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

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).

A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39

BACKGROUND

Interprofessional education (IPE) aims to bring together different professionals to learn with, from, and about one another in order to collaborate more effectively in the delivery of safe, high-quality care for patients/clients. Given its potential for improving collaboration and care delivery, there have been repeated calls for the wider-scale implementation of IPE across education and clinical settings. Increasingly, a range of IPE initiatives are being implemented and evaluated which are adding to the growth of evidence for this form of education.

AIM

The overall aim of this review is to update a previous BEME review published in 2007. In doing so, this update sought to synthesize the evolving nature of the IPE evidence.

METHODS

Medline, CINAHL, BEI, and ASSIA were searched from May 2005 to June 2014. Also, journal hand searches were undertaken. All potential abstracts and papers were screened by pairs of reviewers to determine inclusion. All included papers were assessed for methodological quality and those deemed as "high quality" were included. The presage-process-product (3P) model and a modified Kirkpatrick model were employed to analyze and synthesize the included studies.

RESULTS

Twenty-five new IPE studies were included in this update. These studies were added to the 21 studies from the previous review to form a complete data set of 46 high-quality IPE studies. In relation to the 3P model, overall the updated review found that most of the presage and process factors identified from the previous review were further supported in the newer studies. In regard to the products (outcomes) reported, the results from this review continue to show far more positive than neutral or mixed outcomes reported in the included studies. Based on the modified Kirkpatrick model, the included studies suggest that learners respond well to IPE, their attitudes and perceptions of one another improve, and they report increases in collaborative knowledge and skills. There is more limited, but growing, evidence related to changes in behavior, organizational practice, and benefits to patients/clients.

CONCLUSIONS

This updated review found that key context (presage) and process factors reported in the previous review continue to have resonance on the delivery of IPE. In addition, the newer studies have provided further evidence for the effects on IPE related to a number of different outcomes. Based on these conclusions, a series of key implications for the development of IPE are offered.

Knowledge, attitudes, and practice patterns among healthcare providers in the prevention of recurrent kidney stones in Northern Ontario

INTRODUCTON

Kidney stone recurrence is common. Preventive measures can lead to improved quality of life and costs savings to the individual and healthcare system. Guidelines to prevent recurrent kidney stones are published by various urological societies. Adherence to guidelines amongst healthcare professionals in general is poor, while adherence to preventive management guidelines regarding stone disease is unknown. To understand this issue, we conducted an online study to assess the knowledge, attitudes, and practice patterns of healthcare practitioners in Northern Ontario.

METHODS

We used the database of healthcare providers affiliated with the Northern Ontario School of Medicine, in Sudbury (East Campus) and Thunder Bay (West Campus), Ontario. We designed the survey based on current best practice guidelines for the management of recurrent kidney stones. Questions covered 3 domains: knowledge, attitudes, and practice patterns. Demographic data were also collected. The survey was distributed electronically to all participants.

RESULTS

A total of 68 healthcare providers completed the survey. Of these, most were primary care physicians (72%). To keep uniformity, we analyzed the data of this homogenous group. A total of 70% of the respondents were aware of the current guidelines; however, only 43% applied their knowledge in clinical practice. Most participants lacked confidence while answering most items in the attitude domain.

CONCLUSIONS

Most primary care physician respondents were aware of the appropriate preventive measures for recurrent kidney stones; however, they do not appear to apply this knowledge effectively in clinical practice. A low response rate is a limitation of our study. Further studies involving a larger sample size may lead to information sharing and collaborative care among healthcare providers.

Decision Aid to Technologically Enhance Shared decision making (DATES): study protocol for a randomized controlled trial

BACKGROUND

Clinicians face challenges in promoting colorectal cancer screening due to multiple competing demands. A decision aid that clarifies patient preferences and improves decision quality can aid shared decision making and be effective at increasing colorectal cancer screening rates. However, exactly how such an intervention improves shared decision making is unclear. This study, funded by the National Cancer Institute, seeks to provide detailed understanding of how an interactive decision aid that elicits patient's risks and preferences impacts patient-clinician communication and shared decision making, and ultimately colorectal cancer screening adherence.

