were provided to summit
participants.
The committee endeavored to make the
most ofthe evidence and substantial experience
available, but found in its review of the
available literature, consultation with experts,
and input from other interested parties that the
evidence base needed to assess the current
status of education and oversight processes of
the health professions in each of the five
competencies is limited. There have been few
rigorous long-term evaluations of any aspect of
health professions education, much less
evaluations related to the five competencies
(Furze and Pearcey, 1999; Murray et al., 20004.
It is difficult to locate even a single evaluation
that measures changes in patient outcomes or
satisfaction as a result of any revision of
curriculum. Most studies of clinical education
are qualitative, employing anecdotal
observation of student performance or self-
assessments by learners of changes in
knowledge, skills, and attitudes For the
quantitative studies available, less-rigorous
evaluation measures, such as student
satisfaction, are often employed (Belfield et al.,
2001; Cooper et al.,2001; Jordan, 2000;
O'Brien et al., 20014. The majority of
documented experiences come from medicine,
fewer from nursing and pharmacy, and very few
from allied health (Department of Health and
Human Services, 19984.
In planning the summit and identifying a list
of participants, the committee sought input from
the Council on Graduate Medical Education and
the National Advisory Council on Nurse
Education and Practice, advisory committees to
HSRA. They provided input that led to the
summit participants' encompassing a
multidisciplinary group of allied health, nursing,
medical, and pharmacy educators and students;
health industry representatives; regulators and
accreditors; health organization representatives;
consumers; and policy leaders. Care was taken
to include professionals from diverse
occupations. Individuals from other key
organizations also were consulted during the
planning process. The names and affiliations of
the more than 150 attendees are listed in
Appendix D.
Summit Execution
The summit began with plenary sessions led
by noted health experts, including Kenneth
Shine, then president of the IOM; William
Richardson, president of the W. K. Kellogg
Foundation; and Donald M. Berwick, president
of the Institute for Healthcare Improvement.
These sessions were designed to set the context
of the current reality of health professions
education and the new health care environment
that future health professionals must be
educated to address. Included was a panel
discussion on educational implications of caring
for the chronically ill. The full summit agenda
is provided in Appendix B.
Following the plenary sessions, participants
worked in small interdisciplinary groups to draft
proposed strategies for integrating one of the
above five competencies into clinical education
(see Box 1-1~. The committee then reviewed
and synthesized these strategies and, using
prioritization tools, chose seven priority
strategies for the reform of health professions
education on which summit participants focused
for the next day. On day two of the summit,
participants drafted actions to advance these
strategies for reform. The main strategies,
aggregated into five groups, are detailed in
Appendix C.
21
OCR for page 22
HEALTH PROFESSIONS EDUCATION
Post-Summit Activities
The committee's final meeting was held to
review a draft of this report and its
recommendations. This review was based on an
examination of the salient literature, as well as
consideration of the strategies and actions
proposed at the summit.
Scope of the Report
The content of this report reflects the
committee's commitment to carrying out its
stated charge. Although a number of important
and often controversial areas were discussed
during the committee's deliberations and are
briefly mentioned in the report,
recommendations related to those issues falling
outside the scope ofthe committee's charge are
not addressed. These issues include the
distribution, composition, and shortages of the
health care workforce; issues related to
education preparation and entry into practice;
the financing of health professions education;
changing skill requirements for new
occupations; and student recruitment and
admissions policies. These issues remain
important, and the committee hopes this report
will influence or shape deliberations in these
other areas.
Building Upon Previous Reform
Efforts
In carrying out its charge, the committee
was cognizant of the many outstanding efforts
that have been made to articulate a vision for
the reform of health professions education
(Beliack and O~eil, 2000; Council on Graduate
Medical Education, 1999; Halpern et al., 2001;
Harmening, 1999; Hegge, 1995; Long, 1994;
Mennin, 1998; O~eil and the Pew Health
Professions Commission, 19984. There has
been no shortage of good ideas on how to
reform clinical education, the striking feature of
these ideas being their similarity with regard to
~ A current Institute of Medicine study addressing academic health centers is considering financing questions.
