In This Issue

June 2013 | Bradford H. Gray

The first article in this issue is “Supporting Well-Being in Retirement through Meaningful Social Roles: Systematic Review of Intervention Studies,” by Ben Heaven, Laura Brown, Martin White, Linda Errington, John Mathers, and Suzanne Moffatt. As older people in developed countries have increased in number and as a share of the population, interest has grown in what might be done outside health care systems to maintain their health and well-being. Heaven and his colleagues summarize the results of controlled studies of seven programs, mostly from the United States, that provide new social roles for people who are retired or transitioning to retirement. The well-known Foster Grandparent Program, which links such people to neglected or vulnerable children, is an example.

The authors describe the components and summarize the outcomes of these programs. Those interventions that provide both explicit roles and a supportive group structure had a positive effect on at least one of several outcomes studied, which included life satisfaction, social support and activity, physical health and activity, functional health, and cognition.

Another aspect of the aging population, at least in the United States, is the increasing frequency with which older people undergo surgery. Although this often is attributed to economic incentives and new technologies, the next article in this issue discusses an additional factor. In “The Redefinition of Aging in American Surgery,” Mark Neuman and Charles Bosk examine changes since the mid-twentieth century in how indications (or contraindications) for surgery have been described in surgical journals and textbooks, particularly as the use of general surgical procedures expanded in the two decades following World War II and during the spread of coronary artery bypass surgery between 1975 and 1995. They describe how age, as a contraindication for surgery, came to be supplanted by other factors such as the presence of chronic disease. Whereas surgery was once commonly depicted as risky for the elderly, it came to be portrayed as almost universally beneficial. The consequences, of course, have affected not only the health status of older people but also the patterns of surgery and health care costs.

Although quality improvement and cost containment are both major policy goals in the United States and other countries, the relationship between the two has been a persistent concern for researchers and policymakers. That topic is tackled in the next article in this issue of The Milbank Quarterly: “The Effects of Quality of Care on Costs: A Conceptual Framework,” by Teryl Nuckols, José Escarce, and Steven Asch. They propose a new “Quality-Cost Framework” that builds on the familiar Donabedian structure, process, outcome model, which was first published almost half a century ago in The Milbank Quarterly and remains our most frequently cited article (Donabedian 1966).

Nuckols, Escarce, and Asch extend the Donabedian model by adding subdimensions to the three dimensions of quality, identifying external factors that influence both cost and quality, and incorporating the economic cost dimension. They plan further work to validate the framework, whose purpose is to create a common understanding of how specific dimensions of quality may affect costs and efficiency and thereby facilitate the design and evaluation of research on this relationship.

The quality theme continues in the next article in this issue, “Understanding the Components of Quality Improvement Collaboratives: A Systematic Literature Review,” by Erum Nadeem, S. Serene Olin, Laura Hill, Kimberly Hoagwood, and Sarah Horwitz. Quality improvement collaboratives, originally developed by the Institute for Healthcare Improvement, are among the most widely used approaches to quality improvement. This systematic review, which incorporates and extends a similar review by Schouten and colleagues (2008), looks at some twenty randomized controlled trials and quasi-experimental studies. The authors identify fourteen components (e.g., data reporting and plan-do-study-act [PDSA] cycles) that are commonly part of such collaboratives, noting the great variation in the use of those components. Although the literature generally supports the results of quality improvement collaboratives, the published evidence does not make clear which components are associated with improvements at the patient or provider level.

The final article in this issue returns to an important theme of recent years in the Quarterly—the connection between obesity and public policy. This connection is particularly close in the federal Supplemental Nutrition Assistance Program (SNAP) for low-income populations. Much thought has been given to how the rules of that program might be used to improve the nutritional quality of foods purchased by program beneficiaries—among whom obesity is common. In “Rewarding Healthy Food Choices in SNAP: Behavioral Economic Applications,” Michael Richards and Jody Sindelar apply the concepts and principles of behavioral economics to this problem. They show how behavioral economics, which combines economics and psychology to describe biases built into individuals’ decision making, helps explain why people make unhealthy choices when shopping for food. Richards and Sindelar also use behavioral economics to analyze four previously published proposals to encourage healthier eating (or to discourage the opposite) among SNAP participants, and they offer three new proposals to give SNAP recipients incentives to select higher-quality food. They suggest changing when beneficiaries receive SNAP benefits (not just once a month), awarding prizes for making healthy food choices, and offering options other than in-store food shopping. The authors caution, however, that the politics of welfare programs like SNAP may make some of the proposed reforms difficult to enact.

Bradford H. Gray


Donabedian, A. 1966. Evaluating the Quality of Medical Care. Milbank Memorial Fund Quarterly 44(3):166–206.

Schouten, L.M.T., M.E.J.L. Hulscher, J.J.E. van Everdingen, R. Huijsman, and R.P.T.M. Grol. 2008. Evidence for the Impact of Quality Improvement Collaboratives: Systematic Review. BMJ 336(7659):1491–94; doi: 10.1136/bmj.39570.749884.BE.

Author(s): Bradford H. Gray

Read on Wiley Online Library

Volume 91, Issue 2 (pages 219–221)
DOI: 10.1111/milq.12012
Published in 2013