In This Issue

September 2012 | Bradford H. Gray

Although this issue of The Milbank Quarterly was not planned to be thematic, much of it has turned out to be about major changes in health care systems. The issue begins with “Large-System Transformation in Health Care: A Realist Review” by Allan Best, Trisha Greenhalgh, Steven Lewis, Jessie Saul, Simon Carroll, and Jennifer Bitz. The article grew out of a six-month project, Knowledge to Action for System Transformation, which was carried out for the Saskatchewan Ministry of Health. The task was to summarize what the research literature could teach about factors that affect the success of major health care reforms.

The article is of interest not only for what the literature review produced but also for how it was done. The authors used the theoretical framework of “complex adaptive systems” and the “realist review” approach, which focuses on context as well as on interventions and outcomes (Pawson et al. 2005). They thus paid particular attention to (1) mechanisms and social processes that influence large-system transformations in health care, (2) important contextual factors, (3) the identification of “transition points” in large-system changes, and (4) the role of government. Best and colleagues derived five “simple rules” for increasing the likelihood of success in large-system transformations. These pertain to a blend of designated and distributed leadership, the importance of feedback loops, attention to history, engagement of physicians, and involvement of patients and families.

The next two articles in this issue provide early evidence regarding two of the central components of the transformation goals built into the Patient Protection and Affordable Care Act (ACA): accountable care organizations and the patient-centered medical home. The first of these articles is “Interpretations of Integration in Early Accountable Care Organizations” by Sara Kreindler, Bridget Larson, Frances Wu, Kathleen Carluzzo, Josette Gbemudu, Ashley Struthers, Aricca Van Citters, Stephen Shortell, Eugene Nelson, and Elliott Fisher. Created to improve care coordination in a fragmented system, accountable care organizations (ACOs) are given economic incentives to be responsible for the cost and quality of both hospital and physician care for a defined population. What they will look like and how they will be organized and governed are among the many unanswered questions about ACOs. Kreindler and her colleagues tackled these questions by studying four early examples through the lens of social identity theory (Kreindler et al. 2012). Noting the many contextual differences among these early ACO efforts, they emphasize the importance of building flexibility into the ACO concept.

Changes in payment methods are also an important component of the patient-centered medical home (PCMH) concept. In “Off the Hamster Wheel? Qualitative Evaluation of a Payment-Linked Patient-Centered Medical Home Pilot,” Asaf Bitton, Gregory Schwartz, Elizabeth Stewart, Daniel Henderson, Carol Keohane, David Bates, and Gordon Schiff explore how five primary care practices have responded to a comprehensive risk-adjusted payment model designed to encourage comprehensive care coordination, care teams, and population health management. Their findings point to the heterogeneity of practice settings, the complex effects of payment methods, and the challenges of both achieving and sustaining change in small primary care practices.

Sustaining change is the central theme of the next article, “‘If We Build It, Will It Stay?’ A Case Study of the Sustainability of Whole-System Change in London,” by Trisha Greenhalgh, Fraser Macfarlane, Catherine Barton-Sweeney, and Fran Woodard. They looked at a set of organizations three years after the funding expired for a “modernization” project that sought to improve quality and patient centeredness in organizations providing stroke, kidney, and sexual health services. The reforms persisted for some services, but not for others. Greenhalgh and her colleagues identify and discuss the factors that affected the sustainability of the key organizational reforms.

The next article in this issue is “What Counts? An Ethnographic Study of Infection Data Reported to a Patient Safety Program” by Mary Dixon-Woods, Myles Leslie, Julian Bion, and Carolyn Tarrant. This article reports on a study of British hospitals’ responses to a National Health Service patient-safety program called Matching Michigan, after the famous American program that reduced the incidence of central venous catheter bloodstream infections (Dixon-Woods et al. 2011; Pronovost et al. 2006). In addition to evidence-based interventions to reduce infections, the British program required hospitals to report the data necessary to calculate infection rates.

Dixon-Woods and her colleagues used ethnographic methods to learn how the data collection process worked at seventeen hospitals. They saw little evidence of gaming or goal displacement, but they nevertheless found wide variations in how hospitals implemented the safety and data collection program, and they provide evidence that differences in reported infection rates across hospitals or over time may be due to these variations rather than differences in actual infection rates. Such findings have important implications for programs that rely heavily on performance measurement, particularly for policies that attach consequences to performance. Their study suggests that researchers should pay more attention to the social processes that underlie the production of measures of performance.

This issue concludes with “Fundamental Causes of Colorectal Cancer Mortality: The Implications of Informational Diffusion” by Andrew Wang, Sean Clouston, Marcie Rubin, Cynthia Colen, and Bruce Link. Fundamental cause theory (Link and Phelan 1995) links differences in mortality to social differences in access to the benefits of medical knowledge and technology. Wang and colleagues examined the impact on mortality from colon cancer based on county-level differences in the United States in the diffusion of information about the prevention of the disease. They found that more rapid diffusion of information about prevention can help reduce the increasing socioeconomic differences in colorectal cancer mortality.

Bradford H. Gray


Dixon-Woods, M., C.L. Bosk, E.L. Aveling, C.A. Goeschel, and P.J. Pronovost. 2011. Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement Program. Milbank Quarterly 89(2):167–205.

Kreindler, S.A., D.A. Dowd, N.D. Star, and T. Gottschalk. 2012. Silos and Social Identity: The Social Identity Approach as a Framework for Understanding and Overcoming Divisions in Health Care. Milbank Quarterly 90(2):347–74.

Link, B.G., and J. Phelan. 1995. Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior 35:80–94.

Pawson, R., T. Greenhalgh, G. Harvey, and K. Walshe. 2005. Realist Review—A New Method of Systematic Review Designed for Complex Policy Interventions. Journal of Health Services Research and Policy 10(suppl. 1):21–34.

Pronovost, P., D. Needham, S. Berenholtz, D. Sinopoli, H. Chu, S. Cosgrove, B. Sexton, R. Hyzy, R. Welsh, G. Roth, J. Bander, J. Kepros, and C. Goeschel. 2006. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. New England Journal of Medicine355(26):2725–32.

Author(s): Bradford H. Gray

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Volume 90, Issue 3 (pages 417–420)
DOI: 10.1111/j.1468-0009.2012.00669.x
Published in 2012