22
OCR for page 23
~ NTRODUCTION
the problems identified and proposed solutions
(Beliack and O'Neil, 2000; Christakis, 1995;
Enarson and Burg, 1992; Rivo et al., 19934.
Unfortunately, reform of health professions
education can be exceedingly slow and difficult
to accomplish. A number of reasons have been
cited for the lack of reform. Health professions
education frequently occurs in an environment
of separately housed professional schools and
separate clinical arenas governed by separate
deans, directors, and department chairs, often
resulting in the protection of specific specialties
or interests at the cost of the educational goals
ofthe school (Enarson and Burg, 1992; Regan-
Smith, 1998~. Another reason is the financing
of academic centers which has resulted in many
institutions valuing research and clinical
activities at the expense of education
(LuUmerer, 1999; Regan-Smith, 1998~. This
complex web of competing educational and
oversight systems and processes has made it
difficult for successful institution- or cIassroom-
based innovations to diffuse on a widespread
basis. Many reform efforts have also not taken
root among the professions because there has
been little motivation to change and a lack of
the leadership needed to carry the reforms
forward. This lack of motivation and leadership
in turn reflects the absence of a clear
understanding of why such changes would be
any better than current practice or how they
could be accomplished comprehensively.
Finally, coordination and collaboration within
and among the professions has been extremely
difficult to achieve, and this has posed a key
barrier to reform.
For these reasons, the committee believes a
more intense and coordinated effort will be
needed that spans the various health professions
and those entities responsible for shaping
education in each field. The committee believes
the time is ripe to build upon previous reform
efforts, galvanizing the education, practice, and
oversight communities.
First, these groups increasingly understand
the extent of quality problems and recognize
that the system needs wholesale restructuring;
an essential aspect of that restructuring is
reform of the content, skills, and values taught
to students and faculty. In a 2001 survey of
more than 1,000 health care professionals, 58
percent of providers and administrators rated
health care in the United States as not very
good, and 4 of 5 respondents said they believed
fundamental changes are needed in the U.S.
health care system (Wirthlin Worldwide, 20014.
In another survey, more than half of physicians
said they believe their ability to deliver quality
care has decreased in the past 5 years (Blendon
et al., 20014. Second, health professionals are
dissatisfied with their working and training
conditions, and recruitment difficulties and
personnel shortages have become pressing
issues (Hart et al., 2002; Sochalski,2002~. This
dissatisfaction is driven in part by the mismatch
between what health professionals are called
upon to do and what they are educated to do
(Blumenthal et al., 2001; Cantor et al., 1993;
Weissman et al., 20014. Indeed, two-thirds of
physicians in a recent study reported that their
training was inadequate to enable them to
coordinate care for patients or educate patients
with chronic conditions (Partnership for
Solutions, 20024. Finally, the health care
industry has identified shortcomings of recent
graduates, stating that an increasing amount of
time and resources must be spent to teach new
professionals the competencies required in
today's workplace (Institute of Medicine, 2000;
National Council for State Boards of Nursing,
2001~. Change is needed at all levels,
including, among others, the culture and values
of educational institutions, the infrastructures in
which professions are educated, curricula and
teaching methods, the standards and guidelines
governing education, the ways in which faculty
are prepared and rewarded, and the leadership in
schools and oversight organizations.
Definitional Issues
To address health professions education, it
is necessary to clarify several key terms. To
this end, the committee established common
descriptions and terms for the key entities and
concepts involved in its work, as described
below.
23
OCR for page 24
HEALTH PROFESSIONS EDUCATION
Health Professions
This report places special emphasis on the
following health professionals: nurses (both
registered and advanced practice), pharmacists,
physician assistants, physicians, and others that
sometime come under the rubric of a1/~1/tied
hea1/tth. However, the observations, conclusions,
and recommendations in this report will be of
value to all health professionals caring for
patients, including, for example, psychologists,
counselors, and social workers. The committee
acknowledges that defining what is meant by
the term added hea1/tth and specifying the
disciplines it encompasses is problematic.
