The failure of a controlled trial to improve depression care: a qualitative study

BACKGROUND

The DIAMOND Project (Depression Is A MANageable Disorder), a nonrandomized controlled effectiveness trial, was intended to improve the long-term management of depression in primary care medical clinics. The project tested whether a quality improvement (QI) intervention could implement a systems approach-so that there would be more reliable and effective monitoring of patients with depression, leading to better outcomes. THE QUALITATIVE STUDY: A study was conducted in 1998-2000 to determine why a quality improvement intervention to improve depression care did not have a significant impact. Data consisted of detailed notes from observations of 12 project-related events (for example, team meetings and presentations) and open-ended interviews with a purposive sampling of 17 key informants. Thematic analytic methods were used to identify themes in the contextual data.

PRINCIPAL FINDINGS

Overall, the project implementation was very limited. Five themes emerged: (1) The project received only lukewarm support from clinic and medical group leadership. (2) Clinicians did not perceive an urgent need for the new care system, and therefore there was a lack of impetus to change. (3) The improvement initiative was perceived as too complex by the physicians. (4) There was an inherent disconnect between the commitment of the improvement team and the unresponsiveness of most other clinic staff. (5) The doctor focus in clinic culture created a catch-22 dilemma-the involvement and noninvolvement of physicians were both problematic.

CONCLUSION

Problems in both predisposing and enabling factors accounted for the ultimate failure of the DIAMOND quality improvement effort.

A CQI intervention to change the care of depression: a controlled study

CONTEXT

Although new strategies for managing depression in primary care (e.g., nurse telephone calls, collaborative care) have been shown to be effective, no models are available for their systematic implementation in the "real world."

OBJECTIVE

To test whether a continuous quality improvement (CQI) intervention could be used to implement systems in primary care clinics to improve the care and outcomes for patients diagnosed with depression.

DESIGN

Before-after study with concurrent controls.

INTERVENTION

A multidisciplinary team from the three intervention clinics developed and implemented a graded set of five care management options, ranging from watchful waiting (nurse telephone call in 4 to 6 weeks) to mental health management, which clinicians could order for their patients with depression.

SETTING

9 primary care clinics in greater Minneapolis-St. Paul, Minnesota.

PATIENTS

Outpatients 18 years of age and older whose primary care clinic visit included an International Classification of Diseases, 9th revision, code for depression and who completed baseline and 3-month follow-up surveys before and after the intervention.

MAIN OUTCOME MEASURES

Measures of process of care (follow-up depression visits to physician, mental health visits, follow-up telephone calls) and outcomes of care (improved depression symptoms over 3 months, satisfaction with care).

RESULTS

Although the CQI team appeared to function well, only 30 of the 257 patients identified from depression-coded visits for this study were referred to the new system during the 3-month evaluation period. In both the intervention and control clinics, follow-up visits, mental health referrals, and follow-up telephone calls did not improve significantly from the preintervention levels of about 0.5 for a primary care visit, 0.4 for a mental health visit, or 0.1 for a follow-up phone call per person. The same was true of patient outcomes: The proportion of patients in the intervention and control clinics who had improved depression symptoms and those who were very satisfied with their depression care did not change significantly from the preintervention levels of 43% and 26%, respectively.

CONCLUSIONS

Our attempt to improve the primary care management of depression failed because physicians used the new order system so infrequently. Whether a greater leadership commitment to change or a different improvement process would alter our findings is an open question.

Aids to quitting tobacco use: how important are they outside controlled trials?

BACKGROUND

Although there is good evidence that several pharmacotherapies and counseling can effectively facilitate smoking cessation, there is little information about the use or effectiveness of these or any other quit aids outside of controlled trials.

METHODS

A mailed survey with phone follow-up documented the use of various quit aids among 3,122 health plan members who smoke. A multilevel statistical modeling technique controlled for potentially confounding variables.

