Understanding the effects of generalized and HIT-supported quality improvement initiatives on health care disparities is important given the pervasiveness of disparities and nationwide efforts to promote the adoption of HIT, and this study provides several key insights. First, the implementation of a generalized, HIT-supported, and provider-directed quality improvement initiative was associated with the narrowing of disparities for two of the seven measures with baseline disparities. Even when baseline disparities persisted, in general, the quality of care improved for both groups. Importantly, for measures with no disparities at baseline, the direction of the change in quality following the implementation of the quality improvement initiative was the same for black and white patients in most cases, and there were few new disparities.
Second, the changes in quality following the implementation of the quality improvement initiative tended to differ for intermediate outcome measures compared to process of care and preventive care measures. Quality improved for black and white patients for five of eight process of care measures, four of five preventive care measures, but none of the four intermediate outcome measures. In addition, the improvements in quality tended to be smaller for intermediate outcome measures compared to process of care and preventive care measures. Furthermore, it is notable that two of the three measures for which disparities widened were intermediate measures of disease control: glycemic control and LDL control for patients with diabetes. In both cases, the percentage of patients satisfying the measure improved for white patients only, resulting in a new, albeit small disparity.
Taken together, these findings suggest that generalized and provider-directed HIT tools are likely to have some positive effects on health disparities, particularly for chronic disease process of care measures and preventive care measures. However, in order to achieve more substantial improvements in health care equity, particularly in regards to important measures of disease control, additional strategies, such as tools to improve patient engagement,23,24
and access to care10,20
as well as systems-oriented strategies to improve care delivery will still be needed.
The breast cancer screening measure is the only one for which there was a decline in quality, making it an anomalous case that merits discussion. At approximately the same time that the UPQUAL initiative began, we began to have very long delays (more than 6 months) in scheduling screening mammograms at our institution due to a regional shortage of trained radiologists. Despite efforts to refer women to other sites for mammography, there was a decline in the proportion of white and black women who were up to date on breast cancer screening.
This study has several important limitations. As a single institution study, the results may not be generalizable to other types of settings. We only examined differences between white and black patients, and we used a simple measure of comorbidity with no adjustment for severity of illness to explore differences in patient characteristics by race. We did not adjust our threshold for statistical significance for multiple comparisons. However, as most of the p-values for statistically significant results were <0.001, we do not believe this would have affected our results significantly. In some cases, adherence to quality measures was very high at baseline, particularly for white patients; therefore, the narrowing of disparities for some measures could have been due in part to a ceiling effect (e.g., the rate of improvement was lower for white compared to black patients because white patients had less room for improvement). Furthermore, while we have demonstrated that changes in disparities followed the implementation of the quality improvement initiative, we cannot prove causality because of the quasi-experimental study design. However, we believe that a causal link is likely for several reasons. First, although black and white patients differed in some characteristics at baseline, the changes in key characteristics were similar for black and white patients over the study period. Therefore, we do not believe that changes in patient population over time contributed significantly to the observed changes in disparities. Second, no other major quality improvement initiatives (e.g., pay-for-performance incentives, changes in care team structure) were going on during the study period. Finally, the improvements in quality observed during the study period were greater than those expected based on temporal trends for most measures.21
Nonetheless, this study has several strengths and provides important evidence regarding the effects of HIT-supported quality improvement initiatives on disparities in ambulatory care. This study evaluated a very common form of quality improvement—clinical decision support and provider feedback—delivered via a commercially available and widely used EHR system that aimed to improve a range of ambulatory quality indicators. Thus, the findings should be relevant to a wide range of practices with comprehensive EHRs. Overall, we demonstrated that generalized and provider-directed quality improvement efforts can lead to reductions in disparities across several areas of preventive and chronic disease care, but will not be sufficient for achieving health care equity. Efforts focusing on other levels of the health care system (e.g., patients, heath care organizations, and payment/regulatory systems) and efforts focusing specifically on disparity reduction will still be needed. Moreover, we demonstrated that we do not need to wait until all the challenges surrounding the collection of patients’ racial/ethnic data are resolved and the full implementation of “meaningful use” is completed in order to make meaningful steps towards advancing health care equity.27