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Balasubramanian BA, Marino M, Cohen DJ, Ward RL, Preston A, Springer RJ, Lindner SR, Edwards S, McConnell KJ, Crabtree BF, Miller WL, Stange KC, Solberg LI. Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices. Ann Fam Med 2018; 16:S35-S43. [PMID: 29632224 PMCID: PMC5891312 DOI: 10.1370/afm.2172] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.
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Affiliation(s)
- Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Miguel Marino
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Deborah J Cohen
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Rikki L Ward
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Alex Preston
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Rachel J Springer
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Stephan R Lindner
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Samuel Edwards
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - K John McConnell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Benjamin F Crabtree
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - William L Miller
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Kurt C Stange
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Leif I Solberg
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Cohen DJ, Balasubramanian BA, Gordon L, Marino M, Ono S, Solberg LI, Crabtree BF, Stange KC, Davis M, Miller WL, Damschroder LJ, McConnell KJ, Creswell J. A national evaluation of a dissemination and implementation initiative to enhance primary care practice capacity and improve cardiovascular disease care: the ESCALATES study protocol. Implement Sci 2016; 11:86. [PMID: 27358078 PMCID: PMC4928346 DOI: 10.1186/s13012-016-0449-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/08/2016] [Indexed: 12/15/2022] Open
Abstract
Background The Agency for Healthcare Research and Quality (AHRQ) launched the EvidenceNOW Initiative to rapidly disseminate and implement evidence-based cardiovascular disease (CVD) preventive care in smaller primary care practices. AHRQ funded eight grantees (seven regional Cooperatives and one independent national evaluation) to participate in EvidenceNOW. The national evaluation examines quality improvement efforts and outcomes for more than 1500 small primary care practices (restricted to those with fewer than ten physicians per clinic). Examples of external support include practice facilitation, expert consultation, performance feedback, and educational materials and activities. This paper describes the study protocol for the EvidenceNOW national evaluation, which is called Evaluating System Change to Advance Learning and Take Evidence to Scale (ESCALATES). Methods This prospective observational study will examine the portfolio of EvidenceNOW Cooperatives using both qualitative and quantitative data. Qualitative data include: online implementation diaries, observation and interviews at Cooperatives and practices, and systematic assessment of context from the perspective of Cooperative team members. Quantitative data include: practice-level performance on clinical quality measures (aspirin prescribing, blood pressure and cholesterol control, and smoking cessation; ABCS) collected by Cooperatives from electronic health records (EHRs); practice and practice member surveys to assess practice capacity and other organizational and structural characteristics; and systematic tracking of intervention delivery. Quantitative, qualitative, and mixed methods analyses will be conducted to examine how Cooperatives organize to provide external support to practices, to compare effectiveness of the dissemination and implementation approaches they implement, and to examine how regional variations and other organization and contextual factors influence implementation and effectiveness. Discussion ESCALATES is a national evaluation of an ambitious large-scale dissemination and implementation effort focused on transforming smaller primary care practices. Insights will help to inform the design of national health care practice extension systems aimed at supporting practice transformation efforts in the USA. Clinical Trial Registration NCT02560428 (09/21/15)
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Affiliation(s)
- Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA. .,Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas School of Public Health, Dallas Regional Campus, Dallas, TX, USA
| | - Leah Gordon
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Sarah Ono
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.,Department of Veteran Affairs, Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA
| | | | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers-Robert Wood, Johnson Medical School, New Brunswick, NJ, USA
| | - Kurt C Stange
- Departments of Family Medicine and Community Health, Epidemiology and Biostatistics, Sociology and the Case Comprehensive Cancer Center, and Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, OH, USA
| | - Melinda Davis
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.,Oregon, Rural Practice-Based Research Network, Portland, OR, USA
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Laura J Damschroder
- Center for Clinical Management Research and PROVE QUERI, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - K John McConnell
- Center for Health Systems Effectiveness and Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - John Creswell
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
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