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Background: Whether collaborative care models that enable interactive communication (timely, 2-way exchange of pertinent clinical information directly between primary care and specialist physicians) improve patient outcomes is uncertain. Purpose: To assess the effects of interactive communication between collaborating primary care physicians and key specialists on outcomes for patients receiving ambulatory care. Data Sources: PubMed, PsycInfo, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Web of Science through June 2008 and secondary references, with no language restriction. Study Selection: Studies that evaluated the effects of interactive communication between collaborating primary care physicians and specialists on outcomes for patients with diabetes, psychiatric conditions, or cancer. Data Extraction: Contextual, intervention, and outcome data from 23 studies were extracted by one reviewer and checked by another. Study quality was assessed with a 13-item checklist. Disagreement was resolved by consensus. Main outcomes for analysis were selected by reviewers who were blinded to study results. Data Synthesis: Meta-analysis indicated consistent effects across 11 randomized mental health studies (pooled effect size, -0.41 [95% CI, -0.73 to -0.10]), 7 nonrandomized mental health studies (pooled effect size, -0.47 [CI, -0.84 to -0.09]), and 5 nonrandomized diabetes studies (pooled effect size, -0.64 [CI, -0.93 to -0.34]). These findings remained robust to sensitivity analyses. Meta-regression indicated studies that included interventions to enhance the quality of information exchange had larger effects on patient outcomes than those that did not (-0.84 vs. -0.27; P = 0.002). Limitations: Because collaborative interventions were inherently multifaceted, the efficacy of interactive communication by itself cannot be established. Inclusion of study designs with lower internal validity increased risk for bias. No studies involved oncologists. Conclusion: Consistent and clinically important effects suggest a potential role of interactive communication for improving the effectiveness of primary care-specialist collaboration. Primary Funding Source: RAND Health's Comprehensive Assessment of Reform Options Initiative, the Veterans Affairs Center for the Study of Provider Behavior, The Commonwealth Fund, and the Health Foundation. Ann Intern Med. 2010; 152:247-258. www.annals.0rg For author affiliations, see end of text.

Objective. To review and characterize existing health care efficiency measures in order to facilitate a common understanding about the adequacy of these methods. Data Sources. Review of the MedLine and EconLit databases for articles published from 1990 to 2008, as well as search of the "gray" literature for additional measures developed by private organizations. Study Design. We performed a systematic review for existing efficiency measures. We classified the efficiency measures by perspective, outputs, inputs, methods used, and reporting of scientific soundness. Principal Findings. We identified 265 measures in the peer-reviewed literature and eight measures in the gray literature, with little overlap between the two sets of measures. Almost all of the measures did not explicitly consider the quality of care. Thus, if quality varies substantially across groups, which is likely in some cases, the measures reflect only the costs of care, not efficiency. Evidence on the measures' scientific soundness was mostly lacking: evidence on reliability or validity was reported for six measures (2.3 percent) and sensitivity analyses were reported for 67 measures (25.3 percent). Conclusions. Efficiency measures have been subjected to few rigorous evaluations of reliability and validity, and methods of accounting for quality of care in efficiency measurement are not well developed at this time. Use of these measures without greater understanding of these issues is likely to engender resistance from providers and could lead to unintended consequences. Key Words. Efficiency, provider profiling, performance measurement, systematic review, Rising health care costs are driving increases in health insurance premiums, the erosion of private coverage (Chernew, Cutler, and Keenan 2005), and strains on the fiscal solvency of public insurance [...]

