Quality Care Improvement Program in a Community-Based Participatory Research Project

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INTRODUCTION

The complex set of health status determinants, the disproportionate disease burden experienced in marginalized communities, and the limited effectiveness of traditional prevention research, particularly in minority communities, have increased the demand for more comprehensive and participatory approaches to public health research and practice. In 1985, the Secretary of Health and Human Services Task Force on Black and Minority Health identified diabetes as a major contributor to mortality among minorities in the United States. To respond to the excessive, unnecessary burden of diabetes among African Americans, the Centers for Disease Control and Prevention (CDC) led the development, implementation, and evaluation of Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) in southeast Raleigh, NC.

Diabetes is a major burden for individuals and society in North Carolina, especially Wake County. In 1993, at the inception of Project DIRECT and during the preintervention phase, Research Triangle Institute conducted a pilot survey in Wake County among 1,474 civilian, noninstitutionalized and nonpregnant persons aged 20-74 recruited through a stratified, multistage area probability sampling of 3,000 households. Among the 902 participants who underwent a complete survey and examination, the overall prevalence (SE) of total diabetes (diagnosed and undiagnosed) in Wake County was 4.6% (0.7%). The prevalence (± SE) for African Americans was three times that of whites (10.3% ± 3.0% vs. 3.1% ± 0.7%, p<0.05), and that of impaired glucose tolerance twice as high, though not significantly (11.4% ± 7.5% vs. 6.3% ± 3.5%, p=NS).
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In the mid-90s, the modest results reported by the three largest U.S. community interventions designed to test the feasibility and sustainability of cardiovascular disease programs led the scientific community to rethink the concept of community intervention by giving more importance to the understanding of commu­nity dynamics that influence changes and targeting high-risk communities. Many community-based studies targeting adult diabetes have adopted such a participatory design, i.e., they have involved community stakeholders to variable extents in the research process and used culturally relevant intervention contents. All studies but two carried out in Native Hawaiians and Pima Indians have been conducted out of the United States in high-risk populations. One study used a randomized design, and the others a quasi-experimental design without or with control communities. These studies focused on lifestyle interventions; two actively involved community practitioners as community agents but not through a CQIP. The need to improve the quality of healthcare practices is well documented. For example, Chin et al. identified a gap between usual care and optimal diabetes care as recommended by the American Diabetes Association, especially in safety-net healthcare settings, which they relate to diabetic patients’ behavior enhancement, affordability, accessibility, and efficiency.

CDC implemented Project DIRECT as a demonstration project to assess the viability of using community participatory strategies to improve a community’s diabetes-related outcomes in the target population of African Americans residing in southeast Raleigh. It was the largest and most comprehensive U.S. community demonstration project and was implemented through a partnership that includes the CDC, North Carolina State Department of Health and Human Services, Wake County Human Services, and southeast Raleigh community. North Carolina State and Central Universities, the University of NC at Chapel Hill, and Wake Forest University School of Medicine provided expertise as consultants from the project’s inception. buy levitra uk

Three Main
Primary Prevention of Diabetes
	HEALTH PROMOTION
1 M	Risk Factors Prevention
P A	Increase physical activity	Decrease dietary fat consumption	Health needs
С T			assessment
P	“Ready, Set, Walk”	Diabetes Population:	Church health
R	and	Church nutrition training	assessment tool/
О	“Lay Exercise Leader”	Genera/ Population:	Church health
С	Programs	nutrition education classes	action plan
E		& food demonstration
S S	MEDIA COVERAGE                and

Project DIRECT Intervention
Components
		Diabetes Early Detection	Diabetes Control/Secondary Prevention of Complications
OUTREACH				DIABETES CARE
	Diabetes	Undiagnosed	Increase referral	Increase	Improve quality
	Awareness	diabetes	process	self-management	of diabetes care
		screening
	Media and	Community-based	Partnership with	Diabetes	Quality improvemenl
	community-based	diabetes	federally-funded	self-management	initiative
	organization	screening	health centers	workshops	for providers

Figure 1. Overview of Project DIRECT Intervention

Figure 2. DIRECT Community Model (WG: workgroup; Government: DIRECT Investigators with the Federal/State/Academic Institutions)

Project DIRECT had three arms: a) diabetes care (DC) with two components, the first aimed at improving DC practice in a sample of providers (as described in this report) and the second at improving the self-management skills in a community-based sample of patients; b) nutrition and physical activity education of diabetes patients; and c) outreach to churches and the general population, through which a population-based diabetes screening was conducted (see Figure 1 for details). Patients for the patient-based programs were self- or physician-referred. Details of the design are published elsewhere. Evidence suggests that a multi-faceted intervention strategy is more effective in yielding positive outcomes than is a single intervention strategy. The southeast Raleigh community participated as one of four equal partners, including the Wake County Human Services, the State Department of Health, and the CDC. Community volunteers played different roles depending on whether they were members of the large community coalition and/or of the intervention­domain-restricted workgroups (Figure 2). Those in the former were very involved in raising Project DIRECT awareness, visibility, and support in the community. In fact, the DIRECT office was located in the community. Those in the workgroups were very active in defining/ refining the intervention content, suggesting the most appropriate recruitment and retention strategies, and were actors for implementing some interventions (e.g., lay exercise leader and church-based nutrition education). The positions of chair and vice-chair on the executive committee (EC) were reserved to the community volunteers elected by members of the coalition. The EC community representatives later became advocates for diabetes policy making at the level of the Black Caucus of the NC General Assembly.
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This report focuses on the continuous quality improvement program (CQIP) of the DC component from its inception in August 1996 to June 2000. This evaluation asks whether a targeted provider recruitment and retention plan facilitates CQIP participation by primary care providers and can produce a 70% provider retention; whether a multifaceted diabetes intervention program, which includes education, resources distribution, and consultation, improves DC patterns (i.e., an annual 10% increase in the percentage of diabetes patients with measures of care documented in their charts); and whether glycemic control for the diabetes patient population concomitantly improves.