The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation Among Five Clinics

Abstract

Background: Quality improvement collaboratives (QICs) support rapid testing and implementation of interventions through the collective experience of participating organizations to improve care quality and reduce costs. Although QICs have been societally cost-effective in improving the care of chronic diseases, they may not be adopted by outpatient clinics if their costs are high. Diabetes QICs warrant reexamination as secular trends in the quality of diabetes care, new care guidelines for diabetes, and evolving strategies for quality improvement may have altered implementation costs.

Methods: The costs over the first four years-from June 2009 through May 2013-of an ongoing diabetes QIC were characterized by activities and over time. The QIC, linking six clinics on Chicago's South Side, tailored interventions to minority populations and built community partnerships. Costs were calculated from clinic surveys regarding activities, labor, and purchases.

Results: Data were obtained from five of the six participating clinics. Cost/diabetic patient/year ranged across clinic sites from $6 (largest clinic) to $68 (smallest clinic). Clinics spent 62%-88% of their total QIC costs on labor. The cost/diabetic patient/year changed over time from Year 1 (range across clinics, $5-$51), Year 2 ($11-$84), Year 3 ($4-$57), to Year 4 ($4-$80), with costs peaking at Year 2 for all clinics except Clinic 4, where costs peaked at Year 4.

Discussion: Cost experiences of QICs in clinics were di- verse over time and setting. High per-patient costs may stem from small clinic size, a sicker patient population, and variation in personnel type used. Cost decreases over time may represent increasing organizational learning and efficiency. Sharing resources may have achieved additional cost savings. This practical information can help administrators and policy makers predict, manage, and support costs of QICs as payers increasingly seek high-value health care.

Figure 1

Over time, the costs changed between each year—Year 1 (range across clinics, $5–$51), Year 2 ($11–$84), Year 3 ($4–$57), and Year 4 ($4–$80)— of the QIC. Costs peaked at Year 2 for all clinics, except Clinic 4, where costs peaked at Year 4.

Figure 2

In terms of QIC activity type, the breakdown of resource allocation averaged over the four years included patient-directed interventions (range across clinics, $0.55–$22.52 per patient per year), provider training ($0–$8.11), delivery system redesign ($0–$2.36), community engagement ($0.20–$3.08), collaborative meetings ($0.88–$5.06), internal QI (quality improvement) meetings ($0.67–$12.01), information support ($0–$10.30), and other activities ($0.37–$6.87).

Figure 3

The breakdown of labor costs included physicians (range across clinics, $0.56–$5.42), nursing ($2.23–$6.03), educators/CDEs/nutritionists ($0–$33.35), social workers/case managers ($0–$0.47), nonmanagerial administrative staff ($0.33–$6.69), and managerial administrative staff ($0–$5.12).