Steven M. Ornstein

The Prevalence of Chronic Diseases and Multimorbidity in Primary Care Practice: A PPRNet Report

Introduction: Multimorbidity (multiple chronic illnesses) greatly affects the delivery of health care and assessment of health care quality. There is a lack of basic epidemiologic data on multimorbidity in the United States. This article addresses the prevalence of 24 chronic illnesses and multimorbidity from primary care practices across the United States. Methods: This cross-sectional study was conducted in the PPRNet, a practice-based research network among 226 practices in 43 states that maintains a clinical database derived from a common electronic health record. Practices providing data as of October 1, 2011, and their active adult patients comprised the population used for analyses. The prevalence of each chronic illness and multimorbidity were calculated. Results: Included in these analyses were 148 practices with 667,379 active patients. Median prevalence across practices ranged from 35.8% for hypertension to 0.23% for Parkinson disease, with wide variability among practices for all conditions. Multimorbidity increased steeply with age, leveling off at age 80; overall, 45.2% of patients had more than one chronic illness. Conclusion: Multimorbidity is a prevalent problem in primary care practice, a finding with implications for health care delivery and payment, quality assessment, and research.

Impact of an Electronic Medical Record System on Community-Based Primary Care Practices

Background: Although primary care physicians are increasingly interested in adopting electronic medical record (EMR) systems, few use such systems in practice. This study explores the organizational impact of an EMR system on community-based practices that have overcome the initial barriers and are experienced EMR users. Methods: Five primary care practices that are members of a national research network participated in this study. Using qualitative methods, including semistructured interviews and observations, we assessed the impact of an EMR system on the work lives of various user groups. Results: Physicians and staff indicated that the EMR system has changed not only how they manage patient records but also how they communicate with each other, provide patient care services, and perform job responsibilities. The EMR is also perceived by its users to have an impact on practice costs. Although in most practices physicians and staff were unaware of actual expenses and cost savings associated with the EMR, those in practices that have eliminated duplicate paper-based systems believe they have realized cost savings. Conclusions: Several important themes emerged. The organizational context in which the system is implemented is important. Effective leadership, the presence of a system champion, availability of technical training and support, and adequate resources are essential elements to the success of the EMR.

Alcohol screening and brief counseling in a primary care hypertensive population: a quality improvement intervention

AIMS To determine the effect of an intervention to improve alcohol screening and brief counseling for hypertensive patients in primary care. DESIGN Two-year randomized, controlled trial. SETTING/PARTICIPANTS Twenty-one primary care practices across the United States with a common electronic medical record. INTERVENTION To promote alcohol screening and brief counseling. Intervention practices received site visits from study personnel and were invited to annual network meetings to review the progress of the project and share improvement strategies. MEASUREMENTS Main outcome measures included rates of documented alcohol screening in hypertensive patients and brief counseling administered in those diagnosed with high-risk drinking, alcohol abuse or alcohol dependence. Secondary outcomes included change in blood pressure among patients with these diagnoses. FINDINGS Hypertensive patients in intervention practices were significantly more likely to have been screened after 2 years than hypertensive patients in control practices [64.5% versus 23.5%; adjusted odds ratio (OR) = 8.1; 95% confidence interval (CI) 1.7-38.2; P < 0.0087]. Patients in intervention practices diagnosed with high-risk drinking, alcohol abuse or alcohol dependence were more likely than those in control practices to have had alcohol counseling documented (50.5% versus 29.6%; adjusted OR = 5.5, 95% CI 1.3-23.3). Systolic (adjusted mean decline = 4.2 mmHg, P = 0.036) and diastolic (adjusted mean decline = 3.3 mmHg, P = 0.006) blood pressure decreased significantly among hypertensive patients receiving alcohol counseling. CONCLUSIONS Primary care practices receiving an alcohol-focused intervention over 2 years improved rates of alcohol screening for their hypertensive population. Implementation of alcohol counseling for high-risk drinking, alcohol abuse or alcohol dependence also improved and led to changes in patient blood pressures.

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.

Hypertension management and control in primary care: a study of 20 practices in 14 states.

Study Objective. To describe the management and control of hypertension in primary care practice.

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.

Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices.

BACKGROUND The use of potentially inappropriate medications (PIMs) in the elderly population is common. Interventions to decrease PIM use in primary care settings are needed. OBJECTIVE This study was designed to assess the time trends in use of always inappropriate and rarely appropriate medications in primary care patients aged >or=65 years during a quality improvement project. METHODS A 4-year, prospective demonstration project was delivered to 99 primary care practices that use a common electronic medical record and are members of the Practice Partner Research Network. Each participating practice received quarterly performance reports on the use of always inappropriate and rarely appropriate medications in the elderly. Optional interventions included biannual on-site visits and annual network meetings for performance review, academic detailing, and quality improvement planning. General linear mixed regression models were used to analyze the change in prescribing rates over time. RESULTS Across 42 months of project exposure, 124,802 active patients (61% women, 39% men) aged >or=65 years were included in the analyses. Among the 33 practices that participated in all 42 months of the intervention, the proportion of patients with a prescription for an always inappropriate medication decreased from 0.41% to 0.33%, and the proportion of patients with a prescription for a rarely appropriate medication decreased from 1.48% to 1.30%. Across all 99 practices, the adjusted absolute annual declines for the comprehensive categories of always inappropriate medications (00.018%, P = 0.03) and rarely appropriate medications (0.113%, P = 0.001) were statistically significant. Propoxyphene was the only individual medication that decreased significantly in use over time (baseline proportion, 0.72%; adjusted absolute annual decline, 0.072% [P = 0.001]). CONCLUSIONS Always inappropriate and rarely appropriate medication use decreased over time in this practice-based research network study. Additional studies of robust interventions for improving medication use in the elderly are warranted.

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.