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This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee on March 4, 2000, and by the AGA Governing Board on May 21, 2000.

Benchmarking is generally considered to be an important tool for quality improvement. Traditional approaches to benchmarking have relied on subjective identification of 'leaders in the field'. We derive an objective, reproducible and attainable Achievable Benchmark of Care (ABC) by measuring and analysing performance on process-of-care indicators. Three characteristics of the ABC that we deem essential are: (1) benchmarks represent a measurable level of excellence; (2) benchmarks are demonstrably attainable; (3) benchmarks are derived from data in an objective, reproducible and predetermined fashion. From these characteristics it follows that (4) providers with high performance are selected to define a level of excellence in a predetermined fashion, but (5) providers with high performance on small numbers of cases do not influence unduly benchmark levels. We use the 'pared mean' to operationalize the ABC. Roughly, the pared mean summarizes the performance of top-ranked providers whereby at least 10% of the patient pool across all providers is included. Bayesian estimators for adjustment of performance of providers with small sample sizes are used to rank providers. Randomized controlled trials to assess the independent effect of the ABC in quality improvement projects are under way. We have developed a methodology objectively and reproducibly to derive a level of excellent, attainable performance, based on measured performance by a group of providers. The ABC can be applied to groups of providers in communities, to institutions and departments within them, or to individual practitioners.

The literature is relatively silent on how managers should deal with a reduction in force (RIF). One difficulty is dealing with the "surviving" staff and maintaining credibility. It is important to assess the organizational climate and plan and carry out a forum for the remaining staff. It is especially important to consider the psychologic effects of staff reduction, which include a sense of loss of control, hostility, and a tendency to want to find fault or blame. Lack of attention to these matters can lead to a RIF that compromises the work effectiveness of the organization by reducing the dedication of surviving members of the organization.

A critical review of the literature is undertaken to examine the state of the art and degree of articulation of theories, methods, and findings between health care marketing and the traditional "generic" marketing literature as related to knowledge of information use by and advertising to the elderly consumer. Evaluative criteria suggestive of scientific rigor are applied to this domain as consistencies, discrepancies, and gaps are identified. Recommendations for future research are advanced.