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Learning collaboratives are increasingly used as mechanisms to support and hasten the diffusion and implementation of innovation, clinical evidence, and effective models of care. Factors contributing to the collaboratives' success or failure are poorly understood. The Agency for Healthcare Research and Quality (AHRQ) has sponsored collaboratives for nearly two decades to support improvements in health care quality and value by accelerating the diffusion and implementation of innovation. We examined AHRQ's experience with these collaboratives to characterize their attributes, identify factors that might contribute to their success or failure, and assess the challenges they encountered. Building on the literature and insights from AHRQ's experience, we propose a taxonomy that can offer guidance to decision makers and funders about the factors they should consider in developing collaboratives and planning their evaluation, as well as to researchers who seek to conduct research that will ultimately help decision makers make better investments in diffusing innovation and evidence.

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As recreational visitation to the Sonoran Desert increases, the concern of scientists, managers and advocates who manage its natural resources deepens. Although many studies have been conducted on trampling of undisturbed vegetation and the effects of trails on adjacent plant and soil communities, little such research has been conducted in the arid southwest. We sampled nine 450-m trail segments with different visitation levels in Scottsdale's McDowell Sonoran Preserve over three years to understand the effects of visitation on soil erosion, trailside soil crusts and plant communities. Soil crust was reduced by 27-34% near medium and high use trails (an estimated peak rate of 13-70 visitors per hour) compared with control plots, but there was less than 1% reduction near low use trails (peak rate of two to four visitors per hour). We did not detect soil erosion in the center 80% of the trampled area of any of the trails. The number of perennial plant species dropped by less than one plant species on average, but perennial plant cover decreased by 7.5% in trailside plots compared with control plots 6 m off-trail. At the current levels of visitation, the primary management focus should be keeping people on the originally constructed trail tread surface to reduce impact to adjacent soil crusts.

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There is significant interest in building the next generation of public reporting tools that will more effectively engage consumers and better enable them to make use of comparative performance information when selecting a provider. Demand for public reporting tools that make health care cost and quality information transparent is fueled by a variety of market forces underway. A host of public reporting efforts and studies have identified a number of challenges, highlighting that we still do not understand how best to design public reports to meet the needs of the consumer. We identify five areas for additional research that, if addressed, could foster better design and delivery of quality and cost information to consumers.

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Twenty-seven years after the first public release by the U.S. government of data on the quality of hospital care, public reporting for consumers has expanded substantially. Despite the growth in public reporting activities, there is limited evidence of their use by consumers in ways that significantly affect health care delivery. Support for public reporting continues, in part, because of the face value of transparency. The limited impact of reporting efforts is plausibly due to flaws in the content, design, and implementation of existing public reports rather than inherent limitations of reporting. Substantial work is still needed for public reports to achieve their potential for engaging and informing consumers. We present a vision statement and 10 recommendations to achieve this potential.

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In most health care systems in most countries, providers are not adequately held accountable - by governments, purchasers, provider professional associations or civil society - for the quality of care. One approach to improve provider accountability that is being debated and implemented in a subset of developed countries and a smaller group of developing countries is provider-specific comparative performance reporting. This review discusses universal design options for report cards, summarizes the evidence base, presents developing country examples, reviews challenges and outlines implementation steps. The ultimate aim is to provoke thoughtful debate about if and how comparative performance reporting fits within a developing country's broader framework of strategies to promote quality of care.

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INTRODUCTION: The logic of paying more for high-quality care and less for low-quality resonates. Increasingly health system leaders worldwide acknowledge that payment reforms are needed to do just that, prompted no doubt by the growing body of evidence indicating that quality is not what it should be. PURPOSE: This review was undertaken to explore contexts in which quality-based payment appears feasible. The ultimate intent is to provoke thoughtful debate about whether and how quality-based payment might fit within a particular developing country's framework of policies to ensure and promote quality of care. METHODS: With guidance from key informants with first-hand knowledge of international quality-based payment schemes, a purposive sample of six quality-based payment schemes was assembled. Schemes were examined to identify environmental contexts and design features. RESULTS: Examples illustrate a variety of approaches and a breadth of contexts in which quality-based payment has been implemented. Contrary to what might be expected, implementation does not appear to be constrained to private-sector purchasers, private-sector providers, hospital settings, nor to any particular type of underlying payment system. Further, quality-based payment pioneers are using a variety of incentive structures, and are tapping a rich mix of structural, process, and outcome standards to benchmark quality. CONCLUSION: Despite significant operational challenges, quality-based payment has been implemented in developing as well as developed countries, albeit not frequently in either instance. What we do not know--what the literature is nearly silent on--relates to the sustainability and ultimate impact of alternative incentive schemes.

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On May 28, 2003, the Agency for Healthcare Research and Quality and the Federal Trade Commission co-sponsored an invitational conference entitled, "Provider Competition and Quality: Latest Findings and Implications for the Next Generation of Research." The main objectives of this conference were to share and discuss the latest findings on provider competition and quality, to identify implications for antitrust policy, and to develop an agenda for further research in this area. While it is impossible to completely capture the rich exchange of ideas and perspectives that transpired at the conference, we highlight several key themes that emerged and present a research agenda to guide future investigations.

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