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Reports and Publications

Recent Reports

AN All-or-None Performance Assessment for All Physicians!

Patient safety experts Thomas Nolan, PhD., and Donald M. Berwick, MD, MPP recently wrote in a JAMA report that the movement to all-or-none performance assessment is an important milestone on the journey to high-quality health care. The all-or-none approach to measuring performance offers several important advantages over either item-by-item measurement or composite measurement. read full report

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Taking the Pulse of Health Care Systems: Experiences of

 Patients with HealthProblems in Six Countries

The Commonwealth Fund

A new international survey supported by The Commonwealth Fund finds that one third of U.S. patients with health problems reported experiencing medical mistakes, medication errors, or inaccurate or delayed lab results—the highest rate of any of the six nations surveyed. read more

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A new Institute of Medicine (IOM) report has called for a comprehensive system to measure and report on the performance of health care providers and organizations

If pay-for-performance initiatives and public reporting systems are to be effective in improving the quality of health care in the United States, a comprehensive, universally accepted system is needed to measure and report on the performance of health care providers and organizations, says a new report from the Institute of Medicine of the National Academies.

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Measuring physician performance is critical to improving the quality and efficiency of care

Growing optimism over the promise of "pay for performance" to improve the quality of health care may have been given further impetus following publication of the first study to assess the effects of quality incentives in a large health plan. Early Experience with Pay for Performance:

From Concept to Practice.

Measuring physician performance is critical to improving the quality and efficiency of care and allowing patients to make value-based health care choices. At a recent meeting co-funded by The Commonwealth Fund, participants examined the current state of physician performance measurement and began to develop a research and policy agenda to advance this strategy and improve transparency in the U.S. health care system. The resulting report, Advancing Physician Performance Measurement: Using Administrative Data to Assess Physician Quality and Efficiency, describes the science of measuring physician performance, data issues, and measurement initiatives currently under way. The report also highlights areas that require attention, including a need for research to assess optimal ways to provide feedback to physicians and patients.

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To Err Is Human; To Fail to Improve Is Unconscionable!

Click here for full report

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Residents' Sleep Deprivation Compares to Alcohol Intoxication

Medical residents working 80 to 90 hours a week have performance impairments comparable to residents with a blood-alcohol concentration of 0.04% to 0.05%, according to a report in the Journal of the American Medical Association released Tuesday. Click here for full report

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JAMA, Health Affairs Studies Examine Effect of Damage Caps in Medical Malpractice Suits, Other Related Issues

(Courtesy of the Kaiser Daily Health Policy Report,  Jun 01, 2005)

Several studies released this week examine how tort reform laws in different states -- including 27 with caps on noneconomic damages in malpractice suits -- have affected physician services and malpractice insurance premium rates, the Washington Times reports (Higgins, Washington Times, 6/1). Two of the studies, published in Wednesday's Journal of the American Medical Association, are part of a larger effort by the Pew Charitable Trusts to establish facts in the ongoing debate over tort reform, according to the Pittsburgh Post-Gazette. Two other studies were published online in the journal Health Affairs (Snowbeck, Pittsburgh Post-Gazette, 6/1). A fifth study was released by the Kaiser Family Foundation (Girion, Los Angeles Times, 6/1). Summaries of the studies appear below.

