ABSTRACT
The Health Disparities Collaboratives are the largest national quality improvement (QI) initiatives in community health centers. This article identifies the incentives and assistance personnel believe are necessary to sustain QI. In 2004, 1006 survey respondents (response rate 67%) at 165 centers cited lack of resources, time, and staff burnout as common barriers. Release time was the most desired personal incentive. The highest funding priorities were direct patient care services (44% ranked no. 1), data entry (34%), and staff time for QI (26%). Participants also needed help with patient self-management (73%), information systems (77%), and getting providers to follow guidelines (64%).
Subject(s)
Attitude of Health Personnel , Community Health Centers/standards , Leadership , Total Quality Management , Adult , Burnout, Professional , Community Health Centers/organization & administration , Community Health Centers/statistics & numerical data , Female , Health Services Research , Health Status Disparities , Humans , Male , Middle Aged , Morale , Motivation , Resource Allocation , Time Management , United States , Vulnerable Populations/ethnologyABSTRACT
BACKGROUND: Older persons with diabetes are heterogeneous with respect to life expectancy and frailty, and new guidelines recommend individualizing care. OBJECTIVES: (1) To describe variation in the preferences of older patients with diabetes regarding aggressiveness of glycemic control and avoiding diabetic complications. (2) To determine correlates of patient preferences and physician treatment goals. (3) To assess whether physicians' goals were consistent with their patients' preferences. RESEARCH DESIGN: Cross-sectional surveys and chart reviews in urban academic clinics. SUBJECTS: : Four hundred seventy-three patients with diabetes age 65 or older and 64 physicians. MEASURES: Patient preferences (utilities on a scale from 0 to 1, 0 = death, 1 = perfect health) for diabetic complications and intensity of treatment, and physician target treatment goals and ratings of aggressiveness of approach. RESULTS: Eighty percent of the patients were African American, 63% were women, average age was 73.7 +/- 5.9 years and 26% expected to live 5 years or less. Patient preferences/utilities showed significant variation: blindness 0.39 (SD, 0.32), lower leg amputation 0.45 (0.34), conventional treatment 0.76 (0.27), and intensive insulin treatment 0.64 (0.32). Physicians' hemoglobin A1c goal was < or =7% in 69% of patients. Greater estimated patient life expectancy was consistently associated with higher patient utilities and was associated with physicians' willingness to use aggressive treatments. Physicians' treatment goals and approaches were associated with patients' utilities for treatment. CONCLUSIONS: Older patients vary greatly in their preferences regarding diabetic complications and treatments. Acknowledging patient preferences, along with life goals and prognostic data, may improve quality of treatment decisions.
