Using continuous quality improvement to increase preventive services in clinical practice--going beyond guidelines

The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review

Background

Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach.

Methods

We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English.

Results

Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities.

Conclusions

Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach.

Trial registration

Protocol registered on PROSPERO (CRD42018088309).

Effectiveness of Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) methods in Medicaid-supported prenatal care: Trial III

This two-phase evaluation documented the delivery and effectiveness of evidence-based health education methods by regular staff to pregnant smokers. During Phase 1, a total of 436 Medicaid patients were screened and 416 (95%) gave consent: 334 nonsmokers and 102 smokers. This historical Comparison (C) group was assessed to document the "normal" pretrial smoking prevalence, patient nondisclosure (deception), and cessation rates at the first prenatal visit and during care. After this study, a formative evaluation of SCRIPT methods was conducted among 139 experimental group patients and 126 control group patients. During Phase 2, a total of 6,514 patients were screened over a 36-month period: 1,736 (27%) were smokers and 1,340 (77%) gave consent. After randomization, 247 became ineligible. The remaining 1,093 smokers received brief routine advice to quit. The experimental group (n = 544) also received a Commit to Quit video, A Pregnant Woman's Guide to Quit Smoking, and counseling. Self-reports and saliva were collected at baseline, ≥60 days, and ≤90 days postpartum for cotinine analyses to document cessation and significant reduction (SR) rates. The Phase 1 formative evaluation documented a 24% nondisclosure rate at the onset of care. It also confirmed a significantly higher experimental (17.3%) versus control group (8.8%) cessation rate and experimental versus control group SR rates of 22% and 16%. During Phase 2, unplanned policy changes, and delivery of experimental group counseling procedures to 15% to 20% of control group patients, resulted in a final experimental group cessation rate of 12% and a control group rate of 10%. The experimental group SR rate of 18%, however, was significantly higher than the control group SR rate of 13%. Effectiveness varied by the stability of clinic infrastructure, and degree of fidelity of staff performance of assessment and intervention procedures. The methods and results of this study will assist future health education programs for pregnant smokers to plan and conduct process and impact evaluations in prenatal care.

Promoting growth interpretation and lifestyle counseling in primary care

OBJECTIVE

To pilot a practice-directed intervention to promote growth interpretation and lifestyle counseling during child health supervision visits.

STUDY DESIGN

The intervention at 4 diverse primary care practices included education, facilitation by a practice-change leadership team, tools, and guidance from the study team. Preintervention and postintervention evaluations used were clinician interviews, in-office surveys of parents, 1-month post-visit telephone survey, visit observations, and medical record reviews. Outcomes evaluated growth interpretation documentation, clinician recognition of overweight, topic discussed at health supervision visit, and parental visit content recall and health behavior changes.

RESULTS

The intervention was well accepted, and tools provided were deemed helpful. Documentation of growth interpretation was higher after intervention (pre versus post: 32% vs 87%; P< .001). Parent reports of topics discussed were similar between evaluation periods (pre versus post: growth 96% vs 99%; diet 90% vs 93%; physical activity 81% vs 85%). Observed topics at health supervision visits were similarly high and were unchanged between periods. Parental recall of topics at 1 month was also high and similar between periods. Parental report of adoption of a healthier behavior for themselves or their child at 1 month did not significantly change.

CONCLUSIONS

The Systematic Nutritional Assessment in Pediatric Practice intervention provides a promising model to increase interpretation and documentation of growth.

Consensus guidelines: improving the delivery of clinical preventive services

BACKGROUND

Medical directors from the largest competing health plans in the state came together in a noncompetitive way to collaborate on improving the delivery of clinical preventive service (CPS) among their provider base. They identified one consistent set of CPS guidelines based on U.S. Preventive Services Task Force recommendations, the health plan consensus guidelines (HPCG), that they could endorse as priority for guideline implementation.

PURPOSE

The purposes of this study were to assess clinicians' knowledge and use of CPS recommendations as a guide to delivering preventive care services to their patients and, most importantly, to test the effectiveness of providing the HPCG to clinicians in an effort to increase knowledge and use of CPS guidelines.

DESIGN

Within-subjects repeated-measures design was used. We hypothesized an increase in clinician's knowledge and use of CPS after the provision of the HPCG.

METHODS

Survey methodology, including two surveys that assessed clinicians' knowledge and use of CPS in practice, was used. Health plan clinician databases were obtained from the health plans that participated in the development of the HPCG. Health plan clinicians directly involved in delivering preventive services were invited to participate in the study. Final sample included 163 clinicians. Spearman's rho correlation coefficients were determined to examine the relationships between clinician's knowledge and clinician's use of CPS guidelines. Differences between knowledge and use of CPS before and after HPCG were examined by t tests.

FINDINGS

No difference was found in the familiarity with U.S. Preventive Services Task Force guidelines before and after receipt of HPCG. However, clinician's use increased significantly.

PRACTICE IMPLICATIONS

A consistent set of CPS guidelines provided by competing health plans can improve the delivery of CPS among contracted health plan clinicians. This approach provides a template for competing health plans nationwide to come to consensus on guidelines that support clinicians in the delivery of CPS ().

Study protocol: Audit and Best Practice for Chronic Disease Extension (ABCDE) Project

BACKGROUND

A growing body of international literature points to the importance of a system approach to improve the quality of care in primary health care settings. Continuous Quality Improvement (CQI) concepts and techniques provide a theoretically coherent and practical way for primary care organisations to identify, address, and overcome the barriers to improvements. The Audit and Best Practice for Chronic Disease (ABCD) study, a CQI-based quality improvement project conducted in Australia's Northern Territory, has demonstrated significant improvements in primary care service systems, in the quality of clinical service delivery and in patient outcomes related to chronic illness care. The aims of the extension phase of this study are to examine factors that influence uptake and sustainability of this type of CQI activity in a variety of Indigenous primary health care organisations in Australia, and to assess the impact of collaborative CQI approaches on prevention and management of chronic illness and health outcomes in Indigenous communities.

METHODS/DESIGN

The study will be conducted in 40-50 Indigenous community health centres from 4 States/Territories (Northern Territory, Western Australia, New South Wales and Queensland) over a five year period. The project will adopt a participatory, quality improvement approach that features annual cycles of: 1) organisational system assessment and audits of clinical records; 2) feedback to and interpretation of results with participating health centre staff; 3) action planning and goal setting by health centre staff to achieve system changes; and 4) implementation of strategies for change. System assessment will be carried out using a System Assessment Tool and in-depth interviews of key informants. Clinical audit tools include two essential tools that focus on diabetes care audit and preventive service audit, and several optional tools focusing on audits of hypertension, heart disease, renal disease, primary mental health care and health promotion. The project will be carried out in a form of collaborative characterised by a sequence of annual learning cycles with action periods for CQI activities between each learning cycle. Key outcome measures include uptake and integration of CQI activities into routine service activity, state of system development, delivery of evidence-based services, intermediate patient outcomes (e.g. blood pressure and glucose control), and health outcomes (complications, hospitalisations and mortality).

