A controlled trial of dissemination and implementation of a cardiovascular risk reduction strategy in small primary care practices

Abstract

Objective: To assess the effect of dissemination and implementation of an intervention consisting of practice facilitation and a risk-stratified, population management dashboard on cardiovascular risk reduction for patients at high risk in small, primary care practices. Study Setting: A total of 219 small primary care practices (≤10 clinicians per site) across North Carolina with primary data collection from electronic health records (EHRs) from the fourth quarter of 2015 through the second quarter of 2018. Study Design: We performed a stepped-wedge, stratified, cluster randomized trial of a one-year intervention consisting of practice facilitation utilizing quality improvement techniques coupled with a cardiovascular dashboard that included lists of riskstratified adults, aged 40-79 years and their unmet treatment opportunities. The primary outcome was change in 10-Year ASCVD Risk score among all patients with a baseline score ≥10 percent from baseline to 3 months postintervention. Data Collection/ Extraction Methods: Data extracts were securely transferred from practices on a nightly basis from their EHR to the research team registry. Principle Findings: ASCVD risk scores were assessed on 437 556 patients and 146 826 had a calculated 10-year risk ≥10 percent. The mean baseline risk was 23.4 percent (SD ± 12.6 percent). Postintervention, the absolute risk reduction was 6.3 percent (95% CI 6.3, 6.4). Models considering calendar time and stepped-wedge controls revealed most of the improvement (4.0 of 6.3 percent) was attributable to the intervention and not secular trends. In multivariate analysis, male gender, age >65 years, low-income (<$40 000), and Black race (P < .001 for all variables) were each associated with greater risk reductions. Conclusion: A risk-stratified, population management dashboard combined with practice facilitation led to substantial reductions of 10-year ASCVD risk for patients at high risk. Similar approaches could lead to effective dissemination and implementation of other new evidence, especially in rural and other under-resourced practices.

An Integrative Model for Change: Scoping Review of Human Factors, Implementation Science, and Quality Improvement Approaches in Primary Care

“…Comparison of actual versus desired, or pre- and post-change effects is a critical component of contextualizing analyses. Though this concept is most clearly present in IS with comparisons in randomized controlled trials (Cykert et al, 2020; Krist et al, 2013), it is also present in QI through iterative workflow modeling (Munro et al, 2015), and in HF with evaluations similar to trials (Katz et al, 2017).…”

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association

“…For example, a study may examine the effect of practice facilitation, an implementation strategy whereby experts help clinicians solve problems related to capacity building and clinic workflow challenges 15 to enhance the adoption of guidelines for aspirin use, blood pressure, cholesterol, or smoking (the EBP). 43,44 To achieve cardiovascular health equity, implementation strategies themselves should be culturally and contextually relevant, address social and structural determinants of implementation in historically marginalized populations, and fit within the identified setting. Several guides exist for engaging stakeholders in mapping implementation strategies to barriers identified in step 2.…”

“…15 We then applied our checklist of critical equity considerations (Table 2) to identify gaps in the implementation literature to date (Table 3). 44,52,53,59–67…”

“…18 One stepped wedge cluster randomized trial combining practice facilitation and a population-based dashboard for risk stratification found substantial atherosclerotic CVD risk reduction in high-risk patients in small, rural practices. 44 Although stepped wedge designs are increasingly used in implementation science, researchers need to be aware of the power considerations, inefficiencies when clusters are few, and confounding by temporal trends in policy, service delivery, and other external factors. 18 Future work should consider incorporating an evaluation framework.…”

“…15 We then applied our checklist of critical equity considerations (Table 2) to identify gaps in the implementation literature to date (Table 3). 44,52,53,[59][60][61][62][63][64][65][66][67] Strategies Identified in Policy, Community, Organizational, or Multiple Settings…”