Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board

PURPOSE

To determine if medical students who demonstrate unprofessional behavior in medical school are more likely to have subsequent state board disciplinary action.

METHOD

A case-control study was conducted of all University of California, San Francisco, School of Medicine graduates disciplined by the Medical Board of California from 1990-2000 (68). Control graduates (196) were matched by medical school graduation year and specialty choice. Predictor variables were male gender, undergraduate grade point average, Medical College Admission Test scores, medical school grades, National Board of Medical Examiner Part 1 scores, and negative excerpts describing unprofessional behavior from course evaluation forms, dean's letter of recommendation for residencies, and administrative correspondence. Negative excerpts were scored for severity (Good/Trace versus Concern/Problem/Extreme). The outcome variable was state board disciplinary action.

RESULTS

The alumni graduated between 1943 and 1989. Ninety-five percent of the disciplinary actions were for deficiencies in professionalism. The prevalence of Concern/Problem/Extreme excerpts in the cases was 38% and 19% in controls. Logistic regression analysis showed that disciplined physicians were more likely to have Concern/Problem/Extreme excerpts in their medical school file (odds ratio, 2.15; 95% confidence interval, 1.15-4.02; p =.02). The remaining variables were not associated with disciplinary action.

CONCLUSION

Problematic behavior in medical school is associated with subsequent disciplinary action by a state medical board. Professionalism is an essential competency that must be demonstrated for a student to graduate from medical school.

Sleep duration and body mass index in a rural population

BACKGROUND

A growing body of epidemiological evidence suggests an association between short sleep duration and obesity. Recently, potential hormonal links have been observed that may account for the relationship. The possible connection between sleep duration and body mass index (BMI) has not been explored in rural populations. Rural populations are of interest because obesity rates are high and lifestyle patterns of nutrition, physical activity, work hours, and sleep may differ from those in urban and suburban populations. We conducted this study to determine whether short sleep duration is related to BMI and obesity in a rural population in southeast Iowa.

METHODS

We conducted a cross-sectional analysis of data collected in the Keokuk County Rural Health Cohort Study, 1999-2004. Study participants were from a population-based sample consisting of 990 employed adults in a rural community in southeastern Iowa. The main outcome measure was BMI. Multiple linear regression modeling was used to adjust for potential confounding variables.

RESULTS

Self-reported sleep duration on weeknights was negatively correlated (beta = -0.42; 95% confidence interval, -0.77 to -0.07) with higher BMI after adjusting for sex, age, educational achievement, physical job demand, household income, depressive symptoms, marital status, alcohol consumption, and snoring.

CONCLUSION

These data support an association between short sleep duration and higher BMI in this rural population, which is consistent with the relationship found in other settings.

Characteristics Associated With Physician Discipline

BACKGROUND

There has been increasing attention devoted to patient safety. However, the focus has been on system improvements rather than individual physician performance issues. The purpose of this study was to determine if there is an association between certain physician characteristics and the likelihood of medical board-imposed discipline.

METHODS

Unmatched, case-control study of 890 physicians disciplined by the Medical Board of California between July 1, 1998, and June 30, 2001, compared with 2981 randomly selected, nondisciplined controls. Odds ratios (ORs) were calculated for physician discipline with respect to age, sex, board certification, international medical school education, and specialty.

RESULTS

Male sex (OR, 2.76; P<.001), lack of board certification (OR, 2.22; P<.001), increasing age (OR, 1.64; P<.001), and international medical school education (OR, 1.36; P<.001) were associated with an elevated risk for disciplinary action that included license revocation, practice suspension, probation, and public reprimand. The following specialties had an increased risk for discipline compared with internal medicine: family practice (OR, 1.68; P =.002); general practice (OR, 1.97, P =.001); obstetrics and gynecology (OR, 2.25; P<.001); and psychiatry (OR, 1.87; P<.001). Physicians in pediatrics (OR, 0.62; P =.001) and radiology (OR, 0.36; P<.001) were less likely to receive discipline compared with those in internal medicine.

CONCLUSION

Certain physician characteristics and medical specialties are associated with an increased likelihood of discipline.

