Patient-reported Quality Of Care Research Articles

Investigating the Associations between Patient-Reported Quality of Care and Perceived Coercion: A Norwegian Cross-Sectional Study

Patient perspectives on the quality of care received are fundamental to mental health care. This study aimed to investigate the association between patient-reported mental health care quality, perceived coercion, and various demographic, clinical, and ward-related factors. Using a cross-sectional design, data were collected from 169 patients in Norwegian mental health wards using the quality in psychiatric care–inpatient (QPC-IP) instrument and experienced coercion scale (ECS). The analysis revealed a consistent pattern in which patients with higher perceived coercion consistently rated lower quality on all QPC-IP dimensions. The significant findings of the multiple regression models further supported this association. Beyond coercion, the factors influencing quality ratings include self-reported treatment results, participation in treatment planning, and knowledge of complaint procedures. Emphasizing the pivotal role of coercion in enhancing mental health care quality, these findings contribute to a nuanced understanding of patient experiences and underscore the importance of patient participation in mental health care improvement efforts.

Evaluation of emergency hospital admissions for inflammatory bowel disease as a possible marker of quality of care of British IBD inflammatory bowel disease units

BackgroundKey performance indicators (KPIs) are required to facilitate quality improvement for inflammatory bowel disease (IBD). Emergency admissions for IBD may represent a possible KPI.MethodsIBD emergency admissions for 2018–2019 from Hospital...

321 Alloimmunization in pregnancy: Patient-reported quality of care, mental health effects, and impact upon daily life

321 Alloimmunization in pregnancy: Patient-reported quality of care, mental health effects, and impact upon daily life

Longer-term quality of care, effectiveness, and cost-effectiveness of implementing a model of care for osteoarthritis: A cluster-randomized controlled trial

To assess the quality of care, effectiveness, and cost-effectiveness over 12 months after implementing a structured model of care for hip and knee osteoarthritis (OA) in primary healthcare as compared to usual care. In this pragmatic cluster-randomized, controlled trial with a stepped-wedge cohort design, we recruited 40 general practitioners (GPs), 37 physiotherapists (PTs), and 393 patients with symptomatic hip or knee OA from six municipalities (clusters) in Norway. The model included the delivery of a 3-hour patient education and 8-12 weeks individually tailored exercise programs, and interactive workshops for GPs and PTs. At 12 months, the patient-reported quality of care was assessed by the OsteoArthritis Quality Indicator questionnaire (16 items, pass rate 0-100%, 100%=best). Costs were obtained from patient-reported and national register data. Cost-effectiveness at the healthcare perspective was evaluated using incremental net monetary benefit (INMB). Of 393 patients, 109 were recruited during the control periods (control group) and 284 were recruited during interventions periods (intervention group). At 12 months the intervention group reported statistically significant higher quality of care compared to the control group (59% vs. 40%; mean difference: 17.6 (95% confidence interval [CI] 11.1, 24.0)). Cost-effectiveness analyses showed that the model of care resulted in quality-adjusted life-years gained and cost-savings compared to usual care with mean INMB €2020 (95% CI 611, 3492) over 12 months. This study showed that implementing the model of care for OA in primary healthcare, improved quality of care and showed cost-effectiveness over 12 months compared to usual care. ClinicalTrials.gov NCT02333656.

Associations between quality of health care and clinical outcomes in patients with rheumatic and musculoskeletal diseases: a rehabilitation cohort study

