Relationship between complaints and quality of care in New
Zealand: a descriptive analysis of complainants and non-
complainants following adverse events
M M Bismark, T A Brennan, R J Paterson, P B Davis, D M Studdert
See end of article for
Dr D M Studdert, Harvard
School of Public Health,
02115, USA; studdert@
Accepted for publication
17 October 2005
Qual Saf Health Care 2006;15:17–22. doi: 10.1136/qshc.2005.015743
Objectives: To estimate the proportion and characteristics of patients injured by medical care in New
Zealand public hospitals who complain to an independent health ombudsman, the Health and Disability
Commissioner (‘‘the Commissioner’’).
Design: The percentage of injured patients who lodge complaints was estimated by linking the
Commissioner’s complaints database to records reviewed in the New Zealand Quality of Healthcare Study
(NZQHS). Bivariate and multivariate analyses investigated sociodemographic and socioeconomic
differences between complainants and non-complainants.
Setting: New Zealand public hospitals and the Office of the Commissioner in 1998.
Population: Patients who lodged claims with the Commissioner (n = 398) and patients identified by the
NZQHS as having suffered an adverse event who did not lodge a complaint with the Commissioner
(n = 847).
Main outcome measures: Adverse events, preventable adverse events, and complaints lodged with the
Results: Among adverse events identified by the NZQHS, 0.4% (3/850) resulted in complaints; among
serious, preventable adverse events 4% (2/48) resulted in complaints. The propensity of injured patients to
complain increased steeply with the severity of the injury: odds of complaint were 11 times greater after
serious permanent injuries than after temporary injuries, and 18 times greater after deaths. Odds of
complaining were significantly lower for patients who were elderly (odds ratio (OR) 0.2, 95% confidence
interval (CI) 0.1 to 0.4), of Pacific ethnicity (OR 0.3, 95% CI 0.1 to 0.9), or lived in the most deprived areas
(OR 0.3, 95% CI 0.2 to 0.6).
Conclusion: Most medical injuries never trigger a complaint to the Commissioner. Among complaints that
are brought, severe and preventable injuries are common, offering a potentially valuable ‘‘window’’ on
serious threats to patient safety. The relatively low propensity to complain among patients who are elderly,
socioeconomically deprived, or of Pacific ethnicity suggests troubling disparities in access to and utilisation
of complaints processes.
here is growing international interest in harnessing
patient dissatisfaction and complaints to address pro-
blems with quality in health care.
The value of
complaints as a marker of threats to patient safety depends
on the answers to several questions. Do complaints track
injuries, or are they prompted by more subjective concerns?
Are complaints the ‘‘tip of the iceberg’’ in terms of quality of
care problems and, if so, how representative are they of
broader quality problems? The longstanding obstacle to
addressing these questions is methodological in nature and
concerns the elusiveness of an appropriate metric against
which to measure the prevalence and reasonableness of
In New Zealand, injury compensation and complaints
against healthcare professionals are dealt with in distinct
settings. An innovative accident compensation system
compensates injured patients on a ‘‘no fault’’ basis. An
independent health ombudsman, the Health and Disability
Commissioner (‘‘the Commissioner’’), has statutory respon-
sibility for resolving patient complaints about quality of care,
acts as a gatekeeper to disciplinary proceedings, and strives to
use complaints as a catalyst for improving patient safety.
In this study we linked information on quality of care
complaints lodged with the Commissioner with adverse event
data gathered in the New Zealand Quality of Healthcare
Study (NZQHS). Together, these two datasets permit
estimation of how frequently adverse events led to com-
plaints, and a description of the characteristics of patients
who did and did not complain to the Commissioner.
The Wellington Ethics Committee and the Harvard
Institutional Review Board approved the study.
Baseline data on a random sample of patients who had
experienced adverse events came from the NZQHS. As
NZQHS used a two stage sampling
process to develop a representative sample of 6579 medical
records of patients discharged from publicly funded acute
care hospitals in 1998, excluding psychiatric and same day
discharges. Trained reviewers assessed each episode of care
for the presence of an adverse event and, when an adverse
event was detected, rendered a judgment on whether it was
preventable. Following previous research in the United
adverse events were defined as unintended injuries
caused by healthcare management, rather than the under-
lying disease process, that resulted in disability. The study
included all adverse events detected during or responsible for
the index admission, as well as those occurring during the
index admission that were detected on a subsequent
admission. Serious adverse events were those which caused
death or permanent disability.
