After the creation of a collaborative improvement network, standardization of care, and the application of evidenced-based changes to improve chronic illness care, we observed improvements in specific care processes and an increase in the proportion of CD and UC patients in remission, as well as an increase in the percentage of CD patients not taking corticosteroids.
This project extends the findings of other investigators that redesigning specific elements of chronic care delivery leads to improvements in the quality and outcomes of care. For example, in 32 of 39 studies in a systematic review of diabetes care programs, interventions based on components of the Chronic Care Model improved at least 1 process or outcome measure for diabetic patients,23
although there was often a delay in seeing improvements in clinical outcomes.38
Other studies and reviews suggest that implementing more changes results in more improvement.39–42
Most of this work has taken place in adult primary care practices. Here, we demonstrated its relevance to pediatric subspecialty care.
There is mounting evidence that the use of collaborative improvement networks can improve patients’ outcomes. To date, much of the evidence comes from hospital-based networks.16–19
Primary care networks have demonstrated modest improvements in outcomes for patients with chronic illness.43
Our results provide an estimate of the magnitude of improvements in outcomes that may take place when there is particular emphasis on more consistent and reliable application of existing therapies.18,19,44
Our study has several potential limitations. First, the PGA of disease activity is a relatively subjective measure, which could result in misclassification error. It is unlikely that physicians systematically underestimated illness severity because accurate disease assessment was essential for efficient population management processes. Thus, any misclassification was likely stable over time. Second, we cannot determine if changes in some process measures simply reflected improved documentation. However, accurate documentation is essential to improve the chronic illness care processes. For example, without accurate information about drug doses, previsit planning and population management are difficult to accomplish. Third, improvements in outcome occurring over time could have taken place independent of changes in care delivery as part of the network. No external comparator group was available to help with this determination. However, not all centers showed improvement, and the improvement we observed took place over a relatively short period of time during which no new therapies were introduced into routine clinical practice. Finally, the processes we measured may not be directly responsible for the observed improvement in remission. Rather, as hypothesized by the Chronic Illness Care Model,22–26
these measures are tracers that indicate improvements in the overall systems of care delivery.
As anticipated, improvements did not occur equally across measures or across centers. Three centers were unable to participate fully in the network, demonstrating that a significant investment of time and resources is required simply to participate. Of those centers that were included, some began with high performance on specific measures and maintained that level of care, while others started at lower levels of process reliability and either improved or remained relatively stable. Such variation in the success of the center-based QI efforts likely reflects differences in the degree of implementation of the interventions or the impact of other contextual factors, such as focused leadership and availability of resources to support QI (eg, training, staff devoted to the effort, and allocated physician time).33,45–59
As the network has matured, we have increased the availability of focused coaching to centers which are not demonstrating improved performance to address issues of training, implementation, and leadership. A better understanding of these factors will allow more effective application of QI methods and, thereby, potentially even greater improvements in outcomes.
Similarly, improvements did not occur equally across measures. While improvements were noted in many process and outcome measures, there was not consistent improvement in anthropometrics. This lack of improvement could be attributed to several potential explanations, including (1) a lag period between improvement in remission rates and subsequently growth and nutrition parameters, (2) the fact that improvement occurred most prominently in those with mild disease and, therefore, with fewer growth issues at baseline, and (3) baseline z-scores were near or above 0, leaving little room for improvement.