Background: Many persons and their families are burdened by serious chronic illness in late life. How to best support quality of life is an important consideration for care. Purpose: To assess evidence about interventions to improve palliative and end-of-life care. Data Sources: English-language citations (January 1990 to November 2005) from MEDLINE, the Database of Abstracts of Reviews of Effects, the National Consensus Project for Quality Palliative Care bibliography, and November 2005 to January 2007 updates from expert reviews and literature surveillance. Study Selection: Systematic reviews that addressed 'end of life,' including terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia), and intervention studies (randomized and nonrandomized designs) that addressed pain, dyspnea, depression, advance care planning, continuity, and caregiving. Data Extraction: Single reviewers screened 24 423 titles to find 6381 relevant abstracts and reviewed 1274 articles in detail to identify 33 high-quality systematic reviews and 89 relevant intervention studies. They synthesized the evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification. Data Synthesis: Strong evidence supports treating cancer pain with opioids, nonsteroidals, radionuclides, and radiotherapy; dyspnea from chronic lung disease with short-term opioids; and cancer-associated depression with psychotherapy, tricyclics, and selective serotonin reuptake inhibitors. Strong evidence supports multi-component interventions to improve continuity in heart failure. Moderate evidence supports advance care planning led by skilled facilitators who engage key decision makers and interventions to alleviate caregiver burden. Weak evidence addresses cancer-related dyspnea management, and no evidence addresses noncancer pain, symptomatic dyspnea management in advanced heart failure, or short-acting antidepressants in terminal illness. No direct evidence addresses improving continuity for patients with dementia. Evidence was weak for improving caregiver burdens in cancer and was absent for heart failure. Limitations: Variable literature indexing for advanced chronic illness and end of life limited the comprehensiveness of searches, and heterogeneity was too great to do meta-analysis. Conclusion: Strong to moderate evidence supports interventions to improve important aspects of end-of-life care. Future research should quantify these effects and address the generalizability of insights across the conditions and settings of the last part of life. Many critical issues lack high-quality evidence.

Background: Previous reviews have shown inconsistent effects of publicly reported performance data on quality of care, but many new studies have become available in the 7 years since the last systematic review. Purpose: To synthesize the evidence for using publicly reported performance data to improve quality. Data Sources: Web of Science, MEDLINE, EconLit, and Wilson Business Periodicals (1999-2006) and independent review of articles (1986-1999) identified in a previous systematic review. Only sources published in English were included. Study Selection: Peer-reviewed articles assessing the effects of public release of performance data on selection of providers, quality improvement activity, clinical outcomes (effectiveness, patient safety, and patient-centeredness), and unintended consequences. Data Extraction: Data on study participants, reporting system or level, study design, selection of providers, quality improvement activity, outcomes, and unintended consequences were extracted. Data Synthesis: Forty-five articles published since 1986 (27 of which were published since 1999) evaluated the impact of public reporting on quality. Many focus on a select few reporting systems. Synthesis of data from 8 health plan-level studies suggests modest association between public reporting and plan selection. Synthesis of 11 studies, all hospital-level, suggests stimulation of quality improvement activity. Review of 9 hospital-level and 7 individual provider-level studies shows inconsistent association between public reporting and selection of hospitals and individual providers. Synthesis of 11 studies, primarily hospital-level, indicates inconsistent association between public reporting and improved effectiveness. Evidence on the impact of public reporting on patient safety and patient-centeredness is scant. Limitations: Heterogeneity made comparisons across studies challenging. Only peer-reviewed, English-language articles were included. Conclusion: Evidence is scant, particularly about individual providers and practices. Rigorous evaluation of many major public reporting systems is lacking. Evidence suggests that publicly releasing performance data stimulates quality improvement activity at the hospital level. The effect of public reporting on effectiveness, safety, and patient-centeredness remains uncertain.

Objective. To identify psychometrically sound measures of outcomes in end-of-life care and to characterize their use in intervention studies. Data Sources. English language articles from 1990 to November 2005 describing measures with published psychometric data and intervention studies of end-of-life care. Study Design. Systematic review of end-of-life care literature. Extraction Methods. Two reviewers organized identified measures into 10 major domains. Eight reviewers extracted and characterized measures from intervention studies. Principal Findings. Of 24,423 citations, we extracted 200 articles that described 261 measures, accepting 99 measures. In addition to 35 measures recommended in a prior systematic review, we identified an additional 64 measures of the end-of-life experience. The most robust measures were in the areas of symptoms, quality of life, and satisfaction; significant gaps existed in continuity of care, advance care planning, spirituality, and caregiver well-being. We also reviewed 84 intervention studies in which 135 patient-centered outcomes were assessed by 97 separate measures. Of these, 80 were used only once and only eight measures were used in more than two studies. Conclusions. In general, most measures have not undergone rigorous development and testing. Measure development in end-of-life care should focus on areas with identified gaps, and testing should be done to facilitate comparability across the care settings, populations, and clinical conditions. Intervention research should use robust measures that adhere to these standards. Key Words. Quality of health care, outcome and process assessment (health care), end-of-life care, measures, dying, For the vast majority of Americans, the end of life includes a prolonged experience of chronic progressive disease, often associated with uncertainty, pain, suffering, and cost (Hogan et al. 2000; [...]

