Mental Health Services
Improving Care for Minorities: Can
Quality Improvement Interventions
Improve Care and Outcomes For
Depressed Minorities? Results of a
Randomized, Controlled Trial
Jeanne Miranda, Naihua Duan, Cathy Sherbourne,
Michael Schoenbaum, Isabel Lagomasino, Maga Jackson-Triche,
and Kenneth B. Wells
Objective. 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 improve-
ment (QI) interventions for depressed primary care patients improve care across ethnic
groups and reduce outcome disparities.
Study Setting. 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 Design. 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
Patients and physicians selected treatments. Interventions featured modest accommo-
dations for minority patients (e.g., translations, cultural training for clinicians).
Data Extraction Methods. Multilevel logistic regression analyses assessed interven-
tion effects within and among ethnic groups.
Principal Findings. At baseline, all ethnic groups (Latino, African American, white)
had low to moderate rates of appropriate care and the interventions significantly
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 waslow forcomparing interventionresponseonthis outcome.Itis
likely to be depressed than white patients.
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
and may offer an approach to reduce health disparities.
Key Words. Mental health, quality improvement, ethnic minorities, depression,
managed health care
Ethnic minority individuals in the United States who identify themselves as
members of historically disadvantaged ethnic groups experience poorer
health and premature mortality (Williams and Collins 1995; Ren and Amick
1994; Navarro 1990) when compared with those who identify themselves as
white. Although etiologies of these health disparities are inadequately
understood and are undoubtedly multidetermined, one focus for improving
the health outcomes of ethnic minorities has been through improving the
health care received by this population. Because health care received by
ethnic minorities is often of poorer quality than that of whites (e.g., Ayanian et
al. 1993; Escarce et al. 1993; Winneker and Epstein 1989), reducing these
inequities could help reduce health disparities. Interventions that improve the
qualityof careforethnicminoritiesshouldbe developed and evaluated;yet to
date, we are unaware of any such evaluations.
Quality improvement (QI) programs are implemented widely in
managed care settings to encourage adherence to practice guidelines for
chronic conditions (i.e., hypertension, diabetes, depression) (Brown, Shy, and
McFarland 1995). Recently we reported evidence from a randomized,
This work was funded by the Agency for Healthcare Research and Quality, grant no. R01-
HS08349, the National Institute of Mental Health, grant no. P50MH54623, and the John D. and
Catherine T. MacArthur Foundation, grant no. 96-42901A-HE.
Addresscorrespondence toJeanne Miranda, Ph.D., UCLA-NeuropsychiatricInstitute, Centerfor
Health Services Research, 10920 Wilshire Boulevard, Suite 300, Los Angeles, CA 90024. (At the
Medical Center, Washington, DC). Naihua Duan, Ph.D., is with the UCLA-Neuropsychiatric
Institute and Department of Psychiatry and Biobehavioral Sciences, Los Angeles. Cathy
Sherbourne, Ph.D., and Michael Schoenbaum, Ph.D., are with RAND, Health Program, Santa
Institute and Department of Psychiatry and Biobehavioral Sciences, and Department of Psychiatry,
University of Southern California, Los Angeles. Maga Jackson–Triche, M.D., M.S.H.S., is with the
UCLA-Neuropsychiatric Institute and Department of Psychiatry and Biobehavioral Sciences, Los
Angeles, and SepulvedaVeterans Affairs MedicalCenter, Sepulveda,CA. KennethB.Wells, M.D.,
M.P.H., is with the UCLA-Neuropsychiatric Institute and Department of Psychiatry and
Biobehavioral Sciences, Los Angeles, and RAND, Health Program, Santa Monica, CA.
614 HSR: Health Services Research 38:2 (April 2003)
controlled trial, the Partners in Care (PIC) study, that a QI intervention
intended to increase appropriate diagnosis and treatment of depression
improved rates of appropriate care and patient outcomes when implemented
in diverse managed primary care settings (Wells et al. 2000). The intervention
improved both mental health outcomes and retention of employment over a
year. However, the extent to which QI programs, such as PIC, benefit
is unknown. The PIC study oversampled organizations serving Latinos. The
present study examines the impact of the quality improvement intervention
on Latinos and African Americans as compared with white participants.
Quality improvement programs for depression in primary care settings
are particularly appropriate for examining benefits for ethnic minorities. First,
depression is highly prevalent among all U.S. ethnic groups (Kessler et al.
