A view of health care from the patient's perspective is offered by Sabina B. Gesell, Paul Alexander Clark, and Aimee Williams in their study of two 12-month samples of several thousand heart failure patients. Their objectives were to identify opportunities for improvement in patient-centered care of heart failure patients and suggest strategies for improving the quality of the related patient care services. They conclude that patient involvement in decision making, staff response to the patient's concerns, staff sensitivity to the inconvenience and lifestyle disruption occasioned by heart failure and hospitalization, and emotional and spiritual support are highly important factors in determining patient satisfaction and the quality of care given to heart failure patients.

Not everyone enjoys the luxury of selecting his or her own primary care physician. Frequently, the patient is "assigned" to a particular physician through an organizational system designed to balance caseloads or on the basis of local geography and convenience. However, even under those circumstances the patient may have the option of choosing or changing providers, and researchers have given a good deal of attention to trying to determine what factors shape the patient's decisions in this regard. Garman et al have reported their findings from an analysis of patient satisfaction as a predictor of return-to-provider behavior and the financial implications of the related patient decisions. 1 In this issue of QMHC, Raj Arora and Joseph Singer of the Bloch School of Business and Public Administration of the University of Missouri, Kansas City, MO, and Alisha Arora of the University of North Carolina Hospitals, Chapel Hill, NC, report their findings from a study of the variables that played a part in patients' evaluations of primary care physicians and what they refer to as the "family-centered practice." Interestingly, they found, among other things, that in their sample such "convenience" factors as waiting time for an appointment, waiting time in the office, and the proximity of available parking were not as significant as might be supposed. Factors such as sympathy and compassion far outweighed the convenience factors.

Christopher Hebert and Duncan Neuhauser of the Louis Stokes Cleveland Veterans Administration Hospital and Case Western Reserve University report on the impact of having a patient chart his own blood pressure on his care. They point out that one of the challenges in the treatment of hypertension is obtaining meaningful measures of the level of blood pressure control, and of the changes in blood pressure following an intervention. Twenty-two of the 33 hypertensive patients in the sample succeeded in keeping run charts, whereas others recorded their data in tabular form. Those who maintained run charts tended to find the activity not to be burdensome, but enlightening.

A challenging and provocative view of the concepts involved in quantifying and measuring the quality of patient care is presented by Patricia Rowell. Dr Rowell argues that the quality of care is presently not measurable, and that appropriateness of care, as defined by knowledge-based guidelines, is the characteristic that should be evaluated.

In previous issues of QMHC, Robert A. McNutt, with Mary C. Odwazny, has discussed the program being conducted by the Patient Safety Committee of Rush-St Luke's-Presbyterian Hospital in Chicago. 2,3 In their interview style discussion in this issue, they address the independent review of adverse events. Using critical path analysis, the safety committee searches for those decisions or processes of care that increase the probabilities of adverse events. In its study of adverse events, the committee follows a model based on the Theory of Constraints. In this model, the analyst conducts a critical path analysis to find the core event that, in turn, led to a series of other occurrences that ultimately resulted in the adverse event that triggered the examination. The objective is to help to focus improvement efforts on core causes.

For patients undergoing cardiac catheterization or percutaneous coronary intervention, the administration of excessive amounts of radioactive contrast materials can have significant adverse effects, including radiocontrast nephropathy. In an effort to curtail the volumes of radiocontrast materials used in a cardiac catheterization laboratory, Azimuddin Tareq Khawaja, Venkatraman Srinivasan, Zafir Hawa, and Alan H. Gradman employed behavioral modification techniques. They report here on the methods used and the effect on physicians' ordering patterns.

In a wide-ranging interview, Professor Michael S. Jacobs of the DePaul University College of Law, Chicago, Ill, a leading authority in the field of antitrust issues in health care, discusses barriers to entry in the health professions and the impact of monopoly positions on prices of and access to drugs and services. Professor Jacobs provides an illuminating international comparison of policies that impose and support restrictions on access to the medical profession and the practice of medicine.

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