Proposed new diagnoses of anxious depression and bodily stress syndrome in ICD-11-PHC: an international focus group study.

BACKGROUND: The World Health Organization is revising the primary care classification of mental and behavioural disorders for the International Classification of Diseases (ICD-11-Primary Health Care (PHC)) aiming to reduce the disease burden associated with mental disorders among member countries. OBJECTIVE: To explore the opinions of primary care professionals on proposed new diagnostic entities in draft ICD-11-PHC, namely anxious depression and bodily stress syndrome (BSS). METHODS: Qualitative study with focus groups of primary health-care workers, using standard interview schedule after draft ICD-11-PHC criteria for each proposed entity was introduced to the participants. RESULTS: Nine focus groups with 4-15 participants each were held at seven locations: Austria, Brazil, Hong Kong, New Zealand, Pakistan, Tanzania and United Kingdom. There was overwhelming support for the inclusion of anxious depression, which was considered to be very common in primary care settings. However, there were concerns about the 2-week duration of symptoms being too short to make a reliable diagnosis. BSS was considered to be a better term than medically unexplained symptoms but there were disagreements about the diagnostic criteria in the number of symptoms required. CONCLUSION: Anxious depression is well received by primary care professionals, but BSS requires further modification. International field trials will be held to further test these new diagnoses in draft ICD-11-PHC.

Mental health problems in primary care. A research agenda.

BACKGROUND: The North American Primary Care Research Group (NAPCRG) Task Force on Mental Health Problems was commissioned to explore critical research and policy issues in mental health and to develop a primary care research agenda for review and action by NAPCRG. This paper presents the key findings and recommendations of the task force. METHODS: As co-chairpersons of the task force, we performed a comprehensive review of the primary care mental health literature using MEDLINE searches with manual follow-up and personal communications with many active researchers in the field. Task force members participated in the editing and refinement of this paper through electronic mail and a series of face-to-face meetings. CONCLUSIONS: Rapid changes in the US health care environment threaten to undo the integration of mental and physical health that is at the heart of primary care. It will be necessary for the primary care leaders in the mental health field to step forward to guide policymakers, purchasers, and the public as primary care is reengineered for the next generation. Efforts to use episode of care and comorbidity recording within electronic medical record systems, particularly in cooperation with managed care corporations or primary care research networks, may represent the most effective strategy for promoting the integration of mental health services into primary care. The most promising area for original research may be the exploration of common mental health problems in the context of routine primary care practice.

False positives, false negatives, and the validity of the diagnosis of major depression in primary care.

OBJECTIVE: To explore the issues of diagnostic specificity and psychiatric "caseness" (i.e., whether a patient meets the conditions to qualify as a "case" of a disease or syndrome) for major depression in the primary care setting. DESIGN: A cross-sectional study comparing the demographic, clinical, and mental health characteristics of patients identified as depressed by their family physicians with those meeting diagnostic criteria for major depression on the criterion standard Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. SETTING: The offices of 50 family physicians from private and academic practice in southeast Michigan. PATIENTS: A total of 1580 consecutive adult patients being seen for routine primary care services, from whom a weighted sample of 372 patients completed a set of mental health screening and diagnostic instruments. MAIN OUTCOME MEASURES: Patients were assigned to 1 of 4 groups (true positive, false positive, false negative, and true negative) based on clinician identification and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition diagnosis. Differences between the 4 groups in demographic and clinical characteristics, scores on mental health instruments and mental health history were explored. RESULTS: Physician identification of depression was strongly associated with increased familiarity with the patient and the presence of suggestive clinical cues, such as history of or treatment for depression, patient distress, and presence of vegetative symptoms. Patients in the false-positive group displayed significantly higher levels of distress and impairment and were significantly more likely to have a history of mental health problems and treatment than were those in the true-negative group. The 2 "misidentified" groups, false positives and false negatives, were indistinguishable in their clinical characteristics (impairment, distress, or mental health history). Both groups' scores occupied the middle ground between true positives and true negatives on most clinical characteristics. Physicians appeared to discriminate between these 2 groups on the basis of their knowledge of the patient's clinical history. CONCLUSIONS: Misidentification of depression in primary care may be in part an artifact of the use of the psychiatric model of caseness in the primary care setting. Our results are most consistent with a chronic disease-based model of depressive disorder, in which patients classified as false positive and false negative occupy a clinical middle ground between clearly depressed and clearly nondepressed patients. Family physicians appear to respond to meaningful clinical cues in assigning the diagnosis of depression to these distressed and impaired patients.