Evidence-based public health: an evolving concept

Evidence-based public health (EBPH) has been proposed as a practice model that builds upon the success of evidence-based medicine (EBM). EBM has been described as a more scientific and systematic approach to the practice of medicine. It has enhanced medical training and practice in many settings. Both EBM and EBPH systematically use data, information, and scientific principles to enhance clinical care and population health, respectively. In this paper, we review the evolution of EBPH, propose a new definition for EBPH, and discuss developments that may support its further advancement.

Correlates of Mini-Mental Status Examination scores among elderly demented patients: the influence of race-ethnicity

Data on 1888 patients seen at Alzheimer's Disease Diagnostic and Treatment Centers in California were used to examine possible differences in Mini-Mental State Examination (MMSE) results for different racial-ethnic groups. White patients had scores less indicative of dementia than Black and Hispanic patients using the standard 23 cutting point on the MMSE. However, there were no differences among these groups in the percentages clinically diagnosed as demented. The difference in the percentage of Whites vs Blacks and Hispanics categorized as demented by the MMSE was not accounted for by education, occupation, age, sex, or other variables tested, even though these variables were correlated with MMSE scores. Our data suggest that clinicians should consider MMSE scores for Black and Hispanic patients an underestimate of their cognitive capabilities relative to that of White patients.

Smoking prevalence in Medicaid has been declining at a negligible rate

Background

In recent decades the overall smoking prevalence in the US has fallen steadily. This study examines whether the same trend is seen in the Medicaid population.

Methods and findings

National Health Interview Survey (NHIS) data from 17 consecutive annual surveys from 1997 to 2013 (combined N = 514,043) were used to compare smoking trends for 4 insurance groups: Medicaid, the Uninsured, Private Insurance, and Other Coverage. Rates of chronic disease and psychological distress were also compared.

Results

Adjusted smoking prevalence showed no detectable decline in the Medicaid population (from 33.8% in 1997 to 31.8% in 2013, trend test P = 0.13), while prevalence in the other insurance groups showed significant declines (38.6%-34.7% for the Uninsured, 21.3%-15.8% for Private Insurance, and 22.6%-16.8% for Other Coverage; all P’s<0.005). Among individuals who have ever smoked, Medicaid recipients were less likely to have quit (38.8%) than those in Private Insurance (62.3%) or Other Coverage (69.8%; both P’s<0.001). Smokers in Medicaid were more likely than those in Private Insurance and the Uninsured to have chronic disease (55.0% vs 37.3% and 32.4%, respectively; both P’s<0.01). Smokers in Medicaid were also more likely to experience severe psychological distress (16.2% for Medicaid vs 3.2% for Private Insurance and 7.6% for the Uninsured; both P’s<0.001).

Conclusions

The high and relatively unchanging smoking prevalence in the Medicaid population, low quit ratio, and high rates of chronic disease and severe psychological distress highlight the need to focus on this population. A targeted and sustained campaign to help Medicaid recipients quit smoking is urgently needed.

Put prevention into practice: a controlled evaluation

OBJECTIVES

The purpose of this study was to evaluate whether Put Prevention Into Practice (PPIP) materials affected the delivery of 8 clinical preventive services.

METHODS

Program materials were provided to a family medicine practice serving a diverse, low-income population. Appropriate use of clinical preventive services was assessed via medical record reviews at baseline, 6 months, 18 months, and 30 months at both intervention and control sites.

RESULTS

The delivery rates of 7 clinical preventive services were higher in the intervention site at 6 months. These rates had flattened or decreased by 30 months.

CONCLUSIONS

Use of PPIP materials modestly improved delivery of certain clinical preventive services. Sustained improvement will require substantial system changes and ongoing support.

Financial Incentives to Increase Advance Care Planning Among Medicaid Beneficiaries: Lessons Learned From Two Pragmatic Randomized Trials

CONTEXT

Medicaid populations have low rates of advance care planning (ACP). Potential policy interventions include financial incentives.

OBJECTIVE

To test the effectiveness of patient plus provider financial incentive compared with provider financial incentive alone for increasing ACP discussions among Medicaid patients.

