Questionnaire to assess relevance and credibility of modeling studies for informing health care decision making: an ISPOR-AMCP-NPC Good Practice Task Force report.

The evaluation of the cost and health implications of agreeing to cover a new health technology is best accomplished using a model that mathematically combines inputs from various sources, together with assumptions about how these fit together and what might happen in reality. This need to make assumptions, the complexity of the resulting framework, the technical knowledge required, as well as funding by interested parties have led many decision makers to distrust the results of models. To assist stakeholders reviewing a model's report, questions pertaining to the credibility of a model were developed. Because credibility is insufficient, questions regarding relevance of the model results were also created. The questions are formulated such that they are readily answered and they are supplemented by helper questions that provide additional detail. Some responses indicate strongly that a model should not be used for decision making: these trigger a "fatal flaw" indicator. It is hoped that the use of this questionnaire, along with the three others in the series, will help disseminate what to look for in comparative effectiveness evidence, improve practices by researchers supplying these data, and ultimately facilitate their use by health care decision makers.

Model transparency and validation: a report of the ISPOR-SMDM Modeling Good Research Practices Task Force--7.

Trust and confidence are critical to the success of health care models. There are two main methods for achieving this: transparency (people can see how the model is built) and validation (how well the model reproduces reality). This report describes recommendations for achieving transparency and validation developed by a taskforce appointed by the International Society for Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making. Recommendations were developed iteratively by the authors. A nontechnical description--including model type, intended applications, funding sources, structure, intended uses, inputs, outputs, other components that determine function, and their relationships, data sources, validation methods, results, and limitations--should be made available to anyone. Technical documentation, written in sufficient detail to enable a reader with necessary expertise to evaluate the model and potentially reproduce it, should be made available openly or under agreements that protect intellectual property, at the discretion of the modelers. Validation involves face validity (wherein experts evaluate model structure, data sources, assumptions, and results), verification or internal validity (check accuracy of coding), cross validity (comparison of results with other models analyzing the same problem), external validity (comparing model results with real-world results), and predictive validity (comparing model results with prospectively observed events). The last two are the strongest form of validation. Each section of this article contains a number of recommendations that were iterated among the authors, as well as among the wider modeling taskforce, jointly set up by the International Society for Pharmacoeconomics and Outcomes Research and the Society for Medical Decision Making.

Individualized guidelines: the potential for increasing quality and reducing costs.

BACKGROUND: Current guidelines focus on a particular risk factor and specify criteria for categorizing persons into a small number of treatment groups. OBJECTIVE: To compare current guidelines with individualized guidelines (that use readily available characteristics from each person to calculate the risk reduction expected from treatment and to identify persons for treatment in ranked order of decreasing expected benefit), in the context of blood pressure management. DESIGN: Analysis of person-specific, longitudinal data. SETTING: The ARIC (Atherosclerosis Risk in Communities) Study. PARTICIPANTS: Persons aged 45 to 64 years without preexisting cardiovascular disease who currently do not receive antihypertensive treatment. INTERVENTION: Treatment according to the criteria of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 guidelines); individualized guidelines, or treatment in decreasing order of expected benefit; and random care, or treatment of persons selected at random. MEASUREMENTS: Number of myocardial infarctions (MIs) and strokes and medical costs. RESULTS: Compared with treating people according to random care, individualized guidelines could prevent the same number of MIs and strokes as JNC 7 guidelines at savings that are 67% greater than using JNC 7 guidelines, or it could prevent 43% more MIs and strokes for the same cost as treatment according to JNC 7 guidelines. The superiority of individualized guidelines was not sensitive to a wide range of assumptions about costs, treatment effectiveness, level of risk for cardiovascular disease in the population, or effects on workflow. The degree of superiority was sensitive to the accuracy of the method used to rank patients and to its span (the proportion of the population for whom all of the outcomes of interest can be calculated). LIMITATIONS: Specific results apply to the effects of blood pressure management on MI and stroke in the ARIC Study population. The methods for calculating individual benefits require quantitative evidence about the relationships among risk factors, long-term outcomes, and treatment effects. CONCLUSION: Use of individualized guidelines can help to increase the quality and reduce the cost of care.

Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis.

