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Closing the Quality Gap: Revisiting the State of the Science (Vol. 3: Quality Improvement Interventions To Address Health Disparities)
Evidence Reports/Technology Assessments, No. 208.3
Investigators: Melissa L McPheeters, PhD, MPH, Sunil Kripalani, MD, MSc, Neeraja B Peterson, MD, MSc, Rachel T Idowu, MD, Rebecca N Jerome, MLIS, MPH, Shannon A Potter, MLIS, and Jeffrey C Andrews, MD, FRCSC.
Author Information and AffiliationsStructured Abstract
Objective:
This review evaluates the effectiveness of quality improvement (QI) strategies in reducing disparities in health and health care.
Data Sources:
We identified papers published in English between 1983 and 2011 from the MEDLINE® database, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science Social Science Index, and PsycINFO.
Review Methods:
All abstracts and full-text articles were dually reviewed. Studies were eligible if they reported data on effectiveness of QI interventions on processes or health outcomes in the United States such that the impact on a health disparity could be measured. The review focused on the following clinical conditions: breast cancer, colorectal cancer, diabetes, heart failure, hypertension, coronary artery disease, asthma, major depressive disorder, cystic fibrosis, pneumonia, pregnancy, and end-stage renal disease. It assessed health disparities associated with race or ethnicity, socioeconomic status, insurance status, sexual orientation, health literacy/numeracy, and language barrier. We evaluated the risk of bias of individual studies and the overall strength of the body of evidence based on risk of bias, consistency, directness, and precision.
Results:
Nineteen papers, representing 14 primary research studies, met criteria for inclusion. All but one of the studies incorporated multiple components into their QI approach. Patient education was part of most interventions (12 of 14), although the specific approach differed substantially across the studies. Ten of the studies incorporated self-management; this would include, for example, teaching individuals with diabetes to check their blood sugar regularly. Most (8 of 14) included some sort of provider education, which may have focused on the clinical issue or on raising awareness about disparities affecting the target population. Studies evaluated the effect of these strategies on disparities in the prevention or treatment of breast or colorectal cancer, cardiovascular disease, depression, or diabetes. Overall, QI interventions were not shown to reduce disparities. Most studies have focused on racial or ethnic disparities, with some targeted interventions demonstrating greater effect in racial minorities—specifically, supporting individuals in tracking their blood pressure at home to reduce blood pressure and collaborative care to improve depression care. In one study, the effect of a language-concordant breast cancer screening intervention was helpful in promoting mammography in Spanish-speaking women. For some depression care outcomes, the collaborative care model was more effective in less-educated individuals than in those with more education and in women than in men.
Conclusions:
The literature on QI interventions generally and their ability to improve health and health care is large. Whether those interventions are effective at reducing disparities remains unclear. This report should not be construed to assess the general effectiveness of QI in the health care setting; rather, QI has not been shown specifically to reduce known disparities in health care or health outcomes. In a few instances, some increased effect is seen in disadvantaged populations; these studies should be replicated and the interventions studied further as having potential to address disparities.
Contents
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Discussion
- References
- Acronyms and Abbreviations
- Appendix A Literature Search Strategies
- Appendix B Abstract Review Form
- Appendix C Full-Text Review Form
- Appendix D Cochrane Risk of Bias Tool
- Appendix E Cochrane Risk of Bias Criteria
- Appendix F Newcastle-Ottawa Quality Assessment Scale
- Appendix G Thresholds for Quality Assessment
- Appendix H Quality of Individual Studies
- Appendix I Evidence Table
- Appendix J Strength of Evidence for Outcomes
- Appendix K Applicability Tables
- Appendix L Excluded Papers
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10065. Prepared by: Vanderbilt University Evidence-based Practice Center, Nashville, TN
Suggested citation:
McPheeters ML, Kripalani S, Peterson NB, Idowu RT, Jerome RN, Potter SA, Andrews JC. Quality Improvement Interventions To Address Health Disparities. Closing the Quality Gap: Revisiting the State of the Science. Evidence Report No. 208. (Prepared by the Vanderbilt University Evidence-based Practice Center under Contract No. 290-2007-10065.) AHRQ Publication No. 12-E009-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Vanderbilt University Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10065). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
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