Developing a CQI program in a family medicine department.

BACKGROUND: Efforts to implement continuous quality improvement (CQI) principles in ambulatory or primary care settings still lag behind efforts in the hospital setting. Many physicians view the concept of CQI with unconcealed skepticism; the process of ambulatory care is very different from that of hospital-based care; and the data necessary to guide CQI efforts are often either missing or inaccurate in the outpatient setting. Since fall 1995, the Department of Family Medicine (DFM) at the University of Michigan (Ann Arbor), including approximately 35 faculty members at seven family practice sites, has been engaged in CQI projects. PLANNING AND IMPLEMENTATION: The CQI committee had a six-month deadline to lay out a plan for educating all faculty and staff in the importance of the CQI approach to problems; design methods for all faculty and staff to buy in to the concepts; and develop a plan to address basic clinical CQI activities, administrative systems change and work environment improvement, and larger ad hoc projects in clinical care, educational programs, and research programs. IMPLEMENTATION: CQI activities were incorporated into the routine monthly business agendas at each clinical site, each of which had a functioning local committee and had begun development of at least one CQI project. PROJECTING INTO THE FUTURE AND CONCLUSIONS: Cost cutting has further moved CQI from the sideline to center stage in the DFM's activities. An effective CQI program can be a major asset in the current competitive health care market, but designing and implementing an outpatient CQI program is a difficult and complex process. Three major problems--the ongoing resistance to change, the slow pace of adding CQI projects to already overburdened work schedules, and the need to conduct the program with ever-decreasing resources available-persist.

Effects of recent and past major depression and distress on self-concept and coping.

The Self-Appraisal Questionnaire (J. C. Coyne & M. M. Calarco, 1995) was used to examine how primary care and psychiatric outpatients with recent or past major depression appraised their prospects and structured their lives. They were compared with nondistressed and distressed primary care patients. Both depressed groups scored higher than the nondistressed patients for Lack of Energy, Management of Burden on Others, Need to Maintain a Balance in Life, Fear of Taking Risks, Imposition of Limitations on Life, and Sense of Stigma. The distressed group fell between the depressed psychiatric and the nondistressed groups, and generally did not differ from the depressed primary care group. Past depression did not explain differences associated with more recent depression and distress. Distress entails a need to manage its effects on others, but depression in psychiatric patients may produce a more profound reorganization of self-concept, relationships, and coping.

Depression in the family physician's office: what the psychiatrist needs to know: the Michigan Depression Project.

A rapidly growing body of research suggests that depression in primary care may differ from that in psychiatry in its nature, severity, comorbidity, and responsiveness to treatment. The Michigan Depression Project is a long-term series of studies designed to explore the twin assumptions that depressed primary care patients are similar to depressed psychiatric patients and that identical treatment will benefit both groups. Major findings are (1) criterion-based diagnosis of major depressive disorder in primary care includes many patients with mild depression and little to no impairment; (2) the onset of depression among family practice patients-but not psychiatric patients-is usually preceded by a severe life event; (3) in primary care, outcome for patients with undetected depression appears to be comparable to that for those with detected depression; and (4) family physicians appear to employ historical cues in assigning the diagnosis of depression to distressed and impaired patients. The results of the Michigan Depression Project and the recent work of other researchers suggest that the challenges facing primary care physicians in the diagnosis and treatment of depressed patients are daunting. These challenges lead to a set of consultative skills and behaviors on the part of psychiatrists that may be different than generally expected. One-time, stand-alone psychiatric consultations are often needed, because neither the primary care physician nor the patient desires the psychiatric care to be "carved out" from the continuing care of a set of chronic problems. Future intervention studies should compare subgroups of patients who appear most in need of treatment (on the basis of functional impact) with those who are mildly depressed and barely meet diagnostic criteria. These studies will help primary care physicians focus their energies and therapies where they will have the most benefit in treating what is clearly a common and important, but still poorly understood, problem in primary care medical practice.

Mental health problems in primary care: a research agenda.