METHODS/DESIGN

This is a two-armed single-blinded randomized controlled trial with the target of 300 patients per arm. The setting is eleven community and three academic primary care practices in Metro Detroit. Patients are men and women aged between 50 and 75 years who are not up to date on colorectal cancer screening. ColoDATES Web (intervention arm), a decision aid that incorporates interactive personal risk assessment and preference clarification tools, is compared to a non-interactive website that matches ColoDATES Web in content but does not contain interactive tools (control arm). Primary outcomes are patient uptake of colorectal cancer screening; patient decision quality (knowledge, preference clarification, intent); clinician's degree of shared decision making; and patient-clinician concordance in the screening test chosen. Secondary outcome incorporates a Structural Equation Modeling approach to understand the mechanism of the causal pathway and test the validity of the proposed conceptual model based on Theory of Planned Behavior. Clinicians and those performing the analysis are blinded to arms.

DISCUSSION

The central hypothesis is that ColoDATES Web will improve colorectal cancer screening adherence through improvement in patient behavioral factors, shared decision making between the patient and the clinician, and concordance between the patient's and clinician's preferred colorectal cancer screening test. The results of this study will be among the first to examine the effect of a real-time preference assessment exercise on colorectal cancer screening and mediators, and, in doing so, will shed light on the patient-clinician communication and shared decision making 'black box' that currently exists between the delivery of decision aids to patients and subsequent patient behavior.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01514786.

Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments

Background

Continuous quality improvement (CQI) methods are widely used in healthcare; however, the effectiveness of the methods is variable, and evidence about the extent to which contextual and other factors modify effects is limited. Investigating the relationship between these factors and CQI outcomes poses challenges for those evaluating CQI, among the most complex of which relate to the measurement of modifying factors. We aimed to provide guidance to support the selection of measurement instruments by systematically collating, categorising, and reviewing quantitative self-report instruments.

Methods

Data sources: We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments, reference lists of systematic reviews, and citations and references of the main report of instruments. Study selection: The scope of the review was determined by a conceptual framework developed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). Papers reporting development or use of an instrument measuring a construct encompassed by the framework were included. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarising and comparing instruments. Instrument content was categorised using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care.

Results

We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited.

Conclusions

Many instruments are available for evaluating CQI, but most require further use and testing to establish their measurement properties. Further development and use of these measures in evaluations should increase the contribution made by individual studies to our understanding of CQI and enhance our ability to synthesise evidence for informing policy and practice.

Systematic review and meta-analysis of practice facilitation within primary care settings

PURPOSE

This study was a systematic review with a quantitative synthesis of the literature examining the overall effect size of practice facilitation and possible moderating factors. The primary outcome was the change in evidence-based practice behavior calculated as a standardized mean difference.

METHODS

In this systematic review, we searched 4 electronic databases and the reference lists of published literature reviews to find practice facilitation studies that identified evidence-based guideline implementation within primary care practices as the outcome. We included randomized and nonrandomized controlled trials and prospective cohort studies published from 1966 to December 2010 in English language only peer-reviewed journals. Reviews of each study were conducted and assessed for quality; data were abstracted, and standardized mean difference estimates and 95% confidence intervals (CIs) were calculated using a random-effects model. Publication bias, influence, subgroup, and meta-regression analyses were also conducted.

RESULTS

Twenty-three studies contributed to the analysis for a total of 1,398 participating practices: 697 practice facilitation intervention and 701 control group practices. The degree of variability between studies was consistent with what would be expected to occur by chance alone (I2 = 20%). An overall effect size of 0.56 (95% CI, 0.43-0.68) favored practice facilitation (z = 8.76; P <.001), and publication bias was evident. Primary care practices are 2.76 (95% CI, 2.18-3.43) times more likely to adopt evidence-based guidelines through practice facilitation. Meta-regression analysis indicated that tailoring (P = .05), the intensity of the intervention (P = .03), and the number of intervention practices per facilitator (P = .004) modified evidence-based guideline adoption.

CONCLUSION

Practice facilitation has a moderately robust effect on evidence-based guideline adoption within primary care. Implementation fidelity factors, such as tailoring, the number of practices per facilitator, and the intensity of the intervention, have important resource implications.

