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Evidence-based principles of discharge and discharge criteria

Note: This is a revised version of the report presented at the 1996 AMA Annual Meeting.

Full text

We live in a time of controversy and dispute regarding the provision, cost, and management of medical care. Soaring costs of health care and the need for fiscal restraints make economic considerations a factor in clinical decisions, creating tension among stakeholders in the health care environment. Dissension exists among the patients who are claiming insufficient services for their needs; third party payers such as the federal government, private insurers and health plans; and physicians who must balance the consequences for the patient and the need for cost-containment.

Objective

Concerned that the current trends in the use of pre-determined length-of-stay criteria for patient discharge were moving away from scientific, patient-focused principles of care, potentially resulting in poorer patient outcomes, the Council on Scientific Affairs (CSA) sought to develop the concept and principles of an organized, evidence-based discharge process for determining when patients may be safely discharged from a hospital.

Methods

For 1985 through June 1996, a comprehensive search of the medical literature was conducted using MEDLINE, HealthSTAR, and CINAHL databases. The business, insurance, and legal literature was searched using the Lexis/Nexis files INSURE, ABI, LEXREF, and LEGNEW. Key words used included  patient discharge, discharge planning, discharge criteria, length of stay, severity of illness, utilization review, and  medical ethics. Information also was obtained from government and independent agencies such as the Health Care Financing Administration, the Picker Institute, and the RAND Corporation. Over 600 English-language articles were identified. 

One member of the CSA ad hoc committee assumed primary responsibility for abstract review, and identified 231 documents specifically related to the discharge process and discharge criteria. Articles that appeared in peer-reviewed journals or in the national press, recording timely aspects of the subject, were selected. Articles that were too narrow in scope, addressed only location-specific projects, or that exactly duplicated other works were eliminated. A total of 65 documents were provided to the committee as background information. (A full set of references is available, upon request).

Participants and consensus process

The CSA ad hoc committee consisted of practicing physicians and other health care professionals representing academic medicine, nursing, social work, medical and health services research, managed care organizations, insurance plans, the Health Care Financing Administration, and the Joint Commission on Accreditation of Healthcare Organizations (see list of ad hoc committee members at the end of this report). The committee reviewed the experiences and perceptions of the public, practicing physicians, and scientific researchers. Small group discussion identified and prioritized items of concern, which were later brought to the whole group for further discussion. A modified Delphi process was used to arrive at consensus.

This report of the Council on Scientific Affairs is based on the background information used by the ad hoc committee, the observations and conclusions of the ad hoc committee, and the deliberations and recommendations of the Council on Scientific Affairs.

Evidence

Although there is strong and consistent evidence in the scientific literature that patients are being discharged "quicker"1-5 and some evidence that they are "sicker" or unstable at the time of discharge,6-10  the studies are inconclusive in regard to the outcomes of the abbreviated hospital care and whether patients are harmed by the process. A series of studies conducted by the RAND Corporation (based on a sample of 16,758 Medicare patients in 5 states), comparing patients hospitalized before and after the imposition of the financial restraints of the prospective payment system, found from chart review that there was an increase in inpatient quality of care, while at the same time patients were more unstable at the time of discharge. Although 30-day mortality was lower,5,11 instability at discharge predicted a greater likelihood of post-discharge death.12 A critical review of prior studies on the effects of early discharge for newborns found a variety of limitations (methodology, restricted circumstances, inadequate sample size) that impaired the researchers' ability to conclusively judge the safety of early discharge.13

Concurrent with the scientific debate in the peer-reviewed journals, there has been a public debate in the popular press, in state and federal legislatures, and in the courts.14  The debate on the length of hospitalization for mothers and newborns,13,15  and the perceived inadequate amount of care and the limits imposed by health insurance coverage,16 have been a lightning rod for the larger debate over who makes medical decisions, culminating in both federal and state legislation. At the federal level, P.L. 104-204 Title VI, the Newbornsand Mothers Health Protection Act of 1996, was passed to establish requirements for minimum length of hospital stay for both mother and infant following delivery.17 The legislation, effective January 1, 1998, is intended to return the discharge timing decision-making process to the practitioner and the family. Additionally, approximately 30 states have passed legislation on postpartum length of stay.

