Health Disparities Collaboratives Have Minimal Effect on Racial/Ethnic and Insurance Disparities in US Community Health Centers

In a recent controlled preintervention/postintervention study, researchers found that although Health Resources and Services Administration (HRSA) Health Disparities Collaboratives (HDCs) are known to improve quality of care in community health centers (CHCs), they had minimal effect on racial/ethnic and insurance disparities. The results were published in Archives of Internal Medicine [2010;170(3):279-286].

Publicly supported CHCs are responsible for caring for >15 million Americans, many of whom are members of groups that have previously been documented to receive care of lower quality. Several previous studies examining the quality of healthcare provided in the United States have documented significant problems with quality and disparities according to patient race and socioeconomic status. Federally qualified CHCs are likely to have an increasing role in providing care for these populations.

HDCs are national initiatives sponsored by HRSA aimed at narrowing disparities in processes of care by improving overall quality. HDCs bring CHCs together to learn and disseminate quality improvement techniques developed by the Institute for Healthcare Improvement. Since 1998, approximately two thirds of the CHCs (645 centers) have voluntarily participated in a collaborative focusing on improving care for chronic medical conditions using the chronic care model.

The authors previously conducted a controlled national evaluation of the HRSA HDCs and found that they significantly improved the extent to which processes of care were followed for asthma and diabetes mellitus. Whether the HDCs reduced previously documented racial/ethnic and insurance quality gaps in CHCs remained unknown.

In this study, the authors examined racial/ethnic and insurance differences in quality of care for asthma, diabetes mellitus, and hypertension before and after participation in the HDCs to provide a better understanding of whether the programs differentially narrowed disparities in care in addition to improving overall quality. They examined medical record data from patients receiving care in a nationally representative sample of 64 CHCs participating in this evaluation of the HRSA collaboratives to improve the care of patients with asthma, diabetes, or cardiovascular disease. They included 44 CHCs that participated in 1 of 3 HDCs and 20 CHCs that were not HDC participants for any condition. The earliest collaborative started on January 1, 2000, and the latest collaborative started on August 1, 2001.

Each intervention center also served as an internal control for another condition. For each condition, the authors created an overall quality score, defined disparities in care as the differences in care between racial/ethnic groups and insurance groups, and examined changes in disparity through a series of hierarchical models using a 3-way interaction term among period, patient characteristics of interest, and treatment group.

The authors focused on disparities because they negatively affect ethnic minority groups and the uninsured; therefore, disparity score is the difference in quality between white patients and some other ethnic group or between a group with Medicare or private insurance coverage and uninsured individuals or Medicaid recipients.

The study concluded that HDCs had little effect on disparities in composite measures for asthma, diabetes, and hypertension. For asthma care, collaborative centers had a baseline Hispanic-white disparity of 6.5%, which changed to a higher quality of recommended care for Hispanic patients over white patients by 0.8%, resulting in a significantly reduced Hispanic-white disparity compared with the change in disparity seen in external controls (P=.04). There were no other improvements in racial/ethnic or insurance disparities for any other conditions.

The authors mentioned several limitations in the study. They evaluated quality improvement collaboratives that were based on the Institute for Healthcare Improvement model, the most prevalent and reproducible type of quality improvement program, but there are many variations on this model and multiple other approaches to quality improvement that have been tried. Therefore, they could not determine which aspects of collaborative participation were associated with increasing insurance disparities in diabetes care and improving racial disparities in asthma care.—Tim Casey