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

What AHRQ Learned While Working to Transform Primary Care

Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.

Advancing Cardiovascular Risk Assessment with Artificial Intelligence: Opportunities and Implications in North Carolina

Cardiovascular disease mortality is increasing in North Carolina with persistent inequality by race, income, and location. Artificial intelligence (AI) can repurpose the widely available electrocardiogram (ECG) for enhanced assessment of cardiac dysfunction. By identifying accelerated cardiac aging from the ECG, AI offers novel insights into risk assessment and prevention.

Population health interventions for cardiometabolic diseases in primary care: a scoping review and RE-AIM evaluation of current practices

Introduction

Cardiometabolic diseases (CMD) are the leading cause of death in high-income countries and are largely attributable to modifiable risk factors. Population health management (PHM) can effectively identify patient subgroups at high risk of CMD and address missed opportunities for preventive disease management. Guided by the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework, this scoping review of PHM interventions targeting patients in primary care at increased risk of CMD aims to describe the reported aspects for successful implementation.

Methods

A comprehensive search was conducted across 14 databases to identify papers published between 2000 and 2023, using Arksey and O'Malley's framework for conducting scoping reviews. The RE-AIM framework was used to assess the implementation, documentation, and the population health impact score of the PHM interventions.

Results

A total of 26 out of 1,100 studies were included, representing 21 unique PHM interventions. This review found insufficient reporting of most RE-AIM components. The RE-AIM evaluation showed that the included interventions could potentially reach a large audience and achieve their intended goals, but information on adoption and maintenance was often lacking. A population health impact score was calculated for six interventions ranging from 28 to 62%.

Discussion

This review showed the promise of PHM interventions that could reaching a substantial number of participants and reducing CMD risk factors. However, to better assess the generalizability and scalability of these interventions there is a need for an improved assessment of adoption, implementation processes, and sustainability.

Validation of a Case Definition to Identify Patients Diagnosed With Cardiovascular Disease in Canadian Primary Care Practices

Background

Cardiovascular disease (CVD) is a leading cause of death globally. This study validates a primary care-based electronic medical record case definition for CVD.

Methods

This retrospective, cross-sectional study explores electronic medical record data from 1574 primary care providers participating in the Canadian Primary Care Sentinel Surveillance Network. A reference standard was created by reviewing medical records of a subset of patients in this network (n = 2017) for coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD). Together, these data produced a CVD reference. We applied validated case definitions to an active patient population (≥ 1 visit between January 1, 2018 and December 31, 2019) to estimate prevalence using the exact binomial test (N = 689,301). Descriptive statistics, χ² tests, and t tests characterized patients with vs without CVD.

Results

The optimal CVD Case Definition 2 had a sensitivity of 68.5% (95% Confidence Interval [CI]: 61.6%-74.8%), a specificity of 97.8% (95% CI: 97.0%-98.4%), a positive predictive value of 77.7% (95% CI: 71.6%-82.7%), and a negative predictive value of 96.5% (95% CI: 95.8%-97.1%). Included in this CVD definition was a strong CAD case definition with sensitivity of 91.6% (95% CI: 84.6%-96.1%), specificity of 98.3% (95% CI: 97.6%-98.8%), a PPV of 74.8% (95% CI: 67.8%-80.7%), and an NPV of 99.5% (95% CI: 99.1%-99.7%). This CVD definition also included CeVD and PVD case definitions with low sensitivity (77.6% and 36.6%) but high specificity (98.6% and 99.0%). The estimated prevalence of CVD among primary care patients is 11.2% (95% CI, 11.1%-11.3%; n = 77,064); the majority had CAD (6.4%).

Conclusions

This study validated a definition of CVD and its component parts-CAD, CeVD, and PVD. Understanding the prevalence and disease burden for patients with CVD within primary care settings can improve prevention and disease management.