The Commissioner provided data on all complaints
received by his office that were associated with a public
hospital admission in 1998 (n = 398). To determine which of
these complaints involved adverse events and preventable
adverse events, an investigator with medicolegal expertise
(MMB) reviewed the relevant administrative information
using the NZQHS process of structured implicit review. A
second investigator (TAB), also a medicolegal expert,
independently reviewed a random subsample of 98 com-
plaints, a quarter of the sample. Inter-rater reliability for
determination of whether an adverse event had occurred was
high (k = 0.84); reliability for preventability judgment was
moderate (k = 0.50), although slightly higher than previous
estimates of reliability for preventability determinations.
We matched the NZQHS records to complaints probabil-
istically using national hospital number, date of birth, sex,
and date of injury. Clinical data from the medical record
review was then compared with claims data to confirm that
the NZQHS patient and complainant was the same person
and that the complaint related to the same episode of care.
Two investigators (MB, DS) reviewed potential matches and
reached consensus on whether sufficient information existed
to confirm a match with a high degree of certainty. Among 18
candidate matches, nine were determined not to be matches
and two were excluded on the grounds that there was
insufficient information to confirm a match.
The analyses are descriptive. We compared characteristics
of patients who lodged complaints with the Commissioner
after experiencing an adverse event (‘‘complainants’’) with
characteristics of patients from the NZQHS who experienced
an adverse event and did not file complaints (‘‘non-
complainants’’). Matched cases—that is, patients from the
NZQHS sample whose care involved an adverse event and
who subsequently complained about that instance of care—
were classified as complainants. Figure 1 shows the deriva-
tion of the two populations which were combined for the
Data were analysed using the SAS 9.0 statistical software
package (Cary, NC, USA) Stata 8.0/SE (Stata Corp, College
Station, Texas). We used t tests and x
tests to conduct
bivariate comparisons of the characteristics of complainants
and non-complainants. We investigated predictors of failure
to complain despite having experienced an adverse event
using multivariate logistic regression. The dependent variable
in the regression analysis distinguished complainants from
non-complainants. The independent variables were sex,
ethnicity (Maori, Pacific, Non-Maori/non-Pacific), patient
age (,1 year, 1–17 years, 18–44 years, 45–64 years,
>65 years), disability due to adverse event (temporary,
permanent with ,50% impairment, permanent with .50%
impairment, death), and whether or not the event was
preventable. An additional covariate provided a measure of
the patient’s socioeconomic status using the New Zealand
Index of Deprivation Score.
This index, based on mesh
blocks, combines nine census variables reflecting aspects of
material and social deprivation; following previous studies,
index scores were separated into quintiles for analysis.
To account for the stratified two stage cluster sampling
design in the NZQHS,
the bivariate and multivariate
analyses were weighted. The weighting had negligible effects
on our estimates.
The Commissioner received 398 complaints related to care
delivered in public hospitals in 1998, 254 of which (64%)
related to an episode of care in which the patient had
experienced an adverse event. For 51% of the complaints the
adverse event was judged to be preventable. The NZQHS
review identified 850 adverse events, as previously reported,
of which 315 were preventable, 124 were serious, and 48 were
both serious and preventable.
Patients themselves instigated 105 (41%) of the 254
complaints involving adverse events (fig 2). Third party
complaints were commonly laid by family members, primar-
ily the patient’s child (17%), parent (16%), or spouse (13%).
A total of 79% (313/398) of complaint letters and 75% (191/
254) of the adverse event complaint letters expressed concern
about a health professional’s attitude or communication
either during the index admission or after the adverse event.
There were seven matches between the complaint sample
and the full NZQHS sample (n = 6579). NZQHS reviewers
judged three of these matches to involve adverse events (one
preventable death, one preventable permanent disability, and
one unpreventable temporary injury); the rest did not involve
adverse events. (Besides injuries, the Commissioner also has
jurisdiction to hear complaints relating to informed consent,
discrimination, and a variety of other bases of dissatisfaction
with care.) Hence, 0.4% (3/850) of the patients in the NZQHS
sample who experienced adverse events complained. Among
NZQHS patients judged to have experienced adverse events
that were serious and preventable, 4% (2/48) complained.