Clinical effort against secondhand smoke exposure: development of framework and intervention

OBJECTIVE

The purpose of this work was to describe a novel process and present results of formative research to develop a pediatric office intervention that uses available systems of care for addressing parental smoking.

METHODS

The scientific development of the intervention occurred in 3 stages. In stage 1, we designed an office system for parental tobacco control in the pediatric outpatient setting on the basis of complementary conceptual frameworks of preventive services delivery, conceptualized for the child health care setting through a process of key interviews with leaders in the field of implementing practice change; existing Public Health Service guidelines that had been shown effective in adult practices; and adaptation of an evidence-based adult office system for tobacco control. This was an iterative process that yielded a theoretically framed intervention prototype. In stage 2, we performed focus-group testing in pediatric practices with pediatricians, nurses, clinical assistants, and key office staff. Using qualitative methods, we adapted the intervention prototype on the basis of this feedback to include 5 key implementation steps for the child health care setting. In stage 3, we presented the intervention to breakout groups at 2 national meetings of pediatric practitioners for additional refinements.

RESULTS

The main result was a theoretically grounded intervention that was responsive to the barriers and suggestions raised in the focus groups and at the national meetings. The Clinical Effort Against Secondhand Smoke Exposure intervention was designed to be flexible and adaptable to the particular practices' staffing, resources, and physical configuration. Practice staff can choose materials relevant to their own particular systems of care (www.ceasetobacco.org).

CONCLUSIONS

Conceptually grounded and focus-group-tested strategies for parental tobacco control are now available for implementation in the pediatric outpatient setting. The tobacco-control intervention-development process might have particular relevance for other chronic pediatric conditions that have a strong evidence base and have available treatments or resources that are underused.

Nurses as practice change facilitators for healthy behaviors

This study used nurses as practice change consultants to help primary care medical practices improve their delivery of health behavior services to patients. Nurse consultants worked with 20 practices from 2 healthcare systems. In each practice, the nurses helped clinicians and staff to develop a practice-specific protocol so that they could identify and intervene with the health behavior of their patients. As a result of the nurse consultant intervention, health behavior delivery was improved. This article describes the specific methods and the lessons learned through this study. We encourage practices to use nurse consultants as one way of improving quality of care.

A best evidence systematic review of interprofessional education: BEME Guide no. 9

BACKGROUND AND REVIEW CONTEXT: Evidence to support the proposition that learning together will help practitioners and agencies work better together remains limited and thinly spread. This review identified, collated, analysed and synthesised the best available contemporary evidence from 21 of the strongest evaluations of IPE to inform the above proposition. In this way we sought to help shape future interprofessional education and maximize the potential for interprofessional learning to contribute to collaborative practice and better care.

OBJECTIVES OF THE REVIEW

To identify and review the strongest evaluations of IPE. To classify the outcomes of IPE and note the influence of context on particular outcomes. To develop a narrative about the mechanisms that underpin and inform positive and negative outcomes of IPE.

SEARCH STRATEGY

Bibliographic database searches as follows: Medline 1966-2003, CINAHL 1982-2001, BEI 1964-2001, ASSIA 1990-2003 which produced 10,495 abstracts. Subsequently, 884 full papers were obtained and scrutinized. In addition, hand searching (2003-5 issues) of 21 journals known to have published two or more higher quality studies from a previous review.

TOPIC DEFINITION AND INCLUSION CRITERIA

Peer-reviewed papers and reports included in the review had to be formal educational initiatives attended by at least two of the many professional groups from health and social care, with the objective of improving care; and learning with, from and about each other.

DATA COLLECTION, ANALYSIS AND SYNTHESIS

Standard systematic review procedures were applied for sifting abstracts, scrutinizing full papers and abstracting data. Two members of the team checked each abstract to decide whether the full paper should be read. A third member was consulted over any discrepancies. Similarly, each full paper was read by at least two members of the team and agreement sought before passing it to one member of the team (SR) for data abstraction. Other members of the team checked 10% of the abstraction records. Coding into a Statistical Package for Social Scientists (SPSS) data base led to collection of different outcome measures used in the primary studies via the common metric of an adapted Kirkpatrick's four-level model of educational outcomes. Additionally, a narrative synthesis was built after analysis of primary data with the 3-P model (presage-process-product) of education development and delivery.

