# Presentation: 114554

## Implementing Quality Improvement to Reduce Disparities: The Case of the Health Disparities Collaboratives

- Marshall H. Chin, MD, MPH                        Associate Professor of Medicine
- University of Chicago
- Director, RWJF Finding Answers:
- Disparities Research for Change
- National Program Office

## Goals

- Describe Health Disparities Collaboratives (HDC)
- Review impact on quality of care
- Analyze financial ramifications
- Outline factors important for organizational change
-  List summary conclusions
- Discuss future research recommendations

## RWJF Finding Answers:Systematic Review of Interventions to Reduce Racial and Ethnic Disparities

- Medical Care Research and Review 10/07 supplem
- Intro, Cardiovascular, Depression, Diabetes, Breast cancer, Culture, Pay-for-Performance
- _[www.SolvingDisparities.org](http://www.solvingdisparities.org/)_	Articles and Searchable database of 200 interv.

## RWJF Finding Answers:Disparities Research for ChangeLessons from Systematic Reviews

- Multifactorial interventions that target multiple levers of change
- Culturally tailored quality improvement
- Nurse-led interventions in context of wider systems change

## Community Health Centers

- 5000 sites
- 16 million patients
- 40% uninsured
- 64% minority populationNational Association of Community Health Centers, 2006

## Health Disparities Collaboratives:A Quality Improvement Collaborative

- National effort in > 1000 health centers beginning in 1998_3 Components_
- CQI: Rapid Plan-Do-Study-Act cycles
- Chronic Care Model
- Learning sessions

## Plan-Do-Study-Act Cycles (PDSA)

- Associates in Learning / Institute for Healthcare Improvement

**Notes:**
PDSA:
uses elements of CQI to implement rapid change – developing interventions, implement them on a small scale, and continually revising them

YEAR 2:
Sustaining and spreading QI processes to other chronic diseases

Notes for questions at end of presentation:
Once the area of change is defined
Plan – devise a plan to make this change
Do – implement the action on a small level – say with one provider
Study – Analyze the effectiveness of the intervention
Act – based on the findings, revise the intervention

## MacColl Institute Chronic Care Model

**Informed,**
**Activated**
**Patient**

**Productive**
**Interactions**

**Prepared,**
**Proactive**
**Practice Team**

**Functional and Clinical Outcomes**

**Delivery****System**
**Design**

**Decision**
** ****Support**** **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community**** **

**Health Care Organization**

**MacColl Institute Chronic Care Model**

## Breakthrough Series

- Commitment of CEO
- HDC QI team in each of health center
- 4 regional learning sessions
- Cluster coordinator support
- Monthly telephone conference calls
- Monthly written progress reports
- Computer listserver

## Organizational Schema of Intervention

-   CollaborativeTeamCenter

- 15-20 HCs / Trainers

-    HDC QI Team

- Providers & Patients at HC

## Methods

- Systematic review of literature
- Focus on key studies in this presentation

## Results: Participants’ Perceptions of Outcomes

- HDC is a success and worth effort	> 80%
- Improved patient outcomes		88%
- Improved processes of care		83%
- Improved patient satisfaction		71%
- Qualitative interviews			Similar
- Chin et al.; Chin et al. Diabetes Care 2004; 27:2-8.

## Short-Term Clinical (1-2 years):Diabetes

- Random chart review
- Pre-post improvement in 7 diabetes processes of care
- No improvement in intermediary outcomesChin et al. Diabetes Care. 2004.

## Short-term Clinical:Asthma, Diabetes, Hypertension

- Pre-post controlled (1 yr pre and 1 yr post)
- Improvements in processes of care for asthma and diabetes
- Asthma – Rx anti-inflam med 14%
- Diabetes – HbA1c measurement 16%
- No improvement in intermediary outcomes
- Landon et al.  NEJM 2007; 356:921-934.

## Long-term Clinical (2-4 years):Processes of Care (%)

| Process of Care | 1998  | 2000 | 2002 |
| --- | --- | --- | --- |
| At least 1 A1c  | 71 | 88 | 92  |
| Lipid assessment | 52 | 65 | 70  |
| Aspirin | 22 | 37 | 41 |
| ACE inhibitor | 33 | 42 | 50 |

- Chin et al.  Medical Care.  In press.