1994) and soon is expected to be the second leading cause of disability
worldwide (Murry and Lopez 1996). Second, although both medications and
brief psychotherapy are recommended in national practice guidelines
(Depression Guidelines Panel 1993), treatment rates in managed primary
care settings are low to moderate (Wells et al. 1996; Wells et al. 1999) and
especially low for ethnic minorities (see Results below). Third, because ethnic
minority patients are less likely to use outpatient specialty mental health
services (Neighbors et al. 1992; Takuichi and Uehara, 1996; Miranda and
Green 1999), QI programs that bridge specialty and primary care may
particularly benefit ethnic minorities.
To date, efficacy studies of antidepressant medications and brief
therapies have not included adequate samples of ethnic minority patients to
evaluate differential responses to treatment (U.S. Department of Health and
Human Services 2001), although some studies suggest that minorities do
respond to these treatments (Brown et al. 1999; Organista, Mun ˜oz, and
Gonza ´lez 1994; Arean and Miranda 1996). Studies have repeatedly shown
that ethnic minorities are less likely to obtain mental health care than are
whites,andrecentresultssuggestiftheydo obtain mentalhealthcare,they are
less likely to obtain evidence-based treatments than are whites (U.S.
Department of Health and Human Services 2001). Quality improvement
interventions in primary care settings may be particularly suited for
identifying strategies for improving rates of appropriate care for this
population. For example, ethnic groups may differ in their preference for
antidepressant medication or psychotherapy (Dwight-Johnson et al. 2000), so
QI programs that offer a range of treatment choices and elicit and
accommodate patient preferences for treatment may be successful at
Interventions to Improve Care and Outcomes for Depressed Minorities615
improving treatment rates for ethnic minorities. Also, many ethnic minority
patients face language and cultural barriers to care (Woodward, Dwinell, and
Arons 1992), so that QI interventions including culturally and linguistically
appropriateeducational and intervention materialsmay benecessary.Because
minorities, we hypothesized that the PIC QI interventions would increase
quality of care and clinical outcomes for ethnic minorities and whites. Because
ethnic minorities might have less prior treatment exposure, we thought they
might also be more responsive as a group to new opportunities to obtain
treatment, leading to greater improvement in health for this group.
in employment. Ethnic minority and white participants may have differential
responsiveness to these two types of outcomes. As mentioned above, because
ethnic minorities may generally obtain less mental health care, this population
the other hand, more ethnic minorities than whites may lack the resources
(educational background, employment experiences, fluency in English)
necessary to achieve substantial gains in areas such as employment.
In summary, we examine prospectively the quality of care for under-
served minorities, as compared with white patients, under managed primary
care. We assess whether a QI intervention was effective in improving quality of
care across ethnic groups. We then determine whether the intervention
improved health and employment outcomes among ethnic minorities and
whether these groups improved more than whites, in a study specifically
designed to facilitate comparison of whites and underserved ethnic minorities.
We use data from the Partners in Care (PIC), a Patient Outcomes Research
Quality (AHRQ). The study is a group-level randomized controlled trial
(Murray 1998). The methodology is described in detail elsewhere (Brown,
Shye, and MacFarland 1995; Wells 1999).
Organizations, Clinics, and Providers. We recruited six managed care organiza-
tions, selected to be diverse in geography and organization and to oversample
616 HSR: Health Services Research 38:2 (April 2003)
Latinos. We approached one or two regions per organization; one region
refused and seven agreed. Of 48 primary care practices with at least two
clinicians, 46 participated.
We grouped practice clusters into matched blocks of three per block,
based on patient demographics, clinician specialty, and distance to mental
health providers. We created nine blocks, one each for six regions and three
for the seventh (stratified by low, intermediate, or high percentage of Latino
patients). The clinic clusters are randomized by blocks, to usual care or one of
two QI intervention conditions.
Primary care clinicians were recruited before learning the assignment
their clinic would receive; 97 percent (n5181) agreed to participate. The
clinicians were 87 percent internists or family practice physicians and 13
percent nurse practitioners; 32 percent were minority, including 2 percent
African American, 18 percent Latino, and 12 percent other minorities.
period between June 1996 and March 1997. Patients were eligible for the
study if they intended to use the clinic as a source of care for the next year,
were older than age 17, did not have an acute medical emergency, spoke
covered the intervention care. Eligible patients were screened for depression
using the ‘‘stem’’ items for major depressive and dysthymic disorder from the
12-month Composite International Diagnostic Interview (CIDI), version 2.1
(World Health Organization 1995), and items assessing depressed symptoms
in the past month. Specifically, we defined patients as having probable
pleasurable activities during the last year or persistent depression over the
year, plus having at least one week of depression in the last 30 days. Patients
learned of their intervention status after enrollment.
