OBJECTIVE: To investigate the lifelong health effects, costs, and cost-effectiveness of a quality improvement collaborative focusing on improving diabetes management in an integrated care setting.
STUDY DESIGN AND METHODS: Economic evaluation from a healthcare perspective with lifetime horizon alongside a nonrandomized, controlled, before-after study in the Netherlands. Analyses were based on 1861 diabetes patients in 6 intervention and 9 control regions, representing 37 general practices and 13 out-patient clinics. Change in the United Kingdom Prospective Diabetes Study score, remaining lifetime, and costs per quality-adjusted life year gained were calculated. Probabilistic life tables were constructed using the United Kingdom Prospective Diabetes Study risk engine, a validated diabetes model, and nonparametric bootstrapping of individual patient data.
RESULTS: Annual United Kingdom Prospective Diabetes Study risk scores reduced for cardiovascular events (hazard ratio: 0.83 and 0.98) and cardiovascular mortality (hazard ratio: 0.78 and 0.88) for men and women, respectively. Life expectancy improved by 0.97 and 0.76 years for men and women, and quality-adjusted life years by 0.44 and 0.37, respectively. Higher life expectancy in the intervention group increased lifelong costs by &OV0556;860 for men and &OV0556;645 for women. Initial program costs were about &OV0556;22 per patient. The incremental costs per quality-adjusted life year were &OV0556;1937 for men and &OV0556;1751 for women compared with usual care costs. There is a probability >95% that the collaborative is cost-effective, using a threshold of &OV0556;20,000 per quality-adjusted life year.
CONCLUSION: Optimizing integrated and patient-centered diabetes care through a quality-improvement collaborative is cost-effective compared with usual care.
BACKGROUND: The Swedish quality improvement initiative Quality Improvement in Coronary Care previously demonstrated significant improvements in caregiver adherence to national guidelines for acute myocardial infarction. The associated impact on 1-year clinical outcome is presented here.
METHODS AND RESULTS: During the baseline period July 2001 to June 2002, 6878 consecutive acute myocardial infarction patients <80 years were included at the 19 intervention and 19 control hospitals and followed for a mean of 12 months. During the postintervention period of May 2003 to April 2004, 6484 patients were included and followed in the same way. From baseline to postintervention, improvements in mortality and cardiovascular readmission rates (events per 100 patient-years) were significant in the intervention group (-2.82, 95% CI -5.26 to -0.39; -9.31, 95% CI -15.48 to -3.14, respectively). However, in the control hospitals, there were no significant improvements (0.04, 95% CI -2.40 to 2.47; -4.93, 95% CI -11.10 to 1.24, respectively). Bleedings in the control group increased in incidence (0.92, 95% CI 0.41 to 1.43), whereas the incidence remained unchanged in the intervention group (0.07, 95% CI -0.44 to 0.58). When the difference of changes between the study groups were evaluated, the results still were in favor of the intervention group, albeit significant only for bleeding complications (mortality: -2.70, 95% CI -6.37 to 0.97; cardiovascular readmissions: -6.85, 95% CI -16.62 to 2.93; bleeding complications: -0.82, 95% CI -1.66 to 0.01).
CONCLUSIONS: With a systematic quality improvement initiative aiming to increase the adherence to acute myocardial infarction guidelines, it is possible to achieve long-term positive effects on clinical outcome.
BACKGROUND: Quality improvement collaboratives are used to improve health care quality, but their efficacy remains controversial.
OBJECTIVE: To assess the effects of a quality improvement collaborative on preoperative antimicrobial prophylaxis.
DESIGN: Longitudinal cluster randomized trial, with the quality improvement collaborative as the intervention.
SETTING: United States.
PARTICIPANTS: 44 acute care hospitals, each of which randomly sampled approximately 100 selected surgical cases (cardiac, hip or knee replacement, and hysterectomy) at both the baseline and remeasurement phases.
INTERVENTION: All hospitals received a comparative feedback report. Hospitals randomly assigned to the intervention group (n = 22) participated in a quality improvement collaborative comprising 2 in-person meetings led by experts, monthly teleconferences, and receipt of supplemental materials over 9 months.
