Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative

Transcription

1 Cliical Care/Educatio/Nutritio O R I G I N A L A R T I C L E Improvig Diabetes Care i Midwest Commuity Health Ceters With the Health Disparities Collaborative MARSHALL H. CHIN, MD, MPH 1 SANDY COOK, PHD 1 MELINDA L. DRUM, PHD 1 LEI JIN, MA, MS 1 MYRIAM GUILLEN, BA 1 CATHERINE A. HUMIKOWSKI, BA 1 JULIE KOPPERT, RNC, BSN, CDE 2 JAMES F. HARRISON, MD 3 SUSAN LIPPOLD, MD, MPH 4 CYNTHIA T. SCHAEFER, RN, CS 5 OBJECTIVE To evaluate the Diabetes Health Disparities Collaborative, a iitiative by the Bureau of Primary Health Care to reduce health disparities ad improve the quality of diabetes care i commuity health ceters. RESEARCH DESIGN AND METHODS Oe year before- after trial. Begiig i 1998, 19 Midwester health ceters udertook a diabetes quality improvemet iitiative based o a model icludig rapid Pla-Do-Study-Act cycles from the cotiuous quality improvemet field; a Chroic Care Model emphasizig patiet self-maagemet, delivery system redesig, decisio support, cliical iformatio systems, leadership, health system orgaizatio, ad commuity outreach; ad collaborative learig sessios. We reviewed charts of 969 radom adults for America Diabetes Associatio stadards, surveyed 79 diabetes quality improvemet team members, ad performed qualitative iterviews. RESULTS The performace of several key processes of care assessed by chart review icreased, icludig rates of HbA 1c measuremet (80 90%; adjusted odds ratio 2.1, 95% CI ), eye examiatio referral (36 47%; 1.6, ), foot examiatio (40 64%; 2.7, ), ad lipid assessmet (55 66%; 1.6, ). Mea value of HbA 1c teded to improve ( %; differece 0.2, 95% CI 0.4 to 0.03). Over 90% of survey respodets stated that the Diabetes Collaborative was worth the effort ad was successful. Major challeges icluded eedig more time ad resources, iitial difficulty developig computerized patiet registries, team ad staff turover, ad occasioal eed for more support by seior maagemet. CONCLUSIONS The Health Disparities Collaborative improved diabetes care i health ceters i 1 year. Diabetes care is a critical issue for the 3,000 federally fuded commuity health ceter delivery sites that Diabetes Care 27:2 8, 2004 provide primary care for 11 millio medically uderserved Americas (1,2). Natioally, Africa Americas ad patiets From the 1 Departmets of Medicie ad Health Studies, Diabetes Research ad Traiig Ceter, The Uiversity of Chicago, Chicago, Illiois; 2 Midwest Cluster Health Disparities Collaborative, Keto, Ohio; 3 North Woods Commuity Health Ceter, Miog, Wiscosi; 4 Health Resources ad Services Admiistratio, Chicago, Illiois; ad the 5 Departmet of Nursig ad Health Scieces, Uiversity of Evasville, Evasville, Idiaa. J.F.H. is curretly affiliated with South Lae Medical Group, Cottage Grove, Orego, ad S.L. is curretly affiliated with the Ceters for Disease Cotrol City of Chicago Tuberculosis Program, Chicago, Illiois. Address correspodece ad reprit requests to Marshall H. Chi, MD, MPH, Uiversity of Chicago, Sectio of Geeral Iteral Medicie, 5841 South Marylad Ave., MC 2007, Chicago, Illiois mchi@medicie.bsd.uchicago.edu. Received for publicatio 15 May 2003 ad accepted i revised form 15 September Abbreviatios: BPHC, Bureau of Primary Health Care; HLM, hierarchical liear model; PDSA, Pla, Do, Study, Act. A table elsewhere i this issue shows covetioal ad Système Iteratioal (SI) uits ad coversio factors for may substaces by the America Diabetes Associatio. of lower socioecoomic status suffer disproportioately high morbidity from diabetes (3), ad racial disparities i the quality of diabetes care are prevalet (4). Sice commuity health ceters are vaguard providers of idiget patiets, itervetios i the health-ceter settig are of particular iterest to cliicias, admiistrators, ad policymakers seekig to improve the care of the most vulerable patiets with diabetes (5 7). Providers i all settigs frequetly do ot meet diabetes quality-of-care stadards as outlied by the America Diabetes Associatio (8). Suboptimal care has bee foud i academic medical ceters (9), private doctors offices (10), maaged care orgaizatios (11), Medicare providers (4), ad the Idia Health Service (12). Because health ceters have fewer resources ad more vulerable patiets (13), it might be assumed that their performace o these stadards of care might be lower. However, rates of adherece to the stadards i