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Interventions improve care, not necessarily outcomes
Health Disparities Collaborative helps care centers
A study published in the March 1 issue of the New England Journal of Medicine1 found that interventions for chronic conditions in the Health Disparities Collaboratives led to improvements in processes of care, but the authors could not document improvement in clinical outcomes.
The Health Disparities Collaborative was designed to improve care in community health centers in which many minority and uninsured patients receive care.
The process improvements achieved included:
However, the researchers found no improvement in intermediate outcomes, including:
There are logical explanations for some of the results, notes David M. Stevens, MD, senior medical officer for quality improvement at the Center for Patient Safety & Quality Improvement, Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD, who initiated the Health Disparities Collaboratives while working with the Health Resources and Services Administration (HRSA), which administers the program.
So, for example, in terms of lack of process improvement in hypertension, he notes, "There is limited access to meds, as many of those patients are not insured. This translates as well in the ambulatory care facilities that hospitals run; 30%-40% of patients who are not insured may not have access to the treatments you prescribed."
Nevertheless, it is evident from the results that the collaboratives are doing something right. "We wanted to break new ground; our main message was that this would be different. Our measures were very patient-centered, and we decided to start building from the beginning," Stevens says.
"We had a common language and framework — the 'Care Model' of what care should look like," he says. That model can apply to hospitals as well as to health centers, he adds. "You know what all the key elements are, what you are trying to give the patients, and what outcomes you want," he explains. "The model talks about teams, decision support, and other things that help you get there; it's a common language around improvement, a standard way of doing things, which was very important."
HRSA, Stevens notes, concluded an interagency agreement with AHRQ to study the work of the collaboratives. "When we started this, we only had two measures; we wanted to err on the side on parsimony," he recalls. Steven adds that while the subjects of the study were health centers and not hospitals, "many principles are the same."
One other important factor for successful improvement in health centers that is certainly applicable to hospitals, Stevens continues, is a strong quality improvement team that is fully integrated into the organization — not, he emphasizes, "viewed as a marginal 'science fair project.'" (An important tool aimed at hospitals that Stevens says is helpful is available at www.ahrq.gov/qual/teamstepps.)
Looking at outcomes
One of the reasons outcomes were not seen to improve, Stevens suggests, "is that it takes longer than a year." If a quality manager is looking to measure outcomes, he says, "maybe what you want to do is set up some process measures of your own, so you track not only what is tested and done, but also the structural changes you want.
For example, if you put together a team, you may want to measure whether the team has gone from identifying its aims to small tests, and to implementation. Also, you may want to see if you get some immediate successes, while not expecting to see normal blood pressures right away, and so forth.
One of the key elements in the Care Model, he continues, is patient self-management, but he cautions quality managers against thinking in terms of the word "compliance."
"That word may not be that helpful," he offers. "If you have two different patients, you will have two different sets of goals. You should work with the patient and their family to get a mutually agreed-upon goal and look for ways to support them."
The patient, he continues, also must think about what things will help achieve his goals, and what some of the potential barriers are. "Then, you can help them overcome those barriers, and problem solve. This is very powerful," says Stevens.
This type of approach could be very helpful in the hospital setting, says Stevens, "both on discharge, and also in helping to limit unnecessary ED visits or primary care visits — and of course, by following mutually agreed-upon treatment plans. If we can figure out ways to use our resources to help patients do that and take advantage of new technology like e-mails and the web, I think in the future this model will be very helpful."
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