EDITORIALS
friction in the system-and the cost-being increased by attempts to impose regulations and controls upon it, and is this worth the cost? It seems certain that many dollars now being spent for health could either be saved or spent more productively for health if questions such as these were asked and answered. And this is something that can be done now. In the longer range it will be necessary to face up to the ever growing disparity between health resources and burgeoning needs. Judgmental decisions involving personal goals, societal goals and contemporary ethics will need to be made at all levels of health care. These will involve doctors, patients, consumers, administrators and the public. It will be necessary to develop the means by which a broadly based consensus can be achieved at all levels of health care on where and for what the relatively limited dollars available in this field
will be spent, be they public or private dollars. It is clear that physicians will be involved in all of this. Their knowledge of what constitutes health and its disorders, their direct experience with patients and their more recent experience with the problems created as well as solved by governmental and other interventions will be essential. Their advice should be sought and listened to and they should take part in the decisions at every level. It is not too soon to begin to get some new and more realistic approaches to all of this into place, so that the dollars for health care can both be conserved and used more efficiently and effectively.
Venous Thrombosis
tributed in the United States, has been of greatest value in clinical investigation, where it has provided objective data on occurrence rates. Its most important contribution so far has probably been the trial and proof of low dose heparin as a prophylactic agent in postoperative patients.3'4 Labeled fibrinogen scanning will undoubtedly continue to be valuable as a surveillance method, but its greater application in clinical practice may prove to be as a diagnostic measure in patients in whom a preformed venous thrombus is suspected to exist, even though the technique is less sensitive with established thrombi than when employed as a screening procedure and administered in advance in high risk cases. Recent noninvasive additions to the diagnostic armamentarium, such as plethysmographic techniques,5-7 appear to achieve their highest degree of accuracy in detection of major thrombi in the femoral and iliac veins, which are probably the source of most serious pulmonary emboli. Therefore, they are promising methods for confirmation of a clinical impression based on swelling and tenderness in the thigh. Their advocates claim that, if they give negative findings, they can provide comforting assurance of a minimal hazard of major pulmonary embolism.8 However, these techniques are essentially blind to thrombi in the calves, and this point must be kept in mind in considering their clinical applicability. The litera-
FROM TIME TO TIME, new technology provides both the impetus and the means for a dramatic gain in our ability to cope with a serious disease. So it is with venous thromboembolism. The recent renewal of interest in this familiar problem can be traced largely to the development of improved diagnostic methods. Sensitive and objective techniques now available have led to an appreciation of the prevalence of thromboembolism complicating the postoperative state and occurring in nonoperative patients; they have provided increased understanding of the natural history of the disorder; they have underscored the insensitivity and unreliability of diagnosis when based solely on clinical criteria, and they have afforded investigators a means of generating solid data in studies of prevention or treatment. Radiographic phlebography and scanning of the lower limbs for uptake of labeled fibrinogen have been particularly influential. The former procedure is at present regarded as the ultimate standard for showing the presence of venous thrombosis in the lower extremities of living patients, when carried out by modern techniques."2 Although invasive and not without morbidity, it is superior even to routine autopsy in its sensitivity. The latter method, available for general use now that 1251-labeled fibrinogen is commercially dis-
220
SEPTEMBER 1976 * 125 * 3
-MSMW REFERENCE 1. Trends Affecting U.S. Health Care System. Commissioned by DHEW and prepared by the Cambridge Research Institute. DHEW Publication No. HRA 76-14503. Washington, DC, Government Printing Office, Jan 1976
EDITORIALS
ture on calf thrombi is inconclusive with regard to their ultimate potential for harm, and there is controversy about the relative necessity for their diagnosis, and for their treatment once they are found. That thrombi confined to the calf can lead to embolization is certain. The points at issue relate to frequency, to severity and to how often this occurs without preliminary extension into the thigh.' Having no certain guidelines in respect to these important questions, clinicians should at least be aware of the limitations of noninvasive methods. Careful studies employing objective diagnostic techniques have considered the question of preventing venous thromboembolism in high risk patients, and several modes of prophylaxis have now been shown to be effective in specific patient groups. It is established, for example, that in patients undergoing elective general surgical operations, small subcutaneous doses of heparin will prevent postoperative venous thrombosis and pulmonary embolism, including fatal pulmonary embolism.4 The frequency of bleeding complications, while increased, is not great and, excepting patients with an underlying predisposition to hemorrhage, is an acceptable price to pay for freedom from thromboembolism. Unfortunately, low dose heparin appears to be ineffective in patients with fractures of the hip and in those in whom elective surgical operations on the hip are done,10"'1 and a reasonable extrapolation from this experience would require one to employ a more potent form of prophylaxis in other very high risk patients, such as those with a history of previous thrombo-