CONCLUSION

The ABCD Extension project will contribute directly to the evidence base on effectiveness of collaborative CQI approaches on prevention and management of chronic disease in Australia's Indigenous communities, and to inform the operational and policy environments that are required to incorporate CQI activities into routine practice.

Utilization of prevention research: searching for evidence

OBJECTIVE

Understanding the process of translating prevention research into practice calls for systematic efforts to assess the state of the published literature on the utilization of prevention research in public health programs and policy. This review describes the search strategy, methods, results, and challenges in identifying and reviewing literature relevant to this objective.

METHODS

Systematic searches of topics related to prevention research in literature published in 1995-2002 revealed 86 empiric articles in 12 public health areas.

RESULTS

A lack of uniform terminology, variation in publication sources, and limited descriptions of the stages of research utilization (e.g., adoption and implementation) in the published literature posed major challenges to identifying articles that met study criteria. Most accepted articles assessed the adoption or implementation of prevention research; four examined long-term sustainability. There was approximately equal distribution of reported research set in either health services or public health settings. Few of the articles contained search terms reflecting all four concept areas (prevention, public health, research, and use) targeted by the literature search.

CONCLUSIONS

Refining terms used in prevention research and research utilization could address lack of shared and unique definitions. Expanded reporting of research utilization stages in reports of prevention research could lead to improved literature searches and contribute to more successful adoption, implementation, and further use of prevention research products.

Randomized trial of quality improvement intervention to improve diabetes care in primary care settings

OBJECTIVE

To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics.

RESEARCH DESIGN AND METHODS

Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention.

RESULTS

All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35).

CONCLUSIONS

This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

Redefining primary pediatric care for children with special health care needs: the primary care medical home

PURPOSE OF REVIEW

As considerations of the quality of health care have matured, the role of pediatric primary care providers and models for the delivery of primary care have received growing attention. Particularly for children with chronic conditions, the need for proactive, planned, and coordinated care delivered in partnership with consumers has become more apparent. The primary care medical home has emerged as a model favored by national organizations representing pediatricians and family physicians as well as national public health policy makers, yet implementation of this model remains limited and the evidence base for its value is not yet highly developed.

RECENT FINDINGS

Most studies of primary care outcomes involve individual elements of the medical home such as care coordination and continuity of care. Limited data that are emerging from studies of the medical home model as a whole in practice settings suggest improvements in patient satisfaction and in some areas of utilization. No data are available that examine specific functional or physical health outcomes associated with primary care models like the medical home.

SUMMARY

The pediatric primary care medical home provides a care model for both well children and those with special health care needs that expands primary care services beyond those provided in the examination room by individual providers to include systemic services such as patient registries, explicit care planning and care coordination, planned co-management with specialists, patient advocacy, and patient education. There is an immediate need for large-scale, practice-based studies of the outcomes for children and youth, providers, and the health care system when such improvements in primary care are implemented.

Cancer Prevention Services and Physician Consensus in Primary Care Group Practices

Background: We conducted a randomized clinical trial of interventions to achieve physician consensus, practice changes, and patient activation designed to help primary care group practices enhance the delivery of cancer prevention and screening services. Methods: In each of 42 primary care practices in 1991 to 1994, we studied approximately 60 patients per physician who were between the ages 53 and 64. Data sources included patient and physician questionnaires, medical record audits of consenting patients for evidence of 11 cancer prevention services during the previous 3 years, and telephone interviews with key practice personnel. Results: None of the interventions was associated with significant changes in frequency of services or procedures received or provided. Increased frequencies of services overall and of specific activities were associated with HMO membership or insurance coverage for six screening procedures. Patient reports of clinic staff recommendations to have each of six screening procedures were specifically associated with higher frequencies of services (P = 0.001). Conclusions: Demonstration of intervention impact may have been limited because the rates of prevention services were significantly higher in this study than have been reported elsewhere. These results might be explained by selection biases inherent in studying patients with a regular provider, overall practice trends for changes in provision of the studied services, and the study methods.

The impact of computerized clinical reminders on physician prescribing behavior: evidence from community oncology practice

The objective of this study is to examine the impact of a clinical reminder generated by an electronic medical record (EMR) system on physician prescribing behavior in community oncology practice setting. A case-control trial assessing the prescribing rates of erythropoietin by physicians is used. The participants and setting involves a total of 11,644 physician-patient encounters in 2 community oncology practices in the United States during a 21-month period. The intervention is a clinical reminder generated in real time during a physician-patient encounter by an EMR identifying cancer patients with low hemoglobin (Hgb) levels (ie, anemic), that is, patients with Hgb less then 12 g/dL. The main outcome measure is to determine the frequency of erythropoietin prescription by physicians to cancer patients with low Hgb levels. Implementation of a clinical reminder generated by way of an EMR significantly improved the likelihood of low-Hgb patients receiving treatment with erythropoietin. Low-Hgb patients in the experimental clinic during the time that the clinical reminder system was in place were almost twice as likely (ie, adjusted odds ratio = 1.92, P = .008) to have been treated with erythropoietin. The data support the effectiveness of clinical reminders as a way to influence physician prescribing behaviors and potentially improve the quality of patient care. However, we feel that there is a need to investigate the use of reminders in other aspects of cancer care that may be undertreated or when new drugs may be available but are underused.

Developmental Specialists in Pediatric Practices: Perspectives of Clinicians and Staff

OBJECTIVE

To investigate how introducing early child-development specialists (Healthy Steps Specialists) and enhanced developmental services into routine pediatric care affects perspectives of clinicians and staff.

METHODS

Self-administered questionnaires were completed at baseline and at 30 months by clinicians, clinical staff, and nonclinical staff at pediatric sites participating in the evaluation of the Healthy Steps for Young Children Program. The evaluation included 6 randomization and 9 quasi-experimental sites. Barriers to providing well-child care, visit length, perceptions of care provided, and topics discussed with parents were assessed.