BackgroundThe quality of provided health care may be an important source of variation in rehabilitation outcomes, increasing the interest in associations between quality indicators (QIs) and improved patient outcomes. Therefore, we examined the associations between the quality of rehabilitation processes and subsequent clinical outcomes among patients with rheumatic and musculoskeletal diseases (RMDs).MethodsIn this multicentre prospective cohort study, adults with RMDs undergoing multidisciplinary rehabilitation at eight participating centres reported the quality of rehabilitation after 2 months and outcomes after 2, 7, and 12 months. We measured perceived quality of rehabilitation by 11 process indicators that cover the domains of initial assessments, patient participation and individual goal-setting, and individual follow-up and coordination across levels of health care. The patients responded “yes” or “no” to each indicator. Scores were calculated as pass rates (PRs) from 0 to 100% (best score). Clinical outcomes were goal attainment (Patient-Specific Functional Scale), physical function (30 s sit-to-stand test), and health-related quality of life (EuroQoL 5D-5L). Associations between patient-reported quality of care and each outcome measure at 7 months was analysed by linear mixed models.ResultsA total of 293 patients were enrolled in this study (mean age 52 years, 76% female). Primary diagnoses were inflammatory rheumatic disease (64%), fibromyalgia syndrome (18%), unspecific neck, shoulder, or low back pain (8%), connective tissue disease (6%), and osteoarthritis (4%). The overall median PR for the process indicators was 73% (range 11–100%). The PR was lowest (median 40%) for individual follow-up and coordination across levels of care. The mixed model analyses showed that higher PRs for the process indicators were not associated with improved goal attainment or improved physical function or improved health-related quality of life.ConclusionsThe quality of rehabilitation processes was not associated with important clinical outcomes. An implication of this is that measuring only the outcome dimension of quality may result in incomplete evaluation and monitoring of the quality of care, and we suggest using information from both the structure, process, and outcome dimensions to draw inferences about the quality, and plan future quality initiatives in the field of complex rehabilitation.Trial registrationThe study is part of the larger BRIDGE trial (ClinicalTrials.gov NCT03102814).

The impact of work-place social capital in hospitals on patient-reported quality of care: a cohort study of 5205 employees and 23,872 patients in Denmark

BackgroundDecision-makers increasingly consider patient-reported outcomes as important measures of care quality. Studies on the importance of work-place social capital–a collective work-place resource–for the experience of care quality are lacking. We determined the association between the level of work-place social capital and patient-reported quality of care in 148 hospital sections in the Capital Region of Denmark.MethodsThis cross-sectional study combined section-level social capital from 5205 health care professionals and 23,872 patient responses about care quality. Work-place social capital encompassed three dimensions: trust, justice and collaboration. Patient-reported quality of care was measured as: overall satisfaction, patient involvement, and medical errors. Linear regression analysis and generalized linear models assessed the mean differences in patient reported experience outcomes and the risk of belonging to the lowest tertile of care quality.ResultsA higher level of work-place social capital (corresponding to the interquartile range) was associated with higher patient-reported satisfaction and inpatient and acute care patient involvement. The risk of a section belonging to the lowest tertile of patient involvement was lower in sections with higher social capital providing inpatient (RR = 0.39, 0.19–0.81 per IQR increase) and acute care (RR = 0.53, 0.31–0.89). Patient-reported errors were fewer in acute care sections with higher social capital (RR = 0.65, 0.43 to 0.99). The risk of being in the lowest tertile of patient-reported satisfaction was supported for acute care sections (RR = 0.47, 0.28–0.79).ConclusionsAlthough we found small absolute differences in the association between patient-reported experience measures and social capital, even a small upward shift in the distribution of social capital in the hospital sector would, at the population level, have a large positive impact on patients’ care experience.

Higher quality of care and less surgery after implementing osteoarthritis guidelines in primary care - long-term results from a cluster-randomized controlled trial

Purpose: To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international recommendations. At 6 months, patient-reported quality of care and satisfaction with care were greater, more patients were referred to physiotherapy and fewer to orthopaedic surgeons, and more patients fulfilled physical activity criteria in the intervention group compared to the usual care group. The aim of this study was to assess the long-term effects at 12 months after implementing the model in primary care.

Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial.

