Understanding Stakeholders' Perspectives to Increase COVID-19 Vaccine and Booster Uptake Among Black Individuals With Rheumatic Conditions.

OBJECTIVE: Disparities in COVID-19 vaccine and booster uptake persist. This study aimed to obtain perspectives from community and physician stakeholders on COVID-19 vaccine and booster hesitancy and strategies to promote vaccine uptake among Black individuals with rheumatic and musculoskeletal conditions. METHODS: We invited community leaders and physicians in greater Boston and Chicago to participate in semi-structured interviews using a moderator guide developed a priori. Participants were queried about how to best address vaccine hesitancy, strategies to target high-risk populations, and factors to identify future community leaders. Interviews were audio recorded, transcribed verbatim, and analyzed thematically using Dedoose. RESULTS: A total of 8 physicians and 12 community leaders participated in this study between November 2021 and October 2022. Qualitative analyses revealed misinformation/mixed messaging and mistrust, with subthemes including conspiracy theories, concerns regarding vaccine development and function, racism and historical injustices, and general mistrust of health care systems as the top cited reasons for COVID-19 vaccine hesitancy. Participants also shared demographic-specific differences, such as race, ethnicity, age, and gender that influenced the identified themes, with emphasis on COVID-19 vaccine access and apathy. Strategies for community-based vaccine-related information dissemination included personal storytelling with an iterative and empathetic approach, while recognizing the importance of protecting community leader well-being. CONCLUSION: To increase vaccine uptake among Black individuals with rheumatic conditions, strategies should acknowledge and respond to racial/ethnic and socioeconomic injustices that engender vaccine hesitancy. Messaging should be compassionate, individually tailored, and recognize heterogeneity in experiences and opinions. Results from these analyses will inform a planned community-based intervention in Boston and Chicago.

Factors associated with COVID-19 vaccine trust and hesitancy among adults with chronic conditions.

In a survey of older adults at higher risk for COVID-19 complications, we sought to describe expectations of trust in the safety and efficacy of a future COVID-19 vaccine, and level of hesitancy about receiving it. We also assessed whether these expectations were associated with known or suspected contributors to vaccine hesitancy, disparities in vaccine receipt, and potential targets for public health outreach. From May 1-22, 2020, we performed telephone surveys of 601 older adults with chronic conditions in metro Chicago about their COVID-19 experiences and levels of vaccine trust and hesitancy. All participants previously completed assessments of demographics, health status, health literacy and activation. Bivariate associations were performed using t-tests or one-way ANOVA, and multivariate analyses using least square means. Younger age (<60), Black race, greater complacency about contracting COVID-19, and lower confidence in state or local government were associated with significantly lower trust in a vaccine's safety and efficacy. Black race and greater complacency about contracting COVID-19 were associated with a significantly greater vaccine hesitancy. Amongst Black participants, vaccine hesitancy varied significantly by confidence in the federal government. Trust and hesitancy regarding a future COVID-19 vaccine were associated with age, race, complacency regarding contracting COVID-19, and confidence in government response to the pandemic, but not education, health literacy or activation. Therefore, efforts to vaccinate higher risk older adults must aim not only to educate and provide vaccine access, but engender trust in the vaccine development process and vaccination strategies at both the federal and the local level.

Identifying and addressing social determinants of health in outpatient practice: results of a program-wide survey of internal and family medicine residents.

BACKGROUND: Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents' competence at identifying and addressing SDOH. METHODS: Residents' perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients' challenges related to SDOH through referrals. RESULTS: The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients' challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. CONCLUSIONS: Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.

Developing Equity Report Cards for Residents Training in Primary Care.

BACKGROUND: Most residency programs do not provide trainees with health equity data for their clinic patients. METHODS: Equity report cards were developed for internal and family medicine residents in a large health system. After considering which equity indictors were available, how to attribute patients to residents, and what level of granularity was feasible, equity reports were created for five ambulatory quality measures. Chi-square tests were used to test the significance of differences in quality measure satisfaction between groups. RESULTS: Attributing patients to the physician who had seen them for the greatest proportion of encounters performed best. Creating equity reports for individual resident panels was not possible due to insufficient numbers. Most measures had sufficient patients when combining all residents' patients. Inequities were identified for four of five examined measures. CONCLUSION: Creating aggregate equity reports for all primary care residents across multiple equity indicators was feasible, documenting disparities in health care quality.

