Chronic pain status and health care utilization were assessed in a probability sample of 1016 adult HMO enrollees, and among 242 HMO enrollees seeking treatment for Temporomandibular Disorder (TMD) pain. Likelihood of health care contact for a painful symptom: Among persons reporting back pain, headache, chest pain, abdominal pain or temporomandibular pain in the prior six months, we evaluated whether (1) pain characteristics (severity, persistence, recency of onset), and (2) psychological distress were associated with the likelihood of recent use of health care for each pain symptom. Severity, persistence, and recency of onset of pain were generally associated with recent health care contact for a pain symptom. Females with a pain symptom were no more likely than males to report recent health care contact for the symptom after controlling for pain characteristics. The presence of psychological distress did not increase the likelihood of health care contact for individual pain symptoms. However, psychologically distressed persons were more likely to report pain at multiple anatomical sites and to report recent health care contact for one or more of the five pain symptoms (as a group). Chronic pain status and total use of ambulatory health care: Total number of health care visits (irrespective of reason for visit) was measured by automated data. Chronic pain status (summarized across all five anatomical sites) showed a modest correlation with the volume of health care use. Persons with recurrent pain and severe-persistent pain with no pain-related disability days used ambulatory care at rates close to population means. Persons with severe-persistent pain and seven or more pain related disability days used health care at rates substantially above population means. There was a statistically significant association between the volume of health care use and chronic pain after controlling for age, sex, self-rated health status, and psychological distress.

BACKGROUND: There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. OBJECTIVE: To improve training for residents who provide chronic illness care in teaching practice settings. DESIGN: US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure ≤130/80-and three process measures-retinal and foot examinations, and patient self-management goals-were tracked. PARTICIPANTS: Fifty-seven teams from 37 self-selected teaching hospitals committed to implement the CCM in resident continuity practices; 41 teams focusing on diabetes improvement participated over the entire duration of one of the Collaboratives. INTERVENTIONS: Teaching-practice teams-faculty, residents and staff-participated in Collaboratives by attending monthly calls and regular 2-day face-to-face meetings with the other teams. The national Collaborative faculty led calls and meetings. Each team used rapid cycle quality improvement (PDSA cycles) to implement the CCM and curricular changes. Teams reported education and clinical performance measures monthly. RESULTS: Practices underwent extensive redesign to establish CCM elements. Education measures tracked substantial development of CCM-related learning. The clinical and process measures improved, however inconsistently, during the Collaboratives. CONCLUSIONS: These initiatives suggest that systematic practice redesign for implementing the CCM along with linked educational approaches are achievable in resident continuity practices. Improvement of clinical outcomes in such practices is daunting but achievable.

Results of this study show that it is possible to increase SFDs in children and move organizations toward guideline recommendations on asthma control in settings where most children are receiving controller medications at baseline. However, the improvements were realized with an increase in the costs associated with asthma care.

A s with the discovery of a new wonder drug, the reporting of a major new clinical trial is usually followed by a three-step adjustment period in the collective attitudes of the health-care profession and the general public. There is initial euphoria that this is the answer, the panacea, i.e., the treatment for everyone. These feelings are followed by a rebound response of despondency that the side effects and problems with the new treatment are too serious and that the treatment is too costly and complex to make it useful at all. Finally, a rational place for the new discovery is found in medical practice.In the case of the Diabetes Control and Complications Trial (DCCT), many people are still fluctuating between stages 1 and 2. On the one hand are people who feel that everyone with diabetes should be given intensive therapy, that we need more education programs, and more educators and therapeutic evangelists to persuade and cajole all patients with diabetes to push their HbA lc as close to normal as humanly possible. On the other hand are people already at stage 2 (some of whom were never at stage 1) who have a long list of criticisms, including the belief that the DCCT did not show anything new that was not addressed in many previous smaller studies on the same issue; that you cannot extrapolate from this very select group of participants to other people with diabetes; that the results will not change clinical practice anyway, because trying to get blood glucose levels as low as possible is what everyone tries to do already; that the side effects of hypoglycemia and weight gain are barriers that cannot be overcome; that you cannot improve control in most patients because they will not comply; and that the costs of improving control are unrealistically high, etc.In this commentary, we would like to present a practical, clinical, behavioral, educational, and health-care delivery perspective on the DCCT and recent related studies. Specifically, we will discuss whether the approach to diabetes management should be different now, and if so, how this new approach should be implemented in the real world of escalating health-care costs, shrinking resources, and impending health-care reform.