BackgroundTo improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international recommendations. The objective of this study was to assess the effectiveness of this model in primary care.Methods and findingsWe conducted a cluster-randomised controlled trial with stepped-wedge cohort design in 6 Norwegian municipalities (clusters) between January 2015 and October 2017. The randomised order was concealed to the clusters until the time of crossover from the control to the intervention phase. The intervention was implementation of the SAMBA model, facilitated by interactive workshops for general practitioners and physiotherapists with an update on OA treatment recommendations. Patients in the intervention group attended a physiotherapist-led OA education and individually tailored exercise programme for 8–12 weeks. The primary outcome was patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire; 0–100, 100 = optimal quality) at 6 months. Secondary outcomes included patient-reported referrals to physiotherapy, magnetic resonance imaging (MRI), and orthopaedic surgeon consultation; patients’ satisfaction with care; physical activity level; and proportion of patients who were overweight or obese (body mass index ≥ 25 kg/m2). In all, 40 of 80 general practitioners (mean age [SD] 50 [12] years, 42% females) and 37 of 64 physiotherapists (mean age [SD] 42 [8] years, 65% females) participated. They identified 531 patients, of which 393 patients (mean age [SD] 64 [10] years, 71% females) with symptomatic hip or knee OA were included. Among these, 109 patients were recruited during the control periods (control group), and 284 patients were recruited during interventions periods (intervention group). The patients in the intervention group reported significantly higher quality of care (score of 60 versus 41, mean difference 18.9; 95% CI 12.7, 25.1; p < 0.001) and higher satisfaction with OA care (odds ratio [OR] 12.1; 95% CI 6.44, 22.72; p < 0.001) compared to patients in the control group. The increase in quality of care was close to, but below, the pre-specified minimal important change. In the intervention group, a higher proportion was referred to physiotherapy (OR 2.5; 95% CI 1.08, 5.73; p = 0.03), a higher proportion fulfilled physical activity recommendations (OR 9.3; 95% CI 2.87, 30.37; p < 0.001), and a lower proportion was referred to an orthopaedic surgeon (OR 0.3; 95% CI 0.08, 0.80; p = 0.02), as compared to the control group. There were no significant group differences regarding referral to MRI (OR 0.6; 95% CI 0.13, 2.38; p = 0.42) and proportion of patients who were overweight or obese (OR 1.3; 95% CI 0.70, 2.51; p = 0.34). Study limitations include the imbalance in patient group size, which may have been due to an increased attention to OA patients among the health professionals during the intervention phase, and a potential recruitment bias as the patient participants were identified by their health professionals.ConclusionsIn this study, a structured model in primary care resulted in higher quality of OA care as compared to usual care. Future studies should explore ways to implement the structured model for integrated OA care on a larger scale.Trial registrationClinicalTrials.gov NCT02333656.

Readiness of public health facilities to provide quality maternal and newborn care across the state of Bihar, India: a cross-sectional study of district hospitals and primary health centres

IntroductionPoor access to quality healthcare is one of the most important reasons of high maternal and neonatal mortality in India, particularly in poorer states like Bihar. India has implemented initiatives...

Determinants of patient satisfaction with cancer care delivered by the Danish healthcare system.

Patient-reported quality of care, which is often measured by patients' overall rating of care, is gaining more attention within the field of oncology. The aim of this study was to examine factors that determine adult cancer patients' overall rating of prediagnosis care (PDC) and care provided during treatment (CDT). Data were collected from 2 recurrent nationwide surveys among adult cancer patients in Denmark in 2010 and 2012. Analyses regarding PDC were based on the 2010 study population (n = 3681), and CDT analyses were based on the 2012 follow-up population (n = 2315). Multivariable logistic regression models were applied. Overall, 55.1% of patients reported excellent PDC and 61.9% reported excellent CDT. The odds of rating PDC and CDT as excellent differed significantly according to sex, age, and cancer diagnosis. Furthermore, the extent of supportive relatives, comorbidity, self-reported health, and region of treatment significantly determined ratings of CDT. Patients who reported negative experiences related to waiting time, information, coordination, and continuity of care during PDC and CDT, respectively, were significantly less likely overall to rate their care as excellent. The final regression models for PDC and CDT explained 38.2% and 30.6%, respectively, of the variance in the overall rating. Learning how patient characteristics influence the overall rating of care can enable health care providers to accommodate vulnerable patient groups. Identification of health care aspects that are independently associated with the overall rating of care may enable targeted efforts when planning and prioritizing initiatives aimed at improving the patient-experienced quality of care. Cancer 2017;123:2918-26. © 2017 American Cancer Society.