Understandably, many of the disciplines wish to
avoid being categorized under such a catch-all
term. When possible, therefore, this report
refers to health professionals by their specific
names (e.g., occupational therapists or dental
hygienists). In some cases, however, when
brevity is of concern, the committee employs
the term added hea1/tth to refer to the 10 fields
recognized by the IOM's Committee to Study
the Role of Allied Health Personnel (Institute of
Medicine, 1989) as the largest and best known:
clinical laboratory technology, dental services,
dietetic services, emergency medical services,
medical records/health information
management, occupational therapy, physical
therapy, radiological services, respiratory
therapy, and speech-language pathology/
audiology. Yet it must be recognized that these
disciplines vary greatly in the amount and level
of education required, the nature of clinical
involvement, and the ability to practice
independently as opposed to working only
under the direct supervision of others.
Education, Competency, and Oversight
The term education as used in this report
refers to formal efforts to provide information
and experience and develop new skills and
competencies among students or practicing
health professionals. Continuing education
refers to organized educational activities
undertaken by health professionals who have
graduated from their respective degree
programs and are already in professional
practice. Facility comprise the teaching staff
and members of the administrative staff having
academic rank in an educational institution, and
include clinician teachers and residents.
Currently there is no agreed-upon definition
of competency in health professions education.
For the purposes of this report, the committee
defines professional competence as the habitual
and judicious use of communication,
knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice
for the benefit of the individuals and community
being served (Hundert et al., 19964.
Competency-based education refers to
educational programs designed to ensure that
students achieve prespecified levels of
competence in a given field or training activity.
A core competency is the identified knowledge,
ability, or expertise in a specific subject area or
skill set that is shared across the health
professions. In this report, competency denotes
an individual clinician's actual performance in a
specific job function or task, and competencies
or competency areas are skills considered
necessary to perform a specific job or service
(Kelly-Thomas, 19984.
The term oversight processes denotes the
array of mechanisms and rules meant to ensure
that health professionals are properly educated
and competent to practice. It encompasses
accreditation of educational programs serving
health professionals, as well as professional
licensure and certification. The spectrum of
oversight processes can also include
organizational accreditation, which serves to
accredit practice institutions and health plans,
but has some impact on the continuing
competence of practicing professionals as well
through the standards imposed.
Organization of the Report
This report offers a vision of a better-
prepared health workforce and specific
strategies, actions, and related recommendations
for achieving that vision. Specifically, the
report provides:
24
OCR for page 25
~ NTRODUCTION
· Discussion of the challenges facing the
reform of the health system and their
implications for health professions education
(Chapter 24.
· Explication of the core competencies needed
by health professionals to be effective in the
21 st-century health system (Chapter 3~.
· Assessment of the extent to which the
committee's vision is currently addressed by
academic education programs among
selected health professions (Chapter 4~.
· Assessment of the extent to which this vision
is currently addressed by licensure,
accreditation, and certification bodies of
selected health professions (Chapter 5~.
· Recommendations developed by the
committee for the reform of clinical
education (Chapter 6)
The committee's conclusions and
recommendations in these areas are presented in
the respective chapters, highlighted in bold
print. The appendices contain more-detailed
information about the summit, a list of
participants, and strategies and actions proposed
by summit participants. It was not possible to
present the over 200 actions identified by the
summit participants in the report, but those at
the national level and a small number at the
institutional level are included.
References
Belfield, C., H. Thomas, A. Bullock, R. Eynon, and
D. Wall. 2001. Measuring effectiveness for
best evidence medical education: A discussion.
Medical Teacher 23 (24: 164-70.
Bellack, J.P., end E.H. O'Neil. 2000. Recreating
nursing practice for a new century:
Recommendations and implications of the PEW
health professions commissions final report.
Nursing&Health Care Perspectives 21 (1~:14-
21.
