Rehospitalizations among Medicare beneficiaries are prevalent and costly.

It is possible to assemble information on a diverse set of clinical performance measures that represent performance on the range of services in a health insurance program. These findings indicate substantial opportunities to improve the care delivered to Medicare beneficiaries and urgently invite a partnership among practitioners, hospitals, health plans, and purchasers to achieve that improvement. JAMA. 2000;284:1670-1676.

practices, the distal revascularization-interval ligation (DRIL) procedure has become the preferred method to treat steal syndrome. However, this operation requires a new bypass and results in ligation of the brachial artery distal to the fistula. Although plication of an arteriovenous fistula is a known technique for dealing with steal syndrome, it is rarely reported. In this article, the authors describe their technique, in a small number of patients, for plication of arteriovenous fistulas associated with clinically significant steal. Seven patients were treated with plication. Their symptoms included paresthesia, coolness, and pain in the hand and fingers. No one had ulceration. In six of seven patients, a radial artery pulse returned with compression of the fistula.Plication was performed using a Satinsky clamp as a guide for the degree of plication, with the vein narrowed by a running horizontal mattress suture of 6-0 polypropylene. The length of vein plicated was approximately 1 cm, and the extent of plication was determined by return of a palpable pulse at the wrist or a change from monophasic to a biphasic distal Doppler signal. If the Doppler signal did not improve, the Satinsky clamp was reapplied and the plication repeated, further narrowing the plicated length of the fistula. The radial pulse returned postoperatively in six of seven patients. Mean follow-up was 9 months. At 13 months, symptoms had recurred in only one patient, the patient in whom the radial pulse did not return.Comment: Many patients with steal syndrome can be managed by observation. The inflow vessel dilates, and symptoms may resolve within a few days to weeks. A basic principle of surgical therapy is to perform simple procedures that are effective in preference to more complex procedures. DRIL procedures are effective for steal, with an 83% to 100% success rate; however, they are major operations, and the brachial artery is ligated. This study serves as a reminder that simple plication may be an effective treatment for steal syndrome and should be considered as an alternative treatment for steal before performance of a DRIL procedure. Predictors of Prosthetic Graft Infection after Infrainguinal Bypass

Context.-Medicare has a legislative mandate for quality assurance, but the effectiveness of its population-based quality improvement programs has been difficult to establish.Objective.-To improve the quality of care for Medicare patients with acute myocardial infarction.Design.-Quality improvement project with baseline measurement, feedback, remeasurement, and comparison samples.Setting.-All acute care hospitals in the United States.Patients.-Preintervention and postintervention samples included all Medicare patients in Alabama, Connecticut, Iowa, and Wisconsin discharged with principal diagnoses of acute myocardial infarctions during 2 periods,