The Picker Institute and the American Hospital Association documented public perceptions of health care and hospitals by analyzing focus groups and surveys of over 37,000 patients from 120 hospitals in 1996.18 Their report reveals important problems with patients' experiences of the way the "system" works (or fails to work) and the way decisions about patient care are made, as well as concerns about reduced access to care and higher out-of-pocket costs. Many patients reported feeling "abandoned" when they were released from the hospital. Almost one third complained that they were not well prepared to go home and were not told about "danger signals" to watch for after they went home. Thirty percent of those surveyed reported they were not told about medication side effects, and 37% reported they received no instruction on when they could resume normal activities. 

The current outcry from the public results in part from awareness of the shifted burden of cost and services from the insurers to patients and their families.19 Current public perception is that patients are being harmed by these changes in health care delivery.14,20

While patients and their supporters are lobbying for longer hospital stays, third party payers are responding to other public pressures to control costs, primarily through reducing hospital stays. One successful strategy growing out of the utilization review process has been to establish predetermined guidelines for length of stay. The utilization review management position is that these performance targets are "only guidelines" that must be flexible and based on clinical judgment as to the actual patient's needs, and that they should not be considered "ceilings."21 Physicians complain to utilization reviewers that if the length-of-stay guidelines are the "norms," then their patients must be sicker than the norm.22 Physicians whose patients have longer lengths of stay may then be counseled that they must learn to treat their patients more efficiently to reduce hospital length of stay.22 However, physicians are often unfamiliar with the clinical criteria used by the utilization management organizations as the basis for denial of care in an individual situation. 

The American Accreditation HealthCare Commission (also known as URAC) sets accreditation standards for health utilization management organizations. The standards for review determinations require that the attending physician be notified of the utilization decision by telephone within one business day; written notification must also be sent within one business day. The notification must include the "principal" reasons for denial and a statement that "the clinical rationale used in making the determination shall be provided in writing, upon request." In these situations, if physicians want the "clinical rationale," they must make a separate request after receiving the initial denial. There is no timeframe set for delivering the "clinical rationale."23

Utilization management organizations have not had to prove that their length-of-stay targets lead to practices that are safer or yield better clinical outcomes. Their systems are primarily proprietary, and the logic of their measures and statistical methodologies are generally hidden to protect the financial interests of the vendors, so there is little objective comparative information.24 Instead, it has been left to researchers to determine after the fact if abbreviated hospital services harm patients.

The widespread use of utilization management methodologies such as length-of-stay guidelines25 has cut the costs of care for third party payers. Whereas 10 years ago it was commonly assumed that there would be 1000 hospital bed days utilized per every 1000 covered members per year, there are current reports of utilization of less than 300 bed days per 1000 covered members.26

Milliman and Robertson, Inc. (M&R) is an organization that has been at the forefront of health care change with its Optimal Recovery Guidelines (ORG) that have been widely used in the effort to reduce hospital costs and utilization, by eliminating "unnecessary" hospital days. "Unnecessary" days (as defined by payers) are days in which the patient is no longer so ill as to need the resources of the hospital and could be cared for in a less expensive environment (subacute, skilled nursing facility, outpatient, home).22,27  The Milliman and Robertson Optimal Recovery Guidelines (M&R ORG) were developed by a panel of physician consultants as idealized "best practices" for uncomplicated cases, and are not based on actuarial data.21 The actual lengths of stay per diagnosis targeted for these guidelines fall within the top tenth percentile (ie, the decile with the shortest lengths of stay) of the average length of stay of the Western Region of the United States (which traditionally has shorter lengths of stay than other areas of the country).28 In other words, 90% of patients handled by traditional practices would exceed the length of stay recommended by the M&R ORGs. The M&R premise is that there should be only limited variation in the treatment patterns of resources used and interventions performed on the generic uncomplicated "best patient."29 The ORGs are not based on patient-specific physiological data that could explain or justify the appropriateness of those interventions. 

The profile of the generic, uncomplicated "best patient" does not adequately describe the range of individual patients cared for by physicians. Different systems have been developed to collect "hard data" on physiological variables that could explain the patient's need for medical interventions and resource use. Most of them, such as the APACHE (Acute Physiology and Chronic Health Evaluation30), the AEP (Appropriateness Evaluation Protocol31), the TISS (Therapeutic Intervention Society System32), the SAPSII (New Simplified Acute Physiology Score33), and the ISD Criteria34 (Intensity of service, Severity of Illness and Discharge Criteria) are specific for only one setting and do not bridge both the pre- and post-discharge settings. Moreover, they generally do not cover psychological, social and functional areas, which are important in any discussion of post-hospital care. While also appropriate for only one setting, the Ambulatory Severity Index addresses psychosocial and functional issues.35

