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Emergency Care Needs Improvement
The first-ever assessment of the support each state provides for its emergency medicine system concluded that such systems are characterized by overcrowding, declining access to care, soaring liability costs, and poor capacity to deal with public health or terrorist disasters. The National Report Card on the State of Emergency Medicine: Evaluating the Environment of Emergency Care Systems State by State reflects the findings of a task force of experts assembled by the American College of Emergency Physicians (ACEP). The task force used a range of data to develop 50 measures for grading each state on a scale of A through F for its support in four areas: access to emergency care, quality and patient safety, public health and injury prevention, and medical liability environment. Overall, the nation's emergency medical care system received a grade of C-; on a state-by-state basis, California ranked first in the nation, followed by Massachusetts, Connecticut, and the District of Columbia—all earning the highest overall B grades. ACEP plans to continue measuring state efforts and improvements in emergency medicine over time, using this report as an initial benchmark.

Medical "Follow-Through" Needed
"We tend to view medical advances—the breakthroughs that produce better medications, technology and procedures—as the front line in the war on disease," writes Steven H. Woolf, M.D., M.P.H., a professor of family medicine, epidemiology, and community health at Virginia Commonwealth University, in a recent editorial published in The Washington Post. "But the promise of a cure requires an additional step: Patients must receive the treatments promptly and properly." Yet, he continues, this country lacks a well-functioning system to deliver care, and the majority of federal research funding is directed towards finding new treatments—not on how to deliver them. Last year, for example, Congress gave $29 billion to the National Institutes of Health and only $320 million to the Agency for Healthcare Research and Quality. A recent study Woolf led found that developing new treatments often does less good than ensuring the delivery of older drugs to those in need. Further, the failure to establish systems that ensure everyone receives recommended care causes disease and deaths at levels that can rarely be offset by medical advances. "I am not advocating that medical advances be abandoned in favor of system solutions—both are vital," he concludes. "But our leaders do need to find a new equilibrium between investing in new treatments and investing in delivering them."

Physician Quality-Related Payments Limited
Only two of 12 nationally representative communities studied by the Center for Studying Health System Change—Orange County, Calif., and Boston—have significant experience with physician pay-for-performance programs, according to a report published last month. Physicians in these markets are organized in large medical groups, health systems, and independent practice associations that are better able to measure physician performance, making quality-related payments more feasible. Further, the study, Can Money Buy Quality? Physician Response to Pay for Performance, found that physician attitudes toward pay-for-performance in communities with little to no experience range from skeptical to hostile, due in part to their belief that health plans are taking money from some providers to pay others instead of putting additional dollars into these programs.

NYC Health Dept. Monitoring Diabetes
The New York City Department of Health and Mental Hygiene this month began to require that medical laboratories report information on diabetic patients' blood sugar levels within 24 hours of testing, according to a recent article in The Washington Post. This requirement applies only to the 120 laboratories that have the ability to transmit data electronically. Health officials will use these data to monitor quality of care and determine which areas of the city are most affected by diabetes. The department also plans to test a program in the South Bronx that alerts doctors when their patients' blood sugar levels are not well controlled and contacts patients to offer them advice. This is the first time any U.S. government agency has required routine reporting of laboratory test results to assess the care of people with a major, chronic, noninfectious disease. Some health experts have heralded the program as a bold attempt to improve care for diabetes, while others have raised concerns about confidentiality and government intrusion into medical care.

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