|Home | About | Journals | Submit | Contact Us | Français|
The Health Disparities Collaboratives (HDC), a quality improvement collaborative incorporating rapid quality improvement (QI), a chronic care model, and learning sessions, have been implemented in over 900 community health centers across the country.
To determine the HDC’s effect on clinical processes and outcomes, their financial impact, and factors important for successful implementation.
Systematic review of the literature.
The HDC improve clinical processes of care over short-term 1–2 year periods, and clinical processes and outcomes over longer 2–4 year periods. Most participants perceive that the HDC are successful and worth the effort. Analysis of the Diabetes Collaborative reveals that it is societally cost-effective with an incremental cost-effectiveness ratio of $33,386/quality-adjusted life year (QALY), but that consistent revenue streams for the initiative do not exist. Common barriers to improvement include lack of resources, time, and staff burnout. Highest ranked priorities for more funding are money for direct patient services, data entry, and staff time for QI. Other common requests for more assistance are help with patient self-management, information systems, and getting providers to follow guidelines. Relatively low-cost ways to increase staff morale and prevent burnout include personal recognition, skills development opportunities, and fair distribution of work.
The HDC have successfully improved quality of care and the Diabetes Collaborative is societally cost-effective, but policy reforms are necessary to create a sustainable business case for these health centers that serve many uninsured and underinsured populations.
Quality improvement implementation is challenging under the best of circumstances, and efforts to reduce racial and socioeconomic disparities in health care with QI techniques have additional barriers to hurdle. Many minority patients and patients of lower socioeconomic status receive their care in settings that have limited resources. In addition, vulnerable populations have a variety of economic, educational, and social difficulties that make it harder for them to improve self-management of chronic illnesses. While equity is one of the six fundamental domains of the Institute of Medicine’s definition of quality,1 it has generally received less attention compared with other elements such as effectiveness.2 Moreover, in the health disparities field,3 most of the existing literature documents disparities but a much smaller body of work seeks to develop and evaluate interventions to reduce these disparities.4
Community health centers (HCs) are vanguard providers of health care for vulnerable populations,5, 6 serving 16 million Americans in 5000 sites.7 Forty percent of HC patients are uninsured, 36% have Medicaid coverage, over 60% are racial or ethnic minorities, and 71% are at or below the federal poverty line.8 Nationally, HCs serve 1 out of every 4 people in poverty, 1 out of 10 minorities, and 1 out of 9 rural Americans. HCs are truly a critical provider of health care to underserved populations and a vital part of efforts to reduce national disparities in care.
Therefore, the Health Disparities Collaboratives,9 a massive state-of-the-art effort by the Health Resources and Services Administration’s Bureau of Primary Health Care (HRSA’s BPHC) to improve the quality of care in community health centers across the country, are an important case example to study for using quality improvement techniques to decrease disparities. As of December 2007, 915 HCs have participated in the HDC [personal communication: Charles Daly, Health Resources and Services Administration, December 10, 2007]. In this paper, I describe the HDC and then review the evidence for their impact on quality of care, the financial ramifications for society and the individual HC, and factors important for organizational change at the HCs. I end with summary conclusions and recommendations for future research questions.
In the 1990s, it became known that the quality of care in health centers for conditions such as diabetes was similar to other settings such as private doctors’ offices, academic medical centers, and managed care organizations but still needed to be improved.10, 11 In addition, wide variation in the quality of care was apparent across centers, with some centers performing extremely well and some poorly.10 The 1990s also saw the rise of the MacColl Chronic Care Model as one of the most popular paradigms for approaching chronic disease management,12 and increasing interest in quality improvement collaboratives to improve care across multiple organizations.13, 14 In the QI collaborative model, different organizations learn QI techniques in joint learning sessions, and then share best practices over the ensuing year or longer to leverage and multiply the learning.15 Before-after studies of the QI collaborative model were promising although a controlled trial of HIV care was largely negative.16, 17 HRSA’s BPHC decided to adopt and implement the QI collaborative model in 1998 in an initiative they called the HDC. The HDC have three main components that have been in described in more detail elsewhere: Model for Improvement, MacColl Chronic Care Model, Learning Sessions / Support.18, 19
Each HC creates a HDC team that works to improve the quality of care of the target condition with the support of senior administrative leadership. A critical component is the creation of a patient registry to help track clinical care. Initially a difficult task for many HCs, the BPHC eventually offered standard patient registry software. A Model for Improvement developed by Associates in Learning based upon the Plan, Do, Study, Act (PDSA) cycle was introduced into each HC.20 This Model takes the standard PDSA cycle from continuous quality improvement and emphasizes the goal of rapid cycle improvement – testing an intervention on a small group of patients to allow assessment and then revision of the intervention.
