Innovations in care management processes have improved the care of patients with chronic illnesses, but many patients still do not receive these benefits. The authors have studied the barriers and facilitators to implementing these improvements in leading US physician practices

About 125 million of the 276 million people living in the United States have some type of chronic illness (table 1).1 Four chronic conditions affect nearly half of Americans with a chronic disease: asthma, depression, and diabetes each affect about 15 million,2^–4 while five million have congestive heart failure.5 In 1999 these four chronic diseases were directly responsible for 140 000 deaths in the United States6 and generated at least $173bn (£108bn, €170bn) in medical and other costs. 5 7^–9

Over the past decade the effectiveness of care for patients with these and other major chronic illnesses has been improved by innovations in care management processes such as the use of guidelines, disease management techniques, case management, and patient education to improve self management of chronic disease.10 However, many patients are not benefiting from these advances. Recent studies indicate that fewer than half of US patients with asthma, depression, and diabetes receive appropriate treatment.11^–13 Organisational characteristics of physician practices associated with effective chronic disease care include the use of patient care teams, supportive information systems, and a high volume of patients.14 Hence, we expect that in the United States moderate and large sized, well organised, multispecialty practices are likely to offer chronic disease care that is as good as it gets and provide other physician organisations with benchmarks against which performance can be measured.