PURPOSE: The NAPCRG Task Force on Mental Health Problems was commissioned to explore critical research and policy issues in mental health and to develop a primary care research agenda for review and action by NAPCRG. This "White Paper" presents the key findings and recommendations of the Task Force. METHODS: A comprehensive review of the primary care mental health literature, using MEDLINE searches with manual follow up, and personal communications with many active researchers in the field were performed by the authors; Task Force members participated in the editing and refinement of the White Paper in a series of email and face-to-face meetings. SUMMARY AND CONCLUSIONS: Although primary care researchers have made major contributions to our growing understanding of mental health problems as they exist in the "real world" of primary care, rapid changes in the U.S. health care environment threaten to undo the integration of mental and physical health that is at the heart of primary care. It will be necessary for the primary care leaders in this field to step forward to guide policy-makers, purchasers, and the public as primary care is reengineered for the next generation. Efforts to operationalize episode of care and comorbidity recording with EMR systems, particularly in cooperation with managed care corporations and/or primary care research networks, may represent the most effective strategy for promoting the integration of mental health services into primary care. The most promising area for research in the immediate future may be descriptive studies that capture and explore the clinical epidemiology of common mental health problems as they occur in routine practice.

The effects of insurance coverage on the quality of prenatal care.

OBJECTIVE: To compare the quality of prenatal care provided to patients with traditional fee-for-service, health maintenance organization, and Medicaid insurance using an evidence-based, community-derived prenatal care guideline. DESIGN: Retrospective cohort study. SETTING: Seven private and hospital-based prenatal care sites in a suburban county in southeast Michigan. PATIENTS: A stratified random sample of 267 patients (93 with Medicaid, 92 with health maintenance organization, and 82 with fee-for-service insurance) receiving prenatal care from community physicians (obstetricians-gynecologists and family practitioners) between January 1, 1991, and December 31, 1992. MAIN OUTCOME MEASURE: Adherence to explicit prenatal care criteria as measured by an evidence-based prenatal care guideline developed by a community panel. "Quality scores" were compared across groups in 4 areas: performance of prenatal screening procedures or tests, visit-based screening, substance use screening, and clinician management of abnormal clinical findings. RESULTS: Patients with Medicaid insurance presented for prenatal care significantly later in pregnancy (14.5 vs 10.5 weeks, P < .01). No significant differences were seen between groups in quality scores for screening tests, clinician management of abnormal clinical findings, visit-based screening, or substance use screening. The overall similarity in quality scores did obscure some significant differences in adherence to individual criteria, particularly in the area of screening tests. Significantly more patients with Medicaid were screened for genital infection (P < .001) and fewer for gestational diabetes (P < .001) or anemia (P < .001) than patients in the other 2 groups. CONCLUSIONS: Although patients with Medicaid presented for prenatal care later in pregnancy and received a different "package" of screening tests than the other 2 groups, there was no overall measurable difference in the quality of prenatal care provided to patients with Medicaid, health maintenance organization, and fee-for-service insurance. Clinicians may have altered screening protocols based on preexisting perceptions of patient risk. Although summary quality measures are a promising tool for comparative research, they provide an incomplete picture of the quality of the prenatal care process and must be interpreted with caution.

Can case-finding instruments be used to improve physician detection of depression in primary care?