JAMA Study
States that capped noneconomic damages in malpractice cases experienced a 2.4% increase in overall physician supply compared with states that have no such caps, according to the study in Wednesday's JAMA. The study says physician services increased in every state from 1985 to 2001, but states with damage caps saw a higher than average increase in the number of doctors than states without tort reform. In addition, the study finds that more of the services growth was among doctors with 20 or more years of experience (Washington Times, 6/1). Overall, the study finds that the supply of professionally active doctors throughout the nation increased from 497,140 in 1985 to 709,168 in 2001 (AP/St. Petersburg Times, 6/1). In an accompanying editorial, Peter Budetti, a professor at the University of Oklahoma College of Public Health, said the data shows the impact of tort reform on physician supply is "relatively modest." William Sage, a law professor at Columbia University and director of Pew's Project on Medical Liability in Pennsylvania, said, "It is clear that both physicians and patients are victims of a seriously flawed malpractice system," adding, "In particular, the process of airing and resolving claims through litigation is destructive for all concerned, while the market and regulatory dynamics of malpractice insurance drive premiums into crisis cycles with pernicious consequences." Sage called on the federal government to make available funding for demonstration projects to study comprehensive malpractice reform (Pittsburgh Post-Gazette, 6/1).
Second JAMA Study
Most doctors in Pennsylvania are practicing "defensive medicine" or ordering more tests and procedures that might not be medically necessary but could help shield them from lawsuits, according to a second study in Wednesday's JAMA (Washington Times, 6/1). For the study, Harvard School of Public Health researchers in 2003 surveyed 824 physicians in Pennsylvania in six specialties: emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology and radiology (Reuters/New York Post, 6/1). Ninety-three percent of participants said they sometimes or often practiced defensive medicine, according to the study (Tanner, AP/Long Island Newsday, 5/31). Fifty-nine percent of participants said they often ordered more diagnostic tests than were medically indicated, and 52% said they frequently referred patients to other doctors even though the referrals were not medically necessary. Forty-two percent of the physicians surveyed said that liability concerns forced them to restrict some practices since 2000, including eliminating procedures and avoiding patients with complex medical problems or those who "appeared litigious," the Post-Gazette reports. However, the study authors noted that distinctions between appropriate and inappropriate care are not always clear and that it can be difficult to account for factors other than malpractice for practicing defensive medicine (Pittsburgh Post-Gazette, 6/1). According to the AP/Newsday, the survey was completed shortly after several malpractice insurers had exited Pennsylvania and premiums charged by other insurers had "risen dramatically" (AP/Long Island Newsday, 5/31). "The most frequent form of defensive medicine, ordering costly imaging studies, seems merely wasteful, but other defensive behaviors may reduce access to care and even pose risks of physical harm," lead author David Studdert wrote in the report (Reuters/New York Post, 6/1). In his editorial, Budetti said, "Perhaps the greatest irony is that defensive medicine may be counterproductive and actually might increase malpractice risk" (AP/St. Petersburg Times, 6/1).
Health Affairs Web Exclusive
A separate study published in the online journal of Health Affairs says that the presence of caps on noneconomic damage awards has an impact on where doctors choose to practice, particularly in rural areas (Washington Times, 6/1). The study, by researchers at HHS and the Agency for Healthcare Research and Quality, finds that the 27 states with caps on noneconomic damages had 2.2% more physicians per capita than states without such caps (Los Angeles Times, 6/1). Rural counties in states with noneconomic damage caps had 3.2% more physicians per capita than rural counties in states without caps, according to the study (Pittsburgh Post-Gazette, 6/1). According to study co-author William Encinosa, a senior economist at AHRQ, obstetricians and surgeons -- who are considered more vulnerable to lawsuits -- were most influenced by the presence or absence of caps (Washington Times, 6/1). Donald Palmisano, former president of the American Medical Association, said, "Skyrocketing medical liability premiums are forcing physicians in states without reforms to limit services, retire early or move to states with reforms -- with devastating results for patients seeking medical care." However, Douglas Heller, executive director of the California-based Foundation for Taxpayer and Consumer Rights, attributed the relatively low premiums in California to rate regulation in the state, not caps on damage awards (Los Angeles times, 6/1). Frank Clemente, a spokesperson for Public Citizen, said many states with caps are considered conservative and have experienced large population growth. "Doctors are like anybody else, they go where the business is," he said (Freking, AP/Miami Herald, 6/1). The complete study is available online.

Second Health Affairs Web Exclusive
Another study published in the online edition of Health Affairs found that high damage awards and financial settlements for patients are not responsible for the "explosive increase" in doctors' malpractice insurance premiums, the Boston Globe reports. Lead author Amitabh Chandra, an assistant professor of economics at Dartmouth College, and colleagues examined information from the National Practitioner Data Bank on actual payments made to patients between 1991 and 2003 and found that payments grew an average of 4% annually during the study period, or 52% overall since 1991. However, payments increased 1.6% annually since 2000, according to the study (Kowalczyk, Boston Globe, 6/1). According to Chandra, the average court judgment in 2003 was $461,000, and 96% of cases that year were settled out of court for an average of $257,000. The researchers conclude that malpractice payouts have risen approximately in line with increases in medical care costs. Noting that doctors' malpractice insurance premiums grew far faster than health care costs -- by double-digit percentages in some specialties -- the researchers say the higher premiums likely reflect insurers' efforts to make up for documented losses in the bond market from 1998 to 2001. However, Larry Smarr, president of the Physician Insurers Association of America, said that investment losses accounted for at most 16% of premium increases in recent years. "We don't deny that there are multiple reasons why (malpractice premium) rates are going up. [But it's] mainly due to the increase in the value of claims," he added (Los Angeles Times, 6/1). Other studies have found that doctors' malpractice insurance premiums increased more quickly in states without caps on noneconomic damages, Palmisano noted. Barry Manuel, chair of insurer ProMutual Group, said the study authors did not account for the rising cost of defending malpractice cases (Boston Globe, 6/1). The complete study is available online.