Implementing international osteoarthritis treatment guidelines in primary health care: study protocol for the SAMBA stepped wedge cluster randomized controlled trial.

BackgroundPrevious research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8–12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model.Methods/designA cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants’ treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER).DiscussionThe results from the present study will add to the current knowledge on tailored strategies, which aims to improve the uptake of evidence-based OA care recommendations and improve the quality of OA care in primary health care. The new knowledge can be used in national and international initiatives designed to improve the quality of OA care.Trial registrationClinicalTrials.gov NCT02333656Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0353-7) contains supplementary material, which is available to authorized users.

Associations Between Patient Perceptions of Communication, Cure, and Other Patient-Related Factors Regarding Patient-Reported Quality of Care Following Surgical Resection of Lung and Colorectal Cancer

BackgroundThe objective of the current study was to analyze various patient-related factors related to patient-reported quality of overall and surgical care following surgical resection of lung or colorectal cancer. MethodsBetween 2003 and 2005, 3,954 patients who underwent cancer-directed surgery for newly diagnosed lung (30.3 %) or colorectal (69.7 %) cancer were identified from a population- and health system-based survey of participants from multiple US regions. Factors associated with patient-perceived quality of overall and surgical care were analyzed with multivariable logistic regression models. ResultsOverall, 56.7 % of patients reported excellent quality of overall care and 67.9 % of patients reported excellent quality of surgical care; there was no difference by cancer type (P > 0.05). Factors associated with lower likelihood to report excellent quality of overall and surgical care included female sex, minority race, and the presence of multiple comorbidities (all odds ratio [OR] <1, all P < 0.05). Patients who had higher levels of education (overall quality: OR 1.62; surgical quality: OR 1.26), higher annual income (overall quality: OR 1.29; surgical quality: OR 1.23), and good physical function (overall quality: OR 1.35; surgical quality: OR 1.24) were all more likely to report excellent quality of overall and surgical care (all P < 0.05). Furthermore, patients who reported their physician as having excellent communication skills (overall quality: OR 6.49; surgical quality: OR 3.74) as well as patients who perceived their cancer as likely curable (overall quality: OR 1.17; surgical quality: OR 1.11) were more likely to report excellent quality of overall and surgical care (all P < 0.05). ConclusionPatient-reported quality of care is associated with several factors including race, income, and educational status, as well as physician communication and patient perception of likelihood of cure. Future studies are needed to more closely examine patient–physician relationships and communication barriers, particularly among minority patients and those with lower income and educational status.

Association of Actual and Preferred Decision Roles With Patient-Reported Quality of Care: Shared Decision Making in Cancer Care.

