Ethnic equity in the management of child asthma: Developing and testing a primary care quality improvement tool.

Two of the key challenges for the New Zealand health system are improving quality and reducing inequities in health. My plan was to develop and test a quality improvement intervention for primary care to help close the ethnic health gap for child asthma. To understand the overall context of quality improvement to improve ethnic equity primary care practitioners attending a quality symposium were surveyed. They reported very diverse levels of experience of quality improvement both overall and quality improvement to improve ethnic equity. Major constraints reported were time commitment and the difficulty within the practice of using their own data. Respondents identified need for professional incentives; assistance in identifying ethnic gaps; support in data management and skill development; and specific information on evidence-based changes they could incorporate. The first draft intervention document integrated three existing evidence bases: (i) quality improvement techniques in health care, (ii) child asthma primary care management and (iii) methods for health services to improve ethnic equity. When this approach was tested for feasibility in a practice, the practice made changes in their processes using some of the elements of the intervention. They found particular difficulties with their information system - obtaining meaningful information from data and integrating patient reminders. Major revisions were made to the data procedures in the intervention which subsequently successfully extracted and analysed clinical data from the practice. One year after initiating changes the practice showed statistically significant improvements in quality and in ethnic equity. A revised draft, including the revised data procedures, was tested using focus groups. Participants reported that the draft intervention identified improvements that could be made to child asthma management that would improve quality and equity. Some focus groups thought the revised module would be feasible in their practice and others did not. It was unclear what were the characteristics associated with different practice views. Participants also thought that poor housing, tobacco, cost barriers and lack of language-appropriate family education materials are major factors outside their practice resulting in ethnic inequity affecting their patients. Further changes to the intervention could make it more usable by more practices. However the configuration of many current information system create major barriers to practices identifying whether there are ethnic inequity in their service, let alone measuring if quality changes result in closing ethnic equity gaps. System interface issues can also make it difficult for practices to sustain the use of existing free patient education supports. There is need for more consistent national attention from the profession and the sector in order to understand and act on the steps to improve equity. Until then, inequities from beyond the health sector will continue to be perpetuated within the sector, despite the actions of committed individuals