Improving and sustaining diabetes care in community health centers with the health disparities collaboratives.

BACKGROUND

In 1998, the Health Resources and Services Administration's Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions.

OBJECTIVES

To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further.

SUBJECTS: Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively.

MEASURES: American Diabetes Association standards.

RESEARCH

DESIGN

We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1-2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers.

RESULTS

Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [-0.45%; 95% confidence interval (CI), -0.72 to -0.17] and low-density lipoprotein cholesterol (-19.7 mg/dL; 95% CI, -25.8 to -13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07-2.01] and aspirin (OR, 2.20; 95% CI, 1.28-3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08-0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15-0.75).

CONCLUSIONS

Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.