Chronic disease management quality efforts yield better care delivery

Armen Hareyan's picture

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 HHS Agency for Healthcare Research and Quality and Health Resources and Services Administration and complemented by a grant from The Commonwealth Fund.

The study, published in the March 1 New England Journal of Medicine, focuses on the principle 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 or underinsured or are members of immigrant or minority groups.

"This study indicates that focused quality improvement interventions can enhance how we deliver care and we need to do more to improve clinical outcomes," said Carolyn M. Clancy, M.D., AHRQ director. "These findings will guide our quality improvement efforts in the overall health care system and at health centers, which are a critically important component of a national strategy to deliver quality care to the medically vulnerable."

"The lessons learned from studies conducted at HRSA's Health Disparities Collaboratives have the potential to save lives and improve the health of thousands of Americans," said Elizabeth M. Duke, HRSA administrator. "We know from experience at hundreds of health centers around the nation that the changes promoted by collaboratives result in verifiable health benefits for patients as they struggle with chronic diseases, which this study confirms."

The interventions teach health center personnel quality improvement methods that require measuring quality performance and continuously implementing and refining 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. Experts therefore 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.

They found a number of process improvements:

  • 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.

However, 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.

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.

"There is still much to learn about the tools and methods for quality improvement and their potential effectiveness," Landon said. "The substantial room for improvement in the post intervention period suggests the need for continued refinement of these quality improvement methods."