health ceters have bee as high as other providers or eve better despite the extra challeges (14 17). Noetheless, evidece suggests that diabetes care eeds to be improved i all settigs. I 1998, the Bureau of Primary Health Care (BPHC), the part of the Health Resources ad Services Admiistratio that oversees all federally fuded health ceters, bega a major 6-year Health Disparities Collaborative desiged to reduce health disparities ad improve the quality of care i health ceters. The iitiative aims for rapid quality improvemet through the Istitute for Healthcare Improvemet s Breakthrough Series methodology (18), the MacColl Istitute for Healthcare Iovatio s Chroic Care Model (19), ad regioal or atioal learig sessios. The focus of the first year was diabetes quality improvemet. We aimed to evaluate the effectiveess of the iitiative after the first year ad to idetify facilitators ad barriers to quality improvemet. 2 DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY 2004

2 Chi ad Associates RESEARCH DESIGN AND METHODS Descriptio of the Health Disparities Collaborative ad Breakthrough Series methodology I 1998, the Bureau of Primary Health Care ivited federally fuded commuity health ceters to apply to be part of a Diabetes Collaborative quality improvemet process. The iitiative was atioal, but much of the implemetatio was performed at a regioal level. I the Midwest, 22 health ceters applied. A committee of cliicias, admiistrators, ad represetatives of the BPHC selected 20 ceters based upo criteria icludig a adequate umber of patiets with diabetes, sufficiet computer resources, electroic mail capability, ad commitmet of leadership. Each health ceter was expected to form a diabetes quality improvemet team that would meet regularly with the support of seior admiistrative leadership. Each ceter would also create a registry of patiets with diabetes to help track cliical care. Oe ceter dropped out at the begiig of the project, leavig ietee ceters. Model for improvemet: rapid Pla, Do, Study, Act cycles A rapid chage process called Pla, Do, Study, Act (PDSA) was itroduced ito each health ceter. This model, developed by the Istitute for Healthcare Improvemet, adapts elemets of cotiuous quality improvemet ito a process desiged to improve the quality of care at a accelerated pace. Followig the establishmet of a major aim for improvig the quality of care, the elemets of this process are as follows: 1) Pla defie a itervetio to help the ceter achieve the major aim. The key elemet to plaig ivolves the dissectio of the itervetio ito small, measurable, ad accomplishable steps; 2) Do implemet the itervetio o a small scale; 3) Study aalyze the effects of the itervetio; ad 4) Act based o the study data, revise the itervetio. The emphasis is o rapid PDSA cycles that have quick turaroud times. Thus, the umber of patiets upo which a idividual PDSA cycle is performed may be too small for chage to reach statistical sigificace, but the goal is to have eough patiets to determie practically if the itervetio is workig or requires revisio. Chroic Care Model The MacColl Chroic Care Model aims to create practical, supportive iteractios betwee a iformed, activated patiet ad a proactive, prepared cliical team. The model posits that multiple dimesios must be addressed if care is to be improved. The health system ad orgaizatio of care must be improved, ad commuity resources must be tapped. Specific targets for quality improvemet are patiet self-maagemet, delivery system redesig, decisio support, cliical iformatio systems, leadership ad health system orgaizatio, ad commuity outreach. Breakthrough Series process The Istitute for Healthcare Improvemet provided iitial istructio at a atioal learig sessio, ad the regioal cluster coordiators ad istitute staff (0.4 fulltime equivalet) assisted through telephoe coferece calls, a computer listserve, feedback o required mothly progress reports, ad three regioal meetigs. Mothly progress reports from the ceters were expected to iclude aims, descriptios of rapid PDSA cycles, ad reports of adherece to selected diabetes quality-of-care stadards. At the regioal learig sessios, team members ad admiistrators from all 19 health ceters met to lear qualityimprovemet techiques ad share lessos amog themselves. Goals The BPHC asked all health ceters to perform at least two HbA 1c tests at least 3 moths apart over the year for 