A comprehensive evaluation of a diabetes quality improvement project in privately owned primary care practices that serve minority patients.

The authors conducted a diabetes quality improvement project in 5 privately owned primary care practices serving at least 25% minority patients. Interventions included group-specific and practice-specific training on an electronic patient registry, cultural competency practices and tools, and selected quality improvement strategies. The authors conducted a comprehensive evaluation involving quantitative and qualitative data to assess project impact. Although overall clinical performance did not improve over the 14- to 20-month project time frame, other practice structural characteristics and processes did show improvement: successful implementation of the registry and clinician reminders in all practices, institution of team care and patient reminders in 4 practices, and collection of patient race/ethnicity data in 4 practices. These results highlight the difficulty of bringing about clinical improvement in this subset of practices and also the importance of conducting comprehensive evaluations to fully understand and interpret multicomponent quality improvement projects.

Challenges in recruiting minority-serving private practice primary care physicians to a quality improvement project.

The objectives of this study were the following: (1) describe one organization's experience with recruiting minority-serving private practice primary care physicians to an ambulatory quality improvement (QI) project; (2) compare and contrast physicians who agreed to participate with those who declined; and (3) list incentives and barriers to participation. The authors identified eligible physicians by analyzing Medicare Part B claims data, a publicly available physician database, and office staff responses to telephone inquiries. The recruitment team had difficulty identifying, contacting, and recruiting eligible physicians. Solo practitioners and physicians who had lower scores on certain quality measures were more likely to participate. Barriers to participation were similar in all practices and included concerns about extra work, difficulty of change, and impact on office work flow. Commonly used incentives were offered but were not universally embraced. Additional work is required to refine the process of physician recruitment and to find more compelling incentives for QI.

The Equity and Quality (EQual) Health-Care Project: A Connecticut Health Foundation initiative with Qualidigm.

In response to the growing incidence and prevalence of diabetes, quality and disparity of care concerns, and the increasing diversity of the US and Connecticut's populations, the Connecticut Health Foundation funded Qualidigm to implement the Equity and Quality (EQual) Health-Care Project. Now in its second full year, the EQualHealth-CareProject is helping eight primary-care practices in Connecticut improve the equity and quality of diabetes care through technology, education, and quality improvement.

Understanding barriers to participation in mammography by women with disabilities.

PURPOSE: The study purpose was to identify barriers to mammography screening among women with different disabilities and to suggest interventions to address barriers. METHODS: Forty-two women with self-reported disabilities, ages 40 to 69 years participated. They resided in 24 Connecticut towns, and most had a prior mammogram. Data were collected through six disability-specific focus groups from women with sensory, physical, psychiatric, and cognitive/intellectual impairments. Facilitator-conducted groups used a semistructured guide. Qualitative analysis applied an iterative coding process to generate themes and categories. RESULTS: We identified four themes (i.e., access, beliefs, social support, and comfort/ accommodations) and nine subthemes that characterized barriers. In all focus groups, women mentioned physical access and physical comfort/accommodations as types of barriers. Other major subthemes were communication and professional support. Women also described mammography facilitators. CONCLUSION: Despite frequent use of health care and personal strategies to facilitate mammography screening, women with disabilities reported barriers to getting mammograms. Findings suggest a multifaceted approach to address these barriers.

Physicians' views on public reporting of hospital quality data.

This article describes physicians' responses to patient questions and physicians' views about public reports on hospital quality. Interviews with 56 office-based physicians in seven states/regions used hypothetical scenarios of patients questioning referrals based on public reports of hospital quality. Responses were analyzed using an iterative coding process to develop categories and themes from data. Four themes describe physicians' responses to patients: (a) rely on existing physician-patient relationships, (b) acknowledge and consider patient perspectives, (c) take actions to follow up on patient concerns, and (d) provide patients' perspectives on quality reports. Three themes summarize responses to hospital quality reports: perceived lack of methodological rigor, content considerations in reports, and attitudes/experience regarding reports. Findings suggest that physicians take seriously patients' questions about hospital-quality reports and consider changing referral recommendations based on their concerns and/or preferences. Results underscore the importance of efforts by report developers and physician outreach/education to address physicians' methodological concerns.

Understanding patterns of change over time to improve mammography rates.

This retrospective cohort study determined trends and patterns of mammography rates during 5 years (1997-2001) among female Medicare beneficiaries ages 50 years and older in Connecticut to better understand changes in rates over time and to plan future interventions. Time series analysis and hierarchical Longitudinal logistic regression were used to assess changes over time. Mammography rates increased significantly during the 5-year period (p < .001). A cyclical pattern was observed for all age groups and counties, with dips and peaks in the spring and fall each year (average increase 8% per year), consistent with concentrated intervention activity at those times.

Profiling variations in outpatient care for Medicare beneficiaries in Connecticut.