RESULTS

Over time, despite persistent barriers to delivering high-quality services, clinicians were more likely to report being satisfied with their clinical staff's ability to meet developmental and behavioral needs of children. Moreover, clinicians were more likely to report discussing the importance of routines with control rather than with intervention families, suggesting a reliance on Healthy Steps Specialists. There was no effect on visit length. Thirty months after introducing Healthy Steps Specialists and enhanced services, nearly all clinicians agreed or strongly agreed that the Healthy Steps Specialists talked with parents about their child's development, showed them activities to do with their child, and provided emotional support. Involvement of the Healthy Steps Specialist in these activities was reported more by clinicians than by clinical staff and least by nonclinical staff.

CONCLUSIONS

Clinicians acknowledged the activities performed by and contributions of the developmental specialists. Differences in perspectives of personnel may reflect different interactions among families, developmental specialists, and practice staff.

Premier: a clinical trial of comprehensive lifestyle modification for blood pressure control: rationale, design and baseline characteristics

PURPOSE

To describe PREMIER, a randomized trial to determine the effects of multi-component lifestyle interventions on blood pressure (BP).

METHODS

Participants with above optimal BP through stage 1 hypertension were randomized to: 1) a behavioral lifestyle (BLS) intervention that implements established recommendations, 2) a BLS intervention that implements established recommendations plus the DASH diet, or 3) an advice only standard of care group. The two BLS interventions consist of group and individual counseling sessions for 18 months. The primary outcome is systolic BP at 6 months. Additional outcomes include diastolic BP and homocysteine at 6 months; systolic and diastolic BP at 18 months; fasting lipids, glucose and insulin at 6 and 18 months; and effects in subgroup.

CONCLUSION

Results from the PREMIER trial will provide scientific rationale for implementing multi-component behavioral lifestyle intervention programs to control BP and prevent CVD.

Effects of patient and physician practice socioeconomic status on the health care of privately insured managed care patients

BACKGROUND

Previous research shows that patient socioeconomic status (SES) affects health care, but little is known about the relative effects of patient and physician practice SES among privately insured patients.

OBJECTIVE

To examine the effects of patient and physician practice SES on prevention, disease management, utilization, and cost expenditures.

DESIGN

Cross-sectional analyses of claims data.

SUBJECTS

Primary care physicians (568) and their adult managed care organization patients (437,743) in the Rochester, New York, area.

MEASURES

Pap smears, mammograms, glycohemoglobins, and eye examinations for diabetics, physician visits, referrals, hospitalizations, costs standardized expenditures (diagnostic testing, office visits, and total), patient zip code-based SES, and physician practice SES (mean SES of patients in practice).

RESULTS

After adjustment, lower SES patients had lower compliance with Pap smears, mammograms, and diabetic eye exams, and were less likely to have a referral or make any office visit, but were more likely to be hospitalized, and generated higher testing standardized expenditures. Lower physician practice SES was associated with lower adjusted Pap, mammogram, and glycohemoglobin compliance, lower office visit standardized expenditures, but higher diagnostic testing and total standardized expenditures. Patient SES effects were stronger for mammography, whereas physician practice SES effects were stronger for diagnostic testing costs. For the utilization indicators, the SES effects on utilization exhibited a linear gradient, whereas there was a threshold effect for costs.

CONCLUSIONS

Patient and practice SES are independently associated with care among privately insured patients. These effects are not confined to the poorest patients but span the entire socioeconomic spectrum. Interventions to address these disparities need to be broad-based, but should also address the needs of practices with predominantly lower SES patients.

Effect of patient socioeconomic status on physician profiles for prevention, disease management, and diagnostic testing costs

BACKGROUND

Previous research shows patient socioeconomic status (SES) affects physician profiles for health status and satisfaction, but effects on other aspects of care are not known.

OBJECTIVE

To examine the effect of patient SES on physician profiles for preventive care, disease management, and diagnostic testing costs.

RESEARCH DESIGN

Cross-sectional analysis of a managed care claims data.

SUBJECTS

Five hundred sixty-eight physicians and 600,618 patients.

MEASURES

Patient age, gender, case-mix, and SES based on zip code, likelihood of having a Papanicolaou smear, mammogram, for diabetics having had a glycosylated hemoglobin, diabetic eye exam, and diagnostic testing costs.

RESULTS

For each performance indicator, except glycosylated hemoglobin, there was a statistically significant effect of adjusting for patient SES. For diabetic eye checks, mammograms and Papanicolaou tests respectively, 5%, 16%, and 21% of physicians who were outliers (in the top or bottom 5% of rankings) were no longer outliers after socioeconomic adjustment. For all performance measures the change in physician ranking was strongly correlated with the mean practice SES.

CONCLUSIONS

Patient SES, as measured by zip code, appreciably affects physician profiles for preventive care and diabetes management. Monitoring patient SES using patient zip codes could be used to target resources to improve outcomes for higher risk patients.

Addressing tobacco in managed care: a survey of dentists' knowledge, attitudes, and behaviors

OBJECTIVES

This study assessed the tobacco cessation knowledge, attitudes, and behaviors of dentists participating in a large managed care dental plan.

METHODS

Participating dentists in 4 states were surveyed via mail.

RESULTS

Dentists' perceived success in helping patients quit using tobacco was highly correlated with discussion of specific strategies for quitting, advice about the use of nicotine gum, and time spent counseling patients. Dentists who were confident about their smoking cessation knowledge frequently advised patients to quit and spent more time counseling patients about tobacco cessation.

CONCLUSIONS

Tobacco cessation is not a routine part of dental practice. Knowledge, time spent counseling patients, and specific strategies for quitting were associated with dentists' perceptions of success.

Primary care-based smoking interventions

The primary care setting is an important place for promoting smoking cessation. Randomized clinical trials (RCTs) testing the effect of brief smoking interventions and comprehensive programs delivered in a primary care setting present excellent evidence that such interventions significantly increase patients' smoking cessation rates and that as the dose of intervention increases, the effect increases. Unfortunately, despite widespread dissemination of preventive services guidelines and positive physician attitudes towards such services, the current level of delivery of smoking cessation intervention by physicians in real-world settings is not high, making this a major research and public health concern. Interventions to increase the rate of implementation provider-delivered brief smoking interventions can be grouped broadly into: provider education; clinical systems and procedures (e.g., screening and tracking of patients); and organizational policy (e.g., reimbursement, coverage, performance measures). Given the significant effect that primary care-based interventions can have on smoking cessation, it is important to investigate methods to increase their rate of delivery and their effect. Examples of research to motivate to intervene questions include: what are the best incentives or combination of incentives for physicians? What are the most effective strategies to remind providers to intervene? How can each of these be best implemented in different types of settings and systems? How can a stepped-care and patient-treatment matching model be used? The study of factors such as reimbursement policies and covered benefits do not lend themselves well to tightly-controlled randomized trials. Therefore, use of quasi-experimental designs, and application of qualitative strategies are needed. These designs represent a different challenge to the research community.

