Field of medicine: Health care administration.

Format: Hardcover book.

Audience: Clinicians and administrators, as well as students in the health professions and the general public interested in health care.

Purpose: To familiarize the reader with outcomes measurement, thereby expanding public and professional demand for more sophisticated medical quality improvement initiatives.

Content: Written by journalist Michael Millenson, the book reviews the history of quality measurement in the United States. The first of its four major sections documents wide variations in medical practice and reviews a broad range of strategies developed to improve clinical outcomes. The second section explores revolutionary efforts in outcomes measurement and in employer and consumer empowerment. The third section describes, in greater depth, a wide variety of efforts to promote quality measurement and outcomes management by states, employers, business coalitions, and integrated delivery systems. The last section addresses ways in which the expansion of managed care both advances and complicates efforts to bring patients the benefits of quality measurement.

Highlights: This book covers a wide array of subjects, from the Flexner Report; the HELP information system at LDS hospital in Salt Lake City, Utah; Codman's "End Result Idea"; pre-paid group practice; evidence-based medicine; and the National Committee for Quality Assurance. General themes are highlighted by individual patient case histories, example research projects, and specific practice improvement initiatives. The references are extensive and include an excellent sampling of the relevant primary and secondary literature. The reader is aided by a detailed, accurate, thorough index. The text is enlivened by quotes from sources as diverse as Chinese proverbs, Rudyard Kipling, Thomas Hobbs, and Woodward and Bernstein.

Limitations: This generally well-written work derives not from the disciplines of health services research, history of medicine, or health care policy, but rather from the field of journalism. Therefore, it includes occasional lapses in both technical detail and emphasis. Although the medical facts are largely accurate, there are a few misstatements-for example, diazepam is referred to as a drug widely used in the 1950s, and massive hepatic necrosis is described as involving damage to the kidneys. The dramatization of events and individual contributions adds vibrancy to the text, but perspective is sometimes lost, and the truly revolutionary ideas are occasionally blurred together with evolutionary developments.

Context: This book addresses both the current state of knowledge and the science of health care quality improvement. With its lively writing and compelling case histories, it offers more to lay readers and students of the health professions than other recent works more narrowly focused on health system changes, such as Strong Medicine by Halverson (Random House, 1993). Intended for seasoned professionals in health administration and clinical practice, this book offers a broad perspective and addresses a wide variety of topics but with less depth than scholarly publications, such as Accountability and Quality in Health Care: The New Responsibility, edited by Markson and Nash (Joint Commission for the Accreditation of Healthcare Organizations, 1995). Demanding Medical Excellence is more a work of popular history and social commentary than a work of scholarship. Nonetheless, with its detailed and thoughtful analysis of key developments in health care quality, it is a "must read" for health care students and practitioners and is perhaps comparable in impact to the scholarly, landmark Social Transformation of American Medicine, by Starr (Basic Books, 1982).

Reviewer: Eugene C. Rich, MD, Creighton University School of Medicine, Omaha, Nebraska.