New Zealand Quality of
Healthcare Study reviewed
records of 6579 patients
(approximately 1% of
Health and Disability
699095 patients admitted to New Zealand public hospitals
847 sampled patients suffered an adverse event but did not complain
Figure 1 Identification of injured complainants and non-complainants.
Figure 2 Relationship to injured patient of person writing letter of
complaint (n = 254).
18 Bismark, Brennan, Paterson, et al
Box 1 provides case studies of three patients. The first
patient complained following an adverse event. The second
patient suffered an adverse event and did not complain. The
third patient complained but, because the poor outcome he
experienced was attributable to the condition for which care
was sought rather than the medical care itself, it was not an
Table 1 shows the characteristics of the patients in the full
NZQHS sample, the subset of patients who experienced
adverse events (except for the three who complained), and
the complainants who experienced adverse events. The
average age of the complainants was 47 years and 59% were
female. Among complainants for whom ethnicity data were
available, 14% were Maori and 3% were Pacific. In general,
complainants’ injuries involved were quite severe, with 31%
resulting in permanent injury and 28% in death. Most of the
injuries (79%) were preventable. 44% (110/254) of com-
plaints involved an injury that was both permanent and
Bivariate analyses showed several significant differences
between injured complainants and injured non-complainants
(table 1). Compared with complainants, non-complainants
were significantly older (52 v 47 years, p = 0.003) and more
likely to live in deprived socioeconomic areas. Complainants,
on the other hand, were significantly more likely to have
sustained injuries that led to permanent disability or death,
and preventable adverse events were twice as common in this
group (79% v 37%, p,0.001).
These differences persisted in multivariate comparisons of
the complainants and non-complainants (table 2). Injury
severity was a strong predictor of complaining, with odds of
complaining increasing with injury severity. Compared to
patients with temporary disability, the odds of complaining
for patients with a permanent disability resulting in .50%
impairment were 11.4 times greater (95% CI 5.9 to 22.1), and
for patients who died they were 17.9 times greater (95% CI
9.3 to 34.2). There was also a strong independent correlation
between preventability and odds of complaining (odds ratio
(OR) 7.6, 95% confidence interval (CI) 5.0 to 11.6).
In addition, several sociodemographic factors were asso-
ciated with propensity to complain after an adverse event.
Odds of complaining for patients in the most deprived
quintiles were one third those for patients in the most
privileged quintile (OR 0.3, 95% CI 0.2 to 0.6). Elderly
patients were significantly less likely than their younger
counterparts to complain following an adverse event (OR 0.2,
95% CI 0.1 to 0.4). Odds of complaining for patients of Pacific
ethnicity were lower than for non-Maori/non-Pacific patients
(OR 0.3, 95% CI 0.1 to 0.9). The difference was not
statistically significant for Maori patients, perhaps because
of the relatively small numbers in this category.
This study is the first to match epidemiological data on
medical injuries to complaints about quality of care lodged
with a national health ombudsman. Three findings are
noteworthy. Firstly, while the right to an appropriate
standard of care is only one of 10 patient rights enforced by
the Commissioner, most complaints involved an adverse
event, often a serious one. Secondly, our results suggest that
approximately one in 200 injured patients complain about
their care to the Commissioner. Among patients who
experience injuries that are both serious and preventable,
one in 25 complain. Thirdly, the ‘‘under-complaining’’
phenomenon was not spread uniformly across the patient
population: elderly patients and socioeconomically disadvan-
taged patients were especially unlikely to complain despite
having suffered an injury, and propensity to complain
increased steeply with the severity of the injury sustained.
Legitimacy of complaints
Although New Zealand doctors appear to support the use of
complaints as a quality assurance tool, concerns abound in
the medical community about the prevalence and reason-
ableness of many complaints brought before the
The 2001 survey by Cunningham and
of doctors’ attitudes about complaints found
general support for a forum for hearing and investigating
complaints, but considerable scepticism about the legitimacy
of complaints actually lodged with the Commissioner. Only
one in 10 doctors agreed with the statement that most
complaints were warranted, and half disagreed with the
statement that most complaints are about errors and actual
Box 1 Case studies of injured patients who did
and did not complain
Adverse event with no subsequent complaint
Mrs A, an elderly woman with a history of hyperthyroidism,
asthma, left ventricular failure, hypertension, and gastro-
oesophageal reflux disorder was admitted to hospital with
dizziness and vomiting. She was dehydrated with low
sodium (113 mEq/l, normal range 135–145). Her list of
13 medications prescribed by her general practitioner
included frusemide 80 mg a day and spironolactone
100 mg twice a day. She was diagnosed with hyponatrae-
mia secondary to an excessive dose of diuretics. She was
rehydrated and discharged 8 days later on a reduced
frusemide dose of 40 mg/day. Mrs A did not complain.