METHODS

Between April 2014 and July 2015, we conducted two sequential assessor-blinded pragmatic randomized trials in a health plan that pays primary care providers (PCPs) $100 to discuss ACP: 1) a parallel cluster trial (provider-delivered patient incentive) and 2) an individual-level trial (mail-delivered patient incentive). Control and intervention arms included encouragement to complete ACP, instructions for using an online ACP tool, and (in the intervention arm) $50 for completing the online ACP tool and a small probability of $1000 (i.e., lottery) for discussing ACP with their PCP. The primary outcome was provider-reported ACP discussion within three months.

RESULTS

In the provider-delivered patient incentive study, 38 PCPs were randomized to the intervention (n = 18) or control (n = 20) and given 10 patient packets each to distribute. Using an intention-to-treat analysis, there were 27 of 180 ACP discussions (15%) in the intervention group and 5 of 200 (2.5%) in the control group (P = .0391). In the mail-delivered patient incentive study, there were 5 of 187 ACP discussions (2.7%) in the intervention group and 5 of 189 (2.6%) in the control group (P = .99).

CONCLUSION

ACP rates were low despite an existing provider financial incentive. Adding a provider-delivered patient financial incentive, but not a mail-delivered patient incentive, modestly increased ACP discussions. PCP encouragement combined with a patient incentive may be more powerful than either encouragement or incentive alone.

The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach Through Health Channels

INTRODUCTION

Little is known about how incentives may encourage low income smokers to call for quitline services. This study evaluates the impact of outreach through health channels on California Medicaid (Medi-Cal) quitline caller characteristics, trends, and reach.

STUDY DESIGN

Longitudinal study.

SETTING/PARTICIPANTS

Medi-Cal quitline callers.

INTERVENTION

Statewide outreach was conducted with health providers, Medi-Cal plans (all-household mailings with tracking codes), and public health organizations (March 2012-July 2015). For incentives, Medi-Cal callers could ask for a $20 gift card; in September 2013, callers were offered free nicotine patches.

MAIN OUTCOME MEASURES

Caller characteristics were compared with chi-square analyses, joinpoint analysis of call trends was performed accounting for Medi-Cal population growth, referral source among Medi-Cal and non-Medi-Cal callers was documented, and the annual percentage of the population reached who called the Helpline was calculated. Analyses were conducted 2016-2018.

RESULTS

Total Medi-Cal callers were 92,900, a 70% increase from prior annual averages: 12.4% asked for the financial incentive, 17.3% reported the mailing code, and 73.3% received nicotine patches while offered. Among the two thirds of callers who completed counseling, 15.5% asked for the financial incentive, and 13.6% reported the mailing code. A joinpoint analysis showed call trends increased 23% above expected for the Medi-Cal population growth after mailings to providers and members began, and decreased after outreach ended. Annual reach increased from 2.3% (95% CI=2.1, 2.6) in 2011 to peak at 4.5% (95% CI=3.6, 5.3) in 2014. Among subgroups with higher reach rates, some also had higher rates of asking for the financial incentive (African Americans, American Indian), reporting the tracking code (whites), or both (aged 45-64 years). Medi-Cal callers were more likely than non-Medi-Cal callers to report providers (32.3% vs 23.8%) and plans (19.7% vs 1.4%) as their referral source, and less likely to cite media (20.2% vs 44.4%, p<0.001).

CONCLUSIONS

Statewide outreach through health channels incentivizing Medi-Cal members increased the utilization and reach of quitline services.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

The Growing Proportion of Smokers in Medicaid and Implications for Public Policy

INTRODUCTION

This study examined survey data from before and after California expanded its Medicaid program under the Affordable Care Act. It assessed changes in the insurance status of smokers, the proportion of smokers in Medicaid, and the health and well-being of those smokers relative to their counterparts in other insurance groups.

METHODS

The study compared two data sets from the California Health Interview Study, the 2011-2012 (N=42,935) and 2016 (N=21,055) surveys. Measures include health insurance status, smoking status, chronic health conditions, frequency of doctors' visits, and psychological distress. Data were analyzed in 2018.

RESULTS

From 2011-2012 to 2016, the estimated number of California smokers in Medicaid nearly doubled from 738,113 to 1,447,945, and the proportion of smokers covered by Medicaid increased from 19.3% to 41.5%. Compared with those with private insurance, smokers in Medicaid were more likely to have chronic disease, have made five or more doctors' visits in the past year, and be in severe psychological distress. In 2016, a total of 51.4% of all adult smokers with chronic disease conditions and 57.8% of those in severe psychological distress were covered by Medicaid.

