The dynamics of community health care consolidation: acquisition of physician practices.

CONTEXT: Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems. METHODS: We used key informant interviews, supplemented by document analysis. FINDINGS: The acquisition of physician practices is a process that will be difficult to reverse in the current health care environment. Provider revenue uncertainty is a key factor driving consolidation, with public and private attempts to control health care costs contributing to that uncertainty. As these efforts will likely continue, and possibly intensify, community health care systems now are less consolidated than they will be in the future. Acquisitions of multispecialty and primary care practices by integrated delivery systems follow a common process, with relatively predictable issues relating to purchase agreements, employment contracts, and compensation. Acquisitions of single-specialty practices are less common, with motivations for acquisitions likely to vary by specialty type, group size, and market structure. Total cost of care contracting could be an important catalyst for practice acquisitions in the future. CONCLUSIONS: In the past, market and regulatory forces aimed at controlling costs have both encouraged and rewarded the consolidation of providers, with important new developments likely to create momentum for further consolidation, including acquisitions of physician practices.

Care guides: an examination of occupational conflict and role relationships in primary care.

BACKGROUND: Improving the efficiency and effectiveness of primary care treatment of patients with chronic illness is an important goal in reforming the U.S. health care system. Reducing occupational conflicts and creating interdependent primary care teams is crucial for the effective functioning of new models being developed to reorganize chronic care. Occupational conflict, role interdependence, and resistance to change in a proof-of-concept pilot test of one such model that uses a new kind of employee in the primary care office, a "care guide," were analyzed. Care guides are lay individuals who help chronic disease patients and their providers achieve standard health goals. PURPOSE: The aim of this study was to examine the development of occupational boundaries, interdependence of care guides and primary care team members, and acceptance by clinic employees of this new kind of health worker. METHODOLOGY/APPROACH: A mixed methods, pilot study was conducted using qualitative analysis; clinic, provider, and patient surveys; administrative data; and multivariate analysis. Qualitative analysis examined the emergence of the care guide role. Administrative data and surveys were used to examine patterns of interdependence between care guides, physicians, team members, and clinic staff; obtain physician evaluations of the care guide role; and evaluate the effect of care guides on patient perceptions of care coordination and follow-up. FINDINGS: Evaluation of implementation of the care guide model showed that (a) the care guide scope of practice was clearly defined; (b) interdependent relationships between care guides and providers were formed; (c) relational triads consisting of patient, care guide, and physician were created; (d) patients and providers were supported in managing chronic disease; and (e) resistance to this model among traditional employees was minimized. PRACTICE IMPLICATIONS: The feasibility of implementing a new care model for chronic disease management in the primary care setting, identifying factors associated with a positive organizational experience, was shown in this study.

Unintended consequences of implementing a national performance measurement system into local practice.

BACKGROUND: Although benefits of performance measurement (PM) systems have been well documented, there is little research on negative unintended consequences of performance measurement systems in primary care. To optimize PM systems, a better understanding is needed of the types of negative unintended consequences that occur and of their causal antecedents. OBJECTIVES: (1) Identify unintended negative consequences of PM systems for patients. (2) Develop a conceptual framework of hypothesized relationships between PM systems, facility-level variables (local implementation strategies, primary care staff attitudes and behaviors), and unintended negative effects on patients. DESIGN, PARTICIPANTS, APPROACH: Qualitative study design using dissimilar cases sampling. A series of 59 in-person individual semi-structured interviews at four Veterans Health Administration (VHA) facilities was conducted between February and July 2009. Participants included members of primary care staff and facility leaders. Sites were selected to assure variability in the number of veterans served and facility scores on national VHA performance measures. Interviews were recorded, transcribed and content coded to identify thematic categories and relationships. RESULTS: Participants noted both positive effects and negative unintended consequences of PM. We report three negative unintended consequences for patients. Performance measurement can (1) lead to inappropriate clinical care, (2) decrease provider focus on patient concerns and patient service, and (3) compromise patient education and autonomy. We also illustrate examples of negative consequences on primary care team dynamics. In many instances these problems originate from local implementation strategies developed in response to national PM definitions and policies. CONCLUSIONS: Facility-level strategies undertaken to implement national PM systems may result in inappropriate clinical care, can distract providers from patient concerns, and may have a negative effect on patient education and autonomy. Further research is needed to ascertain how features of centralized PM systems influence whether measures are translated locally by facilities into more or less patient-centered policies and processes.

