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Critical Factors in the Discussion of Clinical Conditions In recommending clinical problem areas for further investigation, we considered the factors listed below. We also assumed that these criteria will be used during further refinement of the list of clinical conditions and selection of specific conditions: high prevalence of We illness in the elderly population andJor in particular subgroups of the elderly; 2. burden of the illness on We elderly, characterized by, for instance, whether it is life-threatening, likely to produce major impairment and disability, or likely to pose a serious decrement to We person's health, well-being, and independence; 3. substantial variation across geographic areas in We per-person use of services for the condition (i.e., variation beyond that explained by differences in patient characteristics or health resources in the areas); 4. substantial variation across geographic areas or institutions in the outcomes of care for We condition (i.e.. variation beyond that explained by the differences in We severity of illness or sociodemographic characteristics of patients); 5. relatively high costs (to the Medicare program l) of reimbursing for the services provided to patients to diagnose and treat the condition; 6. alternative strategies for managing the care of patients with We condition that are in dispute or reflect professional and clinical uncertainty; and 7. reasonable availability of data to address key effectiveness ques- tions, either through HCFA's existing (or anticipated) administrative files or through special studies, surveys, and patient follow-up activities. 10

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11 In addition, we believe that three other areas of concern should receive attention in the Effectiveness Initiative: screening and prevention of illness; the mental and emotional dimensions (anxiety and depression; cognitive functioning) of any illnesses selected for in-depth study; and clarification of the differences between efficacy and electiveness. We are especially concerned that special attention be given to the generation and use of reliable and valid outcome measures that relate to functional status and quality of life. Furthermore, we want to stress the importance of contributions that specific studies on particular kinds of illnesses can provide as prototypes for ways to examine other problems. Thus, we have sought to identify acute illnesses, chronic diseases, and ailments treated by surgery or over proce- dures that could be considered relatively "clear-cut" i.e., readily identif~- able, with straightforward etiologies, relative homogeneity of diagnosis, and clear clinical endpoints. The committee also emphasizes the impor- tance of selecting at least one condition or problem area about which greater ambiguity exists in terms of the ease of defining the condition or specifying the etiology. Hence, we recommend selecting one problem area with heterogeneity of diagnosis and less clear endpoints.