The Effect of a Quality Improvement Initiative on the Quality of Other Aspects of Health Care

The Law of Unintended Consequences?

Published in: Medical Care, v. 45, no. 1, Jan. 2007, p. 8-18

Posted on on December 31, 2006

by David A. Ganz, Neil S. Wenger, Carol P. Roth, Caren Kamberg, John T. Chang, Catherine MacLean, Roy Young, David Solomon, Takahiro Higashi, Lillian Min, David Reuben, Paul G. Shekelle

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PROBLEM: Policymakers and clinicians are concerned that initiatives to improve the quality of care for some conditions may have unintended negative consequences for quality in other conditions. OBJECTIVE: The authors sought to determine whether a practice redesign intervention that improved care for falls, incontinence, and cognitive impairment by an absolute 15% change also affected quality of care for masked conditions (conditions not targeted by the intervention). DESIGN, SETTING, AND PARTICIPANTS: Controlled trial in 2 community medical groups, with 357 intervention and 287 control patients age 75 years or older who had difficulty with falls, incontinence, or cognitive impairment. INTERVENTION: Both intervention and control practices implemented case-finding for target conditions, but only intervention practices received a multicomponent practice-change intervention. Quality of care in the intervention practices improved for 2 of the target conditions (falls and incontinence). MAIN OUTCOME MEASURES: Percent of quality indicators satisfied for a set of 9 masked conditions measured by abstraction of medical records. RESULTS: Before the intervention, the overall percent of masked indicators satisfied was 69% in the intervention group and 67% in the control group. During the intervention period, these percentages did not change, and there was no difference between intervention and control groups for the change in quality between the 2 periods (P = 0.86). The intervention minus control difference-in-change for the percent of masked indicators satisfied was 0.2% (bootstrapped 95% confidence interval, -2.7% to 2.9%). Subgroup analyses by clinical condition and by type of care process performed by the clinician did not show consistent results favoring either the intervention or the control group. CONCLUSION: A practice-based intervention that improved quality of care for targeted conditions by an absolute 15% change did not affect measurable aspects of care on a broad set of masked quality measures encompassing 9 other conditions.

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