Shared decision making is associated with improved patient-reported outcomes of cancer treatment, but not all patients prefer to participate in medical decisions. Results from studies of the effect of matching between actual and preferred medical decision roles on patients' perceptions of care quality have been conflicting. To determine whether shared decision making was associated with patient ratings of care quality and physician communication and whether patients' preferred decision roles modified those associations. We performed a population- and health system-based survey of participants in the Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study diagnosed with lung and/or colorectal cancer between 2003 and 2005 (56% with colorectal cancer, 40% with non-small-cell lung cancer, and 5% with small-cell lung cancer). The CanCORS study included 9737 patients (cooperation rate among patients contacted, 59.9%) treated in integrated care delivery systems, academic institutions, private offices, and Veterans Affairs hospitals. The medical records were abstracted between October 11, 2005, and April 30, 2009; all analyses were conducted between 2013 and 2014. We surveyed patients specifically about their preferred roles in cancer treatment decisions and their actual roles in decisions about surgery, chemotherapy, and radiation therapy. We analyzed the responses of 5315 patients who completed baseline surveys and reported decision roles for a total of 10 817 treatment decisions and assessed associations of patients' decision roles with patient-reported quality of care and physician communication. The outcomes (identified before data collection) included patient-reported excellent quality of care and top ratings (highest score) on a physician communication scale. After adjustment, patients describing physician-controlled (vs shared) decisions were less likely to report excellent quality of care (odds ratio [OR], 0.64; 95% CI, 0.54-0.75; P < .001). Patients' preferred decision roles did not modify this effect (P = .29 for the interaction). Patients describing either actual or preferred physician-controlled (vs shared) roles were less likely to provide a top rating of physician communication (OR, 0.55; 95% CI, 0.45-0.66; P < .001, and OR, 0.67; 95% CI, 0.51-0.87; P = .002, respectively). The preferred role did not modify the effect of the actual role (P = .76 for interaction). Physician-controlled decisions regarding lung or colorectal cancer treatment were associated with lower ratings of care quality and physician communication. These effects were independent of patients' preferred decision roles, underscoring the importance of seeking to involve all patients in decision making about their treatment.

Patient-reported quality of care and pain severity in cancer.

Despite treatment availability, many cancer patients experience severe pain. Although patient assessments of care are increasingly employed to evaluate quality of care, little is known about its association with cancer symptom burden. The objective of our study was to examine the association between patient-reported quality of care and pain severity in a nationally representative cohort of cancer patients. Quality of care was measured in three domains: physician communication, care coordination/responsiveness, and nursing care. Quality scores were dichotomized as optimal versus nonoptimal. Pain was measured on a scale of 0 (least) to 100 (worst). We utilized multivariable linear regression to examine the association between patient-reported quality of care and pain severity. The analytic sample included 2,746 individuals. Fifty and 54% of patients, respectively, rated physician communication and care coordination/responsiveness as nonoptimal; 28% rated nursing care as nonoptimal. In adjusted models, rating physician communication as nonoptimal (versus optimal) was associated with a 1.8-point higher pain severity (p = 0.018), and rating care coordination/responsiveness as nonoptimal was associated with a 2.2-point higher pain severity (p = 0.006). Patient-reported quality of care was significantly associated with pain severity, although the differences were small. Interventions targeting physician communication and care coordination/responsiveness may result in improved pain control for some patients.

How Much Shared Decision Making Occurs in Usual Primary Care of Depression?

Shared decision making (SDM) is an important component of patient-centered care, but there is little information about its use in the primary care of depression, so we sought to study its frequency in usual care as reported by patients. Telephone interview of 1168 depressed patients taking antidepressants in 88 Minnesota primary care clinics who were identified from pharmacy claims data soon after a prescription for an antidepressant. We measured depression severity with the 9-item Patient Health Questionnaire and used a composite measure of SDM that reflected patient involvement in treatment decisions. These patients reported an average score for SDM of 50.7 (standard deviation, 32.8) on a scale of 0 to 100, where higher scores equate with greater SDM. In univariate analyses, the largest differences among scores were for age (scores of 58, 53, 45, and 33 for those aged 18-34, 35-49, 50-64, and >64 years, respectively; P < .0001); duration of treatment (a score of 56.6 on treatment <6 weeks vs 45.5 if longer; P < .001); and other treatments in the past 6 months (60.5 if yes vs. 46.0 if no; P = .001). SDM was not associated with any clinic characteristics, but it was correlated with patient-reported quality of care (r = 0.48; P < .001). Multivariate analyses confirmed some of these findings while showing a more complex set of relationships. Older patients with depression and those who have been in treatment longer report much less SDM in their care. Improving SDM, especially for these groups, may be an important target for improving patient experience and perceived quality.