90% of their target populatio. Health ceters were also asked to pick other specific goals of their ow choice as targets for quality improvemet. Health ceters were asked to start with a subset of their ceter s populatio ad the spread the itervetio to other patiets. By the ed of the year, most health ceters had targeted all of their diabetic patiets at their give site. Data collectio We aalyzed a variety of data for triagulatio ad icreased validity of fidigs. We cocetrated o process ad outcome measures alog both cliical ad orgaizatioal lies. I a brief 1-year evaluatio period, it may be difficult to see sigificat improvemet i outcomes. However, the collaborative could be cosidered successful if we foud improvemet i itermediary processes expected to lead to better outcomes. The Uiversity of Chicago Istitutioal Review Board approved the study, ad iformed coset was obtaied. Chart review. We used a preexistig chart review istrumet developed by a team from The Uiversity of Chicago ad the MidWest Cliicias Network to describe patiet demographics ad evaluate process-of-care measures based o the cliical recommedatios of the America Diabetes Associatio (20). The chart review istrumet was accompaied by a codebook, ad each ceter was istructed i the chart abstractio process. Each ceter was asked to idetify patiets with diabetes through admiistrative records ad Iteratioal Classificatio of Diseases, Cliical Modificatio, 9th editio diagostic code 250.x or patiet registries (21), ad to the perform chart review o 80 patiets with diabetes (cofirmed by chart review), aged years ad chose by radom umber geerator, or o all diabetic patiets aged years if their ceter had fewer tha 80. Pregat wome were excluded. Each ceter abstracted data from the year before the collaborative (1998) ad the year of the collaborative (1999). Whe possible, the same patiets charts were abstracted i 1998 ad If a patiet aalyzed i 1998 was o loger see at the health ceter i 1999, the aother radomly chose diabetic patiet s chart was abstracted i 1999 so that close to 80 patiets per ceter per year were aalyzed. The average umber of chart audits per ceter was 69 i 1998 ad 79 i O average, 72% of the patiets whose charts were audited i 1998 were followed up i To check o the reliability of the chart review, a radom 5% sample of charts was reaudited by the health ceters for the major America Diabetes Associatio process-of-care variables. The overall agreemet of items was 84% with a average statistic of 0.65 (22). Provider surveys. Toward the ed of the first year of the collaborative, we mailed a survey to members ( 106) of each health ceter s diabetes collaborative team. Norespodets were mailed two more copies of the survey ad were the telephoed with a subset of the questios if they still had ot respoded. The survey addressed overall evaluatio of the collaborative, quality improvemet models ad tools, educatio ad assistace, commu- DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY

3 Improvig diabetes care i health ceters icatio, team fuctioig (23), diffusio ad cotiuatio of activities, time, costs, admiistrative support, ad demographic iformatio. Questios developed by the research team geerally were rated o a five-poit Likert-type scale. Semistructured telephoe iterviews of team leaders, team members, ad oteam members. We coducted semistructured telephoe iterviews with team leaders ad team members, iquirig about the ature of the itervetio, program implemetatio at each health ceter, overall assessmet, facilitators ad challeges to the itervetio, ad spread of the iitiative. Team leaders were iterviewed twice (i August 1999 ad April/ May 2000), ad radom team members were iterviewed oce (i April/May 2000). We also coducted similar iterviews durig the latter period with at least oe radomly selected oteam member at each health ceter i order to gauge the awareess of the itervetio by other cliic staff ad its diffusio throughout the health ceter. Iterviews were audiotaped. Aalytical pla Adherece to America Diabetes Associatio Cliical Practice Recommedatios. We performed descriptive statistics o patiet demographic characteristics ad compared the rates at which the processes-of-care stadards were met from 1998 to The primary measures of the quality of care were eight major process measures ad oe outcome measure: 1) at least oe measuremet of HbA 1c, 2) two measuremets of HbA 1c at