Smoking is a significant underlying risk factor for many adverse health conditions (McGinnis and Foege, 1993). Physicians and many other individuals and organizations in the community can influence individuals' smoking behavior.

Social Environment

The excess capacity of the U.S. hospital system is well recognized, but the challenges of downsizing are substantial. A barrier to reallocation of resources from acute care to other sectors is the widespread assumption that greater levels of investment in health care are beneficial. The evidence of benefit from greater spending on personal health care is limited (Bunker et al., 1995), and there is some evidence to the contrary (Guadagnoli et al., 1995). The prevalence of this assumption is difficult to measure directly. However, the media portrayal of health care and public health services represents a potential construct for examining social assumptions regarding the value of health care spending. The data are not currently available.

Physical Environment

The physical environment of health care may provide some evidence of inefficiency. Two examples considered by the committee focus on regionalization. Substantial evidence documents the improved outcomes and lower costs that are achieved when patients receive coronary artery bypass graft surgery in high-volume regional centers (Luft et al., 1990; Hannan et al., 1991). Similarly, because most high-risk deliveries should be identified before birth, inadequate regionalization of high-risk obstetrical care can be identified by the number of low birth weight infants born in centers without appropriate facilities to handle them.

Communities may want to examine the number of avoidable hospitalizations by measuring ambulatory care sensitive (ACS) hospitalizations, an indirect measure of underutilization of outpatient services and poor primary care management (IOM, 1993). Studies correlating ACS hospitalizations with other factors are complex, but a raw count of inpatient hospitalizations for conditions that are known to be manageable in an outpatient setting (e.g., diabetes, asthma) might be adequate for communities. Data may be available through HEDIS and through state comprehensive hospital discharge databases (e.g., the Washington State Commission Hospital Abstract Reporting System), where available.

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