embolic disease. Oral anticoagulants (that is, warfarin and its congeners) have been found effective in these high risk situations. An enormous literature exists in support of the ability of vitamin K antagonists to prevent venous thromboembolism,12"13 and there can be no doubt that they are effective in conditions in which low dose heparin is insufficient. However, an increase in bleeding complications with warfarin has limited acceptance of this mode of prophylaxis in postoperative patients, despite proof of the efficacy of the drug. For patients whose susceptibility to bleeding does not create a hazard in the use of warfarin, it is probably the antithrombotic agent of choice. Drugs whose antithrombotic effect results from their ability to alter platelet function have been evaluated as prophylactic agents, and there is evidence for their success in selected instances.12
Dextran has a large literature to confirm its effectiveness, but frequent side effects such as pulmonary edema and allergic reactions have prevented it from wide adoption as a routine prophylactic drug. Support for the use of aspirin, hydroxychloroquine and other antiplatelet agents is also to be found, but the data are incomplete and further evaluation is necessary. Although early ambulation may be adequate for prevention of venous thrombosis in nonoperative patients, it is inadequate in surgical cases, and elastic stockings and elevation of the legs have also been found insufficient to prevent deep vein thrombosis in high risk patients.14"15 Other physical measures, however, appear more promising. Electrical stimulation of the calf muscles and compression of the calves by inflatable boots have been shown to reduce venous thrombosis. Their efficacy has been documented in general surgical patients,"' in patients undergoing open urological operations'7 and in neurosurgical patients,'8 the last being particularly of interest because they are not candidates for the use of antithrombotic drugs. Patients at very high risk may not receive adequate protection from these techniques,19 and the task at hand is to define the groups in which their use is appropriate and in which they offer an alternative to pharmacologic agents. The availability of a number of effective preventive techniques offers a physician the opportunity to prevent a complication thai is frequent, often disabling and occasionally lethal. One may expect that the wider use of antithrombotic prophylaxis will characterize good practice in the coming years. EDWIN W. SALZMAN, MD Professor of Surgery Harvard Medical School Beth Israel Hospital Boston REFERENCES 1. Williams WJ: Venography. Circulation 47:220, 1973 2. Rabinov K, Paulin S: Roentgen diagnosis of venous thrombosis in the leg. Arch Surg 104:134, 1972 3. Kakkar VV: The diagnosis of deep vein thrombosis using the '2'I fibrinogen test. Arch Surg 104:152, 1972 4. Kakkar VV, Corrigan TP, Fossard DP: Prevention of fatal postoperative pulmonary embolism by low doses of heparin: An international multicentre trial. Lancet ii:45, 1975 5. Wheeler HB, Pearson D, O'Connell D, et al: Impedance phlebography. Arch Surg 104:164, 1972 6. Cranley JJ, Canos AJ, Sull WJ, et al: Phlebographic technique for diagnosing deep venous thrombosis of the lower extremities. Surg Gynecol Obstet 141:331, 1975 7. Barnes RW, Collicott PE, Mozersky DJ, et al: Non-invasive quantitation of maximum venous outflow in acute thrombophlebitis. Surgery 72:971, 1972 8. Hull R, vanAken WG, Hirsh J, et al: Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis. Circulation 53:696, 1976 9. Adar R, Salzman EW: Treatment of thrombosis of veins of the lower extremities. N Engl J Med 292:348, 1975 10. Evarts CM, Alfidi RJ: Thromboembolism after total hip reconstruction: failure of low doses of heparin in prevention. JAMA 225:515, 1973
THE WESTERN JOURNAL OF MEDICINE
221
EDITORIALS I1. Harris WH, Salzman EW, Athanasoulis C, et al: Comparison of warfarin, low molecular weight dextran, aspirin and subcutaneous heparin in prevention of venous thromboembolism following total hip replacement. J Bone Joint Surg 56A: 1552, 1974 12. Clagett GP, Salzman EW: Prevention of venous thromboembolism, In Sonnenblick ElH, Lesch M (Eds): Progress in Cardiovascular Diseases, Vol. XVlI, No. 5. New York, Grune & Stratton, 1975, p 345 13. Salzman EW, Harris WH: Prevention of venous thromboembolism in orthopaedic patients. J Bone Joint Surg (in press) 14. Rosengarten DS, Laird J, Jeyasingh K, et al: The failure of compression stockings (tubigrip) to prevent deep venous thrombosis after operation. Br J Surg 57:296, 1970 15. Rosengarten DS, Laird J: The effect of leg elevation on the incidence of deep-vein thrombosis after operation. Br J Surg 58: 182, 1971 16. Collins REC, Salzman EW: Physical methods of prophylaxis against deep vein thrombosis, In Fratantoni J, Wessler S (Eds): Prophylactic Therapy of Deep Vein Thrombosis and Pulmonary Embolism. HEW pub. No. (NIH) 76-866, 1975, p 158 17. Coe N, Collins R, Klein LA, et at: Prevention of thromboembolism in post-surgical urology patients. (Submitted for publication) 18. Turpie AG, Beattie WS, Gallus AS, et al: Prevention of venous thrombosis in neurosurgical patients by intermittent calf compression. Proc. Vth Congress, Internat. Soc. on Thrombosis and Haemostasis, Paris, Jul 1975, p 366 19. Harris WH, Raines JK, Athanasoulis C, et al: External pneumatic compression versus warfarin for the reduction of deep venous thrombosis following total hip replacement in patients w-ith prior thromboembolic disease. (Submitted for publication)