MEASUREMENTS: Change in the proportion of patients receiving at least 1 antibiotic dose within 60 minutes of surgery (primary outcome) and change in the proportions of patients given any antibiotics, given antibiotics for 24 hours or less, given an appropriate drug, and given a single preoperative dose and receipt of any of the 5 measures (secondary outcome).
RESULTS: The groups did not differ in the change in proportion of patients who received a properly timed antimicrobial prophylaxis dose (-3.8 percentage points [95% CI, -13.9 to 6.2 percentage points]) after adjustment for region, hospital size, and surgery type. Similarly, the groups did not differ in individual measures of antibiotic duration; use of appropriate drug; receipt of a single preoperative dose; or an all-or-none measure combining timing, duration, and selection.
LIMITATIONS: Hospitals volunteered for the effort, thereby resulting in selection for participants who were motivated to change. Implementation of the surgical infection prevention measure reporting requirements by the Centers for Medicare & Medicaid Services and The Joint Commission may have motivated improvement in prophylaxis performance.
CONCLUSION: At a time of heightened national attention toward measures of antimicrobial prophylaxis performance, the trial did not demonstrate a benefit of participation in a quality improvement collaborative over performance feedback for improvement of these measures.
OBJECTIVE: The aim of this study was to use family-centered measures to estimate the effect of a collaborative quality improvement program designed to help practices implement systems to promote early childhood development services.
METHODS: A cohort study was conducted in pediatric and family practices in Vermont and North Carolina. Eighteen collaborative education practices and 17 comparison practices participated in a 12-month program to assist practices in implementing improved systems to provide anticipatory guidance and parental education. The main outcome measures were change over time in parent-reported measures of whether children received each of 4 aspects of recommended care, documentation of developmental and psychosocial screening, and practice-reported care delivery systems.
RESULTS: The number of care delivery systems increased from a mean of 12.9 to 19.4 of 27 in collaborative practices and remained the same in comparison practices (P=.0002). The proportion of children with documented developmental and psychosocial screening among intervention practices increased from 78% to 88% (P<.001) and from 22% to 29% (P=.002), respectively. Compared with control practices, there was a trend toward improvement in the proportion of parents who reported receiving at least 3 of 4 areas of care.
CONCLUSION: The learning collaborative was associated with an increase in the number of practice-based systems and tools designed to elicit and address parents' concerns about their child's behavior and development and a modest improvement in parent-reported measures of the quality of care.
OBJECTIVE: The Organ Donation Breakthrough Collaborative is a quality improvement initiative to encourage adoption of "best practices" for identifying potential donors and obtaining consent for deceased organ donation. We evaluate the impact of the first phase on organ donation rates.
SETTING: We study donation rates in the 95 hospitals that participated in the first phase and a control group of 125 hospitals.
DESIGN: We use a controlled pre/post design. The preperiod is the year before the start of the Collaborative (September 2002 to August 2003), the postperiod is the final 6 months of the first phase (March 2004 to August 2004).
DATA: We use administrative data from the Organ Procurement and Transplantation Network to compute the conversion rate in each hospital group and time period. The conversion rate is the proportion of eligible donors who became actual donors.
PRINCIPAL FINDINGS: Preperiod conversion rates in Collaborative and control hospitals were similar: 52 and 51 percent, respectively. In the postperiod, the conversion rate increased to 60 percent among Collaborative hospitals and remained at 51 percent among control hospitals. The relative change was 8 percentage points (95 percent confidence interval: 2-13: p<.001).
CONCLUSIONS: Our findings suggest that the Breakthrough Collaborative led to an increase in donation rates at participating hospitals.