Kaiser Family Foundation Study
A separate study released by the Kaiser Family Foundation says total malpractice payments increased an inflation-adjusted 3.8% annually between 1991 and 2003, the Los Angeles Times reports. In addition, the study says growth in the number of practicing doctors outpaced the increase in the number of malpractice claims paid through settlements or jury awards between 1991 and 2003, resulting in a decrease in the average number of malpractice claims per physician. Lead author Budetti, who also wrote the editorial accompanying the JAMA studies, said, "For most doctors, there is a perception of a serious problem. [But] the likelihood of having a claim paid on your behalf over the years has diminished" (Los Angeles Times, 6/1). The study is available online.

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Study Finds Medical Conditions, Resulting Financial Issues Contributed to Half of all American Bankruptcies

About half of bankruptcies filed in 2001 were because of medical bills, according to a study published on the Health Affairs Web site. For the study, researchers from Harvard Medical School and Harvard Law School surveyed 1,771 U.S. residents who filed for bankruptcy in 2001 and interviewed 931 of them. People interviewed had cases involving injury or illness, unpaid medical bills of more than $1,000 in the two years prior to filing for bankruptcy, loss of two weeks of work because of illness or injury or mortgaging of a home to pay medical bills.

According to the study, 46.2% of people reporting bankruptcy in 2001 cited illness and medical bills as the cause. The rate rose to 54.5% when births, deaths and gambling addictions were considered as factors. The number of bankruptcies filed in the United States tripled between 1980 and 2001, to nearly 1.5 million couples and individuals. The number of medical-related bankruptcies increased twenty-threefold during that period, the study says. Online

More Findings

According to Steffie Woolhandler, one of the study authors and a doctor at Cambridge Hospital, 76% of people who had a medical-related bankruptcy had health insurance when they first became ill.  According to the study, 38% of those who filed for bankruptcy lost their health coverage at least temporarily by the time they had declared bankruptcy. Most of those who filed for bankruptcy because of medical costs were middle-income homeowners, the study indicates. In addition, people who cited medical bills as a cause for filing bankruptcy were more likely than others to have experienced a gap in health coverage because of costs or because they switched to a new plan and then lost coverage because of pre-existing medical conditions, the study says.

Researchers' Reaction

Elizabeth Warren, a Harvard law professor and one of the study's authors, said, "It doesn't take a medical catastrophe to create a financial catastrophe." David Himmelstein, another author and Harvard Medical School professor, said, "Unless you're Bill Gates, you're just one serious illness away from bankruptcy. Most of the medically bankrupt were average Americans who just happened to get sick. Health insurance offered little protection." Warren said, "These are hard-working, 'play-by-the-rules' people who have health insurance and have discovered that they were just one bad diagnosis away from financial catastrophe. I think that's the real heart of the story. This is about people who thought they were all safe" (Los Angeles Times, 2/2). Woolhandler said, "We need to rethink health reform. Covering the uninsured is not enough. We also must upgrade and guarantee continuous coverage for those who have insurance."

To read the full study, click here.

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Report casts doubt on malpractice damage caps

Associated Press; March 10, 2005

AUSTIN -- Large medical malpractice verdicts and settlements were not to blame for a rapid increase in insurance premiums for Texas doctors and hospitals, according to a study to be released today.

The report by law professors at the University of Texas at Austin and elsewhere comes two years after Texas lawmakers and voters approved strict caps on malpractice damages. Congress now is considering similar limits.

Supporters of the caps say they are needed to rein in runaway insurance premiums and health care costs. They are disputing the study's findings.