BACKGROUND: No clinical trials have assessed the effects or cost-effectiveness of sequential screening strategies to detect new cases of type 2 diabetes. We used a mathematical model to estimate the cost-effectiveness of several screening strategies. METHODS: We used person-specific data from a representative sample of the US population to create a simulated population of 325,000 people aged 30 years without diabetes. We used the Archimedes model to compare eight simulated screening strategies for type 2 diabetes with a no-screening control strategy. Strategies differed in terms of age at initiation and frequency of screening. Once diagnosed, diabetes treatment was simulated in a standard manner. We calculated the effects of each strategy on the incidence of type 2 diabetes, myocardial infarction, stroke, and microvascular complications in addition to quality of life, costs, and cost per quality-adjusted life-year (QALY). FINDINGS: Compared with no screening, all simulated screening strategies reduced the incidence of myocardial infarction (3-9 events prevented per 1000 people screened) and diabetes-related microvascular complications (3-9 events prevented per 1000 people), and increased the number of QALYs (93-194 undiscounted QALYs) added over 50 years. Most strategies prevented a significant number of simulated deaths (2-5 events per 1000 people). There was little or no effect of screening on incidence of stroke (0-1 event prevented per 1000 people). Five screening strategies had costs per QALY of about US$10,500 or less, whereas costs were much higher for screening started at 45 years of age and repeated every year ($15,509), screening started at 60 years of age and repeated every 3 years ($25,738), or a maximum screening strategy (screening started at 30 years of age and repeated every 6 months; $40,778). Several strategies differed substantially in the number of QALYs gained. Costs per QALY were sensitive to the disutility assigned to the state of having diabetes diagnosed with or without symptoms. INTERPRETATION: In the US population, screening for type 2 diabetes is cost effective when started between the ages of 30 years and 45 years, with screening repeated every 3-5 years. FUNDING: Novo Nordisk, Bayer HealthCare, [corrected] and Pfizer.

The impact of prevention on reducing the burden of cardiovascular disease.

OBJECTIVE: Cardiovascular disease (CVD) is prevalent and expensive. While many interventions are recommended to prevent CVD, the potential effects of a comprehensive set of prevention activities on CVD morbidity, mortality, and costs have never been evaluated. We therefore determined the effects of 11 nationally recommended prevention activities on CVD-related morbidity, mortality, and costs in the United States. RESEARCH DESIGN AND METHODS: We used person-specific data from a representative sample of the US population (National Health and Nutrition Education Survey IV) to determine the number and characteristics of adults aged 20-80 years in the United States today who are candidates for different prevention activities related to CVD. We used the Archimedes model to create a simulated population that matched the real US population, person by person. We then used the model to simulate a series of clinical trials that examined the effects over the next 30 years of applying each prevention activity one by one, or altogether, to those who are candidates for the various activities and compared the health outcomes, quality of life, and direct medical costs to current levels of prevention and care. We did this under two sets of assumptions about performance and compliance: 100% success for each activity and lower levels of success considered aggressive but still feasible. RESULTS: Approximately 78% of adults aged 20-80 years alive today in the United States are candidates for at least one prevention activity. If everyone received the activities for which they are eligible, myocardial infarctions and strokes would be reduced by 63% and 31%, respectively. If more feasible levels of performance are assumed, myocardial infarctions and strokes would be reduced 36% and 20%, respectively. Implementation of all prevention activities would add approximately 221 million life-years and 244 million quality-adjusted life-years to the US adult population over the coming 30 years, or an average of 1.3 years of life expectancy for all adults. Of the specific prevention activities, the greatest benefits to the US population come from providing aspirin to high-risk individuals, controlling pre-diabetes, weight reduction in obese individuals, lowering blood pressure in people with diabetes, and lowering LDL cholesterol in people with existing coronary artery disease (CAD). As currently delivered and at current prices, most prevention activities are expensive when considering direct medical costs; smoking cessation is the only prevention strategy that is cost-saving over 30 years. CONCLUSIONS: Aggressive application of nationally recommended prevention activities could prevent a high proportion of the CAD events and strokes that are otherwise expected to occur in adults in the United States today. However, as they are currently delivered, most of the prevention activities will substantially increase costs. If preventive strategies are to achieve their full potential, ways must be found to reduce the costs and deliver prevention activities more efficiently.

Effect of smoking cessation advice on cardiovascular disease.

