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

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

1. Michael L. Parchman, MD, MPH1⇑, 
2. Melissa L. Anderson, MS1, 
3. David A. Dorr, MD, MS2, 
4. Lyle J. Fagnan, MD3, 
5. Ellen S. O’Meara, PhD1, 
6. Leah Tuzzio, MPH1,
7. Robert B. Penfold, PhD1, 
8. Andrea J. Cook, PhD1, 
9. Jeffrey Hummel, MD, MPH5,
10. Cullen Conway, MPH3, 
11. Raja Cholan, BS2 and 
12. Laura-Mae Baldwin, MD4

+Author Affiliations

1. 1Kaiser Permanente Washington Health Research Institute, Seattle, Washington
2. 2Department of Medicine, Oregon Health & Science University, Portland, Oregon
3. 3Oregon Rural Practice Research Network, Oregon Health & Sciences University, Port-land, Oregon
4. 4Department of Family Medicine, Institute of Translational Health Sciences, University of Washington, Seattle, Washington
5. 5HealthInsight/Qualis Health, Seattle, Washington

1. CORRESPONDING AUTHOR: Michael L. Parchman, MD, MPH, Kaiser Permanente Washington Health, Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101, Michael.X.Parchman@kp.org

 

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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.

Key words

• primary health care
• cardiovascular disease
• quality improvement
• chronic illness
• prevention
• health promotion
• quantitative methods
• health services
• organizational change
• practice-based research