Background: Colorectal cancer is the second most common cancer type among new cancer diagnoses in the United States. Attention to the quality of surgical care for colorectal cancer is of particular importance given the increasing numbers of colorectal cancer resections performed in the aging population. A National Cancer Institute-sponsored consensus panel produced guidelines for colorectal cancer surgery in 2000. We have updated and extended that work by using a formal process to identify and rate quality indicators as valid for care during the preoperative, intraoperative, and postoperative periods. Methods: Using a modification of the RAND/UCLA Appropriateness Methodology, we carried out structured interviews with leaders in the field of colorectal cancer surgery and systematic reviews of the literature to identify candidate quality indicators addressing perioperative care for patients undergoing surgery for colorectal cancer. A panel of 14 colorectal surgeons, general surgeons, and surgical oncologists then evaluated and formally rated the indicators using the modified Delphi method to identify valid indicators. Results: A total of 142 candidate indicators were identified in six broad domains: privileging (which addresses surgical credentials), preoperative evaluation, patient-provider discussions, medication use, intraoperative care, and postoperative management. The expert panel rated 92 indicators as valid. These indicators address all domains of perioperative care for patients undergoing surgery for colorectal cancer. Conclusions: The RAND/UCLA Appropriateness Methodology can be used to identify and rate indicators of high-quality perioperative care for patients undergoing surgery for colorectal cancer. The indicators can be used as quality performance measures and for quality-improvement programs.

Background: Experts consider health information technology key to improving efficiency and quality of health care. Purpose: To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care. Data Sources: The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005. Study Selection: Descriptive and comparative studies and systematic reviews of health information technology. Data Extraction: Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs. Data Synthesis: 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited. Limitations: Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited. Conclusions: Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear.

Background: Patient global ratings of care are commonly used to assess health care. However, the extent to which these assessments of care are related to the technical quality of care received is not well understood. Objective: To investigate the relationship between patient-reported global ratings of health care and the quality of providers' communication and technical quality of care. Design: Observational cohort study. Setting: 2 managed care organizations. Patients: Vulnerable older patients identified by brief interviews of a random sample of community-dwelling adults 65 years of age or older who received care in 2 managed care organizations during a 13-month period. Measurements: Survey questions from the second stage of the Consumer Assessment of Healthcare Providers and Systems program were used to determine patients' global rating of health care and provider communication. A set of 236 quality indicators, defined by the Assessing Care of Vulnerable Elders project, were used to measure technical quality of care given for 22 clinical conditions; 207 quality indicators were evaluated by using data from chart abstraction or patient interview. Results: Data on the global rating item, communication scale, and technical quality of care score were available for 236 vulnerable older patients. In a multivariate logistic regression model that included patient and clinical factors, better communication was associated with higher global ratings of health care. Technical quality of care was not significantly associated with the global rating of care. Limitations: Findings were limited to vulnerable elders who were enrolled in managed care organizations and may not be generalizable to other age groups or types of insurance coverage. Conclusions: Vulnerable elders' global ratings of care should not be used as a marker of technical quality of care. Assessments of quality of care should include both patient evaluations and independent assessments of technical quality.

Abstract Objective To evaluate and synthesize the evidence on the effect of Ayurvedic therapies for diabetes mellitus. Design Systematic review of trials. Measurements and main results We found no study [...]