least 3 moths apart, 3) dilated eye examiatio, 4) diet itervetio, 5) detal care, 6) foot care or foot educatio, 7) lipid assessmet, 8) urie microalbumi assessmet, ad 9) the absolute value of HbA 1c (20). The uit of aalysis was the measure i a give year for a idividual patiet, so that idividual measures were ested withi patiets ad patiets were ested withi health ceters. To icorporate correlatio betwee measures o the same patiet ad betwee patiets i the same health ceter, we used hierarchical regressio (24 26). For HbA 1c, which was approximately ormally distributed, we fit hierarchical liear models (HLMs) with patiet ad health ceter as radom effects, usig HLM statistical software, versio 5. The eight process measures were dichotomous variables, which idicated whether a particular process of care had bee performed, ad were aalyzed i HLM usig hierarchical logistic regressio, agai with patiet ad health ceter as radom effects. We performed two sets of outcome aalyses. I the primary aalyses, oly patiets preset i both 1998 ad 1999 are icluded. I the secod set, patiets preset i either 1998 or 1999 are aalyzed. Survey Survey results were tabulated by coceptual domai. Selected items, such as usefuless ad burde of patiet registry were also cross-tabulated. Both summary scales ad idividual items were icluded. The summary scales represet selected coceptual domais ad iclude frequecy ad usefuless of commuicatio betwee the team ad collaborative, team iterpersoal relatios, team efficacy, usefuless of the Chroic Care Model compoets, itet to cotiue collaborative activities, ad costs of participatio i terms of time ad effort. These multi-item scales were costructed as equally weighted averages. Items were reverse coded as eeded to coform to a positive versus egative respose scale. Reliability aalysis idicated good iteral cosistecy of the scales (Crobach s ) (27). To ehace comparability to idividual items, summary scales were recoded to correspod to the origial oe- to five-poit Likert scale usig midpoits as cutpoits betwee levels (e.g., 4.5 as the cutpoit betwee agree ad strogly agree ). Sevety-ie team members retured surveys, for a respose rate of 75%. All 19 participatig commuity health ceters had three or more respodets (rage 3 8, media 5). Niety-three (88%) team members either retured a writte questioaire or aswered the telephoe survey. After verifyig that the telephoe resposes were cosistet with resposes o the larger questioaire, the data from the two sources were pooled. Iterviews Two ivestigators idepedetly listeed to each audiotape or read each trascriptio to esure the validity ad reliability of the theme aalysis. RESULTS Patiet populatio The patiet demographic characteristics i 1998 ad 1999 from the chart review were almost idetical, differig by 3% i ay category of ay variable. Approximately two-thirds (64%) were wome, oe-third (1998: 33%; 1999: 32%) were Africa America, ad 22% were Hispaic. About half (47 ad 46%, respectively) were betwee 51 ad 65 years of age, ad oe-quarter (24 ad 22%) were years old. About 90% (88 ad 90%) had type 2 diabetes, ad approximately oe-third (34 ad 33%) were takig isuli or isuli ad a oral aget. Oe-fourth (24 ad 23%) had Medicare isurace, oe-fourth (26 ad 24%) had Medicaid isurace, ad about oequarter (27 ad 28%) were self-pay, usually o a slidig-fee schedule. Thirtyseve percet of the health ceters were rural. O average, each ceter had 398 patiets with diabetes (rage ). Itervetios Most health ceters performed at least 30 differet itervetios over the course of the year. Examples of frequetly performed itervetios for each elemet of the Chroic Care Model are below. Commuity: collaborate with commuity orgaizatios for health ceter s populatio (89%). Patiet self-maagemet support: selfmaagemet tool or goal sheet to track a patiet s progress (63%). Delivery system redesig: group cluster visits (63%). Decisio support: diabetes flow sheet (100%). Computer iformatio systems: used patiet registry to follow up o examiatio ad laboratory data (37%). Adherece to America Diabetes Associatio Cliical Practice Recommedatios The proportios of patiets for whom each of the major processes of care were performed icreased sigificatly from 1998 to 1999, as determied by chart review (Table 1). Rates of HbA 1c measuremet, eye examiatio referral, dietary couselig, foot examiatio, detal referral, lipid assessmet, ad urie microalbumi assessmet all improved, with ORs ragig from 1.28 to 2.92 for 4 DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY 2004

