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.     

Cost Estimates for Operating a Primary Care Practice Facilitation Program

PURPOSE

Practice facilitation is widely recognized as a promising method for achieving large-scale practice redesign. Little is known, however, about the cost of providing practice facilitation to small primary practices from the prospective of an organization providing facilitation activities.

METHODS

We report practice facilitation costs on 19 practices in South Texas that were randomized to receive facilitation activities. The study design assured that each practice received at least 6 practice facilitation visits during the intervention year. We examined only the variable cost associated with practice facilitation activities. Fixed or administrative costs of providing facilitation actives were not captured. All facilitator activities (time, mileage, and materials) were self-reported by the practice facilitators and recorded in spreadsheets.

RESULTS

The median total variable cost of all practice facilitation activities from start-up through monitoring, including travel and food, was $9,670 per practice (ranging from $8,050 to $15,682). Median travel and food costs were an additional $2,054 but varied by clinic. Approximately 50% of the total cost is attributable to practice assessment and start-up activities, with another 31% attributable to practice facilitation visits. Sensitivity analysis suggests that a 24-visit practice facilitation protocol increased estimated median total variable costs of all practice facilitation activities only by $5,428, for a total of $15,098.

CONCLUSIONS

We found that, depending on the facilitators wages and the intensity of the intervention, the cost of practice facilitation ranges between $9,670 and $15,098 per practice per year and have the potential to be cost-neutral from a societal prospective if practice facilitation results in 2 fewer hospitalizations per practice per year.     

Measuring Physician Quality and Efficiency in an Era of Practice Transformation: PCMH as a Case Study

Practicing physicians face myriad challenges as health care undergoes considerable transformation, including advancing efforts to measure and report on physician quality and efficiency, as well as the growth of new care models such as Accountable Care Organizations and patient-centered medical homes (PCMHs). How do these transformational forces relate to one another? How should practicing physicians focus and prioritize their improvement efforts? This Special Report examines how physicians’ performance on quality and efficiency measures may interact with delivery reforms, focusing on the PCMH. We note that although the PCMH is a promising model, published evidence is mixed. Using data and experience from a large commercial insurer’s performance transparency and PCMH programs, we further report that longitudinal analysis of UnitedHealthcare’s PCMH program experience has shown favorable changes; however, cross-sectional analysis indicates that National Committee for Quality Assurance’s PCMH designation is positively associated with achieving program Quality benchmarks, but negatively associated with program Efficiency benchmarks. This example illustrates some key issues for physicians in the current environment, and we provide suggestions for physicians and other stakeholders on understanding and acting on information from physician performance measurement programs.     

Effects of Facilitated Team Meetings and Learning Collaboratives on Colorectal Cancer Screening Rates in Primary Care Practices: A Cluster Randomized Trial

PURPOSE

The purpose of this study was to evaluate a primary care practice–based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates.

METHODS

The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up.

RESULTS

Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients’ colorectal cancer screening rates. Qualitative analyses provide insights into practices’ QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates.

CONCLUSIONS

Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.     

Annals Journal Club: Yield of Opportunistic Targeted Screening for Type 2 Diabetes in Primary Care: The Diabscreen Study

PURPOSE In screening for type 2 diabetes, guidelines recommend targeting high-risk individuals. Our objectives were to assess the yield of opportunistic targeted screening for type 2 diabetes in primary care and to assess the diagnostic value of various risk factors.METHODS In 11 family practices (total practice population = 49,229) in The Netherlands, we conducted a stepwise opportunistic screening program among patients aged 45 to 75 years by (1) identifying high-risk individuals (=1 diabetes risk factor) and low-risk individuals using the electronic medical record, (2) obtaining a capillary fasting plasma glucose measurement, repeated on a separate day if the value was greater than 110 mg/dL, and (3) obtaining a venous sample if both capillary fasting plasma glucose values were greater than 110 mg/dL and at least 1 sample was 126 mg/dL or greater. We calculated the yield (percentage of invited patients with undiagnosed diabetes), number needed to screen (NNS), and diagnostic value of the risk factors (odds ratio and area under the receiver operating characteristic curve).RESULTS We invited for a first capillary measurement 3,724 high-risk patients seen during usual care and a random sample of 465 low-risk patients contacted by mail. The response rate was 90% and 86%, respectively. Ultimately, 101 high-risk patients (2.7%; 95% confidence interval [CI], 2.2%–3.3%; NNS = 37) and 2 low-risk patients (0.4%; 95% CI, 0.1%–1.6%; NNS = 233) had undiagnosed diabetes (P <.01). The prevalence of diabetes among patients 45 to 75 years old increased from 6.1% to 6.8% as a result. Among diagnostic models containing various risk factors, a model containing obesity alone was the best predictor of undiagnosed diabetes (odds ratio = 3.2; 95% CI, 2.0–5.2; area under the curve=0.63).CONCLUSIONS The yield of opportunistic targeted screening was fair; obesity alone was the best predictor of undiagnosed diabetes. Opportunistic screening for type 2 diabetes in primary care could target middle-aged and older adults with obesity.     