Background: Although assessment of the quality of medical care often relies on measures of process of care, the linkage between performance of these process measures during usual clinical care and subsequent patient outcomes is unclear. Objective: To examine the link between the quality of care that patients received and their survival. Design: Observational cohort study. Setting: Two managed care organizations. Patients: Community-dwelling high-risk patients 65 years of age or older who were continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999. Measurements: Quality of care received by patients (as measured by a set of quality indicators covering 22 clinical conditions) and their survival over the following 3 years. Results: The 372 vulnerable older patients were eligible for a mean of 21 quality indicators (range, 8 to 54) and received, on average, 53% of the care processes prescribed in quality indicators (range, 27% to 88%). Eighty-six (23%) persons died during the 3-year follow-up. There was a graded positive relationship between quality score and 3-year survival. After adjustment for sex, health status, and health service use, quality score was not associated with mortality for the first 500 days, but a higher quality score was associated with lower mortality after 500 days (hazard ratio, 0.64 [95% CI, 0.49 to 0.84] for a 10% higher quality score). Limitations: The observational design limits causal inference regarding the effect of quality of care on survival. Conclusions: Better performance on process quality measures is strongly associated with better survival among community-dwelling vulnerable older adults.

Objective. To assess patients' use of and preferences for information about technical and interpersonal quality when using simulated, computerized health care report cards to select a primary care provider (PCP). Data Sources/Study Setting. Primary data collected from 304 adult consumers living in Los Angeles County in January and February 2003. Study Design/Data Collection. We constructed computerized report cards for seven pairs of hypothetical individual PCPs (two internal validity check pairs included). Participants selected the physician that they preferred. A questionnaire collected demographic information and assessed participant attitudes towards different sources of report card information. The relationship between patient characteristics and number of times the participant selected the physician who excelled in technical quality are estimated using an ordered logit model. Principal Findings. Ninety percent of the sample selected the dominant physician for both validity checks, indicating a level of attention to task comparable with prior studies. When presented with pairs of physicians who varied in technical and interpersonal quality, two-thirds of the sample (95 percent CI: 62, 72 percent) chose the physician who was higher in technical quality at least three out of five times (one-sample binomial test of proportion). Age, gender, and ethnicity were not significant predictors of choosing the physician who was higher in technical quality. Conclusions. These participants showed a strong preference for physicians of high technical quality when forced to make tradeoffs, but a substantial proportion of the sample preferred physicians of high interpersonal quality. Individual physician report cards should contain ample information in both domains to be most useful to patients. Key Words. Quality, health care, primary care, physician profiling, The release of performance data about health care providers to the public as a means of improving quality of care has been advocated by government agencies such as the Centers [...]

The use of complementary and alternative medicine (CAM) continues to grow in the United States. The Agency for Healthcare Research and Quality has devoted a substantial proportion of the Evidence-based Practice Center (EPC) program to systematic reviews of CAM. Such syntheses present different challenges from those conducted on western medicine topics, and in many ways are more difficult. We discuss 3 challenges: identifying evidence about CAM, assessing the quality of individual studies, and addressing rare serious adverse events. We use illustrations from EPC evidence reports to show readers approaches to the 3 areas and then present specific recommendations for each issue.

Background: Controversy exists regarding the effectiveness of surgery for weight loss and the resulting improvement in health-related outcomes. Purpose: To perform a meta-analysis of effectiveness and adverse events associated with surgical treatment of obesity. Data Sources: MEDLINE, EMBASE, Cochrane Controlled Trials Register, and systematic reviews. Study Selection: Randomized, controlled trials; observational studies; and case series reporting on surgical treatment of obesity. Data Extraction: Information about study design, procedure, population, comorbid conditions, and adverse events. Data Synthesis: The authors assessed 147 studies. Of these, 89 contributed to the weight loss analysis, 134 contributed to the mortality analysis, and 128 contributed to the complications analysis. The authors identified 1 large, matched cohort analysis that reported greater weight loss with surgery than with medical treatment in individuals with an average body mass index (BMI) of 40 kg/[m.sup.2] or greater. Surgery resulted in a weight loss of 20 to 30 kg, which was maintained for up to 10 years and was accompanied by improvements in some comorbid conditions. For BMIs of 35 to 39 kg/[m.sup.2], data from case series strongly support superiority of surgery but cannot be considered conclusive. Gastric bypass procedures result in more weight loss than gastroplasty. Bariatric procedures in current use (gastric bypass, laparoscopic adjustable gastric band, vertical banded gastroplasty, and biliopancreatic diversion and switch) have been performed with an overall mortality rate of less than 1%. Adverse events occur in about 20% of cases. A laparoscopic approach results in fewer wound complications than an open approach. Limitations: Only a few controlled trials were available for analysis. Heterogeneity was seen among studies, and publication bias is possible. Conclusions: Surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with a BMI of 40 kg/[m.sup.2] or greater. More data are needed to determine the efficacy of surgery relative to nonsurgical therapy for less severely obese people. Procedures differ in efficacy and incidence of complications.

