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—We agree with Dr Huff about the danger of inferring causation from the association between declining mortality and the statewide programs in New York and northern New England. In fact, the principal message of our Massachusetts study is precisely that the association may not be causal. We do not know which factors have contributed how much to these improvements. The HCFA, New York, and northern New England programs are only a few of the many changes that may have contributed.We also fully agree with Dr Huff that attention to processes of care and their relation to surgical outcomes is of crucial value in quality improvement. Both process and outcome studies are important, and they complement each other.
This letter was shown to Dr Jencks, who declined to reply.
Ghali WA, Ash AS, Hall RE, Moskowitz MA. Have Quality Improvement Efforts Decreased Mortality Rates Following Cardiac Surgery?-Reply. JAMA. 1997;277(19):1519. doi:10.1001/jama.1997.03540430031026