HEADLINE RESULTS

Government calls for enhanced collaboration amongst practitioners frequently leads to IPE that is then developed and delivered by educators, practitioners or service managers. Staff development is a key influence on the effectiveness of IPE for learners who all have unique values about themselves and others. Authenticity and customization of IPE are important mechanisms for positive outcomes of IPE. Interprofessional education is generally well received, enabling knowledge and skills necessary for collaborative working to be learnt; it is less able to positively influence attitudes and perceptions towards others in the service delivery team. In the context of quality improvement initiatives interprofessional education is frequently used as a mechanism to enhance the development of practice and improvement of services.

Networks and social capital: a relational approach to primary healthcare reform

Collaboration among health care providers and across systems is proposed as a strategy to improve health care delivery the world over. Over the past two decades, health care providers have been encouraged to work in partnership and build interdisciplinary teams. More recently, the notion of networks has entered this discourse but the lack of consensus and understanding about what is meant by adopting a network approach in health services limits its use. Also crucial to this discussion is the work of distinguishing the nature and extent of the impact of social relationships – generally referred to as social capital. In this paper, we review the rationale for collaboration in health care systems; provide an overview and synthesis of key concepts; dispel some common misconceptions of networks; and apply the theory to an example of primary healthcare network reform in Alberta (Canada). Our central thesis is that a relational approach to systems change, one based on a synthesis of network theory and social capital can provide the fodation for a multi-focal approach to primary healthcare reform. Action strategies are recommended to move from an awareness of 'networks' to fully translating knowledge from existing theory to guide planning and practice innovations. Decision-makers are encouraged to consider a multi-focal approach that effectively incorporates a network and social capital approach in planning and evaluating primary healthcare reform.

Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors

This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.

Physician practice patterns and variation in the delivery of preventive services

BACKGROUND

Strategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care.

OBJECTIVE

We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations.

DESIGN

Cross-sectional study.

PARTICIPANTS

One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits.

MEASUREMENTS

Physician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model.

RESULTS

Six distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed.

CONCLUSIONS

Similar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.

Challenges to improving chronic disease care and training in residencies

PURPOSE

To improve quality of care for chronic disease, professional organizations and medical providers are adopting new care models. The transition to better delivery systems is not easy and there are many barriers under the best of circumstances. This study investigated residency-based experiences with changes in teaching and delivery of chronic disease care.

METHOD

In 2004-05 at the University of Southern California, the authors conducted qualitative cross-sectional in-depth interviews with directors of grant-funded residency-based chronic care projects. Open- and closed-ended questions explored the intent of and the challenges encountered by primary care residencies implementing improvements in chronic disease care and training.

RESULTS

Six out of 14 program director responded, reporting that rotation-based and longitudinal experiences were used to teach and deliver improved chronic disease care. Common challenges were identified across residency sites, as well as challenges unique to particular residency settings. Among these challenges were engaging faculty and residents who spend limited time in the practice center, as well as institutional barriers related to authority, competing priorities, process, and resources.

CONCLUSIONS

Successful innovations for chronic disease care and training are possible in residencies, but their implementation cannot be taken lightly. There are predictable barriers that can be dealt with locally, but also others that would benefit from coordinated national attention.

Office Systems for Heart Disease Prevention

The provision of heart disease prevention services in primary care is currently inadequate, but can be improved with the establishment of a practice system. The system process involves all members of the practice in a clearly defined, well-organized approach to patient care. An initial review of patient care services will help practices identify prevention areas that they would like to improve by defining protocols, roles, and routines within the practice. Once established, the prevention system can improve patient care and satisfaction of practice staff and physicians, but requires on-going assessment, modification, and commitment.

The health service coverage of quality-certified primary health care units in Metro-Manila, the Philippines

INTRODUCTION

In 1998, the Philippines' Department of Health implemented the Quality Assurance Programme, known as the Sentrong Sigla (Centre of Vitality) Movement, starting with primary health care units. The Department established the National Objectives for Health in 1999, which set targets for health status and service coverage by 2004. The Movement certifies primary health care facilities that comply with its list of quality standards. Three years after implementation of the Sentrong Sigla Movement, the present study assessed it as an intervention for the delivery of health care services. Specifically, it evaluated the 2001 service coverage among certified facilities and compared it with that of non-certified facilities in the National Capital Region (Metro-Manila) of the Philippines, and related service coverage to the targets of the National Objectives for Health for 2001.