PSRO - Update 1976 IT IS NOW well over three years since PL 92-603 with its mandate for Professional Standards Review Organizations (PSRO's) became law and it is time for another commentary in these columns. This is an exceedingly complex law and progress in implementation has been slow, partly because the funding has been at little more than a subsistence level, and perhaps partly due to some wisdom and restraint on the part of those responsible for its implementation. There are now 87 PSRO'S with conditional contracts, 33 more with planning contracts and 83 of the 203 designated PSRO areas still have no contracts. PL 94-182 extended the time professional organizations would have priority in establishing PSRO'S from 1 January 1976 to 1 January 1978-except where the membership association representing the largest number of doctors of medicine in an area has adopted a formal policy of opposition to PSRO'S, or where a professional organization proposed by the Secretary of the Department of Health, Education and Welfare (DHEW) for designation as a PSRO has been voted down. So far this has occurred infrequently. It now appears that further progress depends as much on the availability of the necessary funding as on anything else. The accomplishments to date make possible some reflections on specific problems as these have emerged and evolved. The relationship be222
SEPTEMBER 1976 * 125 * 3
tween cost control and quality assurance-the apparently conflicting stated aims of the lawhas not yet been defined. However, one senses a growing realization that one is not acceptable without the other and that somehow a reasonable accommodation of the two must be achieved. It remains to be seen how this generic problem will be solved. With regard to the less generic and more specific, the bureaucratic infighting between the "H" and "W" within DHEW seems to be less obvious than it was, and an end run by "W" on utilization review regulations was restrained by the courts after suit was brought by the American Medical Association. Presumably new and more workable utilization review regulations will be forthcoming. Also in the crucible is the relationship of the national PSRO administration to local PSRO'S, particularly what is the legal authority of the PSRO "letters of transmittal" and what "due process" is available to a local PSRO in the event of disagreement. These issues are fundamental and pertain to the rights of a local PSRO as a party to a contract with the federal government. Another problem, under discussion and also unresolved, is the collection, use, storage, "ownership" and confidentiality of the patient care data to be collected by the local PSRO'S. Again the issues are fundamental and involve rights to privacy, the rights and responsibilities of practitioners to exercise their judgment and expertise (and the expectations of their patients and consumers of health care that they will do so), and the right and responsibility of government to monitor public funds and to achieve what it perceives to be the nation's goals. In any commentary on the PSRO law it is also well to remember that some basic assumptions of the law are still just that-assumptions. It is assumed but has not yet been really shown (1) that systematic peer review can actually assure quality of care, (2) that by eliminating excessive utilization, costs can be significantly reduced or (3) that the administrative paraphernalia that is to be set up will be cost-or quality-effective. Nor should it be forgotten that the technology that will be needed to accomplish the stated purposes of the law has hardly been developed. So there is much that is unresolved and much that remains to be seen. As well as being based on untested assumptions and requiring technology which has yet to be developed, this complex law addresses many sensitive issues that strike at some
friction in the system-and the cost-being increased by attempts to impose regulations and controls upon it, and is this worth the cost? It seems certain that many dollars now being spent for health could either be saved or spent more productively for health if questions such as these were asked and answered. And this is something that can be done now. In the longer range it will be necessary to face up to the ever growing disparity between health resources and burgeoning needs. Judgmental decisions involving personal goals, societal goals and contemporary ethics will need to be made at all levels of health care. These will involve doctors, patients, consumers, administrators and the public. It will be necessary to develop the means by which a broadly based consensus can be achieved at all levels of health care on where and for what the relatively limited dollars available in this field
will be spent, be they public or private dollars. It is clear that physicians will be involved in all of this. Their knowledge of what constitutes health and its disorders, their direct experience with patients and their more recent experience with the problems created as well as solved by governmental and other interventions will be essential. Their advice should be sought and listened to and they should take part in the decisions at every level. It is not too soon to begin to get some new and more realistic approaches to all of this into place, so that the dollars for health care can both be conserved and used more efficiently and effectively.