Texas lawmakers and voters implemented a $250,000 cap in 2003 on non-economic damages such as pain and suffering in malpractice cases. California and other states have similar caps.

The study, which looked at malpractice claims paid out by insurance companies from 1988 to 2002, concluded that premium increases weren't caused by payments to patients or their lawyers.

"The tort system is a steady sea, not a threatening storm, let alone a tidal wave," said David Hyman, a professor of law and medicine at the University of Illinois. "There is just not much going on that could drive these premium increases."

The study found that the number of malpractice payments under $25,000 fell sharply from 1988 to 2002, and the number of payments greater than $25,000 stayed stable. It also found that median jury verdicts in trials won by patients were for $300,593 in 2002, about the same as in the 1990s.

And total payments to patients in 2002 were $515 million, or 0.6 percent of health care spending, up from $414 million, or 0.8 percent, in 1990. Both numbers are in 2002 dollars.

Proponents of the cap said the study didn't fully take into account the increase in jury awards for damages such as pain and suffering. "They've cooked their data so much, they've cooked the truth," said Jon Opelt, executive director of Texas Alliance for Patient Access, which represents medical providers, businesses and insurance companies. Opelt and the Texas Medical Association pointed out that malpractice insurance rates have come down since voters approved the caps. Malpractice cases also have fallen by as much as 90 percent in Dallas County and elsewhere, trial lawyers said.

Public interest advocates said the study validates their concerns about the caps. "Unfortunately, the voters of Texas were given flawed information when they were asked to sacrifice their constitutional rights," said Alex Winslow, executive director of Texas Watch.

Click here to read full study.

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Two Studies Show Benefits of Reduced Hours for Doctors in Training

Two landmark studies published recently in the New England Journal of Medicine confirm what common sense and previous research have suggested: Reducing the number of hours worked by residents will lead to better-rested residents who make significantly fewer serious medical errors.

The two landmark studies, both led by Dr. Charles A. Czeisler, document more clearly than any prior research the patient-endangering consequences of current work patterns.  In the first study, “Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units,” interns in intensive care units in Brigham and Women’s Hospital at Harvard Medical School were randomized to traditional schedules or an intervention schedule that limited shifts to 16 hours.  

Interns in the traditional schedule made 36 percent more serious medical errors than those in the intervention schedule. Many of the unnecessary errors were medication errors, which were 21 percent higher in the traditional group.  The authors concluded: “Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.” Earlier studies had shown that sleep-deprived residents were more likely to be depressed, to have injurious automobile crashes and to have problems with pregnancy.

In the second study, “Effect of Reducing Interns’ Weekly Work Hours on Sleep and Attentional Failures,” interns in the same rotations at Brigham and Women’s Hospital were studied in detail.  During the intervention period, interns worked 20 fewer hours (65 hours compared to 85 hours) and slept six hours more per week.  The interns also had more than 50 percent fewer episodes of attentional failures (eye-rolling during waking hours, measured by electrooculography) during the intervention period.

These two studies are the most compelling studies ever published in the area of resident work hours. They prove that reducing work hours is feasible and, more convincingly than any prior research, demonstrate that patients will benefit from the more humane treatment of residents.  It is time for the federal government to step in to protect both patients and residents, rather than leave this major public health problem in the hands of the industry that is responsible for the problem in the first place.

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The True Quality of American Health Care

The Commonwealth Fund, 2004


Health care leaders in the United States often claim that the American health system is the best in the world. Based on both per-capita spending and the percentage of national income spent on health care, our nation is certainly far and away the leader. But are Americans really getting what they pay for?

A report from The Commonwealth Fund that examines how well the health system works from the perspective of patients confirms what several other recent studies have shown—that the U.S. performs worse than its peer nations on several dimensions of quality.

According to Mirror, Mirror on the Wall: Looking at the Quality of American Health Care Through the Patient’s Lens , four other industrialized nations—Australia, Canada, New Zealand, and the United Kingdom—scored better than the U.S. on safety, efficiency, effectiveness, and equity, while the U.S. ranked second-to-last on measures of “patient-centered” care. The U.S. did, however, have the shortest waits for hospitalization and elective surgery, and placed second (to New Zealand) on prompt access to primary care physicians and specialists. Click here to read full study.