Complaint following adverse event
Mr D, a middle aged farmer, sustained a penetrating injury
to his right eye while cutting firewood. As a result of this
injury Mr D suffered a detached retina. He was referred to an
ophthalmologist who offered to reattach the retina using an
operation he had recently learned in the United Kingdom.
The scrub nurse was unfamiliar with the proposed operation
which involved the use of diluted SF6 gas. The theatre
supervisor was on a meal break because the operating
schedule was running late. Due to a breakdown in
communication between the nurse and the surgeon, the gas
was not diluted and 100% gas was administered to Mr D’s
eye, resulting in total blindness in that eye. He is no longer
able to run his farm due to the loss of depth perception. Mr
D’s complaint was upheld and his claim for no-fault
compensation was accepted.
Complaint with no adverse event
Mr N, a young man, was admitted to hospital with a severe
crush injury to his right middle finger. A senior orthopaedic
registrar with extensive plastic surgery experience assessed
Mr N and discussed the case with his consultant. They agreed
that it would be appropriate for the registrar to attempt to
preserve Mr N’s fingertip. The registrar stabilised the soft
tissue with loose sutures and administered an antithrombotic
prophylactic, dextran, to try to prevent thrombosis of the
artery. Another orthopaedic registrar, who had not been
involved with Mr N’s initial care, told Mr N that crush injuries
should never be sutured, causing him considerable anxiety.
Following discharge, the hospital tried to arrange a follow up
appointment for Mr N but he insisted on going on holiday to
a remote region of New Zealand and did not contact a
general practitioner as had been agreed. His fingertip
became infected and later required partial amputation. The
Commissioner found that Mr N had received an appropriate
standard of care.
Relationship between complaints and quality of care 19
The second of these opinions is partially correct as a matter
of law. The Commissioner’s obligations extend beyond classic
violations of quality. New Zealand law sets forth a variety of
other rights, including rights to be treated with respect and to
be free from discrimination or financial exploitation.
Perceived breaches of all such rights are legitimate bases
Nonetheless, our analysis suggests that doctors’ attitudes
about the reasonableness of complaints are at odds with
reality, at least among the subset of complaints related to
public hospital care. Nearly two thirds of the complainants in
the study sample had experienced adverse events, of which
79% were preventable and 60% involved permanent injury or
death; 93% of the adverse events were either preventable or
It is incorrect to interpret these results as evidence that
complaints are usually triggered by doctors’ wrongdoing. The
causes of adverse events in medicine are often multifactorial,
involving a complex interplay between individual and system
factors. On the other hand, the prevalence of adverse events—
especially preventable and serious ones—refutes the notion
that most complaints over quality of care are groundless.
Table 1 Characteristics of all patients, non-complainants, and complainants
All patients in
NZQHS, n (%)
(n = 6579)
complainants, n (%)
(n = 847)
(n = 254) p valueÀ
Male 2970 (45) 379 (45) 105 (41)
Mean age (years) 42.6 52.0 46.6 0.003
Non-Maori/non-Pacific 5131 (80) 661 (80) 160 (85)
Maori 1013 (16) 135 (16) 26 (14)
Pacific 240 (4) 32 (4) 3 (3)
Deprivation quintile ,0.001
1 (least deprived) 824 (13) 96 (11) 47 (20)
2 907 (14) 128 (15) 57 (24)
3 1354 (21) 184 (22) 46 (19)
4 1583 (24) 205 (24) 4 9 (21)
5 (most deprived) 1834 (28) 227 (27) 38 (16)
Temporary – 685 (85) 105 (41)
Permanent ,50% – 66 (8) 48 (19)
Permanent .50% – 19 (2) 30 (12)
Death – 37 (5) 71 (28)
Preventable – 313 (37) 201 (79)
HDC, Health and Disability Commissioner.