Venous Thrombosis
tributed in the United States, has been of greatest value in clinical investigation, where it has provided objective data on occurrence rates. Its most important contribution so far has probably been the trial and proof of low dose heparin as a prophylactic agent in postoperative patients.3'4 Labeled fibrinogen scanning will undoubtedly continue to be valuable as a surveillance method, but its greater application in clinical practice may prove to be as a diagnostic measure in patients in whom a preformed venous thrombus is suspected to exist, even though the technique is less sensitive with established thrombi than when employed as a screening procedure and administered in advance in high risk cases. Recent noninvasive additions to the diagnostic armamentarium, such as plethysmographic techniques,5-7 appear to achieve their highest degree of accuracy in detection of major thrombi in the femoral and iliac veins, which are probably the source of most serious pulmonary emboli. Therefore, they are promising methods for confirmation of a clinical impression based on swelling and tenderness in the thigh. Their advocates claim that, if they give negative findings, they can provide comforting assurance of a minimal hazard of major pulmonary embolism.8 However, these techniques are essentially blind to thrombi in the calves, and this point must be kept in mind in considering their clinical applicability. The litera-
FROM TIME TO TIME, new technology provides both the impetus and the means for a dramatic gain in our ability to cope with a serious disease. So it is with venous thromboembolism. The recent renewal of interest in this familiar problem can be traced largely to the development of improved diagnostic methods. Sensitive and objective techniques now available have led to an appreciation of the prevalence of thromboembolism complicating the postoperative state and occurring in nonoperative patients; they have provided increased understanding of the natural history of the disorder; they have underscored the insensitivity and unreliability of diagnosis when based solely on clinical criteria, and they have afforded investigators a means of generating solid data in studies of prevention or treatment. Radiographic phlebography and scanning of the lower limbs for uptake of labeled fibrinogen have been particularly influential. The former procedure is at present regarded as the ultimate standard for showing the presence of venous thrombosis in the lower extremities of living patients, when carried out by modern techniques."2 Although invasive and not without morbidity, it is superior even to routine autopsy in its sensitivity. The latter method, available for general use now that 1251-labeled fibrinogen is commercially dis-
220
SEPTEMBER 1976 * 125 * 3
-MSMW REFERENCE 1. Trends Affecting U.S. Health Care System. Commissioned by DHEW and prepared by the Cambridge Research Institute. DHEW Publication No. HRA 76-14503. Washington, DC, Government Printing Office, Jan 1976
EDITORIALS
ture on calf thrombi is inconclusive with regard to their ultimate potential for harm, and there is controversy about the relative necessity for their diagnosis, and for their treatment once they are found. That thrombi confined to the calf can lead to embolization is certain. The points at issue relate to frequency, to severity and to how often this occurs without preliminary extension into the thigh.' Having no certain guidelines in respect to these important questions, clinicians should at least be aware of the limitations of noninvasive methods. Careful studies employing objective diagnostic techniques have considered the question of preventing venous thromboembolism in high risk patients, and several modes of prophylaxis have now been shown to be effective in specific patient groups. It is established, for example, that in patients undergoing elective general surgical operations, small subcutaneous doses of heparin will prevent postoperative venous thrombosis and pulmonary embolism, including fatal pulmonary embolism.4 The frequency of bleeding complications, while increased, is not great and, excepting patients with an underlying predisposition to hemorrhage, is an acceptable price to pay for freedom from thromboembolism. Unfortunately, low dose heparin appears to be ineffective in patients with fractures of the hip and in those in whom elective surgical operations on the hip are done,10"'1 and a reasonable extrapolation from this experience would require one to employ a more potent form of prophylaxis in other very high risk patients, such as those with a history of previous thrombo-
