The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.

No abstract

OBJECTIVE: Patients' self‐management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient‐physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient‐physician interaction styles on patients' diabetes self‐management. This study assessed the influence of patients' evaluation of their physicians' participatory decision‐making style, rating of physician communication, and reported understanding of diabetes self‐care on their self‐reported diabetes management. DESIGN: We surveyed 2,000 patients receiving diabetes care across 25 Veterans' Affairs facilities. We measured patients' evaluation of provider participatory decision making with a 4‐item scale (Provider Participatory Decision‐making Style [PDMstyle]; α = 0.96), rating of providers' communication with a 5‐item scale (Provider Communication [PCOM]; α = 0.93), understanding of diabetes self‐care with an 8‐item scale (α = 0.90), and patients' completion of diabetes self‐care activities (self‐management) in 5 domains (α = 0.68). Using multivariable linear regression, we examined self‐management with the independent associations of PDMstyle, PCOM, and Understanding. RESULTS: Sixty‐six percent of the sample completed the surveys (N = 1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self‐management assessments (P < .01 in all models). When modeled together, PCOM remained a significant independent predictor of self‐management (standardized β: 0.18; P < .001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self‐management (standardized β: 0.10; P = .004). Understanding was strongly and independently associated with self‐management (standardized β: 0.25; P < .001). CONCLUSION: For these patients, ratings of providers' communication effectiveness were more important than a participatory decision‐making style in predicting diabetes self‐management. Reported understanding of self‐care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self‐management, raising the possibility that both provider styles enhance self‐management through increased patient understanding or self‐confidence.

Much attention has been paid to the inappropriate underuse of tests and treatments but until recently little attention has focused on the overuse that does not add value for patients and may even cause harm. Choosing Wisely is a campaign to engage physicians and patients in conversations about unnecessary tests, treatments and procedures. The campaign began in the United States in 2012, in Canada in 2014 and now many countries around the world are adapting the campaign and implementing it. This article describes the present status of Choosing Wisely programs in 12 countries. It articulates key elements, a set of five principles, and describes the challenges countries face in the early phases of Choosing Wisely. These countries plan to continue collaboration including developing metrics to measure overuse.

Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.

The differences among sociodemographic subgroups in the observed quality of health care are small in comparison with the gap for each subgroup between observed and desirable quality of health care. Quality-improvement programs that focus solely on reducing disparities among sociodemographic subgroups may miss larger opportunities to improve care.

The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients' self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

These findings suggest that a trusting physician relationship may moderate the impact of cost pressures on patients' medication adherence. More generally, addressing noncost barriers to adherence may reduce rates of cost-related medication underuse.