Collaboratives are links to better care, study says

Bringing physicians and other health care professionals together in collaborative groups to develop tailored quality improvement strategies might lead to a smoother process of care, but documented reductions in patients' adverse events have yet to be seen, according to a study published in the May/June Annals of Family Medicine.

"Collaboratives work," said Matthias Schonlau, PhD, lead author and head of the statistical consulting service at the nonprofit research organization RAND Corp. "To make that point even stronger, I would want to have that link to the outcomes, but I'm optimistic."

Dr. Schonlau and his team studied a half-dozen medical practices that participated in the Institute for Healthcare Improvement's Breakthrough Series Collaborative for adult asthma care. Teams from the clinics attended three two-day educational sessions and were evaluated for a year.

The findings: Asthmatic patients from these clinics were more likely to attend self-management educational sessions than those at the control clinics. They also were more likely to have a written action plan, to set goals, to monitor peak flow rates and to use long-term asthma medications. Additionally, they were happier with physician communication styles.

"When patients are happier, that's always a good thing," Dr. Schonlau said.

But although providing care was less bumpy, the actual impact on patient health appeared limited. There was no impact on disease knowledge, health-related quality of life or emergency department visits.

Researchers and program backers say the study's timeline might have been too short and the patient sample size too small to demonstrate a significant impact on these outcomes. But they point out that the impact on treatment processes -- often linked in other studies to outcome improvements -- could be significant enough to expect that these important numbers also would change eventually.

"People in our collaboratives learn to put evidence-based changes into practice, and they are great for getting quick results for organizations," said IHI Executive Director Andrea Kabcenell, RN, MPH. "But it might have been too soon to impact outcomes."

Critics charged, however, that although the study was good, they don't see the results quite so positively. An accompanying editorial expressed disappointment because improvements were seen only in measurements that were very low anyway. The link between those measures that did improve and actual patient outcomes is not as strong as the authors suggest.

"It is positive in that there were some changes, but the actions that they measured, there's not such good evidence that they matter," said Leif I. Solberg, MD, who wrote the editorial and is associate medical director for care improvement research at HealthPartners Research Foundation in Minneapolis. "If we are going to convince medical care groups to put in an effort, we need to show some effect on things that patients and physicians care about."

Dr. Solberg suggested that a local approach that allows participation of many more physicians and other health care professionals from the same area may be the better approach. The one studied is a national program, which means that small teams participate only to return to the same environment they left.

"I believe in collaboratives, and, if practices have an opportunity to attend a local one, that's probably going to be helpful to them," Dr. Solberg said.

"You are not in groups that you are never going to see again, and you can change the local environment and tackle very unique local problems that no one else in the country knows or cares about," he said.

Quality improvement advocates recognize that linking quality improvement initiatives to better patient outcomes long has been a challenging issue bedeviling the movement.

But some experts suggest that, despite the lack of demonstrated improvements in outcomes, the betterment of the other measures could still make this kind of program and others like it valuable.

"It's still worth doing, and we should not give up on quality improvement just yet," said Matthew Mintz, MD, an internist and associate professor of medicine at the George Washington School of Medicine in Washington, D.C.