Development of the continuous quality improvement questionnaire (CQIQ)

PURPOSE

Increasingly, hospitals are engaging in continuous quality improvement (CQI) endeavors, aimed at optimizing patient care. Physician involvement is critical to the success of such initiatives. Little is known about any mediating factors that affect physician participation in these projects, though such knowledge may be potentially important for targeting approaches to maximize physician involvement. The purpose of this study was to develop a reliable and valid instrument to assess physicians' knowledge of and attitudes toward CQI.

MATERIALS AND METHODS

Items for the questionnaire were generated by using interviews and literature re-view and covered areas of knowledge, attitude, and facilitators and barriers to involvement in CQI projects. Five physicians participated in the interviews, 64 participated in the survey, and 9 participated in the assessment of test-retest reliability. Main outcomes were reliability and validity.

RESULTS

The CQI questionnaire (CQIQ) had acceptable internal consistency and Cronbach's alpha correlation coefficient exceeded.70 for all scales. Item-total correlation ranged from.30 to.63 for all scales except for 1 item. Pearson's correlation coefficient for test-retest reliability was 0.85 (P =.02). A 76% response rate was achieved.

CONCLUSIONS

There appears to be complex interactions among psychologic and environmental mediators that influence physician participation in hospital quality initiatives. The CQIQ shows reasonable measurement properties and our findings should be generalizable to physicians in other academic institutions. The CQIQ provides additional information on the implementation of programs and processes that should be validated in other institutional settings to enhance the interpretability of the instrument.

Improving preventive service delivery through office systems

OBJECTIVE

Rates of childhood immunizations and other preventive services are lower in many practices than national goals and providers' own estimates. Office systems have been used in adult settings to improve the delivery of preventive care, but their effectiveness in pediatric practices is unknown. This study was designed to determine whether a group of primary care practices in 1 community could implement office-based quality improvement systems that would significantly improve their delivery of childhood preventive services. The study was part of a larger community-wide intervention study reported in a preceding study.

METHODS

All the major providers of primary care to children in 1 community were recruited and agreed to participate (N = 8 practices). Project staff worked on-site with improvement teams in each practice to develop tailored systems to assess and improve the delivery of immunizations and screening for anemia, tuberculosis, and lead exposure. Office-based quality improvement systems typically involved some combination of chart prescreening, risk assessment forms, Post-it prompts, flow-sheets, reminder/recall systems, and patient education materials. Office systems also often involved redistributing responsibilities among office staff.

RESULTS

All 8 participating practices created improvement teams. Project staff met with the practices 10 to 15 times over 12 months. After the period of office assistance, the overall rates for all preventive services except tuberculosis screening increased by amounts that were both clinically and statistically significant. Absolute percent improvements included: complete immunizations at 12 months, 7%; complete immunizations at 24 months, 12%; anemia screening, 30%; lead screening, 36%. The amount of improvement achieved varied considerably between practices.

CONCLUSIONS

Office systems and the principles of quality improvement that underlie them seem to be effective in improving the delivery of childhood preventive services. Important predisposing factors may exist within practices that affect the likelihood that an individual practice will make significant improvements. prevention, immunizations, improvement, office systems, primary care.

Factors associated with self-reported pneumococcal immunization among adults 65 years of age or older in the Minneapolis-St. Paul metropolitan area

BACKGROUND

As part of a 3-year demonstration project to improve pneumococcal polysaccharide vaccine (PPV) coverage among older adults, the Minnesota Department of Health conducted a baseline evaluation of knowledge, attitudes, and beliefs among the general public regarding PPV.

METHODS

A random-digit dialing telephone survey was conducted among community-dwelling adults age 65 years or older in three metropolitan counties in Minnesota during April through June 1998.

RESULTS

Three hundred fifty-three interviews were completed; self-reported PPV coverage was 59% (95% CI 54%, 64%). Nearly all (94%) respondents reported at least one medical visit in the past year. Unvaccinated respondents expressed willingness to be vaccinated if they knew about PPV's safety, dosage, and preventive role. In a final multivariate regression model, factors associated with PPV vaccination included awareness of PPV (OR 7.8; CI 2.1, 29.2; P = 0.002), opinion that receiving PPV is "very important" (OR 8.3; CI 3.2, 21.6; P < 0.001), awareness that Medicare covers PPV (OR 5.1; CI 1.9, 13.8; P = 0.001), physician ever offering PPV (OR 21.7; CI 6.2, 76.6; P < 0.001), and physician regularly offering PPV (OR 3.9; CI 1.1, 13.7; P = 0.03).

CONCLUSIONS

Respondents were significantly influenced by their physician offering PPV. Therefore, providers' practices are a critical target for improving PPV coverage. Educational efforts to inform patients about PPV and to address misconceptions (e.g., safety, efficacy, Medicare coverage) also may improve vaccination levels.

A report card on quality improvement for children's health care

OBJECTIVE

Improving the quality of health care is a national priority. Nonetheless, no systematic effort has assessed the status of quality improvement (QI) initiatives for children or reviewed past research in child health care QI. This assessment is necessary to establish priorities for QI programs and research.

METHODS

To assess the status of QI initiatives and research, we reviewed the literature and interviewed experts experienced in QI for child health services. We defined QI as activities intended to close the gap between desired processes and outcomes of care and what is actually delivered. We classified reports published between 1985 and 1997 by publication characteristics, study design, clinical problem addressed, site of intervention, the QI method(s) used, and explicit association with a continuous quality improvement program.

RESULTS

We reviewed 68 reports meeting our definition of QI. More than half (48) were published after 1994. The reviewed reports included controlled evaluations in 36% of all identified interventions, and 3% of the reports were associated with continuous quality improvement. QI methods demonstrating some effectiveness included reminder systems for office-based preventive services and inpatient pathways for complex care. Reportedly successful QI initiatives more commonly described improvement in administrative measures such as rate of hospitalization or length of stay rather than functional status or quality of life. Interviews found that barriers to QI for children were similar to those for adults, but were compounded by difficulties in measuring child health outcomes, limited resources among public organizations and small provider groups, and relative lack of competition for pediatric tertiary care providers. Research and dissemination of QI for children were seen as less well developed than for adults.

