How Michigan Collaboratives Reduce Disparities

Special Article - Quality Improvement

J Fam Med. 2015; 2(5): 1037.

How Michigan Collaboratives Reduce Disparities

Bumpus SM1,2*, Kline-Rogers E², Koelling³, Olomu A4, Prager RL³, Upchurch G5 and Eagle KA3

¹School of Nursing, Eastern Michigan University, USA

²Michigan Clinical Outcomes Research and Reporting Program, University of Michigan Health System, USA

³Division of Cardiology, Department of Internal Medicine, University of Michigan Health System, USA

4Department of Medicine, Michigan State University, USA

5Division of Vascular Surgery, Department of Surgery, University of Virginia, USA

*Corresponding author: Bumpus SM, School of Nursing, Eastern Michigan University, MCORRP, Domino’s Farms, USA

Received: August 28, 2015; Accepted: October 07, 2015; Published: October 10, 2015


Background: Disparities exist in both health and health care. Differences in the quality of care received by individuals may result in differential outcomes, including increased prevalence of disease or decreased life expectancy.

Purpose: The purpose of this paper is to describe successful quality collaborative efforts in cardiovascular medicine that demonstrate the impact of creating high quality systems to standardize care, reduce disparities, and improve patient outcomes.

Methods: Six cardiovascular collaboratives within Michigan were reviewed based on their success, innovation, and contributions to knowledge and practice.

Conclusion: Equitably improving care can help to eliminate disparities. Providers, researchers, thought leaders, and institutions must work together. Monitoring outcomes and benchmarking practice while embedding evidencebased guidelines into systems, is one way to improve care quality for all.

Keywords: Access to care, Disparities; Evidence-based medicine; Minority health; Quality of care; Health care Management; Quality management


CVD: Cardiovascular Disease; CABG: Coronary Artery Bypasses Graft; PCI: Percutaneous Coronary Intervention; BMC2: Blue Cross Blue Shield of Michigan Cardiovascular Consortium; AMI: Acute Myocardial Infarction; MRCD: Maximum Radiographic Contrast Dose; MSTCVS: Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative; STS: National Society of Thoracic Surgeons; ACS: Acute Coronary Syndrome; GRACE: Global Registry of Acute Coronary Events; AAA: Abdominal Aortic Aneurysm; ICD9- CM: International Classification of Diseases, Ninth Revision, Clinical Modification; GAP-MI: American College of Cardiology Guidelines Applied in Practice Acute Myocardial Infarction Initiative; GAPHF: Mid-Michigan Guidelines Applied in Practice Heart Failure Initiative; MEDPAR: Medicare Provider Analysis and Review


Cardiovascular Disease (CVD) is the leading cause of death in the United States with disproportionately high rates among minorities [1]. Heightened awareness and technological advances are leading the war toward eliminating such disparities. Equitably improving care quality may further close this gap, but to do so at a lower cost is the challenge for this generation. This review describes the collaborative efforts of six cardiovascular consortiums. These collaboratives translated their research on access, quality, and biology to the bedside through standardizing quality improvements. This research ultimately reduced both health (outcomes) and health care (management) disparities.


Defining disparities

Disparities are unequal differences between groups and are often perceived on a continuum from unintentional to discriminatory [2]. In particular, the term “racial disparity” is highly debated among both researchers and policy makers. For example, interpretations of significant racial differences may range from a phenomenon of interest [3] to being considered representative of unfair and unjust availability and access to care [4] or simply as a result of other differences not yet defined [5]. Within this review a health care disparity is defined as a difference in the quality of care received by individuals, and the associated health outcomes.

Disparities in cardiovascular disease

It is well known that striking disparities exist in CVD, its management, and outcomes; where hypertension, diabetes, and obesity disproportionately affect minorities [6]. CVD accounts for one third of the difference in life expectancy between blacks and whites [7]. The age-adjusted death rate for blacks is 22% greater than whites [8]. Whites tend to use more healthcare services and receive more inappropriate procedures, while blacks are more likely to refuse treatment [9]. Specific to CVD, white Medicare patients are four times more likely to receive coronary artery bypass graft (CABG) surgery than blacks [10]. Blacks are less likely to receive thrombolytic therapy or PCI when they present with chest pain [11]. More myocardial infarctions occur in American Indians/Alaskan Natives under 65 years of age (36%)than in the general population [8,12]. Even when adjustments are made for socioeconomic status and education these differences persist [13]. Clearly standardized evidence-based that are racially competent are needed. The purpose of this paper is to describe successful quality collaboratives in cardiovascular medicine that demonstrate the impact of creating high quality systems to standardize care, reduce disparities, and improve patient outcomes.