Community Efforts to Reduce Racial and Ethnic Health Disparities: Challenges and Facilitators Identified by 16 Multistakeholder Alliances.

The Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program aimed to improve health care quality and reduce racial and ethnic disparities in 16 diverse communities in the United States from 2006 to 2015; yet most communities failed to make substantive progress toward advancing health care equity by the program's end. This qualitative analysis of key stakeholder interviews aims to identify the major contributors to success versus failure in addressing local health disparities during AF4Q and identified five major themes. Three themes highlight challenges related to collecting local data on racial and ethnic health disparities and transitioning from data collection to action. Two themes capture the critical contribution of stakeholder engagement and access to technical expertise to successful efforts. The challenges and facilitators experienced by these 16 AF4Q communities may help inform the disparities reduction efforts of other communities and guide state or federal policies to reduce health disparities.

Social Determinants of Health Training in U.S. Primary Care Residency Programs: A Scoping Review.

PURPOSE: Medical training has traditionally focused on the proximate determinants of disease, with little focus on how social conditions influence health. The authors conducted a scoping review of existing curricula to understand the current programs designed to teach primary care residents about the social determinants of health (SDH). METHOD: In January and March 2017, the authors searched seven databases. Eligible articles focused on primary care residents, described a curriculum related to SDH, were published between January 2007 and January 2017, and were based in the United States. RESULTS: Of the initial 5,523 articles identified, 43 met study eligibility criteria. Most programs (29; 67%) were in internal medicine. Sixteen studies (37%) described the curriculum development process. Overall, 20 programs (47%) were short or one-time sessions, and 15 (35%) were longitudinal programs lasting at least 6 months. Thirty-two programs (74%) reported teaching SDH content using didactics, 22 (51%) incorporated experiential learning, and many programs (n = 38; 88%) employed both. Most studies reported satisfaction and/or self-perceived changes in knowledge or attitudes. CONCLUSIONS: The authors identified wide variation in curriculum development, implementation, and evaluation. They highlight curricula that considered community and resident needs, used conceptual frameworks or engaged multiple stakeholders to select content, used multiple delivery methods, and focused evaluation on changes in skills or behaviors. This review highlights the need not only for systematic, standardized approaches to developing and delivering SDH curricula but also for developing rigorous evaluation of the curricula, particularly effects on resident behavior.

Evaluating a complex, multi-site, community-based program to improve healthcare quality: the summative research design for the Aligning Forces for Quality initiative.

OBJECTIVE: The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed. STUDY DESIGN: A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided. METHODS: The summative research design employed by the evaluation team is discussed. RESULTS: The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program. CONCLUSION: The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

The Aligning Forces for Quality initiative: background and evolution from 2005 to 2015.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances. STUDY DESIGN: Descriptive overview of a multi-site, community-based quality improvement initiative. METHODS: We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders. RESULTS: The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives. CONCLUSION: The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

Summative evaluation results and lessons learned from the Aligning Forces for Quality program.

OBJECTIVE: To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015. METHODS: This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities. RESULTS: Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

The longitudinal impact of Aligning Forces for Quality on measures of population health, quality and experience of care, and cost of care.

OBJECTIVE: To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative. STUDY DESIGN: Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care. DATA: Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). RESULTS: In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.

Lessons learned about advancing healthcare equity from the Aligning Forces for Quality initiative.

OBJECTIVE: The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) initiative aimed to advance healthcare quality and equity in 16 communities across the United States through multi-stakeholder alliances of healthcare payers, providers, and consumers. Our objectives are (1) to summarize the major approaches and activities undertaken by the AF4Q alliances that were most successful in tracking and implementing programs that aimed to reduce local healthcare disparities by race, ethnicity, and primary language spoken (REL), and socioeconomic status (SES); and (2) to identify the major lessons learned from the successes and failures of the AF4Q alliances to inform other equity-focused initiatives. METHODS: We analyzed data from 6 rounds of key informant interviews conducted between 2010 and 2015, and triannual progress reports submitted by the alliances to RWJF between 2008 and 2015. RESULTS: Of the 16 AF4Q alliances, 2 succeeded in developing community wide systems to track local healthcare disparities, 5 alliances implemented substantive programs that aimed to reduce local disparities, and 3 alliances were successful in disparity measurement and program implementation. The alliances that were most active in addressing disparities tended to have long-established relationships with relevant community organizations, focused on improving the quality of care provided by safety-net providers, and shifted quickly toward working to address disparities even if their initial efforts to stratify performance measures by REL failed. CONCLUSION: Few alliances were able to develop community wide systems to track local healthcare disparities or implement large-scale initiatives to reduce disparities during the 7 years that these objectives were advanced by the AF4Q initiative. Establishing robust local disparity-tracking systems and establishing productive relationships with key community stakeholders took substantial time. The AF4Q experience suggests that efforts to reduce disparities should not be held up by disparity measurement challenges.

