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Medicare: A Strategy for Quality Assurance - Volume I
Nursing Quality Assurance, are devoted to operational and management aspects of quality of care. Despite these targeted publications, this quality assurance work tends to be scattered over a wide array of clinical, management, evaluation, and health services research publications. Thus, tracking the knowledge base is a very difficult task.
In the spring of 1988, two leading journals published special issues on quality of care (Health Affairs, 1988; Inquiry, 1988). Several subjects have become especially topical: (1) measurement of patient outcomes and health status; (2) the impact of Medicare’s Prospective Payment System (PPS) and other financing schemes on quality of care (Heinen et al., 1988; ProPAC, 1989; PPRC, 1989); (3) the extraordinary and unexplained variations in population-based rates of use of services across like geographic areas (Chassin et al., 1986; Schroeder, 1987; Brook et al., 1989); and (4) appropriateness of diagnostic and therapeutic procedures and ways to feed information on utilization back to clinicians in those geographic areas.3
Several federal agencies support work in quality assessment and assurance. The National Center for Health Services Research (NCHSR) has funded quality assessment studies for two decades (Brook and Lohr, 1985; Komaroff, 1985). NCHSR has also supported work in many related areas, such as patient and provider relations (Becker, 1985; Inui and Carter, 1985), health information systems (Pryor et al., 1985; Steinwachs, 1985), and clinical decision making (Doubilet and McNeil, 1985). With the new Agency for Health Care Policy and Research (AHCPR), especially its Medical Treatment Effectiveness Program, these efforts can be expected to grow.
The Health Care Financing Administration (HCFA) Office of Research and Demonstrations (ORD) supports nearly 300 research, evaluation, and demonstration projects on many health services and health policy topics relating to Medicare and Medicaid (ORD, 1988). The major focus is the relationship of Medicare program expenditures to reimbursement, coverage, eligibility, and management, but some studies examine the impact of the Medicare program on beneficiary health status, access to services, and use of services. As of 1988, for instance, HCFA was sponsoring about two dozen projects related directly or indirectly to quality of care (ORD, 1988), and the agency had proposed an “effectiveness initiative” to study and document the effectiveness of medical interventions of particular concern to the Medicare program (Roper and Hackbarth, 1988; Roper et al., 1988; IOM, 1989). HCFA’s Health Standards and Quality Bureau (HSQB) and the Peer Review Organizations (PROs) are embarking on pilot projects related to assessing quality of care delivered to Medicare enrollees. HSQB also oversees the development of a Uniform Needs Assessment Instrument for evaluating the needs of Medicare patients for posthospital care. Finally, the American Medical Review Research Center (AMRRC, a PRO membership organization) is conducting a small area variations study that will compare