Qualidigm, the Medicare Quality Improvement Organization for Connecticut, is reporting the rates of four outpatient services for Medicare beneficiaries on its website (www.qualidigm.org). These measures include screening for breast cancer (mammography) and chronic disease management for diabetes (HbAlc, eye exam and lipid profile). Maps of Connecticut illustrate the rates for Whites and Non-whites by Health Service Area. The maps highlight variation across small local areas and between Whites and Non-whites. By reporting these rates publicly, Qualidigm hopes to facilitate ongoing efforts by community organizations and health care providers to make improvements in care, especially for the underserved populations throughout the state.

Using public reports of patient satisfaction for hospital quality improvement.

OBJECTIVE: To explore the impact of statewide public reporting of hospital patient satisfaction on hospital quality improvement (QI), using Rhode Island (RI) as a case example. DATA SOURCE: Primary data collected through semi-structured interviews between September 2002 and January 2003. STUDY DESIGN: The design is a retrospective study of hospital executives at all 11 general and two specialty hospitals in RI. Respondents were asked about hospital QI activities at several points throughout the public reporting process, as well as about hospital structure and processes to accomplish QI. Qualitative analysis of the interview data proceeded through an iterative process to identify themes and categories in the data. PRINCIPAL FINDINGS: Data from the standardized statewide patient satisfaction survey process were used by hospitals to identify and target new QI initiatives, evaluate performance, and monitor progress. While all hospitals fully participated in the public reporting process, they varied in the stage of development of their QI activities and adoption of the statewide standardized survey for ongoing monitoring of their QI programs. Most hospitals placed responsibility for QI within each department, with results reported to top management, who were perceived as giving strong support for QI. The external environment facilitated QI efforts. CONCLUSION: Public reporting of comparative data on patient views can enhance and reinforce QI efforts in hospitals. The participation of key stakeholders facilitated successful implementation of statewide public reporting. This experience in RI offers lessons for other states or regions as they move to public reporting of hospital quality data.

Lessons learned from performance feedback by a quality improvement organization.

Performance feedback is a common quality improvement (QI) intervention strategy in the outpatient setting. This article describes the use by one quality improvement organization (QIO) of performance feedback to primary-care physicians with claims-based measures relating to diabetes, adult vaccinations, and mammography screening. Feedback from the physicians identified themes relating to data accuracy, methodology of the feedback reports, reasons for low performance rates, and suggestions on how the QIO could improve its intervention strategy. The article highlights the value of collecting and analyzing formative data on the process and offers specific recommendations to other QI professionals contemplating the use of claims data for performance feedback.

Methodological issues in public reporting of patient perspectives on hospital quality.

BACKGROUND: Increasing attention is being focused on public reporting of patient satisfaction and experience with hospital care, both nationally and at the state level. Comparative reports on hospital patient satisfaction use a standard survey, but little is known about underlying methodological approaches for reporting these quality measures. METHODS: Literature, Web sites, and key informants were used to identify nine public reports. In-depth reviews were conducted to determine approaches to collecting, analyzing, and publicly reporting comparative data. Data were grouped into four analytic categories: survey, sampling, computation of scores, and reporting of scores. RESULTS: The reports were similar in response rates and sampling procedures but differed in the number of hospitals included, the survey instrument, and survey procedure. The reports varied considerably in the techniques for computing hospital scores and decisions about reporting scores. CONCLUSIONS: Reports from nine locales illustrate the decision making necessary to produce comparative reports on hospital patient satisfaction. Differences stem from decisions about the survey instrument and statistical decisions about how to interpret and report data. These issues should be clearly delineated as part of any public reporting process.

Reducing disparities in utilization of mamography: reaching dually eligible women in Connecticut.

This article describes a two-pronged intervention by the health care Quality Improvement Organization (QIO) for Connecticut to address the disparity in rates of mammography screening between women eligible for both Medicare and Medicaid (i.e., "dually eligible") and other Medicare beneficiaries. The interventions were directed beneficiaries. One intervention addressed information and access needs of the target population: an education session was followed by a mobile mammography van session at low-income housing sites in specific geographic areas. The second intervention was a culturally-sensitive direct mailing to dually eligible beneficiaries across the state. Implementation methods are described including: defining and identifying the target population; specifying the disparity; developing community collaboration; and testing the mail materials. Preliminary results of the education sessions and community testing of the direct mail materials generated information about the target population. Issues in implementation and analysis include: reaching the target population, building community relations, and developing design approaches to test the intervention.

Public reporting of hospital patient satisfaction: the Rhode Island experience.

This article describes a collaborative process for legislatively mandated public reporting of health care performance in Rhode Island that began with hospital patient satisfaction. The goals of the report were both quality improvement and public accountability. Key features addressed include: the legislative context for public reporting; widespread participation of stakeholders; the structure for decision making; and the use of formative testing with cognitive interviews to get responses of consumers and others about the report readability and comprehensibility. This experience and the lessons learned can guide other States considering public reporting on health care performance.