CONCLUSIONS

With Medicaid covering a much higher proportion of smokers, especially of those smokers with chronic disease and in psychological distress, state Medicaid programs and plans must make tobacco cessation a top priority. They should encourage clinicians to ask, advise, and assist all smokers, track progress in reducing smoking prevalence, employ mass communication strategies to drive quit attempts, improve access to medications, and develop or expand programs to help smokers quit.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Racial/Ethnic Differences in the Response to Incentives for Quitline Engagement

INTRODUCTION

Certain racial and ethnic minorities have lower utilization of tobacco cessation services, such as Helpline counseling and cessation medications. The goal of the California Medicaid (Medi-Cal) Incentives to Quit Smoking Program was to facilitate successful cessation by promoting modest financial and cessation medication-related incentives to increase engagement with the California Smokers' Helpline counseling services. Differences in the response to incentives and outreach on engagement with Helpline services among racial/ethnic groups within the Medi-Cal population were examined.

STUDY DESIGN

Analysis of Helpline caller data.

SETTING/PARTICIPANTS

African American (n=18,656); English-speaking Latinx (n=12,792); Spanish-speaking Latinx (n=3,254); and white (n=45,907) Medi-Cal callers.

INTERVENTION

The Medi-Cal Incentives to Quit Smoking team conducted statewide and community-based outreach and facilitated direct-to-member all-household mailings about the Medi-Cal Incentives to Quit Smoking program to engage with Medi-Cal callers and promote Helpline services between March 2012 and July 2015 (analyzed 2017/2018). Medi-Cal callers could ask for a $20 gift card incentive after having completed a counseling session; in September 2013, callers were offered free nicotine replacement therapy.

MAIN OUTCOME MEASURES

Three behavioral outcomes are reported that reflect activated callers and callers who engaged in treatment that is proven to improve chances of quitting smoking: receipt of the $20 incentive, receipt of nicotine replacement therapy, and receipt of counseling.

RESULTS

African Americans and English-speaking Latinx had higher engagement with the financial incentive than whites (African American APR=1.66, 95% CI=1.59, 1.73, English-speaking Latinx APR=1.29, 95% CI=1.22, 1.36). Spanish-speaking Latinx had lower initial engagement with the financial incentive (APR=0.75, 95% CI=0.66, 0.85), but higher engagement with Medi-Cal's all-household mailing (Spanish-speaking Latinx 30.6% vs whites 18.2%, p<0.001). Although African Americans and English-speaking Latinx had similar rates of completing counseling and receiving nicotine replacement therapy as whites, Spanish-speaking Latinx had higher rates than whites.

CONCLUSIONS

The promotion of modest financial and cessation medication incentives through multiple outreach channels increased callers' engagement with the Helpline and appeared to promote ethnic and linguistic equity with respect to the receipt of counseling and nicotine replacement therapy. Targeted community-based outreach may resonate particularly for African Americans, and language-concordant Medi-Cal insurance plan mailings may have reached newly covered Spanish-speaking Latinx.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Outreach to California Medicaid Smokers for Asian Language Quitline Services

INTRODUCTION

Asian male immigrants have high smoking rates. This article describes outreach approaches in the Medi-Cal Incentives to Quit Smoking project to incentivize California Medicaid (Medi-Cal) calls to the California Smokers' Helpline (Helpline) Asian-language lines.

METHODS

Outreach efforts adapted Medi-Cal Incentives to Quit Smoking materials for the Asian-language lines. Community-based efforts included outreach at ethnic supermarkets and distribution through community networks. Leveraging the Helpline's Asian print media campaign, three press releases promoted Medi-Cal Incentives to Quit Smoking with Lunar New Year or community physician messaging. Medi-Cal all-household mailings with tracking codes also included the Asian-language lines. Helpline caller characteristics and trends were examined for project period 2012-2015. Analyses were conducted in 2018.