embolic disease. Oral anticoagulants (that is, warfarin and its congeners) have been found effective in these high risk situations. An enormous literature exists in support of the ability of vitamin K antagonists to prevent venous thromboembolism,12"13 and there can be no doubt that they are effective in conditions in which low dose heparin is insufficient. However, an increase in bleeding complications with warfarin has limited acceptance of this mode of prophylaxis in postoperative patients, despite proof of the efficacy of the drug. For patients whose susceptibility to bleeding does not create a hazard in the use of warfarin, it is probably the antithrombotic agent of choice. Drugs whose antithrombotic effect results from their ability to alter platelet function have been evaluated as prophylactic agents, and there is evidence for their success in selected instances.12
Dextran has a large literature to confirm its effectiveness, but frequent side effects such as pulmonary edema and allergic reactions have prevented it from wide adoption as a routine prophylactic drug. Support for the use of aspirin, hydroxychloroquine and other antiplatelet agents is also to be found, but the data are incomplete and further evaluation is necessary. Although early ambulation may be adequate for prevention of venous thrombosis in nonoperative patients, it is inadequate in surgical cases, and elastic stockings and elevation of the legs have also been found insufficient to prevent deep vein thrombosis in high risk patients.14"15 Other physical measures, however, appear more promising. Electrical stimulation of the calf muscles and compression of the calves by inflatable boots have been shown to reduce venous thrombosis. Their efficacy has been documented in general surgical patients,"' in patients undergoing open urological operations'7 and in neurosurgical patients,'8 the last being particularly of interest because they are not candidates for the use of antithrombotic drugs. Patients at very high risk may not receive adequate protection from these techniques,19 and the task at hand is to define the groups in which their use is appropriate and in which they offer an alternative to pharmacologic agents. The availability of a number of effective preventive techniques offers a physician the opportunity to prevent a complication thai is frequent, often disabling and occasionally lethal. One may expect that the wider use of antithrombotic prophylaxis will characterize good practice in the coming years. EDWIN W. SALZMAN, MD Professor of Surgery Harvard Medical School Beth Israel Hospital Boston REFERENCES 1. Williams WJ: Venography. Circulation 47:220, 1973 2. Rabinov K, Paulin S: Roentgen diagnosis of venous thrombosis in the leg. Arch Surg 104:134, 1972 3. Kakkar VV: The diagnosis of deep vein thrombosis using the '2'I fibrinogen test. Arch Surg 104:152, 1972 4. Kakkar VV, Corrigan TP, Fossard DP: Prevention of fatal postoperative pulmonary embolism by low doses of heparin: An international multicentre trial. Lancet ii:45, 1975 5. Wheeler HB, Pearson D, O'Connell D, et al: Impedance phlebography. Arch Surg 104:164, 1972 6. Cranley JJ, Canos AJ, Sull WJ, et al: Phlebographic technique for diagnosing deep venous thrombosis of the lower extremities. Surg Gynecol Obstet 141:331, 1975 7. Barnes RW, Collicott PE, Mozersky DJ, et al: Non-invasive quantitation of maximum venous outflow in acute thrombophlebitis. Surgery 72:971, 1972 8. Hull R, vanAken WG, Hirsh J, et al: Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis. Circulation 53:696, 1976 9. Adar R, Salzman EW: Treatment of thrombosis of veins of the lower extremities. N Engl J Med 292:348, 1975 10. Evarts CM, Alfidi RJ: Thromboembolism after total hip reconstruction: failure of low doses of heparin in prevention. JAMA 225:515, 1973
THE WESTERN JOURNAL OF MEDICINE
221
EDITORIALS I1. Harris WH, Salzman EW, Athanasoulis C, et al: Comparison of warfarin, low molecular weight dextran, aspirin and subcutaneous heparin in prevention of venous thromboembolism following total hip replacement. J Bone Joint Surg 56A: 1552, 1974 12. Clagett GP, Salzman EW: Prevention of venous thromboembolism, In Sonnenblick ElH, Lesch M (Eds): Progress in Cardiovascular Diseases, Vol. XVlI, No. 5. New York, Grune & Stratton, 1975, p 345 13. Salzman EW, Harris WH: Prevention of venous thromboembolism in orthopaedic patients. J Bone Joint Surg (in press) 14. Rosengarten DS, Laird J, Jeyasingh K, et al: The failure of compression stockings (tubigrip) to prevent deep venous thrombosis after operation. Br J Surg 57:296, 1970 15. Rosengarten DS, Laird J: The effect of leg elevation on the incidence of deep-vein thrombosis after operation. Br J Surg 58: 182, 1971 16. Collins