In This Issue

September 2011 | Bradford H. Gray

End-of-life care presents both quality and cost challenges in many countries, including the United States. While it may not be surprising that a disproportionate share of medical expenditures occur near the end of life, the care patients receive in the United States is often of inadequate quality, as Diane Meier shows in the first article in this issue, “Increased Access to Palliative Care and Hospice Services: Opportunities to Improve Value in Health Care.” The article, which grew out of a paper initially prepared for the National Priorities Partnership of the National Quality Forum, provides an overview of a topic that will be increasingly important as the elderly population grows over the coming decades. Meier summarizes available research and gaps in research about clinical care and costs at the end of life in the United States, as well as outcome studies of palliative care and hospice services. She also explains the need to separate ideas about the appropriateness of palliative care from only the hospice context. Finally, she discusses recent policy initiatives and options for improving patients’ access to high-quality palliative care.

The next article in this issue is “Enriching Patient-Centered Care in Serious Illness: A Focus on Patients’ Experiences of Agency” by Kathleen Montgomery and Miles Little, an American sociologist and an Australian physician. The authors use the concept of agency to refer to factors that affect what happens to patients. Using data collected in multiple interviews at three- and six-month intervals with ten patients (and their caregivers) who were undergoing aggressive inpatient treatment for cancer in an Australian teaching hospital, Montgomery and Little describe how patients’ experiences of care were affected by three types of factors: actors including not only humans but also technologies and the disease itself, actions initiated and received by patients, and domains of action, including not only the health care system but also patients’ bodies and their everyday worlds. The authors suggest that considering care from these perspectives can be useful to both professionals and policymakers in understanding the experiences of patients who are being treated for serious disease and in thinking about the meaning of patient-centered care.

The next article in this issue is “Journey Toward a Patient-Centered Medical Home: Readiness for Change in Primary Care Practices” by Christopher Wise, Jeffrey Alexander, Lee Green, Genna Cohen, and Christina Koster. The patient-centered medical home (PCMH) involves ideas that have been around in various forms for many years, but the concept has been given new impetus by funding provisions of the Patient Protection and Affordable Care Act of 2010. The PCMH combines the core elements of primary care with such ideas as the use of electronic medical records to facilitate care coordination and the redesign of care processes to improve quality, lower cost, and improve patients’ experiences.

Wise and colleagues illuminate the challenges of transforming ordinary primary care practices into PCMHs by reporting on a study of sixteen primary care practices in Michigan that participated in both the Blue Cross and Blue Shield of Michigan’s Physician Group Incentive Program and the Robert Wood Johnson Foundation’s quality improvement initiative called “Aligning Forces for Quality.” Using qualitative interviews and other data sources to make comparisons of practices that scored high and low on a self-assessment regarding the principles of a primary care medical home, Wise and colleagues focused on factors that were associated with practices’ success in moving toward the PCMH model. Factors related to both motivations and capabilities within practices were involved. Wise and colleagues discuss how the implementation of the PCMH concept was enhanced by strategies used within practices (e.g., taking an incremental approach, making use of data, team building). The results of their study should be of interest to both policymakers and practices seeking to advance the PCMH concept.

Systematic reviews of research evidence have become increasingly important to both clinical practice and health policy in recent decades and can easily be taken for granted. But how and why they gained influence is important to understand and is the topic of the next article in this issue, “Systematic Reviews and Health Policy: The Influence of a Project on Perinatal Care since 1988” by Daniel M. Fox. The project on which Fox focuses resulted in a series of highly influential, research-based publications on “effective care” by Iain Chalmers and other organizers of the Cochrane Collaboration (Chalmers 1988–1992; Chalmers, Enkin, and Keirse 1989; Enkin, Keirse, and Chalmers 1989; Sinclair and Bracken 1992). Fox’s focus is on the largely favorable reception of these publications by policymakers in several countries. He contends that the influence of these publications was due to their blend of scientific and polemical discourse, the contemporary growth of a constituency for systematic reviews, and the recognition by some policymakers that systematic reviews could help make health care more cost-effective. The article, which extends Fox’s other work on the use of research to inform policy (Fox 2010), is being co-published with the James Lind Library, which has also posted excerpts from the Chalmers, Enkin, and Keirse 1989 publication at the following link:

The next article embodies the application of research to policy. It is “An Empirical Review of Major Legislation Affecting Drug Development: Past Experiences, Effects, and Unintended Consequences” by Aaron Kesselheim. Kesselheim summarizes the evidence about the effects of four legislative actions to foster public health goals in the pharmaceutical sciences: the Bayh-Dole Act of 1980, which encouraged development of commercial products growing out of federally funded research; the Orphan Drug Act of 1983, which provided several types of incentives to encourage research targeted at diseases that were too uncommon to create market rewards for new products; the Hatch-Waxman Act of 1984, which extended the patent life of pharmaceuticals under certain conditions; and the provisions of the FDA Modernization Act of 1997 that gave incentives to pharmaceutical companies to study the effects of already approved drugs on pediatric populations. All of these legislative actions sought to meet policy goals by using provisions of the drug regulatory process or patent law to provide incentives (patents forestall competition from generic products).

Kesselheim’s review covers research assessing whether each piece of legislation had its intended effects and whether there were unintended effects. He concludes that some positive outcomes have resulted from these policies, but waste and other undesirable effects have also occurred. His conclusions point to the need for more rigorous evaluations of the effects of such policies and for closer ties of such incentive programs to measurable public health outcomes.

The final article in this issue is “Defining Health Diplomacy: Changing Demands in the Era of Globalization” by Rebecca Katz, Sarah Kornblet, Grace Arnold, Eric Lief, and Julie Fischer of George Washington University and the Stimson Global Health Security Program. The authors provide a broad overview of “global health diplomacy”—the integration of health concerns into countries’ foreign policy strategies. The rationale is partly practical, since one of the consequences of globalization is that one country’s health risks can affect another’s, but support of health programs can also serve diplomatic goals. The article explains, and provides examples of, the different bilateral and multilateral forms that global health diplomacy can take. The authors distinguish among core diplomacy, which involves negotiations for dispute resolution and formal agreements between countries; multistakeholder global health diplomacy, in which multiple countries cooperate to address common issues; and informal global health diplomacy, which involves nongovernmental organizations, private enterprise, and the public.

Katz and her colleagues conclude that the rise of global health diplomacy calls for combinations of technical expertise, legal knowledge, and diplomatic skills that have not heretofore been cultivated among either foreign service or global health professionals. They point to the need for both the health and foreign policy communities to consider more deeply the combination of skills and resources needed to accomplish their mutual objectives.

Bradford H. Gray
Editor, The Milbank Quarterly


Chalmers, I, ed. 1988–1992. Oxford Database of Perinatal Trials. Oxford: Oxford University Press.

Chalmers, I., M. Enkin, and M.J. Keirse, eds. 1989. Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press.

Enkin, M., M.J. Keirse, and I. Chalmers. 1989. A Guide to Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press.

Fox, D.M. 2010. The Convergence of Science and Governance: Research, Health Policy and American States. Berkeley: University of California Press.

Sinclair, C., and M.B. Bracken, eds. 1992. Effective Care of the Newborn Infant. Oxford: Oxford University Press.

Author(s): Bradford H. Gray

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Volume 89, Issue 3 (pages 339–342)
DOI: 10.1111/j.1468-0009.2011.00640.x
Published in 2011