CONCLUSIONS

Attempts to improve the quality of child health services have been increasing, and the evidence we reviewed suggests that it is possible to improve the quality of care for children. Nonetheless, numerous gaps remain in the understanding of QI for children, and widespread improvement in the quality of health services for children faces significant barriers.

Adoption of a health education intervention for family members of breast cancer patients

BACKGROUND

Relatives of breast cancer patients often face substantial uncertainty and psychological stress regarding their own health risks and optimal strategies for prevention and early detection. Efficacious educational and counseling interventions are rarely evaluated for their potential adoption and use in medical practice settings. This study evaluates a health education program for first-degree relatives of breast cancer patients based on the program's potential for being adopted and used by medical practices affiliated with cancer centers.

METHODS

A randomized, controlled trial was implemented in four community hospital-based medical practices. After 9 months, clinical and administrative staff at each practice were given self-administered surveys. Of 90 staff members recruited to respond, useable responses were received from 60 (67%), including 13 physicians (31%), 43 nurses (98%), and four program managers (100%). Participants made self-reports of program awareness, program support, perceived program performance, likelihood of program adoption and use, and barriers to adoption.

RESULTS

A strong majority of respondents (80%) reported that all or most staff agreed with the need for the program. Perceived program performance in meeting goals was generally favorable but varied across sites and across staff types. Overall, 56% of respondents indicated that their practices were likely or highly likely to adopt the program in full. The likelihood of adoption varied substantially across sites and across program components.

CONCLUSIONS

Evaluating the potential for program adoption offers insight for tailoring preventive health interventions and their implementation strategies to improve diffusion in the field of practice.

Clinician satisfaction with a preventive services implementation trial. The IMPROVE project

OBJECT

To discover how attempts to increase the delivery of preventive services affect clinician satisfaction.

METHODS

The IMPROVE project was a randomized clinical trial conducted in 44 clinics in and around Minneapolis-St. Paul, Minnesota. Personnel were trained in continuous quality improvement techniques to organize preventive services delivery systems. Satisfaction with delivery of these services and with the sponsoring organizations was measured before the intervention (Time 1), at the end of the intervention (Time 2), and 1 year post-intervention (Time 3).

RESULTS

At no time was the intervention associated with a change in the respondents satisfaction with their places of work or with their job roles. Satisfaction with preventive services delivery increased from Time 1 to Time 3 among intervention-clinic respondents. Satisfaction with the IMPROVE project and the efforts of the two managed care organizations to help the clinics deliver preventive services peaked at Time 2 and declined toward baseline at Time 3. Satisfaction with preventive services delivery tended to increase more in the 13 intervention clinics that implemented a preventive services delivery system than in the nine intervention clinics that did not implement a preventive services delivery system (p = 0.15).

CONCLUSIONS

Planned organizational change to create systems for preventive services delivery can be associated with increased clinician satisfaction with the way these services are delivered. However, increased satisfaction with preventive services does not necessarily indicate that service delivery rates have increased.

Clinical preventive medicine in primary care: background and practice: 2. Delivering primary preventive services

Strategies to incorporate preventive services into primary care settings have been underutilized. The first component of delivering preventive services in the primary care setting is the health risk assessment followed by establishment of practice guidelines and protocols for preventive services--who is eligible for what service (based on age, sex, and other clinical characteristics) and when. A computerized reminder system can be useful to track past and currently due preventive services for each patient and can also serve as a follow-up system for test results. Well-trained paramedical personnel can perform appropriate patient counseling and education. The goal of counseling and education is to change patient behavior. The first step in this difficult process is once again to ascertain health risks and then to determine the patient's stage of readiness--defined as precontemplation, contemplation, preparation, action, and maintenance. The counselor assists in identification of target behavior, advocates and commends behavior change, reinforces health benefits of behavior change, offers resources, strategies, and support, and creates a plan of action and monitoring mechanisms. Improved implementation of preventive services in primary care could have a major impact on the health of the population.

Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care

OBJECTIVE

The purposes of this study were (1) to determine the extent to which tobacco exposure assessment and new patient education methods, derived from a meta-analysis and the Agency for Health Care Policy and Research guideline recommendations, could be provided routinely by trained Medicaid maternity care staff members and (2) to document the behavioral impact of these interventions among pregnant smokers.

STUDY DESIGN

After 265 pregnant smokers were assigned at their first visit to an experimental group (n = 139) or a control group (n = 126), they received standardized risk information and were advised to quit smoking. The experimental group also received evidence-based patient education methods, including the videocassette Commit to Quit During and After Pregnancy, the publication A Pregnant Woman's Guide to Quit Smoking, and a brief counseling session. Self-report and saliva cotinine assessments of tobacco exposure were performed at baseline and at the end of pregnancy.

RESULTS

A significantly higher percentage of patients quit smoking in the experimental group (17.3%) than in the control group (8.8%).

CONCLUSIONS

The application of principles of organizational development and quality improvement at the management and clinical practice levels and the delivery of evidence-based health education methods by trained prenatal care providers significantly increased smoking cessation rates among pregnant Medicaid recipients.

Health care providers' perspectives on patient delay for seeking care for symptoms of acute myocardial infarction

To inform intervention development in a multisite randomized community trial, the Rapid Early Action for Coronary Treatment (REACT) project formative research was undertaken for the purpose of investigating the knowledge, beliefs, perceptions, and usual practice of health care professionals. A total of 24 key informant interviews of cardiologists and emergency physicians and 15 focus groups (91 participants) were conducted in five major geographic regions: Northeast, Northwest, Southeast, Southwest, and Midwest. Transcript analyses revealed that clinicians are somewhat unaware of the empirical evidence related to the problem of patient delay, are concerned about the practice constraints they face, and would benefit from concrete suggestions about how to improve patient education and encourage fast action. Findings provide guidance for selection of educational strategies and messages for health providers as well as patients and the public.

If diabetes is a public health problem, why not treat it as one? A population-based approach to chronic illness

It is increasingly acknowledged that diabetes and other chronic illnesses are major public health problems. Medicare and many managed health care organizations have recognized the enormous personal and societal costs of uncontrolled diabetes in terms of complications, patient quality of life, and health care system resources. However, the current system of reactive acute-episode focused disease care practiced in many settings does not adequately address this public health problem. An alternative proactive, population-based approach to chronic illnesses such as diabetes is proposed and illustrated. This multilevel systems approach addresses supportive and inhibitory social-environmental factors at multiple levels (personal, family, health care team, work, neighborhood, community). Key disciplines contributing to a population-based approach to diabetes include epidemiology, behavioral science, health care services, public health, health economics, and quality of life professions. Current and potential contributions of each of these disciplines are illustrated and an integrative, population-based systems approach to diabetes management and prevention of complications is proposed. This approach is also seen as applicable to other chronic illnesses.