Annals Journal Club: Health Coaching by Medical Assistants to Improve Control of Diabetes,Hypertension, and Hyperlipidemia in Low-Income Patients: A Randomized Controlled Trial

PURPOSE

Health coaching by medical assistants could be a financially viable model for providing self-management support in primary care if its effectiveness were demonstrated. We investigated whether in-clinic health coaching by medical assistants improves control of cardiovascular and metabolic risk factors when compared with usual care.

METHODS

We conducted a 12-month randomized controlled trial of 441 patients at 2 safety net primary care clinics in San Francisco, California. The primary outcome was a composite measure of being at or below goal at 12 months for at least 1 of 3 uncontrolled conditions at baseline as defined by hemoglobin A_1c, systolic blood pressure, and low-density lipoprotein (LDL) cholesterol. Secondary outcomes were meeting all 3 goals and meeting individual goals. Data were analyzed using χ² tests and linear regression models.

RESULTS

Participants in the coaching arm were more likely to achieve both the primary composite measure of 1 of the clinical goals (46.4% vs 34.3%, P = .02) and the secondary composite measure of reaching all clinical goals (34.0% vs 24.7%, P = .05). Almost twice as many coached patients achieved the hemoglobin A_1c goal (48.6% vs 27.6%, P = .01). At the larger study site, coached patients were more likely to achieve the LDL cholesterol goal (41.8% vs 25.4%, P = .04). The proportion of patients meeting the systolic blood pressure goal did not differ significantly.

CONCLUSIONS

Medical assistants serving as in-clinic health coaches improved control of hemoglobin A_1c and LDL levels, but not blood pressure, compared with usual care. Our results highlight the need to understand the relationship between patients’ clinical conditions, interventions, and the contextual features of implementation.     

Practice Environments and Job Satisfaction in Patient-Centered Medical Homes

PURPOSE

We undertook a study to evaluate the effects of medical home transformation on job satisfaction in the primary care setting.

METHODS

We collected primary data from 20 primary care practices participating in medical home pilot projects in Rhode Island and Colorado from 2009 to 2011. We surveyed clinicians and staff about the quality of their practice environments (eg, office chaos, communication, difficulties in providing safe, high-quality care) and job satisfaction at baseline and 30 months, and about stress, burnout, and intention to leave at 30 months. We interviewed practice leaders about the impact of pilot project participation. We assessed longitudinal changes in the practice environment and job satisfaction and, in the final pilot year, examined cross-sectional associations between the practice environment and job satisfaction, stress, burnout, and intention to leave.

RESULTS

Between baseline and 30 months, job satisfaction improved in Rhode Island (P =.03) but not in Colorado. For both pilot projects, reported difficulties in providing safe, high-quality care decreased (P <.001), but emphasis on quality and the level of office chaos did not change significantly. In cross-sectional analyses, fewer difficulties in providing safe, high-quality care and more open communication were associated with greater job satisfaction. Greater office chaos and an emphasis on electronic information were associated with greater stress and burnout.

CONCLUSIONS

Medical home transformations that emphasize quality and open communication while minimizing office chaos may offer the best chances of improving job satisfaction.     

From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The Triple Aim—enhancing patient experience, improving population health, and reducing costs—is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.     

Exploring the Patient and Staff Experience With the Process of Primary Care

PURPOSEPrevious studies suggest that the highest-risk patients value accessible, coordinated primary care that they perceive to be of high technical quality. We have limited understanding, however, of how low-income, chronically ill patients and the staff who care for them experience each individual step in the primary care process.METHODSWe conducted qualitative interviews with uninsured or Medicaid patients with chronic illnesses, as well as with primary care staff. We interviewed 21 patients and 30 staff members with a variety of job titles from 3 primary care practices (1 federally qualified health center and 2 academically affiliated clinics).]RESULTSThe interviews revealed 3 major issues that were present at all stages of a primary care episode: (1) information flow throughout an episode of care is a frequent challenge, despite systems that are intended to improve communication; (2) misaligned goals and expectations among patients, clinicians, and staff members are often an impediment to providing and obtaining care; and (3) personal relationships are highly valued by both patients and staff.CONCLUSIONSVulnerable populations and the primary care staff who work with them perceive some of the same challenges throughout the primary care process. Improving information flow, aligning goals and expectations, and developing personal relationships may improve the experience of both patients and staff.     

Achieving Value in Primary Care: The Primary Care Value Model

The patient-centered medical home (PCMH) model provides a compelling vision for primary care transformation, but studies of its impact have used insufficiently patient-centered metrics with inconsistent results. We propose a framework for defining patient-centered value and a new model for value-based primary care transformation: the primary care value model (PCVM). We advocate for use of patient-centered value when measuring the impact of primary care transformation, recognition, and performance-based payment; for financial support and research and development to better define primary care value-creating activities and their implementation; and for use of the model to support primary care organizations in transformation.     