The Effect of End-of-Life Discussions on Perceived Quality of Care and Health Status Among Patients With COPD

Despite strong preferences for discussions about end-of-life care, patients with COPD do not often have these discussions with their providers. Our objective was to determine whether patients who reported having end-of-life discussions also reported higher perceived markers of quality of care and health status. A cross-sectional study of data collected at baseline for a trial to improve the occurrence and quality of end-of-life communication in patients with COPD was conducted. The primary exposure was self-reported acknowledgment of having discussions about end-of-life planning with their physicians. The primary outcome measures were patient-reported quality of care and satisfaction with care, which were dichotomized as best imaginable quality of care vs other ratings of quality and highest satisfaction vs other ratings of satisfaction. We adjusted for confounding factors, including patient and provider characteristics, using logistic regression clustered by provider. Three hundred seventy-six patients were enrolled, of whom 55 (14.6%) reported having end-of-life discussions. Individuals who reported having end-of-life discussions with their physicians were significantly more likely to rate their quality of care as the best imaginable (OR, 2.07; 95% CI, 1.05-4.09) and to be very satisfied with their medical care (OR, 1.98; 95% CI, 1.10-3.55). Discussions were more likely to have occurred among patients with worse health status as measured by St. George Respiratory Questionnaire total and impact scores. Patients who reported having end-of-life care discussions with their physicians had higher perceived quality of care and satisfaction with their physicians. Discussing end-of-life care with patients who have COPD may improve their perceived overall quality of and satisfaction with care.

Comorbidity and patient-reported quality of care: an evaluation of the primary care based German disease management program for type 2 diabetes

Previous evaluations of the German disease management program (DMP) for type 2 diabetes show that this approach curbs drug and hospital costs, may reduce mortality and improve quality of diabetes care. Otherwise until now there have been no evaluations which analyse the impact of comorbidity (COMORB) on the effectiveness of German DMP to strengthen patient-reported quality of care. Therefore, the study aimed to assess and compare the impact of comorbidity on patient-reported quality of care for patients participating in DMP and in routine care (RC). A questionnaire including the Patient Assessment of Chronic Illness Care (PACIC) was mailed to a random sample of 3,546 patients. We grouped patients according to their participation into DMP and RC. To compare groups, we performed analysis of covariance. We considered all main effects, the interaction of DMP * COMORB and assessed the estimated PACIC scores for each number of other conditions. 1,532 questionnaires were returned (42.2%). Valid data existed for 1,399 patients. The analysis showed that only participation in the DMP (p < 0.0001) and gender (p < 0.001) had an impact on the PACIC. The estimated PACIC score of patients in DMP was higher than in routine care for all numbers of other conditions. Whereas the increasing number of other conditions was associated with lower PACIC scores in DMP, it was associated with increased PACIC scores in RC. Patients with type 2 diabetes in DMP had higher PACIC scores than patients in RC, irrespective of the number of other conditions. Our study revealed no significant impact of comorbidity on the effect of German DMP on patient-reported quality of care.

2007 Robert and Alma Moreton Lecture: Pay for Performance: More Than Rearranging the Deck Chairs?

Over the past 30 years, research exploring the causes and consequences of geographic variations in practice has called into question widely held assumptions about the relationship between spending and quality. Two-fold differences in spending are observed across U.S. regions that are not due to differences in illness or to the prices charged by providers. Rather, higher spending is due primarily to greater use of "supply-sensitive" services: the frequency of visits to physicians and referrals to specialists, the amount of time similar patients spend in the hospital, and the frequency of imaging, tests, and minor procedures. The paradox, however, is that greater use of these services has been shown to be associated with lower quality, no gain in survival, and worse physician and patient-reported quality of care. It may be possible, therefore, to lower spending while improving quality. But this will require addressing the underlying causes of the variations: overuse of discretionary services in a fee-for-service system that ensures that physicians stay busy and that existing capacity remains fully deployed. These findings point to 3 strategies that will be required for pay for performance to achieve its potential: fostering local organizational accountability for the overall quality and costs of care--and for the capacity of the local delivery system; adoption of comprehensive longitudinal performance measures--to reassure the public that lower spending is compatible with higher quality care; and fundamental reform of the payment system.