Promoting tobacco cessation in primary care practice

Promoting tobacco cessation is an important part of the work of clinicians and staff in primary care practice. This article describes the significant public health impact of helping patients quit using tobacco through the use of an effective clinic-based intervention. The most effective strategies are to develop organization commitment, ask every patient about tobacco use at every visit and document it, advise all tobacco users to quit, assess readiness to quit, provide at least brief behavioral counseling, provide follow-up soon after quit date, conduct at least basic evaluations of each component of the process, and assess the quit rate for the practice as a whole.

Diabetes care practices in primary care: results from two samples and three measurement sets

PURPOSE

There has been substantial recent interest in diabetes disease management interventions, guidelines, and care practices. As the vast majority of diabetes care occurs in primary care settings, it makes sense to evaluate current levels of recommended practices in different primary care settings.

METHODS

We report on two separate studies that included a combined total of 389 patients seen by over 30 different providers. Three different sets of recommended practices were assessed: (1) the ADA provider recognition measures, (2) the proposed Diabetes Quality Improvement Project measures, and (3) the state of Oregon Population-Based Guidelines for Diabetes.

RESULTS

In general, there was only a moderate level of adherence to recommended practices, and adherence was much lower for behavioral or patient-focused practices as contrasted with laboratory tests. There was considerable variability across providers and across different guidelines activities.

CONCLUSIONS

Policy and quality improvement implications and future research issues are discussed, including the need for studying different measurement approaches for evaluating guidelines adherence.

Nurses on quality improvement teams: how do they benefit?

As part of a randomized control trial to improve the delivery of preventive services, the authors studied the effect on clinic nurses in the roles of team leaders or facilitators of multidisciplinary, continuous quality improvement (CQI) teams. Our goal was to learn how these nurses felt about their experience with this project, specifically their satisfaction with process improvement, acquired knowledge and skills, and the impact on their nursing role. Overall, the nurses involved in this study reported significant gains in all three areas. This study suggests that CQI can be a valuable vehicle for improving and expanding the nursing role for clinic nurses.

Clinical practice guidelines in end-stage renal disease: a strategy for implementation

Clinical practice guidelines (CPGs) for end-stage renal failure (ESRD) were recently published, and represent a comprehensive review of available literature and the considered judgment of experts in ESRD. To prioritize and implement these guidelines, the evidence underlying each guideline should be ranked and the attributes of each should be defined. Strategies to improve practice patterns should be tested. Focused information for each high priority guideline should be disseminated, including a synopsis and assessment of the underlying evidence, the evidence model used to develop that guideline, and suggested strategies for CPG implementation. Clinical performance measures should be developed and used to measure current practice, and the success of changing practice patterns on clinical outcomes. Individual practitioners and dialysis facilities should be encouraged to utilize continuous quality improvement techniques to put the guidelines into effect. Local implementation should proceed at the same time as a national project to convert high priority CPGs into clinical performance measures proceeds. Patients and patient care organizations should participate in this process, and professional organizations must make a strong commitment to educate clinicians in the methodology of CPG and performance measure development and the techniques of continuous quality improvement. Health care regulators should understand that CPGs are not standards, but are statements that assist practitioners and patients in making decisions.

Replication of clinical innovations in multiple medical practices

BACKGROUND

Many clinical innovations had been successfully developed and piloted in individual medical practice units of Kaiser Permanente in North Carolina during 1995 and 1996. Difficulty in replicating these clinical innovations consistently throughout all 21 medical practice units led to development of the interdisciplinary Clinical Innovation Implementation Team, which was formed by using existing resources from various departments across the region. REPLICATION MODEL: Based on a model of transfer of best practices, the implementation team developed a process and tools (master schedule and activity matrix) to quickly replicate successful pilot projects throughout all medical practice units. The process involved the following steps: identifying a practice and delineating its characteristics and measures (source identification); identifying a team to receive the (new) practice; piloting the practice; and standardizing, including the incorporation of learnings. The model includes the following components for each innovation: sending and receiving teams, an innovation coordinator role, an innovation expert role, a location expert role, a master schedule, and a project activity matrix. Communication depended on a partnership among the location experts (local knowledge and credibility), the innovation coordinator (process expertise), and the innovation experts (content expertise).

RESULTS

Results after 12 months of working with the 21 medical practice units include integration of diabetes care team services into the practices, training of more than 120 providers in the use of personal computers and an icon-based clinical information system, and integration of a planwide self-care program into the medical practices--all with measurable improved outcomes.

CONCLUSION

The model for sequential replication and the implementation team structure and function should be successful in other organizational settings.

Alcohol counseling: physicians will do it

OBJECTIVE

To assess the use of a brief provider-delivered alcohol counseling intervention of 5 to 10 minutes with high-risk drinking patients by primary care provider* trained in the counseling intervention and provided with an office support system.

DESIGN

A group randomized study design was used. Office sites were randomized to either a usual care or special intervention condition, within which physicians and patients were nested. The unit of analysis was the patient.

SETTING

Primary care internal medicine practices affiliated with an academic medical center.

PARTICIPANTS

Twenty-nine providers were randomized by practice site to receive training and an office support system to provide an alcohol counseling special intervention or to continue to provide usual care.

INTERVENTION

Special intervention providers received 2 1/2 hours of training in a brief alcohol-counseling intervention and were then supported by an office system that screened patients, cued providers to intervene, and made patient education materials available as tip sheets.

MEASUREMENTS AND MAIN RESULTS

Implementation of the counseling steps was measured by patient exit interviews (PEI) immediately following the patient visit. The interval between the date of training and the date of the PEI ranged from 6 to 32 months. Special intervention providers were twice as likely as usual care providers to discuss alcohol use with their patients. They carried out every step of the counseling sequence significantly more often than did usual care providers (p < .001). This intervention effect persisted over the 32 months of follow-up.

CONCLUSIONS

Physicians and other health-care providers trained in a brief provider-delivered alcohol intervention will counsel their high-risk drinking patients when cued to do so and supported by a primary care office system.

IMPROVE: bridge over troubled waters

BACKGROUND

The original collaborative project was described in a 1995 Journal article titled "Competing HMOs Collaborate to Improve Preventive Services." IMPROVE (IMproving PRevention through Organization, Vision, and Empowerment) was a large randomized controlled trial using continuous quality improvement to implement clinical systems to improve the delivery of adult preventive services in primary care settings. The project was funded by the Agency for Health Care Policy and Research and initiated as a collaboration between two health maintenance organizations (HMOs) in the Twin Cities: Health Partners and Blue Plus.