Two types of collaborative efforts are presented in this review. The first set engaged regional thought leaders to develop, monitor, and benchmark local practice against national and international registries. The second are interventional projects that demonstrate the power of regional consortiums translating evidence-based practice to the bedside.

Regional collaborative registries

Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2): BMC2 is a multicenter registry for tracking outcomes of patients who underwent percutaneous coronary intervention (PCI). BMC2 began in 1996 with the goal of improving care for PCI patients in Michigan [14]. This registry underwent rigorous auditing and contains data on consecutive patients [15]. The design and goals of the BMC2 consortium began with eight hospitals (academic and nonacademic centers). Detailed descriptions of the structure and function of BMC2 have been previously published [14,15]. Briefly, the structure includes an executive committee, a working group, and a writing committee each made of physicians, administrators, and nurse coordinators from individual sites. Together these groups provided oversight, top down buy-in, quality assurance, and promoted scholarly efforts [14, 15]. Significant contributions from BMC2 include the creation of a prediction tool for estimating in-hospital mortality post-PCI, an algorithm for determining the appropriate administration of blood products post-PCI, and a calculation tool for the maximum radiographic contrast dose for patients undergoing PCI. The simple additive bedside prediction tool for estimating inhospital mortality post-PCI allows patients, families, and providers to make more informed decisions [16]. The algorithm for judicious use of blood products promotes standardized transfusion practices among providers treating patients with post-AMI/PCI anemia [17,18]. The Maximum Radiographic Contrast Dose (MRCD) is the first tool available to help providers avoid contrast-induced nephropathy requiring dialysis post-PCI [19]. The contrast dye used during PCI can cause kidney damage that necessitates dialysis. Though this is a rare complication it is serious problem and affects an unacceptably high percentage of patients [19].

Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS): The MSTCVS is an interdisciplinary state society of Cardiac and Thoracic Surgeons perfusionists, cardiac care teams, and data managers. Over 10 years, the MSTCVS has evolved into a robust quality collaborative whose purpose is to enhance the quality, care, and outcomes of all cardiac surgery patients in Michigan. This collaborative is partially funded by Blue Cross Blue Shield of Michigan and active participation is required to receive funding. Presently, all 33 Michigan hospitals that perform adult cardiac surgery in Michigan are represented [20].

The MSTCVS uses validated outcomes data from their regional database and the National Society of Thoracic Surgeons (STS) database [21], to design and implement changes throughout the state [20]. Two of the recent successes of the MSTCVS were in increasing the utilization of the internal mammary artery for coronary artery bypass grafting (CABG) and the reduction of prolonged ventilation post CABG. On average, use of the internal mammary artery during CABG is associated with improved survival. The MSTCVS designed an educational series, and implemented an ownership environment to improve utilization of the internal mammary artery. All sites, with an emphasis on low-utilization sites, received seminars on the rational for utilization and surgeons were required to submit a justification for cases where the internal mammary artery was not used. Similarly, the MSTCVS identified variations in ventilator dependency following cardiac surgery. Prolonged ventilation is associated with poorer outcomes and increases cost by approximately $30,000 per case [21]. Hospitals with higher than average ventilator times were identified with unblended data at quarterly meetings where candid discussions on the issue took place. The group acknowledged system and resource barriers that contributed to these variations and worked with outlier hospitals to improve their performance.

Acute Coronary Syndrome Registry (ACS), University of Michigan: The University of Michigan maintains a consecutive registry of all ACS patients. Similar to the goals of the Global Registry of Acute Coronary Events (GRACE) [22], the goal of the ACS registry is to improve the quality of care received by ACS patients at the University of Michigan. The registry contains demographic, co-morbidity, clinical presentation, and treatment data similar to the GRACE registry. The ACS registry has been used to describe differences and relationships between patient characteristics, treatment practices, and outcomes [23].

Vascular surgeons collaborative research: Not formally a consortium, this group represents a more traditional type of collaborative effort among an exceptional team of vascular surgeons. This group came together to investigate how access to care influences outcomes for patients with abdominal aortic aneurysms (AAAs). It is well known that blacks have higher mortality than whites from AAA [24]. Using the National Inpatient Sample from 1995 to 2000, data was abstracted on patients with ICD9-CM codes for AAA who were less than 65 years of age (to exclude access to Medicare) [25]. A follow-up study addressing factors predicting racial variation in mortality was undertaken using the Medicare Provider Analysis and Review from 2001 to 2006 [24].

