How can primary care cross the quality chasm?

The challenges of physicians' participation in hospital accreditation programs: a qualitative study in Iran

BACKGROUND

Due to the increasing pressure on hospitals to enhance the quality of services, the participation of physicians in accreditation programs has become more important than ever. The present study was conducted to describe challenges of physicians' participation in hospital accreditation programs in Iran using a qualitative approach.

METHODS

We conducted interviews with 11 managers, 9 physicians and 8 experts in the field of hospital accreditation. Interviewees were selected through purposive snowball sampling. In-depth unstructured and semi-structured interviews were conducted for data collection. The data obtained were analyzed in ATLAS.ti using the conceptual framework method.

RESULTS

The results of this study extracted 3 main themes including: cultural, organizational and behavioral factors. Also, this study found 12 sub-themes and 57 items. Sub-themes in the cultural domain were motivation, patient demand, mutual trust and evaluation system. The organizational domain consisted of seven sub-themes, including high workload, understanding the role of quality management unit, unrealistic accreditation, nature of accreditation, empowerment of physicians in the field of quality, effective communication, resource constraint. Sub-themes in the behavioral dimension were ambiguity in the role and uncertainty about how to participate in accreditation program.

CONCLUSION

Physicians' participation in accreditation programs can be increased through culture building and proper training about accreditation activities in the medical community.

Assessing quality improvement capacity in primary care practices

BACKGROUND

Healthy Hearts Northwest (H2N) is a study of external support strategies to build quality improvement (QI) capacity in primary care with a focus on cardiovascular risk factors: appropriate aspirin use, blood pressure control, and tobacco screening/cessation.

METHODS

To guide practice facilitator support, experts in practice transformation identified seven domains of QI capacity and mapped items from a previously validated medical home assessment tool to them. A practice facilitator (PF) met with clinicians and staff in each practice to discuss each item on the Quality Improvement Capacity Assessment (QICA) resulting in a practice-level response to each item. We examined the association between the QICA total and sub-scale scores, practice characteristics, a measure of prior experience with managing practice change, and performance on clinical quality measures (CQMs) for the three cardiovascular risk factors.

RESULTS

The QICA score was associated with prior experience managing change and moderately associated with two of the three CQMs: aspirin use (r = 0.16, p = 0.049) and blood pressure control (r = 0.18, p = 0.013). Rural practices and those with 2-5 clinicians had lower QICA scores..

CONCLUSIONS

The QICA is useful for assessing QI capacity within a practice and may serve as a guide for both facilitators and primary care practices in efforts to build this capacity and improve measures of clinical quality.

TRIAL REGISTRATION

This trial is registered with www.clinicaltrials.gov Identifier# NCT02839382, retrospectively registered on July 21, 2016.

How to Bridge Research Results to Everyday Clinical Care?

Laboratory and clinical studies are essential to the advancement of sciences. However, a significant gap exists between the research findings and clinical practice. Therefore, research findings can be of little importance if their outcome cannot be directly or indirectly applied to everyday clinical care or readily translated. This paper focuses on how we can shorten the gap between the generation of new knowledge and their implementation into everyday clinical care. A new model is discussed where clinicians are the ones generating the research idea are paired with researchers. They collaborate on studies whose results are readily applicable to everyday practice. Partnering with health providers on studies that address everyday clinical research questions is a potential solution to speed up the translation of the research findings. Generating clinically applicable results can better improve the health of the public. Quoting Dr. Lawrence W. Green: "If we want more evidence-based practice, we need more practice-based evidence." This paper presents the practice-based research model as a solution to address this knowledge gap.

Developing, delivering and evaluating primary mental health care: the co-production of a new complex intervention

BACKGROUND

Health services face the challenges created by complex problems, and so need complex intervention solutions. However they also experience ongoing difficulties in translating findings from research in this area in to quality improvement changes on the ground. BounceBack was a service development innovation project which sought to examine this issue through the implementation and evaluation in a primary care setting of a novel complex intervention.

METHODS

The project was a collaboration between a local mental health charity, an academic unit, and GP practices. The aim was to translate the charity's model of care into practice-based evidence describing delivery and impact. Normalisation Process Theory (NPT) was used to support the implementation of the new model of primary mental health care into six GP practices. An integrated process evaluation evaluated the process and impact of care.