4 Chi ad Associates Table 1 Compariso of diabetes processes ad outcomes from 1998 to 1999 Processes ad outcomes OR/Differeces (95% CI) P Matched patiets* ( 969) Oe HbA 1c measuremet ( ) Two HbA 1c measuremets, at least 3 moths apart ( ) Eye exam referral ( ) 0.02 Dietary couselig/referral to utritioist ( ) 0.10 Foot exam/referral to podiatrist ( ) Detal referral ( ) Lipid assessmet ( ) 0.02 Urie microalbumi assessmet ( ) HbA 1c value (%) ( 0.41 to 0.03) 0.09 All patiets ( 1,628) Oe HbA 1c measuremet ( ) Two HbA 1c measuremets, at least 3 moths apart ( ) Eye exam referral ( ) 0.02 Dietary couselig/referral to utritioist ( ) 0.04 Foot exam/referral to podiatrist ( ) Detal referral ( ) Lipid assessmet ( ) Urie microalbumi assessmet ( ) HbA 1c value (%) ( 0.36 to 0.11) 0.30 Data are % uless otherwise idicated. *Patiets preset i both 1998 ad 1999 chart reviews; all patiets with available chart reviews. patiets preset i both 1998 ad 1999 chart reviews. The mea value of HbA 1c decreased slightly (P 0.09). Evaluatio of the collaborative Survey respodets idicated a high level of support for the collaborative. About 95% of respodets agreed or strogly agreed that the collaborative was worth the effort ad was successful (Table 2), ad 80% iteded to cotiue collaborative activities. Both the Chroic Care Model ad the PDSA system were geerally thought to be helpful, although 11% of respodets did ot fid the PDSA system useful. Teams geerally worked well together. Regardig diffusio, 79% of respodets oted that patiets or oteam coworkers had commeted o chages iitiated by the team. Areas that were most challegig cocered time ad the related burde of data collectio ad report geeratio. Most respodets spet 1 5 h per week o collaborative activities, ad 38% spet 6 10 h or more. Thirty-oe percet of respodets, distributed amog 15 of the 19 participatig commuity health ceters, reported iadequate time to work o collaborative activities. Most respodets agreed that they received support from their health ceter s admiistratio, but oly 41% agreed that the admiistratio had supplied release time from other duties for collaborative activities. A large majority of respodets cosidered the mothly reports ad patiet registry useful but also burdesome. Sigificat team member ad cliic staff turover was reported by about half of the respodets. Overall, i iterviews team leaders ad team members were very proud of their accomplishmets. Major perceived successes icluded improved diabetes care (e.g., lower HbA 1c, more self-maagemet, better commuity likages), better adherece to stadards, more comprehesive care, icreased awareess amog patiets ad providers, developmet of patiet registries ad trackig systems, cluster cliics i which patiets receive multiple aspects of care i oe joit sessio, ad etworkig with other health ceters. The Chroic Care Model ad rapid PDSA cycle models were useful, although may ceters used the PDSA cycles qualitatively as opposed to quatitatively. Most oteam members were aware of the collaborative itervetio ad thought that it had improved the system of diabetes care at their health ceters. Team leaders ad members oted the eed for more staff, time, ad techical support, as well as for more supplies ad educatioal materials for patiets. About oethird of the ceters expressed a desire for more seior support, ad several ceters reported that they wished there was someoe i a positio of authority to ecourage provider adherece with the program. A frotlie champio was usually eeded i additio to seior maagemet support. May ceters iitially had difficulties with developig their computerized patiet registry systems. Some respodets also expressed a preferece for clear directio, clear termiology, ad may cocrete examples. They wated a clear structure, but valued their autoomy. CONCLUSIONS The BPHC s Health Disparities Collaborative is the most ambitious effort to date to improve the quality of diabetes care i commuity health ceters. Breakthrough Series cocepts draw from teets of cotiuous quality improvemet, chroic disease maagemet, ad collaborative learig have become icreasigly popular i recet years, but evaluatio of these techiques has bee limited (18,28). Wager et al. (18) tested the Diabetes Collaborative approach i a group of 23 health care orgaizatios, of which 7 were safety et providers. They oted that may teams reported improvemets i several goals, icludig measuremet of HbA 1c ad actual HbA 1c level. Commuity health ceters had some of the largest gais. Wager et al. primarily used qual- DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY

