Does quality of care systematically differ among government-owned, private not-for-profit, and for-profit hospitals? A large empirical literature provides conflicting evidence. Through quantitative review of 46 studies since 1990, we find that several study features that can explain divergent results: analytic methods, disease studied, and data sources. For unprofitable care, how studies handle market competition and regional differences account for substantial variation. Policymakers should be aware that differences in results appear to arise predominantly from differences between studies' analytic methods. Moreover, conventional methods of meta-analytic synthesis should be applied with great caution given the considerable overlap among studied hospitals.

Although the quality of health care would logically seem to be a universal concept, this study hypothesized that physicians and their patients could differ in their perceptions of high-quality care and that those beliefs might vary by country. Such a mismatch in beliefs may be especially important as clinical practice guidelines developed in the United States are globalized.

A survey of 20 statements describing various components of health care delivery and quality was sent to pediatric cardiologists in 33 countries, who ranked the statements in order of priority for ideal health care. Each participating physician administered the questionnaire to the parents of children with congenital heart disease; 554 questionnaires were received and analyzed. A subanalysis of 9 countries with the largest number of responses was done (Canada, the Czech Republic, France, Germany, Italy, The Netherlands, Sweden, the United Kingdom, and the United States). Doctors and parents rated the same 4 statements among the top 5: the doctor is skillful and knowledgeable; the doctor explains health problems, tests, and treatments in a way the patient can understand; a basic level of healthcare is available to all citizens regardless of their ability to pay; and treatment causes the patient to feel physically well.

Overall, parents' responses differed more among countries than those of physicians; the magnitude of the difference between parents and physicians varied by country. This discrepancy highlights a potential mismatch between patients' and physicians' views about the desired components of health care delivery, in particular the application of American quality standards for health care to systems in other countries.

Background:

Coronary atherosclerosis develops slowly over decades but is frequently characterized clinically by sudden unstable episodes. Patients who present with unstable coronary disease, such as acute myocardial infarction, may systematically differ from patients who present with relatively stable coronary disease, such as exertional angina.

Objective:

To examine whether medication use or patient characteristics influence the mode of initial clinical presentation of coronary disease.

Design:

Case-control study.

Setting:

Large integrated health care delivery system in northern California.

Patients:

Adults whose first clinical presentation of coronary disease was either acute myocardial infarction (n = 916) or stable exertional angina (n = 468).

Measurements:

Use of cardiac medications before the event from pharmacy databases and demographic, lifestyle, and clinical characteristics from self-report and clinical and administrative databases.

Results:

Compared with patients with incident stable exertional angina, patients with incident acute myocardial infarction were more likely to be men, smokers, physically inactive, and hypertensive but were less likely to have a parental history of coronary disease. Patients presenting with myocardial infarction were much less likely to have received statins (19.3% vs. 40.4%; P 0.001) and ß-blockers (19.0% vs. 47.7%; P 0.001) than patients presenting with exertional angina. After adjustment for potential confounders, recent use of statins (adjusted odds ratio, 0.45 [95% CI, 0.32 to 0.62]) and ß-blockers (adjusted odds ratio, 0.26 [CI, 0.19 to 0.35]) was associated with lower likelihoods of presenting with an acute myocardial infarction than with stable angina.

Limitations:

This observational study did not have information on all possible confounding factors, including use of aspirin therapy.

Conclusion:

Statin and ß-blocker use was associated with lower odds of presenting with an acute myocardial infarction than with stable angina. Additional studies are needed to confirm that these therapies protect against unstable, higher-risk clinical presentations of coronary disease.

Background:

Mortality from inhalational anthrax during the 2001 U.S. attack was substantially lower than that reported historically.

Purpose:

To systematically review all published inhalational anthrax case reports to evaluate the predictors of disease progression and mortality.

Data Sources:

MEDLINE (1966-2005), 14 selected journal indexes (1900-1966), and bibliographies of all retrieved articles.

Study Selection:

Case reports (in any language) between 1900 and 2005 that met predefined criteria.

Data Extraction:

Two authors (1 author for non-English-language reports) independently abstracted patient data.