RESULTS

Nearly half (1,513) of these smokers reported a quit attempt during the preceding 6 months. Although 1,036 (33.2%) reported using some type of aid to quitting, primarily nicotine products or bupropion, 10-26% of these "users" did not report an actual quit attempt. Ninety percent of the medication users had a personal cost, averaging $53-$87. Fully 26.9% of those reporting a quit without any type of aid quit for at least 7 days. This rate equals that of users of all types of aids except for nicotine patches and bupropion, both of which had associated 7 or more day quit rates of about 46% (95% CI 39.3-52.2).

CONCLUSIONS

Pharmacotherapeutic quit aids are being widely used, even in the absence of significant insurance coverage.

Variation in clinical preventive services

CONTEXT

Preventive services are not delivered at optimal rates in primary care settings, and the literature suggests that a systems approach is key to improvement. Studying variation among clinics could help us to understand the extent of system use in practice.

PRACTICE PATTERN EXAMINED

The proportion of patients who are up-to-date for preventive services in 44 primary care practices in the Midwest. PREVENTIVE SERVICES EXAMINED: Papanicolaou (Pap) smear, cholesterol testing, mammography, clinical breast examination, blood pressure measurement, influenza and pneumococcal vaccinations, and advice on tobacco use.

DATA SOURCE

6830 patients surveyed after their clinic visit (response rate, 85%).

RESULTS

The proportion of patients up-to-date for preventive services varied widely among clinics. For example, up-to-date rates for Pap smear testing ranged from 70% to 93% and 45% to 88% for cholesterol screening. There was little correlation between a clinic's performance on one preventive service (relative to the other 43 clinics) and its performance on others. When correlations between pairs of up-to-date rates within clinics were examined, only 4 of 28 service pairs were positive and statistically significant and only 1 had a correlation coefficient that exceeded 0.5 (for mammography and clinical breast examination).

CONCLUSION

There is wide variation in the rates at which various preventive services are performed, both between and within clinics. This variation, which is probably due to a lack of organized prevention systems that cover multiple services, provides a clear target for improvement efforts.

Patient satisfaction and discussion of smoking cessation during clinical visits

OBJECTIVE

To learn whether patients who smoke and who receive smoking cessation information during medical office visits were less likely to be satisfied with the smoking cessation help they received than patients who smoke but who did not receive such information.

PATIENTS AND METHODS

A total of 3703 current cigarette smokers were identified by a mailing in November 1998 to 163,596 members of 2 Minnesota health plans, and 2714 (77.3%) responses to a 44-item questionnaire were available for analysis. Using hierarchical analysis to control confounding variables, we assessed the relationship between patient-reported smoking cessation support actions at the last physician visit and satisfaction "with the help received from your doctor about quitting smoking."

RESULTS

Smokers were very satisfied (12.0%), satisfied (25.3%), neutral (48.6%), and dissatisfied or very dissatisfied (13.5%) with physician help. After controlling for other characteristics, the 1898 patients who reported that they had been asked about tobacco use or advised to quit during the latest visit had 10 percentage point greater satisfaction ratings and 5 percentage point less dissatisfaction than those not reporting such discussions (P<.001). Smokers reporting no interest in quitting at the time of the latest visit also demonstrated greater satisfaction in association with these actions.

CONCLUSION

Smoking cessation interventions during physician visits were associated with increased patient satisfaction with their care among those who smoke. This information should reduce concerns of physicians or nurses about providing tobacco cessation assistance to patients during office visits.

Care-seeking behavior for upper respiratory infections

BACKGROUND

Many recent efforts to reduce unnecessary medical services have targeted care of upper respiratory infections (URIs). We tested whether patients who seek care very early in their illness differ from those who seek care later and whether they might require a different approach to care.

METHODS

We surveyed by telephone 257 adult patients and 249 parents of child patients who called or visited one of 3 primary care clinics within 10 days (adults) or 14 days (parents) of the onset of uncomplicated URI symptoms. Those who contacted the clinic within the first 2 days of illness were compared with those who made contact later.

