Rehospitalizations among Medicare beneficiaries are prevalent and costly.

It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement. JAMA. 2000;284:1670-1676.

practices, the distal revascularization-interval ligation (DRIL) procedure has become the preferred method to treat steal syndrome. However, this operation requires a new bypass and results in ligation of the brachial artery distal to the fistula. Although plication of an arteriovenous fistula is a known technique for dealing with steal syndrome, it is rarely reported. In this article, the authors describe their technique, in a small number of patients, for plication of arteriovenous fistulas associated with clinically significant steal. Seven patients were treated with plication. Their symptoms included paresthesia, coolness, and pain in the hand and fingers. No one had ulceration. In six of seven patients, a radial artery pulse returned with compression of the fistula.Plication was performed using a Satinsky clamp as a guide for the degree of plication, with the vein narrowed by a running horizontal mattress suture of 6-0 polypropylene. The length of vein plicated was approximately 1 cm, and the extent of plication was determined by return of a palpable pulse at the wrist or a change from monophasic to a biphasic distal Doppler signal. If the Doppler signal did not improve, the Satinsky clamp was reapplied and the plication repeated, further narrowing the plicated length of the fistula. The radial pulse returned postoperatively in six of seven patients. Mean follow-up was 9 months. At 13 months, symptoms had recurred in only one patient, the patient in whom the radial pulse did not return.Comment: Many patients with steal syndrome can be managed by observation. The inflow vessel dilates, and symptoms may resolve within a few days to weeks. A basic principle of surgical therapy is to perform simple procedures that are effective in preference to more complex procedures. DRIL procedures are effective for steal, with an 83% to 100% success rate; however, they are major operations, and the brachial artery is ligated. This study serves as a reminder that simple plication may be an effective treatment for steal syndrome and should be considered as an alternative treatment for steal before performance of a DRIL procedure. Predictors of Prosthetic Graft Infection after Infrainguinal Bypass

Context.-Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement programs has been difficult to establish.Objective.-To improve the quality of care for Medicare patients with acute myocardial infarction.Design.-Quality improvement project with baseline measurement, feedback, remeasurement, and comparison samples.Setting.-All acute care hospitals in the United States.Patients.-Preintervention and postintervention samples included all Medicare patients in Alabama, Connecticut, Iowa, and Wisconsin discharged with principal diagnoses of acute myocardial infarctions during 2 periods,

The model discussed in this article divides the population into eight groups: people in good health, in maternal/infant situations, with an acute illness, with stable chronic conditions, with a serious but stable disability, with failing health near death, with advanced organ system failure, and with long-term frailty. Each group has its own definitions of optimal health and its own priorities among services. Interpreting these population-focused priorities in the context of the Institute of Medicine's six goals for quality yields a framework that could shape planning for resources, care arrangements, and service delivery, thus ensuring that each person's health needs can be met effectively and efficiently. Since this framework would guide each population segment across the institute's "Quality Chasm," it is called the "Bridges to Health" model. Keywords:Health care reform, community health planning, health services needs and demand, person-focused health. (IOM 2001a) envisioned an approach to health that focuses on the individual person or patient and met six specific aims for care: it must be safe, effective, efficient, patient centered (i.e., meets the patient's desires and preferences within the care delivery environment), timely, and equitable. C ROSSING THE QUALITY CHASM

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About one third of elderly patients with acute myocardial infarction who had no contraindications to aspirin therapy did not receive it within the first 2 days of hospitalization. The elderly patients with the highest risk of death were the least likely to receive aspirin. After adjustment for differences between the treatment groups, the use of aspirin was associated with 22% lower odds of 30-day mortality. The increased use of aspirin for patients with acute myocardial infarction is an excellent opportunity to improve the delivery of care to elderly patients.

Aspirin was not prescribed at discharge to 24% of elderly patients who were hospitalized with an acute myocardial infarction and did not have a contraindication to aspirin. Several patient characteristics were associated with a higher risk for not being prescribed aspirin. Increasing the prescription of aspirin for these patients may provide an excellent opportunity to improve their care.