“While the U.S. spends the most on health care of any country, we’re not getting commensurate value from the view of patients,” said Fund president Karen Davis, the report’s lead author. “We have the most highly skilled health professionals and most advanced medical technology, yet our system doesn’t ensure that patients fully benefit from this wealth of resources.”

The Fund analysis, which was based on patients’ responses to the 2001 International Health Policy Survey and the 2002 International Health Policy Survey of Sicker Adults, used criteria for evaluating quality developed by the Institute of Medicine. For each of the quality dimensions below, an overall score was assigned to each country based on scores on several measures:

Patient Safety: U.S. Ranked Last

Highest reports of medication errors (receiving the wrong medication or dose over the past two years).

Most likely to say a medical mistake was made in their treatment.

Efficiency: U.S. Ranked Last

Last on being sent for duplicate tests by different health care professionals.

Worst on not having medical records or test results reach doctor’s office in time for
appointment.

Effectiveness: U.S. Tied for Last

Last in patients not getting a recommended test, treatment, or follow-up due to cost.

Last in patients not filling a prescription due to cost.

Patient-Centered Care: U.S. Ranked Second to-Last

Ranked last (tied with the U.K.) on physicians spending enough time with patients.

Last on physicians listening carefully to patients’ health concerns.

Timeliness: U.S. Ranked Third

Best on hospital admission waiting times.

Next to last on waiting five days or more for physician appointment when last needed medical attention.

Equity: U.S. Ranked Last for Lower-IncomePatients

Worst on patients having problems paying medical bills.

Worst on patients being unable to get care where they live.

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Patient Safety in American Hospitals

HealthGrades Quality Study
July 2004

An average of 195,000 patients die annually from preventable hospital errors, according to a July, 2004 HealthGrades study. For the study, researchers examined data from 37 million Medicare beneficiaries in all 50 states over three years. Researchers looked for 16 types of errors identified as important by the Agency for Healthcare Research and Quality and estimated a national death rate based on Medicare beneficiaries whose deaths could be attributed to those types of mistakes.

Data from those beneficiaries were adjusted for age. The majority of patient deaths were attributed to an error called "failure to rescue," or mistakes in diagnosing or treating an illness that occurs after an operation, such as pneumonia. The study is the first to estimate deaths caused by "failure to rescue."

Some patient safety analysts said the HealthGrades study "confirms their suspicion" that the IOM estimate was too low. Dr. Lucian Leape of the Harvard School of Public Health and a co-author of the IOM study, said that the IOM estimate was based on a conservative definition of medical errors and that it underestimated the number of preventable deaths. Dr. Kenneth Kizer of the National Quality Forum said HealthGrades' estimates are likely lower than the true total because they do not factor in errors at nursing homes, private doctors' offices and other outpatient settings. Any way you look at it, medical errors are a frightening problem. Click here to read full study.

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Report: Half of All U.S. Patients Get Bad Care

Study finds gap in quality of health coverage

CNN; September 23, 2004

WASHINGTON (AP) Requiring doctors and hospitals to report publicly on their performance and tying their pay to the results would dramatically reduce avoidable deaths and costs attributable to poor medical care, says a new report from an organization that works to improve health care quality.

Wild variations in medical care led to 79,000 avoidable deaths and $1.8 billion in additional medical costs last year, the private National Committee for Quality Assurance said in its annual report released Wednesday. The report described a substantial gap in quality between the best providers and the national average for treating a range of common conditions that would not be tolerated in almost any other sector of the U.S. economy. For example, failure to control high blood pressure resulted in up to 26,000 deaths last year that could have been avoided with competent medical care. "Patients get the correct care only about 50 percent of the time," the report said.

The differences in health care quality persist even as health insurance premiums have risen by more than 10 percent annually for the past four years. "This report underscores that all too often we are not getting good value for that money," said Peter V. Lee, president and chief executive of the Pacific Business Group on Health, a coalition of businesses that provide health insurance to 3 million people.

On the other hand, the report found that health insurance plans that publicly report their performance showed marked improvement in most areas, including cholesterol management, diabetes care, breast cancer screening and flu shots for adults. Better control of blood pressure will lead to 2,500 fewer fatal heart attacks in 2004, the report said. Health plans also did a better job of reducing cholesterol levels among patients with diabetes, it said.