RESULTS

Although 28% of adults and 41% of parents contacted their clinic within the first 2 days of symptom onset, we found very few differences in the characteristics of the caller or patient between those who called early and later. The illnesses of those who called early were not more severe, and they did not have different beliefs, histories, approaches to medical care, or needs. The only clinician-relevant difference was that adult patients calling in the first 2 days had a greater desire to rule out complications (84.7% vs 64.1% calling in 3-5 days and 70.6% calling after 5 days of illness, P < or = .05).

CONCLUSIONS

Those who seek medical care very early for a URI do not appear to be different in clinically important ways. If we are going to reduce overuse of medical care and antibiotics for URIs, clinical trials of more effective and efficient strategies are needed to encourage home care and self-management.

Guideline implementation: what the literature doesn't tell us

BACKGROUND

Despite large numbers of studies and literature reviews about guideline implementation, it remains unclear whether and how clinical guidelines can be used to improve the quality of medical care. This study sought to learn whether these studies and reviews have recognized the importance of systems thinking and organizational change for implementation.

METHODS

A literature search was conducted for systematic reviews of guideline implementation or practice improvement studies. Each review was studied for the extent to which it identified or discussed the value of systems changes, organizational support, practice environmental factors, and use of a change process.

RESULTS

Forty-seven good-quality systematic reviews were found. They largely concurred that using reminders and perhaps using feedback in the course of clinical encounters were the most effective ways of implementing guidelines. However, these same reviews rarely identified these strategies as systems changes, and there was little discussion about any need for organizational support or attention to various environmental variables that might affect implementation. The change process required to introduce a new or changed practice system received even less attention.

CONCLUSION

Reviews of guideline implementation trials have focused on how to change the behavior of individual clinicians. There has been little attention to the impact of practice systems or organizational support of clinician behavior, the process by which change is produced, or the role of the practice environmental context within which change is being attempted. New attention to these issues may help us to better understand and undertake the process of improving medical care delivery.

Failure of a continuous quality improvement intervention to increase the delivery of preventive services. A randomized trial

CONTEXT

Although there has been enormous interest in continuous quality improvement (CQI) as a measure to improve health care, this enthusiasm is based largely on its apparent success in business rather than formal evaluations in health care.

OBJECTIVE

To determine whether a managed care organization can increase delivery of eight clinical preventive services by using CQI.

DESIGN

Primary care clinics were randomly assigned to improve delivery of preventive services with CQI (intervention group) or to provide usual care (control group).

INTERVENTION

Through leadership support, training, consulting, and networking, each intervention clinic was assisted to use CQI multidisciplinary teams to develop and implement systems for delivery of preventive services.

SETTING

44 primary care clinics in greater Minneapolis-St. Paul.

PATIENTS

Patients 19 years of age and older completed surveys at baseline (n = 6830) and at follow-up (n = 6431). Medical chart audits were completed on 4777 patients at baseline and 4546 patients at follow-up.

MAIN OUTCOME MEASURES

The proportion of patients who were up-to-date (according to chart audit) and the proportion of patients who were offered a service if not up-to-date (according to patient report) for 8 preventive services.

RESULTS

Compared with the control group, based on the proportion of patients who were up-to-date, use of only one preventive service--pneumococcal vaccine--increased significantly in the intervention group (17.2% absolute increase from baseline to follow-up compared with a 0.3% absolute increase in the control group, P = 0.003). Similarly, based on patient report of being offered a service if not up-to-date, delivery of only one preventive service--cholesterol testing--significantly increased in the intervention group compared with the control group (4.6% increase vs. 0.4% absolute decrease in the control group; P = 0.006).

CONCLUSION

In this trial, CQI methods did not result in clinically important increases in preventive service delivery rates.

