A randomized trial of practice facilitation to improve the delivery of chronic illness care in primary care: initial and sustained effects

Michael L Parchman, Polly H Noel, Steven D Culler, Holly J Lanham, Luci K Leykum, Raquel L Romero, Raymond F Palmer, Michael L Parchman, Polly H Noel, Steven D Culler, Holly J Lanham, Luci K Leykum, Raquel L Romero, Raymond F Palmer

Abstract

Background: Practice facilitation (PF) is an implementation strategy now commonly used in primary care settings for improvement initiatives. PF occurs when a trained external facilitator engages and supports the practice in its change efforts. The purpose of this group-randomized trial is to assess PF as an intervention to improve the delivery of chronic illness care in primary care.

Methods: A randomized trial of 40 small primary care practices who were randomized to an initial or a delayed intervention (control) group. Trained practice facilitators worked with each practice for one year to implement tailored changes to improve delivery of diabetes care within the Chronic Care Model framework. The Assessment of Chronic Illness Care (ACIC) survey was administered at baseline and at one-year intervals to clinicians and staff in both groups of practices. Repeated-measures analyses of variance were used to assess the main effects (mean differences between groups) and the within-group change over time.

Results: There was significant improvement in ACIC scores (p < 0.05) within initial intervention practices, from 5.58 (SD 1.89) to 6.33 (SD 1.50), compared to the delayed intervention (control) practices where there was a small decline, from 5.56 (SD 1.54) to 5.27 (SD 1.62). The increase in ACIC scores was sustained one year after withdrawal of the PF intervention in the initial intervention group, from 6.33 (SD 1.50) to 6.60 (SD 1.94), and improved in the delayed intervention (control) practices during their one year of PF intervention, from 5.27 (SD 1.62) to 5.99 (SD 1.75).

Conclusions: Practice facilitation resulted in a significant and sustained improvement in delivery of care consistent with the CCM as reported by those involved in direct patient care in small primary care practices. The impact of the observed change on clinical outcomes remains uncertain.

Trial registration: This protocol followed the CONSORT guidelines and is registered per ICMJE guidelines:

Clinical trial registration number: NCT00482768.

Figures

Figure 1
Figure 1
ACIC scores: initial and delayed intervention practices.

References

    1. Baskerville BN, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med. 2012;10:63–64. doi: 10.1370/afm.1312.
    1. Knox L, Taylor EF, Geonnotti K, Machta R, Kim J, Nysenbaum J, Parchman M. Developing and Running a Primary Care Practice Facilitation Program: A How-to Guide (Prepared by Mathematica Policy Research under Contract No. HHSA290200900019I TO 5.) AHRQ Publication No. 12–0011. Agency for Healthcare Research and Quality.: Rockville, MD; 2011.
    1. Nagykaldi Z, Mold JW, Aspy CB. Practice facilitators: a review of the literature. Fam Med. 2005;37(8):581–588.
    1. Solberg LI, Asche SE, Fontaine P, Flottemesch TJ, Anderson LH. Trends in quality during medical home transformation. Ann Fam Med. 2011;9:515–521. doi: 10.1370/afm.1296.
    1. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511–544. doi: 10.2307/3350391.
    1. Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the chronic care model in the new millennium. Health Aff. 2009;28:75–85. doi: 10.1377/hlthaff.28.1.75.
    1. Tsai AC. et al.A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care. 2005;11:478–488.
    1. Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaén C. Transforming Physician Practices To Patient-Centered Medical Homes: Lessons From The National Demonstration Project. Health Aff. 2011;30:439–444. doi: 10.1377/hlthaff.2010.0159.
    1. Parchman ML, Pugh JA, Culler SD, Noël PH, Arar NH, Romero RL. Improving risk factors for diabetes complications in primary care: A protocol for an organizational intervention grounded in complexity science. Implement Sci. 2008;3:15. doi: 10.1186/1748-5908-3-15.
    1. Hussey MA, Hughes JP. Design and analysis of stepped wedge cluster randomized trials. Contemp Clin Trials. 2007;28:182–191. doi: 10.1016/j.cct.2006.05.007.
    1. Bonomi AE, Wagner EH, Glasgow RE, VonKorff M. Assessment of chronic illness care (ACIC): a practical tool to measure quality practice. Health Serv Res. 2002;37:791–820. doi: 10.1111/1475-6773.00049.
    1. Schafer J, Graham J. Missing data: our view of the state of the art. Psychol Methods. 2002;7(2):147–177.
    1. Little RJA, Rubin DB. Statistical Analysis with Missing Data. NY: John Wiley and Sons; 1987.
    1. Scholle SH, Pawlson GP, Solberg LI, Shih SC, Asche SE, Chou AF, Thoele MJ. Measuring practice systems for chronic illness care: accuracy of self-reports from clinic personnel. Jt Comm J Qual & Pt Safety. 2008;34:402–416.
    1. Kaissi AA, Parchman M. Assessing chronic illness care for diabetes in primary care clinics. Jt Comm J Qual Pt Safety. 2006;32:318–323.
    1. Lipitz LA. Understanding health care as a complex system. JAMA. 2012;308:243–245. doi: 10.1001/jama.2012.7551.
    1. Litaker D, Tomolo A, Liberatore V. et al.Using Complexity Theory to Build Interventions that Improve Health Care Delivery in Primary Care. J Gen Intern Med. 2006;21:S30–S34. doi: 10.1007/s11606-006-0272-z.
    1. McDaniel RR, Lanham HJ, Anderson RA. Implications of complex adaptive systems theory for the design of research on health care organizations. Health Care Manage Rev. 2009;34:191–199. doi: 10.1097/HMR.0b013e31819c8b38.
    1. Jordan ME, Lanham HJ, Crabtree BF, Nutting PA, Miller WL, Stange KC, McDaniel RR. The role of conversation in health-care interventions: enabling sense-making and learning. Implement Sci. 2009;4:15. doi: 10.1186/1748-5908-4-15.
    1. Leykum LK, Pugh JA, Lawrence V, Parchman M, Noel PH, Cornell J, McDaniel RR. Organnizational interventions employing principles of complexity science have improved outcomes for patients with type II diabetes. Implement Science. 2007;2:28. doi: 10.1186/1748-5908-2-28.
    1. Lanham HJ, Leykum LK, Taylor BS, McCannon J, Lindberg C, Lester RT. How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts. Soc Sci Med. 2012. Epub ahead of print.
    1. Parchman ML, Wang CP, Pugh JA, Romero RL. Glucose control, self-care behaviors and the presence of the chronic care model in primary care clinics. Diabetes Care. 2007;30:2894–2854.
    1. Solberg LI, Crain AL, Sperl-Hillen JM. et al.Care quality and implementation of the chronic care model: a quantitative study. Ann Fam Med. 2006;4:310–316. doi: 10.1370/afm.571.
    1. Nutting PA, Dickinson WP, Dickinson LM. et al.Use of chronic care model elements is associated with higher-quality care for diabetes. Ann Fam Med. 2007;5:14–20. doi: 10.1370/afm.610.
    1. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F. et al.Designing and evaluating complex interventions to improve health care. BMJ. 2007;334:455–459. doi: 10.1136/.
    1. Grumbach K, Bainbridge E, Bodenheimer T. Facilitating improvement in primary care: the promise of practice coaching. Issue Brief (Commonwealth Fund) 2012;15:1–4.
    1. Grumbach K, Mold JW. A health care cooperative extension agent service: transforming primary care and community health. JAMA. 2009;301:2589–2591. doi: 10.1001/jama.2009.923.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren