Quality of Chronic Disease Care in Community Health Centers

from The Commonwealth Fund

Although the quality of chronic disease care in community health centers (CHCs) compares favorably with care received in other settings, gaps exist, particularly for the uninsured, a study by Harvard Medical School researchers found. This is important, the researchers contend, because publicly funded CHCs are caring for growing numbers of Americans—more than 15 million and counting. Of this group, 23 percent are uninsured and 64 percent are members of minority or immigrant groups.

The study, "The Quality of Chronic Disease Care in U.S. Community Health Centers," by Leroi S. Hicks, M.D., M.P.H., of Harvard Medical School, and colleagues, was published in the November/December issue of Health Affairs.

Parsing Quality at CHCs
The number of patients served by federally qualified CHCs grew by nearly 50 percent from 1999 to 2004. In the future, this is likely to increase as a result of anticipated changes in Medicaid eligibility rules, the rising cost of private insurance, and federal legislation expanding the number of such centers, among other factors.

To gain a better understanding of the quality of care delivered in such facilities, the researchers examined medical records of more than 5,600 patients receiving care for one of three chronic conditions—asthma, diabetes, and hypertension—between 1999 and 2000 in a national sample of 64 publicly funded CHCs.

Less Than Half of Patients Receive Appropriate Care
For 15 of the 22 indicators examined—including asthma management plans, annual foot exams, and beta blocker use—less than half of eligible patients studied received appropriate care. Overall, the mean quality scores (measuring the number of applicable indicators met for each condition, with higher scores representing higher quality of care) were 37 percent for asthma, 37 percent for diabetes, and 59 percent for hypertension.

The authors found that quality of care differed significantly by patients' race or ethnicity, insurance status, education, and income. For example, white patients received recommended care for diabetes and asthma care more frequently than did black and Hispanic patients, while the uninsured received recommended diabetes and asthma care less often than those with public or private insurance coverage.

However, after adjusting for insurance status, racial and ethnic disparities in quality of care for all three conditions examined were eliminated. The authors note that "limitations exist in CHCs' capacity to provide equitable quality of care for the uninsured." Such findings have been supported by other recent studies.

Quality at CHCs Compares Favorably with Other Providers
For most indicators studied, the quality of care delivered by CHCs was found to be, comparable to, and sometimes better than, the quality delivered in other settings that provide care for the underserved. It also compared favorably to some national benchmark data. For example, CHCs' rates of blood pressure control were better than the 37 percent to 45 percent documented in hospital-affiliated clinics, the Veterans Affairs (VA) health system, or in commercial managed care populations.

"Our findings were consistent with studies reporting that CHCs provide better quality care than other health care segments as measured by reduced hospitalizations and emergency department visits, higher rates of vaccination among children and the elderly, and higher rates of cancer screening among the poor and elderly," the authors note. The study highlighted that newer centers (i.e., established less than 30 years ago) provided recommended care more frequently than did older CHCs (48% vs. 43% on a mean basis, respectively). In addition, CHCs with computerized decision support of-fered recommended care more frequently than did those without (47% vs. 43%).

Conclusions
The Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services, plans to develop programs to improve care and reduce disparities in CHCs through the use of quality improvement collaboratives. These initiatives, say the authors, may have a positive effect on the uninsured—the subgroup with the most room for improvement. In addition, more study is needed to determine the extent to which the use of computerized decision support can improve quality of care, given the researchers' findings that CHCs with such capabilities provide better care than those without.

"If policymakers plan to extend coverage for underserved populations through expanding the number of CHC sites, they might need to provide additional resources to meet the needs of uninsured patients at existing sites," the authors conclude.

Facts and Figures

* In the study sample, asthma patients were younger and less likely to be uninsured (12%) than were patients with hypertension (23%) and diabetes (24%).
* In the adjusted comparisons, female patients received recommended care more frequently than males, and uninsured patients received recommended care less frequently than insured patients.
* More than 15 million Americans get care at community health centers, of whom 23 percent are insured and 64 percent are members of immigrant or minority groups. Such groups have been previously documented to receive lower-quality care than do insured, nonimmigrant/minority patients.