The goal of physicians and managers who use clinically based severity-of-illness measures is to accurately capture each patient's condition so that predictions about the need for care (and therefore the appropriate setting and resource use), and the prognosis (and therefore the appropriate outcome of care by which to judge the quality and effectiveness of the care provided) can be made in a reliable and verifiable fashion. The different severity measure systems currently in use are not necessarily compatible or interchangeable. Researchers using the same case studies to compare 2 different severity systems found in their first model that Medicare patients had worse outcomes than expected and that Medicaid patients did substantially better, while in the second model, Medicare patients achieved their expected outcomes, but Medicaid patients fared less well.36

In spite of their limitations, clinical severity-of-illness measures attempt to draw an accurate picture of the physiological condition of the individual patient. The relationship between the identified severity of illness and the actual length of stay in the hospital is not clear. Some researchers have found no correlation between severity of illness and length of stay,37  while others determined that measures rating severity of illness and difficulty of clinical management are correlated and explain variations in length of stay.38 Fluctuating measurements (instabilities) are also a predictor of increased length of stay.38 The importance of instability, or fluctuations in the patient's physiological condition during the hospital stay, on the eventual clinical outcome of care was demonstrated in the RAND post-prospective payment studies,12 which examined whether patients were inappropriately discharged by developing measures of impairment at discharge, then determining if patients discharged with increased levels of impairment had poorer outcomes. The 3 measures of impairment at discharge were: (1) Instability (reflecting clinical problems not present on admission); (2) sickness (regardless whether the problem was present on admission and should or could have been corrected; and (3) abnormal last laboratory values. Although 85% of patients (post-prospective payment) were discharged in stable condition, there was an increased likelihood of post-discharge deaths in those who were unstable at discharge. 

Decreased length of stay39 and increased instability at discharge may play a role in the incidence of early readmission to hospital. Depending on the diagnosis, 5% to 29% of adults were readmitted within a month of a medical/surgical stay40 and 25% of Medicare expenditures for in-patient care were utilized for readmissions within 60 days.41 There appears to be a correlation between unplanned early readmissions and the care provided during the prior hospitalization.42  A case controlled study of men discharged from 12 Veterans Administration hospitals between October 1987 and September 1989 found that substandard care in the first hospitalization (primarily releasing patients before the "readiness-for-discharge" criteria were met) resulted in unplanned readmissions within 14 days in 8% to 14% of the cases.

At the conclusion of the RAND post-prospective payment studies, the researchers urged physicians to accept as part of their responsibility the mandate to complete an assessment of clinical instability at discharge, a determination of the causes of the instability, and, if the patient was to be discharged while unstable, to implement an explicit plan for managing the problem including the setting and timing for follow-up care.43

Follow-up care after discharge from the hospital may be problematic. Interviews with 2248 Medicare beneficiaries discharged from hospitals in 3 metropolitan areas in 1988-1989 formed the basis of a large post-acute care study by the University of Minnesota School of Public Health.44 Data from patient and caregiver interviews were supplemented by medical record reviews and Medicare and Medicaid billing data, with the goal of developing models to predict discharge location and compare outcomes of care. In addition to several measures of severity and the RAND instability measures, the researchers utilized functional status measurements and found that "functional status at discharge" and "living alone" were the 2 most important variables in determining discharge location. Results from other studies also have highlighted the important predictive value of functional status measures45-46 in determining outcomes of care.

The Minnesota post-acute care study44 determined that many of the decisions for placement of patients at time of discharge were not based on clinically relevant variables and did not produce the predicted optimal outcomes. The researchers identified problems with hospital discharge planning due to pressure to discharge patients expeditiously and the lack of empirical data on which to base decisions.

Approximately one third of the patients studied made at least 2 moves to different health care settings within the 6-week period after initial discharge (range 1 to 7). Patients with stroke or congestive heart failure were the most likely to have 4 or more moves.