Racial/Ethnic Disparities in Influenza Vaccination of Chronically Ill US Adults: The Mediating Role of Perceived Discrimination in Health Care.

BACKGROUND: Despite well-established programs, influenza vaccination rates in US adults are well below federal benchmarks and exhibit well-documented, persistent racial and ethnic disparities. The causes of these disparities are multifactorial and complex, though perceived racial/ethnic discrimination in health care is 1 hypothesized mechanism. OBJECTIVES: To assess the role of perceived discrimination in health care in mediating influenza vaccination RACIAL/ETHNIC disparities in chronically ill US adults (at high risk for influenza-related complications). RESEARCH DESIGN: We utilized 2011-2012 data from the Aligning Forces for Quality Consumer Survey on health and health care (n=8127), nationally representative of chronically ill US adults. Logistic regression marginal effects examined the relationship between race/ethnicity and influenza vaccination, both unadjusted and in multivariate models adjusted for determinants of health service use. We then used binary mediation analysis to calculate and test the significance of the percentage of this relationship mediated by perceived discrimination in health care. RESULTS: Respondents reporting perceived discrimination in health care had half the uptake as those without discrimination (32% vs. 60%, P=0.009). The change in predicted probability of vaccination given perceived discrimination experiences (vs. none) was large but not significant in the fully adjusted model (-0.185; 95% CI, -0.385, 0.014). Perceived discrimination significantly mediated 16% of the unadjusted association between race/ethnicity and influenza vaccination, though this dropped to 6% and lost statistical significance in multivariate models. CONCLUSIONS: The causes of persistent racial/ethnic disparities are complex and a single explanation is unlikely to be sufficient. We suggest reevaluation in a larger cohort as well as potential directions for future research.

Individualized Risk Communication and Outreach for Primary Cardiovascular Disease Prevention in Community Health Centers: Randomized Trial.

BACKGROUND: Many eligible primary cardiovascular disease prevention candidates are not treated with statins. Electronic health record data can identify patients with increased cardiovascular disease risk. METHODS AND RESULTS: We performed a pragmatic randomized controlled trial at community health centers in 2 states. Participants were men aged ≥35 years and women ≥45 years, without cardiovascular disease or diabetes mellitus, and with a 10-year risk of coronary heart disease of at least 10%. The intervention group received telephone and mailed outreach, individualized based on patients' cardiovascular disease risk and uncontrolled risk factors, provided by lay health workers. Main outcomes included: documented discussion of medication treatment for cholesterol with a primary care clinician, receipt of statin prescription within 6 months, and low-density lipoprotein (LDL)-cholesterol repeated and at least 30 mg/dL lower than baseline within 1 year. Six hundred forty-six participants (328 and 318 in the intervention and control groups, respectively) were included. At 6 months, 26.8% of intervention and 11.6% of control patients had discussed cholesterol treatment with a primary care clinician (odds ratio, 2.79; [95% confidence interval, 2.25-3.46]). Statin prescribing occurred for 10.1% in the intervention group and 6.0% in the control group (odds ratio, 1.76; [95% confidence interval, 0.90-3.45]). The cholesterol outcome did not differ, and the majority of patients did not repeat lipid levels during follow-up. CONCLUSIONS: Risk communication and lay outreach increased cholesterol treatment discussions with primary care clinicians. However, most discussions did not result in statin prescribing. For outreach to be successful, it should be combined with interventions to encourage clinicians to follow contemporary risk-based cholesterol treatment guidelines. CLINICAL TRIAL REGISTRATION: URL: http://www.clincialtrials.gov. Unique identifier: NCT01610609.

Explaining racial and ethnic disparities in cholesterol screening.

