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REPORT OF A STUDY Health Services Research NAT1ONAE ACADEMY of SCIENCES Washington, D.C. 1979

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NOTICE This is the report of a project undertaken with the approval of the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the' Institute of Medicine. The members of the committee appointed to conduct the project and prepare the report were selected for recognized competence and with due consideration for the balance of disciplines appropriate to the project. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee con- sisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Supported by a contract from the Office of Science and Technology Policy, Executive Office of the President of the United States. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of medical and other pro- fessions for the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 Congressional charter responsibility to be an advisor to the Federal Government, and its own initiative in identifying issues of medical care, research, and education. IOM Publication 78-06 Library of Congress Catalog Card Number 79-84281 International Standard Book Number 0-309-02875-2 Available from Office of Publications National Academy of Sciences 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America

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INSTITUTE OF MEDICINE COMMITTEE ON HEALTH SERVICES RESEARCH Chairman Robert H. EBERT, M.D., President, Milbank Memorial Fund, New York Members . Leonard W. CRONKHITE, Jr., M.D., President, The Medical College of Wisconsin, Milwaukee Robert L. EICHHORN, Ph.D., Professor of Sociology and Director of the Health Services Research Program, Purdue University, Lafayette Scott FLEMING, Senior Vice President, Kaiser Plan Medical Care Program, Oakland Jacob GETSON, Assistant Commissioner, Department of Public Health, Boston Jay GOLDMAN, D.Sc., Professor and Chairman, Department of Industrial Engineering, University of Missouri-Columbia, Columbia Robert J. HAGGERTY, M.D., Director, General Pediatrics Academic Develop- ment Program, Robert Wood Johnson Foundation, Children's Hospital Medical Center, Boston James G. HAUGHTON, M.D., Executive Director, Health and Hospitals Govern- ing Commission of Cook County, Chicago Barbara S. HULKA, M.D., Professor, Department of Epidemiology, University of North Carolina at Chapel Hill, North Carolina Herbert E. KLARMAN, Ph.D., Professor of Economics, Graduate School of Public Administration, New York University, New York Paul A. MARKS, M.D., Vice President for Health Sciences and Professor of Human Genetics and Development, Columbia University, New York David MECHANIC, Ph.D., Professor of Sociology, University of Wisconsin, Madison e -

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Frederick MOSTELLER, Ph.D., Professor of Mathematical Statistics and Chairman, Department of Biostatistics, Harvard University, Boston Alan R. NELSON, M.D., Internist, Salt Lake City Daniel W. PETTENGILL, West Hartford, Connecticut Donald C. RIEDEL, Ph.D, Professor and Chairman, Department of Health Services, University of Washington, Seattle Kerr L. WHITE, M.D., Deputy Director, Division of Health Sciences, Rockefeller Foundation, New York iv

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INSTITUTE OF MEDICINE DAVID A. HAMBURG, M.D., President Division of Health Care Services STUDY OF HEALTH SERVICES RESEARCH Staff Thomas W. BICE, Ph.D., Study Director, Deputy Director, Institute for Health Care Studies, United Hospital Fund of New York, New York* Linda K. DEMLO, Ph.D., Director, Division of Health Care Services, Institute of Medicine, National Academy of Sciences, Washington, D.C. Barbara BUCKLEY, Administrative Secretary, Institute of Medicine, National Academy of Sciences, Washington, D.C. Paul CAMPBELL, M.S., Professional Associate, Institute of Medicine, National Academy of Sciences, Washington, D.C. Peter E. DANS, M.D., Senior Professional Associate, Institute of Medicine, National Academy of Sciences, Washington, D.C. Richard M. SCHEFFLER, Ph.D., Director, Division of Health Manpower and Resources Development, Institute of Medicine, National Academy of Sciences, Washington, D.C. Wallace K. WATERFALL, Director, Office of Communications, Institute of Medicine, National Academy of Sciences, Washington, D.C. Karen WINTRINGHAM, M.H.A., Research Assistant, Institute for Health Cars Studies, United Hospital Fund of New York, New York *Currently Professor, Department of Health Services, University of Washington, Seattle v

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