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the performance of PROs to date in detecting and addressing quality problems, it is helpful to keep in mind the relatively early stage of PRO activities in this area. Unfortunately, PROs too often have directed their attention primarily to utilization and cost containment rather than quality assurance. Therefore, we are pleased that quality review is becoming a more important focus of PROs, and we need to recognize that many of the techniques to identify cases of possible quality problems are still in their infancy.

Providing quality medical care is an enormously complex process in which many subjective as well as objective issues must be considered. For example, is there medical certainty in the relevant clinical area? What treatment options are available? What technology or specialized facilities are available? What are the patients expectations and are those expectations reasonable? What quality-of-life issues should be considered? What other factors should be integrated in the individual treatment decision? Although some of these issues can be quantified, many cannot.

In essence I am saying that there are precious few all black and all white decisions that are made. There are, instead, a great many gray decisions that have to be made.

We agree that ongoing research is essential to identify and improve techniques to collect and analyze data. Yet the limitations inherent in data analysis must be kept in mind. Data analysis will be an important adjunct to, rather than a substitute for, clinical judgment. Improved data and more sophisticated data analysis will be useful to quality assurance activities. However, the data will never substitute for clinical judgment or true medical peer review. Physicians must continue to have the flexibility to tailor medical care to meet individual patient needs.

PRACTICE PARAMETERS

I would like particularly to commend the IOM's report for its emphasis on the role of practice parameters in improving quality and assuring appropriate utilization. Physician organizations have played a key role in the development of such practice parameters. Eight physician organizations had already developed certain practice parameters by 1980. Recently I heard an economist in another city discussing practice parameters, and he was recommending to a group of physicians that they really ought to use them. He presented the subject almost as though economists had invented practice parameters. At this time in 1990, 26 physician organizations have developed useful parameters, and at least 10 additional organizations of physicians are actively engaged in the development of other practice parameters.

Effective practice parameters are an important mechanism to improve quality. For example, the parameters for cardiac pacemaker implantation



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