The HDC use the MacColl Chronic Care Model, which aims to create practical, supportive interactions between an informed, activated patient and a proactive, prepared clinical team.12 The Chronic Care Model’s domains become the targets for the rapid PDSA cycles: patient self-management, delivery system redesign, decision support, clinical information systems, leadership and health system organization, and community outreach.
The Model for Improvement and Chronic Care Model are embedded within regional and national support structures provided by the BPHC. At learning sessions, team members and administrators from groups of 15–20 health centers learn QI techniques and share lessons among themselves, hence the collaborative nature of this QI process. Regional cluster coordinators provide additional assistance through telephone conference calls, a computer listserv, feedback on required monthly progress reports, patient registry and information systems support, and regional meetings. The first year of a given Collaborative involves four regional or national meetings and monthly followup. Subsequent years of participation generally include one regional meeting and quarterly reports to the BPHC. The BPHC paid travel expenses of participants attending the learning sessions. BPHC is currently transitioning HDC infrastructural support from the regions to state Primary Care Associations.
The author systematically reviewed PubMed for articles on the HDC using the key words “Health Disparities Collaborative”, “quality improvement”, “disparities”, and “collaboratives”. He also searched the reference lists of the websites of the Health Disparities Collaboratives and National Association of Community Health Centers (NACHC), and spoke to key informants at BPHC, NACHC, and the research community to ensure that the search was complete.
HC personnel spent considerable time working on the HDC. Team leaders worked nearly 11 hours per week on the HDC, team members 8 hours, chief executive officers 3 hours, and physicians 5 hours.21 Most participants found the Chronic Care Model and PDSA system to be useful, although many used the PDSA system qualitatively rather than quantitatively.18 They would try an intervention in a small number of patients and get a sense of whether it was working or not rather than performing a formal quantitative analysis of the intervention. On average, teams implemented 44 QI activities between 2000–2002. The most common areas of interventions were patient registries and community linkages for patients.22 Implementation of the elements of the Chronic Care Model was reasonably good as measured by the Assessment of Chronic Illness Care (ACIC) survey.23 ACIC scores ranged from 6.7 to 8.1 for target areas in the Chronic Care Model, where 0 is worst and 11 is best.19
Survey and interview studies indicate that HDC participants generally perceive that the HDC have improved outcomes.18 Over 90% of surveyed Diabetes Collaborative participants believe that the collaborative has been a success and worth the effort.18 Qualitative interviews of team leaders and team members are consistent with these survey results; most interviewees were very proud of their accomplishments.18
Two general types of studies are in the literature: evaluations using the existing patient registry data and those employing chart review of randomly selected patients. Most studies assess short-term (1–2 years) processes and outcomes while fewer examine long-term (4-year) results. Patient registry studies highlight the de facto “population of focus.” HDC participants are taught to initially focus on a small group of patients (e.g. – patients of one provider) rather than the entire center’s patients. After initial experience with the population of focus, the center is supposed to spread the initiative to other patients and providers in the center. The major criticisms of patient registry studies are that who is in the registry and when they enter the registry are not random processes and possibly biases towards positive results. In addition, over time the ultimate goal of the HDC is to improve the care of all patients in the center. Therefore, several recent studies utilize random chart reviews as their assessment tool.18, 19, 24
A pre-post study of the first year of the Diabetes Collaborative in the Midwest region showed improvements in seven processes of care but no intermediary processes.18 For example, rates of performing the hemoglobian A1c test increased but actual hemoglobin A1c value did not improve. A controlled pre-post (1 year pre and 1 year post) national study of the Asthma, Diabetes, and Hypertension Collaboratives showed improvements in processes of care for asthma and diabetes, but no improvements in intermediary outcome measures.24
A four year pre-post study of the Diabetes Collaborative in Midwestern and West Central states showed improvement in 11 processes of care and lowering of hemoglobin A1c and LDL cholesterol values.19 A randomized controlled trial comparing the standard HDC to the HDC plus additional organizational support, training of providers in communication and facilitation of patient behavioral change, and videos and brochures that empowered patients to become more actively involved in their care showed marginal benefit to the more intensive intervention, but the standard HDC appeared to account for the majority of the improvements in quality of care seen over time.19
Societal cost-effectiveness analysis of the Diabetes Collaborative using a NIH computer simulation model and outcomes data from the HDC showed that the Diabetes Collaborative is societally cost-effective with an incremental cost-effectiveness ratio (ICER) of $33,386/ quality-adjusted life year (QALY), with ICERs remaining below $100,000/QALY across a variety of sensitivity analyses regarding secular trends, clinical outcomes, and program costs (Table 2).27 The NIH simulation model incorporates epidemiological data from population-based studies and clinical trials and calculates the health effects and costs of interventions to improve risk factor control and the quality of diabetes care.28, 29 Increased use of angiotensin-converting enzyme inhibitors was the most powerful driver of the cost-effectiveness ($23,653/QALY), with glucose control ($104,811/QALY), aspirin use ($151,767/QALY), and cholesterol control ($416,850/QALY) contributing less strongly.
