OBJECTIVE -With performance-based reimbursement pressures, it is concerning that most performance measurements treat each condition in isolation, ignoring the complexities of patients with multiple comorbidities. We sought to examine the relationship between comorbidity and commonly assessed services for diabetic patients in a managed care organization.RESEARCH DESIGN AND METHODS -In 6,032 diabetic patients, we determined the association between the independent variable medical comorbidity, measured by the Charlson Comorbidity Index (CCI), and the dependent variables A1C testing, lipid testing, dilated eye exam, and urinary microalbumin testing. We calculated predicted probabilities of receiving tests for patients with increasing comorbid illnesses, adjusting for patient demographics.RESULTS -A1C and lipid testing decreased slightly at higher CCI: predicted probabilities for CCI quartiles 1, 2, 3, and 4 were 0. CONCLUSIONS -Services received did not differ based on comorbid illness burden. Because it is not clear whether equally aggressive care confers equal benefits to patients with varying comorbid illness burden, more evidence confirming such benefits may be warranted before widespread implementation of pay-for-performance programs using currently available "one size fits all" performance measures. Diabetes Care 30:2999-3004, 2007D elivering high-quality medical care is a major focus in today's health care market. To achieve the desired gains in quality, performance measures rooted in guideline-recommended care have been widely implemented and are being publicly reported (1). Accumulating reports suggest that these practices are having measurable effects, but progress may not be sufficiently rapid (2). This commitment to quality has spawned a new direction in accountability, with clear movement toward tightening the link between reimbursements and highquality care (3).The growing enthusiasm for pay-forperformance (P4P) programs may also usher in a new set of problems. Most performance measures focus on the quality of care provided for a single disease (4). Yet, as the U.S. population ages, the number of patients with a high burden of chronic medical conditions is increasing. In 1999, 48% of Medicare enrollees aged Ն65 years had at least three chronic medical conditions, and 21% had five or more (5).Patients having multiple conditions create considerable management complexity, forcing the clinician to consider and prioritize a large array of recommended interventions and preventive services. Market forces may encourage physicians to "play to the test" (6), possibly replacing valuable time in the office visit that could be spent addressing issues that have a greater impact on quality of life. Ultimately, how we should adjust performance measurement to reflect this complexity presents a major challenge.The forces of quality measurement, performance-based reimbursement, and multiple comorbidities dramatically converge for patients who have diabetes, which affects 20.8 million Americans (7). Many patients with dia...

A brief program can increase physician communication skills to meet the needs of a diverse population.

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What do students in England think about school? This article examines the findings of educational research in England on the aspirations and expectations of young people themselves, and how well these are met through schooling. It focuses on the following issues: liking for school; attitudes towards schoolwork; disaffected pupils; attitudes towards teachers; views on the purposes of education; perceptions of parental interest and support; educational aspirations; students’ views on the curriculum; and absence and related factors. It concludes by bringing together and discussing those findings which might well be regarded as positive and those which might instead be regarded as cause for concern. In order to set these research findings in context, a brief overview of schooling in England is given, followed by information on ways in which educational research is funded and conducted.

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