But those plans cover only about a quarter of the U.S. population, about 69 million people.” The data we have tell a great story, health care quality is improving consistently and dramatically," said Margaret E. O'Kane, NCQA's president. "Why don't we have performance data for the other 75 percent of the U.S. health care system?"

Last year's Medicare prescription drug law took a step in this direction by linking a small portion of Medicare payments to hospitals' willingness to submit quality data and conducting trial runs that tie pay to performance for some health care providers.

One notable exception to the upward trend in quality was treatment of mental illness, which showed no improvement over 2002. Click here to read full study.

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New RAND Study Confirms Correct Care Given Less Than 60% of the Time, with Little Variation Across Diverse Communities

Earlier this week, the RAND Corporation released expanded results from the largest and most comprehensive study of health care quality in the United States ever conducted. The study, published in the journal Health Affairs, shows that on average, residents of twelve US communities receive between 50 and 60 percent of recommended care for acute and chronic conditions, and key preventive services, with little variation across diverse communities. According to the authors, “these findings are consistent with decades of research that demonstrates sizable deficits in the quality of health.” Click here to read full study.

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Publications of Note


Child Health:
U.S. Child Health: What’s Amiss, And What Should Be Done About It?
Starfield B. Health Affairs, 2004 Vol 23:165.
This paper addresses the state of health of U.S. children and finds it to be poorer in virtually every way than that of children in other countries. It explores several possible explanations, including population heterogeneity, social (including income) inequality, and inadequacy of the health services system. The latter explanation is found to relate to the underdevelopment of U.S. primary care. In light of the position taken by the World Health Organization regarding the importance of primary care, adopting the recommendations of a new National Research Council/Institute of Medicine report and some changes in health policy could help improve the health of American children.

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Reducing Errors in the ICU:
Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit.
P. J. Pronovost et al.
Ann. Int. Med. 2004 140:1025.
Complex systems—of which ICUs are certainly an example—are breeding grounds for errors because interdependent components interact in unexpected ways. Careful planning, excellent teamwork and communication and redundancies to recheck care processes can greatly improve the safety of intensive care patients.

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Improving Patient Care:
Improvements in 1-Year Outcomes before and after a Discharge Medication Program for Patients Hospitalized with Heart Disease
Lappé JM, Muhlestein JB, Lappé DL, Badger RS, Bair TL, et al.
Ann. Int. Med 2004 141:446.
Despite evidence to support the effectiveness of a variety of interventions for the secondary prevention of cardiovascular disease, many eligible patients simply do not receive these interventions. This study found that a simple change in a hospital discharge form reminded physicians about the appropriate medications for these patients and resulted in a 19% reduction in cardiovascular mortality 1 year after discharge.

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Unclean Hands . . .Still:
Hand Hygiene among Physicians: Performance, Beliefs, and Perceptions
Pittet D, Simon A, Hugonnet S, Sauvan V, Perneger TV.
Ann. Int. Med 2004 141: 1.
Why do physicians fail to practice good hand hygiene? This observational study of 163 physicians in a university hospital found that overall adherence to hand hygiene guidelines was 57%. Factors associated with poor adherence included having busy workloads, performing activities with high risks for cross-transmission, and being in technical specialties (such as surgery and anesthesiology).

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Quality Counts:
Creating a Culture of Quality: The Remarkable Transformation of the Department of Veterans Affairs Health Care System.
Greenfield S, Kaplan SH.
Ann Int Med.2004 141:316.
The improvement of diabetes care in the Veterans Affairs and other closed health care systems represents major progress toward optimal management for chronic diseases. Applying the experience of these organizations to the broader, less organized U.S. health care delivery system will be a far more serious challenge.

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Healthcare and the Law:
Law as a Tool for Preventing Chronic Diseases: Expanding the Spectrum of Effective Public Health Strategies
Mensah GA, Goodman RA, Zaza S, Moulton AD, Kocher PL, Dietz WH, et al.
2004 CDC

Law, which is a fundamental element of effective public health policy and practice, played a crucial role in many of public health's greatest achievements of the 20th century. Still, conceptual legal frameworks for the systematic application of law to chronic disease prevention and control have not been fully recognized and used to address public health needs. Development and implementation of legal frameworks could broaden the range of effective public health strategies and provide valuable tools for the public health workforce, especially for state and local health department program managers and state and national policy makers.

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Last update on 3/20/06

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