Comparative effectiveness topics from a large, integrated delivery system.

OBJECTIVE: To identify high-priority comparative effectiveness questions directly relevant to care delivery in a large, US integrated health care system. METHODS: In 2010, a total of 792 clinical and operational leaders in Kaiser Permanente were sent an electronic survey requesting nominations of comparative effectiveness research questions; most recipients (83%) had direct clinical roles. Nominated questions were divided into 18 surveys of related topics that included 9 to 23 questions for prioritization. The next year, 648 recipients were electronically sent 1 of the 18 surveys to prioritize nominated questions. Surveys were assigned to recipients on the basis of their nominations or specialty. High-priority questions were identified by comparing the frequency a question was selected to an "expected" frequency, calculated to account for the varying number of questions and respondents across prioritization surveys. High-priority questions were those selected more frequently than expected. RESULTS: More than 320 research questions were nominated from 181 individuals. Questions most frequently addressed cardiovascular and peripheral vascular disease; obesity, diabetes, endocrinology, and metabolic disorders; or service delivery and systems-level questions. Ninety-five high-priority research questions were identified, encompassing a wide range of health questions that ranged from prevention and screening to treatment and quality of life. Many were complex questions from a systems perspective regarding how to deliver the best care. CONCLUSIONS: The 95 questions identified and prioritized by leaders on the front lines of health care delivery may inform the national discussion regarding comparative effectiveness research. Additionally, our experience provides insight in engaging real-world stakeholders in setting a health care research agenda.

Making better use of the policies and funding we already have.

The potential for population health reform could be enhanced by assessing whether we have made the most of policies and resources already available. Opportunities to promote population health independent of major changes in resources or public authority include the following: enforcing laws already in effect; clarifying and updating the application of long-standing policies; leveraging government's and the private sector's purchasing and investment clout; facilitating access to programs by everyone who is eligible for them; evaluating the effectiveness of population health programs, agencies, and policies; and intervening to stop agencies and policies from operating at cross-purposes.

The contribution of hospitals and health care systems to community health.

This article reviews evidence on hospitals' and health systems' impacts on community health improvement. We begin with an overview of the history of community benefit and then discuss the lack of a widely accepted definition and measurement of community benefit activities as well as the expectations and accountability of tax-exempt not-for-profit hospitals and health systems in community initiatives. We highlight the approaches of two systems and identify strategic, cultural, technical, and structural challenges associated with increasing community benefit and health-improvement activities. We conclude by offering recommendations for policy and practice.

America's health care safety net: revisiting the 2000 IOM report.

The committee that wrote the 2000 Institute of Medicine report on the health care safety net reconvened in 2006 to reflect on the safety net from the perspective of rising numbers of uninsured and underinsured people, the aftermath of Hurricane Katrina, high immigration levels, and new fiscal and policy pressures on care for vulnerable populations. Safety-net providers now participate in Medicaid managed care but find it difficult to meet growing needs for specialty services, particularly mental health care and affordable prescription drugs. How current state reforms and coverage expansions will affect care for the poor and uninsured is a critical issue.