A report card on provider report cards: current status of the health care transparency movement.

BACKGROUND: Public reporting of provider performance can assist consumers in their choice of providers and stimulate providers to improve quality. Reporting of quality measures is supported by advocates of health care reform across the political spectrum. OBJECTIVE: To assess the availability, credibility and applicability of existing public reports of hospital and physician quality, with comparisons across geographic areas. APPROACH: Information pertaining to 263 public reports in 21 geographic areas was collected through reviews of websites and telephone and in-person interviews, and used to construct indicators of public reporting status. Interview data collected in 14 of these areas were used to assess recent changes in reporting and their implications. PARTICIPANTS: Interviewees included staff of state and local associations, health plan representatives and leaders of local health care alliances. RESULTS: There were more reports of hospital performance (161) than of physician performance (103) in the study areas. More reports included measures derived from claims data (mean, 7.2 hospital reports and 3.3 physician reports per area) than from medical records data. Typically, reports on physician performance contained measures of chronic illness treatment constructed at the medical group level, with diabetes measures the most common (mean number per non-health plan report, 2.3). Patient experience measures were available in more hospital reports (mean number of reports, 1.2) than physician reports (mean, 0.7). Despite the availability of national hospital reports and reports sponsored by national health plans, from a consumer standpoint the status of public reporting depended greatly on where one lived and health plan membership. CONCLUSIONS: Current public reports, and especially reports of physician quality of care, have significant limitations from both consumer and provider perspectives. The present approach to reporting is being challenged by the development of new information sources for consumers, and consumer and provider demands for more current information.

Do health systems respond to the quality of their competitors?

OBJECTIVES: Some large employers and healthcare analysts have advocated for retail competition that relies on providers competing on performance metrics to improve care quality. Using publicly available performance measures, we determined whether health systems increased the quality of diabetes care provided by their clinics based on performance relative to competitors. STUDY DESIGN: Our analysis examined publicly reported performance measures of diabetes care from 2006 to 2013 for clinics in Minnesota health systems. METHODS: We obtained data for 654 clinics, of which 572 publicly reported diabetes care performance. Because some clinics did not report performance, we estimated a Heckman selection model. First, we predicted whether or not clinics reported performance. Second, we estimated the effect of relative performance (a clinic's performance minus the mean performance of clinics in competing health systems) on clinic performance using the results of the reporting model to control for selection into the sample of reporting clinics. RESULTS: Although diabetes care performance improved during our study, health systems did not differentially improve the diabetes care performance of their clinics performing worse than clinics in competing systems. This result indicates divergence between high-performing and low-performing clinics. This result does not appear to be due to risk selection. CONCLUSIONS: Publicly reporting quality information did not incentivize health systems to increase the performance of their clinics with lower performance than competitors, as would be expected under retail competition. Our results do not support strategies that rely on competition on publicly reported performance measures to improve quality in diabetes care management.

Lessons from evaluations of purchaser pay-for-performance programs: a review of the evidence.

There has been a growing interest in the use of financial incentives to encourage improvements in the quality of health care. Several articles have reviewed past studies of the impact of specific incentive arrangements, but these studies addressed small-scale experiments, making their findings arguably of limited relevance to current improvement efforts. In this article, the authors review evaluations of more recent pay-for-performance initiatives instituted by health plans or by provider organizations in cooperation with health plans. Findings show improvement in selected quality measures in most of these initiatives, but the contribution of financial incentives to that improvement is not clear; the incentives typically were implemented in conjunction with other quality improvement efforts, or there was not a convincing comparison group. However, the literature relating to purchaser pay-for-performance initiatives does underscore several important issues that deserve attention going forward that relate to the design and implementation of pay-for-performance initiatives.

Impact of targeted financial incentives on personal health behavior: a review of the literature.