Of those, 2,417 confirmed insurance eligibility; 241 were found ineligible. Of
those who read the informed consent, 1,356 (79 percent) enrolled.1The
enrolled patients completed the CIDI to determine depressive diagnoses, and
a telephone interview to determine presence of comorbid anxiety disorders,
income, wealth, and employment. Self-administered mail surveys were
obtained at baseline, and every six months for two years. Survey response
rates were 95 percent for the telephone interview, 88 percent for the baseline
used to adjust for differential enrollment probabilities (McCaffey, Duan, and
Interventions to Improve Care and Outcomes for Depressed Minorities617
The interventions were designed to increase access to and adherence with
some form of appropriate care for depression, either medication or
psychotherapy. The interventions were developed by the study investigators
but implemented locally by the practices, that is, the practices were trained to
help themselves improve care under naturalistic practice conditions. We
compare usual care versus two interventions, QI-MEDS and QI-THERAPY.
Because the two intervention conditions are similar in nature, we combine
them in this paper to test our primary hypothesis that QI intervention
improves care and outcomes for minority patients.
The interventions included three common components. First, the
of implementing the interventions plus the time costs for participating in the
evaluation; the other half was paid by the study.
Second, the study trained local expert leaders to implement quality
improvement onsite. The expert leaders team included a primary care
provider, a nursing supervisor, and a mental health specialist from each
site. They participated in a two-day workshop on the study’s depression
treatment model and collaborative care principles; written manuals were
provided to team members. Prior to patient recruitment, expert leaders
oriented clinicians, distributed clinician
lectures, and provided academic detailing as needed. They also held monthly
meetings using intervention staff records to provide feedback on treatment
patients who screened positive for depression, and then used materials
developed by the study (written and videotaped) to educate the patient and
helpactivate them to engage intreatment. Localexperts provided supervision
for the nurses. Using information from the nurse visit, the primary care
clinician then met with the patient to formulate a treatment plan. Intervention
clinicians and patients were free to use these nurses or not.
Each intervention also had intervention-specific resources. In the QI-
MEDS intervention, trained nurses were available to provide follow-up
patients randomized to 12 months). In the QI-THERAPY intervention, the
study trained local psychotherapists to provide individual and group
Cognitive Behavioral Therapy for 8 to 12 sessions and provided them
618 HSR: Health Services Research 38:2 (April 2003)
with patient and therapist manuals (Mun ˜oz and Miranda 1986; Mun ˜oz,
Aguilar-Gaxiola, and Guzman 1986). The organizations reduced copay for
psychotherapy to the primary care amount (i.e., $0–$10 versus $20–$30). In
usual care, no study resources were available, although clinic medical
directors were mailed written copies of national practice guidelines. The QI-
THERAPY patients could receive antidepressant medications, but did not
have access to QI-MEDS study resources, such as follow-up by the nurse.
Further, usual care and QI-MEDS patients did not have access to the study-
sponsored CBT-therapists, but could use other local therapists.
In all conditions, patients and providers had full choice over treatments;
the conditions differed only in availability of resources. All patients could
receive psychotherapy, but only QI-THERAPY patients had access to the
specially trained providers and lowered copayments. All patients could
receive medications, but only QI-MEDS patients had access to nurse follow-
Adaptation of the Interventions for Minorities
Within the overall aim of improving rates of appropriate care, the
interventions had a secondary aim of insuring inclusion of minorities in
opportunities for care. Accordingly, experts in mental health interventions for
minority patients participated in designing the QI educational materials. All
intervention materials were available in English and Spanish; Latino and
African American providers were shown in videotapes that were included in
and ways of overcoming barriers to appropriate treatment for Latino and
African American patients was included in provider training materials.
Furthermore, English- and Spanish-language materials were provided to
improve psychotherapy for depression for ethnically diverse (Mun ˜oz and
Miranda 1986) and Latino (Mun ˜oz, Aguilar-Gaxiola, and Guzman 1986)
patients. Finally, minority investigators provided direct supervision to the
local experts throughout the intervention.