METHODOLOGY

Forty-four clinics were recruited for the study. Initially the 22 intervention clinics received the multifaceted intervention of leadership support, training on CQI and prevention systems, and consultation and networking opportunities. Next, the comparison clinics received similar assistance, and other clinics were invited into the collaboration. Ultimately, 57 clinics were involved in the project. Multiple collaborations--among clinics, leaders, and HMOs--developed during the project.

STATUS

Despite turmoil in the environment during the project, many benefits have been described, including enhanced leadership, growth of systems thinking, better change management skills, and collaboration of competing organizations.

SUMMARY

The IMPROVE collaboration survived and flourished in a very competitive market. It was viewed positively by clinicians, medical clinics, and HMOs, and its benefits have extended into the community.

Implementing nurse-based systems to provide American Indian women with breast and cervical cancer screening

OBJECTIVE

To describe the factors critical to implementation of a nurse-based system to increase access for American Indian women to breast and cervical cancer screening.

MATERIAL AND METHODS

We report the experience of 103 nurses at 40 clinics who were trained to use the nurse-based screening system. In addition, the critical elements are discussed in the context of one particularly successful site.

RESULTS

Fifteen factors were identified as critical to the implementation of a nurse-based cancer screening process once a nurse had been trained to perform clinical breast examinations and collect Papanicolaou (Pap) test specimens: knowledge of benefit, skills, organization, adequate return, perceived patient demand, perceived effectiveness, legitimacy, confidence, commitment, adequate resources, a data-driven iterative approach to program implementation, an objective measure of quality, leadership, the passage of time, and a focus on delivering the service to the patient. For example, in one site that was particularly successful, the nurses, administrators, and other key health-care professionals contributed their respective resources to implement the screening program. The program was also supported by the lay community, the state board of nursing, and the state health department breast and cervical cancer control program. During the 3-year study period, the 103 nurses performed screening tests on 2,483 women, and only 18 of the Pap test specimens were unsatisfactory.

CONCLUSION

Nurse-based systems designed to collect high-quality Pap test specimens and perform detailed clinical breast examinations can be implemented if the factors that are critical to implementation are identified and addressed.

Quality improvement in primary care clinics

BACKGROUND

Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization?

METHOD

Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature.

RESULTS

Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues.

CONCLUSION

QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.

Will primary care clinics organize themselves to improve the delivery of preventive services? A randomized controlled trial

BACKGROUND

There is increasing evidence that the most effective way to improve delivery of preventive services in primary care is to establish organized preventive service systems. This study tests the hypothesis that a managed care organization (MCO) can help its contracted private primary care clinics to develop such systems.

METHODS

Forty-four primary care clinics contracting with two large MCOs were randomized to a comparison (C) or an intervention (I) group. Group (I) clinic team leaders received training plus ongoing consultation and networking. Personnel at all 44 clinics completed surveys prior to and at the end of the intervention to measure adoption of the improvement process and the prevention system.

RESULTS

All 22 (I) clinics identified teams that appeared to follow the seven-step improvement process. The mean numbers of system processes were identical at baseline, 11.2 (I) vs 12.1 (C), while after the intervention this had changed to 25.8 in (I) clinics vs 11.3 in (C) (P = 0.022).

CONCLUSIONS

With training and assistance, interested primary care clinic teams will establish functioning CQI teams that will produce a substantial increase in the presence of functional prevention system processes. Whether this change is sufficient to increase the rates of preventive services remains to be documented.

Delivering clinical preventive services is a systems problem

A steadily increasing number of research trials and prevention advocates are identifying the practice environment as the main source of both problems and solutions to the improved delivery of clinical preventive services. Although these sources are correctly focusing on office systems as solutions, there is a tendency to focus on only parts of a system and to relate this to just one or a few related preventive services. However, the effort required to set up and maintain an office system makes it difficult to justify doing so for a single clinical activity. The process and system thinking of Continuous Quality Improvement (CQI) theory suggests that there may be both efficiency and effectiveness advantages to the concept of all clinical preventive services being served by a single system with many interrelated component processes. Such a system should be usable for all age groups. This system and its literature base are described. The feasibility of applying this concept is being tested in a randomized controlled trial in 44 primary care clinics in Minnesota and Wisconsin.

Continuous quality improvement in primary care: what's happening?

OBJECTIVES

Despite much health care interest in quality and Continuous Quality Improvement, there is little quantitative information about it. The purpose of this study was to measure the attitudes, activities, and organizational cultures concerning Continuous Quality Improvement in a group of Midwestern primary care clinics.

METHODS

Three surveys of the clinicians, nurses, and other staff in 44 primary care clinics in the metropolitan area of Minneapolis and St. Paul were conducted. These surveys assessed: (1) attitudes about quality improvement, (2) previous efforts in these clinics to use process improvement teams, and (3) the extent to which the clinics' organizational cultures were perceived as supporting quality. The Provider Attitude Survey was completed by clinicians and nurses; the Process Improvement Progress was completed by members of the best Continuous Quality Improvement teams, if any; and the Quality Systems Inventory was completed by all personnel.

RESULTS

Most of the clinical personnel reported support for various Continuous Quality Improvement concepts, but their understanding and experience were limited. Only 20 (45%) clinics had had at least one Continuous Quality Improvement team in the past, only five of the 12 teams with adequate information had completed an improvement cycle, and only seven reported improving a process with it. The mean clinic scores for quality culture were no better than those in other types of organizations.

CONCLUSIONS

Despite relatively favorable attitudes and some Continuous Quality Improvement activities, there appears to be a need to help clinics build skill and experience for the required care improvements.

Family physicians' utilization of a brief smoking cessation program following reinforcement contact after training: a randomized trial

BACKGROUND

Previous studies have examined methods of delivery of brief interventions and reinforcement contact and their effects on physicians' utilization of smoking cessation interventions. In this study the objectives were: (1) to determine the ongoing utilization by family physicians of a brief smoking cessation intervention 6 months after a training workshop and (2) to examine the effect of reinforcement contact on physician utilization. A supplementary aim was to assess point prevalence abstinence among patients identified as ready to quit smoking.

