OBJECTIVEQuality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control among adults with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODSWe used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLitWe extracted data regarding intervention, study design, change in HbA 1c , time horizon, perspective, incremental net cost (studies lasting £3 years), incremental costeffectiveness ratio (ICER) (studies lasting ‡20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA 1c and incremental net cost. RESULTSOf 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA 1c declined by 0.26% (95% CI 0.17-0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting £3 years, incremental net costs were $116 (95% CI 2$612 to $843) per patient annually. Long-term ICERs were $100,000-$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000-$99,999/QALY in 1 RCT, $0-$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias. CONCLUSIONSDiverse multifaceted QI interventions that lower HbA 1c appear to be a fair-to-good value relative to usual care, depending on society's willingness to pay for improvements in health.

Internal medicine residents, at least on hypothetical scenarios, demonstrate inconsistent stewardship practices. Findings support room for improvement in confidence when faced with requests for nonindicated care and suggest the need for greater curricular emphasis on stewardship.