RESULTS

Among 4,306 Asian American Pacific Islander Medi-Cal callers, there were 37% Asian-speaking Asian Americans (9.5% Chinese, 17.2% Vietnamese, and 10.5% Korean); 44% English-speaking Asian Americans; 9% Pacific Islanders; and 10% Asian American Pacific Islander not otherwise specified. Almost 10% of Asian-speaking Asian Americans were activated by the financial incentive and this was similar for all-household mailings, although this was lower than the other groups. Medi-Cal calls to the Asian-language lines increased, from an average of 18 calls/month to 47 calls/month (162% increase) in the first and last 12 project months respectively. Community outreach was limited by timing and sustainability. The 3-month call totals before and after the Asian-language press releases were significantly greater for Asian-speaking calls than for English-speaking calls (Cochran-Mantel-Haenszel p<0.001, OR=1.70, 95% CI=1.45, 1.99).

CONCLUSIONS

Whereas community outreach is challenging, promising population-based methods for in-language, culturally tailored outreach can include press releases with ethnic media and direct-to-member mailings.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Direct-to-Member Household or Targeted Mailings: Incentivizing Medicaid Calls for Quitline Services

INTRODUCTION

Innovative methods are needed to promote tobacco cessation services. The Medi-Cal Incentives to Quit Smoking project (2012-2015) promoted modest financial and medication incentives to encourage Medi-Cal smokers to utilize the California Smokers' Helpline (Helpline). This article describes the implementation and impact of two different direct-to-member mailing approaches.

METHODS

Medi-Cal Incentives to Quit Smoking promotional materials were mailed directly to members using two approaches: (1) household mailings: households identified through centralized membership divisions and (2) individually targeted mailings: smokers identified by medical codes from Medi-Cal managed care plans. Mailings included messaging on incentives, such as gift cards or nicotine patches. Number of calls per month, calls per unit mailed, and associated printing costs per call were compared during and 1 month after mailings. Activated caller response was based on reporting a household mailing promotional code or based on requesting financial incentives for individually targeted mailings. Analyses were conducted in 2018.

RESULTS

Direct-to-member mailings, particularly with incentive messaging, demonstrated an increase in call volumes during and 1 month after mailing, and increased Medi-Cal calls to the Helpline per unit mailed. Mailings with only counseling messages had the lowest percentage of activated calls per unit mailed, whereas the incentive messaging mailings were consistently higher. Although household mailings demonstrated lower printing costs per call, individually targeted mailings had a higher percentage of activated calls per unit mailed.

CONCLUSIONS

Household and individually targeted mailings are feasible approaches to increase Medi-Cal calls to the Helpline, particularly with incentive messaging. Choosing an approach and messaging depends on available resources, timing, and purpose.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Case management: a controlled evaluation of persons with diabetes

Case management has been widely used with the intent of improving clinical outcomes while reducing medical costs. Studies of case management, however, have shown variable effectiveness. This study assessed the impact of a state health department case management program on hospitalizations, emergency department (ED) visits, and preventive services among persons with diabetes receiving Medicaid fee-for-service health care. The patients enrolled in the non-disease-specific case management program were low-income, chronically ill and medically complex. Nurse case managers authorized and coordinated services in the home for these patients and established links to health-care professionals and community resources. A retrospective, non-randomized, controlled time series design using paid claims files was employed. Case management reduced admissions and hospital days but did not significantly impact ED visits or use of preventive services.

Implementing a Quality Improvement Collaborative to Improve Hypertension Control and Advance Million Hearts Among Low-Income Californians, 2014-2015

From January through December 2015, the California Department of Health Care Services, which administers Medi-Cal, the nation’s largest Medicaid program, conducted a quality improvement collaborative (QIC) with 9 Medi-Cal managed care plans (MCPs) aimed at improving hypertension control consistent with the Million Hearts initiative. The QIC included quarterly webinars and links to local, state, and national resources that consisted of materials and consultations with subject matter experts. Participating MCPs demonstrated an average increase of 5.0 percentage points in their rates of controlled hypertension. Collaboratives can achieve substantial quality improvement in Medicaid managed care plans.

