Patient Safety and Quality

Efforts to improve chronic disease management quality yield better care delivery but not better intermediate outcomes

A national series of interventions designed to improve the quality of care in health centers for three prevalent chronic conditions has improved processes of care for these conditions but did not improve intermediate clinical outcomes, according to results of a study collaboratively supported by the Agency for Healthcare Research and Quality (HS13653), the Health Resources and Services Administration (HRSA), and the Commonwealth Fund.

The study focused on the principal quality improvement efforts adopted by HRSA for 1,000 health centers nationally, the Health Disparities Collaboratives. The Health Center Program, administered by HRSA, supports high-quality, comprehensive, and community-oriented primary care delivery systems serving low-income residents in inner cities and in rural and isolated areas. The collaborative improvement interventions focused on diabetes, asthma, and hypertension, which together affect more than 25 percent of the U.S. adult population. Health centers provide care for more than 14 million Americans, many of whom are uninsured, underinsured, or are members of immigrant or minority groups.

The interventions teach health center personnel quality improvement methods to measure quality performance and continuously implement and refine small-scale changes that collectively result in improvements in the processes of care. Typically, quality improvement efforts target both processes, such as use of certain tests or medications, which in turn will lead to improvements in intermediate outcomes, such as control of high blood pressure. Improvements in outcomes are more difficult to achieve because of factors that may lie beyond the control of the provider, such as age of the patient or whether the patient complies with medication instructions. As such, experts also gauge progress by measuring improvements in the processes of care as well as intermediate outcomes.

The researchers, led by Bruce E. Landon, M.D., M.B.A., of the Department of Health Care Policy at Harvard Medical School, analyzed interventions with 9,658 patients at 44 health centers nationwide, approximately half of which were in urban areas. They used nationally validated quality measures that were collected from medical record reviews conducted over a 1-year period before the intervention and the same period after the intervention, and judged them against external control centers for comparison. Process improvements included:

• A 21 percent increase in foot examinations for patients with diabetes.
• A 14 percent increase in the use of anti-inflammatory medication for patients with asthma.
• A 16 percent increase in the level of screening for glycated hemoglobin in persons with diabetes mellitus.
• Overall, across the three conditions, a 6 percent improvement in processes of care related to screening and disease prevention and a 5 percent improvement in processes related to disease monitoring and treatment.

Even though processes were improved, the researchers found no improvement in intermediate outcomes, including:

• Control of glycated hemoglobin for people with diabetes.
• Control of blood pressure to normal levels for patients with hypertension.
• No reduction in urgent care, emergency department visits, or hospitalization for people with asthma.

The researchers observed that this focus on short-term outcomes to the exclusion of important longer-term outcomes may underestimate the true effect of quality improvement collaboratives.

See "Improving the management of chronic disease at community health centers," by Dr. Landon, LeRoi S. Hicks, M.D., M.P.H., A. James O'Malley, Ph.D., and others, in the March 1, 2007, New England Journal of Medicine 356(9), pp. 921-934.

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