Planning for the delivery of continuing care after hospitalization has been part of hospital care and social work practice for at least 50 years.47 Discharge planning has been a statutory requirement since the passage of Medicare and Medicaid, Title XVIII and XIX in 1965,48 but identifying patients who need planning for post-hospital care is difficult. In a study of 1100 patients >60 years of age from 5 Baltimore hospitals,49-50 98% of the patients interviewed 2 weeks post-discharge had post-hospital care needs; 33% had unmet needs. Patients with unmet needs had significantly higher rates of complications and poorer outcomes, and the involvement of a discharge planning case manager lead to a significant reduction in unmet treatment needs. However, only 18% of the patients received discharge planning services and another 15% received some screening but no services. Sixty-seven percent had no contact with social workers or post-hospital planning. Direct referrals from health care professionals were effective in identifying patients with post-hospital needs49; screening admission summaries have been reported to have high false-positive rates (up to 65%).48, 51

The generally accepted axiom that beginning discharge planning early will improve the outcomes of care has been supported in randomized clinical trials.45, 52-53 Randomized clinical trials have also demonstrated the value of comprehensive, multidisciplinary team discharge planning in improving outcomes of care (fewer readmissions, fewer total days rehospitalized, lower charges for health care services after discharge).54 The multidisciplinary team brings expertise to assess the medical, functional, nursing, social, psychological, and financial issues.48

A national survey from a random sample of 548 hospital discharge programs identified the importance of well-defined roles and job descriptions for each member of the discharge planning team.47 Furthermore, the study found the single most important variable in effective hospital discharge planning is the support and cooperation of the physician staff.

While there is general agreement about the data that needs to be collected for comprehensive discharge planning, that information may not be collected in the hospital or may not be transferred to the post-hospital care site. One study found that only 57% of the standard referral information was transferred from hospital discharge planners to home health agencies.55

Concern about the variability of information collected and transferred was expressed in the Senate Special Committee on Aging's Quality of Care Hearings in 1985-1986, was incorporated in the Omnibus Reconciliation Act of 1986, and led to the charge to the Secretary of Health and Human Services to develop a uniform needs assessment instrument (UNAI).56 The UNAI is designed to collect data prior to discharge on health status, cognitive/behavioral status, functional status, environmental factors, nursing care requirements, family and community support, patient/family goals and preferences and options for continuing care. The UNAI is currently undergoing revision and field testing and could be mandated in the future. Similar data collection is required for assessment and care planning on admission to post-hospital care in nursing homes (the Resident Assessment Instrument-Minimum Data Set: RAI-MDS) and will be required in home health agencies (The Outcome and Assessment Information Set: OASIS).

The availability of appropriate sites for post-acute care placement is a major limiting factor.44,49  Lack of flexibility in placement may increase the risk of discharge plan failure.49 In the study of patients from 5 Baltimore hospitals, social workers reported that in 48% of the cases the discharge plan would not withstand many changes in the patient's physical condition and/or treatment.49

Instability of physiological condition at the time of discharge from hospital was identified in the RAND study as a risk factor for poor outcome.12 It is apparently also a risk factor for poor outcomes and frequent changes in placement in post-acute care.

Discussion of the Ad Hoc Committee

After reviewing the evidence and discussing it in light of their own clinical practice experiences, the CSA ad hoc committee determined that considerations of the patient's well-being must take precedence over the generic pressures for cost-containment. It was the consensus of the group that patients should not be moved to less expensive levels of care if those settings could not safely accommodate the patient's needs. Thus the ad hoc committee identified 1 major tenet for determining when patients may be safely discharged from a hospital:

The needs of the patient must be matched to an environment with the ability to meet those needs.

The committee felt there was sufficiently strong evidence to recommend to the CSA the following 6 components of a structured discharge process to identify and assure that the patient's needs were met.

  1. Discharge criteria should be based on data from assessments of physiological, psychological, social and functional needs.
  2. An interdisciplinary team is necessary for comprehensive planning to meet the patient s needs.
  3. Early assessment and planning should be organized so that necessary personnel, equipment or training can be arranged in time for discharge.
  4. Post-discharge medical care requires arrangements (before discharge) for easy access to continuing physician care.
  5. Patient and caregiver education in meeting post-discharge patient needs should occur prior to discharge. Patients and caregivers should be able to demonstrate their understanding and ability to meet the care needs before discharge.
  6. Coordinated, timely and effective communication between all health professionals, caregivers and the patient is essential and should be well established before discharge.

The ad hoc committee designed a model of the comprehensive, coordinated, patient-centered discharge process.

Conclusions of the Council on Scientific Affairs

The CSA was very appreciative of the work of the ad hoc committee in clarifying the many aspects of this complex problem. Although the evidence is not conclusive, the CSA felt that it certainly suggests that the intensive cost containment pressures placed on medical and hospital care by third party payers may have adverse effects on some patients. Physiological instability and the presence of unmet needs in the post-hospital setting appear to increase the risks of poor outcomes (with their attendant high medical costs).

