Introduction

This chapter will describe the development of quality assurance (audit) measures and outcomes research in the United States. Over the past two decades a number of problems have developed in the US health care system, many of which have provided a strong stimulus to push participants toward a vigorous assessment of the quality, appropriateness and effectiveness of medical care in this country.

Health care in the United States is recognised as generally being innovative and of high quality. The financing mechanisms in our system have encouraged vast amounts of research and technological innovation. It is well known that the US system is the most expensive in the world, spending $2051 per capita as opposed to $758 in England and $1483 in Canada (calculated in US dollars for 1987). It is also recognised that while we provide abundant medical care for most of our citizens, some 37 million Americans are at great risk because they have no health insurance coverage.

We have also learned that much of the care we provide may not be necessary, appropriate, or effective. As a result, we appear to be expending too many resources on care for many people while a large number go without even minimal levels of care.