Background: In response to the increase in obesity, pharmacologic treatments for weight loss have become more numerous and more commonly used. Purpose: To assess the efficacy and safety of weight loss medications approved by the U.S. Food and Drug Administration and other medications that have been used for weight loss. Data Sources: Electronic databases, experts in the field, and unpublished information. Study Selection: Up-to-date meta-analyses of sibutramine, phentermine, and diethylpropion were identified. The authors assessed in detail 50 studies of orlistat, 13 studies of fluoxetine, 5 studies of bupropion, 9 studies of topiramate, and 1 study each of sertraline and zonisamide. Meta-analysis was performed for all medications except sertraline, zonisamide, and fluoxetine, which are summarized narratively. Data Extraction: The authors abstracted information about study design, intervention, co-interventions, population, outcomes, and methodologic quality, as well as weight loss and adverse events from controlled trials of medication. Data Synthesis: All pooled weight loss values are reported relative to placebo. A meta-analysis of sibutramine reported a mean difference in weight loss of 4.45 kg (95% CI, 3.62 to 5.29 kg) at 12 months. In the meta-analysis of orlistat, the estimate of the mean weight loss for orlistat-treated patients was 2.89 kg (CI, 2.27 to 3.51 kg) at 12 months. A recent meta-analysis of phentermine and diethylpropion reported pooled mean differences in weight loss at 6 months of 3.6 kg (CI, 0.6 to 6.0 kg) for phentermine-treated patients and 3.0 kg (CI, -1.6 to 11.5 kg) for diethytpropion-treated patients. Weight loss in fluoxetine studies ranged from 14.5 kg of weight lost to 0.4 kg of weight gained at 12 or more months. For bupropion, 2.77 kg (CI, 1.1 to 4.5 kg) of weight was lost at 6 to 12 months. Weight loss due to topiramate at 6 months was 6.5% (CI, 4.8% to 8.3%) of pretreatment weight. With one exception, long-term studies of health outcomes were lacking. Significant side effects that varied by drug were reported. Limitations: Publication bias may exist despite a comprehensive search and despite the lack of statistical evidence for the existence of bias. Evidence of heterogeneity was observed for all meta-analyses. Conclusions: Sibutramine, orlistat, phentermine, probably diethylpropion, bupropion, probably fluoxetine, and topiramate promote modest weight loss when given along with recommendations for diet. Sibutramine and orlistat are the 2 most-studied drugs.

Background: Although pharmacotherapy is critical to the medical care of older patients, medications can have considerable toxicity in this age group. To date, research has focused on inappropriate prescribing and policy efforts have aimed at access, but no comprehensive measurement of the quality of pharmacologic management using explicit criteria has been performed. Objective: To evaluate the broad range of pharmacologic care processes for vulnerable older patients. Design: Observational cohort study. Setting: 2 managed care organizations enrolling older persons. Patients: Community-dwelling high-risk patients 65 years of age or older continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999. Measurements: Patients' receipt of care as specified in 43 quality indicators covering 4 domains of pharmacologic care: 1) prescribing indicated medications; 2) avoiding inappropriate medications; 3) education, continuity, and documentation; and 4) medication monitoring. Results: Of 475 vulnerable older patients, 372 (78%) consented to participate and had medical records that could be abstracted. The percentage of appropriate pharmacologic management ranged from 10% for documentation of risks of nonsteroidal anti-inflammatory drugs to 100% for avoiding short-acting calcium-channel blockers in patients with heart failure and avoiding [beta]-blockers in patients with asthma. Pass rates for quality indicators in the 'avoiding inappropriate medications' domain (97% [95% CI, 96% to 98%]) were significantly higher than pass rates for 'prescribing indicated medications' (50% [CI, 45% to 55%]); 'education, continuity, and documentation' (81% [CI, 79% to 84%]); and 'medication monitoring' (64% [CI, 60% to 68%]). Limitations: Fewer than 10 patients were eligible for many of the quality indicators measured, and the generalizability of these findings in 2 managed care organizations to the general geriatric population is uncertain. Conclusions: Failures to prescribe indicated medications, monitor medications appropriately, document necessary information, educate patients, and maintain continuity are more common prescribing problems than use of inappropriate drugs in older patients.