OBJECTIVE: To explore the issue of diagnostic specificity for major depression in the primary care setting by examining the relative accuracy of 3 methods to detect major depression in primary care. DESIGN: Comparison of performance characteristics of 3 case-finding methods for depression (ie, the Center for Epidemiologic Studies-Depression scale [CES-D], unaided physician detection, and "augmented" physician detection by use of a case-finding instrument), with the standard criterion being the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). SETTING: The offices of 50 family physicians from private and academic practice in southeastern Michigan. PATIENTS: Adult patients (N = 1580) who presented for routine care, from which a weighted random sample of 425 patients completed the Structured Clinical Interview for DSM-III-R. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive predictive value, and positive likelihood ratio for each case-finding method. RESULTS: Major depression was present in 13.4% of the sample. Both the CES-D and unaided physician detection methods performed poorly in identifying patients who met DSM-III-R criteria for major depressive disorder. The CES-D had high sensitivity but low specificity at standard and high cut points, resulting, respectively, in low positive predictive values (0.307 and 0.385) and low positive likelihood ratios (2.9 and 4.0). Unaided physician detection showed lower sensitivity, higher specificity, and a slightly higher positive predictive value (0.45) and positive likelihood ratio (4.9). Raising of the CES-D threshold for a positive test did not enhance the detection of depression. Augmented physician detection with CES-D scores resulted in minimal improvement. Although the positive predictive value and positive likelihood ratio increased to 0.50 and 6.1, respectively, using the most stringent case-finding definition (ie, physician identification plus the CES-D score [score > or = 22]), the proportion of depressed patients who were correctly identified decreased to 26.9%. CONCLUSIONS: Neither high scores on the CES-D nor unaided physician detection accurately identified patients with major depression who were seen in primary care settings, while the supplementation of physician detection with CES-D scores had a minimal net effect on the accuracy of detection. The data do not support the routine use of the CES-D as a primary care screening instrument for depression, either as a stand-alone measure or as a supplement to physician detection.

Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients.

The aims of this study were to determine whether detection of major depression in primary care was associated with improved outcome, and to compare the 4.5 month outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients. Primary care patients with major depression were recruited from the practices of 50 family physicians in Southeastern Michigan using a two-stage selection procedure employing the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Structured Clinical Interview for DSM-III-R (SCID); clinician detection of depression was ascertained by response to a direct query on a rating form. Depressed patients seeking treatment in an outpatient psychiatric setting also received the CES-D and the SCID. Data on patient demographics and clinical characteristics were obtained for both primary care and psychiatric patients. Initial and 4.5 month scores on the Hamilton Depression Rating Scale (HAM-D) were obtained for 34 undetected and 25 detected depressed primary care and 55 depressed psychiatric patients. Improvement in depression over time was assessed by the change in HAM-D scores over the 4.5 months. The three groups did not differ in initial severity. Both psychiatric and undetected primary care patients showed significant improvement at 4.5 months, whereas detected primary care patients did not improve. At 4.5 months there were no differences in mean HAM-D scores between undetected, depressed primary care patients and depressed psychiatric outpatients. This result did not change after controlling for age and severity of depression at initial presentation, nor did it change after exclusion of cases of mild depression to control for a possible "floor effect." However, differences among groups in the stage of depressive episodes may have affected this comparison. These findings suggest that an exclusive focus on increasing detection of depression in primary care patients is unlikely to improve outcomes, and that undetected depression among primary care patients does not necessarily represent poor quality of care. Although depressed psychiatric patients in this study had better outcomes than detected depressed primary care patients, the presence of unmeasured differences among groups in the stage of the depressive episode makes it impossible to determine whether treatment of depression by psychiatrists is superior to that provided by primary care physicians. These findings should stimulate efforts to examine a more comprehensive model for detection and treatment of depression in primary care.

Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care.

A considerable body of knowledge noe exists in the area of depressive disorders in primary care. Primary care clinicians appear to identify less than half of patients with major depressive disorder and adequately treat only a portion of those they identify. However, recent research suggests that identification and treatment of depressive disorders in primary care is a far more complex process than previously assumed. The presence of significant differences in patient expectations, the process of care, and the clinical epidemiology of depression between psychiatric and primary care settings makes it difficult to interpret existing studies of primary care clinician performance. This paper describes an alternative conceptual model for the identification and management of depression in primary care which incorporates the concept of "competing demands" derived from the preventive services literature. The central premise of this model is that primary care encounters present competing demands for the attention of the clinician and that there is not enough time to address each demand. The identification and treatment of depression represents an active choice from multiple clinician and patient priorities such as treatment of acute illness, provision of preventive services, and response to patient requests. Choice is influenced by three sets of interrelated "domains," representing the clinician, the patient, and the practice ecosystem. Each domain is indirectly influenced by the general policy environment. Detection and treatment of depression in this model occurs over time as clinicians work through these competing demands. Although the competing demands model contains many unproven elements, it is likely to have a great deal of "face validity" for practicing primary care clinicians, and its validity can be empirically tested. Using the model as a framework to guide inquiry into the identification and management of depression and other mood disorders in primary care may lead to the discovery of more creative and effective solutions to the problem of underdiagnosis and undertreatment.