The basic tenet proposed by the ad hoc committee that "the needs of the patient must be matched to an environment with the ability to meet those needs" with its prioritizing of patient well being over immediate economic concerns is consistent with the American Medical Association's code of Ethics57 (E 8.03. Conflicts of Interest Guidelines and E-8.54. Financial Incentives and the Practice of Medicine): "Although physicians have an obligation to consider the needs of broader patient populations within the context of the physician-patient relationship, their first duty must be to the individual patient. This obligation must override considerations of the reimbursement mechanism or specific financial incentives applied to a physician's clinical practice."

Prudent judgments by the physician should be based on careful and comprehensive assessments (with the assistance of an interdisciplinary team) and vigilant oversight of the patient's condition at time of discharge and in the post-hospital setting.

A structured discharge process as described by the ad hoc committee should be adaptable and flexible across many dimensions of health care, including: 1) flexibility to accommodate single-system disease as well as complex, multi-system disease; (2) flexibility to accommodate local or regional variation in services provided by different health care settings; (3) flexibility to keep pace with general trends for higher-skilled services to be provided outside the hospital setting; and (4) flexibility to keep pace with advances in medical and surgical therapies that can result in shorter hospital stays, result in less need for higher-skilled services, or improve outcomes for patients.

The CSA recognizes that there are many related areas that require additional study and should be addressed in the future. In particular, there is need for widely accepted and standardized definitions of physiological stability and severity of illness. There also are needs to develop more uniform measures of functional status, to define the responsibilities for care of vulnerable populations, and to explore ways to use these principles across the health care system in a cooperative fashion.

Recommendations

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1996 AMA Annual Meeting. 

  1. The AMA defines discharge criteria as organized, evidence-based guidelines that protect patients' interests in the discharge process by following the principle that the needs of patients must be matched to settings with the ability to meet those needs.   
  2. The AMA calls on physicians, specialty societies, insurers, and other involved parties to join in developing, promoting, and using evidence-based discharge criteria that are sensitive to the physiological, psychological, social, and functional needs of patients and that are flexible to meet advances in medical and surgical therapies and adapt to local and regional variations in health care settings and services.   
  3. The AMA encourages incorporation of discharge criteria into practice parameters, clinical guidelines, and critical pathways that involve hospitalization.   
  4. The AMA promotes the local development, adaptation, and implementation of discharge criteria.   
  5. The AMA promotes training in the use of discharge criteria to assist in planning for patient care at all levels of medical education. Use of discharge criteria will improve understanding of the pathophysiology of disease processes, the continuum of care and therapeutic interventions, the use of health care resources and alternative sites of care, the importance of patient education, safety, outcomes measurements, and collaboration with allied health professionals.   
  6. The AMA encourages research in the following areas: clinical outcomes after care in different health care settings; the utilization of resources in different care settings; the actual costs of care from onset of illness to recovery; and reliable and valid ways of assessing the discharge needs of patients.  
  7. The AMA endorses the following principles in the development of evidence-based discharge criteria and an organized discharge process: 
    1. As tools for planning patients' transition from one care setting to another and for determining whether patients are ready for the transition, discharge criteria are intended to match patients' care needs to the setting in which their needs can best be met.   
    2. Discharge criteria consist of, but are not limited to:
      1. Objective and subjective assessments of physiologic and symptomatic stability that are matched to the ability of the discharge setting to monitor and provide care.   
      2. The patient's care needs that are matched with the patient's, family's, or caregiving staff's independent understanding, willingness, and demonstrated performance prior to discharge of processes and procedures of self care, patient care, or care of dependents.   
      3. The patient's functional status and impairments that are matched with the ability of the care givers and setting to adequately supplement the patients' function.   
      4. The needs for medical follow-up that are matched with the likelihood that the patient will participate in the follow-up. Follow-up is time-, setting-, and service-dependent. Special considerations must be taken to ensure follow-up in vulnerable populations whose access to health care is limited. 