Abstract Objective To assess the relative effectiveness of interventions to prevent falls in older adults to either a usual care group or control group. Design Systematic review and meta-analyses. Data [...]

Background: Many people 65 years of age and older are at risk for functional decline and death. However, the resource-intensive medical care provided to this group has received little evaluation. Previous studies have focused on general medical conditions aimed at prolonging life, not on geriatric issues important for quality of life. Objective: To measure the quality of medical care provided to vulnerable elders by evaluating the process of care using Assessing Care of Vulnerable Elders quality indicators (QIs). Design: Observational cohort study. Setting: Managed care organizations in the northeastern and southwestern United States. Patients: Vulnerable older patients identified by a brief interview from a random sample of community-dwelling adults 65 years of age or older who were enrolled in 2 managed care organizations and received care between July 1998 and July 1999. Measurements: Percentage of 207 QIs passed, overall and for 22 target conditions; by domain of care (prevention, diagnosis, treatment, and follow-up); and by general medical condition (for example, diabetes and heart failure) or geriatric condition (for example, falls and incontinence). Results: Patients were eligible for 10 711 QIs, of which 55% were passed. There was no overall difference between managed care organizations. Wide variation in adherence was found among conditions, ranging from 9% for end-of-life care to 82% for stroke care. More treatment QIs were completed (81%) compared with other domains (follow-up, 63%; diagnosis, 46%; and prevention, 43%). Adherence to QIs was lower for geriatric conditions than for general medical conditions (31% vs. 52%; P < 0.001). Conclusions: Care for vulnerable elders falls short of acceptable levels for a wide variety of conditions. Care for geriatric conditions is much less optimal than care for general medical conditions.

Background: Few treatments for back pain are supported by strong scientific evidence. Conventional treatments, although widely used, have had limited success. Dissatisfied patients have, therefore, turned to complementary and alternative medical therapies and providers for care for back pain. Purpose: To provide a rigorous and balanced summary of the best available evidence about the effectiveness, safety, and costs of the most popular complementary and alternative medical therapies used to treat back pain. Data Sources: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Study Selection: Systematic review of randomized, controlled trials (RCTs) that were published since 1995 and that evaluated acupuncture, massage therapy, or spinal manipulation for nonspecific back pain and RCTs published since the reviews were conducted. Data Extraction: Two authors independently extracted data from the reviews (including number of RCTs, type of back pain, quality assessment, and conclusions) and original articles (including type of pain, comparison treatments, sample size, outcomes, follow-up intervals, loss to follow-up, and authors' conclusions.) Data Synthesis: Because the quality of the 20 RCTs that evaluated acupuncture was generally poor, the effectiveness of acupuncture for treating acute or chronic back pain is unclear. The three RCTs that evaluated massage reported that this therapy is effective for subacute and chronic back pain. A meta-regression analysis of the results of 26 RCTs evaluating spinal manipulation for acute and chronic back pain reported that spinal manipulation was superior to sham therapies and therapies judged to have no evidence of a benefit but was not superior to effective conventional treatments. Conclusions: Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.

Background: Low back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low back pain. Purpose: To resolve the discrepancies related to use of spinal manipulative therapy and to update previous estimates of effectiveness by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. Data Sources: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and previous systematic reviews. Study Selection: Randomized, controlled trials of patients with low back pain that evaluated spinal manipulative therapy with at least 1 day of follow-up and at least one clinically relevant outcome measure. Data Extraction: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). Data Synthesis: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. Conclusions: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.