Facilitating implementation of primary care mental health over time and across organizational contexts: a qualitative study of role and process

BACKGROUND

Healthcare organizations have increasingly utilized facilitation to improve implementation of evidence-based practices and programs (e.g., primary care mental health integration). Facilitation is both a role, related to the purpose of facilitation, and a process, i.e., how a facilitator operationalizes the role. Scholars continue to call for a better understanding of this implementation strategy. Although facilitation is described as dynamic, activities are often framed within the context of a staged process. We explored two understudied characteristics of implementation facilitation: 1) how facilitation activities change over time and in response to context, and 2) how facilitators operationalize their role when the purpose of facilitation is both task-focused (i.e., to support implementation) and holistic (i.e., to build capacity for future implementation efforts).

METHODS

We conducted individual monthly debriefings over thirty months with facilitators who were supporting PCMHI implementation in two VA networks. We developed a list of facilitation activities based on a literature review and debriefing notes and conducted a content analysis of debriefing notes by coding what activities occurred and their intensity by quarter. We also coded whether facilitators were "doing" these activities for sites or "enabling" sites to perform them.

RESULTS

Implementation facilitation activities did not occur according to a defined series of ordered steps but in response to specific organizational contexts through a non-linear and incremental process. Amount and types of activities varied between the networks. Concordant with facilitators' planned role, the focus of some facilitation activities was primarily on doing them for the sites and others on enabling sites to do for themselves; a number of activities did not fit into one category and varied across networks.

CONCLUSIONS

Findings indicate that facilitation is a dynamic and fluid process, with facilitation activities, as well as their timing and intensity, occurring in response to specific organizational contexts. Understanding this process can help those planning and applying implementation facilitation to make conscious choices about the facilitation role and the activities that facilitators can use to operationalize this role. Additionally, this work provides the foundation from which future studies can identify potential mechanisms of action through which facilitation activities enhance implementation uptake.

From guidelines to decision aids and adherence supports: Insights from the process of evidence translation

OBJECTIVE

To explore the evidence-translator's experience of the expert-recommended process of translating guidelines into tools for decision making, action, and adherence with the goal of improvement.

METHODS

A single reviewer dual reviewed the content, quality, certainty, and applicability of primary atherosclerotic cardiovascular prevention guidelines from the U.S. Preventive Services Task Force at the time of this work and used targeted searches of Medline to define the ideal structure and outcomes of tools; fill in gaps in guidelines; identify end-user needs; and choose and optimize existing tools in preparation for testing.

RESULTS

Guidelines addressed screening, treatments, and/or supports, but never the combination of all three. None provided all of the information needed for evidence translation. Searches in Medline filled in some evidence gaps and provided key insights into end-user needs and effective tools. However, evidence translators are left with complicated decisions about how to use and align evidence.

CONCLUSION

Guidelines provide some, but not all, of the evidence needed for evidence translation, requiring additional intensive work. Evidence gaps result in complicated decisions about how to use and align evidence and balance feasibility and rigor.

PRACTICE IMPLICATIONS

Guidelines, standards groups, and researchers should work to better support the process of evidence translation.

Estimating the Cardiovascular Disease Risk Reduction of a Quality Improvement Initiative in Primary Care: Findings from EvidenceNOW

BACKGROUND

This study estimates reductions in 10-year atherosclerotic cardiovascular disease (ASCVD) risk associated with EvidenceNOW, a multi-state initiative that sought to improve cardiovascular preventive care in the form of (A)spirin prescribing for high-risk patients, (B)lood pressure control for people with hypertension, (C)holesterol management, and (S)moking screening and cessation counseling (ABCS) among small primary care practices by providing supportive interventions such as practice facilitation.

DESIGN

We conducted an analytic modeling study that combined (1) data from 1,278 EvidenceNOW practices collected 2015 to 2017; (2) patient-level information of individuals ages 40 to 79 years who participated in the 2015 to 2016 National Health and Nutrition Examination Survey (n = 1,295); and (3) 10-year ASCVD risk prediction equations.

MEASURES

The primary outcome measure was 10-year ASCVD risk.