BACKGROUND: The Health Disparities Collaboratives of the Health Resources and Services Administration (HRSA) were designed to improve care in community health centers, where many patients from ethnic and racial minority groups and uninsured patients receive treatment. METHODS: We performed a controlled preintervention and postintervention study of community health centers participating in quality-improvement collaboratives (the Health Disparities Collaboratives sponsored by the HRSA) for the care of patients with diabetes, asthma, or hypertension. We enrolled 9658 patients at 44 intervention centers that had participated in the collaboratives and 20 centers that had not participated (external control centers). Each intervention center also served as an internal control for another condition. Quality measures were abstracted from medical records at each health center. We created overall quality scores by standardizing and averaging the scores from all of the applicable measures. Changes in quality were evaluated with the use of hierarchical regression models that controlled for patient characteristics. RESULTS: Overall, the intervention centers had considerably greater improvement than the external and internal control centers in the composite measures of quality for the care of patients with asthma and diabetes, but not for those with hypertension. As compared with the external control centers, the intervention centers had significant improvements in the measures of prevention and screening, including a 21% increase in foot examinations for patients with diabetes, and in disease treatment and monitoring, including a 14% increase in the use of antiinflammatory medication for asthma and a 16% increase in the assessment of glycated hemoglobin. There was no improvement, however, in any of the intermediate outcomes assessed (urgent care or hospitalization for asthma, control of glycated hemoglobin levels for diabetes, and control of blood pressure for hypertension). CONCLUSIONS: The Health Disparities Collaboratives significantly improved the processes of care for two of the three conditions studied. There was no improvement in the clinical outcomes studied.
OBJECTIVE: We sought to assess whether participation in a quality-improvement collaborative changed care processes, systems, and organization of outpatient human immunodeficiency virus (HIV) clinics.
METHODS: We surveyed clinicians, medical directors, and HIV program administrators before and after an 18-month quality improvement collaborative at 54 intervention and 37 control clinics providing HIV care. Surveys assessed clinic structures, processes, systems, and culture. During the collaborative, a clinician-administrator team from each intervention clinic attended 4 2-day sessions on quality improvement techniques. Conference calls, a website, and an e-mail list provided support and facilitated communication among collaborative participants.
RESULTS: Survey response rates were 85% or greater. Six of 54 organizational measures differed significantly between baseline and follow-up. Intervention clinicians reported greater computer availability (82% vs. 67%, P = 0.03) and use (3.13 vs. 2.68, P = 0.02; 4-point scale), attended more local (14.2 vs. 8.6, P < 0.01) and national (4.1 vs. 2.9, P = 0.01) conferences, and rated leaders' ability to implement quality improvement higher (3.8 vs. 3.4, P = 0.01; 5-point scale). Intervention directors were more likely to compare quality data to other clinics (79% vs. 54%, P = 0.04). For the set of 54 measures, intervention clinics were more likely to have higher post-intervention scores than controls (sign test, mean = 14.5, P < 0.0001).
CONCLUSIONS: A quality-improvement collaborative for HIV clinics resulted in modest organizational changes. Achieving greater change may require more focused and/or intensive interventions, greater resources for participating clinics, and better developed information technology.
To investigate the lifelong health effects, costs, and cost-effectiveness of a quality improvement collaborative focusing on improving diabetes management in an integrated care setting.
STUDY DESIGN AND METHODS:
Economic evaluation from a healthcare perspective with lifetime horizon alongside a nonrandomized, controlled, before-after study in the Netherlands. Analyses were based on 1861 diabetes patients in 6 intervention and 9 control regions, representing 37 general practices and 13 out-patient clinics. Change in the United Kingdom Prospective Diabetes Study score, remaining lifetime, and costs per quality-adjusted life year gained were calculated. Probabilistic life tables were constructed using the United Kingdom Prospective Diabetes Study risk engine, a validated diabetes model, and nonparametric bootstrapping of individual patient data.
RESULTS:
Annual United Kingdom Prospective Diabetes Study risk scores reduced for cardiovascular events (hazard ratio: 0.83 and 0.98) and cardiovascular mortality (hazard ratio: 0.78 and 0.88) for men and women, respectively. Life expectancy improved by 0.97 and 0.76 years for men and women, and quality-adjusted life years by 0.44 and 0.37, respectively. Higher life expectancy in the intervention group increased lifelong costs by &OV0556;860 for men and &OV0556;645 for women. Initial program costs were about &OV0556;22 per patient. The incremental costs per quality-adjusted life year were &OV0556;1937 for men and &OV0556;1751 for women compared with usual care costs. There is a probability >95% that the collaborative is cost-effective, using a threshold of &OV0556;20,000 per quality-adjusted life year.
CONCLUSION:
Optimizing integrated and patient-centered diabetes care through a quality-improvement collaborative is cost-effective compared with usual care.