C. The discharge process includes, but is not limited to:


  1. Planning: Planning for transition/discharge must be based on a comprehensive assessment of the patient's physiological, psychological, social, and functional needs. The discharge planning process should begin early in the course of treatment for illness or injury (prehospitalization for elective cases) with involvement of patient, family and physician from the beginning.
  2. Teamwork: Discharge planning can best be done with a team consisting of the patient, the family, the physician with primary responsibility for continuing care of the patient, and other appropriate health care professionals as needed.
  3. Contingency Plans/Access to Medical Care: Contingency plans for unexpected adverse events must be in place before transition to settings with more limited resources. Patients and caregivers must be aware of signs and symptoms to report and have a clearly defined pathway to get information directly to the physician, and to receive instructions from the physician in a timely fashion.
  4. Responsibility/Accountability: Responsibility/accountability for an appropriate transition from one setting to another rests with the attending physician. If that physician will not be following the patient in the new setting, he or she is responsible for contacting the physician who will be accepting the care of the patient before transfer and ensuring that the new physician is fully informed about the patient's illness, course, prognosis, and needs for continuing care. If there is no physician able and willing to care for the patient in the new setting, the patient should not be discharged.

    Notwithstanding the attending physician's responsibility for continuity of patient care, the health care setting in which the patient is receiving care is also responsible for evaluating the patient's needs and assuring that those needs can be met in the setting to which the patient is to be transferred.

  5. Communication: Transfer of all pertinent information about the patient (such as the history and physical, record of course of treatment in hospital, laboratory tests, medication lists, advanced directives, functional, psychological, social, and other assessments), and the discharge summary should be completed before or at the time of transfer of the patient to another setting. Patients should not be accepted by the new setting without a copy of this patient information and complete instructions for continued care. 

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  48. Potthoff SJ, Kane RL, Franco SJ. Hospital discharge planning for elderly patients: Improving decisions, aligning incentives, final report. Minneapolis: Institute for Health Services Research, School of Public Health, University of Minnesota, 1995 (HCFA contact 93-101/GF).   
  49. Oktay J, Steinwachs DM, Mamon J, Bone LR, Fahey M. Evaluating social work discharge planning services for elderly people: access, complexity and outcome.  Health Social Work. 1992;17(4):290-298.   
  50. Mamon J, Steinwachs DM, Fahey M, Bone LR, Oktay J, Klein L. Impact of hospital discharge planning on meeting patient needs after returning home.  Health Services Res. 1992;27:155-175.   
  51. Berkman B, Millar S, Holmes W, Bonander E. Screening elder cardiac patients to identify need for social work services.  Health Social Work. 1990;15:64-72.   
  52. Evans RL, Hendricks RD. Evaluating hospital discharge planning: a randomized clinical trial.  Medical Care. 1993;31 (4):358-370.   
  53. Farren EA. Effects of early discharge planning on length of hospital stay.  Nursing Economics. 1991;9(1):25-30, 63.   
  54. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly.  Ann Intern Med. 1994;120:999-1006.   
  55. Anderson MA, Helm LB. Quality improvement in discharge planning: an evaluation of factors in communication between health care providers.  J. Nursing Care Quality. 1994;8(2):62-72.   
  56. Health Care Financing Administration. Advisory panel to develop uniform needs assessment instrument(s): Report to Congress. December 1992.   
  57. Council on Ethical and Judicial Affairs . Code of Medical Ethics: Current Opinions. Chicago: American Medical Association, 1998.

Ad Hoc Committee Members

  • Herman I. Abromowitz, MD, AMA Council on Medical Services, Dayton, Ohio 
  • Paula Braveman, MD, University of California, San Francisco, San Francisco, California 
  • Loren Fishman, MD, Physical Medicine and Rehabilitation, Flushing, New York 
  • Stephan Jencks, MD, MPH, Health Care Financing Administration, Baltimore, Maryland
  • Linda Johnson, RN, Employee Health Plan, Baltimore, Maryland
  • Katherine Kahn, MD, Health Program of the RAND Corporation, Santa Monica, California
  • Nancy Morrow-Howell, PhD, Washington University, St. Louis, Missouri
  • Paul Schyve, MD, Joint Commission on Accreditation of Health Care Organizations, Oakbrook Terrace, Illinois
  • Joanne G. Schwartzberg, MD, American Medical Association, Chicago, Illinois
  • Frederick W. Spong, MD, MBA, FACP, Milliman and Robertson, Inc., San Diego, California
  • Robert J. Weierman, MD, AMA Organized Medical Staff Section, South Orange, New Jersey
  • Michael A. Williams, MD, AMA Council on Scientific Affairs, Baltimore, Maryland
  • Arnold L. Widen, MD, Blue Cross Blue Shield of Illinois, Chicago, Illinois
  • Donald C. Young, MD, AMA Council on Scientific Affairs, Iowa City, Iowa

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Last updated: Sep 25, 2007
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