Lessons from experienced guideline implementers: attend to many factors and use multiple strategies

BACKGROUND

Studies of clinical guideline implementation have focused almost entirely on changing individual clinician behavior with single intervention strategies and without much attention to the situational context. The goal of this project was to learn from clinic leaders, seasoned in the guideline implementation process, what contextual variables they viewed as important and whether implementation success could be expected if only a single implementation strategy was used.

METHODS

In 1998, 12 people with extensive experience in leading clinical guideline implementation were identified who were thought to have particularly keen insight into the process. They were interviewed to generate variables they considered important, as well as strategies they considered effective when used appropriately. A modified nominal group/Delphi process was then used for rating these variables and strategies, and the reactions of international experts were obtained to add perspective to this information.

RESULTS

Eighty-seven variables and 25 strategies were identified, clustering in 6 categories (ranked in order of importance by the panel): organizational capabilities for change, infrastructure for implementation, implementation strategies, medical group characteristics, guideline characteristics, and external environment. All six categories were considered to be important, key, or essential by the experienced implementers, although variables within a medical group that directly affect its ability to undertake planned change were rated as much more important than either guideline characteristics or the external environment.

DISCUSSION

Although the opinions of those experienced in the process of guideline implementation are primarily of value for generating hypotheses, panel members believe that implementation efforts focusing on the individual physician with a single strategy are unlikely to be successful. Rather, implementation efforts must use multiple strategies that take account of multiple characteristics of the guideline, practice organization, and external environment.

Clinician satisfaction with a preventive services implementation trial. The IMPROVE project

OBJECT

To discover how attempts to increase the delivery of preventive services affect clinician satisfaction.

METHODS

The IMPROVE project was a randomized clinical trial conducted in 44 clinics in and around Minneapolis-St. Paul, Minnesota. Personnel were trained in continuous quality improvement techniques to organize preventive services delivery systems. Satisfaction with delivery of these services and with the sponsoring organizations was measured before the intervention (Time 1), at the end of the intervention (Time 2), and 1 year post-intervention (Time 3).

RESULTS

At no time was the intervention associated with a change in the respondents satisfaction with their places of work or with their job roles. Satisfaction with preventive services delivery increased from Time 1 to Time 3 among intervention-clinic respondents. Satisfaction with the IMPROVE project and the efforts of the two managed care organizations to help the clinics deliver preventive services peaked at Time 2 and declined toward baseline at Time 3. Satisfaction with preventive services delivery tended to increase more in the 13 intervention clinics that implemented a preventive services delivery system than in the nine intervention clinics that did not implement a preventive services delivery system (p = 0.15).

CONCLUSIONS

Planned organizational change to create systems for preventive services delivery can be associated with increased clinician satisfaction with the way these services are delivered. However, increased satisfaction with preventive services does not necessarily indicate that service delivery rates have increased.

Improving prevention systems in primary care practices: the Health Education and Research Trial (HEART)

BACKGROUND

The Health Education and Research Trial (HEART) was a multicenter clinical trial designed to test methods to improve primary care practice systems for heart disease prevention services. We present the trial methodology, the practices' use of medical record tools, and changes in documentation of cardiovascular risk factor screening and management.

METHODS

Primary care practices were recruited from 4 Midwestern states. The factorial design resulted in 4 study groups: conference only, conference and quality improvement consultations, conference and prevention coordinator, and all interventions combined. Medical record audits and physician, staff, and patient surveys assessed practice change in cardiovascular disease risk factor documentation.

RESULTS

Practices participated fully in this project, set goals to improve preventive services, and implemented recommended medical record tools. The number of goals set and the increase in the use of medical record tools were greatest in the combined intervention group, with improvements noted in all groups. The use of patient history questionnaires, problem lists, and flow sheets was significantly higher in the combined intervention group when compared with the conference-only group. Documentation of risk factor screening in a recommended-medical record location improved in all intervention groups, with significant sustained improvements in the practices that received the combined intervention. Documented risk factor management significantly improved in all intervention groups compared with the conference-only control.