OBJECTIVE: To determine whether racial and ethnic disparities in cholesterol screening persist after controlling for socioeconomic status, access to care and language. METHODS: Data were obtained from the 2011 Behavioral Risk Factor Surveillance System for men aged 35 and older and women aged 45 and older in accordance with the United States Preventive Services Task Force guidelines. Self-reported cholesterol screening data are presented for 389,039 respondents reflecting over 141million people. Sequential logistic regression models of the likelihood of never having been screened are presented adjusted for demographic characteristics, health status, behavioral risk factors, socioeconomic status, health care access, and questionnaire language. RESULTS: A total of 9.1% of respondents, reflecting almost 13million individuals, reported never having been screened. After adjustment for socioeconomic status, health care access and Spanish language, disparities between whites and Blacks and Hispanics, but not Asians and Pacific Islanders, were eliminated. CONCLUSIONS: Lower socioeconomic status, lack of healthcare access and language barriers explained most of the racial and ethnic disparities in cholesterol screening. Expanding insurance coverage, simplifying cardiac risk assessment and improving access to culturally and linguistically appropriate care hold the greatest promise for improving cardiovascular disease screening and treatment for vulnerable populations.

Factors Influencing the Increasing Disparity in LDL Cholesterol Control Between White and Black Patients With Diabetes in a Context of Active Quality Improvement.

After implementing a multifaceted physician-directed quality improvement (QI) initiative, an increased disparity in low-density lipoprotein (LDL) cholesterol control between white and black diabetes patients was observed. To examine possible causes, a retrospective analysis of 962 black and white patients treated continuously between 2008 and 2010 was performed. At baseline, 55.0% of whites and 49.8% of blacks were controlled (5.2% disparity). The disparity increased, with 61.8% of whites and 44.6% of blacks having control in 2010 (17.2% disparity). Among patients uncontrolled at baseline, blacks were less likely to become controlled. Among patients controlled at baseline, blacks were less likely to remain controlled; accounting for patient characteristics and changes in lipid-lowering drug prescription regimens did not attenuate these relationships. Physician-facing, general QI interventions may be insufficient to produce equity in LDL cholesterol control. Helping patients maintain prior success controlling cholesterol appears as important in addressing this disparity as is helping uncontrolled patients achieve control.

Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial.

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English proficiency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODS All adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual clinician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the outreach protocol. Outcome measures were compared using the Fisher exact test. RESULTS Analyses were based on 104 patients assigned to the outreach intervention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P <.001). Nearly all of the screenings were by FOBT. The groups did not differ significantly with respect to the percentage of patients making a clinician visit or the percentage for whom a clinician placed an order for a screening test. CONCLUSIONS The mailing of FOBT kits directly to patients was efficacious for promoting colorectal cancer screening among a population with high levels of poverty, limited English proficiency, and racial and ethnic diversity. Non-visit-based outreach to patients may be an important strategy to address suboptimal rates of colorectal cancer screening among populations most at risk for not being screened.

Changes in disparities following the implementation of a health information technology-supported quality improvement initiative.

BACKGROUND: Health information technology (HIT)-supported quality improvement initiatives have been shown to increase ambulatory care quality for several chronic conditions and preventive services, but it is not known whether these types of initiatives reduce disparities. OBJECTIVES: To examine the effects of a multifaceted, HIT-supported quality improvement initiative on disparities in ambulatory care. DESIGN: Time series models were used to assess changes in racial disparities in performance between white and black patients for 17 measures of chronic disease and preventive care from February 2008 through February 2010, the first 2 years after implementation of a HIT-supported, provider-directed quality improvement initiative. PATIENTS: Black and white adults receiving care in an academic general internal medicine practice in Chicago. INTERVENTIONS: The quality improvement initiative used provider-directed point-of-care clinical decision support tools and quality feedback to target improvement in process of care and intermediate outcome measures for coronary heart disease, heart failure, hypertension, and diabetes as well as receipt of several preventive services. MAIN MEASURES: Modeled rate of change in performance, stratified by race and modeled rate of change in disparities for 17 ambulatory care quality measures KEY RESULTS: Quality of care improved for 14 of 17 measures among white patients and 10 of 17 measures among black patients. Quality improved for both white and black patients for five of eight process of care measures, four of five preventive services, but none of the four intermediate outcome measures. Of the seven measures with racial disparities at baseline, disparities declined for two, remained stable for four, and increased for one measure after implementation of the quality improvement initiative. CONCLUSIONS: Generalized and provider-directed quality improvement initiatives can decrease racial disparities for some chronic disease and preventive care measures, but achieving equity in areas with persistent disparities will require more targeted, patient-directed, and systems-oriented strategies.