Depression in primary care--more like asthma than appendicitis: the Michigan Depression Project.

OBJECTIVE: To explore the relationships between detection, treatment, and outcome of depression in the primary care setting, based upon results from the Michigan Depression Project (MDP). METHODS: A weighted sample of 425 adult family practice patients completed a comprehensive battery of questionnaires exploring stress, social support, overall health, health care utilization, treatment attitudes, self-rated levels of stress and depression, along with the Center for Epidemiologic Studies Depression Scale (CES-D), the Hamilton Rating Scale for Depression (HAM-D), and the Structured Clinical Interview for DSM-III (SCID), which served as the criterion standard for diagnosis. A comparison sample of 123 depressed psychiatric outpatients received the same assessment battery. Family practice patients received repeated assessment of depressive symptoms, stress, social support, and health care utilization over a period of up to 60 months of longitudinal follow-up. RESULTS: The central MDP findings confirm that significant differences in past history, severity, and impairment exist between depressed psychiatric and family practice patients, that detection rates are significantly higher for severely depressed primary care patients, and that clinicians use clinical cues such as past history, distress, and severity of symptoms to "detect" depression in patients at intermediate and mild levels of severity. As well, there is a lack of association between detection and improved outcome in primary care patients. CONCLUSION: These results call into question the assumption that "depression is depression" irrespective of the setting and physician, and they are consistent with a model of depressive disorder as a subacute or chronic condition characterized by clinical parameters of severity, staging, and comorbidity, similar to asthma. This new model can guide further investigation into the epidemiology and management of mood disorders in the primary care setting.

Episodes of care for abdominal pain in a primary care practice.

OBJECTIVES: To explore the usefulness of episodes of care in describing the clinical epidemiology of abdominal pain in the primary care setting and to develop methods to analyze clinician decision-making strategies during abdominal pain episodes. DESIGN: Complete episodes of care for nonpregnant adults with nonspecific abdominal pain from an established episode-based clinical information system were supplemented and validated by medical record review. Utilization decisions during episodes were quantified by summing the costs of all visits, services, tests, and referrals ordered or performed by the clinician. A decision model was used to analyze significant influences on utilization decisions. SETTING: An established faculty practice site of a Midwestern academic family practice department. SUBJECTS: Two hundred ten nonpregnant adults who had nonspecific abdominal pain. MAIN OUTCOME MEASURES: Utilization and costs generated during the episode of care. RESULTS: The average abdominal pain episode required 1.32 visits and cost $123.36. In more than half of all episodes (51%), a specific diagnosis was not reached. The most common specific diagnoses were gastritis and gastroesophageal reflux disease (5% each). Bivariate analyses showed that two variables, clinician uncertainty about diagnosis and a nonspecific diagnosis, were significantly associated with episode cost. Patient age, gender, comorbidity, and the presence or absence of specific clinical findings were not associated with episode cost. Stepwise regression modeling resulted in a two-factor model. Clinician uncertainty and complexity explained only 9% of the variance in episode cost. CONCLUSIONS: Episodes of abdominal pain most often remained undiagnosed. The decision model did not predict episode cost. Utilization decisions did not seem to be driven by commonly cited clinical risk factors, but by diagnostic uncertainty or individualized decision rules.

The future of procedural training in family practice residency programs: look before you LEEP.

Procedural training is a tremendously important issue and has implications for what and how we teach family physicians. Should we continue with an increasingly densely packed longitudinal model of training, or do we move to a more explicitly structured block design? Should our decisions be guided by community needs, marketplace demands, or available technology? Finally, and most importantly, how can we determine the performance quality of the procedures we choose to perform and teach? Each of these questions calls for an extended dialogue among practicing family physicians, family physician educators, and those who participate in--and pay for--primary health care. It is clearly time for this dialogue to begin in earnest.

Using ICPC in a computer-based primary care information system.