RESULTS

EvidenceNOW practices cared for an estimated 4 million patients ages 40 to 79 who might benefit from ABCS interventions. The average 10-year ASCVD risk of these patients before intervention was 10.11%. Improvements in ABCS due to EvidenceNOW reduced their 10-year ASCVD risk to 10.03% (absolute risk reduction: -0.08, P ≤ .001). This risk reduction would prevent 3,169 ASCVD events over 10 years and avoid $150 million in 90-day direct medical costs.

CONCLUSION

Small preventive care improvements and associated reductions in absolute ASCVD risk levels can lead to meaningful life-saving benefits at the population level.

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

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

A Heart Healthy Intervention Improved Tobacco Screening Rates and Cessation Support in Primary Care Practices

We examined whether an evidence-based cardiovascular disease risk reduction intervention (Heart Health Now) would improve rates for tobacco cessation screening and counseling in small primary care practices in North Carolina. Heart Health Now was a stepped wedge, stratified, cluster randomized trial for primary care practices that were staffed by 10 or fewer clinicians and had an electronic health record. The Heart Health Now intervention consisted of education tools, onsite practice facilitation for one year, and a practice-specific cardiovascular population management dashboard that included monthly, measure-specific run charts to help guide quality improvement. Our primary outcomes were practice-level rates of tobacco screening and tobacco cessation support-extracted from practices' electronic health records-and measured at pre-intervention and 6 months post-intervention. The 28 practices included in our analyses represented 78,120 patients and 17,687 smokers. Significant change occurred in practices' tobacco screening rates and cessation support rates over time. From pre- to post-intervention, screening rates significantly increased from 82.7 to 96.2% (p < 0.001). Similarly, cessation support rates significantly increased from 44.3 to 50.1% (p = 0.03). Several practice-level factors were associated with improvement including being in an academic health center or faculty practice, having more clinicians, and having a lower percentage of White patients. In conclusion, a multi-component intervention focused on multiple cardiovascular disease risk reduction in multiple small primary care practices successfully improved rates of tobacco screening and cessation support.

Assessing Preconception Wellness in the Clinical Setting Using Electronic Health Data

Background: One key strategy to reduce maternal morbidity and mortality involves optimizing prepregnancy health. Although nine core indicators of preconception wellness (PCW) have been proposed by clinical experts, few studies have attempted to assess the preconception health status of a population using these indicators. Methods: We conducted a retrospective chart review study of patients who received prenatal or primary care, identified by pregnancy-related ICD-10 codes, at either of two health systems in geographically and socioeconomically different areas of North Carolina between October 1, 2015, and September 30, 2018. Our primary study aim was to determine the feasibility of measuring the proposed PCW indicators through retrospective review of prenatal electronic health records at these two institutions. Results: Data were collected from 15,384 patients at Site 1 and 6,983 patients at Site 2. The indicators most likely to be documented and to meet the preconception health goal at each site were avoidance of teratogenic medications (98.8% and 98.3% at Sites 1 and 2, respectively) and entry to care in the first trimester (64.5% and 73.5% at Sites 1 and 2, respectively), whereas our measures of folic acid use, depression screening, and discussion of family planning were documented less than 20% of the time at both sites. Conclusions: Differences in measuring and documenting PCW indicators across the two health systems in our study presented barriers to monitoring and optimizing PCW. Efforts to address health and wellness before pregnancy will likely require health systems and payors to standardize, incorporate, and promote preconception health indicators that can be consistently measured and analyzed across health systems.

Social Deprivation and Peripheral Artery Disease

The link between peripheral artery disease and socioeconomic status is complex. The objective of this narrative review is to explore this relationship in detail, including how social factors impact the development, management, and outcomes of peripheral artery disease. Although the current literature on this topic is limited, some patterns do emerge. Populations of low socioeconomic status appear to be at increased risk for the development of peripheral artery disease, due to factors such as increased prevalence of cardiovascular risk factors (i.e. cigarette smoking) and decreased access to care. However, variables that are more difficult to quantify, such as chronic stress and health literacy, also likely play a significant role. Among those who are living with peripheral artery disease, socioeconomic status can also affect disease management. Secondary prevention strategies, such as medication use, smoking cessation, and exercise therapy, are underutilized in socially deprived populations. This underutilization of evidence-based management leads to adverse outcomes in these groups, including increased rates of amputation and decreased post-operative survival. The recognition of the importance of social factors in prognosis is an important first step towards addressing this health disparity. Moving forward, interventions that help to identify those who are at high risk and help to improve access to care in populations of low socioeconomic status, will be critical to improving outcomes.