Background: Because of overcrowding and cost-control efforts, emergency departments are under pressure to refer patients with nonacute conditions to other settings. However, no validated systematic methods exist for safely performing such referrals. Objective: To determine the effects on health status and access to care of systematically referring patients with nonacute conditions to next-day primary care. Design: Randomized, controlled trial. Setting: An emergency department in a public hospital. Patients: 156 adults who used the emergency department on weekdays from 7:00 a.m. to 3:00 p.m. and met criteria for deferred care. The criteria applied to three symptom complexes that account for 33% of U.S. emergency department visits by adults. Intervention: Next-day care at the study site?s primary care center or usual same-day care. Measurements: Self-reported health status and use of health services during 1-week follow-up. Results: Patients assigned to next-day care did not demonstrate clinically important disadvantages in health status or physician visits compared with usual care patients. In each group, more than 95% of patients were evaluated at least once by a physician, 4% sought health services after their initial evaluation, and no patients were hospitalized or died. At follow-up, both groups reported improved health status and fewer days in bed or with disability, although the deferred care group reported less improvement on all three measures. The 95% CIs were sufficiently narrow to exclude a clinically significant difference in self-reported health status. However, the possibility of 1 additional day in bed or with disability in the deferred care group could not be excluded. Conclusions: Clinically detailed standardized screening criteria can safely identify patients at public hospital emergency departments for referral to next-day care. However, larger studies are needed to assess the possibility of adverse effects.

Purpose: The relative effectiveness of the diverse approaches used to promote preventive care activities, such as cancer screening and adult immunization, is unknown. Despite many high-quality published studies, practices and policymakers attempting to improve preventive care have little definitive information on which to base decisions. Thus, we quantitatively assessed the relative effectiveness of previously studied approaches for improving adherence to adult immunization and cancer screening guidelines. Data Sources: MEDLINE, the Cochrane Effective Practice and Organization of Care Review Group register, previous systematic reviews, and the Medicare Health Care Quality Improvement Project database. Study Selection: Controlled clinical trials that assessed interventions to increase use of immunizations for influenza and pneumococcal pneumonia and screening for colon, breast, and cervical cancer in adults. Data Extraction: Two reviewers independently extracted data on characteristics and outcomes from unmasked articles. Intervention components to increase use of services were classified as reminder, feedback, education, financial incentive, legislative action, organizational change, or mass media campaign. Data Synthesis: Of 552 abstracts and articles, 108 met the inclusion criteria. To assess the effect of intervention components, meta-regression models were developed for immunizations and each cancer screening service by using 81 studies with a usual care or control group. The most potent intervention types involved organizational change (the adjusted odds ratios for increased use of services from organizational change ranged from 2.47 to 17.6). Organizational change interventions included the use of separate clinics devoted to prevention, use of a planned care visit for prevention, or designation of nonphysician staff to do specific prevention activities. The next most effective intervention components were patient financial incentives (adjusted odds ratios, 1.82 to 3.42) and patient reminders (adjusted odds ratios, 1.74 to 2.75); the adjusted odds ratios ranged form 1.29 to 1.53 for patient education and from 1.10 to 1.76 for feedback. Conclusions: Rates of adult immunization and cancer screening are most likely to improve when a health care organization supports performance of these activities through organizational changes in staffing and clinical procedures. Involving patients in self-management through patient financial incentives and reminders is also likely to positively affect performance.

Analysis of longitudinal survey data has shown that self-reported diagnoses and conditions, when added to a function-based targeting system, do not enhance predictive ability. The function-based targeting system depends on self-report and is easy to transport across care settings. It works significantly better than a model using just age and self-reported diagnoses.

The ACOVE indicators for treating pain in elderly patients are presented. The ACOVE project consists of 236 quality indicators for 22 conditions that commonly affect the elderly. These indicators provide a minimum set of standards to ensure that the elderly receive quality medical care.