Performance measures and guidelines encourage physicians to advise smokers to quit. The effect of these efforts on the morbidity, mortality, and cost of cardiovascular disease is not known. This article analyzes the effects of offering smoking cessation advice in the US population. The Archimedes model is used to simulate several clinical trials in which basic advice and medication advice are offered and to calculate the rates of myocardial infarctions, congestive heart disease deaths, strokes, life years, quality-adjusted life years (QALYs), costs, and cost/ QALY. The simulated population is a representative sample of the US population drawn from the Third National Health and Nutrition Survey conducted just before the performance measures and guidelines were introduced. The results show that offering basic advice and medication advice can prevent about 13% and 19% of myocardial infarctions and strokes, respectively. The 30-year cost/QALY is approximately $3000 less than the base-case assumptions and less than $10 000 under pessimistic assumptions.

Accuracy versus transparency in pharmacoeconomic modelling: finding the right balance.

As modellers push to make their models more accurate, the ability of others to understand the models can decrease, causing the models to lose transparency. When this type of conflict between accuracy and transparency occurs, the question arises, "Where do we want to operate on that spectrum?" This paper argues that in such cases we should give absolute priority to accuracy: push for whatever degree of accuracy is needed to answer the question being asked, try to maximise transparency within that constraint, and find other ways to replace what we wanted to get from transparency. There are several reasons. The fundamental purpose of a model is to help us get the right answer to a question and, by any measure, the expected value of a model is proportional to its accuracy. Ironically, we use transparency as a way to judge accuracy. But transparency is not a very powerful or useful way to do this. It rarely enables us to actually replicate the model's results and, even if we could, replication would not tell us the model's accuracy. Transparency rarely provides even face validity; from the content expert's perspective, the simplifications that modellers have to make usually raise more questions than they answer. Transparency does enable modellers to alert users to weaknesses in their models, but that can be achieved simply by listing the model's limitations and does not get us any closer to real accuracy. Sensitivity analysis tests the importance of uncertainty about the variables in a model, but does not tell us about the variables that were omitted or the structure of the model. What people really want to know is whether a model actually works. Transparency by itself can't answer this; only demonstrations that the model accurately calculates or predicts real events can. Rigorous simulations of clinical trials are a good place to start. This is the type of empirical validation we need to provide if the potential of mathematical models in pharmacoeconomics is to be fully achieved.

Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes.

BACKGROUND: Lifestyle modification can forestall diabetes in high-risk people, but the long-term cost-effectiveness is uncertain. OBJECTIVE: To estimate the effects of the lifestyle modification program used in the Diabetes Prevention Program (DPP) on health and economic outcomes. DESIGN: Cost-effectiveness analysis using the Archimedes model. DATA SOURCES: Published basic and epidemiologic studies, clinical trials, and Kaiser Permanente administrative data. TARGET POPULATION: Adults at high risk for diabetes (body mass index >24 kg/m2, fasting plasma glucose level of 5.2725 to 6.9375 mmol/L [95 to 125 mg/dL], 2-hour glucose tolerance test result of 7.77 to 11.0445 mmol/L [140 to 199 mg/dL]). TIME HORIZON: 5 to 30 years. PERSPECTIVE: Patient, health plan, and societal. INTERVENTIONS: No prevention, DPP's lifestyle modification program, lifestyle modification begun after a person develops diabetes, and metformin. MEASUREMENTS: Diagnosis and complications of diabetes. RESULTS OF BASE-CASE ANALYSIS: Compared with no prevention program, the DPP lifestyle program would reduce a high-risk person's 30-year chances of getting diabetes from about 72% to 61%, the chances of a serious complication from about 38% to 30%, and the chances of dying of a complication of diabetes from about 13.5% to 11.2%. Metformin would deliver about one third the long-term health benefits achievable by immediate lifestyle modification. Compared with not implementing any prevention program, the expected 30-year cost/quality-adjusted life-year (QALY) of the DPP lifestyle intervention from the health plan's perspective would be about 143,000 dollars. From a societal perspective, the cost/QALY of the lifestyle intervention compared with doing nothing would be about 62,600 dollars. Either using metformin or delaying the lifestyle intervention until after a person develops diabetes would be more cost-effective, costing about 35,400 dollars or 24,500 dollars per QALY gained, respectively, compared with no program. Compared with delaying the lifestyle program until after diabetes is diagnosed, the marginal cost-effectiveness of beginning the DPP lifestyle program immediately would be about 201,800 dollars. RESULTS OF SENSITIVITY ANALYSIS: Variability and uncertainty deriving from the structure of the model were tested by comparing the model's results with the results of real clinical trials of diabetes and its complications. The most critical element of uncertainty is the effectiveness of the lifestyle program, as expressed by the 95% CI of the DPP study. The most important potentially controllable factor is the cost of the lifestyle program. Compared with no program, lifestyle modification for high-risk people can be made cost-saving over 30 years if the annual cost of the intervention can be reduced to about 100 dollars. LIMITATIONS: Results depend on the accuracy of the model. CONCLUSIONS: Lifestyle modification is likely to have important effects on the morbidity and mortality of diabetes and should be recommended to all high-risk people. The program used in the DPP study may be too expensive for health plans or a national program to implement. Less expensive methods are needed to achieve the degree of weight loss seen in the DPP.

