1. Using Quality Improvement to Insure Equality in Healthcare Quality Kevin Fiscella, MD, MPH University of Rochester School of Medicine & Dentistry Departments of Family Medicine Community & Preventive Medicine

2. Why Quality Improvement? Equity is a core dimension of quality Avoids marginalization of disparity efforts. Relies on evidence-based interventions. Leverages existing resources

3. Getting started

4. Assembling a QI/disparity team Racially/ethnically diverse team. Relevant areas of expertise

5. Choosing an area of focus Local disparity data Published literature Impact on minority population health Begin with areas ripe for success

6. Sources of race/ethnicity data Hospital data and other linked data sources Surveys such as CAHPS Geocoding/surname analysis Collection of data on admission/enrollment

7. Data on Healthcare Quality Self-report Claims data Chart review

8. Intervening

9. Tracking, recall, and prompts Near elimination of racial disparities in childhood immunizations in Rochester. Elimination of racial disparities in influenza immunizations in many VA hospitals.

10. Practice Guidelines The Hypertension and Follow-up Program reduced racial disparities in hypertension control and mortality using a stepped care approach and protocol driven management.

11. Chronic Disease Management The Diabetes Control and Complications Trial eliminated socioeconomic disparities in diabetic control with intensive teaching and management. Has been shown to reduce racial disparities in depression treatment and outcomes.

12. Patient Empowerment Patient coaching has been shown to improve diabetes and hypertension control among poor and minority patients.

13. Provider blinding May be useful when the intervention involves costly or limited resources and where there is considerable discretion in allocation. Blinded review of cases at the Cleveland VA eliminated racial disparity in coronary artery revascularization.

14. Assess Impact of Intervention Modify approach/restudy problem Move on to next priority area

15. Conclusion Organizational QI is vital to eliminating disparities in healthcare. Many of the steps and approaches can be adopted from conventional QI.