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IMPROVING PATIENT CARE

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.

Effects of a Quality Improvement Collaborative on the Outcome of Care of Patients with HIV Infection: The EQHIV Study

Bruce E. Landon, MD, MBA; Ira B. Wilson, MD, MSc; Keith McInnes, MS; Mary Beth Landrum, PhD; Lisa Hirschhorn, MD, MPH; Peter V. Marsden, PhD; David Gustafson, PhD; and Paul D. Cleary, PhD

1 June 2004 | Volume 140 Issue 11 | Pages 887-896

Background: Multi-institution collaborative quality improvement programs are a well-established and broadly applicable quality improvement strategy, but there is little systematic assessment their effectiveness.

Objective: To evaluate the effectiveness of a quality improvement collaborative in improving the quality of care for HIV-infected patients.

Design: Controlled pre- and postintervention study.

Setting: Clinics receiving funding from the Ryan White Comprehensive AIDS Resources Emergency Act.

Participants: 44 intervention clinics and 25 control clinics matched by location (urban or rural), region, size, and clinic type.

Measurements: Changes in quality-of-care measures abstracted from medical records of pre- and postintervention samples of patients at each study clinic. Measures examined included use and effectiveness of antiretroviral therapy, screening and prophylaxis, and access to care.

Intervention: A multi-institutional quality improvement collaborative (the "Breakthrough Series").

Results: 9986 patients were studied. Clinical and sociodemographic characteristics of the intervention and control patients were similar (P > 0.05). Differences in changes in the quality of care were not statistically significant. The proportion of patients with a suppressed viral load increased by 11 percentage points (from 40.1% to 51.1%) in the intervention group compared with 5.3 percentage points (from 43.6% to 48.8%) in the control group, but this difference was not statistically significant (P = 0.18). In addition, rates of appropriate screening tests and prophylaxis did not differ between intervention and control sites.

Limitations: It was not possible to perform a pure randomized trial of the intervention or to assess other measures of quality, such as adherence and satisfaction.

Conclusions: This prospective, matched study of almost 10 000 patients found that a quality improvement collaborative did not significantly affect the quality of care. Additional research is needed to improve methods of teaching and implementing quality improvement programs to achieve better results.

Editors' Notes Context Multi-institutional quality improvement collaboratives are popular, but are they effective? Contribution This controlled study evaluated an HIV care "Breakthrough Series" program that emphasized provider teams, sessions on quality improvement theory and techniques, and report backs about implementing quality improvement. A review of the medical records of 9986 HIV-infected patients showed no important differences in quality of care (viral load suppression, pneumocystitis prophylaxis, and screening for tuberculosis and hepatitis) between the 44 intervention clinics and the 25 control clinics. Cautions Patient adherence and satisfaction were not measured, and some control clinics may have used quality improvement techniques similar to those recommended by the collaborative program. –The Editors

 

Author and Article Information

From Harvard Medical School, Beth Israel Deaconess Medical Center, New England Medical Center, and Dimock Community Health Center, Boston, Massachusetts; Harvard University, Cambridge, Massachusetts; and The University of Wisconsin, Madison, Wisconsin.

Acknowledgments: The authors thank their colleagues at the HIV AIDS Bureau of the Health Resources and Services Administration for their efforts and expertise. They also thank Lin Ding, PhD, for assistance with expert statistical programming; Deborah Collins for assistance with manuscript preparation; Carol Cosenza, MSW, and Patricia Gallagher, PhD, of the Center for Survey Research for assistance with instrument development and survey administration; and Barbara J. McNeil, MD, PhD, for comments on an earlier version of this manuscript.

Grant Support: By a grant from the Agency for Healthcare Research and Quality (R-01HS10227).

Potential Financial Conflicts of Interest:Other: D. Gustafson (board member of the Institute for Healthcare Improvement).

Requests for Single Reprints: Bruce E. Landon, MD, MBA, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail, landon{at}hcp.med.harvard.edu.

Current Author Addresses: Drs. Landon, McInnes, Landrum, and Cleary: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.

Dr. Wilson: The Health Institute, Division of Clinical Care Research, Tufts–New England Medical Center, 750 Washington Street, PO Box 345, Boston, MA 02111.

Dr. Hirschhorn: 26 Berkshire Road, Newton, MA 02460.

Dr. Marsden: William James Hall, 630, Harvard University, 33 Kirkland Street, Cambridge, MA 02138.

Dr. Gustafson: Center for Health Systems Research and Analysis, WARF Building, 11th Floor, 610 Walnut Street, Madison, WI 53705-2397.

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