Over the past decade, there has been a substantial increase in the use of financial incentives by private employers and public programs to encourage healthy behaviors, wellness activities, and use of preventive services. The research evidence regarding the effectiveness of this approach is reviewed, summarizing relevant findings from literature reviews and from recent evaluations. The article concludes that financial incentives, even relatively small incentives, can influence individuals' health-related behaviors. However, the findings regarding health promotion and wellness are based primarily on analyses of a limited number of private sector initiatives, whereas the evidence regarding preventive services is based on evaluations of initiatives sponsored predominantly by public programs and directed at low-income populations. In either case, there are several important limitations in the ability of the published findings to provide clear guidance for public program administrators or private purchasers seeking to design and implement effective incentive programs.

Hospital responses to the leapfrog group in local markets.

The Leapfrog (LF) initiative, directed at improving patient safety in hospitals, may be the most ambitious, coordinated attempt to date on the part of large employers to shape the delivery of health care in America. This article assesses the role of market conditions and other factors in influencing hospital responses to LF activities at the community level. Community characteristics were found to be important in explaining hospital participation in a LF safety standards survey at the study sites. However, characteristics of the individual hospitals, and of the LF goals themselves, were more important in explaining the relatively limited progress by hospitals across all sites in achieving those goals over a 5-year period.

Consumer-directed health plans: new evidence on spending and utilization.

This study examined three-year spending and utilization trends associated with enrollment in a consumer-directed health plan (CDHP) offered by a large employer alongside a preferred provider organization (PPO) and a point-of-service (POS) plan. The CDHP cohort spent considerably more money on hospital care than the POS cohort. Results found evidence of pent-up demand in the CDHP, but not enough to explain the spending trend. Lower prescription drug spending--where the CDHP modestly controlled allowable costs--was associated with less hospital and emergency room use in following periods. Findings suggest the CDHP had too little out-of-pocket cost-sharing to control medical spending.

Is Anyone Paying Attention to Physician Report Cards? The Impact of Increased Availability on Consumers' Awareness and Use of Physician Quality Information.

OBJECTIVE: To determine if the release of health care report cards focused on physician practice quality measures leads to changes in consumers' awareness and use of this information. PRIMARY DATA SOURCES: Data from two rounds of a survey of the chronically ill adult population conducted in 14 regions across the United States, combined with longitudinal information from a public reporting tracking database. Both data were collected as part of the evaluation for Aligning Forces for Quality, a nationwide quality improvement initiative funded by the Robert Wood Johnson Foundation. STUDY DESIGN: Using a longitudinal design and an individual-level fixed effects modeling approach, we estimated the impact of community public reporting efforts, measured by the availability and applicability of physician quality reports, on consumers' awareness and use of physician quality information (PQI). PRINCIPAL FINDINGS: The baseline level of awareness was 12.6 percent in our study sample, drawn from the general population of chronically ill adults. Among those who were not aware of PQI at the baseline, when PQI became available in their communities for the first time, along with quality measures that are applicable to their specific chronic conditions, the likelihood of PQI awareness increased by 3.8 percentage points. For the same group, we also find similar increases in the uses of PQI linked to newly available physician report cards, although the magnitudes are smaller, between 2 and 3 percentage points. CONCLUSIONS: Specific contents of physician report cards can be an important factor in consumers' awareness and use of PQI. Policies to improve awareness and use of PQI may consider how to customize quality report cards and target specific groups of consumers in dissemination.

Do Health Systems Have Consistent Performance Across Locations and Is Consistency Associated With Higher Performance?

This study addresses whether health systems have consistent diabetes care performance across their ambulatory clinics and whether increasing consistency is associated with improvements in clinic performance. Study data included 2007 to 2013 diabetes care intermediate outcome measures for 661 ambulatory clinics in Minnesota and bordering states. Health systems provided more consistent performance, as measured by the standard deviation of performance for clinics in a system, relative to propensity score-matched proxy systems created for comparison purposes. No evidence was found that improvements in consistency were associated with higher clinic performance. The combination of high performance and consistent care is likely to enhance a health system's brand reputation, allowing it to better mitigate the financial risks of consumers seeking care outside the organization. These results suggest that larger health systems are most likely to deliver the combination of consistent and high-performance care. Future research should explore the mechanisms that drive consistent care within health systems.

Physician pay-for-performance. Implementation and research issues.

