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Letters
November 16, 2011

Cross-Level Bias and Variations in Care

Author Affiliations

Author Affiliations: Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, California (john.finney@va.gov).

JAMA. 2011;306(19):2096-2097. doi:10.1001/jama.2011.1662

To the Editor: Drs Livingston and McNutt1 highlighted the hazards of leaping from aggregated effects (averaged across patients) in intervention trials to “one-size-fits-all” health care performance measures applied to every patient. They noted this practice can devalue appropriate variation in provider care that can lead to better patient outcomes. We believe that “aggravation from aggregation” in the performance measurement realm goes beyond drawing clinical practice guidance from averaged results in clinical trials.

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