Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.

APS BETWEEN MEDICAL CARE as actually practiced and the recommendations derived from evidence-based research are large and widespread. 1-3 Because more complete use of these recommendations should result in the prevention of considerable morbidity and mortality, 4,5 research on methods to bridge these gaps is important. Quality improvement approaches such as medical record audit and feedback, opinion leaders, academic detailing, chart-based reminders, and computerized decision support have been evaluated. 6-17 As explained recently by Samsa and Matchar, 18 testing the general continuous quality improvement (CQI) approach to health care in randomized controlled trials (RCTs) is rare and, perhaps of necessity, inconclusive. 19 Testing specific interventions deriving from a CQI approach in RCTs is more common, but still not abundant. 18 These RCTs represent efforts to examine improvement activities with the same rigorous standards of evidence as those becoming increasingly accepted in the practice of evidence-based medicine. 20 Our study is an RCT that tests

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In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262

Objective To assess whether active and passive smokers are more likely than non-smokers to develop clinically relevant glucose intolerance or diabetes. Design Coronary artery risk development in young adults (CARDIA) is a prospective cohort study begun in 1985-6 with 15 years of follow-up. Setting Participants recruited from Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California, USA. Participants Black and white men and women aged 18-30 years with no glucose intolerance at baseline, including 1386 current smokers, 621 previous smokers, 1452 never smokers with reported exposure to secondhand smoke (validated by serum cotinine concentrations 1-15 ng/ml), and 1113 never smokers with no exposure to secondhand smoke. Main outcome measure Time to development of glucose intolerance (glucose ≥ 100 mg/dl or taking antidiabetic drugs) during 15 years of follow-up. Results Median age at baseline was 25, 55% of participants were women, and 50% were African-American. During follow-up, 16.7% of participants developed glucose intolerance. A graded association existed between smoking exposure and the development of glucose intolerance. The 15 year incidence of glucose intolerance was highest among smokers (21.8%), followed by never smokers with passive smoke exposure (17.2%), and then previous smokers (14.4%); it was lowest for never smokers with no passive smoke exposure (11.5%). Current smokers (hazard ratio 1.65, 95% confidence interval 1.27 to 2.13) and never smokers with passive smoke exposure (1.35, 1.06 to 1.71) remained at higher risk than never smokers without passive smoke exposure after adjustment for multiple baseline sociodemographic, biological, and behavioural factors, but risk in previous smokers was similar to that in never smokers without passive smoke exposure. Conclusion These findings support a role of both active and passive smoking in the development of glucose intolerance in young adulthood.