In this issue

March 2007 | Gray, BH

This issue of The Milbank Quarterly contains several articles that address the challenges of making major changes in the way that health services are provided. The issue begins with Adam Oliver’s article “The Veterans Health Administration: An American Success Story?” Oliver, an economist at the London School of Economics, examines the late 1990s’ reforms in the facilities operated by the Veterans Health Administration (VHA). After describing the VHA’s transformation from a hospital system into an integrated health system and summarizing the evidence of improved performance on an array of quality and financial measures, Oliver analyzes the factors that contributed to the VHA’s success, using information from publications, governmental documents, and interviews with knowledgeable informants.

Leadership and vision are important parts of the story, but many other factors were involved as well, including the medical staff’s engagement in the planning process, the implementation and use of electronic health records, the availability and use of health services research, and the use of performance measurement and competition within the system.

Oliver ends the article’s title with a question mark. Although the VHA story is impressive, questions can be raised about both how success should be defined for a system as large, multifaceted, and complex as the VHA and whether success can be sustained in a system that is so directly subject to the political process. Oliver suggests that the VHA’s status as an integrated, centrally controlled system facilitated changes that would have been very difficult in other U.S. health care organizations, most of which are privately owned and dependent on fee-for-service reimbursement from multiple sources. But because accounts of the successful transformation of large professionally dominated organizations are unusual, the VHA’s experience is valuable.

The next article in this issue, “SA HealthPlus: A Controlled Trial of a Statewide Application of a Generic Model of Chronic Illness Care,” by Malcolm Battersby and collaborators, describes a large-scale effort to change the care of patients with chronic disease in South Australia. SA HealthPlus included eight randomized trials to test the effects of shifting the delivery of services to several chronically ill populations from a “funding-based” or fee-for-service model to an “outcome-based” model. In the new model, the funds for all aspects of care for a defined population were pooled to implement a case management system based on the chronic care model developed by Ed Wagner and colleagues in the United States (Wagner et al. 2001; Wagner, Austin, and Von Korff 1996).

The approach included the development of twelve-month care plans based on each patient’s perceptions of his or her “problems and goals,” the use of evidence-based guidelines, and care coordination within a continuous-learning framework. The overall project had two purposes. The first was to improve patient outcomes and determine whether this could be done with existing resources. The second was to learn more about making system-level changes.

The authors report improvements in self-assessed health status in six of the eight projects and cost savings for patients who had undergone previous hospitalizations, although these savings did not cover the costs of coordinated care, as had been hoped. The authors’ broad conclusions are that service coordination is a “necessary” addition to the current health system and that it is feasible.

The chronic care model is central also to the next article in this issue. In “Rethinking Prevention in Primary Care: Applying the Chronic Care Model to Address Health Risk Behaviors,” Dorothy Hung, Thomas Rundall, Alfred Tallia, Deborah Cohen, Helen Halpin, and Benjamin Crabtree report on a study of prevention activities in a national sample of primary care practices in the United States participating in a health promotion initiative sponsored by the Robert Wood Johnson Foundation. Although the applicability of the chronic care model to prevention has been previously proposed (Glasgow et al. 2001), this is one of the first studies of its use in primary care practice.

The authors studied the extent to which the model’s components (including self-management support, system design features, decision support for clinicians, and clinical information systems) were actually being used in primary care practices and whether those practices that used them also provided preventive services (pertaining to tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity) recommended by the U.S. Preventive Services Task Force.

The authors report that those practices that used at least some elements of the chronic care model were the most likely to offer the behavioral interventions that were studied, but the use of health risk assessments, behavioral counseling, and referrals to community-based programs was infrequent. The reasons for this include limits of time and resources, as well as a general resistance to change.

The next article offers a different approach to the challenge of improving health care—the use of theoretically guided research. In “Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives,” Richard Grol, Marije Bosch, Marlies Hulscher, Martin Eccles, and Michel Wensing, a group of researchers from the Netherlands and the United Kingdom, observe that quality improvement frequently depends on behavioral change by health professionals, as well as many other factors. They argue for the systematic use of theory in planning and evaluating interventions, and they show that different theories generate different quality improvement strategies.

The authors conducted an extensive review of the literature on quality improvement and change in health care to identify the full range of available theoretical approaches, which differ in focus, perspective, and underlying paradigms. The authors distinguish between process theories and impact theories, whose focus may be on the individual professional, social setting, organizational context, or political and economical context. After summarizing how these theories have been used, the authors illustrate how each theory and associated constructs translate into practical strategies for two “exemplar” quality challenges, one involving individual professionals (improving hand hygiene routines) and one involving multidisciplinary teams (improving the management of patients with diabetes mellitus). As did Greenhalgh and colleagues (2004), they urge that future research on change interventions in health care focus more on applying specific theories of change.

The final article in this issue, “Understanding Population Health Terminology,” by David Kindig, is substantially a glossary of terms. It is intended as an introduction to the field of population health (a term that appeared in the subtitle of this journal in 2004). Kindig suggests how the field should be understood. This is difficult because the field’s concepts, terminology, and even its logic come from several disciplines. Kindig contends that for policymakers, the central question about population health should be the optimal balance of investments in the multiple determinants of health that will maximize overall health outcomes over the life course and minimize health inequalities in the population. He maintains that clear communication about the concepts he defines is essential to taking up that challenge.

Bradford H. Gray
Editor, The Milbank Quarterly


Glasgow, R.E., C.T. Orleans, E.H. Wagner, S.J. Curry, and L.I. Solberg. 2001. Does the Chronic Care Model Serve Also as a Template for Improving Prevention? The Milbank Quarterly 79(4):579–612.

Greenhalgh, T., G. Robert, F. MacFarlane, P. Bate, and O. Kyriakidou. 2004. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. The Milbank Quarterly 82(4):581–629.

Wagner, E.H., B.T. Austin, C. Davis, M. Hindmarsh, J. Schaefer, and A.E. Bonomi. 2001. Improving Chronic Illness Care: Translating Evidence into Action. Health Affairs 20(6):64–78.

Wagner, E.H., B.T. Austin, and M. Von Korff. 1996. Organizing Care for Patients with Chronic Illness. The Milbank Quarterly 74(4):511–44.

Author(s): Gray, BH

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Volume 85, Issue 1 (pages 1–4)
DOI: 10.1111/j.1468-0009.2007.00474.x
Published in 2007