5 Improvig diabetes care i health ceters Table 2 Evaluatio of Breakthrough Series by diabetes quality improvemet team members disagree Disagree Neither Agree agree Overall The Diabetes Collaborative was worth the effort * Participatio i the Diabetes Collaborative was successful * Will cotiue Diabetes Collaborative model ad itervetios. (5 items) Models ad tools PDSA System was used to implemet chage, useful, will cotiue to use (3 items) Chroic Disease Model Chroic Disease Model used as coceptual guide, useful, will cotiue to use (3 items) Diabetes Collaborative helpful i improvig elemets of Chroic Disease Model i CHC (6 items) Data i mothly reports useful to cliic * Patiet registry useful. (2 items) Educatio ad assistace Istitute for Healthcare Improvemet traiig helpful Istitute for Healthcare Improvemet traiig clear Midwest Cluster Coordiator helpful. (2 items) Team leared from other CHCs i Midwest Cluster Commuicatio withi Collaborative. (6 items) Very iaccurate Mostly iaccurate Slightly iaccurate Ucertai Slightly accurate Mostly accurate Very accurate Team fuctioig Team fuctioig (14-item scale) Never Rarely Occasioally Sometimes Fairly ofte Almost always Always Team role Idividual role clarity (4 items) Missio clarity (4 items) disagree Disagree Neither Agree agree Team iterpersoal relatios Team iterpersoal relatios (7 items) Team efficacy (3 items) Collaborative atmosphere/cosesus at meetigs: (2 items) (atmosphere: 1 tese/cofrotatioal,..., 5 relaxed/collaborative) (cosesus: 1 ever, seldom, sometimes, ofte, 5 always) Cotiued ity improvemet data ad methods for their study ad suggested that more rigorous research ad program evaluatios eeded to be doe. Our study adds importat iformatio. It was desiged to be a research evaluatio ad, thus, icluded rigorous data from multiple data sources ad statistical techiques that adjusted for clusterig of patiets withi ceters. Our data also allowed us to describe some of the facilitators ad barriers to the itervetio i more detail. Our study icludes a broader rage of health ceters ad is therefore more geeralizable to all types of commuity health ceters. 6 DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY 2004

6 Chi ad Associates Table 2 Cotiued Meetigs ad hours of work Frequecy of team meetigs Average attedace of respodet: percet of meetigs Hours per week o collaborative Mothly Biweekly Weekly % 20% 40% 60% 80% 100% disagree Disagree Neither Agree agree Costs of Diabetes Collaborative participatio Data collectio burdesome (2 items) Adequate time to work o Diabetes Collaborative (3 items) Support Admiistrative support * Noteam coworker support Time away from other duties by admiistratio to work o collaborative Geeral istitutioal eviromet Sigificat team member/cliic staff turover durig collaborative (2 items) Diffusio Patiets/oteam coworkers commeted o chages iitiated by team (2 items) Data are % uless otherwise idicated. *Icludes telephoe respodets. May health ceters felt that they eeded more resources to free staff time for the project. I additio, more resources may be eeded to provide some services, such as dilated eye examiatios. The delay i fidig a efficiet ad commo electroic patiet registry impeded may ceters from quickly idetifyig their populatio ad startig desired itervetios. The Chroic Care Model was uiversally thought to be useful. I compariso, the rapid PDSA methodology received less support, although it was still viewed favorably overall. The proper balace of structure ad autoomy eeds to be foud. The Breakthrough Series is a geeral model, but may health ceters wated a meu of cocrete model itervetios to choose from. By the ed of the first year, differet optios were beig preseted, such as the learig sessios i which health ceters could share model programs. Templates for basic ifrastructural compoets, such as the patiet registry, were provided. Buy-i from seior maagemet was critical ad variable, ad subsequet Diabetes Collaborative efforts have facilitated this through explicit expectatios ad commitmets from seior maagemet ad through traiig of both leaders