The STUN (STop UNhealthy) Alcohol Use Now trial: study protocol for an adaptive randomized trial on dissemination and implementation of screening and management of unhealthy alcohol use in primary care

BACKGROUND

Unhealthy alcohol use is a leading cause of preventable deaths in the USA and is associated with many societal and health problems. Less than a third of people who visit primary care providers in the USA are asked about or ever discuss alcohol use with a health professional.

METHODS/DESIGN

This study is an adaptive, randomized, controlled trial to evaluate the effect of primary care practice facilitation and telehealth services on evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use in small-to-medium-sized primary care practices. Study participants will include primary care practices in North Carolina with 10 or fewer providers. All enrolled practices will receive a practice facilitation intervention that includes quality improvement (QI) coaching, electronic health record (EHR) support, training, and expert consultation. After 6 months, practices in the lower 50th percentile (based on performance) will be randomized to continued practice facilitation or provision of telehealth services plus ongoing facilitation for the next 6 months. Practices in the upper 50th percentile after the initial 6 months of intervention will continue to receive practice facilitation alone. The main outcome measures include the number (and %) of patients in the target population who are screened for unhealthy alcohol use, screen positive, and receive brief counseling. Additional measures include the number (and %) of patients who receive pharmacotherapy for AUD or are referred for AUD services. Sample size calculations determined that 35 practices are needed to detect a 10% increase in the main outcome (percent screened for unhealthy alcohol use) over 6 months.

DISCUSSION

A successful intervention would significantly reduce morbidity among adults from unhealthy alcohol use by increasing counseling and other treatment opportunities. The study will produce important evidence about the effect of practice facilitation on uptake of evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use when delivered on a large scale to small and medium-sized practices. It will also generate scientific knowledge about whether embedded telehealth services can improve the use of evidence-based screening and interventions for practices with slower uptake. The results of this rigorously conducted evaluation are expected to have a positive impact by accelerating the dissemination and implementation of evidence related to unhealthy alcohol use into primary care practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04317989 . Registered on March 23, 2020.

Successful Trial of Practice Facilitation for Plan, Do, Study, Act Quality Improvement

BACKGROUND

Practice facilitation (PF) is a promising but relatively new intervention supporting data-driven practice change. There is a need to better detail research-based facilitation methods, which must balance intervention fidelity and time restrictions with the flexibility required for the intervention. As part of a multi-level 4-armed cluster randomized clinical trial (RCT), 32 rural primary care practices received PF for 1 year. We evaluated the feasibility of having facilitators guide practices to perform 4 key driver domain activities, implemented as Plan-Do-Study-Act (PDSA) cycles, to better understand facilitation "exposure." We describe the intervention and activity length such that our experiences may be useful to other PF research efforts.

METHODS

Thirty-two practices serving rural patients involved in the Southeastern Collaboration to Improvement Blood Pressure Control engaged with a facilitator to develop and implement PDSAs nested within key drivers of change domains. Numbers of months practices worked on activities deemed most likely to be sustained were captured along with practice satisfaction data.

RESULTS

All practices engaged in at least 4 domain-level activities, and 59% of the PDSAs were active for at least 3 months. There was variation by domain in the average length of the PDSA activities. Ninety-seven percent (31 of 32) of practices recommended similarly structured facilitation services to other primary care practices, and 84% (27 of 32) noted substantive changes in their care processes.

CONCLUSION

In this trial, it was feasible for PFs to engage practices in at least 4 Key Driver quality improvement activities within 1 year, which will inform PF methods and protocol development in future trials.

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

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 risk-stratified 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. Registration: ClinicalTrials.Gov 15-0479.