METHODS

For the intervention group, the study randomly selected 82 of the 143 certified facilities (57.3%), with 88 of the 223 non-certified facilities (39.5%) serving as the control group. Using reliable and valid measurement indicator tools, data were collected on preventive health services programmes, curative programmes and monitoring programmes. To compare service coverage of the intervention and control groups, the data were analyzed using chi-squared tests, prevalence ratios, clustered sampling analysis and linear regressions of the rates.

RESULTS

The overall 2001 service coverage shows that certified facilities had significantly less success in the preventive and monitoring programmes than the non-certified facilities, but were not significantly different in the curative programmes. Neither type of facility reached the targets of the 2001 National Objectives for Health for preventive programmes. After adjusting for clustering, the certified facilities showed significantly lower service coverage, compared with non-certified facilities, only for enrolling new acceptors to the Family Planning Programme and for water-supply testing in the Environmental Sanitation Programme.

CONCLUSION

Unlike previous studies, the results and analysis of the present study show that, generally, the Sentrong Sigla Movement had not improved the processes required to achieve better outcomes. Factors that could have contributed to the findings are described and strategies for improvement are recommended.

The role of perceived team effectiveness in improving chronic illness care

BACKGROUND/OBJECTIVES

The importance of teams for improving quality of care has received increased attention. We examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness. STUDY SETTING AND METHODS: Data were obtained from 40 teams participating in the national evaluation of the Improving Chronic Illness Care Program. Based on current theory and literature, measures were derived of organizational culture, a focus on patient satisfaction, presence of a team champion, team composition, perceived team effectiveness, and the actual number and depth of changes made to improve chronic illness care.

RESULTS

A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among culture values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care. The variables examined explain between 24 and 40% of the variance in different dimensions of perceived team effectiveness; between 13% and 26% in number of changes made; and between 20% and 42% in depth of changes made.

CONCLUSIONS

The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness.

Design and analysis of group-randomized trials: a review of recent practices

We reviewed group-randomized trials (GRTs) published in the American Journal of Public Health and Preventive Medicine from 1998 through 2002 and estimated the proportion of GRTs that employ appropriate methods for design and analysis. Of 60 articles, 9 (15.0%) reported evidence of using appropriate methods for sample size estimation. Of 59 articles in the analytic review, 27 (45.8%) reported at least 1 inappropriate analysis and 12 (20.3%) reported only inappropriate analyses. Nineteen (32.2%) reported analyses at an individual or subgroup level, ignoring group, or included group as a fixed effect. Hence increased vigilance is needed to ensure that appropriate methods for GRTs are employed and that results based on inappropriate methods are not published.

Eliminating disparities: empowering health promotion within preventive medicine

The estimated 800,000 U.S. deaths in 1990 related to behavioral decisions challenge physicians to better assist behavioral change through expanded health promotion activities. Based on the format guidelines of this special issue, this brief paper first examines the current and optimal roles of health promotion within Preventive Medicine, including five physician roles for improving modifiable public health-risk behavior burdens: (1) preventive services clinician, (2) health promotion researcher, (3) educator-communicator, (4) systems manager, and (5) health promotion advocate. After presenting a new vision statement, this paper proceeds to discuss the opportunities and barriers, including system, clinician-office, and patient factors, to attaining this new vision of empowering health promotion within Preventive Medicine. Finally, all physicians are invited to engage in a threefold strategic plan for change through at least one of five action items: (1) health promotion advocacy, (2) health promotion research, (3) public communication, (4) protocol dissemination and implementation, and (5) Preventive Medicine training.

Improving quality of organizing cardiovascular preventive care in general practice by outreach visitors: a randomized controlled trial

BACKGROUND

Adequate care for patients with cardiovascular risks requires an adequate practice organization. Educational outreach visits are a promising approach to modifying professional behavior. We aimed to assess whether the quality of cardiovascular preventive care in general practice can be improved through a comprehensive intervention implemented by an educational outreach visitor.

