feedback to providers. We propose a program that generates new knowledge from clinical practice and that returns that information to providers in a timely way that improves clinical decision making.

Although any quality assurance program must be concerned with individual providers and specific incidents of care, as is presently the case, we believe that the future program must place stronger emphasis on systems of care, the joint production of services by many different providers, and continuity and episodes of care. The Medicare peer review programs have traditionally focused on hospital inpatient care and have been able to do little or nothing with ambulatory, office-based care or care in other nonhospital settings. We thus see a need for a major thrust toward quality assurance in all major settings in which the elderly receive care. Quality assurance in those settings is important in its own right, but it also is necessary if patient outcomes and episodes of care are to become significant components of this new program.

A major deficiency of the present program, in our view, is the lack of evaluation and public oversight. It is virtually impossible to know what the nation is getting for the Medicare resources presently devoted to the peer review program or to know which parts of that program are successful and which are not. In our reformulation, therefore, we place considerable em-