ad staff regardig this issue. A champio of the Breakthrough Series at each ceter was critical. Our study has several limitatios. Chart review examies chartig practices that may ot wholly represet the actual care provided. We may have uderestimated the effect of the Breakthrough Series because we took a radom sample of patiets charts from each ceter. To the extet that a health ceter did ot target all of its patiets with diabetes at their site for itervetios, radom chart audit may uderestimate the effects of the itervetio. However, virtually all health ceters reported that they had targeted all of their diabetic patiets for itervetios by the latter moths of the iitiative. A additioal limitatio existed because some of the patiets targeted durig the latter moths of the year had a relatively short time to beefit from the itervetio. Loger follow-up is eeded to determie the full ad lastig effects of the itervetio. Also, ot every health ceter targeted each of the idividual America Diabetes Associatio stadards for quality improvemet. Thus, our aalysis of pooled data from each health ceter about each quality stadard may be a coservative estimate of the Breakthrough Series effect. While our 75% survey respose is high for a provider survey (29), orespodet bias is still possible. However, through telephoe follow-up of orespodets to the writte survey, we obtaied a 88% respose rate to several of the most importat global evaluatio questios of the Diabetes Collaborative. Give that the results of the telephoe respodets were similar to those from the subsample of the 75% of providers aswerig the writte questioaire, we felt that bias was miimal. I additio, our study is oradomized. Coceivably, secular chages urelated to the itervetio may have led to the improvemet i diabetes care. However, this is ulikely as the Diabetes Collaborative was by far the domiat ifluece betwee the 2 years of data measuremet. Our study of the first year of the iitiative idicates that the Breakthrough Series is a promisig itervetio to improve processes of diabetes care. I additio, sice this first experiece implemetig a chroic disease collaborative i health ceters has subsequetly led to refiemets i how the Breakthrough Series is orgaized ad ru, future collaboratives are eve more likely to be successful. However, several importat research questios remai. Whether quality improvemet ca be sustaied beyod 1 year eeds to be determied. Is it possible DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY

7 Improvig diabetes care i health ceters to sustai improvemet without more fudig for staff time? Ca morale be maitaied? Are cotiued collaborative activities ecessary to esure sustaiability? If so, what types of activities ad support are most critical? How much staff time eeds to be freed for collaborative activities? Is it critical to free time for the team leader, the team members, or both parties? I additio, it is ukow whether quality improvemet efforts ca survive major turover i staff. How ca the Breakthrough Series efforts be istitutioalized so that health ceters are ot depedet o ay oe champio or few idividuals? How does oe create the culture ad support for chage ad quality improvemet? As health ceters broade their quality improvemet efforts, it will be importat to determie how diabetes care ca be itegrated ito a overall ogoig improvemet process to avoid a segmeted, disease of the moth feel. Balacig attetio ad resources for diabetes with other worthy competig goals at the health ceters will be challegig, ad it will be importat to determie if the collaborative itervetio is cost-effective. The BPHC s Diabetes Breakthrough Series ad wider 6-year Health Disparities Collaborative are bold itervetios to improve the quality of care i health ceters. Our iitial evaluatio of this effort i Midwest health ceters idicates that the model, i cojuctio with the ethusiasm ad hard work of cliicias ad admiistrators, has led to sigificat improvemets i diabetes care i 1 year as assessed through chart review. Ackowledgmets This project was supported by the Bureau of Primary Health Care, the Agecy for Healthcare Research ad Quality (R01 HS ), ad the Natioal Istitute of Diabetes ad Digestive ad Kidey Diseases Diabetes Research ad Traiig Ceter (P60 DK20595). M.H.C. is a Robert Wood Johso Foudatio Geeralist Physicia Faculty Scholar. Preseted i part at the America Diabetes Associatio Aual Meetig, Jue 23, 2001, Philadelphia, Pesylvaia, ad at the America Public Health Associatio Aual Meetig, October 22, 2001, Atlata, Georgia. Refereces 1. Lefkowitz B, Todd J: A overview: health ceters at the crossroads. J Ambulatory Care Maage 22:1 12, Natioal Associatio of Commuity Health Ceters, Available at Accessed 21 August Harris MI, Cowie CC, Ster MP, Boyko EJ, Reiber GE, Beett PH, Eds: Diabetes i America. 