INTRODUCTION: Although the framework of the episode of care offers much promise in examining the process of primary health care, the development of episode-oriented, automated data sources has proceeded slowly. Experience with the International Classification of Primary Care (ICPC) in the European Community has confirmed its usefulness in creating and analyzing episodes of care, but it has seen little use in the United States. We describe the development of a Primary Care Information System (PCIS), which employs ICPC to create episodes of care from routinely collected clinical data. METHODS: The PCIS is a partially computerized medical information system running on a standard Macintosh microcomputer. The PCIS integrates ICPC, ICD-9-CM, and CPT-4 coding structures to provide episode-oriented data for clinical, administrative, research, and reimbursement needs. The performance of the PCIS was assessed based on five major issues: clinician cooperation, data-entry accuracy, validity of episode data, cost, and perceived value to users. RESULTS: The data collection and entry process required minimal additional effort from clinicians and data-entry personnel, and data-entry accuracy exceeded published estimates for other primary care data sources. Data management costs of about $1 per encounter compare favorably to published estimates for other office-based clinical information systems. The major problem seen during pilot testing was inaccurate tracking of episode boundaries through changes in providers and consequent changes in labels for problems and diagnoses. This problem has been addressed in development of the second-generation PCIS. CONCLUSION: The combination of an episode-oriented framework such as ICPC and a flexible medical information system provides a promising platform for the study of the content and process of primary health care.

Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network.

BACKGROUND: Although intensively studied in hospital and emergency settings, chest pain has remained largely unstudied in primary care, where it is associated with considerable diagnostic uncertainty and high utilization of medical resources. METHODS: We employed an established primary care research network to prospectively collect detailed information on episodes of care for chest pain. Over a 12-month period, Michigan Research Network (MIRNET) clinicians prospectively collected demographic, clinical, and clinician decision-making information for all patients seen in their offices with the complaint of chest pain. RESULTS: Three hundred ninety-nine complete episodes were collected and used for analysis. Episodes were well distributed among urban, rural, academic, and private sites. The average episode length was 1.53 visits. Musculoskeletal chest pain accounted for 20.4% of all diagnoses, followed by reflux esophagitis (13.4%) and costochondritis (13.1%). Stable angina pectoris was the primary diagnosis in only 10.3% of episodes, unstable angina or possible myocardial infarction in 1.5%. Most of the ancillary services used were directed toward finding or excluding cardiac disease. CONCLUSION: A practice-based network can be used to study episodes of care. Resource use during episodes of chest pain in primary care are directed toward exclusion of cardiac disease, despite the surprisingly low frequency of cardiac diagnoses.

A criterion-based review of preventive health care in the elderly. Part 2. A geriatric health maintenance program.

Although the geriatric population is growing rapidly and using an increasing portion of health care dollars, no consensus exists about the best approach to preventive medicine in this age group. The most comprehensive review to date is the 1989 United States Preventive Services Task Force (USPSTF) recommendations. However, the USPSTF did not specifically address the unique situation of the elderly. Consequently, we have evaluated numerous screening tests and preventive interventions for the elderly by systematically applying the geriatric-specific criteria for preventive services proposed in Part 1 of this article (J Fam Pract 1992; 34: 205-224). Tests and interventions were measured against specific screening criteria and put into one of three categories: those that have been proven effective, those that may be effective but about which more research is needed, and those that are not effective. Recommendations were compared with those of the USPSTF. Proof of the efficacy of most screening tests and interventions in the current literature was found to be lacking, pointing to the need for substantial future research in this area.

A criterion-based review of preventive health care in the elderly. Part 1. Theoretical framework and development of criteria.

The magnitude of health care resources devoted to care for the elderly is increasing; however, little is known about the efficacy of the services purchased with those resources. This is especially true in the area of preventive health care. In the absence of a consistent and comprehensive definition of health for the elderly population, it has been difficult either to establish criteria for evaluating preventive services or to assess the impact of those services. This article extends criterion-based review to the assessment of preventive services for the elderly. Health in the elderly can be defined by three related factors: the absence of disease, the maintenance of optimal function, and the presence of an adequate support system. Based on this definition of health, goals for preventive care should include compression of morbidity in addition to prevention of disease, and will require that quality of life be measured to completely assess the value of services. Unfortunately, existing measures of quality of life are difficult to apply to the elderly population, and there are no consistent societal values on which to base a new definition for quality of life. Because existing sets of criteria for the evaluation of preventive services do not address the distinctive health issues affecting the elderly, we have constructed a set of six criteria designed specifically for the well elderly population. In a companion article, we will apply these criteria to candidate preventive services for the elderly population to develop a geriatric health maintenance protocol for use in clinical practice.