REC, Salzman EW: Physical methods of prophylaxis against deep vein thrombosis, In Fratantoni J, Wessler S (Eds): Prophylactic Therapy of Deep Vein Thrombosis and Pulmonary Embolism. HEW pub. No. (NIH) 76-866, 1975, p 158 17. Coe N, Collins R, Klein LA, et at: Prevention of thromboembolism in post-surgical urology patients. (Submitted for publication) 18. Turpie AG, Beattie WS, Gallus AS, et al: Prevention of venous thrombosis in neurosurgical patients by intermittent calf compression. Proc. Vth Congress, Internat. Soc. on Thrombosis and Haemostasis, Paris, Jul 1975, p 366 19. Harris WH, Raines JK, Athanasoulis C, et al: External pneumatic compression versus warfarin for the reduction of deep venous thrombosis following total hip replacement in patients w-ith prior thromboembolic disease. (Submitted for publication)
PSRO - Update 1976 IT IS NOW well over three years since PL 92-603 with its mandate for Professional Standards Review Organizations (PSRO's) became law and it is time for another commentary in these columns. This is an exceedingly complex law and progress in implementation has been slow, partly because the funding has been at little more than a subsistence level, and perhaps partly due to some wisdom and restraint on the part of those responsible for its implementation. There are now 87 PSRO'S with conditional contracts, 33 more with planning contracts and 83 of the 203 designated PSRO areas still have no contracts. PL 94-182 extended the time professional organizations would have priority in establishing PSRO'S from 1 January 1976 to 1 January 1978-except where the membership association representing the largest number of doctors of medicine in an area has adopted a formal policy of opposition to PSRO'S, or where a professional organization proposed by the Secretary of the Department of Health, Education and Welfare (DHEW) for designation as a PSRO has been voted down. So far this has occurred infrequently. It now appears that further progress depends as much on the availability of the necessary funding as on anything else. The accomplishments to date make possible some reflections on specific problems as these have emerged and evolved. The relationship be222
SEPTEMBER 1976 * 125 * 3
tween cost control and quality assurance-the apparently conflicting stated aims of the lawhas not yet been defined. However, one senses a growing realization that one is not acceptable without the other and that somehow a reasonable accommodation of the two must be achieved. It remains to be seen how this generic problem will be solved. With regard to the less generic and more specific, the bureaucratic infighting between the "H" and "W" within DHEW seems to be less obvious than it was, and an end run by "W" on utilization review regulations was restrained by the courts after suit was brought by the American Medical Association. Presumably new and more workable utilization review regulations will be forthcoming. Also in the crucible is the relationship of the national PSRO administration to local PSRO'S, particularly what is the legal authority of the PSRO "letters of transmittal" and what "due process" is available to a local PSRO in the event of disagreement. These issues are fundamental and pertain to the rights of a local PSRO as a party to a contract with the federal government. Another problem, under discussion and also unresolved, is the collection, use, storage, "ownership" and confidentiality of the patient care data to be collected by the local PSRO'S. Again the issues are fundamental and involve rights to privacy, the rights and responsibilities of practitioners to exercise their judgment and expertise (and the expectations of their patients and consumers of health care that they will do so), and the right and responsibility of government to monitor public funds and to achieve what it perceives to be the nation's goals. In any commentary on the PSRO law it is also well to remember that some basic assumptions of the law are still just that-assumptions. It is assumed but has not yet been really shown (1) that systematic peer review can actually assure quality of care, (2) that by eliminating excessive utilization, costs can be significantly reduced or (3) that the administrative paraphernalia that is to be set up will be cost-or quality-effective. Nor should it be forgotten that the technology that will be needed to accomplish the stated purposes of the law has hardly been developed. So there is much that is unresolved and much that remains to be seen. As well as being based on untested assumptions and requiring technology which has yet to be developed, this complex law addresses many sensitive issues that strike at some