RESULTS

Implementation quickly stalled as we identified problems with the described model of care when applied in a changing and variable primary care context. The team therefore switched to using the NPT framework to support the systematic identification and modification of the components of the complex intervention: including the core components that made it distinct (the consultation approach) and the variable components (organisational issues) that made it work in practice. The extra work significantly reduced the time available for outcome evaluation. However findings demonstrated moderately successful implementation of the model and a suggestion of hypothesised changes in outcomes.

CONCLUSIONS

The BounceBack project demonstrates the development of a complex intervention from practice. It highlights the use of Normalisation Process Theory to support development, and not just implementation, of a complex intervention; and describes the use of the research process in the generation of practice-based evidence. Implications for future translational complex intervention research supporting practice change through scholarship are discussed.

Change in Residents' Experience in Continuity Clinic After Patient-Focused Primary Care Redesign

OBJECTIVE

Evaluation of efforts to redesign primary care has primarily focused on clinical services, with limited assessment of the effect on learners. This study evaluated the change in pediatric residents' perception of training, teamwork, and patient care in 2 different continuity clinic settings that were implementing patient-focused primary care redesign.

METHODS

Continuity clinic residents at 2 large urban pediatric training programs completed a survey, developed de novo, before and after primary care redesign. Differences in the proportion of positive (≥4 of 5) ratings before and after redesign were compared using chi-squared tests in 2 practice sites, each of which focused on improving specific aspects of their practice.

RESULTS

The response rate was >70% in both sites and in both years. Residents in the site focused on teamwork and continuity were more likely to report improved teamwork training (64% vs 83%; P < .05) and teamwork among residents (82% vs 98%; P < .05) after redesign. Perception of overall quality of care in clinic also improved (47% vs 68%; P < .05). Residents in the site focused on clinic flow were more likely to report that physicians, nurses, and administrative staff worked together to optimize patient flow after redesign (25% vs 48%; P < .05). No improvements were seen in domains without focused interventions in either site.

CONCLUSIONS

Practice redesign focused on clinical outcomes can positively affect resident perception of their training and clinical experience in continuity clinic. Future redesign efforts deliberately involving residents might further enhance continuity clinic training.

Translating research into everyday clinical practice: lessons learned from a USA dental practice-based research network

OBJECTIVES

This paper discusses practice-based research (PBR) as a means to speed up the translation of research findings to clinical practice. It also reviews repair versus replacement of defective restorations as one example of the delay in the application of research findings to clinical practice.

METHODS

Despite the existence of clinical studies, a significant delay exists between the generation of new knowledge and its application into the medical/dental community and their patients. One example is the repair of defective dental restorations. About 75% of practitioners in general dental practices do not consider the repair of dental restorations as a viable alternative to the replacement of defective restorations. Engaging and partnering with health practitioners in the field on studies addressing everyday clinical research questions may offer a solution to speed up the translation of the research findings.

RESULTS

Practice-based research (PBR) offers a unique opportunity for practitioners to be involved in the research process, formulating clinical research questions. Additionally, PBR generates evidence-based knowledge with a broader spectrum that can be more readily generalized to the public. With PBR, clinicians are involved in the entire research process from its inception to its dissemination.

SIGNIFICANCE

Early practitioner interaction in the research process may result in ideas being more readily incorporated into practice. Clinical studies are of paramount importance for testing and translation of the research findings to the community.

[Research in primary care as an area of knowledge. SESPAS Report 2012]

Primary care offers huge potential for research. This setting is an area of knowledge that must expand to improve the quality of its services and patients' health. Population-based clinical studies with a focus on health promotion and primary, secondary and tertiary disease prevention offer unique research opportunities. Developing research in the biopsychosocial model of clinical practice and new models of integrated healthcare and community care is therefore a priority. The framework and activities carried out by the Research Network in Preventive Activities and Health Promotion have been instrumental in the development of research in primary care in Spain. Despite the efforts invested by various institutions, foundations, teaching and research departments in primary care research, the projected outputs in terms of volume, quality and impact have not been achieved. The involvement of primary care professionals in research platforms is insufficient, with scarce contribution toward investment in specific primary care research projects. To change the current status of research in primary care, a number of measures are required, namely, the consolidation of research organisms specific to primary care with adequate allocation of funding and staff, and the allocation of specific time for research to primary care professionals to enable them to produce significant projects and consolidate established research lines in their areas of expertise, with applications mainly in quality improvement and innovation of primary care services.

