OBJECTIVE: Care remains suboptimal for a substantial proportion of the more than 17 million patients in the United States with diabetes. This review examines strategies for improving the quality of care for adult type 2 diabetic patients, through changes in provider behavior and modifications to the organization of care. SEARCH STRATEGY AND
INCLUSION CRITERIA: The researchers searched the MEDLINE® database, the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) registry, article bibliographies, and relevant journals for experimental evaluations of quality improvement (QI) interventions involving outpatient care for adults with type 2 diabetes mellitus. The investigators included randomized or quasi-randomized controlled trials, controlled before-after studies, and interrupted time series in which at least one reported outcome involved changes in serum hemoglobin A1c or a measure of provider adherence to a recommended process of care.
DATA COLLECTION AND ANALYSIS: Two reviewers independently abstracted relevant data, including classifying the components of each QI intervention as provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self-management, patient reminders, audit and feedback, organizational change, or financial incentives. Certain categories were further subdivided into major subtypes (e.g., professional meetings for provider education and disease management for organizational change). The investigators also assessed the impact of clinical information systems as a mediator for interventions of all types. They compared different QI strategies in terms of the median effects achieved for glycemic control and for a generalized measure of clinician adherence. In addition, linear regression analyses were performed using methodologic features and QI types as predictors, taking into account baseline groups differences and study size.
MAIN RESULTS: Fifty-eight articles reporting a total of 66 trials met the established inclusion criteria. The most common interventions employed were organizational change in 40 trials, patient education in 28 trials, and provider education in 24 trials. Fifty-two trials involved interventions employing more than one QI strategy, with a median of 2 strategies per trial and a maximum of 5. The included trials reported a median absolute reduction in HbA1c of 0.48% (interquartile range: 0.20%, 1.38%), and a median improvement in clinician adherence of 4.9% (interquartile range: 3.8%, 15.0%). Trials in the lower 2 quartiles of sample size reported substantially larger effect sizes, as did non-randomized trials, strongly suggesting the presence of publication bias, with publication of smaller non-randomized trials occurring more often when reported improvements are large. Multifaceted trials reported a median reduction in HbA1c of 0.60% (interquartile range: 0.30%, 1.40%), compared to a median reduction of 0.0% (interquartile range: -0.08%, 0.16%) for trials of a single intervention (p=0.01). The benefit of employing more than one QI strategy appeared to persist among larger, randomized trials, but the small numbers of studies limits the reliability of this impression. The investigators did not find any specific type of QI strategy to confer unambiguous benefit. Provider education and disease management were the only strategies to approach statistical significance, compared with interventions absent these strategies.
CONCLUSION: The authors' analysis of quality improvement strategies for diabetes care showed no particular type of QI to have an advantage over others, but suggested that employing at least two strategies provides a greater chance of success than single-faceted interventions, in terms of improving glycemic control or provider adherence. These conclusions are limited by probable publication bias favoring smaller trials and non-randomized trials, and the confounding presence of multiple QI strategies in a given intervention, as well as important patient and provider factors, and organizational characteristics.

This is the first study to examine the prevalence and effects of major depression (MDD) in a sample of adolescent smokers (N = 211) undergoing treatment for nicotine dependence. We assessed MDD at baseline and end of treatment with the mood disorders portion of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Eleven percent of participants reported a history of MDD (6% of males and 21% of females). Study variables did not distinguish those with and without a history of MDD. End of treatment abstinence rates and relapse rates were similar in both groups. Two participants (1%), both female, experienced onset of MDD during the treatment. The findings provide further evidence that MDD is a comparatively common disorder among children and adolescents and that clinicians should monitor and be prepared to respond to depression that may emerge during the treatment of nicotine-dependent adolescents.

Background: Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care.

Objective: To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma.

Methods: We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study.

Results: Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables.

Conclusions: A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.

The traditional focus of disability research has been on the elderly, with good reason. Chronic disability is much more prevalent among the elderly, and it has a more direct impact on the demand for medical care. It is also important to understand trends in disability among the young, however, particularly if these trends diverge from those among the elderly. These trends could have serious implications for future health care spending because more disability at younger ages almost certainly translates into more disability among tomorrow's elderly, and disability is a key predictor of health care spending. Using data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Study (NHIS), we forecast that per-capita Medicare costs will decline for the next fifteen to twenty years, in accordance with recent projections of declining disability among the elderly. By 2020, however, the trend reverses. Per-capita costs begin to rise due to growth in disability among the younger elderly. Total costs may well remain relatively flat until 2010 and then begin to rise because per-capita costs will cease to decline rapidly enough to offset the influx of new elderly people. Overall, cost forecasts for the elderly that incorporate information about disability among today's younger generations yield more pessimistic scenarios than those based solely on elderly data sets, and this information should be incorporated into official Medicare forecasts.