Blendon, R.J., C. Schoen, K. Donelan, R. Osborn, C.
M. DesRoches, K. Scoles, K. Davis, K. Binns,
and K. Zapert. 2001. Physicians views on
quality of care: A five-country comparison.
Health Affairs 20 (3~:233-43.
Blumenthal, D., M. Gokhale, E.G. Campbell, and J.
S.Weissman. 2001. Preparedness for clinical
practice: Reports of graduating residents at
academic health centers. Journal of the
American Medical Association 286 (9~: 1027-
34.
Cantor, J.C., L.C. Baker, and R.G. Hughes. 1993.
Preparedness for practice. Young physicians
views of their professional education. JAMS
270 (94:1035-40.
Chassin, M.R. 1998. Is health care ready for Six
Sigma quality? Milbank Quarterly 76~4~:565-
91, 510.
Christakis, N.A. 1995. The similarity and frequency
of proposals to reform U.S. medical education:
Constant concerns. Journal of American
MedicalAssociation 274~94:706-11.
Cooper, H., C. Carlisle, T. Gibbs, and C. Watkins.
2001. Developing an evidence base for
interdisciplinary learning: A systematic review.
JournalofAdvancedNursing 35~2~:228-37.
Council on Graduate Medical Education. 1999.
Physician Education for a Changing Health
Care Environment. Rockville, MD: Health
Resources and Services Administration.
Counsell, S., R. Kennedy, P. Szwabo, N.
Wadsworth, and C. Wohlgemuth. 1999.
Curriculum recommendations for resident
. . . . . . . . .
tra~n~ng ~n genatr~cs ~nterd~sc~pl~nary team care.
Journal of the American Geriatrics Society 47
(9~:1145-48.
Depardnent of Health and Human Services, Health
Resources and Services Administration, Bureau
of Primary Health Care. 1998. Health Center
Program Expectations. Bureau of Primary
Health Care Policy Information Notice: 98-23.
Enarson, C., and F.D. Burg. 1992. An overview of
reform initiatives in medical education. 1906
through 1992. [Review] [22 refs]. Journal of
American Medical Association 268 (9~: 1141 -
43.
Furze, G. and P. Pearcey. 1999. Continuing
education in nursing: a review of the literature.
Journal of Advanced Nursing 29 (2)
Halpern, R., M.Y. Lee, P.R. Boulter, and R.R.
Phillips. 2001. A synthesis of nine major
reports on physicians competencies for the
emerging practice environment. Academic
Medicine 76 (64:606-15.
25
OCR for page 26
HEALTH PROFESSIONS EDUCATION
Harmening, D.M. 1999. "Pioneering Allied Health
Clinical Education Reform. A National
Consensus Conference." Online. Available at
Up ://ftp.hrsa. gov/bhpr/publications/cerpdf.pdf
[accessed Aug., 20023.
Hart, L.G., E. Salsberg, D.M. Phillips, and D.M.
Lishner. 2002. Ruralhealth care providers in
the United States. Journal of Rural Health 18
Suppl:211-32.
Hegge, M. 1995. Restructuring registered nurse
curricula. [Review] [41 refs]. Nurse Educator
20 (6):39-44.
Hundert, E.M., F. Hafferty, and D. Christakis.
1996. Characteristics of the informal curriculum
and trainees ethical choices. Academic
Medicine 71 (64:624-42.
Hyde, R.S., and J.M. Vermillion. 1996. Driving
qualify through Hoshin planning. Joint
Commission Journal on Quality Improvement
22 (14:27-35.
Institute of Medicine. 1989. Allied Health Services
Avoiding Crises. Washington, DC: National
Academy Press.
2000. To Err Is Human: Building a Safer
Health System. Linda T. Kohn, Janet M.
Corrigan, and Molla S. Donaldson, eds.
Washington, DC: National Academy Press.
. 2001. Crossing the Quality Chasm: A New
Health System for the 21st Century.
Washington, DC: National Academy Press.
