Kurt Elward

Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial

PURPOSE Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined. METHODS In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute’s Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar’s test and multivariate modeling were used to evaluate the impact of the interventions. RESULTS Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7–3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5–3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation. CONCLUSIONS Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.

Improving Cardiovascular Risk Reduction for Primary Prevention—Utility of Lifetime Risk Assessment

Abstract The objective of this article is to review the evidence basis for short-term risk assessments of overall coronary heart disease (CHD) burden as compared with lifetime risk estimates of CHD, based on the current medical literature. We reviewed literature published in the last 6 years using the terms “cardiovascular prevention,” “Framingham risk scoring,” “lifetime risk,” and “cardiovascular risk assessment,” and subsequently evaluated 98 publications to determine the variation in these approaches to estimate cardiovascular risk factors and impact on clinical decision making. The current evidence base suggests that lifetime risk estimates offset the significant impact of age on traditional, short-term risk estimates of cardiovascular risk. We conclude that the use of lifetime risk estimates may be more clinically meaningful than traditional, short-term risk estimates to assess an individuals overall risk burden, and may prevent the potential delay of therapeutic interventions to reduce cardiovascular events. For primary care, this difference may be of relevance to patients and should be communicated to them.