METHODS

After baseline measurements, general practices (n = 124) in the southern half of The Netherlands were randomly allocated to either intervention or control group. The intervention, based on the educational outreach model, comprised 15 practice visits over a period of 21 months and addressed a large number of issues around task delegation, availability of instruments and patient leaflets, record-keeping, and follow-up routines. Twenty-one months after the start of the intervention, postintervention measurements were performed. The difference between ideal and actual practice in each aspect of organizing preventive care was defined as a deficiency score. Primary outcome measure was the difference in deficiency scores before and after the intervention.

RESULTS

All practices completed both baseline and postintervention measurements. The difference in change between intervention and control group adjusted for baseline was statistically significant (P < 0.001) for each aspect of organizing preventive care. The largest absolute improvement was found for the number of preventive tasks performed by the practice assistant.

CONCLUSIONS

This study showed that a comprehensive intervention implemented by outreach visitors was effective in improving organization of cardiovascular preventive care in general practice.

Organizing cardiovascular preventive care in general practice: determinants of a successful intervention

BACKGROUND

Although outreach visitor interventions have proven to be effective, more detailed studies are needed to understand what elements of interventions work and why. In this study we investigate the determinants of success of an intervention for optimizing cardiovascular preventive care in general practice.

METHODS

After baseline measurements and randomization, 62 general practices received a comprehensive intervention program, by means of outreach visitors, lasting 21 months. Data on practice management and preventive activities were gathered at baseline and at postintervention measurements. Key characteristics of the intervention considered possible determinants of success were gathered by questionnaire. The difference between ideal and actual practice in each aspect of organizing cardiovascular preventive care was calculated as a deficiency score. The difference between deficiency scores before and after the intervention were the main outcome measures.

RESULTS

The key characteristic, duration of exposure to an aspect (in months), was positively related to the change in availability of separate clinics and in the amount of teamwork. The improvement in instruments and materials was positively related to the general practitioner's opinion about the given feedback. No relations were found between the key characteristics and changes in record-keeping or follow-up routines.

CONCLUSIONS

Although implementation of a comprehensive prevention program is effective, we could not fully disentangle the "black box" of the intervention. The duration of exposure to an aspect of organizing cardiovascular care was the key determinant to success.

Integrating occupational health services and occupational prevention services

BACKGROUND

Despite the human and monetary costs of occupational injury and illness, occupational health care has focused more on treatment than prevention, and prevention is not part of many clinical occupational health practices. This represents a failure of occupational health care to meet the health care needs of the working patients.

METHODS

MEDLINE searches were conducted for literature on occupational medical treatment and the prevention of occupational injury and illness were reviewed to for linkages between prevention and treatment. Policy discussions which identify examples of programs that integrated prevention and treatment were included.

RESULTS

Although examples of the integration of clinical and preventive occupational health services exist, there are challenges and barriers to such integration. These include inaction by clinicians who do not recognize their potential role in prevention; the absence of a relationship between the clinician and an employer willing to participate in prevention; economic disincentives against prevention; and the absence of tools that evaluate clinicians on their performance in prevention.

CONCLUSIONS

Research is needed to improve and promote clinical occupational health preventive services.

The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites

OBJECTIVE

To determine whether the implementation of the Put Prevention Into Practice (PPIP) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics.

METHODS

Chart review was conducted before (n=372) and 33 to 39 months after (n=376) the implementation of the PPIP office-based system in two community health centers and three family practice residency programs in Texas. The population included all adult patients aged > or = 19 years who had presented to the clinic during the study periods.

RESULTS

Documentation of timely cholesterol screening increased from 70% to 84%; smoking assessment, from 56% to 80%; for women, up-to-date Papanicolaou smear, from 70% to 81%; annual mammograms (women aged > or =51), from 30% to 48%; and up-to-date tetanus-diphtheria immunizations, from 19% to 59%. For adults aged > or =66 years, documentation of pneumococcal immunization increased from 22% to 48%, while influenza immunizations improved, although not significantly (45% to 49%). Blood pressure screening was almost universal (99%) at baseline and at 33- to 39-month follow-up.

CONCLUSION

PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services.

A clinical trial of tailored office systems for preventive service delivery. The Study to Enhance Prevention by Understanding Practice (STEP-UP)

BACKGROUND

The potential of primary care practice settings to prevent disease and morbidity through health habit counseling, screening for asymptomatic disease, and immunizations has been incompletely met. This study was designed to test a practice-tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling.

