Do Quality Improvement Programs Improve Care for HIV-Infected Patients?

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The summary below is from the full report titled "Effects of a Quality Improvement Collaborative on the Outcome of Care of Patients with HIV Infection: The EQHIV Study." It is in the 1 June 2004 issue of Annals of Internal Medicine (volume 140, pages 887-896). The authors are B.E. Landon, I.B. Wilson, K. McInnes, M.B. Landrum, L. Hirschhorn, P.V. Marsden, D. Gustafson, and P.D. Cleary.

What is the problem and what is known about it so far?

Problems with health care are often a result of "system" failings. Continuous quality improvement (CQI) programs aim to improve the quality of health care by addressing these failings. The programs involve several steps. First, health care organizations identify what they want to improve. Second, they develop processes to address those areas. Third, they test the processes by monitoring performance and outcomes. If the processes improved quality of care, the health care organizations use them routinely and widely. If not, they refine and retest different processes. This cycle ideally continues until the organization achieves optimal performance. Although many organizations embrace these methods, few large studies test whether CQI programs actually improve quality of care.

Why did the researchers do this particular study?

To assess a large collaborative CQI program aimed at improving the care of HIV-infected patients.

Who was studied?

9986 HIV-infected patients from 69 clinics in the United States. About two thirds were from 44 clinics where the CQI intervention was tried. The rest were from 25 control clinics where the intervention was not tried.

How was the study done?

The intervention and control clinics were matched for size and urban or rural location. Intervention clinics selected teams of at least 1 administrator and 1 clinician to focus on HIV care. The 44 intervention teams had 4 face-to-face interactive sessions with expert CQI faculty during a 16-month period. During sessions, they discussed specific ways to improve HIV care and reviewed CQI methods, including how to develop and use information systems to monitor care. Team members also submitted regular reports about their progress in using CQI programs and participated in monthly conference calls with CQI faculty. To assess quality of care, researchers reviewed medical records of HIV-infected patients who were seen at the intervention and control clinics before and after the time period of the CQI intervention.

What did the researchers find?

The researchers found no important differences in changes in quality of care between the intervention and control clinics. About 80% of the patients in both clinic groups received appropriate antiviral drug therapy. About 50% in both groups responded to therapy (had undetectable or very low levels of virus in their blood). Similar numbers in both groups received influenza shots and tests for tuberculosis and hepatitis.

What were the limitations of the study?

Some control clinics may have used methods similar to those recommended by the CQI program. Most patients in the clinics were taking appropriate antiviral therapy. This left little room for improvement. Some important measures, such as patient satisfaction with care, were not assessed. The findings may not apply to care for disorders other than HIV infection.

What are the implications of the study?

Continuous quality improvement programs are not always effective.