Cancer Risk Assessment Tools in Primary Care: A Systematic Review of Randomized Controlled Trials

PURPOSE

We conducted this review to identify published randomized controlled trials (RCTs) of cancer risk assessment tools used in primary care and to determine their impact on clinical utility (clinicians), screening uptake (patients), and psychosocial outcomes (patients).

METHODS

We searched EMBASE, PubMed and the Cochrane databases for RCTs of cancer risk assessment tools in primary care up to May 2014. Only studies set in primary care, with patients eligible for screening, and English-language articles were included.

RESULTS

The review included 11 trials of 7 risk tools. The trials were heterogeneous with respect to type of tool that was used, type(s) of cancer assessed, and outcomes measured. Evidence suggested risk tools improved patient risk perception, knowledge, and screening intentions, but not necessarily screening behavior. Overall, uptake of a tool was greater if initiated by patients, if used by a dedicated clinician, and when combined with decision support. There was no increase in cancer worry. Health promotion messages within the tool had positive effects on behavior change. Trials were limited by low-recruitment uptake, and the heterogeneity of the findings necessitated a narrative review rather than a meta-analysis.

CONCLUSIONS

Risk tools may increase intentions to have cancer screening, but additional interventions at the clinician or health system levels may be needed to increase risk-appropriate cancer screening behavior.     

The Cost of Sustaining a Patient-Centered Medical Home: Experience From 2 States

PURPOSE

As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these “advanced primary care” functions. A key required input is personnel effort. This study’s objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards.

METHODS

We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions.

RESULTS

Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado.

CONCLUSIONS

Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions.     

Quality Improvement in Healthcare Delivery Utilizing the Patient-Centered Medical Home Model

Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.     

Solo and Small Practices: A Vital,Diverse Part of Primary Care

PURPOSE

Solo and small practices are facing growing pressure to consolidate. Our objectives were to determine (1) the percentage of family physicians in solo and small practices, and (2) the characteristics of and services provided by these practices.

METHODS

A total of 10,888 family physicians seeking certification through the American Board of Family Medicine in 2013 completed a demographic survey. Their practices were split into categories by size: solo, small (2 to 5 providers), medium (6 to 20 providers), and large (more than 20 providers). We also determined the rurality of the county where the physicians practiced. We developed 2 logistic regression models: one assessed predictors of practicing in a solo or small practice, while the other was restricted to solo and small practices and assessed predictors of practicing in a solo practice.

RESULTS

More than one-half of respondents worked in solo or small practices. Small practices were the largest group (36%) and were the most likely to be located in a rural setting (20%). The likelihood of having a care coordinator and medical home certification increased with practice size. Physicians were more likely to be practicing in small or solo practices (vs medium-sized or large ones) if they were African American or Hispanic, had been working for more than 30 years, and worked in rural areas. Physicians were more likely to be practicing in small practices (vs solo ones) if they worked in highly rural areas.

CONCLUSIONS

Family physicians in solo and small practices comprised the majority among all family physicians seeking board certification and were more likely to work in rural geographies. Extension programs and community health teams have the potential to support transformation within these practices.     

Targeted Melanoma Prevention Intervention: A Cluster Randomized Controlled Trial

PURPOSE

Targeted interventions to reduce the risk and increase the early detection of melanoma have the potential to save lives. We aimed to assess the effect of such an intervention on patient prevention behavior.

METHODS

We conducted a pilot clustered randomized controlled trial, comparing a targeted screening and education intervention with a conventional information-based campaign in 20 private surgeries in western France. In the intervention group, 10 general practitioners identified patients at elevated risk for melanoma with a validated assessment tool, the Self-Assessment Melanoma Risk Score (SAMScore), examined their skin, and counseled them using information leaflets. In the control group, 10 general practitioners displayed a poster and the leaflets in their waiting room and examined patients’ skin at their own discretion. The main outcome measures were sunbathing and skin self-examinations among patients at elevated risk, assessed 5 months later with a questionnaire.

RESULTS

Analyses were based on 173 patients. Compared with control patients, intervention patients were more likely to remember the campaign (81.4% vs 50.0%, P = .0001) and to correctly identify their elevated risk of melanoma (71.1% vs 42.1%, P = .001). Furthermore, intervention patients had higher levels of prevention behaviors: they were less likely to sunbathe in the summer (24.7% vs 40.8%, P = .048) and more likely to have performed skin self-examinations in the past year (52.6% vs 36.8%, P = .029). The intervention was not associated with any clear adverse effects, although there were trends whereby intervention patients were more likely to worry about melanoma and to consult their general practitioner again about the disease.

CONCLUSIONS

The combination of use of the SAMScore and general practitioner examination and counseling during consultations is an efficient way to promote patient behaviors that may reduce melanoma risk. Extending the duration of follow-up and demonstrating an impact on morbidity and mortality remain major issues for further research.