Health Promotion Interventions for Low-Income Californians Through Medi-Cal Managed Care Plans, 2012

Introduction

Prevention is the most cost-effective approach to promote population health, yet little is known about the delivery of health promotion interventions in the nation’s largest Medicaid program, Medi-Cal. The purpose of this study was to inventory health promotion interventions delivered through Medi-Cal Managed Care Plans; identify attributes of the interventions that plans judged to have the greatest impact on their members; and determine the extent to which the plans refer members to community assistance programs and sponsor health-promoting community activities.

Methods

The lead health educator from each managed care plan was asked to complete a 190-item online survey in January 2013; 20 of 21 managed care plans responded. Survey data on the health promotion interventions with the greatest impact were grouped according to intervention attributes and measures of effectiveness; quantitative data were analyzed using descriptive statistics.

Results

Health promotion interventions judged to have the greatest impact on Medi-Cal members were delivered in various ways; educational materials, one-on-one education, and group classes were delivered most frequently. Behavior change, knowledge gain, and improved disease management were cited most often as measures of effectiveness. Across all interventions, median educational hours were limited (2.4 h), and median Medi-Cal member participation was low (265 members per intervention). Most interventions with greatest impact (120 of 137 [88%]) focused on tertiary prevention. There were mixed results in referring members to community assistance programs and investing in community activities.

Conclusion

Managed care plans have many opportunities to more effectively deliver health promotion interventions. Establishing measurable, evidence-based, consensus standards for such programs could facilitate improved delivery of these services.

Referral outcomes from a community-based preventive health care program for elderly people

The purpose of this study was to determine referral outcomes in a community-based, preventive health program for low-income elderly people in California. We examined the records of 2,750 clients who participated in a complete screening exam and who accepted at least one referral. Twenty-four percent of the participants had received a new diagnosis, a new medication, a change in medication dose, a biopsy, or surgery. These results are encouraging for screening clinics focused on low-income seniors.

Risk factors for the development of osteoarthrosis of the knee

The roles of physical activity (both work and leisure time), obesity, and history of significant knee injury on the development of severe osteoarthrosis (OA) of the knee were evaluated. A case-control design compared 46 cases with a history of severe OA of the knee with 46 community controls matched for age and gender. Data were gathered with a self-administered questionnaire. The OA cases were 3.5 times more likely than controls to have been obese at 20 years of age, two to three times more likely than controls to have performed heavy work, and almost five times more likely than controls to have had a significant knee injury. In contrast, leisure-time physical activity was not significantly different in cases compared with controls. Obesity, significant knee injury, and long-term heavy physical activity are important risk factors for the development of OA of the knee.

Estimating the costs of caring for people with Alzheimer disease in California: 2000-2040

The costs of caring for people with Alzheimer disease (AD) in California are estimated using data from a study of the costs of caring for community-resident and institutionalized people with AD, combined will prevalence and population projections. Costs for community-resident patients will increase 83 percent in the period 2000 ($23.4 billion) to 2020 ($42.8 billion), and will grow an additional 59 percent from 2020 to 2040 ($68.1 billion). Costs for AD patients in institutions will increase 84 percent from 2000 ($2.5 billion) to 2020 ($4.6 billion), and will grow an additional 61 percent from 2020 to 2040 ($7.4 billion), assuming the supply of nursing home beds meets projected demand. Total costs of caring for AD patients will nearly triple between 2000 and 2040. The rapid aging of the U.S. population makes more aggressive societal action necessary if the personal and societal burden of Alzheimer's disease is to be reduced in the future.

A Quality Strategy to Advance the Triple Aim in California's Medicaid Program

The California Department of Health Care Services (DHCS) administers the nation's largest Medicaid program. In 2012, DHCS developed a Quality Strategy modeled after the National Quality Strategy to guide the Department's activities aimed at advancing the Triple Aim. The Triple Aim seeks to improve the patient experience of care and the health of populations as well as reduce the per capita cost of health care. An academic team was contracted to assist DHCS in developing the strategy, which also was informed by extensive stakeholder input, an advisory committee, and a comprehensive inventory of DHCS quality improvement (QI) activities. From 2012 to 2018, the strategy included 129 unique QI activities. Most activities were intended to deliver more effective, efficient, affordable care or to advance disease prevention. This qualitative assessment of the DHCS Quality Strategy provides insights that may inform other Medicaid programs or large health systems as they develop quality strategies.