Chris Feifer

Strategies for Increasing Adherence to Clinical Guidelines and Improving Patient Outcomes in Small Primary Care Practices

BACKGROUND The best way to get research findings into practice needs to be determined, particularly in small practices. The Practice Partner Research Network (PPRNet) is a nationwide practice-based research network of small primary care practices that use the same electronic medical record (EMR). Between 2000-2003 the PPRNet Translating Research into Practice (TRIP) project tested a multimethod intervention to help practices improve primary and secondary prevention of cardiovascular disease and stroke. Intervention sites each hosted six to seven site visits and participated in two annual network meetings during the two-year intervention period. A model describing practice-based improvement strategies was validated using prospective data from 10 intervention and 9 control sites. RESULTS The model consisted of five categories of improvement strategies: Prioritize Performance, Involve All Staff, Redesign Delivery Systems, Activate Patients, and Use EMR Tools. PPRNet-TRIP intervention practices used more of the model items than did controls (69% versus 48%, p = .053), as did high-performing practices versus mid-range or low performers (81% versus 39% versus 46%, p = .001). CONCLUSION The PPRNet-TRIP Improvement Model might guide small practices in their efforts to translate research into practice and improve care outcomes.

The logic behind a multimethod intervention to improve adherence to clinical practice guidelines in a nationwide network of primary care practices.

The gap between evidence-based guidelines for clinical care and their application in medical settings is well established and widely discussed. Effective interventions are needed to help health care providers reduce this gap. Whereas the development of clinical practice guidelines from biomedical and clinical research is an example of Type 1 translation, Type 2 translation involves successful implementation of guidelines in clinical practice. This article describes a multimethod intervention that is part of a Type 2 translation project aimed at increasing adherence to clinical practice guidelines in a nationwide network of primary care practices that use a common electronic medical record (EMR). Practice performance reports, site visits, and network meetings are intervention methods designed to stimulate improvement in practices by addressing personal and organizational factors. Theories and evidence supporting these interventions are described and could prove useful to others trying to translate medical research into practice. Additional theory development is needed to support translation in medical offices.

Using a summary measure for multiple quality indicators in primary care: the Summary QUality InDex (SQUID)

BackgroundAssessing the quality of primary care is becoming a priority in national healthcare agendas. Audit and feedback on healthcare quality performance indicators can help improve the quality of care provided. In some instances, fewer numbers of more comprehensive indicators may be preferable. This paper describes the use of the Summary Quality Index (SQUID) in tracking quality of care among patients and primary care practices that use an electronic medical record (EMR). All practices are part of the Practice Partner Research Network, representing over 100 ambulatory care practices throughout the United States.MethodsThe SQUID is comprised of 36 process and outcome measures, all of which are obtained from the EMR. This paper describes algorithms for the SQUID calculations, various statistical properties, and use of the SQUID within the context of a multi-practice quality improvement (QI) project.ResultsAt any given time point, the patient-level SQUID reflects the proportion of recommended care received, while the practice-level SQUID reflects the average proportion of recommended care received by that practices patients. Using quarterly reports, practice- and patient-level SQUIDs are provided routinely to practices within the network. The SQUID is responsive, exhibiting highly significant (p < 0.0001) increases during a major QI initiative, and its internal consistency is excellent (Cronbachs alpha = 0.93). Feedback from physicians has been extremely positive, providing a high degree of face validity.ConclusionThe SQUID algorithm is feasible and straightforward, and provides a useful QI tool. Its statistical properties and clear interpretation make it appealing to providers, health plans, and researchers.

From Research to Daily Clinical Practice: What Are the Challenges in “Translation”?

BACKGROUND Translating research findings into sustainable improvements in clinical and patient outcomes remains a substantial obstacle to improving the quality and safety of care. The Agency for Healthcare Research and Quality funded two initiatives to assess strategies for improvements--Translating Research into Practice (TRIP). The TRIP II initiative supported 13 quality improvement projects. SURVEYING THE TRIP II STUDIES: The principal investigators (PIs) of the 13 projects were surveyed regarding encountered barriers to implementation at 6 months and 18 months (when they were also asked about solutions). RESULTS Seven of the 13 PIs responded to the survey at both times--6 and 18 months. For each project stage--Select a TRIP focus and develop intervention strategies (Stage 1), Conduct the intervention (Stage 2), and Measure the Impact (Stage 3)--barriers were described, and field-tested solutions were provided. For example, for Stage 2, if the target audience lacked buy-in and would not participate, solutions would be to get up-front buy-in from all staff, not just leaders; address root causes of problems; use opinion leaders and incentives; plan interventions ahead and provide make-up videos; and accept that targets vary in their readiness to change. DISCUSSION The framework and examples provided should help overcome challenges in any work in which research findings are applied to clinical practice.

Different Paths to High-Quality Care: Three Archetypes of Top-Performing Practice Sites

PURPOSE Primary care practices use different approaches in their quest for high-quality care. Previous work in the Practice Partner Research Network (PPRNet) found that improved outcomes are associated with strategies to prioritize performance, involve staff, redesign elements of the delivery system, make patients active partners in guideline adherence, and use tools embedded in the electronic medical record. The aim of this study was to examine variations in the adoption of improvements among sites achieving the best outcomes. METHODS This study used an observational case study design. A practice-level measure of adherence to clinical guidelines was used to identify the highest performing practices in a network of internal and family medicine practices participating in a national demonstration project. We analyzed qualitative and quantitative information derived from project documents, field notes, and evaluation questionnaires to develop and compare case studies. RESULTS Nine cases are described. All use many of the same improvement strategies. Differences in the way improvements are organized define 3 distinct archetypes: the Technophiles, the Motivated Team, and the Care Enterprise. There is no single approach that explains the superior performance of high-performing practices, though each has adopted variations of PPRNet’s improvement model. CONCLUSIONS Practices will vary in their path to high-quality care. The archetypes could prove to be a useful guide to other practices selecting an overall quality improvement approach.