Methods for Building and Validating Equations for Physiology-Based Mathematical Models: Glucose Metabolism and Type 2 Diabetes in the Archimedes Model.

OBJECTIVES: Describe steps for deriving and validating equations for physiology processes for use in mathematical models. Illustrate the steps using glucose metabolism and Type 2 diabetes in the Archimedes model. METHODS AND RESULTS: The steps are as follows: identify relevant variables, describe their relationships, identify data sources that relate the variables, correct for biases in data sources, use curve fitting algorithms to estimate equations, validate the accuracy of curve fitting against empirical data, perform partially and fully independent external validations, examine any discrepancies to determine causes and make corrections, and periodically update and revalidate equations as necessary. Specific methods depend on the available data. Specific data sources and methods are illustrated for equations that represent the cause of Type 2 diabetes and its effect on fasting plasma glucose in the Archimedes model. Methods for validating the equations are illustrated. Applications enabled by including physiological equations in healthcare models are discussed. CONCLUSIONS: The methods can be used to derive equations that represent the relationships between physiological variables and the causes of diseases and that validate well against empirical data.

El entrenamiento de la lucha olímpica para el desarrollo personal y social en adolescentes: una propuesta extracurricular desde la Educación Física / Treinamento da luta-livre olímpica para o desenvolvimento pessoal e social dos adolescentes: uma proposta extracurricular de Educação Física / The training in the Olympic Wrestling for the social and personal development in teenagers: an extracurricular proposal from the Physical Education

RESUMEN El objetivo de este artículo es presentar una propuesta educativa, basada en el entrenamiento de la lucha olímpica para el desarrollo personal y social en adolescentes, en escenarios extracurriculares. Para ello, se utilizaron las metodologías: etnográfica y documental, con la finalidad de poder contestar a la interrogante: ¿Puede haber desarrollo personal y social al entrenar la lucha libre en las instituciones educativas? Se aplicó la revisión bibliográfica en dos fases: la primera, denominada fase I, permitió el análisis de las unidades temáticas seleccionadas para luego asumir una fase II la cual fue propositiva con base en la argumentación teórica y la contextualización que permitiera presentar los objetivos, la metodología pedagógica, la relación con el currículo oficial de Educación Física, las actividades generales y la evaluación para completar algunos vacíos de información. Se aplicó la entrevista a diez profesores de Educación Física de instituciones educativas de la región costa; todos ellos exdeportistas de lucha libre. Ambos instrumentos se basaron bajo dos dimensiones: la primera la lucha olímpica, entre lo curricular y lo extracurricular y la segunda, la lucha olímpica en la formación personal y social del adolescente. Después de hacer un análisis crítico a los resultados, se pudo obtener la propuesta extracurricular de lucha libre. Se aborda la importancia de la implementación de la lucha olímpica como actividad innovadora extracurricular, que potencia el desarrollo personal en cuanto a la autoestima, autocontrol y cuidado de sí mismo, así como habilidades sociales de cooperación, respeto a las reglas y cuidado del otro.