CONCLUSION

Primary care practices are interested in improving prevention systems and can change these systems in response to supportive external interventions. Promoting organizational change to produce sustained improvement in preventive service clinical outcomes is a complex process that requires further research.

The need for a system in the care of depression

BACKGROUND

Many problems have been identified in the usual care of patients with depression, including lack of identification, overreliance on medications, and inadequate treatment and follow-up. Most of these problems can be attributed to an absence of depression care systems in primary care practice. We collected information from a group of practices to assess the need for and acceptability of such systems.

METHODS

We conducted 4 focus groups with primary care physicians and their staffs to identify attitudes and perceived behaviors for depression problems and to determine the participants' level of acceptance of alternative systematic approaches. We also surveyed clinicians and a sample of patients who recently visited their practices.

RESULTS

Systematic screening was viewed unfavorably, and many barriers were identified with collaborative care with mental health clinicians. Participants did support involvement of other office staff and more systematic follow-up for patients with depression. The patient survey suggested that some patients with depressive symptoms were unrecognized and undertreated, but the key finding was considerable variation in care among practices.

CONCLUSIONS

These findings suggest that a more systematic approach could improve the problems associated with treatment of patients with depression in primary care and would be acceptable to physicians if introduced appropriately. There are at least 2 promising approaches to introducing such changes. One involves external feedback of data about their care to the practices, followed by offering a variety of systems concepts and tools. The other involves an internal change process in which a multiclinic improvement team collects its own data and develops its own systematic solutions using rapid-cycle testing.

How satisfied are mothers with 1-day hospital stays for routine delivery?

CONTEXT

Payers and health plans are encouraging shorter hospital stays after routine vaginal delivery.

OBJECTIVE

To assess the satisfaction of mothers who had 1-day or 2-day stays after routine delivery.

DESIGN

We mailed questionnaires to mothers 7 to 9 months after delivery. The self-administered survey contained questions about the mothers' satisfaction with the care they received, clinical complications, and the mothers' preparedness after discharge.

SETTING

A mixed-staff, network-model managed care plan in Minnesota that encourages but does not require 1-day hospital stays after routine delivery.

PARTICIPANTS

All plan members who delivered a baby vaginally in the first quarter of 1995 (n = 1009).

RESULTS

56% of the mothers responded to the survey. Of these, 202 had 1-day stays and 292 had 2-day stays. Mothers with 1-day stays were more likely than mothers with 2-day stays to report that their length of stay was "too short" (75% vs. 37%; P < 0.001), and 81% of mothers with 1-day stays would want to stay longer if they had another child. The frequency of self-reported maternal or infant complications did not differ substantially between the two groups. More mothers with 1-day stays than mothers with 2-day stays received home health care visits (44% vs. 10%; P < 0.001).

CONCLUSION

Although length of stay does not seem to be related to clinical outcomes after vaginal delivery, mothers with 1-day stays are less satisfied with their length of stay.

Nurses on quality improvement teams: how do they benefit?

As part of a randomized control trial to improve the delivery of preventive services, the authors studied the effect on clinic nurses in the roles of team leaders or facilitators of multidisciplinary, continuous quality improvement (CQI) teams. Our goal was to learn how these nurses felt about their experience with this project, specifically their satisfaction with process improvement, acquired knowledge and skills, and the impact on their nursing role. Overall, the nurses involved in this study reported significant gains in all three areas. This study suggests that CQI can be a valuable vehicle for improving and expanding the nursing role for clinic nurses.

Is having a regular provider of diabetes care related to intensity of care and glycemic control?

BACKGROUND

We investigated whether having a regular health care provider for diabetes was related to the intensity of care, use of preventive services, or glycemic control in a well-defined population of adults with diabetes.

