Improving Care for Minorities: Can Quality Improvement Interventions Improve Care and Outcomes For Depressed Minorities? Results of a Randomized, Controlled Trial

Department of Psychiatry, Georgetown University Medical Center, Washington, DC, USA.
Health Services Research (Impact Factor: 2.78). 05/2003; 38(2):613-30. DOI: 10.1111/1475-6773.00136
Source: PubMed


Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities.
The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder. STUDY DEIGN: Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians).
Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups.
At baseline, all ethnic groups Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8-20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients.
Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities.

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    • "In a Swedish study at a psychiatric outpatient clinic in a suburb south of Stockholm in a multicultural immigrant/refugee population only 40% of the diagnosable patients were recognized with diagnosis of PTSD [49]. Under-diagnosis and under-treatment for historically disadvantaged ethnic groups may be especially high [50-52]. Despite the inherent and current limitations of primary care, such as its fast-pace and time constraints, it remains the ideal place for diagnosis and treatment of health and mental health problems and primarily health care can be less stigmatizing than special mental health clinics and despite the many barriers, can meet the immigrants’ entire spectrum of mental health and medical needs. "
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    BMC Medical Education 08/2013; 13(1):110. DOI:10.1186/1472-6920-13-110 · 1.22 Impact Factor
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    • "The CPIC Council modified depression QI toolkits4,27 supporting clinician assessment and medication management (manual and pocket cards), case management (manual), patient and education (brochure, video), and CBT (individual and group manuals) for use by diverse agencies, adding a lay health worker manual and team support tools28 from a post-disaster initiative blending QI toolkits8,12,29 (Table 1). The toolkits were available to programs online and through flash drives and hardcopy. "
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    ABSTRACT: BACKGROUND: Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors. OBJECTIVE: To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients' mental health-related quality of life (HRQL) and services use. DESIGN: Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles. PARTICIPANTS: From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up. MEASURES: Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use. RESULTS: CEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p < 0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p > 0.05). CONCLUSION: Community engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.
    Journal of General Internal Medicine 05/2013; 28(10). DOI:10.1007/s11606-013-2484-3 · 3.42 Impact Factor
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    • "Variability in treatment retention and outcome for ethnic/racial minorities has been found in anxiety and mood disorders, even when SES or education level is controlled (Fortuna, Alegria, & Gao, 2010; Hankerson et al., 2011; Lesser et al., 2007; Lester, Resick, Young-Xu, & Artz, 2010; Miligan, Nich, & Carroll, 2004). Multiple studies indicate that thoughtful and data-driven treatment adaptations may help address observed disparities, such as a quality improvement study that demonstrated that interventions providing modest accommodations for depressed minority patients (e.g., translations, cultural training for clinicians) resulted in improved outcome (Miranda et al., 2003). However, no study of BED has fully examined whether treatment outcome differs by race and ethnicity. "
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    ABSTRACT: Objective: Binge eating disorder (BED) is prevalent among individuals from minority racial/ethnic groups and among individuals with lower levels of education, yet the efficacy of psychosocial treatments for these groups has not been examined in adequately powered analyses. This study investigated the relative variance in treatment retention and posttreatment symptom levels accounted for by demographic, clinical, and treatment variables as moderators and predictors of outcome. Method: Data were aggregated from 11 randomized, controlled trials of psychosocial treatments for BED conducted at treatment sites across the United States. Participants were N = 1,073 individuals meeting criteria for BED including n = 946 Caucasian, n = 79 African American, and n = 48 Hispanic/Latino participants. Approximately 86% had some higher education; 85% were female. Multilevel regression analyses examined moderators and predictors of treatment retention, Eating Disorder Examination (EDE) global score, frequency of objective bulimic episodes (OBEs), and OBE remission. Results: Moderator analyses of race/ethnicity and education were nonsignificant. Predictor analyses revealed African Americans were more likely to drop out of treatment than Caucasians, and lower level of education predicted greater posttreatment OBEs. African Americans showed a small but significantly greater reduction in EDE global score relative to Caucasians. Self-help treatment administered in a group showed negative outcomes relative to other treatment types, and longer treatment was associated with better outcome. Conclusions: Observed lower treatment retention among African Americans and lesser treatment effects for individuals with lower levels of educational attainment are serious issues requiring attention. Reduced benefit was observed for shorter treatment length and self-help administered in groups.
    Journal of Consulting and Clinical Psychology 05/2013; 81(4). DOI:10.1037/a0032946 · 4.85 Impact Factor
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