RESUMO O objetivo deste artigo é apresentar uma proposta educativa, baseada na formação da luta olímpica para o desenvolvimento pessoal e social dos adolescentes, em contextos extracurriculares. Para este efeito, foram utilizadas as seguintes metodologias: etnográfica e documental, a fim de responder à pergunta: Pode haver desenvolvimento pessoal e social na formação de luta livre em instituições de ensino? A revisão bibliográfica foi aplicada em duas fases: a primeira, chamada fase I, permitiu a análise das unidades temáticas selecionadas e depois assumir uma fase II que foi propositiva com base na argumentação teórica e na contextualização que permitiu apresentar os objetivos, a metodologia pedagógica, a relação com o currículo oficial da Educação Física, as atividades gerais e a avaliação para completar algumas lacunas de informação. A entrevista foi conduzida com dez professores de Educação Física de instituições educativas da região da costa, todos eles ex-atletas de luta-livre. Ambos os instrumentos se baseavam em duas dimensões: a primeira era a luta olímpica, entre o curricular e extracurricular, e a segunda, a luta olímpica na formação pessoal e social do adolescente. Após uma análise crítica dos resultados, foi obtida a proposta de luta livre extracurricular. É abordada a importância da implementação da luta livre olímpica como actividade extracurricular inovadora, que potência o desenvolvimento pessoal em termos de autoestima, autocontrolo e autocuidado, bem como competências sociais de cooperação, respeito pelas regras e cuidados com os outros.

ABSTRACT The objective of this article is to present an educational proposal based on Olympic Wrestling training for personal and social development in teenagers in extracurricular settings. For this, the ethnographic and documentary methodologies were used in order to answer the question, can there be personal and social development when training wrestling in educational institutions? The bibliographic review was applied in two phases, the first one, called phase I, allowed the analysis of the selected thematic units to later assume a phase II, which was propositional based on the theoretical argumentation and the contextualization that allowed to present the objectives, the pedagogical methodology, the relationship with the official Physical Education curriculum, general activities and evaluation; to fill in some information gaps, the interview was applied to ten physical education teachers from educational institutions in the Costa region, all of them former wrestling athletes. Both instruments were based on two dimensions: the first one, The Olympic Wrestling: between the curricular and the extracurricular, and the second one, The Olympic wrestling in the personal and social formation of the teenagers. After a critical analysis of the results, the extracurricular wrestling proposal was obtained. It addresses the importance of implementing Olympic Wrestling as an innovative extracurricular activity, which promotes personal development in terms of self-esteem, self-control and self-care, as well as social skills of cooperation, respect for rules and care for others.

Evidence-based medicine: a unified approach.

Behind the wide acceptance of the idea of "evidence-based medicine" are two curious facts: There are two very different approaches to applying evidence to medicine, and the most commonly cited definition applies to only one of them. This paper describes the problem that we are asking "evidence" to solve and the different methods by which evidence can be used to help solve that problem, and recommends a unified approach.

Archimedes: a trial-validated model of diabetes.

OBJECTIVE: To build a mathematical model of the anatomy, pathophysiology, tests, treatments, and outcomes pertaining to diabetes that could be applied to a wide variety of clinical and administrative problems and that could be validated. RESEARCH DESIGN AND METHODS: We used an object-oriented approach, differential equations, and a construct we call "features." The level of detail and realism was determined by what clinicians considered important, by the need to distinguish clinically relevant variables, and by the level of detail used in the conduct of clinical trials. RESULTS: The model includes the pertinent organ systems, more than 50 continuously interacting biological variables, and the major symptoms, tests, treatments, and outcomes. The level of detail corresponds to that found in general medical textbooks, patient charts, clinical practice guidelines, and designs of clinical trials. The model is continuous in time and represents biological variables continuously. As demonstrated in a companion article, the equations can simulate a variety of clinical trials and reproduce their results with good accuracy. CONCLUSIONS: It is possible to build a mathematical model that replicates the pathophysiology of diabetes at a high level of biological and clinical detail and that can be tested by simulating clinical trials.

Validation of the archimedes diabetes model.

