Adherence to (or compliance with) a medication regimen is generally defined as the extent to which patients take medications as prescribed by their health care providers. The word "adherence" is preferred by many health care providers, because "compliance" suggests that the patient is passively following the doctor's orders and that the treatment plan is not based on a therapeutic alliance or contract established between the patient and the physician. Both terms are imperfect and uninformative descriptions of medication-taking behavior. Unfortunately, applying these terms to patients who do not consume every pill at the desired time can stigmatize these patients in their future relationships with health care providers. The language used to describe how patients take their medications needs to be reassessed, but these terms are still commonly used.1 Regardless of which word is preferred, it is clear that the full benefit of the many effective medications that are available will be achieved only if patients follow prescribed treatment regimens reasonably closely.

Concern about health care expenditures is not a new phenomenon. Seventy-five years ago, President Herbert Hoover appointed a committee to investigate the cost of medical care under the chairmanship of Ray Lyman Wilbur, MD, president of Stanford University. Thirty-eight years ago, John Gardner, Secretary of Health, Education, and Welfare, convened a national conference on medical care costs. Since then, not a year has passed without professional and lay periodicals addressing this subject. Most recently, Annals has published 4 articles by Thomas Bodenheimer on health care costs, the last of which, coauthored by Alicia Fernandez, appears in this issue. These articles provide valuable background material and address several key questions about expenditures from many different perspectives. Possible approaches to cost containment are discussed, with special emphasis on the potential role of physicians and with the caveat that this is "an overview of a complex topic, written by a noneconomist for noneconomists."

This editorial, written by an economist for physicians, emphasizes some critical distinctions and offers a somewhat different set of questions and answers. It differentiates sharply between levels of expenditures and their rates of growth, addresses the question of why either should be of concern for public policy, and discusses strategies for containing expenditures.

Background: The current national measure set for the quality of health care underrepresents the spectrum of outpatient care and makes limited use of readily available national ambulatory care survey data.

Methods:We examined 23 outpatient quality indicators in 1992 and again in 2002 to measure overall performance and racial/ethnic disparities in outpatient care in the United States. The National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey yielded information about ambulatory services provided in private physician offices and hospital outpatient departments, respectively. Quality indicator performance was defined as the percentage of applicable visits receiving appropriate care.

Results: In 2002, mean performance was 50% or more of applicable visits for 12 quality indicators, 7 of which were in the areas of appropriate antibiotic use and avoiding unnecessary routine screening. The performance of the remaining 11 indicators ranged from 15% to 42%. Overall, changes between 1992 and 2002 were modest, with significant improvements in 6 indicators: treatment of depression (47% vs 83%), statin use for hyperlipidemia (10% vs 37%), inhaled corticosteroid use for asthma in adults (25% vs 42%) and children (11% vs 36%), avoiding routine urinalysis during general medical examinations (63% vs 73%), and avoiding inappropriate medications in the elderly (92% vs 95%). After adjusting for potential confounders, race/ethnicity did not seem to affect quality indicator performance, except for greater angiotensin-converting enzyme inhibitor use for congestive health failure among blacks and less unnecessary antibiotic use for uncomplicated upper respiratory tract infections among whites.

Conclusions: Measurable quality deficits and modest improvements across time call for greater adherence to evidence-based medicine in US ambulatory settings. Although significant racial disparities have been described in a variety of settings, we observed that similar, although less than optimal, care is being provided on a per-visit basis regardless of patient racial/ethnic background.

Some important health policy topics, such as those related to the delivery, organization, and financing of health care, present substantial challenges to established methods for evidence synthesis. For example, such reviews may ask: What is the effect of for-profit versus not-for-profit delivery of care on patient outcomes? Or, which strategies are the most effective for promoting preventive care? This paper desc ribes innovative methods for synthesizing evidence related to the delivery, organization, and financing of health care. We found 13 systematic reviews on these topics that described novel methodologic approaches. Several of these syntheses used 3 approaches: conceptual frameworks to inform problem formulation, systematic searches that included nontraditional literature sources, and hybrid synthesis methods that included simulations to address key gaps in the literature. As the primary literature on these topics expands, so will opportunities to develop additional novel methods for performing high-quality comprehensive syntheses.

In recent years, hepatitis B has taken a backseat to hepatitis C because of the increased prevalence of hepatitis C in the United States and western Europe. However, hepatitis B has reclaimed the attention of gastroenterologists and other health care professionals because of 3 developments: the introduction of polymerase chain reaction (PCR)-based hepatitis B virus (HBV) DNA testing; the improved understanding of the nature of HBV-related disease; and the introduction of potent, orally administered new antiviral agents. In our editorial, we discuss the treatment of HBV, which has evolved rapidly, and then comment on the cost-effectiveness of HBV therapies.

The Patient Safety Consortium included a group of 26 diverse hospitals in or near California. In 2001 and 2002, many consortium hospitals were surveyed using the Patient Safety Climate in Healthcare Organizations (PSCHO) tool to present quantitative measures of hospital safety climate and qualitative reports on safety practices over 2 years. Investigators engaged in discussions with consortium hospitals to elicit reports about their patient safety activities. Overall quantitative measures of safety climate remained approximately the same over the 2 years, although in some specific survey areas climate appeared to improve. Hospitals reported a range and mix of patient safety activities. While considered an essential enabler of safety, cultural change takes time. Significant hospital efforts appear to be underway, and attention to a number of lessons from past patient safety efforts may benefit future undertakings.

The incidence of obesity has increased dramatically in the U.S. Obese individuals tend to be sicker and spend more on health care, raising the question of who bears the incidence of obesity-related health care costs. This question is particularly interesting among those with group coverage through an employer given the lack of explicit risk adjustment of individual health insurance premiums in the group market. In this paper, we examine the incidence of the healthcare costs of obesity among full time workers. We find that the incremental healthcare costs associated with obesity are passed on to obese workers with employer-sponsored health insurance in the form of lower cash wages. Obese workers in firms without employer-sponsored insurance do not have a wage offset relative to their non-obese counterparts. Our estimate of the wage offset exceeds estimates of the expected incremental health care costs of these individuals for obese women, but not for men. We find that a substantial part of the lower wages among obese women attributed to labor market discrimination can be explained by the higher health insurance premiums required to cover them.

In 1998, the Chinese government proposed a universal health-insurance program for urban employees. However, this reform has been advancing slowly, primarily due to an unpractical financing policy. We surveyed over 2000 families and evaluated the financial impacts of Beijing's reform on public and private enterprises. We found that most state-owned enterprises provided effective health insurance, whereas most private firms did not; overall, 33% of employees had little or no coverage. On average, employees of private firms were healthier and earned more compared to public firms. Because the premium was proportional to income, private firms would pay more for insurance than the predicted health-care expense of their employees. International firms subsidize the most, contributing more than 60% of their insurance premiums to the employees of the public sector. Such an aggressive cross-subsidization policy is difficult to be accepted by private firms.