METHODS

Adults with diabetes who were continuously enrolled in a health maintenance organization (HMO) for 1 year were identified by diagnostic and pharmacy databases (estimated sensitivity = 0.91, positive predictive value = 0.94). In a stratified random sample, 1828 patients were sent a survey by mail that had a corrected response rate of 85.6%. Further data on utilization of services and glycosylated hemoglobin values were obtained from administrative databases and linked to survey responses.

RESULTS

HMO members who reported having a regular health care provider (RP) for their diabetes (N = 1243) were comparable with those (N = 144) who denied having such a provider (NRP) in age, race, sex, comorbidity, and years of education, but had longer-duration diabetes (10.9 years vs 8.3 years; P = .002). After adjusting for age, sex, education level, duration of diabetes, and type of HMO clinic (owned vs contracted), RP subjects were more likely than NRPs (all P < .001) to follow a special diet for patients with diabetes (55% vs 33%), regularly monitor glucose levels at home (68% vs 47%), have greater frequency of glycosylated hemoglobin (Hb A1c) testing (65% vs 38%), have more foot examinations (42% vs 17%), have recommended cholesterol checks (77% vs 63%), and have had a recent preventive examination (86% vs 68%). Smaller differences favoring having a regular provider were noted for insulin use (48% vs 33%, odds ratio [OR] = 1.71, P = .013), for an influenza immunization within 1 year (65% vs 51%, P = .029), and for dilated retinal examinations (64% vs 51%, P < .027). No differences between groups were noted for dental checkups (69% vs 67%, P = .724) or likelihood of endocrinology referral (17% vs 10%, P = .104). Mean Hb A1c level was 8.2% (normal is < 6.1%) in the RP group and 8.6% in the NRP group (P = .182). Twelve percent of RPs and 24% of NRPs had an Hb A1c level of greater than 10% (chi 2 = 3.7, OR = 0.48, P = .05) after adjusting for age, sex, duration of diabetes, and education level.

CONCLUSIONS

After adjustment for case mix, patients with diabetes who identified a regular primary health care provider for their diabetes were more likely to receive most recommended elements of diabetes care and to have better glycemic control than patients without such a provider. This effect was partially, but not completely, mediated by a higher number of clinic visits for those with a regular health care provider. Innovators seeking to improve diabetes care should be mindful of the relationship between having a regular primary health care provider and the quality of diabetes care.

IMPROVE: bridge over troubled waters

BACKGROUND

The original collaborative project was described in a 1995 Journal article titled "Competing HMOs Collaborate to Improve Preventive Services." IMPROVE (IMproving PRevention through Organization, Vision, and Empowerment) was a large randomized controlled trial using continuous quality improvement to implement clinical systems to improve the delivery of adult preventive services in primary care settings. The project was funded by the Agency for Health Care Policy and Research and initiated as a collaboration between two health maintenance organizations (HMOs) in the Twin Cities: Health Partners and Blue Plus.

METHODOLOGY

Forty-four clinics were recruited for the study. Initially the 22 intervention clinics received the multifaceted intervention of leadership support, training on CQI and prevention systems, and consultation and networking opportunities. Next, the comparison clinics received similar assistance, and other clinics were invited into the collaboration. Ultimately, 57 clinics were involved in the project. Multiple collaborations--among clinics, leaders, and HMOs--developed during the project.

STATUS

Despite turmoil in the environment during the project, many benefits have been described, including enhanced leadership, growth of systems thinking, better change management skills, and collaboration of competing organizations.

SUMMARY

The IMPROVE collaboration survived and flourished in a very competitive market. It was viewed positively by clinicians, medical clinics, and HMOs, and its benefits have extended into the community.

The case of the missing clinical preventive services systems

OBJECTIVE

To examine the presence and comprehensiveness of organized processes and systems in a sample of primary care clinics shown to have high variation in rates of providing preventive services.

DESIGN

Survey study.