The methods for developing the ACOVE quality indicators are described. The ACOVE project includes 236 quality indicators covering 22 medical conditions that commonly affect the elderly. These indicators are used to determine whether elderly patients are receiving quality medical care.

The Assessing Care of Vulnerable Elders (ACOVE) project developed 236 quality indicators covering 22 medical conditions that commonly affect elderly people. These quality indicators are used to evaluate health systems or health plans, not individual doctors. The indicators provide a minimum standard of care that should be followed.

Selecting target conditions for quality-of-care improvement in vulnerable older adults is discussed. A study involving discussion and two rounds of ranking of conditions by a panel of geriatric clinical experts who had studied literature reviews was carried out and 21 conditions were selected as targets. The conditions selected are prevalent in the group and probably account for 50%+ of the hospital/ambulatory care given to the group.

Background: Recent U.S. practice guidelines recommend spinal manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking. Objective: To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain. Design: Retrospective review of chiropractic office records against preset criteria for appropriateness that were developed from a systematic review of the literature and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit. Setting: 131 of 185 (71%) chiropractic offices randomly sampled from sites in the United States and Canada. Patients: 10 randomly selected records of patients presenting with low back pain from each office (1310 patients total). Measurements: Sociodemographic data on patients and chiropractors; use of health care services by patients; assessment of the decision to initiate spinal manipulation as appropriate, uncertain, or inappropriate. Results: Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and in appropriate in 29% of cases. Patients who did not undergo spinal manipulation were less likely to have a presentation judged appropriate and were more likely to have a presentation judged inappropriate than were patients who did undergo spinal manipulation (P = 0.01). Conclusions: The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased., Many spinal manipulations performed by chiropractors appear to be initiated for appropriate medical symptoms. Researchers evaluated the medical records of 859 patients seen by chiropractors. A panel of chiropractors and medical specialists determined that 46% of patients received spinal manipulation appropriately, and 25% of patients received care of uncertain appropriateness. The panel concluded that, in 29% of cases, spinal manipulation was initiated inappropriately. The proportion determined to be appropriate is similar to evaluations of other medical procedures.

Objective. To assess the feasibility of the appropriateness method in the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline Development process, and to compare the results of the appropriateness method with those obtained using evidence tables and an informal consensus method. Setting. AHCPR Low Back Problems Clinical Practice Guideline. Design. Two different group process methods with the same panel of experts were used in observational comparison of results of and satisfaction with guideline development. Data Collection. Practice guideline statements were created for topics using the conventional AHCPR method; then six months later new guideline statements for four topics were created using the appropriateness method. Panelist satisfaction with each process and resulting set of guideline statements was assessed. Principal Findings. Results of the appropriateness method for TENS, discography, and traction showed no disagreement among panel members and no appropriate indications for their use in the patient scenarios considered. These results are qualitatively similar to the guideline statements produced using evidence tables and informal consensus. Clinical practice guideline statements about electro-diagnostics created from appropriateness ratings were much more clinically specific than those created using evidence tables and informal consensus. Neither informal consensus building nor the appropriateness method was clearly preferred by a majority of panelists. Conclusions. It is feasible to use the appropriateness method in the AHCPR Clinical Practice Guideline Development process, and in some instances it produces more clinically specific guideline statements than does informal consensus. Key Words. Practice guidelines, appropriateness, group process

Objective: As part of a synthesis of evidence regarding the efficacy and safety of ephedra, the authors describe data on psychiatric adverse events from reports submitted to the Food and Drug Administration (FDA). Method: The authors reviewed all 1,820 adverse event reports related to dietary supplements containing herbal ephedra from FDA MedWatch files as of Sept. 30, 2001. Fifty-seven serious psychiatric events were reported. Results: The most commonly reported events were psychosis, severe depression, mania or agitation, hallucinations, sleep disturbance, and suicidal ideation. Ten events involved physical harm to self or others; five events resulted in legal action due to criminal behavior. Twenty-six events resulted in hospitalization, at least six of which were involuntary. Of importance, two-thirds of all cases involved patients with preexisting psychiatric conditions and/or use of other medications or illicit substances. Conclusions: Clinicians should be aware that serious psychiatric symptoms could be associated with ephedra use.