*Percentages were calculated using non-missing values as denominators. Ethnicity data were missing for 19 non-complainants (2.3%) and 65 complainants
(25.6%); deprivation scores were missing for seven non-complainants (0.8%) and 17 complainants (6.7%); disability information was missing for 40 non-
complaints (4.7%) and one complainant (0.4%).
p values were calculated for the difference between complainants and non-complainants using t test or x
test as appropriate. Hospitals were weighted to account
for NZQHS cluster sampling methodology.
Table 2 Multivariate odds of complaint among patients who experienced an adverse
Odds of complaint
(n = 1101) 95% CI p value
Male 0.75 0.49 to 1.12 0.16
Infant (0–1) 1.06 0.50 to 2.22 0.9
1–17 0.52 0.25 to 1.09 0.08
18–44 1 (ref)
45–64 0.55 0.33 to 0.92 0.02
>65 0.24 0.14 to 0.40 ,0.001
Non-Maori/non-Pacific 1 (ref)
Maori 0.78 0.45 to 1.36 0.4
Pacific 0.30 0.10 to 0.91 0.03
1 (least deprived) 1 (ref)
2 0.77 0.42 to 1.41 0.4
3 0.47 0.24 to 0.92 0.03
4 0.69 0.37 to 1.28 0.2
5 (most deprived) 0.32 0.16 to 0.63 0.001
Temporary 1 (ref)
Permanent ,50% 5.88 3.47 to 9.97 ,0.001
Permanent .50% 11.43 5.91 to 22.10 ,0.001
Death 17.86 9.31 to 34.24 ,0.001
Preventable 7.60 4.98 to 11.60 ,0.001
20 Bismark, Brennan, Paterson, et al
Complaint rates were low. The finding that only 0.4% of
adverse events and 4% of serious preventable adverse events
triggered complaints is consistent with crude estimates of
0.3% (254/85 000) and 2.3% (110/4800) obtained using the
number of complaints as the numerator and an extrapolation
of adverse event rates to the national level as the denomi-
In an earlier analysis of the same survey data, Cunningham
found that one in three doctors had
experienced a complaint at some time in their career; the
study estimated a complaint rate of 5.7% per doctor per year
and used these data to conclude that there was a ‘‘high
incidence’’ of complaints. From the perspective of busy
practitioners, this may be so. But from a health policy
perspective, the prevalence of poor quality care rather than
the number of physicians is the appropriate baseline against
which to measure complaint frequency. Using this metric, we
reach the opposite conclusion: complaints are rare in the
sense that the vast majority of preventable adverse events
never trigger one.
Why are complaint rates so low? Felstiner and colleagues’
conceptualisation of the evolution of disputes through a
process of ‘‘naming, blaming, and claiming’’ helps organise
the most likely explanations.
Firstly, many patients may not
be aware that they have sustained an injury from medical
care. Disentangling medical injury from the progression of
underlying illness is not straightforward, especially in the
inpatient setting where that illness may be severe.
Secondly, patients may recognise their injury but be
unaware of the Commissioner’s services, or unwilling to
commit the time and energy needed to take action. In theory,
the complaints process should pose few barriers—patients
can lodge a complaint by writing a letter or by making a free
phone call (0800 11 22 33); a lawyer’s assistance is not
required. However, in perception or reality, it may not be
straightforward for some aggrieved patients. The complaints
process has been described as ‘‘confusing, cumbersome,
difficult to access, and costly, both financially and emotion-
Moreover, health professionals are provided with a
copy of the letter of the complaint, including the patient’s
name, so some patients may hold back out of concern that
such action will bring tension into their relationship with
Thirdly, despite both recognising their injury and under-
standing the complaint option, some patients may simply
adopt the attitude that ‘‘what’s done can’t be undone’’, put
the event down to bad luck, and move on. Alternatively, they
may elect to take action, but not with the Commissioner.
Several other options are available to injured patients seeking
redress or accountability following an adverse event.
Monetary compensation is available through the national
no-fault compensation scheme. Patients seeking an apology,
an explanation, or system change to protect others from
suffering a similar harm can have those interests met by
bringing their concerns directly to the attention of their
healthcare provider by using free independent patient
advocacy services, or by lodging a complaint with the
Disparities in use of complaints
A study by Tapper and colleagues
of complaints against
surgeons found that they were more likely to be brought by
women and patients in older age groups. Again, analyses of
complaints that do not calibrate their frequency to the
underlying rate and patterns of injury can be misleading.
