Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety.

Policy changes in the mid-1990s sent veterans to outpatient facilities for treatment, mirroring trends in the overall U.S. health care system.

Substance use disorders are a major problem among the nation's veterans. The U.S. Department of Veterans Affairs(VA), which provides health care to more than three million veterans, is the nation's largest provider of substance abuse treatment. The VA trains large numbers of physicians and other mental health professionals; it plays an important role in defining standards of mental health care in the United States.

In the past decade several initiatives have transformed the VA. These policies were inspired by changing views about the role and size of government and by growing use of managed care. This paper considers the effect of these changes on specialized VA programs for substance abuse treatment.

The growth of managed care has prompted numerous questions about its effect on the quality of health care. This paper reviews evidence on the effects of managed care on quality. Most comparisons of care for patients in different plans within similar markets suggest that there is little systematic difference in quality between HMOs and other managed care plans and non-managed-care plans. However, these studies may ignore important effects of managed care on the structure and functioning of the health care system that would be evident only across markets. We suggest that these effects could be important and provide evidence from an analysis of treatment patterns for cancer patients. We conclude by describing how more careful attention to the empirical evidence on the effects of managed care could improve current policy debates about managed care regulation.

Sara J. Singer, Alan M. Garber,and Alain C. Enthoven have designed a comprehensive, new approach for expanding access to health insurance. The proposal is built on the following key elements:

THE PLAN WOULD PROVIDE near-universal coverage by making private plans more affordable and helping low- and middle-income people buy coverage. This would be accomplished though tax credits and by creating “insurance exchanges” that would provide health insurance choices and promote competition among health plans.

INSURANCE EXCHANGES WOULD BE OPERATED by public or private entities or employers (for their own employees). Exchanges would offer individuals a choice of at least two health plans in every geographic region at community- rated premiums. The “U.S. Insurance Exchange”would be established to serve individuals and companies with fewer than 50 employees in areas where private exchanges do not emerge. Coverage purchased through exchanges would be exempt from state small-group reform laws and insurance mandates.

LOW- AND MIDDLE-INCOME AMERICANS who purchase insurance through an exchange would receive refundable tax credits valued at 70 percent of the median-cost plan. The credits would apply only for coverage purchased through the exchanges. Eligible low-income individuals who did not enroll in a health plan would be automatically enrolled in a federally funded default plan organized by the state. Other individuals would continue to exclude from taxable income their individual or employer-paid health insurance contributions, but a phased-in cap would limit this exclusion.

A NEW “INSURANCE EXCHANGE COMMISSION” would be created. It would be similar to the Securities and Exchange Commission—having authority to distribute tax credits and default payments, accredit insurance exchanges, risk-adjust premiums across insurance exchanges, and serve as an information clearinghouse for consumers.

Healthcare quality has received heightened attention over the last decade, leading to a growing demand by providers, payers, policymakers, and patients for information on quality of care to help guide their decisions and efforts to improve health care delivery. At the same time, progress in electronic data collection and storage has enhanced opportunities to provide data related to health care quality. In 1989, the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality, AHRQ) initiated the Healthcare Cost and Utilization Project (HCUP). HCUP is an ongoing federal-state-private collaboration to build uniform databases from administrative hospital-based data collected by state data organizations and hospital associations.

The HCUP quality indicator set, developed in 1994, and hereafter referred to as HCUP I, consists of 33 measures, constructed using administrative data available in the NIS. Included in the set are indicators of utilization of procedures, ambulatory care sensitive condition admissions, post-operative and other complications, and mortality.

Since the original HCUP QI development work in 1994, numerous managed care organizations, state Medicaid agencies and hospital associations, quality improvement organizations, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the National Committee on Quality Assurance (NCQA), academic researchers and others have contributed substantially to the knowledge base of hospital quality indicators. Based on input from current users and advances to the scientific base for specific indicators, AHRQ decided to fund a research project to refine and further develop the HCUP QIs.

As a result, AHRQ charged the UCSF-Stanford Evidence-based Practice Center (EPC) to revisit the initial 33 indicator set (HCUP I QIs), evaluate their effectiveness as indicators, identify potential new indicators, and ultimately propose a revised set of indicators. This report documents the evidence project to develop recommendations for improvements to the HCUP I indicators.

Although technological change is a hallmark of health care worldwide, relatively little evidence exists on whether changes in health care differ across the very different health care systems of developed countries. We present new comparative evidence on heart attack care in seventeen countries showing that technological change--changes in medical treatments that affect the quality and cost of care--is universal but has differed greatly around the world. Differences in treatment rates are greatest for costly medical technologies, where strict financing limits and other policies to restrict adoption of intensive technologies have been associated with divergences in medical practices over time. Countries appear to differ systematically in the time at which intensive cardiac procedures began to be widely used and in the rate of growth of the procedures. The differences appear to be related to economic and regulatory incentives of the health care systems and may have important economic and health consequences.