Appropriate Care. We examine the rate of appropriate care during each 6-
month assessment period. We define appropriate care as identifying need for
care and providing guideline concordant treatments. Appropriate treatment
withantidepressantmedications requires that they are given at guideline daily
dosage (i.e., at or above the minimum dosage recommended in the AHRQ
Interventions to Improve Care and Outcomes for Depressed Minorities619
Guidelines, with comparable criteria for newer antidepressant medications)
specialty mental health visits with an active component (e.g., engaging in
pleasant activities, solving problems). At baseline and at 6-month follow-up,
all depressed subjects were considered in need of care because they met
screening criteria for probable depression within the prior 6 months (i.e., at
baseline, 6-month follow-up, or both). However, at 12-month follow-up some
patients receiving no treatments could have appropriate care if they had been
free of depression for several months. To capture this change in the indicator
of appropriate care, for 12-month follow-up we defined two groups as follows:
persons with depression at 12- or 6-month follow-up who received no
appropriate treatment in the prior 6 months were designated as not having
appropriate care; and those who were either similarly symptomatic and had
appropriate treatment or those who were well with or without treatment were
considered to have appropriate care. In this paper, we use the term
‘‘appropriate care’’ to refer to the indicator that applies to each follow-up
point, in effect, any appropriate treatment for baseline and 6 months and the
indicator described above for 12 months.
Clinical Outcomes. We use an indicator for probable continued
depressive disorder, based on administration at each follow-up of the screener
measure for probable disorder, as described above, but referring to the 6-
month period just prior to measurement (omitting the dysthymia stem item,
which applies only to a 2-year time period). We classify patients as having
probable disorder for each 6-month follow-up. The contrast category is
Employment. Items from the screener and baseline telephone survey
assessed whether respondents were employed at baseline. The 6- and
12-months surveys assessed employment status at these follow-up times.
We apply patient-level intent-to-treat logistic regression analyses, with
intervention status (being in either type of intervention clinic versus a care
as usual clinic), ethnicity (African Americans, Latinos, whites), and
randomization blocks as the independent variables. We include interactions
between intervention and ethnicity to examine the differential intervention
effectsby ethnicgroup. Becausepatientsareclustered withinclinics,we adjust
for the cluster effect.
620HSR: Health Services Research 38:2 (April 2003)
We control for patient baseline characteristics, including all socio-
demographic and clinical differences between the samples.
To help interpret the results, we present standardized predictions of the
intervention effects for each outcome (Graubard and Korn 1999). We use the
regression parameters and individual’s actual values for the covariates other
than intervention status to generate a predicted value for each individual
within their ethnic group, first as an intervention subject and then as a control
subject. We then average the intervention and control predictions for each
Nonresponse weights are used to mitigate potential bias due to
enrollment nonresponse and wave nonresponse (McCaffey, Duan, and
Morton 2000). We use multiple imputation for missing data at the item level.
We impute five datasets, average the regression coefficients and predictions,
and adjust the standard errors for the uncertainty due to imputation (Schafer
1997; Rubin 1996, 1998).
As reported earlier (Wells et al. 2000), patients in QI did not differ from
patients in the intervention at baseline. However, at 6 months, QI patients
were more likely than controls to receive counseling or use antidepressant
medications at an appropriate dosage (50.9 percent versus 39.7 percent,
p o.001), with a similar pattern at 12 months (p5.006). At 6 months, QI
patients were less likely than controls to meet criteria for probable depressive
disorder (39.9 percent versus 49.9 percent, p5.001), with a similar pattern at
12 months (p5.005). Initially, employed QI patients were more likely to be
working at 12 months relative to controls (89.7 percent versus 84.7 percent,
Ethnic Group Differences at Baseline
Patient baseline characteristics are presented by ethnicity in Table 1. The
ethnic groups differ substantially in demographic and clinical characteristics.
The differences are generally reflective of demographic differences among
ethnic groups in the United States.2African American patients were more
likely to be female and unmarried than white patients. Latino and African
American patients were younger than white patients. Latinos had less formal
education than white and African American patients. Latino patients were
Interventions to Improve Care and Outcomes for Depressed Minorities621
more likely to have co-occurring anxiety disorder than white patients; white
patients were more likely to meet criteria for major depression than Latino
patients. Latinos were less likely to receive prior appropriate care when
compared with white participants and less likely to receive any depression
Table1: Characteristics of Enrolled Patients by Ethnicity
(SD) or %
(SD) or %
(SD) or %
Mean age (SD)
o High school
Mean MCS-12 (SD)
Mean PCS-12 (SD)
Lifetime and current
Any baseline care
45.5 ( 9.9)
SD: Standard deviation for numerical variables.