Women and the elderly are leading users of the healthcare
they are also over-represented among injured
Calibrating complaints to baseline data on injury,
we found no sex differences in complaint behaviour. Elderly
patients, on the other hand, were one quarter as likely as
their younger counterparts to complain following an adverse
Similarly, socioeconomic disparities in complaint beha-
viour are not readily apparent from a discrete analysis of
complaint data. The incidence of complainants is fairly evenly
distributed across the five deprivation quintiles, but multi-
variate regression analysis controlling for the presence and
severity of injury showed that patients from the most
socioeconomically deprived areas were significantly less likely
to complain. These results echo studies of malpractice
litigation in the United States in which both old age
and lower socioeconomic status
have been correlated with
lower propensity to sue.
Severity of injury
The strong relationship we identified between severity of
injury and propensity to take legal action is also consistent
with findings from medicolegal research from the United
Although the Commissioner’s complaint processes
attract only a small proportion of adverse events, the odds
that an injury will materialise as a complaint increase steeply
with severity of the injury; the odds are also substantially
greater if the injury is preventable. There is thus a clear
‘‘bias’’ in the severity and types of injuries that come before
the Commissioner. Complaints data should not be construed
as representative of general patterns of medical injury. On the
other hand, the skew towards serious and preventable events
is precisely what policymakers might hope for from a system
whose goals are to protect consumers from the most serious
safety hazards and identify opportunities for quality improve-
Limitations of study
Our study has several limitations. Firstly, complaints relating
to episodes of care in 1998 may have been (or might be)
lodged later than 30 June 2004, the date our complaints
sample was drawn, although this is unlikely because virtually
all complaints are filed within 2 years of the date of the
alleged injury (mean 10 months, median 5 months). The
5.5 year window for complaints that we allowed is therefore
Secondly, estimating adverse event rates through medical
record review has recognised limitations.
In our review of
complaint files, inter-reviewer agreement on the prevent-
ability judgment was only fair. To the extent that complaints
were judged not to involve preventable adverse events and
they did, our regression analysis will underestimate the
predictive value of preventability in complaining.
Thirdly, several of the other variables used in our analyses
were suboptimal. Ethnicity data were missing for one quarter
of complainants, and misclassification of ethnicity is a
The use by the New Zealand Index of
Deprivation of small area-based measures to assign socio-
economic characteristics at the individual level creates the
potential for measurement error.
The direction and magni-
tude of potential biases stemming from these data limitations
are unknown, but we know of no reason why they would
differ systematically between complainants and non-com-
plainants and thus affect the results of our analyses.
Given the absence of tort remedies and the availability of a
free independent complaints mechanism, it might be
expected that patients in New Zealand would frequently
lodge complaints following adverse events. Indeed, some
physicians in New Zealand feel under siege by complaints
processes and the medicolegal environment has been
Relationship between complaints and quality of care 21
described as one of the ‘‘most hostile’’ in the world.
when complaints to the Commissioner are set against the
underlying rate of injury, it becomes apparent that they
represent only the tip of an iceberg of adverse events. That tip
misrepresents what is beneath the surface in two important
ways. Firstly, the relatively low propensity to complain
among patients who are elderly, socioeconomically deprived,
or of Pacific ethnicity suggests troubling disparities in access
to and utilisation of complaints processes. Further research is
required to better understand and address these disparities.
Secondly, the probability of a complaint increases steeply
with severity of injury, and preventable events are much
more likely to lead to a complaint than unpreventable ones.
In this regard, complaints offer a valuable portal for
observing serious threats to patient safety and may facilitate
efforts to improve quality.
The authors thank Jean-Marie Berthelot and Roy Lay-Yee for their
expert statistical assistance. Elana Curtis offered valuable comments
on the manuscript.
M M Bismark, T A Brennan, D M Studdert, Harvard School of Public
Health, Boston, Massachusetts 02115, USA
R J Paterson, Health and Disability Commissioner, P O Box 1791,
Auckland, New Zealand
P B Davis, Department of Sociology, The University of Auckland, Private
Bag 92019, Auckland, New Zealand
Funding for this study was provided by the Commonwealth Fund, an
independent non-profit organization based in New York City. The
authors’ work was independent of the funders.
Competing interests: none.
M M Bismark was a Harkness Fellow in Healthcare Policy in 2004–5.
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22 Bismark, Brennan, Paterson, et al