DESIGN

Group randomized clinical trial and multimethod process assessment.

SETTING/PARTICIPANTS

Seventy-seven community family practices in northeast Ohio.

INTERVENTION

After a 1-day practice assessment, a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aimed at increasing preventive service delivery.

MAIN OUTCOME MEASURE

Summary scores of the health habit counseling, screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during randomly selected chart review days.

RESULTS

A significant increase (p=0.015) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group (31% to 42%) compared to the control group (35% to 37%). Rates specifically for health habit counseling (p=0.007) and screening services (p=0.048) were increased, but not for immunizations.

CONCLUSIONS

An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates.

Organization development strategies for continuing medical education

BACKGROUND

The purpose of this study was to identify organizational strategies for improving staff performance in primary care practices. The study rationale was based on theory, research, and practice regarding educational interventions that help people help themselves. Analysis of qualitative and quantitative data produced both plausible explanations of organizational change and implications for future efforts.

METHODS

The Health Education and Research Trial (HEART) Project was an experimental study designed to improve prevention services for cardiovascular disease. Primary care clinics were randomized into four experimental treatments. Two representative practices from each treatment arm were chosen for an in-depth cross-case analysis. Extensive data from each selected practice included patient medical record reviews and questionnaires, interviews and questionnaires from physicians and clinic staff, project records, and follow-up interviews. After detailed case descriptions were created for each practice, a cross-case analysis was performed.

RESULTS

Each practice improved cardiovascular prevention services somewhat. However, there was a great range of impact, likely reflecting both experimental intervention and local contingencies. Eight positive influences were identified: effective leadership, priority setting, joint planning, cooperation and teamwork, acquisition of resources, increased support and ownership, accomplishment of improvements, and personal changes. Major influences that hindered improvement included patient load, turmoil related to reorganization, lack of wide-spread routines, hospital-affiliated practice, poor communication, and fragmentation within a clinic.

FINDINGS

Continuing medical education providers can enhance preventive services to improve patient health status by promoting organizational change. Suggested strategies supported by this study include selecting able leaders, focusing on accomplishments, obtaining agreement on prevention priorities, addressing local contingencies, increasing teamwork, engaging in joint planning, emphasizing quality improvement, acquiring resources, encouraging persistence, and reducing hindrances.

Direct observation of rates of preventive service delivery in community family practice

BACKGROUND

Data on preventive service delivery in primary care practice have been limited by indirect methods of measurement. This study describes directly observed rates of preventive service delivery during outpatient visits to community family physicians.

METHODS

In a multimethod cross-sectional study, research nurses directly observed consecutive patient visits in the offices of 138 family physicians in Northeast Ohio. Patient eligibility for services recommended by the U.S. Preventive Services Task Force was determined from medical record review. Service delivery was assessed by direct observation of outpatient visits. Rates of delivery of specific preventive services were computed. Global summary measures were calculated for health habit counseling, screening, and immunization services.

RESULTS

Among 4,049 visits by established patients with available medical records, wide variation was observed among rates of different preventive services delivered during well-care visits. During illness visits, rates were uniformly low for all preventive services. Counseling services were delivered at only slightly lower rates during illness visits compared to well visits. Patients were up to date on 55% of screening, 24% of immunization, and 9% of health habit counseling services.

CONCLUSION

Rates of preventive service delivery are low. Illness visits are important opportunities to deliver preventive services, particularly health habit counseling, to patients. Preventive service delivery summary scores are useful in providing a patient population perspective on the delivery of preventive services and in focusing attention on delivery of a comprehensive portfolio of services.

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.

Systems change resulting from HIV/AIDS education and training. A cross-cutting evaluation of nine innovative projects

An evaluation of nine diverse HIV/AIDS training programs assessed the degree to which the programs produced changes in the ways that health care systems deliver HIV/AIDS care. Participants were interviewed an average of 8 months following completion of training and asked for specific examples of a resulting change in their health care system. More than half of the trainees gave at least one example of a systems change. The examples included the way patient referrals are made, the manner in which agency collaborations are organized, and the way care is delivered.