Improving Diabetes Care Through a Multicomponent Quality Improvement Model in a Practice-Based Research Network

This article reports the impact of a multicomponent quality improvement intervention on adherence with 13 measures of diabetes care and a summary measure, the Diabetes Summary Quality Index (Diabetes-SQUID). The intervention was conducted between January 1, 2004, and July 1, 2005, within 66 primary care practices in 33 states, including 372 providers and 24 250 adult patients with diabetes. Across all practices, the average Diabetes-SQUID was 50.6% (10th percentile 36.5%, 90th percentile 63.0%) on January 1, 2004, and 58.4% (10th percentile 47.6%, 90th percentile 69.7%) on July 1, 2005, with an average absolute improvement of 7.8% (95% confidence interval, 5.9%-9.7%). Significant improvements occurred for 12 of the 13 individual measures: blood pressure and urine microalbumin monitoring; HDL cholesterol, LDL cholesterol, triglyceride, and glycosylated hemoglobin measurements; prescription of antiplatelet therapy; and blood pressure, HDL-cholesterol, LDL-cholesterol, triglyceride, and glycosylated hemoglobin control. The findings suggest that a multicomponent intervention can have a robust impact on quality of care for diabetes.

Challenges to improving chronic disease care and training in residencies.

Purpose To improve quality of care for chronic disease, professional organizations and medical providers are adopting new care models. The transition to better delivery systems is not easy and there are many barriers under the best of circumstances. This study investigated residency-based experiences with changes in teaching and delivery of chronic disease care. Method In 2004–05 at the University of Southern California, the authors conducted qualitative cross-sectional in-depth interviews with directors of grant-funded residency-based chronic care projects. Open- and closed-ended questions explored the intent of and the challenges encountered by primary care residencies implementing improvements in chronic disease care and training. Results Six out of 14 program director responded, reporting that rotation-based and longitudinal experiences were used to teach and deliver improved chronic disease care. Common challenges were identified across residency sites, as well as challenges unique to particular residency settings. Among these challenges were engaging faculty and residents who spend limited time in the practice center, as well as institutional barriers related to authority, competing priorities, process, and resources. Conclusions Successful innovations for chronic disease care and training are possible in residencies, but their implementation cannot be taken lightly. There are predictable barriers that can be dealt with locally, but also others that would benefit from coordinated national attention.

Initial steps taken by nine primary care practices to implement alcohol screening guidelines with hypertensive patients: the AA-TRIP project.

Abstract Many medical conditions are caused or exacerbated by heavy drinking, necessitating alcohol screening and discussion in primary care practices. This is particularly true of hypertension, the most common primary diagnosis in the United States, which has been linked to the regular consumption of 3 or more standard alcoholic beverages a day. The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed to improve detection and management of alcohol problems in primary care patients with hypertension. Medical providers are being trained using the Practice Partner Research Networks-Translating Research into Practice (PPRNet-TRIP) quality improvement model. This includes a multi-method intervention (electronic medical records, on-site academic detailing, practice feedback reports and annual network meetings) to help practices increase adherence to clinical guidelines. Qualitative analyses of initial steps taken by nine primary care practices toward the routine implementation of alcohol screening guidelines are presented. Organizational factors and provider and patient characteristics all influenced the method and consistency of alcohol screening and intervention. Perceived time constraints, patient sensitivity to questions about alcohol, and possible stigma associated with a diagnosis of alcoholism were also relevant barriers requiring problem solving.

The effect of ethnicity on outcomes in a practice-based trial to improve cardiovascular disease prevention

BackgroundHealth disparities are a growing concern. Recently, we conducted a practice-based trial to help primary care physicians improve adherence with 21 quality indicators relevant to the primary and secondary prevention of cardiovascular disease and stroke. Although the primary concern in that study was whether patients in intervention practices outperformed those in control practices, we were also interested in determining whether minority patients were more, less, or just as likely to benefit from the intervention as non-minorities.MethodsBaseline (fourth quarter 2000) and follow-up (fourth quarter 2002) data were obtained from 3 intervention practices believed to have at least 10% minority representation. Two practices had a black (non-Hispanic) population sufficient for analysis, while the other had a sufficient Hispanic population. Within each practice, changes in the 21 indicators were compared between the minority patient population and the entire patient population. The proportion of measures in which minority patients exhibited greater improvement was calculated for each practice and for all 3 practices combined, and comparisons were made using non-parametric methods.ResultsFor all black patients, the observed improvement in 50% of 22 eligible study indicators was better than that observed among all white patients in the same practices. The average changes in the study indicators observed among the black and white patients were not significantly different (p = 0.300) from one another. Likewise for all minority patients in all 3 practices combined, the observed improvement in 14 of 29 (43.3%) eligible study indicators was better than that observed among all white patients. The average changes in the study indicators among all minority patients were not significantly different from the changes observed among the white patients (p = 0.272).ConclusionsAmong 3 intervention practices involved in a quality improvement project, there did not appear to be any significant disparity between minority and non-minority patients in the improvement in study indicators.

HEALTH SYSTEM CHANGE AND ACADEMIC DEPARTMENTS

Health system change is a now a reality in the United States and presents opportunities for family medicine to contribute rational solutions to the twin problems of high cost and variable quality confronting American health care. Academic health centers in particular will need to change if they are