A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care

Abstract

PURPOSE We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance. METHODS Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach. RESULTS Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76). CONCLUSIONS Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

Fidelity Evaluation of the Compared Procedures for Conducting the PREDIAPS Implementation Strategy to Optimize Diabetes Prevention in Primary Care

“…Additionally, the exposure indicators suggest that professionals assigned to execute the strategy through sequential engagement of colleagues (starting with nurses who later sought the engagement of the physicians) had an unexpectedly higher degree of exposure to the implementation strategy actions, particularly in the case of nurses, the staff responsible for providing the active element of the clinical intervention. As described in the literature, commonly reported obstacles faced by physicians to fully engaging in implementation actions included heavy workload, staff turnover, di culties in investing time and effort improvement initiatives beyond providing care, and existing practice priorities [28][29][30].…”

Project ECHO Integrated Within the Oregon Rural Practice-based Research Network (ORPRN)

“…We designed the project based on our experiences working with over 100 primary care practices on quality improvement activities for cardiovascular health, including tobacco cessation. 22 ORPRN's goals for the tobacco project included increasing the capacity of rural primary care practices to routinely screen for, document, and counsel patients about tobacco use. After conducting a needs assessment, ORPRN created a project that began with a 5-session ECHO program for clinical and CCO quality improvement staff.…”

Assessing Quality Improvement Capacity in Primary Care Practices

“…Healthy Hearts Northwest (H2N) took place within 209 smaller (10 or fewer clinicians) primary care practices across Washington State, Oregon and Idaho and the results of this randomized trial have been previously reported. 26 All practices were supported by a practice facilitator (PF) for 15 months.…”