Data Synthesis:

The authors found 106 reports of 82 cases of inhalational anthrax. Mortality was statistically significantly lower for patients receiving antibiotics or anthrax antiserum during the prodromal phase of disease, multidrug antibiotic regimens, or pleural fluid drainage. Patients in the 2001 U.S. attack were less likely to die than historical anthrax case-patients (45% vs. 92%; P < 0.001) and were more likely to receive antibiotics during the prodromal phase (64% vs. 13%; P < 0.001), multidrug regimens (91% vs. 50%; P = 0.027), or pleural fluid drainage (73% vs. 11%; P < 0.001). Patients who progressed to the fulminant phase had a mortality rate of 97% (regardless of the treatment they received), and all patients with anthrax meningoencephalitis died.

Limitations:

This was a retrospective case review of previously published heterogeneous reports.

Conclusions:

Despite advances in supportive care, fulminant-phase inhalational anthrax is usually fatal. Initiation of antibiotic or anthrax antiserum therapy during the prodromal phase is associated with markedly improved survival, although other aspects of care, differences in clinical circumstances, or unreported factors may contribute to this observed reduction in mortality. Efforts to improve early diagnosis and timely initiation of appropriate antibiotics are critical to reducing mortality.

Objective: Unnecessary prescribing of antibiotics is a major problem in the U.S. and worldwide, contributing to the problem of antimicrobial resistance (AMR). This review examines the effects of quality improvement strategies on reducing inappropriate prescribing of antibiotics, targeting both prescribing of antibiotics for non-bacterial illnesses ("the antibiotic treatment decision") and prescribing of broad-spectrum antibiotics when narrow-spectrum agents are indicated ("the antibiotic selection decision").

Search Strategy and Inclusion Criteria: We evaluated studies examining the effectiveness of quality improvement (QI) strategies targeting outpatient antibiotic prescribing for acute illnesses. Studies were identified by searching the Cochrane Collaboration's Effective Practice and Organisation of Care registry and MEDLINE®. We included randomized and quasi-randomized controlled trials, controlled before-after studies, and interrupted time series that reported measures of antimicrobial use. QI strategies were classified as clinician education, patient education, provision of delayed prescriptions, audit and feedback, clinician reminders, and financial or regulatory incentives. Our primary outcomes were the percentage of patients prescribed an antibiotic (for antibiotic treatment studies); or the percentage of patients prescribed a recommended antibiotic or guideline-concordant antibiotic therapy (for antibiotic selection studies). Secondary outcomes included effects on antimicrobial resistance, intervention safety (disease outcomes and adverse events), prescribing costs, and patient satisfaction.

Data Collection and Analysis: Two reviewers abstracted data on the components of the QI intervention, study population, targets, and outcomes. We compared the effects of QI strategies in terms of the median effect achieved for the primary outcomes, using nonparametric tests; studies not eligible for median effects analysis were summarized qualitatively.

Main Results: Fifty-four studies reporting a total of 74 trials met the inclusion criteria; 34 studies (reporting 41 trials) addressed the treatment decision, and 26 studies (reporting 33 trials) addressed the selection decision. Six studies evaluated both decisions. Study methodologic quality was generally fair. Nearly all studies took place in outpatient primary care clinics.

• Studies addressing the antibiotic treatment decision: Most studies addressed prescribing for acute respiratory infections (ARIs). Interventions were effective at reducing prescribing, with a median absolute effect of -8.9% [interquartile range (IQR) -12.4% to -6.7%]. No individual QI strategy (or combination of strategies) was more effective at reducing prescribing. Within clinician education, active educational strategies appeared more effective than passive strategies. When extrapolated to a population level, strategies targeting general antibiotic prescribing appeared to reduce antibiotic prescribing more than strategies targeting prescribing for a single condition. Few studies addressed secondary endpoints; patient satisfaction was not worsened by QI interventions, but effects on AMR or costs could not be assessed.
• Studies addressing the antibiotic selection decision: Interventions targeted prescribing for ARIs or urinary tract infections (UTIs). Interventions were effective, with a median absolute improvement in prescribing of recommended antibiotics of 10.6% (IQR 3.4% to 18.2%). Clinician education alone appeared more effective than education in combination with audit and feedback, but this finding likely represents confounding. Very few studies addressed secondary outcomes.

Abstract

Recent innovations in biomedicine seem poised to revolutionize medical practice. At the same time, disease and disability are increasing among younger populations. This paper considers how these confluent trends will affect the elderly's health status and health care spending over the next thirty years. Because healthier people live longer, cumulative Medicare spending varies little with a beneficiary's disease and disability status upon entering Medicare. On the other hand, ten of the most promising medical technologies are forecast to increase spending greatly. It is unlikely that a "silver bullet" will emerge to both improve health and dramatically reduce medical spending.