## Long-term Clinical:Outcomes

| Outcome | 1998  | 2000 | 2002 |
| --- | --- | --- | --- |
| HbA1c (%) | 8.6 | 8.5 | 7.9 |
| LDL (mg/dl) | 127 | 116 | 108 |
| Systolic BP (mm Hg) | 133 | 135 | 133 |
| Diastolic BP (mm Hg) | 79 | 80 | 78 |

- Chin et al.  Medical Care.  In press.

## Societal Cost-Effectiveness Analysis:  Diabetes

- Incorporate clinical results into a NIH simulation model of diabetes complications
- Simulation model needed to translate changes in processes and risk factor levels into complicationsHuang et al. HSR 2007 (OnlineEarly Articles).

## Base Case Results

|  | Program 1: Without HDC  | Program 2: 
With HDC |
| --- | --- | --- |
| Blindness,% | 17 | 15 |
| ESRD,% | 18 | 15 |
| Amputation,% | 20 | 20 |
| CHD,%  | 28 | 24 |
| Quality-adjusted life years, mean | 10.58 | 10.93 |
| Lifetime costs, mean | $90,085 | $101,770 |

- ICER = $33,386/QALY

## Business Case:  Case Study of 5 Health Centers with Diabetes

- Huang ES, et al. The cost consequences of improving diabetes care: the community health center experience.  *Joint Commission Journal on Quality and Patient Safety.  *In press.
- Brown SES, et al. Estimating the costs of quality improvement for outpatient health care organizations: a practical methodology.  Quality and Safety in Health Care. 2007; 16 (4): 248-251.** **

## Slide 20

## Business Case Study Results

- Additional admin cost = $6-$22 per patient  (Year 1)
- No regular source of revenue for these costs
- Balance of diabetes clinical costs/revenues did not clearly improve
- QI programs represent a new cost
- Many non-quantifiable benefits

## CEO Cost Survey

- Majority reported increased costs
- Costs per patient  72%
- Overall health center costs  73%
- Majority reported no change in funding
- Reimbursement for patient care  75%
- Funding from government agencies  73%
- Funding from private foundations  75%
- Divided over overall effect
- Worsened finances  38%
- No change  48%
- Improved finances  14%
- Huang et al. HSR 2007.

## Organizational Change and Implementation

- Common barriers
- Lack of resources
- Lack of time
- Staff burnoutChin et al.

## Wish List fromBureau of Primary Health Care

| Percentage Ranked #1 |  |
| --- | --- |
| Direct patient care services | 44 |
| Data entry activities | 34 |
| Staff time spent on quality improvement | 26 |
| Training in quality improvement techniques | 20 |
| Information system technical support | 18 |

## Additional Support

- Help patients with self-management		73%
- Information systems				77%
- Get providers to follow guidelines		64%

## Predictors of Staff Morale and Burnout

-  Low cost
- Personal recognition
- Career promotion
- Skills development
- Fair distribution of work
- More expensive – Funding, personnelGraber et al.

## Unintended Consequences

- Quality of care of chronic conditions not emphasized by HDC increased		45%
- HDC has drawn time, energy, resources away from other health center activities		61%
- Chien et al.

## Summary Conclusions

- HDC improve clinical processes of care over short-term 1-2 year time periods and improve both processes of care and outcomes over longer 2-4 year periods.

## Conclusions 2

- Diabetes Collaborative is societally cost-effective, but there are no consistent financial streams for individual centers, raising concerns about the whether there is a business case for CEOs to adopt and sustain the HDC over the longterm.

## Conclusions 3

- Some methods to enhance implementation of the HDC are low-cost and reasonably feasible.
- Some methods to enhance implementation of the HDC will require more resources and work.

## Non-Community Health Center Settings

- _Pros_
- Payor mix
- Possibly integrated delivery system
- _Cons_
- Size
- Culture

## Key Research Questions

- How to tailor implementation of the HDC to different HCs that may be at different stages of organizational readiness to change and that may have different strengths, weaknesses, organizational contexts, and patient populations?

## Research Questions 2

- How to create a viable long-term business case for the HDC to complement the analysis demonstrating that the Diabetes Collaborative is societally cost-effective?

## Research Questions 3

- How to successfully spread the HDC across multiple diseases, conditions, and processes?
- How to sustain the HDC over time?
- How to integrate the general QI process of the HDC with menus of specific model programs?

## Funding

- AHRQ R01 HS 10479
- AHRQ/HRSA U01 HS13635
- NIA 1K23 AG021963
- NIH/NIDDK P60 DK20595 Diabetes Research & Training Center
- NIDDK K24 DK071933
- RWJF Generalist Physician Faculty Scholar