METHODS

This was a randomized controlled trial of family physicians (98 in the Contact and 100 in the Noncontact group). Training was conducted in a 2-hr workshop. Doctors in the Contact group received three brief telephone calls at 2 weeks, 2 months, and 4 months after training. Main outcome measures were: (1) utilization, determined by responses to a mailed questionnaire about use of the program, and (2) the number of booklets distributed by full-time doctors, collected by practice secretaries or research assistant.

RESULTS

At 6 months 88% of physicians (93% of the Contact group and 84% of the Noncontact group, P = 0.06) were current users of the smoking cessation intervention. Full-time physicians in the Contact group distributed significantly more booklets (40.1) over 6 months than those in the Noncontact group (32.8) (P < 0.05). Twenty-one percent of patients reported not smoking at follow-up at an average of 9.9 months after intervention.

CONCLUSIONS

Most doctors continued to use the program 6 months after training and reinforcement contact encouraged greater recruitment of patients.

Using continuous quality improvement to improve diabetes care in populations: the IDEAL model. Improving care for Diabetics through Empowerment Active collaboration and Leadership

BACKGROUND

The care of patients with chronic diseases, especially those with diabetes mellitus, has been less than ideal. However, despite clear national guidelines, various examples of better care models, and multiple attempts to improve care, an effective process for facilitating and replicating diabetes care improvements in typical primary care practices has been elusive.

METHODS

On the basis of the approach and lessons from developmental work at the Minnesota Diabetes Control Program and a trial of continuous quality improvement for clinical preventive services (IMPROVE), a clinic-based intervention processes (IDEAL) has been developed to improve the system and process of care for patients with diabetes as a model for all chronic diseases. The intervention incorporates facilitation of leadership actions in support of change, training for the leader and facilitator of an intraclinic multidisciplinary continuous quality improvement (CQI) team, and consultative and networking support of the change process. Each element of this intervention emphasizes a seven-step process improvement approach and a system for care of patients with diabetes. This model is being developed and tested in a unique partnership between the Minnesota Department of Health and HealthPartners, a large managed care organization (MCO).

RESULTS

A prepilot demonstration has succeeded in improving glycemic control, three primary care clinics affiliated with HealthPartners have succeeded in a pilot of the intervention, and an additional 13 clinics are participating in a randomized controlled trial of a refined intervention.

CONCLUSIONS

The IDEAL model holds promise for substantial improvements in care, not only for diabetes but for all chronic diseases and for other settings.

Physician-based smoking intervention: a rededication to a five-step strategy to smoking research

It is well established that physicians can have a significant effect on the smoking behavior of their patients. To do this, attention must be paid to putting in place multiple strategies or mechanisms in the organization where the physician practices, as well as in the macroenvironment (i.e., social and public policy). It has been questioned whether or not there is stagnation in the field of clinical smoking intervention requiring a rededication to basic research regarding smoking. With respect to physician-based smoking intervention, we alternatively suggest that recommitment to all phases of research is essential for moving forward physician-based smoking interventions in the rapidly changing health services and social environment. In this article, we first review the essential framework of the National Cancer Institute's research science approach to cancer prevention and control. Evidence concerning physician-based interventions is then reviewed, followed by a schematic of a comprehensive framework for thinking about the process and intervention components needed for physician-based smoking intervention to take place in the health-care setting, the impact they have, and the eventual outcome of such interventions. There is a discussion of the challenges for the delivery of smoking-cessation services presented by the rapidly changing healthy delivery system of the 1990s. Finally, we present recommendations concerning research priorities for physician-based smoking intervention and the research funding process.

Delivery rates for preventive services in 44 midwestern clinics

OBJECTIVE

To determine the rates at which private primary-care clinics are recommending blood pressure and cholesterol measurement, smoking cessation, clinical breast examination, screening mammography, Papanicolaou testing, and influenza and pneumococcus immunizations.

MATERIAL AND METHODS

We conducted a mail survey of 7,997 randomly selected patients from 44 primary-care clinics in and around Minneapolis-St. Paul, Minnesota, of whom 6,830 (85.4%) completed the questionnaire on preventive services delivery rates. The responses were analyzed statistically, including stratification by reason for the clinic visit.

RESULTS

On the average, about two-thirds of the patients in each clinic reported being up-to-date on preventive services before their clinic visit; an exception was pneumococcus immunization (mean rate, 33%). Except for blood pressure and smoking cessation advice, less than 30% of patients who were not up-to-date on a preventive service were offered it if the clinic visit was for a reason other than a checkup or physical examination. For patients who said that they saw their physician for a checkup or physical examination, the rate was more than 50% only for Papanicolaou smear. In contrast, nearly all responding practitioners agreed that each of the eight preventive services was very important or important.

CONCLUSION

Preventive services consensus goals are not being met, even for patients who report that their clinic visit was for a checkup or physical examination. This finding suggests that it may be necessary to develop clinical systems that support and enable the delivery of preventive services.

Are physicians less likely to recommend preventive services to low-SES patients?

BACKGROUND

Do low-SES adult patients visiting private primary care clinics differ from higher SES adult patients in their need for eight preventive services or in receiving either a recommendation for or the needed services?

METHODS

Randomly identified adult patients were surveyed within 2 weeks of a visit to 22 clinics in the Minneapolis-St. Paul area. Questions assessed patient recollection of the latest receipt of eight services and whether needed services had been recommended during the visit or received then soon after.

RESULTS

Of those surveyed, 4,245 patients (1,650 low SES) responded (84.3%), showing that low SES patients were less likely to be up to date for cholesterol measurement, Pap smear, mammography, breast exam, and flu or pneumonia shots (P < 0.004), but not for blood pressure measurement. Low-SES patients needing services received recommendations to have them and actually received them at the same rate as higher SES patients.

CONCLUSIONS

The 22 primary care clinics studied appear to be recommending and providing needed preventive services to visiting patients at the same rate regardless of income or insurance status. The reasons for differences in prevention status by SES are complex but the low proportion of all patients receiving recommendations for needed services suggests the need to take advantage of all visits for updating prevention needs.

The three faces of performance measurement: improvement, accountability, and research

In the current climate of public accountability, many clinicians have become uncomfortable with any efforts to create measurement systems. That is unfortunate because measurements are absolutely essential to efforts for improving the processes of medical care. In their guideline implementation and measurement efforts, ISCI and the IMPROVE Project in Minnesota have gradually learned how to distinguish between measurement for improvement and that for accountability. Both approaches are different from the approach that physicians are used to in their encounters with medical research. Understanding these differences and respecting the confidentiality of individual medical groups has been crucial to moving past confusion and suspicion to genuine improvement actions involving multiple medical groups and their contracting managed care plans.