ABased on CIDI diagnosis.
nDiffer significantly from white with po.05.
+Differ significantly from white with po.01.
++Differ significantly from white with po.001.
aHispanic differ from African American with p50.05.
aaHispanic differ from African American with po.001.
622 HSR: Health Services Research 38:2 (April 2003)
care than were white participants. African Americans were more likely to
report depressive symptoms in the absence of current or lifetime disorder.
African Americans were more likely to be employed than were Latinos.
Appropriate Care. At baseline, Latinos were less likely to receive
appropriate care for depression than were white patients (12.8 percent versus
35.3 percent, p o .001). Approximately 29.4 percent of African American
patients were receiving appropriate care.
Intervention Effects by Ethnic Groups
Appropriate Care. There was no significant interaction between intervention
and ethnic group for the rate of appropriate care. As shown in Table 2, the
interventions’ effect on quality of care was evident for all ethnic groups. For
Latinos, the rate of appropriate care for those in the intervention clinics was
8–13 percentage points higher than among those in control clinics, with the
difference reaching statistical significance at month 12. For African Americans,
the rate of appropriate care for those in the intervention clinics was
12–21 percentage points higher than among those in the control clinics, and
was statistically significantat month 6. For the white sample, rate of appropriate
care for those in the intervention clinics was 8–9 percentage points higher than
among those in the control clinics and was statistically significant at month 6.
Under usual care, the minorities continue to receive less appropriate
received appropriate care; whereas, only 35.2 percent of African American
and 26.4 percent of Latino patients received appropriate care. This latter
is significant (p5.0002).
Outcomes. There was a significant interaction between intervention and
ethnic group for probable depression (p5.001 at month 6 and p5.11 at
month 12). As shown in Table 2, rate of probable depression wassubstantially
month 6 (by about 17 percentage points for Latinos and more than 30
percentage points for African Americans) and at month 12 (about 27
percentage points for Latinos and about 27 percentage points for African
Americans); all are statistically significant. The intervention effects on the rate
of probable depression for white patients were substantively small and not
Because this pattern of improved results for minorities could be a result
of better care in sites with high numbers of Latino patients, we conducted
Interventions to Improve Care and Outcomes for Depressed Minorities623
Adjusted Percentage of Patients Receiving Appropriate Care and Positive Outcomes by Ethnicity and
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
% (95% CI)
T (p): T statistic and p-value comparing intervention versus control patients by ethnic groups.
N vary across waves and outcomes: 1,188 at baseline; 1,150–1,156 at 6 months; 1,075–1,126 at 12 months.
All N are at that wave, except for appropriate care at month 12, which requires having data at month 6 and month 12.
aLatino QI significantly different from white QI with p5.025;
bLatino QI significantly different from white QI with p5.023;
cLatino control significantly different from white controls with p5.002;
dLatino control significantly different from white controls with p5.05;
eAfrican American QI significantly different from white QI with p5.002;
fAfrican American control significantly different from white controls with p5.043;
gLatino control significantly different from white controls p50.06;
hAfrican American control significantly different from white controls with p5.004.
624 HSR: Health Services Research 38:2 (April 2003)
sensitivity analyses including only those sites with a high concentration of
Latino patients. The pattern of results remained similar within those sites.
There was no significant interaction between intervention and ethnic
group for work status. Reported employment rates for Latinos and African
the white sample, rates of employment were 5–7 percentage points higher
among those who received the intervention as compared with the control
sample; differences are statistically significant for whites at months 6 and 12.
We had poor precision for contrasting intervention effects for whites and
minority groups for this outcome.
Under usual care, minorities had poorer clinical outcomes than did
whites. At month 12, Latinos (65.6 percent) and African Americans (58.0
percent) in the control clinics were more likely to have probable depressive
disorder than were whites (41.4 percent) in the control clinics; these
differences are statistically significant. However, employment outcomes have
employed, as compared with 59.8 percent of white participants. At month 12,
African Americans in the control clinics were more likely to be employed
(75.6 percent) than were white participants.
