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Effectiveness Initiative Setting Priorities for Clinical Conditions Report of a Smby by a Committee of tile INSTITUTE OF MEDICINE Division of Heals Care Services National Academy Press Washington, D.C. 1989

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NOTICE: The project Cat is the subject of this report was approved by He Governing Board of He National Research Council, whose members are drawn from the councils of He National Academy of Sciences, He National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and win regard for appropriate balance. The report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the heal of the public. In ~is, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This workshop was supported by He Health Care Financing Administration, U.S. Department of Heath and Human Services, under Purchase Order Nos. HCFA-89-00 12 and HCFA-89-00 15. 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Publication IOM-89-04 Printed in He United States of America

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INSTITUTE OF MEDICINE Division of Health Care Services HCFA Effectiveness Initiative Clinical Workshop KENNETH I. SHINE, Chair, Dean, UCLA School of Medicine, Los Angeles, Californua I. CLAUDE BENNETT, Professor and Chairman, Department of Medicine, The University of Alabama School of Medicine, Birmingham, Alabama CHRISTINE CASSELL, Chief, Section of General Internal Medicine, University of Chicago, Chicago, TIlinois THOMAS C. CHALMERS, Distinguished Physician, Boston VA Medical Center; President and Dean Emeritus, Mt. Sinai Medical Center, Harvard School of Public Health, Boston, Massachusetts lAMESON L. CHASSIN, Director, Department of Surgery, Booth Memorial Medical Center, Flushing, New York RONALD G. EVENS, Elizabeth Mallinckro~t Professor and Head, Radiology Department, Washington University School of Medicine; Director, Mallinckrodt Institute of Radiology, St. Louis, Missouri WALTER F. LEAVELL, President, Charles Drew University of Medicine and Science, Los Angeles, California DAVID G. MURRAY, Professor, Department of Orthopedic Surgery, SUNY Health Services Center at Syracuse, New York ALAN R. NELSON, Associate, Memorial Medical Center, Salt Lake City, Utah PAUL S. RUSSELL, John Homans Professor of Surgery, Harvard Medical School; Visiting Surgeon and Chief, Transplantation Unit, Massachusetts General Hospital, Boston, Massachusetts G. RICHARD SMITH, Associate Professor of Psychiatry and Medicine, Department of Psychiatry, University of Arkansas for the Medical Sciences, Little Rock, Arkansas HAROLD C. SOX, JR., Professor and Chairman, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire GEORGE E. THIBAULT, Associate Chief of Medicine, Massachusetts General Hospital, Boston, Massachusetts SAMUEL O. THIER, President, Institute of Medicine, National Academy of Sciences, Washington, D.C. ~

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INSTITUTE OF MEDICINE SAMUEL O. THIER, Deadest STUDY see K^^ D. YoRDY Director Dlv~lon of Heals Care Sedges K~^EEN N. LOHR, Senior Visional Assoclam RICHARD ^. ^0IG, Senior Stag Officer COME ROBERTBERENSON, pdva~ Practice of internal medicine, ~shingmn, D.C. 1V