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Rigorous experimental methods suppress differences among study participants (noise) to detect true intervention effects (signals). But suppressing participants' heterogeneity obscures an essential dimension of biological and clinical knowledge. Medicine is therefore ambivalent about the influence of heterogeneity on outcomes and struggles to find ways to take it properly into account in both clinical practice and research. This analysis explores the roots of that ambivalence. Drawing on the evaluation of 2 health care improvement initiatives, this article examines the unique features of improvement that help to understand heterogeneity's influence on study methods, and suggests a variety of ways to assess the effect of heterogeneity on study outcome measures. [ABSTRACT FROM AUTHOR]

In 2005, draft guidelines were published for reporting studies of quality improvement as the initial step in a consensus process for development of a more definitive version. The current article contains the revised version, which we refer to as Standards for QUality Improvement Reporting Excellence (SQUIRE). This narrative progress report summarizes the special features of improvement that are reflected in SQUIRE and describes major differences between SQUIRE and the initial draft guidelines. It also explains the development process, which included formulation of responses to informal feedback, written commentaries, and input from publication guideline developers; ongoing review of the literature on the epistemology of improvement and methods for evaluating complex social programs; and a meeting of stakeholders for critical review of the guidelines' content and wording, followed by commentary on sequential versions from an expert consultant group. Finally, the report discusses limitations of and unresolved questions about SQUIRE; ancillary supporting documents and alternative versions under development; and plans for dissemination, testing, and further development of SQUIRE. [ABSTRACT FROM AUTHOR]

Editorial. Discusses various issues related to the drug pricing of prescription drugs in the United States. Percent increase of average price of drugs per prescription; Sales performance of the pharmaceutical industry; Cost-effectiveness of drug therapies; Impact of genetic abnormalities in disease pathogenesis and drug efficacy.

Objective: A consensus conference on the reasons for the undertreatment of depression was organized by the National Depressive and Manic Depressive Association (NDMDA) on January 17-18, 1996. The target audience included health policymakers, clinicians, patients and their families, and the public at large. Six key questions were addressed: (1) Is depression undertreated in the community and in the clinic? (2) What is the economic cost to society of depression? (3) What have been the efforts in the past to redress undertreatment and how successful have they been? (4) What are the reasons for the gap between our knowledge of the diagnosis and treatment of depression and actual treatment received in this country? (5) What can we do to narrow this gap? (6) What can we do immediately to narrow this gap?Participants: Consensus panel members were drawn from psychiatry, psychology, family practice, internal medicine, managed care and public health, consumers, and the general public. The panelists listened to a set of presentations with background papers from experts on diagnosis, epidemiology, treatment, and cost of treatment.Evidence: Experts summarized relevant data from the world scientific literature on the 6 questions posed for the conference.Consensus Process: Panel members discussed openly all material presented to them in executive session. Selected panelists prepared first drafts of the consensus statements for each question. All of these drafts were read by all panelists and were edited and reedited until consensus was achieved.Conclusions: There is overwhelming evidence that individuals with depression are being seriously undertreated. Safe, effective, and economical treatments are available. The cost to individuals and society of this undertreatment is substantial. Long suffering, suicide, occupational impairment, and impairment in interpersonal and family relationships exist. Efforts to redress this gap have included provider educational programs and public educational programs. Reasons for the continuing gap include patient, provider, and health care system factors. Patient-based reasons include failure to recognize the symptoms, underestimating the severity, limited access, reluctance to see a mental health care specialist due to stigma, noncompliance with treatment, and lack of health insurance. Provider factors include poor professional school education about depression, limited training in interpersonal skills, stigma, inadequate time to evaluate and treat depression, failure to consider psychotherapeutic approaches, and prescription of inadequate doses of antidepressant medication for inadequate durations. Mental health care systems create barriers to receiving optimal treatment. Strategies to narrow the gap include enhancing the role of patients and families as participants in care and advocates; developing performance standards for behavioral health care systems, including incentives for positive identification, assessment, and treatment of depression; enhancing educational programs for providers and the public; enhancing collaboration among provider subtypes (eg, primary care providers and mental health professionals); and conducting research on development and testing of new treatments for depression. [ABSTRACT FROM AUTHOR]

Objective: The In-Training Examination in Internal Medicine (ITE-IM) has been offered to internal medicine trainees annually since 1988 as an instrument for self-assessment. This report outlines the manner in which the test is prepared, reviews the results of annual examinations, and analyzes trends during the past 6 years.Design: Results of each examination were reviewed with regard to the demographic characteristics of persons taking the test, their previous medical training, and their present program affiliations.Results: Then number of residents participating in the ITE-IM has increased steadily over the past 6 years. In 1993, more than 12,000 residents from more than 90% of internal medicine training programs in the United States participated in the examination; the percentage of international medical school graduates taking the examination increased from 27% in 1988 to 47% in 1993. Statistical analyses of each examination have shown it to be reliable, internally consistent, and discriminating. Over the past 6 years, graduates of U.S. medical schools have scored consistently higher than those of international medical schools and schools of osteopathic medicine on all annual examinations. However, in 1993, for residents at all levels of training, the differences in scores between graduates of U.S. medical schools and graduates of international medical schools narrowed substantially. From 1988 to 1993, there has been a trend toward lower scores by every cohort on each subsequent examination. The decreases in scores are most pronounced for graduates of U.S. medical school and those of schools of osteopathic medicine. The lower scores may be caused by either an increased level of difficulty in the examination or decreased knowledge among examinees.Conclusions: The ITE-IM is a useful instrument to assess the knowledge base of residents and program directors with a reliable evaluation of themselves and their programs in comparison to their national peer groups. It also provides objective data to monitor trends over time in residents' scores and relates them to the changing demographic characteristics of trainees and to innovations in the clinical curricula of internal medicine training programs. [ABSTRACT FROM AUTHOR]

With increasing pressure to measure quality, patient- based assessments of medical care are becoming increasingly important. Patients offer a unique perspec tive for evaluating the nontechnical aspects of medical care. This study reviews the importance of utilizing pa tients' perceptions to measure quality of care in office settings. It also reviews the principles required to con duct a well done survey. The concept of patient percep tions differs from the more commonly measured concept of patient satisfaction, in that perceptions measure whether a patients' needs and expectations are met, in addition to satisfaction. One of the most accurate and efficient means of measuring patients' perceptions is through the use of surveys. As with all standardized data collection, creating and performing high quality surveys of patients' perceptions can be challenging. Valid and reliable patient survey data can enable prac titioners to identify areas for improvement, and demon strate to external reviewers the quality of care they provide to their patients. [ABSTRACT FROM PUBLISHER]

Editorial. Comments on the importance of peer review as an integral part of the editorial process. Author's experiences as editor of a medical journal; Implications of abandoning peer review and publishing; Researchers' views on the journal editorial process.

This article presents a letter to the editor regarding race as a component of medical treatment, as reported in the February 25, 2007 issue.

Editorial. Argues for the institutionalization of health care rights in the United States Constitution. Problems affecting health care reform efforts; Socioeconomic status and public measures as important determinants of health; Definition of `basic and essential' health care; Constitution's protection of citizens against the law and the state rather than the community and nature.

Editorial. Presents information pertaining to the aspects associated with peer review process. Description of this process; Reference to the contents of medical journals; Information on blinding authors.