Objective:

Care remains suboptimal for a substantial proportion of the more than 17 million

patients in the United States with diabetes. This review examines strategies for improving the quality of care for adult type 2 diabetic patients, through changes in provider behavior and modifications to the organization of care.

Search Strategy and Inclusion Criteria: The researchers searched the MEDLINE® database, the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) registry, article bibliographies, and relevant journals for experimental evaluations of quality improvement (QI) interventions involving outpatient care for adults with type 2 diabetes mellitus. The investigators included randomized or quasi-randomized controlled trials, controlled before/after studies, and interrupted time series in which at least one reported outcome involved changes in serum hemoglobin A1c or a measure of provider adherence to a recommended process of care.

Data Collection and Analysis:

Two reviewers independently abstracted relevant data, including classifying the components of each QI intervention as provider education, provider reminders, facilitated relay of clinical information, patient education, promotion of self management,patient reminders, audit and feedback, organizational change, or financial incentives. Certain categories were further subdivided into major subtypes (e.g., professional meetings for provider education and disease management for organizational change). The investigators also assessed the impact of clinical information systems as a mediator for interventions of all types. They compared different QI strategies in terms of the median effects achieved for glycemic control and for a generalized measure of clinician adherence. In addition, linear regression analyses were performed using methodologic features and QI types as predictors, taking into account baseline groups differences and study size.

Main Results:

Fifty-eight articles reporting a total of 66 trials met the established inclusion criteria. The most common interventions employed were organizational change in 40 trials, patient education in 28 trials, and provider education in 24 trials. Fifty-two trials involved interventions employing more than one QI strategy, with a median of 2 strategies per trial and a maximum of 5. The included trials reported a median absolute reduction in HbA1c of 0.48% interquartile range: 0.20%, 1.38%), and a median improvement in clinician adherence of 4.9% (interquartile range: 3.8%, 15.0%). Trials in the lower 2 quartiles of sample size reported substantially larger effect sizes, as did non-randomized trials, strongly suggesting the presence of publication bias, with publication of smaller non-randomized trials occurring more often when reported improvements are large. Multifaceted trials reported a median reduction in HbA1c of 0.60% (interquartile range: 0.30%, 1.40%), compared to a median reduction of 0.0% (interquartile range: -0.08%, 0.16%) for trials of a single intervention (p=0.01). The benefit of employing more than one QI strategy appeared to persist among larger, randomized trials, but the small numbers of studies limits the reliability of this impression. The investigators did not find any specific type of QI strategy to confer unambiguous benefit. Provider education and disease management were the only strategies to approach statistical significance, compared with interventions absent these strategies.

Conclusion:

The authors' analysis of quality improvement strategies for diabetes care showed no particular type of QI to have an advantage over others, but suggested that employing at least two strategies provides a greater chance of success than single-faceted interventions, in terms of improving glycemic control or provider adherence. These conclusions are limited by probable publication bias favoring smaller trials and non-randomized trials, and the confounding presence of multiple QI strategies in a given intervention, as well as important patient and provider factors, and organizational characteristics.

Objective: To quantify the effects of informal caregiver availability and public funding on formal long-term care (LTC) expenditures in developed countries.

Data Source/Study Setting: Secondary data were acquired for 15 Organization for Economic Cooperation and Development (OECD) countries from 1970 to 2000. Study Design. Secondary data analysis, applying fixed- and random-effects models to time-series cross-sectional data. Outcome variables are inpatient or home heath LTC expenditures. Key explanatory variables are measures of the availability of informal caregivers, generosity in public funding for formal LTC, and the proportion of the elderly population in the total population.

Data Collection/Extraction Method: Aggregated macro data were obtained from OECD Health Data, United Nations Demographic Yearbooks, and U.S. Census Bureau International Data Base.