SETTING

44 primary care clinics recruited for a scientific trial of a quality improvement intervention to improve preventive services.

PARTICIPANTS

647 clinicians and nurses.

MEASUREMENTS

The presence of 10 organized prevention processes for eight adult preventive services as reported by those clinicians and nurses on a detailed written survey.

RESULTS

In more than 50% of clinics, 7 of the 10 prevention processes were reported to be absent for all eight services. Only the follow-up process was commonly present; this was also the only process that was usually present for most applicable services.

CONCLUSIONS

The paucity of recognizable organized processes to support the systematic delivery of adult preventive services in clinics with highly varying rates of providing these services supports the idea that lack of systems may be an important source of the variability and low rates. Most of the existing processes are fragmented and do not function across multiple preventive services.

Quality improvement in primary care clinics

BACKGROUND

Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization?

METHOD

Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature.

RESULTS

Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues.

CONCLUSION

QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.

The future of primary care. The enhanced primary care model

In today's competitive health care market, only innovators who demonstrate improvements in both quality and price will survive. Primary care physicians can survive, and even thrive, in this environment if they take a hard look at their goals, reflect on necessary changes, and experiment boldly to forge a new primary care model that can achieve the necessary goal of improved clinical care effectively and efficiently. We propose a new model of primary care, the Enhanced Primary Care Model, that combines clinical tools with quality improvement methods to improve health outcomes. Tools include clinical guidelines, patient registries, team care, monitoring, tracking, prioritization, outreach, and the formation of multidisciplinary teams that use continuous quality improvement (CQI) methods. The Enhanced Primary Care Model has many advantages for both patients and clinicians as compared with competing models, such as the Subspecialty Model and the Disease Management Carve-out Model. There is a short window of opportunity for primary care physicians to demonstrate improved health care processes and outcomes using the Enhanced Primary Care Model. Some improvements in primary care have been achieved by increasing efficiency and rearranging what we have to make it work better. However, more radical change is now urgently needed. In the absence of radical improvement in quality of care, the future of primary care may be much more bleak than most physicians have assumed.

Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial

BACKGROUND

There is increasing evidence that the most effective way to improve delivery of preventive services in primary care is to establish organized preventive service systems. This study tests the hypothesis that a managed care organization (MCO) can help its contracted private primary care clinics to develop such systems.

METHODS

Forty-four primary care clinics contracting with two large MCOs were randomized to a comparison (C) or an intervention (I) group. Group (I) clinic team leaders received training plus ongoing consultation and networking. Personnel at all 44 clinics completed surveys prior to and at the end of the intervention to measure adoption of the improvement process and the prevention system.

RESULTS

All 22 (I) clinics identified teams that appeared to follow the seven-step improvement process. The mean numbers of system processes were identical at baseline, 11.2 (I) vs 12.1 (C), while after the intervention this had changed to 25.8 in (I) clinics vs 11.3 in (C) (P = 0.022).

CONCLUSIONS

With training and assistance, interested primary care clinic teams will establish functioning CQI teams that will produce a substantial increase in the presence of functional prevention system processes. Whether this change is sufficient to increase the rates of preventive services remains to be documented.

Delivering clinical preventive services is a systems problem

A steadily increasing number of research trials and prevention advocates are identifying the practice environment as the main source of both problems and solutions to the improved delivery of clinical preventive services. Although these sources are correctly focusing on office systems as solutions, there is a tendency to focus on only parts of a system and to relate this to just one or a few related preventive services. However, the effort required to set up and maintain an office system makes it difficult to justify doing so for a single clinical activity. The process and system thinking of Continuous Quality Improvement (CQI) theory suggests that there may be both efficiency and effectiveness advantages to the concept of all clinical preventive services being served by a single system with many interrelated component processes. Such a system should be usable for all age groups. This system and its literature base are described. The feasibility of applying this concept is being tested in a randomized controlled trial in 44 primary care clinics in Minnesota and Wisconsin.