The business case financial analysis from the perspective of the CEO was investigated in a case study of five Midwestern health centers examining administrative and clinical costs, as well as changes in payor mix.30, 31 HDC administrative costs/year ranged from $6.41-$21.93 per patient. The balance of diabetes clinical costs and revenues was variable; the balance of costs and revenues did not clearly improve. In addition, the payor mix of diabetes patients, that is the relative proportions of uninsured, poorly insured, and well insured patients, did not improve either. Overall the HDC introduced new costs without new revenues. However, the HDC program for this Diabetes Collaborative example was a small percentage of the overall HC budget, ranging from 1.9% to 8.2%
In a survey of 74 CEOs participating in the Diabetes Collaborative, most thought that the HDC increased patient costs and overall health center costs without changing reimbursement or government or private foundation funding.30 A related analysis of 100 CEOs engaging in any Health Disparities Collaborative found that one-third, especially those leading centers with a higher proportion of uninsured patients, believed that the HDC had a negative financial impact on their health center.32
In a detailed analysis of interventions recorded in monthly reports, Grossman et al. were unable to determine which interventions within the Chronic Care Model are correlated with improvements in quality of care and outcomes.22 Common barriers to improvement included lack of resources, time, and staff burnout.21, 33 When asked to rank their number priority for more funding, HDC participants listed money for direct patient resources (44%), data entry (34%), and staff time for QI (26%). They also requested more assistance with patient self-management (73%), information systems (77%), and getting providers to follow guidelines (64%).21 Insurance type was associated with the quality of diabetes care within health centers. Patients with no insurance or Medicaid insurance tended to have lower quality of care than patients with private insurance.34 In a case study of six health centers in North Carolina participating in the Diabetes Collaborative, staff indicated that shared problem solving and peer learning among HDC teams greatly aided implementation of patient registries.33
Graber et al. examined predictors of staff morale and burnout.35 Some of the predictors were relatively low-cost and modifiable such as receiving personal recognition, career promotion, skills development opportunities, fair distribution of work, effective training of new hires, and regular provider participation. More expensive predictors included sufficient funding and personal.
The Health Disparities Collaboratives provide an important case example for efforts to use quality improvement techniques to reduce racial, ethnic, and socioeconomic disparities in care. HCs serve predominantly vulnerable patients, and thus the primary focus of the HDC has been improving the quality of care and outcomes of all patients they serve rather than reducing intra-center variation in care across different subgroups. In addition, most HDC studies do not use controls external to the health center setting because it is frequently difficult to find a feasible comparison group comparable to federally qualified health centers. Several conclusions can be drawn from this systematic review of the literature:
Several important research questions remain and include:
The HDC are one of the boldest efforts to improve quality of care and reduce disparities for vulnerable populations. The HDC are also the largest example of implementation of the QI collaborative approach. The HDC demonstrate that such approaches can be successful, but that thoughtful policy and managerial initiatives will be necessary to complement clinical leadership for longterm viability.38
Grant Support: This project was supported by the National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Research and Training Center (P60 DK20595). Dr. Chin is supported by a Midcareer Investigator Award in Patient-Oriented Research from the National Institute of Diabetes and Digestive and Kidney Diseases (K24 DK071933).