Principal Findings: Most of the 15 OECD countries experienced growth in LTC expenditures over the study period. The availability of a spouse caregiver, measured by male-to-female ratio among the elderly, is associated with a $28,840 (1995 U.S. dollars) annual reduction in formal LTC expenditure per additional elderly male. Availability of an adult child caregiver, measured by female labor force participation and full-time/part-time status shift, is associated with a reduction of $310 to $3,830 in LTC expenditures. These impacts on LTC expenditure vary across countries and across time within a country.

Conclusions: The availability of an informal caregiver, particularly a spouse caregiver, is among the most important factors explaining variation in LTC expenditure growth. Long-term care policies should take into account behavioral responses: decreased public funding in LTC may lead working women to leave the labor force to provide more informal care.

Objective: To determine whether health maintenance organizations (HMOs) attract enrollees who use relatively few medical resources and whether a simple risk-adjustment system could mitigate or eliminate the inefficiency associated with risk selection.

Data Sources: The first and second rounds of the Community Tracking Study Household Survey (CTSHS), a national panel data set of households in 60 different markets in the United States.

Study Design: We use regression analysis to examine medical expenditures in the first round of the survey between enrollees who switched plan types (i.e., from a non-HMO plan to an HMO plan, or vice versa) between the first and second rounds of the survey versus enrollees who remained in their original plan. The dependent variable is an enrollee's medical resource use, measured in dollars, and the independent variables include gender, age, self-reported health status, and other demographic variables.

Data Collection Methods: We restrict our analysis to the 6,235 non-elderly persons who were surveyed in both rounds of the CTSHS, received health insurance from their employer or the employer of a household member in both years of the survey, and were offered a choice of an HMO and a non-HMO plan in both years.

Principal Findings: We find that people who switched from a non-HMO to an HMO plan used 11 percent fewer medical services in the period prior to switching than people who remained in a non-HMO plan, and that this relatively low use persisted once they enrolled in an HMO. Furthermore, people who switched from an HMO to a non-HMO plan used 18 percent more medical services in the period prior to switching than those who remained in an HMO plan.

Conclusions: HMOs are experiencing favorable risk selection and would most likely continue to do so even if employers adjusted health plan payments based on enrollees' gender and age because the selection is based on enrollee characteristics that are difficult to observe, such as preferences for medical care and health status.

We all have a stake in the size of the physician workforce. With too few physicians, access to care will be compromised; with too many, there will be strong pressures to overconsume health services. Increasing the production of U.S.-trained physicians by expanding physical resources of medical schools and creating new residency and fellowship positions will be costly and will have delayed, long-lasting effects on the supply of physicians' services. According to those who believe that physicians increase the demand for their own services, every additional physician would generate added health care costs for the length of a career, which now averages about 30 years. These increased expenditures would dwarf the short-term costs of expanding our capacity to train physicians.

Because new graduates are a small fraction of the total physician workforce, the supply of physicians would change little in the short run, even if it were possible to expand the number of training positions instantly. In an article in this issue (1), Richard Cooper forcefully argues that this delay is an important reason to take immediate action to increase the production of physicians. He projects that the United States will have 200 000 fewer physicians than we need in 2020. We agree that demographic and economic trends could increase the demand for physician services in the coming years, but we also believe that his forecast contains far too many uncertainties to serve as the basis for taking immediate action. We think that Cooper's analysis does not take account of important factors that could change the need for large increases in physician supply. In this commentary, we discuss the potential roles of a healthier aging population, changes in government policy, new technology, physician-induced demand for health care, and changes in the price of health care.

BACKGROUND/OBJECTIVES: The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. STUDY SETTING AND METHODS: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care. RESULTS: A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made. Conclusions: The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.

We conducted a cross-sectional survey of 210 patients who came to a free medical clinic for health care over an 8-month period. We (1) measured their satisfaction with care, (2) determined the frequency of missed opportunities for providing health education and social work consultation, and (3) assessed whether patient-specific factors drive the frequency of these missed opportunities. Of the 210 patients surveyed, a total of 168 (80.0%) completed the entire survey. The mean satisfaction rating was high (4.6 on a scale of 1 to 5). A significant number of missed opportunities occurred, with only 28% of patients receiving patient education material, and 32% of patients visiting the social worker. No particular patient groups emerged as most susceptible to these missed opportunities. This study shows both the high degree of patient satisfaction at this free clinic and the many opportunities for improving patient education and social services. Adding health education and social work consultation to the patient encounter could improve the health of these patients.