Recent research underscores the gaps that exist between evidence-based medical practices and the care that many patients actually receive. Recognizing this, large purchasers are experimenting with new reimbursement arrangements called pay-for-performance (P4P) that tie a portion of payments for physician services to measures of quality. Agency theory, from the discipline of economics, provides a perspective on the challenges P4P is likely to encounter. The focus of most P4P initiatives on medical group performance raises additional questions about its potential effectiveness as a catalyst for change.

Health plan pay-for-performance strategies.

OBJECTIVE: To examine health plan strategies, planning, development, and implementation of pay-for-performance programs (financial incentives for hospitals and physicians tied to quality and efficiency) at the community level, focusing on differences across markets. STUDY DESIGN: A fifth round of site visits to 12 nationally representative metropolitan areas between January 2005 and June 2005, based on more than 1000 protocol-driven interviews with representatives from health plans, provider organizations, employers, and policy makers. METHODS: In each of 12 communities, we interviewed several executives from 35 health plans, including chief executive officers, marketing executives, and network contracting directors. Additional perspectives were obtained from representatives of employers, large medical groups, and hospital systems. RESULTS: Growing numbers of health plans are developing and implementing pay-for-performance programs for physicians and hospitals. Although in their early stages, plans' customized programs show substantial design variation within and across markets. This design variation reflects local conditions that include information technology capabilities, data availability, relative leverage of health plans and providers, willingness of providers to participate, and employer influence. The concerns of providers include the administrative burden of health plans' customized programs and the potential for conflicting financial incentives. CONCLUSIONS: Most health plans are committed to pay-for-performance programs. Although providers would prefer health plans in their communities to use a single standardized set of measures and methods, this is unlikely given local market environments. A national effort directed at standardization might significantly reduce the extent of customization but also may limit the opportunities for local collaboration with providers.

Health System Consolidation and Diabetes Care Performance at Ambulatory Clinics.

OBJECTIVE: We addressed two questions regarding health system consolidation through the acquisition of ambulatory clinics: (1) Was increasing health system size associated with improved diabetes care performance and (2) Did the diabetes care performance of acquired clinics improve postacquisition? DATA SOURCES/STUDY SETTING: Six hundred sixty-one ambulatory clinics in Minnesota and bordering states that reported performance data from 2007 to 2013. STUDY DESIGN: We employed fixed effects regression to determine if increased health system size and being acquired improved clinics' performance. Using our regression results, we estimated the average effect of consolidation on the performance of clinics that were acquired during our study. DATA COLLECTION/EXTRACTION METHODS: Publicly reported performance data obtained from Minnesota Community Measurement. PRINCIPAL FINDINGS: Acquired clinics experienced performance improvements starting in their third year postacquisition. By their fifth year postacquisition, acquired clinics had 3.6 percentage points (95 percent confidence interval: 2.0, 5.1) higher performance than if they had never been acquired. Increasing health system size was associated with slight performance improvements at the end of the study. CONCLUSIONS: Health systems modestly improved the diabetes care performance of their acquired clinics; however, we found little evidence that systems experienced large, system-wide performance gains by increasing their size.

Reporting provider performance: what can be learned from the experience of multi-stakeholder community coalitions?

OBJECTIVES: This analysis assessed the evolution of public reporting of provider performance in Aligning Forces for Quality (AF4Q) alliances, contrasted alliances that stopped reporting with those that plan to continue, and drew insights from alliance public reporting efforts for the national transparency movement. METHODS: Combined with document review, qualitative research methods were used to analyze interview data collected, over a nearly 10-year period, from the 16 participating alliances. RESULTS: AF4Q alliances made their greatest contributions to provider transparency in reporting ambulatory quality and patient experience measures. However, reporting ambulatory cost/efficiency/utilization measures was more challenging for alliances. Alliances contributed the least with respect to measures of inpatient performance. Six alliances ceased reporting at the end of the AF4Q program because of their inability to develop stable funding sources and overcome stakeholder skepticism about the value of public reporting. Insights provided by alliance leaders included the need to: focus on provider, rather than consumer, responses to public reports as the most likely avenue for improving quality; address the challenge of funding the reporting infrastructure from the beginning; explore collaborations with other entities to increase public reporting efficiency; and develop a strategy for responding to efforts at the national level to increase the availability of information on provider performance. CONCLUSION: The AF4Q initiative demonstrated that a wide variety of voluntary stakeholder coalitions could develop public reports with financial and technical support. However, the contents of these reports varied considerably, reflecting differences in local environments and alliance strategies. The challenges faced by alliances to maintain their reporting efforts were substantial, and not all alliances chose to report. Nevertheless, there are potential roles for alliances going forward in contributing to the national transparency movement.

