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Quality of Care/Patient Safety

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Quality improvement initiatives can improve health care for minorities

Two recent studies supported by the Agency for Healthcare Research and Quality show improved care for minorities resulting from quality improvement (QI) initiatives. The first AHRQ-study (HS08349) demonstrated that QI interventions that made modest modifications in QI design for minority patients suffering from depression decreased their likelihood of continued depression. A second AHRQ-supported study (KO2 HS00006) revealed improved survival among frail elderly blacks who participated in a program that provided them with access to and coordination of comprehensive medical and long-term care services. The studies are briefly summarized here.

Miranda, J., Duan, N., Sherbourne, C., and others (2003, April). "Improving care for minorities: Can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial." Health Services Research 38(2), pp. 613-630.

When depressed black and Hispanic patients in this study were provided with recommended medications or psychotherapy by culturally competent providers, as well as language translation when needed, they were substantially less likely than similar patients receiving usual care to still be depressed 6 or 12 months later. These researchers randomly assigned 398 Hispanics, 93 blacks, and 778 whites from 46 primary care practices in 6 U.S. managed care organizations to either usual care for depression or one of two QI programs. These programs were designed to increase access to and adherence to either antidepressants at recommended doses or psychotherapy (at least four specialty mental health visits focused on problem solving).

The programs trained local experts to educate clinicians about recommended depression treatment; train nurses to educate, assess, and followup with patients; and train psychotherapists to conduct culturally appropriate cognitive behavioral therapy. Patients and physicians selected treatments. The programs also provided language translation for patients and cultural training for clinicians. The researchers examined continued depression and retention in employment at 6 and 12 months.

At study enrollment, all groups had low to moderate rates of appropriate care. The QI programs significantly improved appropriate care at 6 months (8-20 percentage points) within each ethnic group. They also significantly decreased the likelihood that patients would report probable depression at 6- and 12-month followup. White patients in the QI programs did not differ from whites in the usual care group in reported probable depression at either followup point, while minorities in the QI programs had less depression at followup than their usual care counterparts. The QI programs significantly improved the employment rate for whites, but the same was not true for minorities.

Tan, E.J., Lui, L., Eng, C., and others (2003, February). "Differences in mortality of black and white patients enrolled in the Program of All-Inclusive Care for the Elderly." Journal of the American Geriatric Society 51, pp. 246-251.

The Program of All-Inclusive Care for the Elderly (PACE) was carried out at 12 demonstration sites around the country from 1990 to 1996 and involved 2,861 patients (859 blacks and 2,002 whites). PACE provides comprehensive medical and long-term care services—ranging from physical therapy and durable medical equipment to medications and transportation—for nursing home-eligible older people who live in the community. A greater proportion of black elders enrolled in PACE survived, compared with white elders, according to this study. Black patients were younger than white patients (mean age 77 vs. 80) but had worse functional status at enrollment, perhaps due to previous barriers to care.

Survival for black and white patients was 88 percent and 86 percent at 1 year, 67 percent and 61 percent at 3 years, and 51 percent and 42 percent at 5 years, respectively. After adjustment for coexisting medical conditions, functional status at study enrollment, and demographic characteristics such as income, elderly black PACE patients still had a 23 percent lower mortality rate than white patients. The survival advantage for black patients did not emerge until about 1 year after PACE enrollment. The researchers conclude that the survival advantage of black patients enrolled in PACE may be related to the comprehensive access to and coordination of services provided by the PACE program.

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