Targeting beta-cell function early in the course of therapy for type 2 diabetes mellitus

OBJECTIVE

This report examines current perspectives regarding likely mechanisms of beta-cell failure in type 2 diabetes and their clinical implications for protecting or sparing beta-cells early in the disease progression. In addition, it considers translation strategies to incorporate relevant scientific findings into educational initiatives targeting clinical practice behavior.

PARTICIPANTS

On January 10, 2009, a working group of basic researchers, clinical endocrinologists, and primary care physicians met to consider whether current knowledge regarding pancreatic beta-cell defects justifies retargeting and retiming treatment for clinical practice. Based on this meeting, a writing group comprised of four meeting participants subsequently prepared this consensus statement. The conference was convened by The Endocrine Society and funded by an unrestricted educational grant from Novo Nordisk.

EVIDENCE

Participants reviewed and discussed published literature, plus their own unpublished data.

CONSENSUS PROCESS

The summary and recommendations were supported unanimously by the writing group as representing the consensus opinions of the working group.

CONCLUSIONS

Workshop participants strongly advocated developing new systems to address common barriers to glycemic control and recommended several initial steps toward this goal. These recommendations included further studies to establish the clinical value of pharmacological therapies, continuing basic research to elucidate the nature and mechanisms of beta-cell failure in type 2 diabetes mellitus, and exploring new educational approaches to promote pathophysiology-based clinical practices. The Endocrine Society has launched a new website to continue the discussion between endocrinologists and primary care physicians on beta-cell pathophysiology in type 2 diabetes and its clinical implications. Join the conversation at http://www.betacellsindiabetes.org

Partnership research: a practical trial design for evaluation of a natural experiment to improve depression care

BACKGROUND

Translational research is increasingly important as academic health centers transform themselves to meet new requirements of National Institutes of Health funding. Most attention has focused on T1 translation studies (bench to bedside) with considerable uncertainty about how to enhance T2 (effectiveness trials) and especially T3 (implementation studies).

OBJECTIVE

To describe an innovative example of a T3 study, conducted as partnership research with the leaders of a major natural experiment in Minnesota to improve the primary care of depression.

METHODS

All health plans in the state have agreed on a new payment model to support clinics that implement the well-evidenced collaborative care model for depression in the Depression Improvement Across Minnesota: Offering a New Direction initiative. The Depression Improvement Across Minnesota: Offering a New Direction study was developed in an ongoing partnership with the Initiative leaders from 7 health plans, 85 clinics, and a regional quality improvement collaborative to evaluate the implementation and its impacts on patients and other stakeholders. We agreed on a staggered implementation, multiple baseline research design, using the concepts of practical clinical trials and engaged scholarship and have collaborated on all aspects of conducting the study, including joint identification of patient and clinic survey recipients.

RESULTS

Complex study methods have worked well through 20 months because of the commitment of all stakeholders to both the Initiative and the Study. Over 1500 subjects have been recruited from health plan information delivered weekly, and 99.7% of 316 physicians and administrators from all participating clinical organizations have completed the Study surveys.

CONCLUSIONS

Partnership research can greatly facilitate translational research studies.

The National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Leicestershire, Northamptonshire and Rutland (LNR): a programme protocol

Background

In October 2008, the National Institute for Health Research launched nine new research projects to develop and investigate methods of translating research evidence into practice. Given the title Collaborations for Leadership in Applied Health Research and Care (CLAHRC), all involve collaboration between one or more universities and the local health service, but they are adopting different approaches to achieve translation.

Methods

The translation and implementation programme of this CLAHRC has been built around a pragmatic framework for undertaking research to address live concerns in the delivery of care, in partnership with the managers, practitioners, and patients of the provider organisations of the CLAHRC. Focused on long-term conditions, the constituent research themes are prevention, early detection, self-management, rehabilitation, and implementation. Individual studies have various designs, and include both randomised trials of new ways to deliver care and qualitative studies of, for example, means of identifying barriers to research translation. A mix of methods will be used to evaluate the CLAHRC as a whole, including use of public health indicators, social research methods, and health economics.

Discussion

This paper describes one of the nine collaborations, that of Leicestershire, Northamptonshire, and Rutland. Drawing a distinction between translation as an organising principle for healthcare providers and implementation as a discrete activity, this collaboration is built on a substantial programme of applied research intended to create both research generation and research use capacity in provider organisations. The collaboration in Leicestershire, Northamptonshire, and Rutland has potential to provide evidence on how partnerships between practitioners, patients, and researchers can improve the transfer of evidence into practice.