From rhetoric to reality: consumer engagement in 16 multi-stakeholder alliances.

OBJECTIVE: A key component of the Aligning Forces for Quality (AF4Q) program was engaging consumers in their health and healthcare. We examined the extent to which the alliances embraced 4 areas of consumer engagement: self-management, consumer friendliness of reports of healthcare provider quality, involvement of consumers in alliance governance, and the integration of consumers into quality improvement teams. METHODS: We used a largely qualitative approach. The evaluation team conducted 1100 in-depth interviews with alliance stakeholders. Two authors reviewed the consumer engagement data for each alliance to assess its level of embrace in the 4 consumer engagement areas. For consumer friendliness of public reporting websites, we also assessed alliance public reports for reading level, technical language, and evaluable displays. Population-level effects were also examined for self-management and public reporting. RESULTS: Consumer engagement was new to most alliances, and few had staff with consumer engagement expertise or existing consumer constituencies. For each area of consumer engagement, some alliances enthusiastically embraced the work, other alliances made a concerted but limited effort to develop programs, and a third group of alliances did the minimum work required. Integrating consumers into governance was the area most often embraced, followed by making public reports consumer friendly. Two alliances strongly embraced both self-management and integrating patients into quality improvement efforts. The AF4Q program did not have greater population level effects from self-management or public reporting than were those observed in a national comparison sample. CONCLUSION: The AF4Q program sparked a few alliances to develop robust consumer engagement programming, while most alliances tried consumer engagement efforts for the first time and developed an appreciation for integrating consumer perspectives into their work.

Referrals to integrative medicine in a tertiary hospital: findings from electronic health record data and qualitative interviews.

OBJECTIVE: To examine patterns of, and decision-making processes, informing referrals for inpatient access to integrative medicine (IM) services at a large, acute care hospital. DESIGN: Retrospective electronic health record review and structured qualitative interviews. SETTING: A 630-bed tertiary care hospital with an IM service available to inpatients. PARTICIPANTS: IM referrals of all inpatients aged ≥18 years between July 2012 and December 2014 were identified using the hospital's electronic health record. Fifteen physicians, 15 nurses and 7 administrators were interviewed to better understand roles and perspectives in referring patients for IM services. RESULTS: In the study hospital, primary sources of referrals for IM services were the orthopaedic and neuroscience/spine service lines. While the largest absolute number of IM referrals was made for patients with lengths of stay of 3 days or fewer, a disproportionate number of total IM referrals was made for patients with long lengths of stay (≥10 days), compared with a smaller percentage of patients in the hospital with lengths of stay ≥10 days. Physicians and nurses were more likely to refer patients who displayed strong symptoms (eg, pain and anxiety) and/or did not respond to conventional therapies. IM referrals were predominantly nurse-initiated. A built-in delay in the time from referral initiation to service delivery discouraged referrals of some patients. CONCLUSIONS: Conventional providers refer patients for IM services when these services are available in a tertiary hospital. Referral patterns are influenced by patient characteristics, operational features and provider perspectives. Nurses play a key role in the referral process. Overcoming cultural and knowledge differences between conventional and IM providers is likely to be a continuing challenge to providing IM in inpatient settings.

Evaluating a complex, multi-site, community-based program to improve healthcare quality: the summative research design for the Aligning Forces for Quality initiative.

OBJECTIVE: The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed. STUDY DESIGN: A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided. METHODS: The summative research design employed by the evaluation team is discussed. RESULTS: The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program. CONCLUSION: The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

Summative evaluation results and lessons learned from the Aligning Forces for Quality program.

OBJECTIVE: To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015. METHODS: This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities. RESULTS: Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

The longitudinal impact of Aligning Forces for Quality on measures of population health, quality and experience of care, and cost of care.

OBJECTIVE: To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative. STUDY DESIGN: Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care. DATA: Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). RESULTS: In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.