Reducing Disparities. To determine whether the interventions improved
quality of care or health outcomes more for minorities than for whites, we
grouped the Latino and African American minorities together and contrasted
them withwhites. There were no significant interactionsbetween intervention
status and minority status for appropriate care at either 6 or 12 months. The
intervention–ethnicity interaction was significant, however, in predicting
probable depression at 6 months (t52.54, p5.02). The direction of the effect
is for more improvement under the interventions among minorities than
among whites. There were no significant interactions in predicting employ-
These results offer a promising direction for improving care and outcomes for
depressed, ethnic minority primary care patients. We found that when
following their own practical goals and largely within their existing resources,
they were able to improve by 8 to 20 percentage points the rate of appropriate
care for depression. The Latino, African American, and white participants all
Interventions to Improve Care and Outcomes for Depressed Minorities625
modification of thebasic intervention design to accommodate ethnic minority
patients. The major modifications were: including experts in treating ethnic
minorities among the intervention team, making information relevant to
treatment of ethnic minorities available for providers, and translating patient
materials into Spanish.
The intervention specifically improved clinical outcomes among the
ethnic minorities. Since the minorities were at substantially greater risk of
receiving less appropriate care and having poor outcomes (especially Latinos)
without the intervention, this led to a reduction in health disparity by ethnic
status among depressed, minority patients. In our knowledge, this is the first
evidence that a general quality improvement program is effective for diverse
The QI intervention improved clinical outcomes among ethnic
minorities but not among whites. This could mean that the populations differ,
such that the minorities include a higher proportion of initial treatment
responders whohavenotalready been treatedand improved. Consistent with
forallethnicgroupswerequalitatively stronger among personsnotpreviously
receiving care, compared to those previously receiving care. An alternative
explanation would be that factors such as social or family support or diet-
related metabolic responsiveness to care differed between the ethnic
minorities and whites resulting in improved responsiveness to care in the
ethnic minority samples.
In contrast, the QI intervention increased employment for white
like the descriptive results, was weaker for minorities. Thus, both groups
benefit, but we have the most confidence that the minorities did so clinically
while the whites did so functionally through employment. The relationship
between depression, its treatment, and employment is poorly understood and
it is interesting to note that improvement in one outcome is possible without
improvement in the other. Because the whites were more likely to have prior
treatment, they may have already improved clinically and the intervention
provided further improvement leading to better employment; or the whites
may have had better opportunities to respond to any improvement through
increasing employment. It is possible that a more sustained intervention or
ethnic-focused adaptation would be needed to accomplish a similar employ-
ment benefit among minorities. This study raises new questions about the
626 HSR: Health Services Research 38:2 (April 2003)
effects of medical interventions on multiple components of need and
Several limitations should be noted in this study. First, there was sample
loss during enrollment, a factor that could result in under- or overreport of the
interventions effects. All measures are self-report, including race or ethnicity.
The African American sample was small; generalizations cannot be made to
sites serving large numbers of African American patients or to sites with less
diversity. The results suggest there may be ethnic differences in outcomes in
response to the interventions. The clinical outcomes were primarily among
minorities whereas the employment outcomes were primarily among the
white patients. These results were not anticipated and, therefore, cannot be
clearly interpreted. One possibility is that changes in clinical outcomes
associated with QI interventions would only be effective in ethnically diverse
settings. However, we would caution against interpreting these findings to
indicate that clinical improvements will not be found in white patients when
organizations implement these QI interventions. Factors such as prior
experience with care may have been associated with ethnic status and could
those in rural areas,may also show differentialclinical response to care. These
the interventions should be attributed to the QI interventions rather than to
These results suggest that practice-initiated quality improvement
programs may offer an approach to improve quality of care equitably with
respect to ethnic groups, without increasing disparities in health outcomes, a
risk that is common for diffusion of social innovations (Rogers 1996).
specific outcomes. In this respect, medicine may have a feasible strategy to
overcoming some disparities within the context of managed care. This is
encouraging news because it implies that some progress on reducing
disparities could proceed without much larger changes in public policy. A
similar level of implementation and outcome improvement seems feasible for
similarpractices,which span privateandpublic,ruralandurban,networkand
staff/group practices. Although the intervention in this study provided
improved care for the minority patients, minority patients continued to
patients. Even with improved opportunities for care, minorities may face
substantial barriers, such as need for child care, demanding work environ-
ments, lack of Spanish-speaking providers, failure to include families in
Interventions to Improve Care and Outcomes for Depressed Minorities627