OBJECTIVE: To validate the Archimedes model of diabetes and its complications for a variety of populations, organ systems, treatments, and outcomes. RESEARCH DESIGN AND METHODS: We simulated a variety of randomized controlled trials by repeating in the model the steps taken for the real trials and comparing the results calculated by the model with the results of the trial. Eighteen trials were chosen by an independent advisory committee. Half the trials had been used to help build the model ("internal" or "dependent" validations); the other half had not. Those trials comprise "external" or "independent" validations. RESULTS: A total of 74 validation exercises were conducted involving different treatments and outcomes in the 18 trials. For 71 of the 74 exercises there were no statistically significant differences between the results calculated by the model and the results observed in the trial. Considering only the trials that were never used to help build the model-the independent or external validations-the correlation was r = 0.99. Including all of the exercises, the correlation between the outcomes calculated by the model and the outcomes seen in the trials was r = 0.99. When the absolute differences in outcomes between the control and treatment groups were compared, the correlation coefficient was r = 0.97. CONCLUSIONS: The Archimedes diabetes model is a realistic representation of the anatomy, pathophysiology, treatments, and outcomes pertinent to diabetes and its complications for applications that involve the populations, treatments, outcomes, and health care settings spanned by the trials.

Evidencing Continual Professional Development: Maximising Impact and Informing Career Planning.

Continuing professional development (CPD) is essential for radiographers to maintain and update their specialised knowledge base in light of constant professional changes. CPD is the continuous and systematic maintenance, improvement, and broadening of knowledge and skills and the development of personal qualities necessary for the execution of professional and technical duties. Professional and regulatory bodies are increasingly relying on proof of CPD through a variety of learning opportunities to provide evidence of clinical competence. Importantly, CPD has been linked not only to competence but also to motivation and job satisfaction. However, for CPD to be embraced fully, the individual needs to see how activity can be planned and recorded in a way that is meaningful to them in the context of their career aspirations. This article will review basic principles of why evidence is needed for CPD, what constitutes evidence (direct and indirect), and how that evidence can be presented. This will be discussed in the context of having a longer-term career vision, and embedded within Donner and Wheeler's five-phase career planning and development model.

A standardized vascular disease health check in europe: a cost-effectiveness analysis.

BACKGROUND: No clinical trials have assessed the effects or cost-effectiveness of health check strategies to detect and manage vascular disease. We used a mathematical model to estimate the cost-effectiveness of several health check strategies in six European countries. METHODS: We used country-specific data from Denmark, France, Germany, Italy, Poland, and the United Kingdom to generate simulated populations of individuals aged 40-75 eligible for health checks in those countries (e.g. individuals without a previous diagnosis of diabetes, myocardial infarction, stroke, or serious chronic kidney disease). For each country, we used the Archimedes model to compare seven health check strategies consisting of assessments for diabetes, hypertension, lipids, and smoking. For patients diagnosed with vascular disease, treatment was simulated in a standard manner. We calculated the effects of each strategy on the incidence of type 2 diabetes, major adverse cardiovascular events (MACE), and microvascular complications in addition to quality of life, costs, and cost per quality-adjusted life-year (QALY). RESULTS: Compared with current care, health checks reduced the incidence of MACE (6-17 events prevented per 1000 people screened) and diabetes related microvasular complications (5-11 events prevented per 1000 people screened), and increased QALYs (31-59 discounted QALYs) over 30 years, in all countries. The cost per QALY of offering a health check to all individuals in the study cohort ranged from €14903 (France) to cost saving (Poland). Pre-screening the population and offering health checks only to higher risk individuals lowered the cost per QALY. Pre-screening on the basis of obesity had a cost per QALY of €10200 (France) or less, and pre-screening with a non-invasive risk score was similar. CONCLUSIONS: A vascular disease health check would likely be cost effective at 30 years in Denmark, France, Germany, Italy, Poland, and the United Kingdom.

A simulation shows limited savings from meeting quality targets under the Medicare Shared Savings Program.

The Medicare Shared Savings Program, created under the Affordable Care Act, will reward participating accountable care organizations that succeed in lowering health care costs while improving performance. Depending on how the organizations perform on several quality measures, they will "share savings" in Medicare Part A and B payments-that is, they will receive bonus payments for lowering costs. We used a simulation model to analyze the effects of the Shared Savings Program quality measures and performance targets on Medicare costs in a simulated population of patients ages 65-75 with type 2 diabetes. We found that a ten-percentage-point improvement in performance on diabetes quality measures would reduce Medicare costs only by up to about 1 percent. After the costs of performance improvement, such as additional tests or visits, are accounted for, the savings would decrease or become cost increases. To achieve greater savings, accountable care organizations will have to lower costs by other means, such as through improved use of information technology and care coordination.