Regional collaborative interventional projects

American College of Cardiology Guidelines Applied in Practice Acute Myocardial Infarction Initiative (GAP-MI): The GAP-MI program was a prospective interventional study, funded by the American College of Cardiology, to evaluate the change in quality of care and outcomes when national guidelines were systematically applied in practice. The first guidelines for the management of acute myocardial infarction (AMI) were published in 1996 [26]. Despite evidence supporting improved quality and outcomes from the use of these guidelines, application remains low and inconsistent; especially among Medicare and Medicaid patients, women, and elderly [27, 28]. The GAP-MI project together with the Michigan Peer Review Organization sought to integrate and measure the utilization of AMI guidelines in practice [26, 29]. The infrastructure of this program included members from the American College of Cardiology, Michigan Peer Review Organization, and the Southeast Michigan Quality Forum for Cardiovascular Care. This consortium was a unique collaborative that carried considerable clinical expertise and credibility. A project oversight team, responsible for the intervention, was selected from the above groups and a core group of physician and nurse champions were appointed to facilitate the intervention [26, 29].

Within the Southeast Michigan consortium, 32 hospitals participated in three separate studies. Ten hospitals were initially selected as intervention sites. Cases were identified using ICD-9-CM code for AMI [26, 29]. Baseline and study data was collected from control and intervention sites between July 1, 1998 and December 15, 2000. In accordance with ethical practice, control sites continued to make quality improvements as part of their usual operations [26, 29].

The core of the GAP-MI program consisted of customized tool kits designed to enhance utilization of the National guidelines. The kit included preprinted admission and discharge order sets (including a physician-patient discharge contract), pocket guides for physicians, clinical pathways for nurses, and educational materials for patients [26, 29]. Intervention sites received chart stickers and performance charts.

Mid-Michigan Guidelines Applied in Practice Heart Failure Initiative (GAP-HF): The main objective of GAP-HF was to determine the effect of heart failure guideline adherence on quality of care, mortality, and rehospitalization [30]. The GAP-HF initiative was an expansion of the original multifaceted GAP-MI project redesigned for heart failure patients. The collaboration included members from the American College of Cardiology, Michigan Peer Review Organization, the Greater Flint Health Coalition, Michigan Cardiovascular Outcomes Research and Reporting Program, and local physician leaders. Fourteen mid-Michigan hospitals participated in this program (8 interventional, 6 control) [23]. The sampling procedure for this intervention mirrored the GAP-MI project using ICD9-CM codes for heart failure in place of AMI. The intervention was also based on the GAP-MI program employing the American College of Cardiology guidelines for heart failure instead.


Blue cross blue shield of michigan cardiovascular consortium (BMC2)

Today the BMC2 registry has data on more than 260,000 PCIs from more than 44 hospitals throughout Michigan (A. Jensen, personal communication, March 2, 2011). In 2001, the Simple Bedside Additive Tool for Prediction of In-hospital Mortality post- PCI was published from a sample of 10,796 consecutive procedures [16]. AMI, shock, renal insufficiency, cardiac arrest, number of diseased vessels, greater than 70 years of age, low ejection fraction, thrombus, peripheral vascular disease, and gender were identified as independent predictors of mortality in this population. The model demonstrated excellent discrimination with an area under the ROC curve of 0.90. The model was further validated in a sample of 5,863 consecutive cases with similar discrimination (area under the ROC = 0.92). In 1998 BMC2 established a sample of 4,623 patients with post-PCI anemia from a review of 67,051 consecutive PCIs [17]. Blood transfusions studied at one institution were associated with a higher risk of in-hospital mortality (OR = 2.02, 95% CI 1.47-2.79, p <0.001). After cardiology adopted the transfusion algorithm for the appropriate usage of blood products the transfusion rate at the targeted hospital decreased by nearly 66%, and was lower than the mean of the consortium by 2000 [18].

Intervention to reduce the incidence of renal nephropathy requiring dialysis post-PCI was conducted on 10,592 consecutive PCI patients. A follow-up validation study was later conducted on a sample of 5,863 patients. In the primary study in-hospital mortality for patients with nephropathy-requiring dialysis was higher than for those without this complication (39.0% vs. 1.4%, P <0.001). Multivariate analysis revealed five independent risk factors for nephropathy requiring dialysis: peripheral vascular disease, diabetes, pre-procedure renal insufficiency, heart failure, and cardiogenic shock (c-statistic = .89). However, exceeding the MCRD was the strongest predictor of nephropathy requiring dialysis (OR=6.2, 95% CI =3.0-12.8). The risks of nephropathy-requiring dialysis and in-hospital mortality were higher for patients whose contrast load exceeded that recommended by the MCRD (nephropathy 2.4% vs. 0.2%, p <0.001; in-hospital mortality 4.8% vs. 1.1%, p < 0.001) [19]. Following a statewide adoption of the MCRD there was a 57% reduction in nephropathy-requiring dialysis in post-PCI patients (Figure 1). Cumulative evaluation of BMC2 demonstrates global success in reducing procedural complications and negative outcomes (Figure 2) [31].