Improving and Sustaining Diabetes Care in Community Health Centers With the Health Disparities Collaboratives

Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois 60637, USA.
Medical Care (Impact Factor: 2.94). 01/2008; 45(12):1135-43. DOI: 10.1097/MLR.0b013e31812da80e
Source: PubMed

ABSTRACT In 1998, the Health Resources and Services Administration's Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions.
To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further.
Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively.
American Diabetes Association standards.
We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1-2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers.
Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [-0.45%; 95% confidence interval (CI), -0.72 to -0.17] and low-density lipoprotein cholesterol (-19.7 mg/dL; 95% CI, -25.8 to -13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07-2.01] and aspirin (OR, 2.20; 95% CI, 1.28-3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08-0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15-0.75).
Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.

Download full-text


Available from: Michael T Quinn, May 10, 2015
1 Follower
  • Source
    • "Participating primary care settings include practices that already have adopted state-of-the art e-health technologies for tracking patients’ care, enabling an examination of the merger of patient-centered assessment and intervention approaches and EHRs in high resourced settings [68,69]. On the other end of the continuum, inclusion of a number of community health centers, typically with less access to state-of-the art technologies, has generated problem-solving about the best strategies for conducting assessment and interventions in contexts where staff are challenged to see large caseloads of more diverse, low income/low educated populations with characteristically complex medical and psychosocial needs, and lower levels of health literacy and numeracy [70]. The mantra remains consistent: involving relevant stakeholders is important for both the initial adoption as well as the long-term sustainability of evidence-based patient assessment and intervention. "
    [Show abstract] [Hide abstract]
    ABSTRACT: There is a pressing need for greater attention to patient-centered health behavior and psychosocial issues in primary care, and for practical tools, study designs and results of clinical and policy relevance. Our goal is to design a scientifically rigorous and valid pragmatic trial to test whether primary care practices can systematically implement the collection of patient-reported information and provide patients needed advice, goal setting, and counseling in response. This manuscript reports on the iterative design of the My Own Health Report (MOHR) study, a cluster randomized delayed intervention trial. Nine pairs of diverse primary care practices will be randomized to early or delayed intervention four months later. The intervention consists of fielding the MOHR assessment -- addresses 10 domains of health behaviors and psychosocial issues -- and subsequent provision of needed counseling and support for patients presenting for wellness or chronic care. As a pragmatic participatory trial, stakeholder groups including practice partners and patients have been engaged throughout the study design to account for local resources and characteristics. Participatory tasks include identifying MOHR assessment content, refining the study design, providing input on outcomes measures, and designing the implementation workflow. Study outcomes include the intervention reach (percent of patients offered and completing the MOHR assessment), effectiveness (patients reporting being asked about topics, setting change goals, and receiving assistance in early versus delayed intervention practices), contextual factors influencing outcomes, and intervention costs. The MOHR study shows how a participatory design can be used to promote the consistent collection and use of patient-reported health behavior and psychosocial assessments in a broad range of primary care settings. While pragmatic in nature, the study design will allow valid comparisons to answer the posed research question, and findings will be broadly generalizable to a range of primary care settings. Per the pragmatic explanatory continuum indicator summary (PRECIS) framework, the study design is substantially more pragmatic than other published trials. The methods and findings should be of interest to researchers, practitioners, and policy makers attempting to make healthcare more patient-centered and relevant.Trial registration: NCT01825746.
    Implementation Science 06/2013; 8(1):73. DOI:10.1186/1748-5908-8-73 · 3.47 Impact Factor
  • Source
    • "Mangione- Smith et al. 2005 12 months 11 Schonlau et al. 2005 12 months 12 Chin et al. 2007 12 months 13 Landon et al. 2007 Unclear 14 Polacsek et al. 2009 TABLE 2—Continued "
    [Show abstract] [Hide abstract]
    ABSTRACT: In response to national efforts to improve quality of care, policymakers and health care leaders have increasingly turned to quality improvement collaboratives (QICs) as an efficient approach to improving provider practices and patient outcomes through the dissemination of evidence-based practices. This article presents findings from a systematic review of the literature on QICs, focusing on the identification of common components of QICs in health care and exploring, when possible, relations between QIC components and outcomes at the patient or provider level. A systematic search of five major health care databases generated 294 unique articles, twenty-four of which met our criteria for inclusion in our final analysis. These articles pertained to either randomized controlled trials or quasi-experimental studies with comparison groups, and they reported the findings from twenty different studies of QICs in health care. We coded the articles to identify the components reported for each collaborative. We found fourteen crosscutting components as common ingredients in health care QICs (e.g., in-person learning sessions, phone meetings, data reporting, leadership involvement, and training in QI methods). The collaboratives reported included, on average, six to seven of these components. The most common were in-person learning sessions, plan-do-study-act (PDSA) cycles, multidisciplinary QI teams, and data collection for QI. The outcomes data from these studies indicate the greatest impact of QICs at the provider level; patient-level findings were less robust. Reporting on specific components of the collaborative was imprecise across articles, rendering it impossible to identify active QIC ingredients linked to improved care. Although QICs appear to have some promise in improving the process of care, there is great need for further controlled research examining the core components of these collaboratives related to patient- and provider-level outcomes.
    Milbank Quarterly 06/2013; 91(2):354-94. DOI:10.1111/milq.12016 · 5.06 Impact Factor
  • Source
    • "The CCM has been used by the Health Disparities Collaborative (Chin et al., 2007, Martin et al., 2007) and other health care organizations (Franks and Fiscella, 2008) with the aim of improving the quality of care and of decreasing the health inequalities. Although there is evidence that the CCM is efficient (Wagner et al., 2001), the evidence on the impact of this model on the social gradient in health (Franks and Fiscella, 2008, Chin et al., 2007, Martin et al., 2007), is contradictory. A further analysis of the mechanisms through which the CCM may act on the social determinants of health may help us understanding this contradictory evidence. "
Show more