Jordan, S. 2000. Educationalinput and patient
outcomes: Exploring the gap. Journal of
Advanced Nursing 31 (24:461-71.
Kaiser Family Foundation and Agency for
Healthcare Research and Quality. 2000.
"National Survey on Americans as Health Care
Consumers: An Update on the Role of Quality
Information." Online. Available at http://www.
kff.org/content/2000/3093/AHRQToplines.pdf
[accessed Oct. 14, 20023.
Kelly-Thomas, K. 1998. Clincial and Nursing Staff
Development. Philadelphia, PA: Lippincott.
Long, K.A. 1994. Masters degree nursing education
and health care reform: Preparing for the future.
Journal of Professional Nursing 10 (24:71 -6.
Ludmerer, K. 1999. Time to Heal: American
Medical Education from the Turn of the Century
to the Era of Managed Care. New York, NY:
26
Oxford University Press.
Mennin, S., and S.P. Kalishman. 1998. Issues and
strategies for reform in medical education:
Lessons from eight medical schools. Academic
Medicine (Supplement) 73 (9)
Murray, E., L. Gruppen, P. Catton, R. Hays, and J.O.
Woolliscroft. 2000. The accountability of
clinical education: Its definition and assessment.
Medical Education 34 (10~:871-79.
National Council for State Boards of Nursing. 2001.
Report of Findings from the 2001 Employers
Survey. Chicago, IL: National Council for State
Boards of Nursing.
OBrien, T., N. Freemantle, A.D. Oxman, F. Wolf, D.
A. Davis, and J. Herrin. 2001. Continuing
education meetings and workshops: Effects on
professional practice and health care outcomes.
Cochrane Database System Review (2~:
CD003030.
ONeil, E. H. and the Pew Health Professions
Commission. 1998. Recreating health
professionalpractice for a new century - The
fourth report of the PEW health professions
Commission. San Francisco, CA: Pew Health
Professions Commission.
Partnership for Solutions. 2002. "Physician
Concerns: Caring for People with Chronic
Conditions." Online. Available at http://www.
partnershipborsolutions. org/pdf_files/2002/
physicianccern.pdf [accessed Oct. 8, 20023.
Platt, D., and C. Laird. 1995. CQI: Using the
Ho shin planning system to design an orientation
process. Radiology Management 17 (24:42-50.
President's Advisory Commission on Consumer
Protection and Quality in the Health Care
Industry. 1998. "Quality First: Better Health
Care for All Americans." Online. Available at
http://www.hcqualitycommission.gov/final/
[accessed Sept. 9, 20003.
Regan-Smith, M.G. 1998. "Reform without
change": update, 1998. Academic Medicine 73
(54:505-7.
Rivo, M.L., J. Debbie M., and C.F. Lawrence. 1993.
Comparing physician workforce reform
recommendations. JournalofAmerican
Medical Association 270 (9~: 1083-84.
Schuster, M.A., E.A. McGlynn, and R.H. Brook.
1998. How good is the quality of health care in
OCR for page 27
~ NTRODUCTION
the United States? Milbank Quarterly 76
(4~:517-63, 509.
Sochalski, J. 2002. Nursing shortage redux:
Turning the corner on an enduring problem.
Health Affairs 2 1 (5~: 1 57-64.
Weissman, J.S., E.G. Campbell, M. Gokhale, and D.
Blumenthal. 2001. Residents preferences and
preparation for caring for underserved
populations. Journal of Urban Health 78
(34:535-49.
Wirthlin Worldwide. 2001 . "Pursing Perfection--
Research Conducted for the Robert Wood
Johnson Foundation." Online. Available at
h t t p : I I w w w . i h i . o r g / p u r s u i n g p e r f e c t i o n / n e w s /
PP_Researchslides.ppt [accessed Oct. 14, 20023.
Wu, S., and A. Green. 2000. Projection of Chronic
Illness Prevalence and Cost Inflation.
California: RAND Health.
27
OCR for page 28
Representative terms from entire chapter:
health professionals