2d ed. Bethesda, MD, Natioal Istitutes of Health (NIH publicatio o ), Chi MH, Zhag JX, Merrell K: Diabetes i the Africa-America Medicare populatio: morbidity, quality of care, ad resource utilizatio. Diabetes Care 21: , Walker EA, Egel SS, Zybert PA: Dissemiatio of diabetes care guidelies: lessos leared from commuity health ceters. Diab Educ 27: , Walker EA, Wylie-Rosett J, Shamoo H, Egel S, Basch CE, Zybert P, Cypress M: Program developmet to prevet complicatios of diabetes: assessmet of barriers i a urba cliic. Diabetes Care 18: , Deeb LC, Pettijoh FP, Shirah JK, Freema G: Itervetios amog primarycare practitioers to improve care for prevetable complicatios of diabetes. Diabetes Care 11: , Marrero DG: Curret effectiveess of diabetes health care i the U.S.: how far from the ideal? Diabetes Reviews 2: , Miller KL, Hirsch IB: Physicias practices i screeig for the developmet of diabetic ephropathy ad the use of glycosylated hemoglobi levels. Diabetes Care 17: , Starfield B, Powe NR, Weier JR, Stuart M, Steiwachs D, Scholle SH, Gersteberger A: Costs vs. quality i differet types of primary care settigs. JAMA 272: , Peters AL, Legorreta AP, Ossorio RC, Davidso MB: Quality of outpatiet care provided to diabetic patiets: a health maiteace orgaizatio experiece. Diabetes Care 19: , Mayfield JA, Rith-Najaria SJ, Acto KJ, Schraer CD, Stah RM, Johso MH, Gohdes D: Assessmet of diabetes care by medical record review: the Idia Health Service model. Diabetes Care 17: , Chi MH, Cook S, Ji L, Drum ML, Harriso JF, Koppert J, Thiel F, Harrad AG, Schaefer CT, Takashima HT, Chiu SC: Barriers to providig diabetes care i commuity health ceters. Diabetes Care 24: , Chi MH, Auerbach SB, Cook S, Harriso JF, Koppert J, Ji L, Thiel F, Karriso TG, Harrad AG, Schaefer CT, Takashima HT, Egbert N, Chi SC, McNabb WL: Quality of diabetes care i commuity health ceters. Am J Public Health 90: , Bell RA, Camacho F, Gooa K, Dure- Wifield V, Aderso RT, Koe JC, Goff DC Jr: Quality of diabetes care amog lowicome patiets i North Carolia. Am J Prev Med 21: , Wylie-Rosett J, Basch C, Walker EA, Zybert P, Shamoo H, Egel S, Cypress M: Ophthalmic referral rates for patiets with diabetes i primary-care cliics located i disadvataged urba commuities. J Diabetes Complicatios 9:49 54, Porterfield DS, Kisiger L: Quality of care for uisured patiets with diabetes i a rural area. Diabetes Care 25: , Wager EH, Glasgow RE, Davis C, Boomi AE, Provost L, McCulloch D, Carver P, Sixta C: Quality improvemet i chroic illess care: a collaborative approach. Jt Comm J Qual Improvemet 27: 63 80, Wager EH, Austi BT, Vo Korff M: Orgaizig care for patiets with chroic illess. Milbak Q 74: , America Diabetes Associatio: Cliical practice recommedatios Diabetes Care 26 (Suppl. 1), Medicode: The Iteratioal Classificatio of Diseases, 9th Revisio, Cliical Modificatio. 5th ed. Salt Lake City, UT, Medicode Publicatios, Ladis JR, Koch GG: The measuremet of observer agreemet for categorical data. Biometrics 33: , Alexader JA, Lichtestei R, Jiett K, D Auo TA, Ullma E: The effects of treatmet team diversity ad size o assessmets of team fuctioig. Hosp Health Serv Admi 41:37 53, Bryk AS, Raudebush SW: Hierarchical Liear Models: Applicatios ad Data Aalysis Methods. Newbury Park, CA, Sage Publicatios, Harville DA: Maximum likelihood approaches to variace compoet estimatio ad to related problems. J Am Stat Assoc 72: , Lidstrom MJ, Bates DM: Noliear mixed effects models for repeated measures data. Biometrics 46: , Crobach LJ: Coefficiet alpha ad the iteral structure of tests. Psychometrica 16: , Solberg LI, Kottke TE, Brekke ML, Maga S, Davidso G, Calomei CA, Co SA, Amudso GM, Nelso AF: Failure of a cotiuous quality improvemet itervetio to icrease the delivery of prevetive services: a radomized trial. Effective Cliical Practice 3: , Asch DA, Jedrziewski MK, Christakis NA: Respose rates to mail surveys published i medical jourals. J Cli Epidemiol 50: , DIABETES CARE, VOLUME 27, NUMBER 1, JANUARY 2004